La llevaron a un hospital en Clovis, una ciudad del condado de Fresno, cerca de donde viven los Reisz. Pero por la gravedad de las lesiones (Megan tenía cuatro costillas rotas y un pulmón parcialmente colapsado) los médicos decidieron trasladarla 12 millas en ambulancia hasta el centro de traumatología Nivel I del Centro Médico Regional Comunitario en Fresno.

Mientras Megan todavía se recuperaba de las lesiones en su hogar, recibió una factura de $2,400 de la compañía de ambulancias, después que el plan de salud familiar pagara casi $2,200.

“Cuando recibimos la factura, pensé que nuestra aseguradora estaba procesando el reclamo incorrectamente”, dijo Jennifer Reisz. Reisz, quien es abogada, dice que pasó horas hablando por teléfono con el plan de salud, la compañía de ambulancias y algunos defensores del consumidor.

Se enteró que la compañía de ambulancias no estaba en la red de su plan médico, y que se le permitía facturar a los pacientes cualquier parte no cubierta de sus cargos, una práctica conocida como facturación de saldo.

A partir del 1 de enero de 2024, los operadores de ambulancias terrestres ya no podrán llevar a cabo esta práctica, gracias a una nueva ley firmada por el gobernador demócrata Gavin Newsom. California es el decimocuarto estado que brinda cierta protección contra la facturación de saldo por viajes en ambulancia terrestre.

A nivel federal, un comité asesor establecido por el No Surprises Act, está trabajando en un plan para abordar el problema a nivel nacional.

Tanto la ley federal, que entró en vigencia en 2022, como una ley de California anterior prohibieron en gran medida la facturación del saldo de la atención hospitalaria y los servicios de ambulancia aérea, pero no los de ambulancias terrestres.

Y eso no es justo, ya que en una emergencia médica los pacientes no tienen control sobre qué compañía de ambulancias responde, si está dentro de la red, o cuánto cobrará.

​En California, casi tres cuartas partes de los traslados de emergencia en ambulancia terrestre generan facturas fuera de la red. La factura sorpresa promedio por un viaje en ambulancia terrestre en California es de $1,209, la más alta del país, según un estudio de diciembre.

La nueva ley, que se aplica a alrededor de 14 millones de californianos inscritos en planes de salud comerciales regulados por el estado, limita cuánto un operador de ambulancia fuera de la red puede cobrar a los pacientes con respecto al monto que pagarían por una ambulancia dentro de la red.

La ley también limita las facturas de las personas sin seguro, estipulando que no se les puede cobrar más que la tarifa de Medi-Cal o Medicare, la que sea mayor. (Medi-Cal es el programa de Medicaid de California, que brinda cobertura a personas con bajos ingresos o con ciertas discapacidades). Y prohíbe a los operadores de ambulancias y cobradores de deudas reportar a los pacientes a una agencia de calificación crediticia o emprender acciones legales contra ellos durante al menos 12 meses después de la factura inicial.

Según la ley actual, las personas en peligro a veces se niegan a llamar a una ambulancia por temor a una factura enorme, lo que podría[BW1] [BW2]  ponerlos a ellos mismos o a un ser querido en riesgo, dijo Katie Van Deynze, defensora legislativa y de políticas de Health Access California, que patrocinó la legislación. Afirma que con la nueva ley “tendrán tranquilidad”.

Las leyes existentes ya protegen a los beneficiarios de Medicare y Medi-Cal de facturas sorpresa por el uso de ambulancias terrestres. La nueva ley no cubre a los casi 6 millones de californianos inscritos en el subconjunto de planes de salud patrocinados por empleadores que están regulados a nivel federal.

El comité asesor que trabaja en una solución federal acordó la primera semana de noviembre propuestas no vinculantes que prohibirían, entre otras cosas, la facturación de saldo para la gran mayoría de los viajes en ambulancia y limitarían la responsabilidad financiera de los pacientes a $100. El comité planea informar formalmente sus recomendaciones al Congreso a principios del próximo año para una potencial legislación.

Según la nueva ley de California, los pacientes pueden esperar ahorrar un promedio de casi $1,100 por viaje en ambulancia de emergencia y más de $800 por viaje que no sea de emergencia durante el primer año, según un análisis legislativo realizado a principios de este año.

Los planes de salud deberán pagar a los operadores de ambulancias las tarifas establecidas por las autoridades del condado, lo que según el estudio aumentaría la cantidad promedio que pagan las aseguradoras por viaje en alrededor de $2,000.

Dado que los viajes en ambulancia representan un pequeño porcentaje del gasto general de los planes de salud, esos aumentos no deberían elevar mucho las primas.

Pero, con el tiempo, las autoridades locales podrían verse tentadas a aumentar las tarifas de las ambulancias para aumentar los ingresos de los operadores de ambulancias públicos, como los departamentos de bomberos, dijo Loren Adler, director asociado de la Iniciativa Brookings Schaeffer sobre Políticas de Salud. Eso podría impulsar a los planes de salud a aumentar los copagos de las ambulancias, eliminando algunos de los ahorros para los consumidores derivados de la nueva ley, apuntó Adler.

Jenn Engstrom, directora de CalPIRG, un grupo de defensa que ayudó a impulsar la ley a través de la legislatura, señaló que habrá responsabilidad incorporada, ya que la legislación requiere informes públicos sobre las tarifas de las ambulancias. “Si notamos que las cosas empiezan a dispararse, será necesaria una acción legislativa o una acción local”, dice Engstrom.

Reisz dijo que la compañía de ambulancias que transportó a su hija canceló la factura después que ella dejara en claro que no tenía intención de pagarla, y después que su plan de salud amortiguó el gasto un poco más. Pero, como señala, no todas las personas son abogadas expertas en defender su causa.

Incluso si no eres un maestro de la retórica, puedes tomar medidas sencillas para protegerte contra errores o contra operadores de ambulancias que ignoren la nueva ley.

Revisa tu póliza para conocer tu deducible y cualquier copago o coseguro en caso de que alguna vez necesites una ambulancia. Si recibes una factura por un traslado en ambulancia, no la pagues de inmediato. Consulta la explicación de beneficios de tu aseguradora para asegurarte que lo que [BW3] dice que debes coincida con lo que crees que debería ser el monto de tu costo compartido. Si la factura es más alta, es posible que la compañía de ambulancias esté intentando engañar. Llama a la compañía de ambulancias y diles que deben reducir la factura. Si no lo hacen, presenta una queja ante tu plan de salud e incluye una copia de la factura.

Si no estás de acuerdo con la decisión de tu plan, o el plan tarda más de 30 días en responder, lleva tu queja al regulador.

La nueva ley exige que tu aseguradora te informe si tu plan de salud está regulado por el estado y, por lo tanto, sujeto al estatuto. Si es así, es probable que el regulador sea el Departamento de Atención Médica Administrada.

Puedes comunicarte con esa agencia en línea (www.healthhelp.ca.gov) o por teléfono al 1-888-466-2219. Si tu plan de salud está regulado por el Departamento de Seguros, puedes presentar una queja en línea (www.insurance.ca.gov) o llamar al 1-800-927-4357.

Otro buen recurso es Health Consumer Alliance, que ofrece asistencia legal gratuita en varios idiomas. Llama al 1-888-804-3536.

Este artículo fue producido por  KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

She was taken to a hospital in Clovis, a city in Fresno County, near where the Reisz family lives. But the severity of Megan’s injuries — four broken ribs and a partially collapsed lung — prompted doctors to transport her 12 miles by ambulance to the Level I trauma center at Community Regional Medical Center in Fresno.

While Megan was still recovering at home from her injuries, she received a $2,400 bill from the ambulance company — after the family’s health plan had paid nearly $2,200.

