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  • For-profit companies open psychiatric hospitals in areas clamoring for care

    For-profit companies open psychiatric hospitals in areas clamoring for care

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    A for-profit company has proposed turning a boarded-up former nursing home here into a psychiatric hospital, joining a national trend toward having such hospitals owned by investors instead of by state governments or nonprofit health systems.

    The companies see a business opportunity in the shortage of inpatient beds for people with severe mental illness.

    The scarcity of inpatient psychiatric care is evident nationwide, especially in rural areas. People in crisis often are held for days or weeks in emergency rooms or jails, then transported far from their hometowns when a bed opens in a distant hospital.

    Eight nonprofit Iowa hospitals have shuttered their psychiatric units since 2007, often citing staffing and financial challenges. Iowa closed two of its four mental health institutions in 2015.

    The state now ranks last in the nation for access to state-run psychiatric hospitals, according to the Treatment Advocacy Center. The national group, which promotes improving care for people with severe mental illness, recommends states have at least 50 state-run psychiatric beds per 100,000 people. Iowa has just two such beds per 100,000 residents, the group said.

    Two out-of-state companies have developed psychiatric hospitals in Iowa in the past four years, and now a third company has obtained a state “certificate of need” to open a 60-bed facility in Grinnell.

    Before 2020, Iowa had no privately owned, free-standing psychiatric hospitals. But several national companies specialize in developing such facilities, which treat people in crisis from conditions such as depression, schizophrenia, or bipolar disorder, sometimes compounded by drug or alcohol abuse. One of the companies operating in Iowa, Universal Health Services, says it has mental health facilities in 39 states.

    Lisa Dailey, the Treatment Advocacy Center’s executive director, said that for-profit hospitals don’t necessarily provide worse care than nonprofit ones but that they tend to be less transparent and more motivated by money. “Private facilities are private,” she said. “As a result, you may not have a great insight into why they make the decisions that they make.”

    Dailey said solid data on privately run mental health hospitals nationwide is scarce. But she has heard for-profit companies have recently set up free-standing psychiatric hospitals in several states, including California. The California Department of Public Health confirmed three such facilities have opened there since 2021, in Aliso Viejo, Madera, and Sacramento.

    The latest Iowa psychiatric hospital would be housed in a vacant nursing home on the outskirts of Grinnell, a college town of 9,500 people in a rural region of the state. The project’s developers noted there are no other inpatient mental health facilities in Poweshiek County, where Grinnell is located, or in any of the eight surrounding counties. The nearest inpatient mental health facilities are 55 miles west in Des Moines.

    The Indiana-based company proposing the hospital, Hickory Recovery Network, primarily runs addiction treatment centers in Indiana. But it opened psychiatric hospitals in Ohio and Texas in 2023 and 2024, and it told Iowa regulators it could open the Grinnell hospital by August.

    An affiliated company ran the facility as a nursing home, called the Grinnell Health Care Center, until 2022, according to a Hickory Recovery Network filing with Iowa regulators.

    Medicare rated the nursing home’s overall quality at just two out of five stars. And in 2020, the facility was suspended indefinitely from Iowa’s Medicaid program because of billing issues, state records show.

    Officials from Hickory Recovery Network responded only briefly to KFF Health News inquiries, including about how the former Iowa nursing home’s spotty record could affect the proposed psychiatric hospital.

    In a short telephone interview in February, Melissa Durkin, the company’s chief operating officer, declined to say who owns Hickory Recovery Network.

    Durkin denied in the interview that her organization was associated with the company that ran the defunct and troubled Grinnell nursing home.

    However, Hickory Recovery’s application for a certificate of need refers to the nursing home operator as “Hickory’s affiliated company.” In testimony before Iowa regulators, Durkin made a similar reference as she expressed confidence her organization could find sufficient staff to reopen the facility as a psychiatric hospital. “We have a history with that building. We operated a nursing home there before,” she said at the video-recorded hearing.

    Durkin said in the interview that company leaders had not decided for sure to redevelop the vacant Iowa nursing home into a psychiatric hospital, although they twice went through the complicated process of applying for a state “certificate of need” for the project. The first attempt was stymied in 2023 by a tie vote of the board that considers such permits, which are a major hurdle for large health care projects. The second application was approved by a unanimous vote after a hearing on Jan. 25.

    Keri Lyn Powers, a Hickory executive, told regulators the company planned to spend $1.5 million to remodel the building. The main changes would include making rooms safe for people who might be suicidal, she said.

    The company predicted in its application that 90% of the hospital’s patient revenues would come from Medicare or Medicaid, public programs for seniors or people who have low incomes or disabilities. It doesn’t mention that the nursing home was suspended from Iowa’s Medicaid program, which covers about half of the state’s nursing home residents.

    Iowa authorities suspended the Grinnell Health Care Center nursing home in 2020 for failing to repay nearly $25,000 in overpayments from Medicaid, state records show. When the nursing home closed in 2022, its former medical director told the local newspaper part of the reason for its demise was its inability to collect Medicaid reimbursements. Iowa administrators recently notified the owners that the former nursing home owed $284,676 to Medicaid. A state spokesperson said in March that neither amount had been repaid.

    The proposal to reopen the building as a psychiatric hospital won support from patient advocates, Grinnell’s nonprofit community hospital, and the regional mental health coordinator.

    The only opposition at the state hearing came from Kevin Pettit, leader of one of Iowa’s two other private free-standing psychiatric hospitals. Pettit is chief executive officer of Clive Behavioral Health Hospital, a 100-bed facility in suburban Des Moines that opened in 2021. Pettit told regulators he supports expanding mental health services, but he predicted the proposed Grinnell facility would struggle to hire qualified employees.

    He said despite strong demand for care, many Iowa psychiatric facilities are limiting admissions. “The beds exist, but they’re not actually open, … because we’re dealing with staffing issues throughout the state,” Pettit testified.

    Overall, Iowa has 901 licensed inpatient mental health beds, including in psychiatric units at community hospitals, in free-standing psychiatric hospitals, and in the two remaining state mental health institutes, according to the Iowa Department of Health and Human Services. But as of January, just 738 of those beds were staffed and being used.

    Pettit’s facility is run by Pennsylvania-based Universal Health Services in partnership with MercyOne, a hospital system based in the Des Moines area.

    In an interview, Pettit said his hospital only has enough staff to use about half of its beds. He said it’s especially difficult to recruit nurses and therapists, even in an urban area with a relatively robust labor supply.

    State inspectors have cited problems at the Clive facility, including four times declaring that deficiencies put patients’ safety in “immediate jeopardy.” Those issues included insufficient staff to properly monitor patients and insufficient safeguards to prevent access to items patients could use to choke or cut themselves.

    Pettit said such citations are not unusual in the tightly regulated industry. He said the organization is committed to patient safety. “We value the review by our regulatory entities during the survey process and view any finding as an opportunity for continuous improvement of our operations,” he wrote in an email.

