Rehab News – Page 42

Health Secretary Becerra Touts Extreme Heat Protections. Farmworkers Want More.

CLARKSBURG — On a sunny August morning in this agricultural town, before temperatures soared to 103 degrees, U.S. Health and Human Services Secretary Xavier Becerra stood outside the small public library.

He came to talk about the Biden administration’s efforts to protect farmworkers from extreme heat and wildfire smoke, two emerging public health issues at the forefront of the climate crisis.

“There are still not enough protections for workers that are picking the food that we eat,” Becerra told a group of local reporters and government officials, who outnumbered the farmworkers in the audience.

Becerra, whose father worked in the fields, had just come from visiting women picking grapes who protect themselves from the sun by dressing in sweaters, long pants, and kerchiefs that cover their noses and mouths. The summers are long and intense in Clarksburg, a town of about 300 people along the Sacramento River that supplies California’s wine industry with petite sirah, sauvignon blanc, and other grapes harvested by hundreds of farmhands.

“It’s going to be a hot day,” he added. “But they are still dressed as if it were winter.”

The nation’s top health officer, who is mulling a run for governor, has emerged as one of the Biden administration’s leading voices on climate change, focusing attention on low-income and other marginalized workers, who feel the impacts of extreme weather the most. In March, HHS released voluntary safety guidelines and educational materials that farms can use to protect their workers from smoke and heat.

Becerra’s appearance before reporters in front of the library was brief and scheduled to mark Farmworker Appreciation Day, not far from his home in Sacramento, where his wife, a doctor specializing in high-risk pregnancies, remains at work. He advertised the educational materials on the risks of heat illness and when temperatures might be too high to work. But he acknowledged that there is only so much he can do because workplace protections are overseen by the Department of Labor.

“Much of our jurisdiction doesn’t reach those workers directly,” Becerra acknowledged after meeting with grape pickers. “We owe everyone who is working to put food on our table the best effort to make sure that they are working under the safest conditions.”

His aides distributed a press release that listed a number of resources, including free workplace health investigations by the Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health; a training on the dangers of heat and smoke from the National Institute of Environmental Health Sciences Worker Training Program; and planned awards to 77 health care providers in high-need areas, totaling $50 million, from the Health Resources and Services Administration.

A woman with dark hair and a green t-shirt sits on the floor outside, holding her knees — Farmworker Lizbeth Mastache says she has had headaches, fatigue, and nausea from the heat, and has gone to the emergency room after smoky skies triggered her asthma.(Vanessa G. Sánchez/KFF Health News)

Climate change is increasing the frequency and intensity of extreme heat, which is already the No. 1 weather-related killer in the U.S., as well as fueling wildfires across the nation. There’s no official count of farmworker deaths from weather, but heat-related deaths have increased in recent years, jumping from 1,722 in 2022 to about 2,300 last year.

The U.S. Department of Labor in July released a proposed workplace heat standard that would require employers to give rest breaks, water, and shade or air conditioning to workers exposed to excessive heat, but a final rule is likely years away. It’s unclear if it would supersede state regulations.

Five states have heat safety protections for workers in outdoor or indoor settings. In California, for instance, employers must provide water, cool-down areas, and breaks to workers when temperatures hit 82 degrees indoors and 80 degrees outdoors. The other states are Colorado, Minnesota, Oregon, and Washington, and Maryland is expected to finalize a heat standard this year.

While Becerra said states can create their own workplace safety regulations, a federal heat safety standard would offer protections nationwide, forcing states like Florida and Texas — whose Republican governors have signed laws banning heat safety protections — to comply with minimum standards.

Becerra is hoping states will tap into the programs his health department is offering even though they are optional. Even in California, which has one of the country’s toughest heat protection standards, workers could benefit.

Lizbeth Mastache, who met privately with Becerra beforehand, said the days she spends in the fields picking grapes shrouded in wildfire smoke and extreme heat are not only becoming more frequent, but they are also making her sick.

Rows of grape trees in a vineyard — A vineyard stretches along the Sacramento River in Northern California. (Vanessa G. Sánchez/KFF Health News)

Four women stand side by side — Secretary Xavier Becerra met with members of Líderes Campesinas, a statewide women’s farmworker advocacy organization, to hear about the risks California farmworkers face as weather conditions become more extreme. (Vanessa G. Sánchez/KFF Health News)

She has had headaches, fatigue, and nausea from the heat, and has gone to the emergency room after smoky skies triggered her asthma. She and other farmworkers told Becerra they need guaranteed sick leave — to care for themselves when the smoke and heat sickens them — and affordable health insurance.

“I had to work picking grapes during the wildfires and they didn’t give us masks,” said Mastache, a farmworker for the past 14 years.

She said some farms haven’t allowed outreach workers onto their property to educate workers about how to prevent heat illness.

That’s a problem when many seasonal workers, who move for work among different states, don’t know that California requires employers to provide water, breaks, and training.

About three years ago, researchers at the University of California-Merced’s Community and Labor Center found that 15% of California farmworkers did not receive minimum rest breaks, and over 40% said their employer never provided a heat illness prevention plan. More than a third of farmworkers said they would not file a report against their employer, most of them for fear of retaliation.

The California Farm Bureau, which represents about 29,000 farmers, disputes the center’s findings, saying there have been few cases of heat illness among its members’ workers. Bryan Little, director of employment policy at the bureau, said his organization has trained hundreds of farmers and ranchers on how to protect workers from heat illness, such as by providing water and portable shaded spaces in the field for employees to cool off.

“They’re doing things every day to try to make sure that we can avoid exposing human beings to these risks, to the greatest extent that we can,” Little said.

A woman in a green t-shirt with a hat, stands outside, leaning against a wall — Outreach worker Virginia Moscoso said some farms haven’t allowed her to come onto their property to educate workers about how to prevent heat illness. (Vanessa G. Sánchez/KFF Health News)

While farmworker advocates praise Becerra for drawing attention to the harmful and sometimes fatal impacts of heat and wildfire smoke, they worry federal dollars won’t reach the most vulnerable. For example, there’s no guarantee much of that $50 million earmarked for health care providers will go to health care centers that serve farmworkers, said Amy Liebman, a chief program officer at the Migrant Clinicians Network, who has worked in migrant safety and health for over two decades.

“We need to make sure that our health centers are prepared and our clinicians are prepared,” Liebman said. “So that means that there needs to be a shift in terms of not just this emphasis, but some of the funding for it.”

As Becerra left his podium, covered with the sign “Protecting Communities From Extreme Heat,” he disappeared into the library and minutes later departed for Stockton to champion the next issue — lower prescription drug prices — with Democratic Rep. Josh Harder, who represents a competitive Central Valley congressional district.

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As Interest From Families Wanes, Pediatricians Scale Back on Covid Shots

When pediatrician Eric Ball opened a refrigerator full of childhood vaccines, all the expected shots were there — DTaP, polio, pneumococcal vaccine — except one.

“This is where we usually store our covid vaccines, but we don’t have any right now because they all expired at the end of last year and we had to dispose of them,” said Ball, who is part of a pediatric practice in Orange County, California.

“We thought demand would be way higher than it was.”

Pediatricians across the country are pre-ordering the updated and reformulated covid-19 vaccine for the fall and winter respiratory virus season, but some doctors said they’re struggling to predict whether parents will be interested. Providers like Ball don’t want to waste money ordering doses that won’t be used, but they need enough on hand to vaccinate vulnerable children.

The Centers for Disease Control and Prevention recommends that anyone 6 months or older get the updated covid vaccination, but in the 2023-24 vaccination season only about 15% of eligible children in the U.S. got a shot.

Ball said it was difficult to let vaccines go to waste last year. It was the first time the federal government was no longer picking up the tab for the shots, and providers had to pay upfront for the vaccines. Parents would often skip the covid shot, which can have a very short shelf life compared with other vaccines.

A photo of a pediatrician's waiting room with murals and colorful chairs. — Murals adorn the walls of the waiting room at Ball’s pediatrics practice.(Jackie Fortiér/KFF Health News)

“Watching it sitting on our shelves expiring every 30 days, that’s like throwing away $150 repeatedly every day, multiple times a month,” Ball said.

This year, Ball slashed his fall vaccine order to the bare minimum to avoid another costly mistake.

“We took the number of flu vaccines that we order, and then we ordered 5% of that in covid vaccines,” Ball said. “It’s a guess.”

That small vaccine order cost more than $63,000, he said.

Pharmacists, pharmacy interns, and techs are allowed to give covid vaccines only to children age 3 and up, meaning babies and toddlers would need to visit a doctor’s office for inoculation.