“When we received the bill, I thought our insurance company was processing the claim incorrectly,” says Jennifer Reisz. An attorney, Reisz says she then spent hours on the phone with the health plan, the ambulance company, and a few consumer advocates. She learned that the ambulance company was not in the health plan’s network and was permitted to bill patients for any uncovered portion of its charges — a practice known as balance billing.

Starting Jan. 1, ground ambulance operators will be barred from doing that because of a new law signed by Democratic Gov. Gavin Newsom. California is the 14th state to provide some protection against balance billing for ground ambulance rides.

At the federal level, an advisory committee established under the No Surprises Act is working on a plan to address the problem nationally.

Both the federal law, which took effect in 2022, and a California law that predates it largely banned balance billing for hospital care and air ambulance services, but not ground ambulance services.

And that is hardly fair, since patients have zero control in a medical emergency over which ambulance company responds, whether it is in network, or how much it will charge.

In California, nearly three-quarters of emergency ground ambulance rides result in out-of-network bills. The average surprise bill for a ground ambulance ride in California is $1,209, the highest in the nation, according to a December study.

The new law, which applies to about 14 million Californians enrolled in state-regulated commercial health plans, limits how much a non-network ambulance operator can charge patients to the amount they would pay for an in-network ambulance.

The law also caps bills for uninsured people, stipulating they can’t be charged more than the Medi-Cal or Medicare rate, whichever is greater. (Medi-Cal is California’s Medicaid program, providing coverage to people with low incomes or disabilities.) And it prohibits ambulance operators and debt collectors from reporting patients to a credit rating agency or taking legal action against them for at least 12 months after the initial bill.

Under current law, people in distress sometimes decline to call an ambulance for fear of a huge bill, putting themselves or a loved one at risk, says Katie Van Deynze, policy and legislative advocate for Health Access California, which sponsored the legislation. With the new law, she says, “they will have peace of mind.”

Existing laws already protect Medicare and Medi-Cal beneficiaries from surprise ground ambulance bills. The new law does not cover the nearly 6 million Californians enrolled in the subset of employer-sponsored health plans that are federally regulated.

The advisory committee working on a federal fix agreed last week on nonbinding proposals that would, among other things, prohibit balance billing for the vast majority of ambulance rides and cap patients’ financial liability at $100. The committee plans to formally report its recommendations to Congress early next year for potential legislation.

Under California’s new law, patients can expect to save an average of nearly $1,100 per emergency ambulance ride and over $800 per nonemergency ride in the first year, according to a legislative analysis conducted this year.

Health plans will be required to pay ambulance operators the rates set by county authorities, which the study said would increase the average amount insurers pay per ride by around $2,000.

Since ambulance rides account for a tiny percentage of overall health plan spending, those increases should not raise premiums by much.

But local authorities might be tempted to hike ambulance rates over time to increase revenue for publicly run ambulance operators, such as fire departments, says Loren Adler, associate director of the Brookings Schaeffer Initiative on Health Policy. That could prompt health plans to raise ambulance copays, offsetting some of the consumer savings from the new law, Adler says.

Jenn Engstrom, director of CalPIRG, an advocacy group that helped shepherd the law through the legislature, notes there will be built-in accountability, since the legislation requires public reporting of ambulance rates. “If we notice that things start to skyrocket, there will be a need for legislative action or local action,” Engstrom says.

Reisz says the ambulance company that transported her daughter wrote off the bill after she made it clear she had no intention of paying it — and after her health plan ponied up a little more. But as she notes, not everyone is a lawyer adept at arguing their cause.

Even if you are no rhetorical wizard, you can take simple steps to protect yourself against errors or ambulance operators that disregard the new law.

Check your insurance policy to know your deductible and any copay or coinsurance should you ever need an ambulance. If you get an ambulance bill, don’t pay it right away. Check your insurer’s explanation of benefits to make sure what it says you owe matches what you think your cost-sharing amount should be. If the bill is higher, the ambulance company may be trying to pull a fast one. Call the ambulance company and tell them they need to knock the bill down. If they don’t, file a complaint with your health plan and include a copy of the bill.

If you disagree with your plan’s decision, or it takes more than 30 days for the plan to respond, take your complaint to the regulator.

The new law requires your insurer to tell you if your health plan is regulated by the state and thus subject to the statute. If it is, the regulator is likely to be the Department of Managed Health Care. You can contact that agency online (www.healthhelp.ca.gov) or by phone at 1-888-466-2219. If your health plan is regulated by the Department of Insurance, you can file a complaint online (www.insurance.ca.gov) or call 1-800-927-4357.

Another good resource is the Health Consumer Alliance, which offers free legal assistance in multiple languages. Call 1-888-804-3536.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Unless a deal is struck, more than 75,000 health workers will walk out for three days from Oct. 4-7, disrupting care for KP patients in California, Colorado, Oregon, Virginia, Washington, and Washington, D.C. The unions represent a wide range of KP health workers, including lab technicians, phlebotomists, pharmacists, optometrists, social workers, orderlies, and support staff.

A strike, if it occurs, would affect most of Kaiser Permanente’s 39 hospitals and 622 medical offices across the U.S., and would disrupt care for many of its nearly 13 million patients. If workers walk off their jobs, “it will start to impact patient care right away,” said John August, director of health care and partner programs at Cornell University’s Scheinman Institute on Conflict Resolution, who is a former head of the union coalition currently negotiating with KP.

“You are immediately subject to problems with not being able to get patients in and out of the hospital. You risk problems with infection control. You’re not going to get meals,” August said.

Arlene Peasnall, Kaiser Permanente’s senior vice president for human resources, said the Oakland, California-based health care giant’s goal is “to reach a mutually beneficial agreement before any work stoppage occurs.” But she also said the nonprofit has plans in place to blunt the impact of a walkout.

“We will be bargaining with Kaiser up until the day we go on strike,” said Caroline Lucas, executive director of the Coalition of Kaiser Permanente Unions, which represents about 40% of KP’s workforce. “Our front-line health care workers are fed up, and we really need Kaiser executives to seize the initiative and move forward on resolving the contract.”

The current contract expires Sept. 30 and, after months of talks, the two sides still disagree over pay and staffing. The coalition wants a $25-an-hour minimum wage across the company. KP executives agree there should be an organization-wide floor, but they’ve proposed $21.

KP prefers varying wage increases across regions, since the cost of living can vary sharply. The coalition, which is pushing for uniform wage increases across all regions, contends that management’s proposal is part of a “divide-and-conquer strategy.” Peasnall said the union’s stance “would prevent us from addressing fair market wages where we need to pay more to attract and retain the best people.”

The unions say their lowest-paid workers can barely make ends meet in the face of soaring prices for food, gasoline, and other essentials. And, they say, KP hospitals and clinics are severely understaffed, forcing workers to put in long hours and fill multiple roles. They argue that management is not moving quickly enough to fill positions and that the quality of care has suffered as patients, some with serious illnesses, often wait months for appointments, face extremely long waits in the emergency room, and experience delays in hospital admissions.

An industrywide labor shortage hangs heavily over the contract talks. The pandemic was particularly brutal for health care workers who often worked long hours in grueling conditions, as colleagues fell ill, died, or quit. Workers say many of the positions that became vacant during the pandemic still have not been filled.

Miriam De La Paz, a secretary in the labor and delivery department of KP’s Downey Medical Center in Southern California and a union steward, said when she is alone on a shift, she is responsible for two labor and delivery stations as well as triage, where patients are prioritized based on the acuity of their cases.

“Imagine if I’m putting this baby in the system and your wife shows up in pain, crying, but I’m not there to register her,” De La Paz said. “I can’t break myself in two.”

Unions want KP to invest more in education, training, and recruitment to fill current openings and create a pipeline of future workers. KP says it is doing so.