    Iowa’s other privately owned psychiatric hospital, Eagle View Behavioral Health in Bettendorf, also has been cited by state inspectors. The 72-bed hospital was purchased in 2022 by Summit BHC from Strategic Behavioral Health, which opened the facility in 2020. Both companies are based in Tennessee.

    State inspectors have cited the Bettendorf facility twice for issues posing “immediate jeopardy” to patient safety. In 2023, inspectors cited the facility for insufficient supervision of patients, “resulting in inappropriate sexual activity” between adult and adolescent patients. In 2021, the facility was cited for insufficient safety checks to prevent suicide attempts and sexual misconduct.

    Eagle View officials did not respond to requests for comment.

    Advocates for Iowa patients have supported the development of free-standing psychiatric hospitals.

    Leslie Carpenter of Iowa City, whose adult son has been hospitalized repeatedly for severe mental illness, spoke in favor of the Grinnell facility’s application for a certificate of need.

    In an interview afterward, Carpenter said she was optimistic the new facility could find enough staff to help address Iowa’s critical shortage of inpatient psychiatric care.

    She said she would keep a close eye on how the new facility fares. “I think if a company were willing to come in and do the job well, it could be a game changer.”




    Kaiser Health NewsThis article was reprinted from khn.org, 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.

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  • Study explores factors contributing to rural-urban difference in cervical cancer screening

    Study explores factors contributing to rural-urban difference in cervical cancer screening

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    Study reveals English proficiency, income, and area-level unemployment are among the influential factors and highlights need for tailored interventions to increase screening rates. 

    In the United States, community health centers (CHCs) mainly serve historically marginalized populations. New research reveals that both before and during the COVID-19 pandemic, females receiving care at rural CHCs were less likely to be up to date with cervical cancer screening than those in urban CHCs. Factors associated with these differences included the proportion of patients with limited English proficiency and low income, as well as area-level unemployment and primary care physician density. The findings are published by Wiley online in CANCER, a peer-reviewed journal of the American Cancer Society. 

    In the analysis of data from CHCs in operation across all 50 states and the District of Columbia, investigators found that 38.2% of females receiving care at rural CHCs were up to date on cervical cancer screening during 2014–2019, compared with 43.0% of females receiving care at urban CHCs. This difference widened during the pandemic to 43.5% versus 49.0%. 

    The rural-urban difference in screening was mostly explained by differences in CHC-level proportions of patients with limited English proficiency. This accounted for 55.9% of the difference. Differences in the proportions of patients with income below the poverty level accounted for 12.3% of the rural-urban difference in screening, and the proportion of females aged 21–64 years accounted for 9.8% of the difference. Differences in area-level unemployment accounted for 3.4% of the difference, and differences in primary care physician density accounted for 3.2% of the difference. Differences between rural-urban CHCs were counterbalanced (meaning that differences were reduced) by the proportion of uninsured patients and patients with Medicaid coverage. (There were lower proportions of uninsured or Medicaid patients in rural CHCs. If rural CHCs had equal or larger proportions of uninsured or Medicaid patients as urban CHCs, the rural-urban gap would have been larger.) 

    The contributing factors’ effects on rural-urban differences in cervical cancer screening generally increased during the pandemic in 2020–2021. 

    “In our study, a higher proportion of patients best served in a language other than English in urban CHCs was the top contributor to rural-urban differences in up-to-date cervical cancer screening. A possible explanation for this finding might be greater access to language translation services in urban CHCs, as clinics serving a greater proportion of racial and ethnic minority groups are more likely to provide better translation services,” said lead author Hyunjung Lee, PhD, MS, MPP, MBA, of the American Cancer Society.

    Increasing access to language translation services or adaptation of patient navigator interventions might improve completion and timeliness of cancer screening in CHCs and among patients with limited English proficiency, especially in rural CHCs. Insufficient funding remains a challenge to initiate and manage these activities, particularly in rural CHCs.” 

    Hyunjung Lee, PhD, MS, MPP, MBA, Lead Author, American Cancer Society

    Dr. Lee stressed that the prevalence of cervical cancer screening in CHCs is generally lower than in the general population, underscoring the need to improve cancer screening rates in both rural and urban CHCs to detect the disease at earlier stages, when treatment is most successful.

    Source:

    Journal reference:

    Lee, H., et al. (2024). Factors contributing to differences in cervical cancer screening in rural and urban community health centers. Cancer. doi.org/10.1002/cncr.35265.

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  • Your doctor or your insurer? Little-known rules may ease the choice in Medicare Advantage

    Your doctor or your insurer? Little-known rules may ease the choice in Medicare Advantage

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    Bart Klion, 95, and his wife, Barbara, faced a tough choice in January: The upstate New York couple learned that this year they could keep either their private, Medicare Advantage insurance plan — or their doctors at Saratoga Hospital.

    The Albany Medical Center system, which includes their hospital, is leaving the Klions’ Humana plan — or, depending on which side is talking, the other way around. The breakup threatened to cut the couple’s lifeline to cope with serious chronic health conditions.

    Klion refused to pick the lesser of two bad options without a fight.

    He contacted Humana, the Saratoga hospital, and the health system. The couple’s doctors “are an exceptional group of caregivers and have made it possible for us to live an active and productive life,” he wrote to the hospital’s CEO. He called his wife’s former employer, which requires its retirees to enroll in a Humana Medicare Advantage plan to receive company health benefits. He also contacted the New York StateWide Senior Action Council, one of the nationwide State Health Insurance Assistance Programs that offer free, unbiased advice on Medicare.

    Klion said they all told him the same thing: Keep your doctors or your insurance.

    With rare exceptions, Advantage members are locked into their plans for the rest of the year — while health providers may leave at any time.

    Disputes between insurers and providers can lead to entire hospital systems suddenly leaving the plans. Insurers must comply with extensive regulations from the Centers for Medicare & Medicaid Services, including little-known protections for beneficiaries when doctors or hospitals leave their networks. But the news of a breakup can come as a surprise.

    In the nearly three decades since Congress created a private-sector alternative to original, government-run Medicare, the plans have enrolled a record 52% of Medicare’s 66 million older or disabled adults, according to the CMS. But along with getting extra benefits that original Medicare doesn’t offer, Advantage beneficiaries have discovered downsides. One common complaint is the requirement that they receive care only from networks of designated providers.

    Many hospitals have also become disillusioned by the program.

    “We hear every day, from our hospitals and health systems across the country, about challenges they experience with Medicare Advantage plans,” said Michelle Millerick, senior associate director for health insurance and coverage policy at the American Hospital Association, which represents about 5,000 hospitals. The hurdles include prior authorization restrictions, late or low payments, and “inappropriate denials of medically necessary covered services,” she said.

    “Some of these issues get to a boiling point where decisions are made to not participate in networks anymore,” she said.