It’s difficult to predict how parents will feel about the shots this fall, said Chicago pediatrician Scott Goldstein. Unlike other vaccinations, covid shots aren’t required for kids to attend school, and parental interest seems to wane with each new formulation, he said. For a physician-owned practice such as Goldstein’s, the upfront cost of the vaccine can be a gamble.

“The cost of vaccines, that’s far and away our biggest expense. But it’s also the most important thing we do, you could argue, is vaccinating kids,” Goldstein said.

Insurance doesn’t necessarily cover vaccine storage accidents, which can put the practice at risk of financial ruin.

“We’ve had things happen like a refrigerator gets unplugged. And then we’re all of a sudden out $80,000 overnight,” Goldstein said.

A photo of a note attached to a vaccine fridge that reads, "Refrigerator or freezer are not to be unplugged for any reason." — An unplugged refrigerator could spoil the vaccines inside, costing the practice thousands of dollars.(Jackie Fortiér/KFF Health News)

South Carolina pediatrician Deborah Greenhouse said she would order more covid vaccines for older children if the pharmaceutical companies that she buys from had a more forgiving return policy.

“Pfizer is creating that situation. If you’re only going to let us return 30%, we’re not going to buy much,” she said. “We can’t.”

Greenhouse owns her practice, so the remaining 70% of leftover shots would come out of her pocket.

Vaccine maker Pfizer will take back all unused covid shots for young children, but only 30% of doses for people 12 and older.

Pfizer said in an Aug. 20 emailed statement, “The return policy was instituted as we recognize both the importance and the complexity of pediatric vaccination and wanted to ensure that pediatric offices did not have hurdles to providing vaccine to their young patients.”

Pfizer’s return policy is similar to policies from other drugmakers for pediatric flu vaccines, also recommended during the fall season. Physicians who are worried about unwanted covid vaccines expiring on the shelves said flu shots cost them about $20 per dose, while covid shots cost around $150 per dose.

“We run on a very thin margin. If we get stuck holding a ton of vaccine that we cannot return, we can’t absorb that kind of cost,” Greenhouse said.

Vaccine maker Moderna will accept covid vaccine returns, but the amount depends on the individual contract with a provider. Novavax will accept the return of only unopened vaccines and doesn’t specify the amount they’ll accept.

Greenhouse wants to vaccinate as many children as possible but said she can’t afford to stock shots with a short shelf life. Once she runs out of the doses she’s ordered, Greenhouse said, she plans to tell families to go to a pharmacy to get older children vaccinated. If pediatricians around the country are making the same calculations, doses for very small children could be harder to find at doctors’ offices.

“Frankly, it’s not an ideal situation, but it’s what we have to do to stay in business,” she said.

Ball, the California pediatrician, worries that parents’ limited interest has caused pediatricians to minimize their vaccine orders, in turn making the newest covid shots difficult to find once they become available.

“I think there’s just a misperception that it’s less of a big deal to get covid, but I’m still sending babies to the hospital with covid,” Ball said. “We’re still seeing kids with long covid. This is with us forever.”

A photo of Eric Ball sitting in a chair in an exam room. — Ball treats patients from birth to age 21.(Jackie Fortiér/KFF Health News)

Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for their newsletters here.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

Sleep-deprived, cyberbullied teenagers addicted to smartphones now a common global phenomenon

Newswise — Combine cyberbullying, smartphone use, lack of sleep and poor mental health, and you have the perfect storm for a teenage meltdown.

Australian researchers have polled more than 50,000 primary and secondary school students aged 7-19 years about the link between their sleep and nighttime phone habits, experience of cyberbullying and stress levels.

Researchers from the Behaviour-Brain-Body Research Centre at the University of South Australia found that across all genders and age groups, phone use overnight not only robbed children of sleep, but it also had a negative impact on their mental health, especially among those who had been cyberbullied.

Whether one habit causes or stems from another is not crystal clear, but the study findings should send a clear signal to parents about the need to manage digital device use at home.

Approximately 66% of teenage girls and 58% of teenage boys (aged 12-19 years) reported being cyberbullied at least once in the preceding school term. Among the girls, 17% said they slept less than eight hours a night and the corresponding figure for the teenage boys was 13%.

Stress levels in the moderate-to-severe range were reported by 38% of teenage girls and 23% of teenage boys.

While cyberbullying and lack of sleep were not as common in primary aged children (7-11 years), one in five reported moderate-to-severe stress.

For the purposes of the study, “nighttime” refers to phone use when children are supposed to be sleeping, not prior to bed.

UniSA researcher and co-author Dr Stephanie Centofanti says that girls are particularly vulnerable because their smartphone use at night is higher than other age groups and they start using social media at a younger age.

“We found that frequency of nighttime phone use and getting less than eight hours sleep a night not only peaked in early adolescence but was also more evident in young girls,” Dr Centofanti says.

“Pre-teens are at higher risk for socio-emotional disorders because they are at a developmental stage where they are less prepared cognitively, behaviourally and neurobiologically.”

The researchers say that outside of the digital environment, boys are more likely to be physically bullied, while girls normally resort to psychological or relational bullying, which is more easily enabled online.

Approximately 15% of children in the study reported being cyberbullied, with a higher frequency of boys in primary school and girls in secondary school.

More than one third of primary school children and over 60% of teenagers in the study reported using their phone at night when they were supposed to be sleeping.

Of the children who experienced cyberbullying, almost 75% admitted they checked their phone throughout the night, compared to less than half for those who had never been cyberbullied.

“It is clear that parents need to pay closer attention to managing smartphone use at night, particularly if their children are more vulnerable to cyberbullying, and to ensure their children get enough sleep,” Dr Centofanti says.

The findings are published in the journal Adolescents.

Notes for editors

“Nighttime phone use and past exposure to cyberbullying and their impact on sleep and psychological wellbeing in Australian children aged 7-19 years” is co-authored by researchers from the University of South Australia and Resilient Youth Australia. DOI: 10.3390/adolescents4030025

Watch: Tips on Finding a Good Nursing Home

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Finding a nursing home for yourself or a parent can be daunting. Many facilities are understaffed and the worker shortages have gotten worse since the start of the pandemic. KFF Health News senior correspondent Jordan Rau shares tips about finding nearby homes, evaluating staffing levels, what to look for when visiting, and more.

Find additional resources here.

Universidad favorece un costoso programa de doctorado para enfermeras parteras en plena crisis de la atención materna

Uno de los dos programas de formación de enfermeras parteras de California ha dejado de admitir estudiantes mientras renueva su plan de estudios para ofrecer sólo doctorados, una medida que ha generado protestas de ex alumnos, expertos en políticas de salud y profesores que acusan a la Universidad de California (UC) de anteponer beneficios económicos a las necesidades de salud pública.

La prestigiosa escuela de enfermería de la UC-San Francisco graduará a su última promoción de enfermeras parteras la próxima primavera.

Luego, la universidad cancelará su programa de máster de dos años en enfermería obstétrica, junto con otras disciplinas de enfermería, en favor de un doctorado en enfermería de tres años, o DNP.

El cambio pondrá entre paréntesis la formación de enfermeras parteras que la UCSF ha impartido durante casi cinco décadas, al menos hasta 2025, y duplicará con creces el costo para los estudiantes.

Mia Bonta, legisladora de la Asamblea Estatal que preside el comité de salud, dijo que estaba “descorazonada” al saber que la UCSF cancelaba su programa de maestría en enfermería obstétrica y temía que el tiempo y los costos adicionales para obtener un doctorado disuadieran a futuros postulantes.

“En lugar de agregar obstáculos, tenemos que construir y ampliar un canal de proveedores cultural y racialmente competentes para apoyar la mejora de los resultados del parto, especialmente para las parturientas afroamericanas y latinas”, expresó Bonta en un correo electrónico.

El cambio a la formación doctoral forma parte de un movimiento nacional que exige que todas las enfermeras registradas de práctica avanzada, incluidas las enfermeras parteras y las especializadas, obtengan títulos de doctorado, según declaró Kristen Bole, vocera de la UCSF. La formación doctoral incluirá clases adicionales sobre liderazgo y mejora de la calidad en la atención.

Sin embargo, este movimiento, que se remonta a 2004, no se desarrolló de la forma que imaginó la Asociación Estadounidense de Facultades de Enfermería cuando pidió que, para 2015, tener un doctorado fuera obligatorio para practicar la enfermería especializada. Ese plazo se cumplió.

Ahora, la acuciante necesidad de profesionales de salud materna hace que algunas universidades se muevan en otra dirección.