Peasnall said KP has already filled more than 9,700 out of 10,000 new coalition-represented jobs the two sides had agreed to create this year. And she said KP’s turnover rate is one-third the industry rate, in part because of “excellent pay and benefits.”

Earlier this month, California lawmakers passed legislation to gradually raise the minimum wage for health care workers in the state to $25 an hour. If Democratic Gov. Gavin Newsom signs the bill into law, KP will have to comply. And nearly 80% of workers represented by the coalition in the current contract talks are in California.

On Sept. 22, as bargaining continued in San Francisco, the unions announced that more than 75,000 of the 85,000 workers they represent would stage the three-day walkout if there’s no deal. Federal law requires 10 days’ notice of strikes at health care facilities. The coalition said it is “prepared to engage in another longer, stronger strike in November,” if no agreement is reached by then.

A coalition spokesperson, Betsy Twitchell, said workers would welcome the Biden administration’s involvement in the talks “because of the importance of these negotiations to millions of patients and 75,000 frontline healthcare workers.”

The unions say KP can afford to be more generous, citing its robust financial health.

Although KP reported a net loss of almost $4.5 billion in 2022, it generated a cumulative net income of nearly $22 billion over the three preceding years — both results driven largely by investment performance. In the first half of this year, KP posted profits of over $3 billion. And it is in a strong position to manage its debt, according to a report earlier this year by Fitch Ratings.

The unions note that Kaiser Permanente’s CEO, Greg Adams, received almost $16 million in compensation in 2021 and that dozens of others in KP management made more than $1 million, according to a KP filing with the IRS.

Peasnall said the compensation of KP’s senior management is less than that of their peers at other health care companies.

A KP walkout would be the latest in a string of worker movements. Strikes have hit Hollywood, hotels, auto manufacturers, and other industries. Public approval of unions is at a nearly 60-year high, according to a Gallup Poll released in August 2022.

Health workers are increasingly engaged, too. Several hospital groups have been hit by strikes, including Cedars-Sinai Medical Center in Los Angeles and numerous facilities belonging to Sutter Health in Northern California, as well as health care organizations in other states.

“There is an atmosphere in the country: It’s labor summer, it’s strike summer, it’s all that,” August said. “That definitely has an influence on union leadership that says, ‘We need to be a part of that.’”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

El consultorio ya había cerrado, pero todo el equipo estaba allí esperándome. Uno de ellos me pinchó los globos oculares con un instrumento punzante para drenar el líquido que se había acumulado. Eso alivió la presión y me devolvió la visión.

Pero era el cuarto pico de presión ocular que amenazaba mi visión en nueve días, y los doctores temían que volviera a suceder durante el fin de semana. Así que me fui a la sala de emergencias, donde pasé la noche conectado a un tubo intravenoso que suministraba un poderoso agente antiinflamatorio.

Más tarde, cuando le contaba esta historia a mis amigos y colegas, algunos de ellos no entendían la importancia de la presión ocular o ni siquiera lo que era. “No sabía que se podía medir la presión sanguínea en los ojos”, me dijeron.

La mayoría de las personas consideran que su visión es de suma importancia. Sin embargo, muchas de ellas saben muy poco sobre las enfermedades oculares más graves.

En un estudio de 2016 publicado en JAMA Ophthalmology, basado en una encuesta nacional en línea, casi la mitad de los encuestados dijeron que temían perder la vista más que la memoria, el habla, el oído o sus extremidades. Sin embargo, muchos “no tenían conciencia de enfermedades oculares importantes”, según el estudio.

Un estudio publicado este mes, realizado por Wakefield Research para las organizaciones sin fines de lucro Prevent Blindness y Regeneron Pharmaceuticals, reveló que una cuarta parte de los adultos con mayor riesgo de desarrollar enfermedades de la retina, como degeneración macular y retinopatía diabética, atrasaron la búsqueda de atención médica para sus problemas de visión.

“Se hace mucho menos énfasis en la salud ocular que en la salud general”, afirma Rohit Varma, director fundador del Southern California Eye Institute de Hollywood Presbyterian Medical Center.

Varma dice que, debido a que muchas veces las enfermedades de los ojos no causan dolor y avanzan lentamente, “la gente se acostumbra, y a medida que envejece empieza a pensar, ‘esto es una parte normal del envejecimiento'”. Pero si sintiera un dolor intenso, agrega, la misma persona buscaría atención médica.

Pero para muchos no es fácil tener un examen de la vista o recibir tratamiento. Millones no tienen seguro de salud, otros no pueden pagar su parte del costo, o viven en comunidades donde no hay muchos oftalmólogos.

“El hecho de que la gente sepa que necesita atención médica no significa que pueda pagarla o que tenga acceso a ella”, dice Jeff Todd, director y presidente de Prevent Blindness.

Otro reto que refleja la brecha entre la atención oftalmológica y la atención de salud general es que el seguro médico suele cubrir solo el cuidado de ojos para diagnosticar o tratar enfermedades, excepto en el caso de los niños.

Muchos planes de salud cubren los exámenes de visión de rutina, pero estos generalmente no incluyen el tipo de examen que se utiliza para recetar anteojos y lentes de contacto. Tampoco suelen cubrir el costo de los lentes. En algunos casos se necesita un seguro de visión aparte para estos servicios; consulta con tu plan de salud para saber qué cubre.

Desde que me diagnosticaron glaucoma hace 15 años, he tenido más controles de presión ocular, exámenes de visión, recetas de gotas para los ojos y cirugías láser de los que puedo recordar. Yo no debería subestimar la importancia de mi vista. Y sin embargo, cuando mis ojos se llenaron de esa niebla que empañaba mi visión en marzo pasado, me sentí extrañamente optimista.

Resultó que esos picos de presión en serie habían sido provocados por una reacción adversa a las gotas a base de esteroides que me recetaron tras una operación de cataratas. Mi oftalmólogo me dijo más tarde que había estado “a pocas horas” de perder la vista.

Espero que mi experiencia de estar cerca de la ceguera inspire a la gente a ser más consciente de sus ojos.

Los anteojos o los lentes de contacto pueden marcar una gran diferencia en la calidad de vida de una persona al corregir los errores de refracción, que afectan a 150 millones de estadounidenses. Pero no hay que ignorar el riesgo de los trastornos oculares mucho más graves, que pueden sorprendernos. En muchos casos se pueden controlar, si se detectan a tiempo.

El glaucoma, que afecta a unas 3 millones de personas en Estados Unidos, ataca primero la visión periférica y puede causar daños irreversibles en el nervio óptico. Es hereditario y es cinco veces más prevalente en las personas afroamericanas que en la población general.

Casi 10 millones de personas en este país tienen retinopatía diabética, una complicación de la diabetes que ocurre cuando se dañan los vasos sanguíneos de la retina. Y unas 20 millones de personas de 40 años o más tienen degeneración macular, una enfermedad de la retina asociada con el envejecimiento que, con el tiempo, disminuye la visión central.

Las cataratas causan opacidad en el cristalino, la lente natural del ojo. A medida que las personas envejecen, es muy común que las desarrollen: la mitad de las personas de 75 años o más las tienen. Las cataratas pueden causar ceguera, pero se tratan con cirugía.

Si tienes más de 40 años y no te has realizado un examen ocular completo en un tiempo, o nunca, pónlo en tu lista de tareas pendientes. Y hazlo antes de esa edad si tienes diabetes, antecedentes familiares de glaucoma o si eres una persona afroamericana o parte de otro grupo racial o étnico con alto riesgo de ciertas enfermedades oculares.

Y no te olvides de los más jóvenes. Múltiples afecciones oculares pueden afectar a los niños. Los errores de refracción, tratables con lentes correctivas, pueden causar problemas más adelante en la vida si no se tratan lo suficientemente temprano.