    An escape hatch

    CMS gives most Advantage members two chances to change plans: during the annual open enrollment period in the fall and from January until March 31.

    But a few years ago, CMS created an escape hatch by expanding special enrollment periods, or SEPs, which allow for “exceptional circumstances.” Beneficiaries who qualify can request SEPs to change plans or return to original Medicare.

    According to CMS rules, there’s an SEP patients may use if their health is in jeopardy due to problems getting or continuing care. This may include situations in which their health care providers are leaving their plans’ networks, said David Lipschutz, an associate director at the Center for Medicare Advocacy.

    Another SEP is available for beneficiaries who experience “significant” network changes, although CMS officials declined to explain what qualifies as significant. However, in 2014, CMS offered this SEP to UnitedHealthcare Advantage members after the insurer terminated contracts with providers in 10 states.

    When providers leave, CMS ensures that the plans maintain “adequate access to needed services,” Meena Seshamani, CMS deputy administrator and director of the federal Center for Medicare, said in a statement.

    While hospitals say insurers are pushing them out, insurers blame hospitals for the turmoil in Medicare Advantage networks.

    “Hospitals are using their dominant market positions to demand unprecedented double-digit rate increases and threatening to terminate their contracts if insurers don’t agree,” said Ashley Bach, a spokesperson for Regence BlueShield, which offers Advantage plans in Idaho, Oregon, Utah, and Washington state.

    Patients get caught in the middle.

    “It feels like the powers that be are playing chicken,” said Mary Kay Taylor, 69, who lives near Tacoma, Washington. Regence BlueShield was in a weeks-long dispute with MultiCare, one of the largest medical systems in the state, where she gets her care.

    “Those of us that need this care and coverage are really inconsequential to them,” she said. “We’re left in limbo and uncertainty.”

    Other breakups this year include Baton Rouge General hospital in Louisiana leaving Aetna’s Medicare Advantage plans and Baptist Health in Kentucky leaving UnitedHealthcare and Wellcare Advantage plans. In San Diego, Scripps Health has left nearly all the area’s Advantage plans.

    In North Carolina, UNC Health and UnitedHealthcare renewed their contract just three days before it would have expired, and only two days before the deadline for Advantage members to switch plans. And in New York City, Aetna told its Advantage members this year to be prepared to lose access to the 18 hospitals and other care facilities in the NewYork-Presbyterian Weill Cornell Medical Center health system, before reaching an agreement on a contract last week.

    Limited choices

    Taylor didn’t want to lose her doctors or her Regence Advantage plan. She’s recovering from surgery and said waiting to see how the drama would end “was really scary.”

    So, last month, she enrolled in another plan, with help from Tim Smolen, director of Washington’s SHIP, Statewide Health Insurance Benefits Advisors program. Soon afterward, Regence and MultiCare agreed to a new contract. But Taylor is allowed only one change before March 31 and can’t return to Regence this year, Smolen said.

    Finding an alternative plan can be like winning at bingo. Some patients have multiple doctors, who all must be easy to get to and covered by the new plan. To avoid bigger, out-of-network bills, they must find a plan that also covers their prescription drugs and includes their preferred pharmacies.

    “A lot of times, we may get through the provider network and find that that’s good to go but then we get to the drugs,” said Kelli Jo Greiner, state director of Minnesota’s SHIP, Senior LinkAge Line. Since Jan. 1, counselors there have helped more than 900 people switch to new Advantage plans after HealthPartners, a large health system based in Bloomington, left Humana’s Medicare Advantage plans.

    Choices are more limited for low-income beneficiaries who receive subsidies for drugs and monthly premiums, which only a few plans accept, Greiner said.

    For almost 6 million people, a former employer chooses a Medicare Advantage plan and requires them to enroll in it to receive retiree health benefits. If they want to keep a provider who leaves that plan, those beneficiaries must forfeit all their employer-subsidized health benefits, often including coverage for their families.

    The threat of losing coverage for their providers was one reason some New York City retirees sued Mayor Eric Adams to stop efforts to force 250,000 of them into an Aetna Advantage plan, said Marianne Pizzitola, president of the New York City Organization of Public Service Retirees, which filed the lawsuit. The retirees won three times, and city officials are appealing again.

    CMS requires Advantage plans to notify their members 45 days before a primary care doctor leaves their plan and 30 days before a specialist physician drops out. But counselors who advise Medicare beneficiaries say the notice doesn’t always work.

    “A lot of people are experiencing disruptions to their care,” said Sophie Exdell, a program manager in San Diego for California’s SHIP, the Health Insurance Counseling & Advocacy Program. She said about 32,000 people in San Diego lost access to Scripps Health providers when the system left most of the area’s Advantage plans. Many didn’t get the notice or, if they did, “they couldn’t get through to someone to get help making a change,” she said.

    CMS also requires plans to comply with network adequacy rules, which limit how far and how long members must travel to primary care doctors, specialists, hospitals, and other providers. The agency checks compliance every three years or more often if necessary.

    In the end, Bart Klion said he had no alternative but to stick with Humana because he and his wife couldn’t afford to give up their retiree health benefits. He was able to find doctors willing to take on new patients this year.

    But he wonders: “What happens in 2025?”




    Kaiser Health NewsThis article was reprinted from khn.org, 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.

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  • California is expanding insurance access for teenagers seeking therapy on their own

    California is expanding insurance access for teenagers seeking therapy on their own

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    When she was in ninth grade, Fiona Lu fell into a depression. She had trouble adjusting to her new high school in Orange County, California, and felt so isolated and exhausted that she cried every morning.

    Lu wanted to get help, but her Medi-Cal plan wouldn’t cover therapy unless she had permission from a parent or guardian.

    Her mother — a single parent and an immigrant from China — worked long hours to provide for Fiona, her brother, and her grandmother. Finding time to explain to her mom what therapy was, and why she needed it, felt like too much of an obstacle.

    “I wouldn’t want her to have to sign all these forms and go to therapy with me,” said Lu, now 18 and a freshman at UCLA. “There’s a lot of rhetoric in immigrant cultures that having mental health concerns and getting treatment for that is a Western phenomenon.”

    By her senior year of high school, Lu turned that experience into activism. She campaigned to change state policy to allow children 12 and older living in low-income households to get mental health counseling without their parents’ consent.

    In October of last year, Gov. Gavin Newsom signed a new law expanding access to young patients covered by Medicaid, which is called Medi-Cal in California.

    Teenagers with commercial insurance have had this privilege in the state for more than a decade. Yet parents of children who already had the ability to access care on their own were among the most vocal in opposing the expansion of that coverage by Medi-Cal.

    Many parents seized on the bill to air grievances about how much control they believe the state has over their children, especially around gender identity and care.

    One mother appeared on Fox News last spring calling school therapists “indoctrinators” and saying the bill allowed them to fill children’s heads with ideas about “transgenderism” without their parents knowing.