Este año, la Universidad Rutgers restableció la formación de máster en enfermería obstétrica que había eliminado en 2016. La Universidad de Alabama-Birmingham también reinició su programa de máster en enfermería obstétrica en 2022, tras un paréntesis de 25 años. Además, la Universidad George Washington de Washington, DC, la Universidad Loyola de Nueva Orleans y la Universidad de Nevada-Las Vegas agregaron formación de máster en enfermería obstétrica.

La UCSF calcula que la matrícula y las tasas costarán $152,000 por un doctorado de tres años en obstetricia, frente a los $65,000 de un máster de dos años. Los estudios muestran que el 71% de los estudiantes de máster en enfermería y el 74% de los estudiantes de doctorado en enfermería dependen de préstamos estudiantiles, y las enfermeras con doctorado ganan igual o poco más que las que tienen un máster.

Kim Q. Dau, que dirigió el programa de enfermería obstétrica de la UCSF durante una década, dimitió en junio porque se sentía incómoda con la eliminación del máster en favor de un requisito de doctorado que, según dijo, contradice las necesidades de mano de obra del estado y es innecesario para la práctica clínica.

“Estarán igualmente preparadas clínicamente, pero a un costo mayor para el estudiante y con una mayor inversión de tiempo”, expresó Dau.

Las enfermeras parteras son enfermeras tituladas en enfermería obstétrica. Con licencia en los 50 estados, trabajan especialmente en hospitales y pueden practicar abortos y recetar medicamentos, aunque también están capacitadas para tratar el dolor del parto con duchas, masajes y otros medios naturales. En cambio, las parteras o comadronas tituladas estudian obstetricia a nivel de postgrado fuera de las escuelas de enfermería y sólo están autorizadas en algunos estados. Las parteras profesionales tituladas atienden partos fuera de los hospitales.

La Asociación de Enfermeras Obstetras de California también criticó el cambio de programa de la UCSF, que se produce en medio de una crisis nacional de mortalidad materna, una grave escasez de proveedores de obstetricia y una creciente dependencia de las parteras.

Según el informe “White House Blueprint for Addressing the Maternal Health Crisis” (Plan de la Casa Blanca para abordar la crisis de salud materna) de 2022, Estados Unidos tiene la tasa de mortalidad materna más alta de todos los países desarrollados y necesita miles de parteras más y otros proveedores de salud para la mujer que reduzcan la creciente brecha.

Ginger Breedlove, fundadora y CEO de Grow Midwives, una consultora nacional, comparó el cambio de la UCSF de la formación de máster a la de doctorado con “un terremoto”.

“¿Por qué estamos retrasando la entrada de proveedores de cuidados esenciales haciéndoles cursar un año más de estudios, que no agrega nada a su preparación clínica ni a su seguridad para servir a la comunidad?”, se preguntó Breedlove, ex presidenta del American College of Nurse-Midwives (ACNM, Colegio Profesional de Enfermeras Parteras). “Resulta incomprensible que hayan elegido hacer esto durante la peor escasez de mano de obra combinada con la peor crisis de salud materna que hemos tenido en 50 años”.

Un informe de 2020 publicado en Nursing Outlook no encontró que las enfermeras registradas de práctica avanzada con doctorados fueran más competentes clínicamente que las que tenían maestrías. “Por desgracia, hasta la fecha, los datos son escasos”, concluyó el informe.

El ACNM también denunció el requisito del doctorado, al igual que las asociaciones profesionales de enfermeras neonatales, citando “la falta de pruebas científicas de que… la formación a nivel de doctorado sea beneficiosa para los pacientes, los profesionales o la sociedad”.

Según Breedlove, no hay pruebas de que las enfermeras obstétricas con doctorado proporcionen mejores cuidados.

“Se busca beneficio económico, no un mejor resultado”, agregó.

Bole rebatió la acusación de lucro hecha por Breedlove. Consultada por las razones del cambio, ofreció declaraciones generales: “La decisión de actualizar nuestro programa se tomó para garantizar que nuestros graduados estén preparados para los retos a los que se enfrentarán en el cambiante campo de la salud”.

Al igual que Breedlove, Liz Donnelly, vicepresidenta del comité de políticas de salud de la Asociación de Enfermeras Parteras de California, teme que el cambio de la UCSF a un título de doctorado agrave la doble crisis de la mortalidad materna y la disminución del personal de obstetricia en California y en el país.

En promedio, de 10 a 12 enfermeras obstetras se han graduado del programa de maestría de la UCSF cada año durante la última década, según Bole. El programa de máster en enfermería obstétrica que queda en California está en la Universidad Estatal de California en Fullerton, (CSU-Fullerton), al sur de Los Angeles, en donde se graduaron ocho enfermeras obstétricas el año pasado, y 11 este año.

Más de la mitad de los condados rurales de Estados Unidos carecieron de atención obstétrica en 2018, según un informe de la Oficina de Rendición de Cuentas del Gobierno.

En algunas áreas de California, las futuras madres deben conducir dos horas para recibir atención, señaló Bethany Sasaki, quien dirige Midtown Nurse Midwives, un centro de nacimientos en Sacramento que ha tenido que dejar de aceptar nuevas pacientes porque no encuentra comadronas.

Donnelly predijo que el cierre del programa de la UCSF reducirá significativamente el número de enfermeras parteras que se incorporen al mercado laboral, e impedirá que las personas con menos recursos asistan al programa. “En concreto, creo que se reducirá el número de personas de color, de comunidades rurales y de comunidades pobres”, afirmó.

El cambio de la UCSF también afectará con toda probabilidad los esfuerzos por formar a proveedores con una herencia diversa.

Natasha, afropuertorriqueña, de 37 años y madre de dos hijos, lleva una década preparándose para ser enfermera partera y poder ayudar a mujeres como ella durante el embarazo y el parto. Pidió que sólo se la identificara por su nombre de pila por miedo a reducir sus posibilidades de ser admitida en una escuela de posgrado.

La pausa del programa de la UCSF, más el tiempo y los gastos que se suman para obtener un doctorado, han enturbiado su trayectoria profesional.

“El máster era el programa perfecto”, afirmó Natasha, que vive en la zona de la Bahía de San Francisco y no puede viajar al otro extremo del estado para asistir a CSU-Fullerton. “Estoy frustrada y me siento desmoralizada. Ahora tengo que buscar otra carrera”.

Physical health has its yardsticks. Mental health is still searching for the right ruler

Original post: August 29, 2024 2:05 pm Newswise - Substance Abuse Physical health has its yardsticks. Mental health is still searching for the right ruler

Newswise — While doctors can track cancer progression at the cellular level or use a blood test to obtain precise blood cholesterol levels, talk therapy’s impact on mental health is still largely reliant on gut feelings more than hard data.

A national initiative led by the National Institute of Mental Health is now underway to find figurative “rulers” that can accurately measure and compare the quality of the various mental health treatments available. To lead off this effort, UCLA Health researchers were awarded a four-year, $2.1 million federal grant to study and test whether such a quality measure can be created and applied across all social groups in the United States.

“We have so many problems with mental health in this country that are only getting worse,” said Dr. Alexander Young, professor at UCLA Health’s Department of Psychiatry and Biobehavioral Sciences. “We really need to be able to provide access to high quality care for all the diverse populations that we serve.”

Demand for mental health care in America has soared in recent years, with a majority of psychologists reporting having waiting lists for new patients, according to a recent survey by the American Psychological Association. Meanwhile, more treatment options are available including numerous evidence-based psychotherapies, neuromodulation including Transcranial Magnetic Stimulation, new medications and telehealth services among others.

While some larger health care providers have made efforts to address the issue, the effectiveness and quality of these treatments have generally not been accurately monitored at a national level, resulting in a scarcity of clinical data on patient outcomes, Young said.

As a result, governmental organizations, provider organizations, insurance companies, patients and families have little information to gauge the quality of the mental health services they are supporting or receiving, Young said.

As part of a national initiative, UCLA researchers will aim to create accurate quality measurement based on routine, regular patient reports of their symptoms. To develop and test this, Young and his colleagues will utilize a unique database of more than 5 million symptom assessments from 500,000 patients collected during mental health treatment. The data are being analyzed in conjunction with the ACORN Collaboration, an international consortium that includes mental health and substance abuse treatment centers.

One important aspect of the project will work to ensure that the quality measure supports improvement in socioeconomic disparities in both the access to and quality of mental health treatment.

“We need to come up with a measurement that’s consistent across social groups and accurate given the diversity of people and situations in the United States,” Young said.

Other collaborators in the study from UCLA include Li Cai, Nick Jackson, April Thames and Lucinda Leung.

Public Voices Often Ignored in States’ Opioid Settlement Money Decisions

The conversation wasn’t sounding good for Kensington residents on June 20.