Los estilos de vida saludables también benefician a tus ojos. “Todo lo que ayuda a tu salud general ayuda a tu visión”, dice Andrew Iwach, vocero clínico de la Academia Americana de Oftalmología y director ejecutivo del Glaucoma Center of San Francisco.

Reduce el estrés, haz ejercicio regularmente y sigue una dieta saludable. También deja de fumar. Aumenta el riesgo de enfermedades oculares graves.

Y considera adoptar hábitos que protejan tus ojos de lesiones: usa lentes de sol cuando estés al aire libre, descansa de la pantalla de tu computadora y teléfono celular regularmente, y usa anteojos protectores cuando trabajes en la casa o practiques deportes.

El sitio web de Prevent Blindness ofrece información sobre prácticamente todo lo relacionado con la salud ocular, incluyendo el seguro. Otras buenas fuentes son el sitio EyeSmart de la Academia Americana de Oftalmología y el Instituto Nacional del Ojo.

Así que lee y comparte lo que has aprendido. “Cuando te reúnas con tu familia para las fiestas”, dice Iwach, “si no sabes de qué hablar, habla de tus ojos”.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The office was already closed, but the whole eye care team was there waiting for me. One of them pricked my eyeballs with a sharp instrument, allowing the ocular fluid that had built up to drain. That relieved the pressure and restored my vision.

But it was the fourth vision-impairing pressure spike in nine days, and they feared it would happen again — heading into a weekend. So off I went to the emergency room, where I spent the night hooked up to an intravenous tube that delivered a powerful anti-swelling agent.

Later, when I told this story to friends and colleagues, some of them didn’t understand the importance of eye pressure, or even what it was. “I didn’t know they could measure blood pressure in your eyes,” one of them told me.

Most people consider their vision to be vitally important, yet many lack an understanding of some of the most serious eye diseases. A 2016 study published in JAMA Ophthalmology, based on an online national poll, showed that nearly half of respondents feared losing their eyesight more than their memory, speech, hearing, or limbs. Yet many “were unaware of important eye diseases,” it found.

A study released in July, conducted by Wakefield Research for the nonprofit Prevent Blindness and Regeneron Pharmaceuticals, showed that one-quarter of adults deemed at risk for diseases of the retina, such as macular degeneration and diabetic retinopathy, had delayed seeking care for vision problems.

“There is significantly less of an emphasis placed on eye health than there is on general health,” says Rohit Varma, founding director of the Southern California Eye Institute at Hollywood Presbyterian Medical Center.

Because eye diseases can be painless and progress slowly, Varma says, “people get used to it, and as they age, they begin to feel, ‘Oh, this is a normal part of aging and it’s OK.’” If people felt severe pain, he says, they would go get care.

For many people, though, it’s not easy to get an eye exam or eye treatment. Millions are uninsured, others can’t afford their share of the cost, and many live in communities where eye doctors are scarce.

“Just because people know they need the care doesn’t necessarily mean they can afford it or that they have the access to it,” says Jeff Todd, CEO and president of Prevent Blindness.

Another challenge, reflecting the divide between eye care and general health care, is that medical insurance, except for children, often covers only eye care aimed at diagnosing or treating diseases. More health plans are covering routine eye exams these days, but that generally does not include the type of test used to determine eyeglass and contact lens prescriptions — or the cost of the lenses. You may need separate vision insurance for that. Ask your health plan what’s covered.

Since being diagnosed with glaucoma 15 years ago, I’ve had more pressure checks, eye exams, eyedrops, and laser surgeries than I can remember. I should know not to take my eyesight for granted. And yet, when my peepers were filling with that vision-threatening fog last March, I felt oddly sanguine.

It turned out that those serial pressure spikes were triggered by an adverse reaction to steroid-based eyedrops prescribed to me following cataract surgery. My ophthalmologist told me later that I had come “within hours” of losing my eyesight.

I hope my brush with blindness can help inspire people to be more conscious of their eyes.

Eyeglasses or contact lenses can make a huge difference in one’s quality of life by correcting refractive errors, which affect 150 million Americans. But don’t ignore the risk of far more serious eye conditions that can sneak up on you. They are often manageable if caught early enough.

Glaucoma, which affects about 3 million people in the U.S., attacks peripheral vision first and can cause irreversible damage to the optic nerve. It runs in families and is five times as prevalent among African Americans as in the general population.

Nearly 10 million in this country have diabetic retinopathy, a complication of diabetes in which blood vessels in the retina are damaged. And some 20 million people age 40 and up have macular degeneration, a disease of the retina associated with aging that diminishes central vision over time.

The formation of cataracts, which cause cloudiness in the eye’s natural lens, is very common as people age: Half of people 75 and older have them. Cataracts can cause blindness, but they are eminently treatable with surgery.

If you are over 40 and haven’t had a comprehensive eye exam in a while, or ever, put that on your to-do list. And get an exam at a younger age if you have diabetes, a family history of glaucoma, or if you are African American or part of another racial or ethnic group at high risk for certain eye diseases.

And don’t forget children. Multiple eye conditions can affect kids. Refractive errors, treatable with corrective lenses, can cause impairment later in life if they are not addressed early enough.

Healthful lifestyle choices also benefit your eyes. “Anything that helps your general health helps your vision,” says Andrew Iwach, a clinical spokesperson for the American Academy of Ophthalmology and executive director of the Glaucoma Center of San Francisco.

Minimize stress, get regular exercise, and eat a healthy diet. Also, quit smoking. It increases the risk of major eye diseases.

And consider adopting habits that protect your eyes from injury: Wear sunglasses when you go outside, take regular breaks from your computer screen and cellphone, and wear goggles when working around the house or playing sports.

The Prevent Blindness website offers information on virtually everything related to eye health, including insurance. Other good sources include the American Academy of Ophthalmology’s “EyeSmart” site and the National Eye Institute.

So read up and share what you’ve learned.

“When you get together for the holidays,” says Iwach, “if you aren’t sure what to talk about, talk about your eyes.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The program is offering an additional $240.5 million in no-interest loans to 16 other troubled hospitals, including Beverly Community Hospital in Montebello and Hazel Hawkins Memorial Hospital in Hollister, both of which filed for bankruptcy earlier this year.

Hazel Hawkins will get a loan of $10 million, and Beverly will get a bridge loan of $5 million while it is being purchased out of bankruptcy by Adventist Health’s White Memorial in Los Angeles, according to the state’s Department of Health Care Access and Information, which unveiled the lending details Thursday.

Adventist Health has also agreed conditionally to manage Madera if it reopens. If all goes well it would take six to nine months to reopen, officials said.

Madera will get a bridge loan of $2 million to cover basic costs while Adventist Health, a large multistate health system with 22 hospitals in California, works on a “comprehensive hospital turnaround plan,” the department said. Once such a plan is approved, Madera “can be eligible for an additional $50 million loan” from the distressed hospital program, it said.

For most of last year, Fresno-based St. Agnes Medical Center, part of the large Catholic hospital chain Trinity Health, appeared poised to rescue Madera Community Hospital from financial ruin in a planned acquisition that was approved by California Attorney General Rob Bonta. But Trinity walked away from the deal at the last minute with scant explanation, infuriating Bonta along with multiple other political leaders, community advocates, and health care officials.

Trinity, which had loaned Madera $15.4 million during their merger talks, became its largest creditor in the bankruptcy that ensued. At the time of its bankruptcy filing in March, Madera reported total debts of just over $30 million.

Adventist Health agreed last month to a nonbinding letter of intent to manage Madera. At the time, Kerry Heinrich, Adventist’s president and CEO, said that if the shuttered hospital got the requisite financing, Adventist Health would use its expertise in “helping to secure a sustainable future for healthcare” in the county.

Adventist Health spokesperson Japhet De Oliveira said Thursday that his organization remains intent on doing so. Reopening Madera “would be a really good thing, and we will put every effort into making that happen,” De Oliveira said. He added: “We will need all parties to be involved in developing the approved plan and negotiating the terms of management services.”