    Those arguments were then repeated on social media and at protests held across California and in other parts of the country in late October.

    At the California Capitol, several Republican lawmakers voted against the bill, AB 665. One of them was Assembly member James Gallagher of Sutter County.

    “If my child is dealing with a mental health crisis, I want to know about it,” Gallagher said while discussing the bill on the Assembly floor last spring. “This misguided, and I think wrongful, trend in our policy now that is continuing to exclude parents from that equation and say they don’t need to be informed is wrong.”

    State lawmaker salaries are too high for them or their families to qualify for Medi-Cal. Instead, they are offered a choice of 15 commercial health insurance plans, meaning children like Gallagher’s already have the privileges that he objected to in his speech.

    To Lu, this was frustrating and hypocritical. She said she felt that the opponents lining up against AB 665 at legislative hearings were mostly middle-class parents trying to hijack the narrative.

    “It’s inauthentic that they were advocating against a policy that won’t directly affect them,” Lu said. “They don’t realize that this is a policy that will affect hundreds of thousands of other families.”

    Sponsors of AB 665 presented the bill as a commonsense update to an existing law. In 2010, California lawmakers had made it easier for young people to access outpatient mental health treatment and emergency shelters without their parents’ consent by removing a requirement that they be in immediate crisis.

    But at the last minute, lawmakers in 2010 removed the expansion of coverage for teenagers by Medi-Cal for cost reasons. More than a decade later, AB 665 is meant to close the disparity between public and private insurance and level the playing field.

    “This is about equity,” said Assembly member Wendy Carrillo, a Los Angeles Democrat and the bill’s author.

    The original law, which regulated private insurance plans, passed with bipartisan support and had little meaningful opposition in the legislature, she said. The law was signed by a Republican governor, Arnold Schwarzenegger.

    “Since then, the extremes on both sides have gotten so extreme that we have a hard time actually talking about the need for mental health,” she said.

    After Carrillo introduced the bill last year, her office faced death threats. She said the goal of the law is not to divide families but to encourage communication between parents and children through counseling.

    More than 20 other states allow young people to consent to outpatient mental health treatment without their parents’ permission, including Colorado, Ohio, Tennessee, and Alabama, according to a 2015 paper by researchers at Rowan University.

    To opponents of the new law, like Erin Friday, a San Francisco Bay Area attorney, AB 665 is part of a broader campaign to take parents’ rights away in California, something she opposes regardless of what kind of health insurance children have.

    Friday is a self-described lifelong Democrat. But then she discovered her teenager had come out as transgender at school and for months had been referred to by a different name and different pronouns by teachers, without Friday’s knowledge. She devoted herself to fighting bills that she saw as promoting “transgender ideology.” She said she plans to sue to try to overturn the new California law before it takes effect this summer.

    “We’re giving children autonomy they should never have,” Friday said.

    Under the new law, young people will be able to talk to a therapist about gender identity without their parents’ consent. But they cannot get residential treatment, medication, or gender-affirming surgery without their parents’ OK, as some opponents have suggested.

    Nor can minors run away from home or emancipate themselves under the law, as opponents have also suggested.

    “This law is not about inpatient psychiatric facilities. This law is not about changing child custody laws,” said Rachel Velcoff Hults, an attorney and the director of health of the National Center for Youth Law, which supported AB 665.

    “This law is about ensuring when a young person needs counseling or needs a temporary roof over their head to ensure their own safety and well-being, that we want to make sure they have a way to access it,” she said.

    Removing the parental consent requirement could also expand the number of mental health clinicians in California willing to treat young people on Medi-Cal. Without parental consent, under the old rules, clinicians could not be paid by Medi-Cal for the counseling they provided, either in a private practice or a school counselor’s office.

    Esther Lau struggled with mental health as a high school student in Fremont. Unlike Lu, she had her parents’ support, but she couldn’t find a therapist who accepted Medi-Cal. As the only native English speaker in her family, she had to navigate the health care bureaucracy on her own.

    For her, AB 665 will give clinicians incentive to accept more young people from low-income households into their practices.

    “For the opposition, it’s just about political tactics and furthering their agenda,” Lau said. “The bill was designed to expand access to Medi-Cal youth, period.”




    Kaiser Health NewsThis article was reprinted from khn.org, 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.

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  • After Appalachian hospitals merged into a monopoly, their ERs slowed to a crawl

    After Appalachian hospitals merged into a monopoly, their ERs slowed to a crawl

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    In the small Appalachian city of Bristol, Virginia, City Council member Neal Osborne left a meeting on the morning of Jan. 3 and rushed himself to the hospital.

    Osborne, 36, has Type 1 diabetes. His insulin pump had malfunctioned, and without a steady supply of this essential hormone, Osborne’s blood sugar skyrocketed and his body was shutting down.

    Osborne went to the nearest hospital, Bristol Regional Medical Center. He said he settled into a wheelchair in the emergency room waiting area, where over the next few hours he drifted in and out of consciousness and retched up vomit, then bile, then blood. After 12 hours in the waiting room, Osborne said, he was moved to an ER bed, where he stayed until he was sent to the intensive care unit the next day. In total, the council member was in the ER for about 30 hours, he said.

    Osborne said his ordeal echoes stories he’s heard from constituents for years. In his next crisis, Osborne said, he plans to leave Bristol for an ER about two hours away.

    “I want to go to Knoxville or I want to go to Roanoke, because I do not want to further risk my life and die at a Ballad hospital,” he said. “The wait times just to get in and see a doctor in the ER have grown exponentially.”

    Ballad Health, a 20-hospital system in the Tri-Cities region of Tennessee and Virginia, benefits from the largest state-sanctioned hospital monopoly in the United States. In the six years since lawmakers in both states waived anti-monopoly laws and Ballad was formed, ER visits for patients sick enough to be hospitalized grew more than three times as long and now far exceed the criteria set by state officials, according to Ballad reports released by the Tennessee Department of Health.

    Tennessee and Virginia have so far announced no steps to reduce time spent in Ballad ERs. The Tennessee health department, which has a more direct role in regulating Ballad, has each year issued a report saying the agreement that gave Ballad a monopoly “continues to provide a Public Advantage.” Department officials have twice declined to comment to KFF Health News on Ballad’s performance.

    According to Ballad’s latest annual report, which was released this month and spans from July 2022 to June 2023, the median time that patients spend in Ballad ERs before being admitted to the hospital is nearly 11 hours. This statistic includes both time spent waiting and time being treated in the ER and excludes patients who weren’t admitted or left the ER without receiving care.

    The federal government once tracked ER speed the same way. When compared against the latest corresponding federal data from 2019, which includes more than 4,000 hospitals but predates the covid-19 pandemic, Ballad ranks among the 100 hospitals with the slowest ERs. More current federal data is not available because the Centers for Medicare & Medicaid Services retired this statistic in 2020 in favor of other measurements.