The Philadelphia neighborhood is a critical center of the nation’s opioid crisis, and the city had decided to spend $7.5 million in opioid settlement money to improve the quality of life there. But on that day, a Pennsylvania oversight board was about to vote on whether to reject the city’s decision.

It was a thorny issue with major implications — both for Kensington residents and people across the state, as the decision could set a precedent for what kind of spending the board would allow for years to come.

But a lot of people were shut out of the discussion.

Pennsylvania’s board doesn’t allow members of the public to speak at its meetings, a rule that sets it apart from about two dozen similar opioid councils nationwide.

“It’s another moment where folks not connected to this community are making decisions for this community, and I think that’s inappropriate,” said Bill McKinney, a Kensington resident whose nonprofit is involved in some of the city’s settlement-funded initiatives. “Those that are sort of most affected are not at the table.”

It’s one example of how the public, including people who have lost loved ones to the opioid crisis or are dealing with it daily, are routinely shut out of having a meaningful say in how this windfall can be best used to address the damage. They are eager to suggest solutions for dollars that many of them consider blood money. But a first-of-its-kind survey conducted by KFF Health News and Spotlight PA found that, in many places, their voices are systematically dismissed.

In at least 39 states and Washington, D.C., councils consisting of government officials, clinicians, law enforcement officers, and others guide decisions about how to spend settlement dollars. These powerful groups are influencing addiction policy and funding at a time when more than 100,000 Americans are dying of overdoses annually.

At least 14 of these councils — including Pennsylvania’s — routinely block members of the public from speaking at their meetings. Four of those typically conduct their meetings in secret, barring the public from even attending or observing.

The survey also found:

The majority of councils do not make video recordings of their meetings readily available online for those who cannot attend live. Although some councils said recordings can be accessed through public records requests, at least one — Minnesota’s Opioid Epidemic Response Advisory Council — deletes its recordings after using them to create meeting minutes. (Minnesota law does not require the council to record its open meetings or post recordings online.)
At least five states have used committees or work groups that meet in private, or have a policy for allowing such private meetings. In Pennsylvania, such work groups have become a point of contention, with victims, advocates, and even one member of the council questioning their legality. (The Pennsylvania Opioid Misuse and Addiction Abatement Trust’s administrative director said the work groups’ meetings are not required to be public. They make recommendations that the full council decides on.)

Practices that close the public out of settlement spending discussions are “unconscionable,” said Stephen Loyd, chair of Tennessee’s Opioid Abatement Council, which regularly allows public attendance and comment at its meetings. “This is the population we’re there to serve. They have to have a voice in this process.”

Different Stances on Public Comment

People directly affected by the issue are a staple of the Tennessee council’s meetings. This year, commenters have included several parents holding photos of their deceased children and choking back tears, and at least one frustrated community member.

At the June meeting in Memphis, Peter Hossler, an associate professor at Rhodes College, said he was “very angry” about how the council’s recent grant awards of $81 million seemed to shortchange the western part of the state.

Loyd called such critique “invaluable,” comparing it to the feedback he received from loved ones during his recovery journey.

“We have to be held accountable,” he told KFF Health News and Spotlight PA. “And then we have to fix it.” Hossler’s comments are changing the council’s conversation about its next round of grants, Loyd added.

Loyd believes people who have been failed by the current system know what needs to be improved “better than anybody.”

“I want to talk to the people who had medication stopped in jail and laid there and withdrew,” he said. “I want to talk to the people who got out of jail with no money, a couple of felonies hanging over their heads, three meetings they had to make that week or they’re going to be in violation of their probation, and they ain’t got a car or driver’s license.”

A man wearing a baseball cap and rain jacked speaks into a megaphone. — Stephen Loyd chairs Tennessee’s Opioid Abatement Council, which oversees millions in opioid settlement cash. The council regularly allows public attendance and comment at its meetings. “This is the population we’re there to serve,” Loyd says. “They have to have a voice in this process.”(Aneri Pattani/KFF Health News)

States cited a variety of reasons for limiting public involvement. In some, state law does not require councils to take public comment at meetings. Several officials said they’ve sought feedback in other ways. An official in New Jersey said its council held public listening sessions, but that its monthly meetings are not public.

Some officials may worry that public comment would add to meetings that already run multiple hours, but several states manage that by limiting each person’s comment to a few minutes.

For communities of color, being shut out of opioid settlement discussions can compound the negative effects not just from today’s overdose crisis but from the earlier crack cocaine epidemic. Many people considered the government’s response at that time to be ineffective and harmful.

If settlement money is used only to “build on what’s already in place, you’ve already failed,” said Philip Rutherford, an expert on substance use disorder at the National Council for Mental Wellbeing.

At a July 2023 meeting of Illinois’ settlement council, Fanya Burford-Berry said the current system doesn’t work for women of color with substance use disorder — they can risk losing custody of their children. Burford-Berry, director of the West Side Heroin/Opioid Task Force in Chicago, hopes comments like hers will prompt the council to support solutions tailored to women of color, including bringing together more organizations that already work in those communities.

“When you allow more people to be involved, and then they have an idea, and they get excited about it, then they get more people involved and the circle of healing can become larger,” she said.

A man speaks into a microphone mounted on a lectern. — Philip Rutherford is an expert on substance use disorder at the National Council for Mental Wellbeing. (Lindsay Dively)

A woman in a white polo shirt stands on a sidewalk besides a waist-high dispenser with a sign that reads "Free Naloxone" with diagrams for "How to recognize an overdose" and "How to use Narcan Nasal Spray." — Fanya Burford-Berry is director of the West Side Heroin/Opioid Task Force in Chicago, which regularly conducts street outreach and distributes naloxone, a medication that can reverse opioid overdoses. (Leonardo Zanders)

‘A Retraumatizing Moment’

In Pennsylvania, the state’s 13-member opioid settlement board has the power to withhold future funding if it decides local governments spent their money inappropriately. At its June meeting, the board — which includes a state senator representing part of Kensington — voted to disapprove of Philadelphia’s use of $7.5 million for park improvements, home repairs, rent relief, and other initiatives in Kensington. (Philadelphia later appealed the rejection; the issue is pending.)

McKinney, the Kensington resident and executive director of the New Kensington Community Development Corporation, called the board’s decision “a retraumatizing moment” for residents and criticized the way they were silenced.

“I think it’s unfortunate that things were chosen to be done that way,” McKinney said.

Others have also been frustrated by Pennsylvania’s settlement council.

Gail Groves Scott, a public health policy advocate who has a child in sustained recovery from an opioid use disorder, attended a board meeting in person last year. Not allowing the public to comment at meetings, she said, prevents them from offering feedback at critical times, such as when the board is considering county spending plans or contracts for its operations.

“We could be questioning those decisions or adding information they may not be aware of,” Groves Scott said. “It’s disappointing that, despite pushback from multiple people, they have not changed.”

Some advocates say the closed sessions of work groups, which make recommendations about which programs to approve, obscure why the full board takes certain action.

Pennsylvania trust officials have defended their practices.

Briana Anderson, the trust’s administrative director, downplayed the group’s role, saying it does not make specific spending decisions on settlement money but reviews choices made by local governments. State law doesn’t require the trust to offer public comment at its meetings but the public is encouraged to participate at the local level, Anderson added.

Pennsylvania’s practices contrast sharply with the way councils operate in places like Illinois, Kentucky, and Oregon, which routinely allow public comment at both full council and smaller committee meetings. In Kentucky, the open process has allowed members of the public to weigh in on a fierce debate over funding research into ibogaine, a psychedelic drug that has shown potential to treat addiction. At least eight people spoke in favor of the drug at the council’s January meeting.

Back in Tennessee, council chair Loyd said he hopes to increase public participation by creating an advisory panel that consists primarily of people who have personally experienced addiction or their loved ones.

He also encouraged other settlement councils to embrace opportunities to hear from people in their states.

“You’ll make better decisions as a result. I can’t be convinced otherwise,” he said.

In June and July, reporters from KFF Health News and Spotlight PA surveyed opioid settlement councils in 39 states and Washington, D.C., to assess their general and standard practices for engaging with the public. The team also reviewed council websites, meeting minutes, agendas, and, in some cases, hours of meeting recordings. These councils have various roles, including directly deciding how to spend the money, making recommendations, or providing oversight. Although they go by different names, including advisory councils, boards, committees, and commissions, we refer to them as councils as a broad, encompassing term.

Spotlight PA is an independent, nonpartisan, and nonprofit newsroom producing investigative and public-service journalism that holds power to account and drives positive change in Pennsylvania. Sign up for its free newsletters.