Karen Paolinelli, the CEO of Madera Community Hospital, did not respond to emailed questions by publication time.

State political leaders representing the region expressed satisfaction with Thursday’s news. “It brings me tremendous relief to know that Madera Community Hospital and Hazel Hawkins Memorial Hospital in San Benito County have received grant awards and will be able to ensure that community members can once again receive services in their own communities,” said Sen. Anna Caballero, a Democrat who represents the areas in which those facilities are located.

The Adventist letter of intent for Madera said that in addition to paying off creditors in the bankruptcy, the hospital would need to secure $55 million in the first year to pay for all aspects of reopening, plus an additional $30 million in the second year.

The $52 million the state proposes lending to Madera is significantly short of the $80 million the hospital applied for. Assuming the full $52 million materializes, the total amount loaned to the 17 hospitals would be $292.5 million — nearly the entire $300 million available to the fund for fiscal years 2023 and 2024. The program is scheduled to end after 2031.

With $52 million from the state, Madera Community Hospital would still need to find an additional $33 million. Madera said in a bankruptcy court filing earlier this year that it expects just over $33 million in revenues from “provider fees” and from the Federal Emergency Management Agency.

The law that created the distressed hospital loan fund, AB 112, initially provided for $150 million in lending to help troubled hospitals, mostly rural ones, that faced the risk of closing. Another $150 million was later added to the pot. Small hospitals across the state — and the country — have been buffeted by the ill economic winds of the covid-19 pandemic, which ratcheted up the cost of drugs, supplies, and labor.

Hospital industry officials have also pointed to low payment rates by government programs, especially Medi-Cal, California’s Medicaid program, which they say has saddled many hospitals with financial losses.

Madera made the same argument, but state data shows it received enough supplemental payments to earn nearly $15 million from Medi-Cal in 2021, though it lost over $11 million treating Medicare patients.

The hospitals awarded the largest loans by the distressed hospital fund are Tri-City Medical Center in Oceanside, with $33.2 million; Dameron Hospital Association in Stockton, with $29 million; Pioneers Memorial Healthcare District in Imperial County, with $28 million; and El Centro Regional Medical Center, with $28 million.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Bullied and ostracized, Wrangell started repressing those feelings in middle school and kept them bottled up for a long time. That led to decades of sadness, isolation, and even a couple of suicide attempts. What gnawed at Wrangell was gender dysphoria, a condition widely acknowledged in the medical community, which causes severe distress to people whose gender identity does not match their sex assigned at birth.

“It’s a sense of wrongness, like someone attached an arm to my head badly, and it just punches me in the face every time,” said Wrangell, 38, who grew up and still lives in this idyllic central California beach community. Facial and body hair is particularly upsetting: “I see my face in the mirror, and anytime I have to deal with hair, it is uncomfortable. I hate seeing it.”

Wrangell is nonbinary, meaning neither a man nor a woman, and uses the pronouns they and them. For over three years, they have been undergoing gender transition treatments to take on more feminine physical traits. These treatments have included genital transformation, known as bottom surgery; hormone replacement therapy using estradiol; and electrolysis hair removal for their face, neck, and chest.

All of it is paid for by Medi-Cal, California’s version of the federal Medicaid insurance program for people with low incomes. California law requires Medi-Cal and all other state-regulated health plans to cover gender-affirming care that is deemed medically necessary. But therein lies the rub.

Wrangell, an enrollee of the Central California Alliance for Health, the only Medi-Cal health plan in Santa Cruz, said it has been laborious to get the care they need. They contend with seemingly endless paperwork and phone calls to prove what they’ve already established — that their need for treatments is real and ongoing.

“There is a joke among the trans community, where they are always asking for letters, along the lines of, ‘Oh, did they think I stopped being trans or did the hair magically go away?’” Wrangell said.

And it requires a lot of work to find and vet the scant number of gender-affirming care providers who take Medi-Cal patients, Wrangell said.

Over 1.6 million people ages 13 and older in the U.S. are transgender, according to the UCLA School of Law’s Williams Institute, which conducts legal and policy research on gender identity and sexual orientation. Data from the institute shows an estimated 276,000 transgender people in the U.S. are enrolled in Medicaid, including 164,000 in states where transgender care is covered. Of those, 36,000 are in California, one of 25 states, plus Washington, D.C., whose Medicaid policies cover gender-affirming care.

“I think there’s a lot of pressure in society to fit into a very narrow set of narratives, and I don’t think honestly that works for most people,” Wrangell said. “For some people, it’s so ill-fitting, it’s disastrous.”

A national survey of transgender people shows they disproportionately experience physical abuse, economic hardship, and mental health problems. And research finds gender-affirming care can significantly enhance their quality of life.

But as Wrangell has learned, coverage and care are not the same thing. Hair removal, their top priority, has been hard to get. After 2½ years of electrolysis treatment, they’ve had roughly only about half the total number of hours their electrologist said they needed.

Permanently removing the facial hair of a transgender person assigned male at birth can require 400 or more hours of electrolysis spread over several years. For those paying out of their own pockets, the cost would easily reach tens of thousands of dollars. That doesn’t include the cost of facial, bottom, and body-shaping surgeries.

Wrangell said their health plan has limited the number of sessions it authorizes at a time, requiring constant reauthorization.

Dennis Hsieh, deputy chief medical officer of the Central California Alliance for Health, said the health plan recently updated its policy to allow 50% more electrolysis in a three-month period and eliminate a rule requiring patients to submit photos of relevant body parts.

Hsieh acknowledged a shortage of providers and said the alliance contracts with clinicians across several counties to provide more options.

To a large extent, the challenges transgender people encounter seeking care are the same ones many people face in the “terror dome of U.S. health care,” said Kellan Baker, the executive director of the Washington, D.C.-based Whitman-Walker Institute, which conducts research and education on topics of concern to gay, bisexual, and transgender people. “There are a lot of people in a lot of circumstances who cannot get medically necessary care for their conditions, whether that’s gender dysphoria or cancer or diabetes.”

Legal aid lawyers and transgender activists say another big reason for denials or delays in gender-affirming care, especially hair removal, is that many people in the medical world still think of it as cosmetic.

Medi-Cal, like most commercial insurance plans, does not cover cosmetic treatments. “But if it’s affecting your mental health, and it’s affecting your life opportunities, and it’s affecting your ability to get a job, and it’s affecting your ability to get housing, is that cosmetic?” asked Elana Redfield, the federal policy director at the Williams Institute.

Despite their travails in obtaining care, Wrangell said, the treatment is improving their life. The estradiol, they said, makes them feel “way more relaxed, much less on edge all the time.” And Wrangell feels good about an uncommon bottom surgery they got last October, but they are facing more paperwork for a needed follow-up operation.

They are frustrated about all the red tape they’ve encountered, precisely because the treatments are helping. “This is working,” Wrangell said. “Please finish it.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Now, with the nonprofit Madera, California, hospital bankrupt and shuttered, St. Agnes looms as a dark knight, pushing to liquidate the hospital to get a loan it made to Madera paid back — even if that means dashing the hopes of the community activists, political leaders, and health care officials that the hospital can still reopen.

A pivotal moment in the case could come July 25, when a bankruptcy judge in Fresno will hear arguments on whether the Madera hospital should be allowed to spend its dwindling cash reserves on things such as building maintenance, security, utilities, and the salaries of its three top executives.

The hospital wants to run a skeletal operation while it seeks a buyer and develops a reopening plan. But the federal bankruptcy court in Fresno has authorized it to spend money only through July 29. If the judge doesn’t think the hospital has a viable plan, he may refuse an extension, which would likely mean liquidation.