    Newer data tells a similar story. The Joint Commission, a nonprofit that accredits health care organizations, collected this same measurement for 2022 from about 250 hospitals that volunteered the data, finding a median ER speed of five hours and 41 minutes — or about five hours faster than Ballad’s latest annual report.

    Ballad Health spokesperson Molly Luton said in an email statement that, by holding patients in the ER, where they are observed while waiting for a bed, Ballad avoids “overwhelming” its staff. Luton said ER delays are also caused by two nationwide crises: a nursing shortage and fewer admissions at nursing homes and similar facilities, which can create a backlog of patients awaiting discharge from the hospital.

    Luton added that Ballad’s ER time for admitted patients has dropped to about 7½ hours in the months since the company’s latest annual report.

    “On those issues Ballad Health can directly control, our performance has rebounded from 2022, and is now among the best in the nation,” Luton said.

    Luton also noted that Ballad performs better than or close to the national average on several other measurements of ER performance, including having fewer patients who leave without being treated. CMS data shows the national average is about 3%. Ballad reported 1.4% in its latest annual report.

    Osborne, the Bristol council member, attributed this statistic to Ballad’s monopoly.

    “Just because they aren’t leaving the ER doesn’t mean they are happy where they are,” he said. “It just means they don’t have anywhere else they could be.”

    Ballad’s big monopoly

    Ballad Health was formed in 2018 after state officials approved the nation’s biggest hospital merger based on a so-called Certificate of Public Advantage, or COPA, agreement. COPAs have been used in about 10 hospital mergers over the past three decades, but none has involved as many hospitals as Ballad’s.

    State lawmakers in Tennessee and Virginia waived federal anti-monopoly laws so rival hospital systems — Mountain States Health Alliance and Wellmont Health System — could merge into a single company with no competition. Ballad is now the only option for hospital care for most of about 1.1 million residents in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina.

    The Federal Trade Commission warns that hospital monopolies lead to increased prices and decreased quality of care. To offset the perils of Ballad’s monopoly, officials required the new company to commit to a long list of special conditions, including dozens of quality-care metrics spelled out with specific benchmarks.

    In its latest annual report, Ballad improved on many quality-of-care metrics over the prior year, including several that the company prioritized, but still fell short on 56 of 75 benchmarks.

    ER time for admitted patients is one of those. The benchmark was set at three hours and 47 minutes in the original COPA agreement. Ballad met or nearly met this goal for three years, according to its annual reports. Then the ERs slowed.

    In 2022, Ballad reported a median ER time for admitted patients of about six hours.

    In 2023, it reported the same statistic at seven hours and 40 minutes.

    In the latest report, ER time for admitted patients had reached 10 hours and 45 minutes.

    CMS, which grades thousands of hospitals nationwide, warns on its website that timely ER care is “essential for good patient outcomes,” and that more time spent in the ER has been linked to higher complication rates and delays in patients getting pain medication and antibiotics.

    Ben Harder, chief of health analysis for U.S. News & World Report, said extensive ER times can be a symptom of slowdowns throughout a hospital, including in the operating room.

    “A long delay in getting patients admitted is both a risk in itself, in that a test may not get conducted as promptly,” Harder said. “But it’s also an indication that the hospital is backed up, and that there are problems getting patients moved from one unit to another.”

    Bill Christian, a spokesperson for the Tennessee Department of Health, said Ballad’s rising ER times had been “noted” but did not say if the agency had taken or was considering any action. Christian directed questions about Ballad’s latest stats to the company itself.

    ‘A nightmare for community members’

    Ballad has also fallen short — by about $191 million over the past five years — of its obligation to Tennessee to provide charity care, which is free or discounted care for low-income patients, according to health department documents and Ballad’s latest report. The health department waived this obligation in each of the past four fiscal years. Ballad has said it would ask for another this year.

    In a two-hour interview last year, Ballad CEO Alan Levine defended his company and said that because the Tri-Cities region could not support two competing hospital companies, the COPA merger had likely prevented at least three hospital closures. Levine attributed Ballad’s failure to meet quality benchmarks to the pressure of the covid pandemic and said charity care shortfalls were partly caused by Medicaid changes beyond Ballad’s control.

    “Our critics say, ‘No Ballad. We don’t want Ballad.’ Well, then what?” Levine said. “Because the hospitals were on their way to being closed.”

    Some residents see Ballad as a savior. John King, who runs a physical therapy clinic in the core of Ballad’s region, said at a public hearing last June that in multiple visits to Ballad ERs, including one for a stroke, he found their care to be quick and compassionate.

    “If it weren’t for Ballad Health, I literally would not be here today,” King said, according to a hearing transcript.

    Ballad’s failures to live up to the terms of the COPA agreement were detailed in a KFF Health News investigation last September, and the company faced a new wave of criticism in the months that followed.

    Local leaders in Carter County, Tennessee, in October debated but did not pass a resolution calling for Ballad to be better regulated or broken up. Tennessee Attorney General Jonathan Skrmetti, a Republican, said in an interview with the Tennessee Lookout published in November that Ballad must be constantly monitored in light of community complaints. Earlier this month, Tennessee state Rep. David Hawk (R-Greeneville), who represents a region within Ballad’s monopoly, called for Levine’s resignation, according to wjhl.com.

    In response, Ballad Health said in a statement it has “strong relationships with the majority of elected officials” in Carter County and welcomed scrutiny from the Tennessee attorney general. Ballad said Hawk’s “opinion certainly does not reflect our broader relationships” within the area. Tennessee lawmakers are also considering legislation to forbid future COPA mergers in the state, which Ballad said “risks putting more hospitals at risk for closure.”

    The bill was introduced by state Sen. Heidi Campbell (D-Nashville) and state Rep. Gloria Johnson (D-Knoxville), who is running for the U.S. Senate. Johnson said the bill would end Ballad’s protection from antitrust laws.

    “It’s just been a nightmare for community members out there,” Johnson said. “And they have no other option.”




    Kaiser Health NewsThis article was reprinted from khn.org, 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.

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  • Study suggests treating anxiety and depression significantly reduces ER visits and rehospitalizations among heart disease patients

    Study suggests treating anxiety and depression significantly reduces ER visits and rehospitalizations among heart disease patients

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    Ischemic heart disease (IHD) is a major cause of illness and death in developed countries. While advanced technology has boosted survival and rehabilitation odds, not much is known about the impact of anxiety or depression on the eventual outcomes. The prevalence of heart failure (HF) is predicted to increase by half in 2030. This will mean that eight million adults with HF, with almost $31 billion being required to treat them.

    Study: Impact of Mental Health Treatment on Outcomes in Patients With Heart Failure and Ischemic Heart Disease. Image Credit: sitthiphong/Shutterstock.com
    Study: Impact of Mental Health Treatment on Outcomes in Patients With Heart Failure and Ischemic Heart Disease. Image Credit: sitthiphong/Shutterstock.com

    A new study looks at this area in order to provide evidence for key recommendations in the treatment of such patients.