An Arm and a Leg: Don’t Get ‘Bullied’ Into Paying What You Don’t Owe

Caitlyn Mai thought she did everything right. She called ahead to make sure her insurer would cover her cochlear implant surgery. She thought everything went according to plan but she still got a bill for the full cost of the surgery: more than $139,000.

What Caitlyn did next is a reminder of why a beloved former guest once said you should “never pay the first bill.”
This episode of “An Arm and a Leg” is an extended version of the July installment of the “Bill of the Month” series, created in partnership with NPR.

click to open the transcript

Don’t Get ‘Bullied’ Into Paying What You Don’t Owe

Dan: Hey there —

One morning when she was in eighth grade, Caitlin Mai did what she always did when she woke up.

Caitlyn Mai: Music has always been a big part of my life. And so I immediately put in my headphones and started putting on music as I was about to get out of bed and get ready. And I noticed my earbud in my right ear wasn’t working.

Dan: It was obvious, because on this Beatles tune she’d cued up, Eleanor Rigby, the vocals are almost all on the right-hand side, and she couldn’t hear them.

Caitlyn: I was like, that’s kind of weird. So I switched the earbuds and it worked fine. But then it was, the other one wasn’t working in my right ear. And I was like, what?

Dan: Yeah, confusing. And then she tried getting out of bed.

Caitlyn: I was so dizzy. It was my first time experiencing vertigo, and it was so severe, I couldn’t walk across the room without getting severely motion sick.

Dan: With that vertigo, Caitlin could barely walk at all. She had no sense of balance — that actually relies on a mechanism inside our ears. Later, doctors found she had lost 87 percent of her hearing on the right side.

Caitlyn: They think I just had some sort of virus that settled in my ear, and it damaged my ear. But I went to bed completely healthy the night before. Woke up, couldn’t hear out of my ear.

Dan: She had to learn how to walk all over again.

Caitlyn: I have to rely on my eyes. My friends still find it hilarious if I close my eyes, I fall over.

Dan: That was eighth grade. Caitlyn made it through high school, in Tulsa where she grew up without a lot of accommodations.

Caitlyn: Cause in middle school, early high school, you don’t want to bring attention to your disability. At least I really didn’t want to at the time. I was super anxious about that.

Dan: Catilyn’s 27 now, she works as a legal assistant in Oklahoma City. Her husband’s a lawyer. And for the longest time, she couldn’t access a tool that helps restore hearing for lots of people: Cochlear implants — small devices that stimulate nerves inside the ear.

The FDA didn’t approve them for just one ear until a couple of years ago. Last year, Caitlin got her insurance to approve one for her. She had surgery in December to insert the implant. And in January, an audiologist attached an external component to switch on Caitlin’s right-side hearing.

Caitlyn: She said, okay, at some point, you’re gonna start hearing some beeps, just say yes when you can hear them. And my husband said my face just, out of nowhere, lit up, and I go, yes! It was streaming directly to my cochlear implant. And I definitely started tearing up.

Dan: Then, two weeks later, Caitlin got an alert from the hospital on her phone.

Caitlyn: And I open it up, and I immediately started having a panic attack.

Dan: It was a bill for a hundred and thirty-nine thousand dollars. The full amount for Caitlin’s surgery.

Which, given that Caitlyn had gotten her insurance company’s OK for the procedure in advance, was a pretty big surprise. NPR featured Caitlyn’s story recently for a series they do with our pals at KFF Health News.

NPR HOST: Time now for the latest installment in our bill of the month series, where we dissect and explain confusing or outrageous medical bills.

Dan: I interviewed Caitlyn for that story. And we’re bringing you an expanded version here because Caitlin’s situation — well, it was a good story. And it made me curious about a couple things.

It also reminded me of some good advice we’ve heard here before — and it reminded me of an important colleague and teacher. And the bottom line to Caitlyn’s story? Stand up for yourself. Don’t cave. Make the next call.

This is An Arm and a Leg — a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge — so our job on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful.

To get her insurance company’s approval, Caitlyn had already spent a lot of time — and a lot of money — in the months before surgery. For instance …

Caitlyn: To prove to insurance that a hearing aid wouldn’t work had to be fitted for a hearing aid and then do a couple hours of testing to prove, yep, it doesn’t help.

Dan: There were reviews with audiologists, with her surgeon, and an MRI to make sure there wasn’t too much scar tissue for an implant to take.

Caitlyn: That took a long time to get scheduled, get insurance to approve, pay for, then get back for another appointment. I counted up at one point — it’s like around eight or ten appointments that I had before the final, okay, let’s schedule surgery.

Dan: And — you caught that, right? Where she mentioned she had to get her insurance to approve paying for the MRI? Every one of these preliminary steps cost money, and she had to wrangle with her insurance to get their OK.

But of course even with her insurance saying yes, there were still copays, and deductibles, and what’s called co-insurance — where you pay a percentage of any bill from a hospital.

Which meant Caitlyn was chipping away at what’s called her out-of-pocket maximum: The most she could be on the hook for in a given calendar year. The surgery got scheduled for December — the same calendar year as all those tests — and she checked to see what she might have to pay.

Caitlyn: I looked at my little portal for insurance, I’m showing what’s left on my out-of-pocket max for the year is around 2,000, give or take, 200 dollars.

Dan: She called the insurance company to confirm that estimate. And then she cranked up her due diligence.

Caitlyn: I called the hospital, and I asked for the names of the anesthesiologist, the radiologist. I asked for all of the details of who is possibly going to be on my case. And then I turned around and I called insurance and I said, I want to make sure all of these physicians are going to be in network on this date.

Dan: Caitlyn had done her homework. Probably more than a lot of us would have thought to do. I asked her: How’d you get so diligent? And first, like a lot of folks I’ve talked with, she said: Having a major health issue as a kid — losing her hearing — gave her an early heads-up to watch out.

Caitlyn: A little bit was, uh, experience of my mom dealing with insurance battles with me growing up. I remember her running into issues with that.

Can: And she’s got some experts in her life now. Her brother and her sister in law work in health care. One of her best friends is a healthcare lawyer and had some tips.

Caitlyn: But honestly, I think a lot of it is I have anxiety, and so I was just really paranoid.

Dan: The surgery went great. And a few weeks later, Caitlyn was in the audiologist’s office, getting that external component attached, and hearing on her right side for the first time in 15 years. Caitlyn says it all took some getting used to.

Caitlyn: I remember those, like, first few days especially, it wasn’t really like I was hearing full sounds. It was kind of just different pitches. I wasn’t hearing the words and everything, it was just the breakdown of the different pitches. And they also were just so much higher than they should be.

Dan: So interesting. Radiolab may have already done this story — [but] I’m just like, let’s find out what that’s about.

Caitlyn: I love Radiolab.

Dan: Me too! Anyway, two weeks after she starts getting used to her new hearing situation, Caitlyn gets that alert on her phone.

Caitlyn: And it tells me I have a new invoice. And I was like, oh, awesome! I’m not stressed at all, I did my due diligence. I know it’s gonna be expensive, but affordable.

Dan: Except, right: It’s a hundred and thirty-nine thousand dollars! Six figures. The full amount for her surgery. You might remember, Caitlyn said she had a panic attack. That was literal: Heart palpitations, hyperventilating.

It took her 20 or 30 minutes to get calm enough to start making calls. And she says her insurance told her they hadn’t paid because the hospital had neglected to send something important.

Caitlyn: The itemized bill. Which has all the codes and everything,

Dan: Caitlyn says she immediately asked the hospital, in writing to send her insurance the itemized bill, and she says sent a follow-up a week later. But her phone kept pinging with alerts about owing the hospital a hundred and thirty-nine thousand dollars.

Caitlyn: The app so conveniently told me that I could sign up for monthly payments of 11,000 dollars a month, which is just so absurd.

Dan: After two weeks, she asked her insurance: Do you have that itemized bill yet? They didn’t. So she called the hospital again.

Caitlyn: The girl I spoke with said she was putting in a request to have it faxed to my insurance and that would take two to three weeks. And I said, hold on, it takes you two to three weeks to fax a document?

Dan: Answer: Apparently yes? And Caitlyn says even three weeks later, her insurance company still hadn’t gotten that itemized bill the hospital promised to fax.

And all this time Caitlyn was still getting notices from the hospital billing department. And the latest one said, “past due.” She tried something new: So she called the hospital and demanded they send the itemized bill directly to her, immediately. Which they did.

Caitlyn: So I turned around and faxed it to my insurance.

Dan: Yeah but, this did not end things, not yet. Caitlyn says she got more notices labeled past due. She fought her way to a direct conversation with a supervisor.