Problems like Madera’s are common among other small, financially challenged hospitals in California and nationwide. They typically have low patient volumes and rely disproportionately on payments from Medicaid and Medicare, which constrains revenue and makes it difficult to attract talent or invest in cutting-edge equipment. Add to the mix a crushing surge in expenses stemming from the covid-19 pandemic, and dozens of such facilities are struggling to survive. Two others, both in California, have filed for bankruptcy this year.

Yet Madera had problems that were all of its own making. The hospital made money on patients insured by Medi-Cal, the state safety-net insurance program that pays notoriously low rates, according to financial data filed with state regulators. But it lost money on its commercially insured patients due to low volume and bad deals with insurance providers. It also failed to seek covid relief funds in a timely manner. A state hospital bailout fund came too late.

Plus, Madera had no backup plan when St. Agnes and its parent company, the hospital chain Trinity Health, walked away from a proposed merger with the troubled hospital late last year, giving virtually no notice and scant explanation. Their move shocked and infuriated officials, former employees, and community advocates in Madera and Sacramento.

In a brief December press release, St. Agnes and Trinity blamed their decision on “complex circumstances” and “additional conditions” imposed by state Attorney General Rob Bonta. But industry experts said Bonta had agreed to most of what St. Agnes asked for and were baffled as to why they walked away from the deal.

The spectacle of St. Agnes and Trinity now pushing in court for the liquidation of tiny Madera has drawn Bonta’s ire.

“For Trinity, it was always about profit, not the health of the Madera community,” Bonta told KFF Health News in a statement. “They are now attempting to use their position as Madera’s biggest creditor to extract every dollar possible, instead of keeping the community’s interests at heart.”

Bonta said his office had “offered maximum flexibility to Trinity in recognition of Madera’s financial circumstances.”

An agricultural area of 2,150 square miles and home to nearly 160,000 people, Madera County is 60% Hispanic, and more than one-fifth of its residents live below the poverty line, according to census data.

A Community Left in the Lurch

Jennifer Lara, a former Madera Community Hospital nursing assistant, said she and colleagues had been looking forward to positive change after the anticipated merger with St. Agnes. “We were floored when we found out the hospital was closing,” she said. “We didn’t think anything other than the hospital continuing on was going to happen.”

St. Agnes and Trinity declined to comment. The longtime CEO of St. Agnes, Nancy Hollingsworth, retired in May amid a reorganization that made the hospital part of a regional group based in Idaho. It’s unclear whether her departure was related to the collapse of the Madera deal. Hollingsworth could not be reached for comment.

St. Agnes’ considerable leverage in the bankruptcy case is the result of a $15.4 million loan it extended to Madera during merger talks last year. Madera has since repaid $8 million, leaving a debt of over $7 million, which still makes St. Agnes its largest creditor.

St. Agnes, one of 88 hospitals belonging to Trinity, a multistate, Catholic, nonprofit health system headquartered in Livonia, Michigan, argued in a recent bankruptcy court filing that Madera still has made no significant progress finding a buyer, more than four months after filing for Chapter 11 bankruptcy protection on March 10, and should not be allowed to continue spending money “without a serious path forward to either sell or mothball the hospital.”

The hospital has been talking to three potential partners, “one of whom is late to the game,” said Riley Walter, Madera’s bankruptcy lawyer.

Mohammad Ashraf, a cardiologist and member of the executive committee of Madera’s medical staff, said the first two entities in question, whom he declined to identify, are management service organizations, not hospital groups. “They don’t want to spend any money to buy it. They just want to run it,” he said.

Without a convincing strategy for the future of Madera Community Hospital, the end of the bankruptcy case could come quickly.

Ranjit S. Rajpal, a Madera cardiologist for over 40 years, said the closure of the hospital is bad news for patients who need time-sensitive care, such as for heart attacks, strokes, or other traumas, and who now must travel greater distances to get it.

And the closure will exacerbate existing health inequities for people who face challenges getting care because of immigration status, language barriers, lack of transportation, or other socioeconomic factors, he said. “Those disparities will be compounded as time goes by.”

Community leaders and the hospital’s leadership hold out hope for reopening. The hospital has applied for $80 million from California’s new, $300 million loan fund for distressed hospitals. Hospital leaders must produce a reopening plan by July 31, but even if it does, it’s unlikely to get the full requested amount: Sixteen hospitals have already applied for loans totaling over $385 million, said Joe DeAnda, spokesperson for the California State Treasurer’s Office.

“They’re not going to give a quarter of their total fund to one hospital that doesn’t even have a partner,” said Glenn Melnick, a health economist at the University of Southern California who authored an analysis commissioned by the AG’s office of the proposed St. Agnes-Madera merger. “Eighteen months ago, the ask would have been a lot smaller.”

Even if Madera Community Hospital finds a viable partner and gets the funding it needs, reopening would be daunting and expensive. The hospital would need to hire hundreds of nurses, technicians, and other staffers in a tight and expensive health care labor market and find a way to avoid the financial problems that landed it in bankruptcy.

“Some things an acute care hospital offers are profitable, and others are not,” said Jay Varney, Madera County’s administrative officer, whose role is akin to a CEO. “It doesn’t make much sense to have it reopen like it was and have it go bankrupt again.”

‘Running Out of Time’

Reopening the facility with all the services it provided before is not the only option. Baldwin Moy, an attorney for California Rural Legal Assistance, a community advocacy group, said he and colleagues have been arguing for the court to allow Madera additional time either to find a buyer or for the county “to put together a package that can reopen the emergency room with some stripped-down clinical operation.” But, Moy said, they are “running out of time.”

Karen Paolinelli, the hospital’s CEO, said the current suitors are interested in reopening it as an acute care facility that “may or may not have all services that were previously offered by Madera Hospital on day one.”

If the hospital can hold out for a few more months, it says, it can collect $23.5 million owed by the state for “provider fees,” and possibly an additional $10 million from the Federal Emergency Management Agency. Those payments would more than cover the hospital’s entire debt of $30 million. But the amount and timing of payments are unclear.

Paolinelli, voicing a common industry complaint, said the hospital has a disproportionately high number of Medi-Cal patients and Medi-Cal rates do not cover the cost of providing care. But state data shows that Madera received enough supplemental payments to earn nearly $15 million from Medi-Cal in 2021, though it lost over $11 million treating Medicare patients. Madera also lost about $6.8 million on commercially insured patients in 2021, the state data shows. Commercial insurance payments covered only 59.5% of what it cost to care for those patients. That compares with a statewide average of 156%, according to Melnick.

Paolinelli said Madera tried to negotiate better rates with commercial health plans but “does not have much leverage with the payors.” She added that many residents of Madera who get commercial insurance through their employers choose Kaiser Permanente, whose nearest acute care hospital is in Fresno, 20 miles away.

State Democratic Sen. Anna Caballero, whose district includes parts of Madera, Merced, and Fresno counties, said that if Madera Community Hospital were to successfully reopen, more people with commercial insurance would have to choose it over other hospitals outside the county, which they had not been doing frequently.

“The county and the city may need to say, ‘If you need hospitalization, you need to go to Madera, and there will be no copay, but if you go out of the county, there’s a copay you have to pay,’” Caballero said.

But with no clear path to reopening yet in sight, Caballero said, that discussion is premature.

Melissa Montalvo covers Latino communities for The Fresno Bee as part of the Central Valley News Collaborative, a partnership that includes The Fresno Bee, Vida en el Valle, Valley Public Radio, and Radio Bilingüe. This article is part of the Central Valley News Collaborative, which is supported by the Central Valley Community Foundation with technology and training support from Microsoft Corp.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Ahora, después que el hospital sin fines de lucro de Madera cerrara y se declarara en bancarrota, la situación no podría ser más distinta.