    Mental health and heart disease outcomes

    Several previous studies have reported that anxiety and depression are independent risk factors for IHD and HF. Anxiety increases the incidence of IHD and HF by 41% and 35%, respectively, while increasing IHD-related mortality by 41%. Since anxiety and depression may originate in common factors, further research on their cross-linkage with cardiovascular disease and its outcomes is necessary.

    Moreover, anxiety and depression both increase the odds of rehospitalizations and Emergency Department (ED) visits, pushing up healthcare costs. However, there is contradictory evidence for the benefits of treating anxiety or depression in IHD or HF, including recent trials like the SADHEART (Sertraline Antidepressant Heart Attack Randomized Trial).

    Yet these mental and physical conditions reduce the quality of life, acting synergistically with the others due to their shared pathways. For instance, “coexistence of depression results in perception of symptom severity that exceed measures of actual functional impairment.”

    About the study

    The aim of the current study, published online in the Journal of the American Heart Association, aimed to examine the effect of treatment for anxiety or depression on the odds of repeated hospital admissions, ED visits, or mortality.

    The researchers used a population-based cohort from the Ohio Medicaid database, exploring data retrospectively to assess the link between being treated for these conditions and future outcomes. All participants had ischemic heart disease (IHD) or heart failure, along with anxiety or depression.

    There were ~1,500 participants, over 80% being White, with a mean age of 50 years. The upper age limit was 64 since people older than this are not eligible for Medicaid.

    Treatment of anxiety and depression in the cohort

    Over 92% were diagnosed with anxiety and 56% with depression. About half were disabled, a similar number had a history of substance use, and almost 60% had lung disease.

    They were treated medically with antidepressant medication, or with psychotherapy, or both. About a quarter were on both courses of treatment, while ~30% were on antidepressants only and 15% on psychotherapy alone.

    Anxiety was diagnosed in 90% of those on both therapies and depression in 70%. In the antidepressant group, 93% were anxious, and 53% were depressed. The corresponding figures in the psychotherapy group were similar.

    The majority of those on treatment with antidepressants, alone or in combination with psychotherapy, were on benzodiazepines, antipsychotics, or mood stabilizers. Tricyclic antidepressants were used by a small proportion of patients.

    About half the patients were on beta-blockers for their heart conditions, 36% on angiotensin-converting enzyme inhibitors (ACEIs), and 26% on calcium channel blockers. 

    How did treatment affect outcomes?

    For all outcomes except mortality from IHD, “those who received some form of mental health treatment were significantly less likely to experience the outcome than those who received no mental health treatment.”

    Those who received both psychotherapy and antidepressant therapy showed the greatest benefit in all three outcomes compared to no treatment and also when compared to either therapeutic modality alone.

    The group treated with both modalities was 75% less likely to require another hospitalization or ED visit. After compensating for all known confounding factors, the risk of all-cause mortality dropped by 65% compared to those not treated for their mental ill-health.

    With psychotherapy alone, there was a 40% reduction in mortality from all causes. There was no significant difference in the antidepressant-only group. None of the treatments resulted in a difference in the risk of IHD mortality, perhaps because the study was underpowered to detect this effect.

    ED visits were reduced with all treatments. The combination therapy group showed a reduction of 74% compared to the no-treatment group. Psychotherapy alone, or antidepressants alone, was linked to a reduction in risk by 50%.

    Hospital readmissions were also lower with combined therapy, at ~75% below the no-treatment group. With psychotherapy alone or antidepressants alone, the risk was approximately 50% and 60% lower, respectively.

    Future implications

    “This article is the first to show that mental health treatment may be associated with reduced risk for relevant outcomes.”

    The unequivocal findings indicate the need to screen heart patients for anxiety and depression. If these conditions are diagnosed, providing appropriate treatment markedly improves the risk of rehospitalization and ED visits. Strategies must be optimized to diagnose and treat anxiety and depression in this group of patients to improve their quality of life.

    Sympathetic activation occurs with anxiety and depression, along with heart disease. This results in the release of pro-inflammatory cytokines, promoting the progression of all three conditions. This may explain in part why treatment of mental ill-health improves the incidence of cardiovascular events.

    This marks an advance from earlier studies that focused mostly on the safety of administering such medications to patients with IHD or HF and fills this research gap. Treating anxiety and depression in heart patients not only improves their health outcomes but may significantly reduce their healthcare costs, with a positive cost-benefit ratio.

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  • California’s expanded health coverage for immigrants collides with Medicaid reviews

    California’s expanded health coverage for immigrants collides with Medicaid reviews

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    Medi-Cal health coverage kicked in for Antonio Abundis just when the custodian needed it most.

    Shortly after Abundis transitioned from limited to full-scope coverage in 2022 under California’s expansion of Medi-Cal to older residents without legal immigration status, he was diagnosed with leukemia, a cancer affecting the blood cells. The soft-spoken father of three took the news in stride as his doctor said his blood test suggested his cancer wasn’t advanced. His next steps were to get more tests and formulate a treatment plan with a cancer team at Epic Care in Emeryville. But all of that was derailed when he showed up last July for bloodwork at La Clínica de La Raza in Oakland and was told he was no longer on Medi-Cal.

    “They never sent me a letter or anything telling me that I was removed,” Abundis, now 63, said in Spanish about losing his insurance.

    Abundis is among hundreds of thousands of Latinos who have been kicked off Medi-Cal, California’s Medicaid program for low-income people, as states resume annual eligibility checks that were paused at the height of the covid-19 pandemic. The redetermination process, as it is known, has disproportionately affected Latinos, who make up a majority of Medi-Cal beneficiaries. According to the California Department of Health Care Services, more than 653,000 of the more than 1.3 million residents who have been disenrolled over eight months identify as Latino. Some, including Abundis, had only recently gained coverage as the state expanded Medi-Cal to residents without legal residency.

    The collision of state and federal policies has not only set off enrollee whiplash but swelled demand for enrollment assistance as people are dropped from Medi-Cal, often for procedural issues. Health groups serving Latino communities report being inundated by requests for help, but at the same time, a state-sponsored survey suggests Hispanic households are more likely than other ethnic or racial groups to lose coverage because they’re less knowledgeable of the renewal process. They may also struggle to advocate for themselves.

    Some health advocates are pressing for a pause. They warn that disenrollments will not only undercut the state’s effort to reduce the number of uninsured but could exacerbate health disparities, particularly for an ethnic group that bore the brunt of the pandemic. One national study found that Latinos in the U.S. were three times as likely to contract covid and twice as likely to die of it than the general population, in part because they tend to live in more crowded or multigenerational households and work in front-line jobs.