Caitlyn: They kept saying,‘well, a supervisor’s not available right now.’ I said, No, you’re finding a supervisor. I don’t care if they’re cutting their lunch short. I’m talking to a supervisor right now. I don’t care if I sound like a Karen. It’s been a long, long year already.

Dan: Eventually, Caitlyn got a supervisor on the line and got the supervisor to get permission from a manager to stop sending her bills while the hospital waited for insurance to pay.

By this time, it was late March, almost two months after that first bill gave Caitlyn that panic attack. Also by this time, Caitlyn had sent her bill to the folks at NPR and KFF Health News for that Bill of the Month feature they do.

Caitlyn: I was like, I just need to vent. And so I submitted it just to vent it out. Never expecting anyone to reach out.

Dan: But they did. And on April 9th, Caitlyn got a call from a regional Patient Service Center manager.

Caitlyn: And she was super nice and tried to be really apologetic, but never actually accepting any blame. Or outright saying,‘we’re so sorry.’ Just said, ‘I’m sorry for your frustration, that sounds awful.’

Dan: She DID tell Caitlyn that the hospital had received payment from her insurance. And that Caitlyn could expect a final bill within a week. And that instead of a hundred thirty nine thousand, it was gonna be one thousand, nine hundred eighty-two dollars and twenty-five cents.

Caitlyn: I said,‘yep, that actually matches what my insurance said,’ and she said,‘oh, you know what was left on your out-of-pocket, most people don’t,’ and I said,‘I’m very well versed in every dollar sign at this point in this entire case.’

Dan: Caitlyn says she got that bill four days later and paid it immediately.

Caitlyn: And I saved the receipt of that, I have saved everything. It feels like it’s resolved, but there’s part of me that’s still waiting for the other shoe to drop

Dan: So, Caitlyn’s story brings up a LOT. Of course, I loved the way she kept fighting, and ultimately took control of the situation. And I hated how she got trapped between these two big entities and how much time and stress the whole thing cost her.

Because, you know, the hospital could’ve resolved this so quickly by just sending that itemized bill to Caitlyn’s insurance company.

Caitlyn: And the hospital did not do that. They just turned around and billed me. Which was a stupid idea, since the insurance company is more likely to have the money. Not the legal assistant in Oklahoma.

Dan: Caitlyn’s story raised a few questions, and brought back a lot of themes we’ve touched on before. We dug in also found some new tips, and some memories I want to share. That’s coming right up.

This episode of An Arm and a Leg is a co-production of Public Road Productions and KFF Health News, a nonprofit newsroom covering healthcare in America. Their senior contributing editor, Elisabeth Rosenthal, reported Caitlyn’s story for KFF and NPR. She wrote a book about U.S. healthcare. It’s called “An American Sickness,” and it was an inspiration for this show.

One question we ask sometimes on this show when we see a bill that’s so wildly ridiculous and unfair is: Can they freaking DO that?!? Like, is that even legal?

Like in this instance, can they just keep billing you while they’re apparently not even playing ball with your insurance? And: Do we have any legal weapons to fight back with?

We asked a bunch of legal experts, and they pretty much all said: Yes, they probably can do that, and no, we probably don’t have any easy legal weapons we can fight with. But then I talked with Berneta Haynes. She’s a senior attorney with the National Consumer Law Center.

And she had some practical thoughts that are super-worth sharing. She used to work for a nonprofit called Georgia Watch — that’s a state-level consumer protection group. They operated a hotline people could call for help.

Berneta Haynes: Consumers and patients would call us with all kinds of hospital billing issues and medical debt issues. And we’ve had these kinds of weird questions where really, there wasn’t a particular lever at the legal level to actually help them. But if they feel like they’re experiencing what could be considered potentially an unfair business practice, it is totally within their right to file a complaint within their state A. G.’s office.

Dan: The A.G. The state attorney general. Whoever’s doing you wrong, you can file a complaint.

Berneta: Whether or not there’s any real hook that your AG could use to hold them accountable is always a question that’s up in the air. But even just the act of filing a complaint is very likely to get that entity, that company, to behave correctly.

Dan: Basically, go up the chain. Whether to a government watchdog, or in the organization that’s bugging you. We’ve heard this before, but I loved the specifics that Berneta Haynes shared with me about her own experiences.

Berneta: I will tell you, one of the mechanisms my husband and I have had to utilize repeatedly, not in a hospital context, but in various other service contexts is to reach out or threaten to reach out to the CEO or president. And it gets results every time. It gets results every time!

Dan: Oh, and here’s the pro tip.

Berneta: My husband has repeatedly, when he’s had to do it, set up a LinkedIn premium account just to find the CEO and message them directly.

Dan: Ooh, that’s good!

Berneta: That has been the way we’ve gotten resolution on all kinds of issues related to insurance companies not wanting to do right by us. And so forth.

Dan: So that was fun. Now, I do want to talk a little bit about what Caitlyn did, and what allowed her to do it. Caitlyn figures she made at least a dozen phone calls. And she says she’s lucky — privileged — to have a job where she could do that. Here’s the first thing she says she did once she got over that panic attack when the bill arrived.

Caitlyn: I just went to my boss’s office and I said, I’m going to have to make some phone calls. There’s a problem with my hospital bill. She’s like, don’t worry about it. Do what you need to.

Dan: And she had people in her corner, like the friend who’s a healthcare lawyer. And legal advice wasn’t the big thing that friend gave Caitlyn.

Caitlyn: Most of the time I was just venting to her, and she was like,‘you need to keep pushing, like, keep going at them. Don’t let them win. Don’t roll over. Just keep pushing. They should be paying.’

Dan: And at that point, I told Caitlyn, she and her story were really reminding me of someone.

Dan: There’s a reporter named Marshall Allen. He worked for ProPublica for a long time. He wrote on healthcare, and he wrote on stuff like this. And eventually he wrote a book, giving advice to people. And the title of the book was, Never Pay the First Bill.

Caitlyn: Oh!

Dan: And I told Caitlyn, Marshall was on my mind at the time because when Caitlyn and I talked in May, Marshall had just died, like less than two weeks before. And he was young — 52. He had three kids.

Caitlyn: So sad.

Dan: Super, super, super sad.

Dan: And of course the title of Marshall’s book — Never Pay the First Bill — that’s exactly how Caitlyn played things. She wasn’t going to think about paying anything until she got her questions answered. And it is worth remembering.

When we were talking with legal experts, one thing a few of them said was: If you pay something that insurance was supposed to cover, and then insurance comes through, you’re supposed to get a refund. But who wants to chase that?

Yeah. Don’t pay that first bill until you’ve made sure this is money you really owe. So, this seems like a good time to memorialize Marshall Allen a little bit. He liked to compare the healthcare system to a schoolyard bully. Here’s what he told me when he was on this show in 2021 when his book had just come out.

Marshall Allen: What I think we need to do is stand up to the bully. We need to stop being afraid. We need to stop thinking someone else is going to stick up for us. And I wrote the book to equip and empower people to stand up to the bullies.

And I think it’s tremendously empowering, but it’s hard, and standing up to a bully takes incredible courage. It takes fortitude. It takes persistence. You might get beat up in the process. There’s no guarantee of victory. It’s risky, right? But if we don’t try, we don’t have a chance.

Dan: Marshall was a Christian minister before he became a reporter. He wrote a thoughtful essay about how his work as an investigative reporter fit with his faith. The gist was: The Bible is pretty clear that cheating people and exploiting them is wrong.

And to me, it seems like there was an element of ministry– not just evangelism — to what he did after his book came out. Here’s what he told me in 2021:

Marshall: I’ve started taking calls, and I’m responding to emails that I get from people and I’m saying,‘call me, let’s talk it through, let me help you with this. Let’s work through this together.’ And now I’m helping people work through their bills, work through these situations where they’re being cheated. It’s super satisfying and gratifying, so it’s my new hobby.

Dan: He kept at it. He left ProPublica and took a job with the Office of the Inspector General at the federal department of Health and Human Services. And he published a newsletter — it was free, but he encouraged people to pay if they could, and he used the money to hire medical-bill advocates to help people with especially tricky cases.

And Marshall was funny. I want to close out this episode with a story he told me the first time we talked, in 2019. It’s kind of an origin story.

Marshall: So when I was 16 years old, um, I worked for this dinner theater in Golden, Colorado, where I grew up. One day I show up for work, and they’ve closed down the business. They owed me like three weeks of pay.

The guy had closed the place without paying us and said,‘there’s no money. We shut down the business. We can’t afford to pay you. You’re out of luck.’ Well, we were all pretty angry about that. We were really angry because they had opened a sister dinner theater under the same company umbrella across town. And we all knew that. And we were like, well, if you can afford to keep your other place open, you can afford to pay us. And they said,‘sorry, kids, you’re out of luck.’