St. Agnes está impulsando la liquidación de los bienes del hospital para recuperar un préstamo que le hizo a Madera, aunque signifique acabar con las esperanzas de los activistas comunitarios, líderes políticos y funcionarios de salud que esperan que el centro de salud todavía pueda reabrir.

Un momento crucial en el caso podría ocurrir el 25 de julio, cuando el juez de un tribunal de bancarrota de Fresno escuche argumentos sobre si se debería permitir que el hospital de Madera gaste sus escasas reservas de efectivo para cubrir el mantenimiento del edificio, costos de seguridad, servicios públicos y los salarios de sus tres ejecutivos.

El hospital quiere mantener una operación con un mínimo de personal mientras busca un comprador y desarrolla su plan de reapertura. Pero el tribunal federal de bancarrota de Fresno le permitió gastar dinero solo hasta el 29 de julio. Si el juez piensa que el plan del hospital no es viable, podría rechazar una extensión, lo cual probablemente significaría la liquidación.

Problemas como el de Madera son comunes en otros hospitales pequeños con situaciones financieras precarias en California, y en todo el país. Por lo general, estos hospitales tienen un bajo volumen de pacientes y dependen desproporcionadamente de los pagos de Medicaid y Medicare, lo cual limita los ingresos y la posibilidad de atraer talento o invertir en equipos de última generación.

A esto se le suman los gastos abrumadores ocasionados por la pandemia de covid-19. Docenas de estos hospitales luchan por sobrevivir; otros dos, también en California, se declararon en bancarrota este año.

Sin embargo, Madera también tenía problemas generados internamente. El hospital ganó dinero con pacientes asegurados por Medi-Cal, el programa de seguro para californianos de bajos ingresos cuyas tarifas son notoriamente bajas, según datos financieros presentados ante los reguladores estatales. Pero perdió dinero con pacientes cubiertos por seguros comerciales, debido al bajo volumen y a acuerdos no favorables con los proveedores de seguros.

Y no recurrió de manera oportuna a programas de asistencia financiera durante la pandemia de covid. Un fondo de rescate estatal para el hospital llegó demasiado tarde.

Además, Madera no contaba con un plan de contingencia cuando St. Agnes y su compañía matriz, la cadena de hospitales Trinity Health, abandonaron su propuesta de fusionarse con el hospital a fines del año pasado, prácticamente sin aviso y con pocas explicaciones. Esta decisión conmocionó y enfureció a los funcionarios, ex empleados y defensores comunitarios en Madera y Sacramento.

En un breve comunicado de prensa en diciembre, St. Agnes y Trinity atribuyeron su decisión a “circunstancias complejas” y “condiciones adicionales” impuestas por el fiscal general estatal Rob Bonta. Pero expertos en la industria dijeron que Bonta había aceptado la mayor parte de lo que pedía St. Agnes y que las razones por las que abandonaron el acuerdo eran un misterio.

El hecho de que St. Agnes y Trinity ahora estén impulsando la liquidación del pequeño hospital ha provocado la ira de Bonta.

“Lo importante para Trinity siempre ha sido el dinero y no la salud de la comunidad de Madera”, dijo Bonta a KFF Health News en un comunicado. “Ahora están tratando de usar su posición como el mayor acreedor de Madera para extraer cada dólar posible, en lugar de tener en cuenta los intereses de la comunidad”.

Bonta dijo que le había “ofrecido la máxima flexibilidad a Trinity en reconocimiento a las circunstancias financieras de Madera”.

Madera es una zona agrícola de 2,150 millas cuadradas con una población de casi 160,000 personas. El condado es 60% hispano y más de una quinta parte de sus residentes viven por debajo de la línea de pobreza, según datos del censo.

Una comunidad abandonada

Jennifer Lara, ex asistente de enfermería del Madera Community Hospital, dijo que ella y sus colegas esperaban cambios positivos después de la esperada fusión con St. Agnes. “Cuando nos enteramos de que el hospital iba a cerrar, no lo podíamos creer”, dijo. “Solo pensamos que el hospital iba a continuar”.

St. Agnes y Trinity se negaron a hacer comentarios. Nancy Hollingsworth, directora ejecutiva de St. Agnes por muchos años, se jubiló en mayo en medio de una reorganización de la compañía que hizo al hospital parte de un grupo regional con sede en Idaho. No está claro si su salida estuvo relacionada con lo que pasó con el acuerdo con Madera. No se pudo contactar a Hollingsworth para un comentario.

La considerable ventaja de St. Agnes en el caso de bancarrota es el resultado de un préstamo de $15.4 millones que le otorgó a Madera durante las conversaciones sobre la fusión el año pasado. Desde entonces, Madera pagó $8 millones, dejando una deuda de más de $7 millones. St. Agnes sigue siendo su mayor acreedor.

St. Agnes, uno de los 88 hospitales pertenecientes a Trinity, un sistema de salud sin fines de lucro católico y multiestatal con sede en Livonia, Michigan, argumentó recientemente en un documento para el tribunal de bancarrota que Madera todavía no ha hecho avances significativos en su búsqueda de un comprador, más de cuatro meses después de solicitar la protección por bancarrota del Capítulo 11 el 10 de marzo, y que no se le debe permitir seguir gastando dinero “sin un camino serio hacia la venta o el cierre del hospital”.

El hospital ha estado hablando con tres socios potenciales, “uno de los cuales llega tarde al juego”, dijo Riley Walter, abogado de Madera especialista en bancarrotas.

Mohammad Ashraf, cardiólogo y miembro del comité ejecutivo del personal médico de Madera, dijo que las dos primeras entidades en cuestión, a las que se negó a identificar, son organizaciones de servicios de gestión, no grupos hospitalarios. “No quieren gastar dinero para comprarlo. Solo quieren ejecutarlo”, dijo.

Sin una estrategia convincente para el futuro de Madera Community Hospital, el final del caso de bancarrota podría llegar rápidamente.

Ranjit S. Rajpal, cardiólogo de Madera durante más de 40 años, dijo que el cierre del hospital es una mala noticia para los pacientes que necesitan atención de urgencia, como aquellos que sufren un ataque cardíaco, un accidente cerebrovascular u otros traumas, y que ahora deben viajar más lejos para recibir atención.

Y el cierre profundizará las desigualdades de salud existentes para las personas que enfrentan desafíos para recibir atención debido a su estatus migratorio, barreras de idioma, falta de transporte u otros factores socioeconómicos, dijo. “Esas disparidades se agravarán con el tiempo”.

Los líderes comunitarios y la dirección del hospital tienen la esperanza de reabrir. El hospital ha solicitado $80 millones del nuevo fondo de préstamo de $300 millones de California para hospitales en apuros.

Los líderes de los hospitales deben diseñar un plan de reapertura antes del 31 de julio, pero incluso si lo hacen, es poco probable que obtengan el monto total solicitado: 16 hospitales ya pidieron préstamos por un total de más de $385 millones, dijo Joe DeAnda, vocero de la Oficina del Tesorero del Estado de California.

“No van a dar una cuarta parte del total de su fondo a un hospital que ni siquiera tiene un socio”, dijo Glenn Melnick, economista de salud de la Universidad del Sur de California y autor de un análisis sobre la propuesta de fusión de St. Agnes y Madera encargado por la oficina del Procurador General. “Hace dieciocho meses, la demanda habría sido mucho menor”.

Incluso si Madera Community Hospital encuentra un socio viable y obtiene los fondos que necesita, la reapertura sería difícil y costosa. El hospital tendría que contratar a cientos de enfermeros, técnicos y otro personal en un mercado laboral de atención de salud limitado y caro, y encontrar la manera de evitar los problemas financieros que lo llevaron a la bancarrota.

“Algunas cosas que ofrece un hospital de cuidados intensivos son rentables y otras no”, dijo Jay Varney, oficial administrativo del condado de Madera, cuyo trabajo es similar al de un director ejecutivo. “No tiene mucho sentido que se vuelva a abrir como estaba y que quiebre de nuevo”.