    “These difficulties place all of us as a community in this more fragile state where the safety net means even more now,” said Seciah Aquino, executive director of the Latino Coalition for a Healthy California, a health advocacy organization.

    Assembly member Tasha Boerner, an Encinitas Democrat, has introduced a bill that would slow disenrollments by allowing people 19 and older to keep their coverage automatically for 12 months and extend flexible pandemic-era policies such as not requiring proof of income in certain cases for renewals. That would benefit Hispanics, who make up nearly 51% of the Medi-Cal population compared with 40% of the overall state population. The governor’s office said it does not comment on pending legislation.

    Tony Cava, a spokesperson for the Department of Health Care Services, said in an email that the agency has taken steps to increase the number of people automatically reenrolled in Medi-Cal and does not consider a pause necessary. The disenrollment rate dropped 10% from November to December, Cava said.

    Still, state officials acknowledge more could be done to help people complete their applications. “We’re still not reaching certain pockets,” said Yingjia Huang, assistant deputy director of health care benefits and eligibility at DHCS.

    California was the first state to expand Medicaid eligibility to all qualified immigrants regardless of legal status, phasing it in over several years: children in 2016, young adults ages 19-26 in 2020, people 50 and older in 2022, and all remaining adults this year.

    But California, like other states, resumed eligibility checks last April, and the process is expected to continue through May. The state is now seeing disenrollment rates return to pre-pandemic levels, or 19%-20% of the Medi-Cal population each year, according to DHCS.

    Jane Garcia, CEO of La Clínica de La Raza, testified before the Alameda County Board of Supervisors’ health committee that disenrollments continue to pose a challenge just as her team tries to enroll newly eligible residents. “It’s a heck of a load on our staff,” she told supervisors in January.

    Although many beneficiaries no longer qualify because their incomes rose, more have been dropped from the rolls for failing to respond to notices or return paperwork. Often, renewal packets were sent to old addresses. Many find out they’ve lost coverage only upon seeking medical care.

    “They knew something was happening,” said Janet Anwar, eligibility manager at Tiburcio Vasquez Health Center in the East Bay. “They didn’t know exactly what it was, how it was gonna affect them until actually the day came and they were disenrolled. And they were getting checked in or scheduling an appointment, then, ‘Hey, you lost your coverage.’”

    But reenrollment is a challenge. A state-sponsored survey published Feb. 12 by the California Health Care Foundation found 30% of Hispanic households tried but were unable to complete a renewal form, compared with 19% for white non-Hispanic households. And 43% of Hispanics reported they would like to restart Medi-Cal but did not know how, versus 32% of people in white non-Hispanic households. 

    The Abundis family is among those who don’t know where to get their questions answered. Though Abundis’ wife submitted the family’s Medi-Cal renewal paperwork in October, his wife and two children who still live with them were able to maintain coverage; Abundis was the only one dropped. He hasn’t received an explanation for being disenrolled nor been notified how to appeal or reapply. Now he worries he may not qualify on his own based on his roughly $36,000 annual income since the limit is $20,121 for an individual but $41,400 for a family of four.

    It is likely an eligibility worker could check if he and his family qualify as a household or assist him with signing up for a private plan that can run less than $10 a month for premiums on Covered California. The health insurance exchange allows for special enrollment when people lose Medi-Cal or employer-based coverage. But Abundis assumes he won’t be able to afford premiums or copays, so he hasn’t applied.

    Abundis, who first visited a doctor in May 2022 about unrelenting fatigue, constant pain in his back and knees, shortness of breath, and unexplained weight loss, worries he’s unable to afford medical care. La Clínica de La Raza, the community health clinic where he received blood testing, worked with him that day so he didn’t have to pay upfront, but he has since stopped seeking medical care.

    More than a year after his diagnosis, Abundis still doesn’t know which stage cancer he has, or what his treatment plan should be. Though early cancer detection can lead to a higher chance of survival, some types of leukemia advance quickly. Without further testing, Abundis does not know his outlook.

    “I’ve mentally prepared,” Abundis said of his cancer. “What happens, happens.”

    Even those who seek help run into challenges. Marisol, a 53-year-old immigrant from Mexico who lives in Richmond, California, without legal permission, tried to reestablish coverage for months. Although the state saw a 26% drop in disenrollments from December to January, the share of Latinos disenrolled during that period remained nearly the same, suggesting they face more barriers to renewal.

    Marisol, who requested her last name be withheld out of fear of deportation, also qualified for full-scope Medi-Cal during the state expansion to all immigrants 50 and older.

    She received a packet in December letting her know that her household income exceeded Medi-Cal’s threshold — something she believed was an error. Marisol’s husband is out of work due to a back injury, she said, and her two children primarily support their family with part-time jobs at Ross Dress for Less.

    That month, Marisol visited a Richmond branch office of the Contra Costa County Employment and Human Services Department, hoping to speak to an eligibility worker. Instead, she was told to leave her paperwork and to call a phone number to check her application status. Since then, she made numerous calls and spent hours on hold, but has not been able to speak with anyone.

    County officials acknowledged longer wait times due to increased calls and said the average wait time is 30 minutes. “We understand community members’ frustration when they have difficulty getting through at times,” spokesperson Tish Gallegos wrote in an email. Gallegos noted the call center increases staffing during peak hours.

    After El Tímpano reached out to the county for comment, Marisol said she was contacted by an eligibility worker, who explained that her family was dropped because their children had filed taxes separately, so the Medi-Cal system determined their eligibility individually rather than as one household. The county reinstated Marisol and her family on March 15.

    Marisol said regaining Medi-Cal was a joyous but bittersweet ending to a months-long struggle, especially knowing that other people get dropped for procedural issues. “Sadly, there has to be pressure for them to fix something,” she said.

    Jasmine Aguilera of El Tímpano is participating in the Journalism & Women Symposium’s Health Journalism Fellowship, supported by The Commonwealth Fund. Vanessa Flores, Katherine Nagasawa, and Hiram Alejandro Durán of El Tímpano contributed to this article.




    Kaiser Health NewsThis article was reprinted from khn.org, 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.

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  • Special drug-pricing program boosts prostate cancer treatment adherence

    Special drug-pricing program boosts prostate cancer treatment adherence

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    Prostate cancer patients receiving care at hospitals that are part of a special drug-pricing program were more likely to stick to their prescription drug therapy than patients at other hospitals, according to a study from researchers at the University of Michigan’s Rogel Cancer Center and Institute for Healthcare Policy and Innovation.

    The 340B Drug Pricing Program is a federal program that requires the pharmaceutical industry to provide a discount on the cost of drugs to participating hospitals who serve a disproportionate number of Medicare and Medicaid patients. The program was started to enable hospitals to stretch scarce resources, reach more patients and provide more comprehensive services.