Dan: Marshall goes home, tells his mom what’s going on.

Marshall: And my mom tells me you should sue him. I’m like, mom, what do you mean? I can barely drive. How can I sue the guy? She goes,‘you should take him to small claims court.’ So lo and behold, I go down, I fill out the paperwork.

It’s a few paragraphs. It’s easy to fill out the paperwork in small claims court. I fill out the paperwork and turn in like 10 bucks at the time or whatever it costs. It’s not that expensive to file one of these cases. And I get a notice in the mail like six weeks later. And I have a court date, and I’m like geared up for this big Perry Mason moment.

Dan: Perry Mason was a lawyer on this super old TV show — courtroom drama. But this wasn’t a courtroom.

Marshall: It’s more like a conference room and there’s some administrative hearing judge in there. And lo and behold, the owner of the company and his attorney had to show up in court there with me.

And I thought we’d have a big argument all the administrative judge did is he read my few paragraphs on the little thing I’d written up and he looks over at the owner and he goes,‘is what this kid saying true?’And the owner’s like, ‘well, yeah.’ And the judge is like,‘give this kid his money.’ And I was like, This is amazing. You know what? Maybe the court system does actually work every now and then maybe every now and then the little guy can win.

Dan: Marshall and I both stayed interested in how people can use the legal system to get our rights. I learned a lot from Marshall, and like a lot of people, I just loved his spirit. Marshall Allen, thank you. And here’s the end of my conversation with Caitlyn.

Dan: Marshall Allen would have been extremely proud of you.

Caitlyn: Yeah.

Dan: Caitlyn has the final word here.

Caitlyn: I got to the point where I was like, it’s my fight. I’ve got gasoline in the fire. I’m, I’m going for it.

Dan: We’ll be back with a new episode in a few weeks. Till then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport — and edited by Ellen Weiss.

KFF senior contributing editor Elisabeth Rosenthal reported Caitlyn’s story for KFF and NPR. She was editor in chief there when she invited me to collaborate with KFF to make this show’s second season, and we’ve been colleagues ever since. I’ve never felt so lucky or so thankful.

Special thanks to Christopher Robertson at Boston University’s School of Law, Wendy Epstein of the College of Law at DePaul University, Sabrina Corlette at Georgetown University’s Center on Health Insurance Reforms, and Elisabeth Benjamin from the Community Service Society of New York for pitching in with legal expertise here.

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager.

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling, and journalism.

Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. Finally, thank you to everybody who supports this show financially. You can join in any time at https://armandalegshow.com/support/. Thank you so much for pitching in if you can — and, thanks for listening.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

With Only Gloves To Protect Them, Farmworkers Say They Tend Sick Cows Amid Bird Flu

GREELEY, Colo. — In early August, farmworkers gathered under a pavilion at a park here for a picnic to celebrate Farmworker Appreciation Day. One sign that this year was different from the others was the menu: Beef fajitas, tortillas, pico de gallo, chips, beans — but no chicken.

Farms in Colorado had culled millions of chickens in recent months to stem the transmission of bird flu. Organizers filled out the spread with hot dogs.

No matter the menu, some dairy workers at the event said they don’t exactly feel appreciated. They said they haven’t received any personal protective equipment beyond gloves to guard against the virus, even as they or colleagues have come down with conjunctivitis and flu-like symptoms that they fear to be bird flu.

“They should give us something more,” one dairy worker from Larimer County said in Spanish. He spoke on the condition of anonymity out of fear he’d lose his job for speaking out. “What if something happens to us? They act as if nothing is wrong.”

Agricultural health and safety experts have been trying to get the word out about how to protect against bird flu, including through bilingual videos on TikTok showing the proper way to gear up with respirators, eye protection, gloves, and coveralls. And Colorado’s health and agriculture departments have offered a free month’s supply of protective equipment to any producer who requests it.

But so far, many farms aren’t taking them up on it: According to numbers provided by the state health department in late August, fewer than 13% of the state’s dairies had requested and received such PPE.

The virus is known to infect mammals — from skunks, bears, and cows to people and house pets. It began showing up in dairy cattle in recent months, and Colorado has been in the thick of it. Ten of the 13 confirmed human cases in the U.S. this year have occurred in Colorado, where it continues to circulate among dairy cows. It isn’t a risk in cooked meat or pasteurized milk but is risky for those who come into contact with infected animals or raw milk.

Weld County, where the farmworker event was held, is one of the nation’s top milk producers, supplying enough milk each month this year to fill about 45 Olympic-size swimming pools, according to U.S. Department of Agriculture data. Neighboring counties are notable producers, too.

Concerns are growing about undiagnosed illness among farmworkers because of a lack of testing and safety precautions. One reason for concern: Bird flu and seasonal flu are capable of gene trading, so if they ended up in the same body at the same time, bird flu might end up with genes that boost its contagiousness. The virus doesn’t appear to be spreading easily between people yet. That could change, and if people aren’t being tested then health officials may be slow to notice.

Strains of seasonal flu already kill some 47,000 people in the U.S. a year. Public health officials fear the havoc a new form of the flu could wreak if it spreads among people.

The Centers for Disease Control and Prevention recommends that dairy workers don a respirator and goggles or a face shield, among other protections, whether they are working with sick animals or not.

a box containing N95 masks, a small box of gloves, and plastic, clear goggles — A group called Project Protect Food Systems Workers plans to distribute N95 masks, goggles, and gloves to people who may be exposed to animals carrying the bird flu at their workplaces.(Zoila Gomez)

A recent study found that not all infected cows show symptoms, so workers could be interacting with contagious animals without realizing it. Even when it is known that animals are infected, farmworkers often still have to get in close contact with them, sometimes under grueling conditions, such as during a recent heat wave when Colorado poultry workers collected hundreds of chickens by hand for culling because of the outbreak. At least six of the workers became infected with bird flu.

One dairy worker in Weld County, who spoke on the condition of anonymity for fear of losing his job, said his employer has not offered any protective equipment beyond gloves, even though he works with sick cows and raw milk.

His bosses asked the workers to separate sick cows from the others after some cows produced less milk, lost weight, and showed signs of weakness, he said. But the employer didn’t say anything about the bird flu, he said, or suggest they take any precautions for their own safety.

He said he bought protective goggles for himself at Walmart when his eyes became itchy and red earlier this summer. He recalled experiencing dizziness, headaches, and low appetite around the same time. But he self-medicated and pushed through, without missing work or going to a doctor.

“We need to protect ourselves because you never know,” he said in Spanish. “I tell my wife and son that the cows are sick, and she tells me to leave, but it will be the same wherever I go.”

He said he’d heard that his employers were unsympathetic when a colleague approached them about feeling ill. He’d even seen someone affiliated with management remove a flyer about how people can protect themselves from the bird flu and throw it in a bin.

The dairy worker in neighboring Larimer County said he, too, has had just gloves as protection, even when he has worked with sick animals — close enough for saliva to wipe off on him. He started working with them when a colleague missed work because of his flu-like symptoms: fever, headache, and red eyes.

“I only wear latex gloves,” he said. “And I see that those who work with the cows that are sick also only wear gloves.”

He said he doesn’t have time to wash his hands at work but puts on hand sanitizer before going home and takes a shower once he arrives. He has not had symptoms of infection.

Such accounts from dairy workers echo those from farmworkers in Texas, as reported by California Healthline in July.

“Employers who are being proactive and providing PPE seem to be in the minority in most states,” said Bethany Boggess Alcauter with the National Center for Farmworker Health, a not-for-profit organization based in Texas that advocates for improving the health of farmworkers and their families. “Farmworkers are getting very little information.”

But Zach Riley, CEO of the Colorado Livestock Association, said he thinks such scenarios are the exception, not the rule.

“You would be hard-pressed to find a dairy operation that isn’t providing that PPE,” he said. Riley said dairies typically have a stockpile of PPE ready to go for situations like this and that, if they don’t, it’s easily accessed through the state. “All you have to do is ask.”

A woman wearing gloves, plastic goggles, and and N95 mask, holds a box of blue nitrile gloves — Zoila Gomez, a community health worker in Alamosa, Colorado, working with the group Project Protect Food Systems Workers, received a shipment of personal protective equipment from the state on Aug. 26 to distribute to farmworkers there. (Zoila Gomez)

Producers are highly motivated to keep infections down, he said, because “milk is their life source.” He said he has heard from some producers that “their family members who work on the farm are doing 18-to 20-hour days just to try to stay ahead of it, so that they’re the first line between everything, to protect their employees.”