“Se está acabando el tiempo”

Reabrir el hospital con todos los servicios que brindaba antes no es la única opción.

Baldwin Moy, abogado de California Rural Legal Assistance, un grupo de defensa de la comunidad, dijo que él y sus colegas han estado abogando para que el tribunal le otorgue a Madera tiempo adicional para encontrar un comprador o para que el condado “reúna fondos para reabrir la sala de emergencias con una operación clínica simplificada”. Pero “se les está acabando el tiempo”, dijo Moy.

Karen Paolinelli, directora ejecutiva del hospital, dijo que los postulantes actuales están interesados ​​en reabrirlo como un centro de cuidados intensivos que “tendría o no todos los servicios que ofrecía el hospital de Madera antes”.

Si el hospital pudiera resistir unos meses más, dice, podría cobrar $23.5 millones que debe el estado en “tarifas de proveedores” y posiblemente $10 millones más de la Agencia Federal para el Manejo de Emergencias (FEMA). Esos pagos cubrirían con creces la deuda total del hospital de $30 millones. Pero la cantidad y fecha de los pagos no están claros.

Paolinelli, al expresar una queja común de la industria, dijo que el hospital tiene una cantidad desproporcionadamente alta de pacientes de Medi-Cal y que las tarifas que tiene este programa no cubren el costo de brindar atención.

Pero los datos estatales muestran que Madera recibió pagos suplementarios que suman casi $15 millones de Medi-Cal en 2021, aunque perdió más de $11 millones en el tratamiento de pacientes de Medicare. Madera también perdió alrededor de $6.8 millones en pacientes con seguros comerciales en 2021, según muestran los datos estatales. Los pagos de seguros comerciales cubrieron solo el 59.5% de lo que costó atender a esos pacientes. Eso se compara con un promedio estatal de 156%, según Melnick.

Paolinelli dijo que Madera trató de negociar mejores tarifas con los planes de salud comerciales, pero “no tienen mucha influencia sobre los proveedores”. Agregó que muchos residentes de Madera que obtienen un seguro comercial a través de sus empleadores eligen Kaiser Permanente, cuyo hospital de atención aguda más cercano está en Fresno, a 20 millas de distancia.

La senadora estatal demócrata Anna Caballero, cuyo distrito incluye partes de los condados de Madera, Merced y Fresno, dijo que si Madera Community Hospital reabriera con éxito, más personas con seguro comercial tendrían que elegirlo en lugar de ir a otros hospitales fuera del condado, algo que no habían estado haciendo con frecuencia.

“El condado y la ciudad van a tener que decir: ‘Si necesitas hospitalización, debes ir a Madera y no habrá copago, pero si sales del condado, tendrás un copago”, dijo Caballero.

Pero sin un plan claro para la reapertura, esa discusión es prematura, agregó.

Melissa Montalvo cubre las comunidades latinas para The Fresno Bee como parte de Central Valley News Collaborative, una asociación que incluye The Fresno Bee, Vida en el Valle, Valley Public Radio y Radio Bilingüe. Este artículo es parte de Central Valley News Collaborative, que cuenta con el respaldo de Central Valley Community Foundation con tecnología y soporte de capacitación de Microsoft Corp.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

About three weeks before his May move, Tennison called the agency that administers Medi-Cal in Contra Costa County, where Walnut Creek is located, to inform them he’d be moving to San Joaquin County.

Little did he suspect his transfer would get tangled in red tape, disrupt his care, and saddle him with two bills totaling nearly $1,700 after he was removed from his old plan without notice before his new one in Stockton took effect.

Medi-Cal members who move counties are often bumped temporarily from managed care insurance plans into traditional Medi-Cal, also known as “fee for service,” in which the state pays providers directly for each service rendered. But managed care practitioners who don’t participate in traditional Medi-Cal have no way to get paid when they see such patients, and they sometimes bill them directly — even though that’s prohibited.

Medi-Cal is a statewide program, but it is administered by the counties, which have separate government bureaucracies and different approaches to care: Some have just one county-operated Medi-Cal plan. Others have only commercial health plans, which are paid by the state to manage the care of Medi-Cal patients. Many have one of each.

Traveling from Walnut Creek to Stockton takes a little more than an hour by car, but as far as Tennison is concerned, the two cities might as well be on opposite sides of the planet.

Tennison, 63, needed a smooth health care transition. With severe chronic pain in his back, shoulders, and neck, he requires regular physical therapy and monitoring by an orthopedist, as well as multiple pain medications. He also has carpal tunnel syndrome and Type 2 diabetes.

Because of miscommunication and confusion surrounding his move, several physical therapy appointments he’d made for June 2022 were canceled, and he had to wait nearly two months for new ones.

“To me the whole issue is the confusion,” Tennison said. “Right hand and left hand, nobody talks to each other, and nobody talked to me.”

The first hint of trouble came when he called Contra Costa County Employment & Human Services in late April 2022 to report his upcoming move and was told the new county had to initiate the transfer — only to hear from a worker at San Joaquin’s Human Services Agency that it was the other way around.

They were both wrong: Medi-Cal members who move can inform either county.

Tennison persuaded a Medi-Cal worker in San Joaquin County to initiate the transfer. He also filed a notice of his move online, which Medi-Cal workers in Contra Costa processed and flagged for a June 2 transfer date, said Marla Stuart, director of the county’s Employment & Human Services Department.

They set that date, Stuart said, because they believed Tennison might have some medical appointments in May under his Contra Costa Anthem Blue Cross plan.

Medi-Cal workers in San Joaquin County, however, set a move date of May 5, which overrode Contra Costa’s June 2 date and bumped Tennison from his Anthem plan for most of May, according to Stuart.

“If anybody had called me to verify any of this, I definitely would have told them May 5 was the wrong date,” said Tennison, who moved to Stockton on May 17.

“There were good intentions all around,” said Stuart. “It’s unfortunate what happened.”

Being cut from Anthem left Tennison with fee-for-service Medi-Cal, a rapidly shrinking part of the program.

He discovered it only in mid-July, when he called the Office of the Ombudsman for managed care Medi-Cal to complain about two bills he’d received — one for $886.92 from his orthopedic surgeon and another for $795 from his physical therapist.

He had seen both providers in May, when he thought he was still covered by Anthem. But he wasn’t, and they billed him directly, despite signed agreements and a state law that prohibit billing patients for services covered by Medi-Cal.

The bills caught Tennison by surprise, because the ombudsman had told him in early June that he had still been on Anthem through May, he said.

“To me, that’s how insurance works: One insurance ends, the other begins,” he said.

When Medi-Cal patients are between health plans and temporarily in fee for service, it theoretically ensures they have ongoing access to health care. But in practice, that’s not always the case.

“Because the state is pushing most Medi-Cal members into managed care, fewer providers are accepting fee for service,” said Hillary Hansen, an attorney with Legal Services of Northern California who is handling Tennison’s case.

The prohibition against billing Medi-Cal patients is spottily enforced, Hansen said. And although the patients are not legally required to pay, she said, their credit rating can suffer if they don’t. Michael Bowman, a spokesperson for Anthem, said the company regularly communicates with its providers to ensure compliance with the terms of their contracts and Medi-Cal rules.

Hansen is not confident Tennison’s bills will be paid anytime soon. After legal aid lawyers sent a letter to state officials about improper Medi-Cal billing, and later met with them about it, the officials instructed them to have their clients submit reimbursement claims.

But the reimbursement rules require that patients have already paid the bills, and Medi-Cal beneficiaries typically can’t afford that, Hansen said.

Tennison submitted his reimbursement form in May and is waiting to hear back. “Getting medical care should not be this difficult,” he said. “Here it is a year later, and I’m still trying to work this out.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).