Colorado’s health department is advertising a hotline that ill dairy workers can call for help getting a flu test and medicine.

Project Protect Food Systems Workers, an organization that emerged early in the covid-19 pandemic to promote farmworker health across Colorado, is distributing PPE it received from the state so promotoras — health workers who are part of the community they serve — can distribute masks and other protections directly to workers if employers aren’t giving them out.

Promotora Tomasa Rodriguez said workers “see it as another virus, another covid, but it is because they don’t have enough information.”

She has been passing out flyers about symptoms and protective measures, but she can’t access many dairies. “And in some instances,” she said, “a lot of these workers don’t know how to read, so the flyers are not reaching them, and then the employers are not doing any kind of talks or trainings.”

The CDC’s Nirav Shah said during an Aug. 13 call with journalists that awareness about bird flu among dairy workers isn’t as high as officials would like it to be, despite months of campaigns on social media and the radio.

“There’s a road ahead of us that we still need to go down to get awareness on par with, say, what it might be in the poultry world,” he said. “We’re using every single messenger that we can.”

KFF Health News correspondents Vanessa G. Sánchez and Amy Maxmen contributed to this report.

Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for their newsletters here.

Feds Killed Plan To Curb Medicare Advantage Overbilling After Industry Opposition

A decade ago, federal officials drafted a plan to discourage Medicare Advantage health insurers from overcharging the government by billions of dollars — only to abruptly back off amid an “uproar” from the industry, newly released court filings show.

The Centers for Medicare & Medicaid Services published the draft regulation in January 2014. The rule would have required health plans, when examining patient’s medical records, to identify overpayments by CMS and refund them to the government.

But in May 2014, CMS dropped the idea without any public explanation. Newly released court depositions show that agency officials repeatedly cited concern about pressure from the industry.

The 2014 decision by CMS, and events related to it, are at the center of a multibillion-dollar Justice Department civil fraud case against UnitedHealth Group pending in federal court in Los Angeles.

The Justice Department alleges the giant health insurer cheated Medicare out of more than $2 billion by reviewing patients’ records to find additional diagnoses, adding revenue while ignoring overcharges that might reduce bills. The company “buried its head in the sand and did nothing but keep the money,” DOJ said in a court filing.

Medicare pays health plans higher rates for sicker patients but requires that the plans bill only for conditions that are properly documented in a patient’s medical records.

In a court filing, UnitedHealth Group denies wrongdoing and argues it shouldn’t be penalized for “failing to follow a rule that CMS considered a decade ago but declined to adopt.”

This month, the parties in the court case made public thousands of pages of depositions and other records that offer a rare glimpse inside the Medicare agency’s long-running struggle to keep the private health plans from taking taxpayers for a multibillion-dollar ride.

“It’s easy to dump on Medicare Advantage plans, but CMS made a complete boondoggle out of this,” said Richard Lieberman, a Colorado health data analytics expert.

Spokespeople for the Justice Department and CMS declined to comment for this article. In an email, UnitedHealth Group spokesperson Heather Soule said the company’s “business practices have always been transparent, lawful and compliant with CMS regulations.”

Missed Diagnoses

Medicare Advantage insurance plans have grown explosively in recent years and now enroll about 33 million members, more than half of people eligible for Medicare. Along the way, the industry has been the target of dozens of whistleblower lawsuits, government audits, and other investigations alleging the health plans often exaggerate how sick patients are to rake in undeserved Medicare payments — including by doing what are called chart reviews, intended to find allegedly missed diagnosis codes.

By 2013, CMS officials knew some Medicare health plans were hiring medical coding and analytics consultants to aggressively mine patient files — but they doubted the agency’s authority to demand that health plans also look for and delete unsupported diagnoses.

The proposed January 2014 regulation mandated that chart reviews “cannot be designed only to identify diagnoses that would trigger additional payments” to health plans.

CMS officials backed down in May 2014 because of “stakeholder concern and pushback,” Cheri Rice, then director of the CMS Medicare plan payment group, testified in a 2022 deposition made public this month. A second CMS official, Anne Hornsby, described the industry’s reaction as an “uproar.”

Exactly who made the call to withdraw the chart review proposal isn’t clear from court filings so far.

“The direction that we received was that the rule, the final rule, needed to include only those provisions that had wide, you know, widespread stakeholder support,” Rice testified.

“So we did not move forward then,” she said. “Not because we didn’t think it was the right thing to do or the right policy, but because it had mixed reactions from stakeholders.”

The CMS press office declined to make Rice available for an interview. Hornsby, who has since left the agency, declined to comment.

But Erin Fuse Brown, a professor at the Brown University School of Public Health, said the decision reflects a pattern of timid CMS oversight of the popular health plans for seniors.

“CMS saving money for taxpayers isn’t enough of a reason to face the wrath of very powerful health plans,” Fuse Brown said.

“That is extremely alarming.”

Invalid Codes

The fraud case against UnitedHealth Group, which runs the nation’s largest Medicare Advantage plan, was filed in 2011 by a former company employee. The DOJ took over the whistleblower suit in 2017.

DOJ alleges Medicare paid the insurer more than $7.2 billion from 2009 through 2016 solely based on chart reviews; the company would have received $2.1 billion less if it had deleted unsupported billing codes, the government says.

The government argues that UnitedHealth Group knew that many conditions it had billed for were not supported by medical records but chose to pocket the overpayments. For instance, the insurer billed Medicare nearly $28,000 in 2011 to treat a patient for cancer, congestive heart failure, and other serious health problems that weren’t recorded in the person’s medical record, DOJ alleged in a 2017 filing.

In all, DOJ contends that UnitedHealth Group should have deleted more than 2 million invalid codes.

Instead, company executives signed annual statements attesting that the billing data submitted to CMS was “accurate, complete, and truthful.” Those actions violated the False Claims Act, a federal law that makes it illegal to submit bogus bills to the government, DOJ alleges.

The complex case has featured years of legal jockeying, even pitting the recollections of key CMS staff members — including several who have since departed government for jobs in the industry — against those of UnitedHealthcare executives.

‘Red Herring’

Court filings describe a 45-minute video conference arranged by then-CMS administrator Marilyn Tavenner on April 29, 2014. Tavenner testified she set up the meeting between UnitedHealth and CMS staff at the request of Larry Renfro, a senior UnitedHealth Group executive, to discuss implications of the draft rule. Neither Tavenner nor Renfro attended.

Two UnitedHealth Group executives on the call said in depositions that CMS staffers told them the company had no obligation at the time to uncover erroneous codes. One of the executives, Steve Nelson, called it a “very clear answer” to the question. Nelson has since left the company.

For their part, four of the five CMS staffers on the call said in depositions that they didn’t remember what was said. Unlike the company’s team, none of the government officials took detailed notes.

“All I can tell you is I remember feeling very uncomfortable in the meeting,” Rice said in her 2022 deposition.

Yet Rice and one other CMS staffer said they did recall reminding the executives that even without the chart review rule, the company was obligated to make a good-faith effort to bill only for verified codes — or face possible penalties under the False Claims Act. And CMS officials reinforced that view in follow-up emails, according to court filings.

DOJ called the flap over the ill-fated regulation a “red herring” in a court filing and alleges that when UnitedHealth asked for the April 2014 meeting, it knew its chart reviews had been under investigation for two years. In addition, the company was “grappling with a projected $500 million budget deficit,” according to DOJ.

Data Miners

Medicare Advantage plans defend chart reviews against criticism that they do little but artificially inflate the government’s costs.

“Chart reviews are one of many tools Medicare Advantage plans use to support patients, identify chronic conditions, and prevent those conditions from becoming more serious,” said Chris Bond, a spokesperson for AHIP, a health insurance trade group.

Whistleblowers have argued that the cottage industry of analytics firms and coders that sprang up to conduct these reviews pitched their services as a huge moneymaking exercise for health plans — and little else.

“It was never legitimate,” said William Hanagami, a California attorney who represented whistleblower James Swoben in a 2009 case that alleged chart reviews improperly inflated Medicare payments. In a 2016 decision, the 9th Circuit Court of Appeals wrote that health plans must exercise “due diligence” to ensure they submit accurate data.

Since then, other insurers have settled DOJ allegations that they billed Medicare for unconfirmed diagnoses stemming from chart reviews. In July 2023, Martin’s Point Health Plan, a Portland, Maine, insurer, paid $22,485,000 to settle whistleblower allegations that it improperly billed for conditions ranging from diabetes with complications to morbid obesity. The plan denied any liability.

A December 2019 report by the Health and Human Services Inspector General found that 99% of chart reviews added new medical diagnoses at a cost to Medicare of an estimated $6.7 billion for 2017 alone.

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