    In the field of advanced prostate cancer, there’s been a paradigm shift to using newer targeted oral treatments. But these drugs are expensive, and cost can limit access to these drugs, particularly among those who are socioeconomically disadvantaged. We wanted to see if the 340B program could help mitigate this disparity.”

    Kassem Faraj, M.D., study first author, urologic oncology fellow at Michigan Medicine

    The team looked back at a 20% sample of Medicare beneficiaries diagnosed with advanced prostate cancer and assessed who was treated with these targeted therapies at a hospital-based program. They identified 2,237 men treated at 340B-participating hospitals and 1,100 treated at non-participating hospitals.

    They then looked at the social vulnerability index, a measure developed by the U.S. Centers for Disease Control and Prevention that characterizes socioeconomic, racial and household characteristics at the community-level. They found that patients from areas with greater social vulnerability were less likely to use the oral drugs. There was no difference in use between 340B and non-340B hospitals.

    However, patients receiving treatment at 340B hospitals were more likely to continue treatment. The researchers saw that in non-340B hospitals, as social vulnerability increased, adherence dropped. But in 340B hospitals, adherence remained flat regardless of social vulnerability. Results were published in Cancer.

    “There are many reasons why adherence to these drugs can drop. We suspect that 340B hospitals potentially have some resources or mechanisms that are helping these vulnerable patients maintain adherence,” Faraj said. This could include medication management programs or financial help for out-of-pocket drug costs.

    “While 340B participation didn’t increase the number of patients using this therapy, it was associated with better treatment adherence among patients from socially vulnerable areas,” Faraj said.

    Additional authors: Samuel R. Kaufman, Mary Oerline, Lindsey Herrel, Avinash Maganty, Megan E.V. Caram, Vahakn B. Shahinian, Brent K. Hollenbeck

    Funding for this work is from National Cancer Institute grants T32 CA180984, R01 CA275993, R01 CA269367.

    Source:

    Michigan Medicine – University of Michigan

    Journal reference:

    Faraj, K. S., et al. (2024). The 340B Program and oral specialty drugs for advanced prostate cancer. Cancer. doi.org/10.1002/cncr.35262.

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  • Treatment for anxiety and depression associated with improved heart disease outcomes

    Treatment for anxiety and depression associated with improved heart disease outcomes

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    Treating anxiety and depression reduced emergency room visits and rehospitalizations among people with heart disease, according to new research published today in the Journal of the American Heart Association, an open access, peer-reviewed journal of the American Heart Association.

    For patients who had been hospitalized for coronary artery disease or heart failure and who had diagnoses of anxiety or depression, treatment with psychotherapy, pharmacotherapy or a combination of the two was associated with as much as a 75% reduction in hospitalizations or emergency room visits. In some cases, there was a reduction in death.”


    Philip Binkley, M.D., M.P.H., lead study author, executive vice chair of the department of internal medicine and emeritus professor of internal medicine and public health at The Ohio State University in Columbus, Ohio

    Binkley noted that anxiety and depression are common in people with heart failure, and mental health can have a significant impact on an individual’s risk of other health conditions, disability and death.

    In this study, Binkley and colleagues examined the association of mental health treatment with antidepressant medication or psychotherapy, also known as talk therapy or a combination of the two in relation to, emergency room visits, hospitalizations and death in people with blocked arteries or heart failure and with a formal diagnosis of anxiety or depression before hospitalization.

    The analysis found using three different statistical models that adjusted for different variables and compared to patients not receiving treatment for anxiety or depression:

    • For people who received both medication and talk therapy for anxiety or depression the risk of hospitalization was reduced by 68% to 75% the risk of being seen in the emergency department was reduced by 67% to 74%, and the risk of death from any cause was reduced by 65% to 67%.

    • Psychotherapy treatment alone was associated with a 46% to 49% reduction of risk for hospital readmission and a 48% to 53% reduction in emergency room visits.

    • Medication treatment alone reduced hospital readmission by 47% to 58% and reduced ER visits by 41% to 49%.

    • Follow-up time was variable based on the needs of each patient.

    “Heart disease and anxiety/depression interact such that each promotes the other,” Binkley said. “There appear to be psychologic mechanisms that link heart disease with anxiety and depression that are currently under investigation. Both heart disease and anxiety/depression are associated with activation of the sympathetic nervous system. This is part of the so-called involuntary nervous system that increases heart rate, blood pressure and can also contribute to anxiety and depression.”

    Binkley considers the large number of people with heart disease and the marked reduction in hospitalizations and emergency room visits and the drop in death to be the strength of the study.

    “I hope the results of our study motivate cardiologists and health care professionals to screen routinely for depression and anxiety and demonstrate that collaborative care models are essential for the management of cardiovascular and mental health. I would also hope these findings inspire additional research regarding the mechanistic connections between mental health and heart disease,” he said.

    Study details and background:

    • 1,563 adults ages 22 to 64 over a three-year period were included, and all participants had a first hospital admission for blocked arteries or heart failure and had two or more health insurance claims for an anxiety disorder or depression.

    • Sixty-eight percent of participants were women, and 81% were noted as white race. All were enrolled in Ohio’s Medicaid program during the six months prior to the hospital admission. Health data was from two sources: Ohio Medicaid claims and Ohio death certificate files from July 1, 2009, to June 30, 2012.

    • Participants were followed through the end of 2014 or until death or the end of Medicaid enrollment.

    • About 23% of participants received both antidepressant medications and psychotherapy; nearly 15 percent received psychotherapy alone; 29% took antidepressants alone; and 33% received no mental health treatment.

    • About 92% of participants in the study were diagnosed with anxiety and 55.5% with depression prior to hospitalization.

    The study was limited to people enrolled in Medicaid, therefore, it may not be representative of people covered by commercial health insurance plans. In addition, the majority of participants were noted as white race, therefore, these finding are not applicable to people of other races, ethnicities or communities.

    Source:

    American Heart Association

    Journal reference:

    Carmin, C. N., et al. (2024) Impact of Mental Health Treatment on Outcomes in Patients With Heart Failure and Ischemic Heart Disease. Journal of the American Heart Association. doi.org/10.1161/JAHA.123.031117.

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  • Amid mental health staffing crunch, Medi-Cal patients help one another

    Amid mental health staffing crunch, Medi-Cal patients help one another

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    Three people gathered in a classroom on a recent rainy afternoon listened intently as Derrick Cordero urged them to turn their negative feelings around.

    “What I’m hearing is that you’re a self-starter,” he told one participant, who had taken up gardening but yearned for a community with which to share the hobby.

    Cordero, 48, is guiding the discussion at Holding Hope, a weekly therapy group for people struggling with mental health. Anyone receiving mental health services through Solano County can participate.

    A former member, Cordero is now the group’s volunteer peer leader. He initially joined in 2020 while dealing with mental illness and substance use — and found that sharing with others who had been through similar trials could be deeply healing.

    “Not all of us are going to speak about” pain, said Cordero, who is covered by Medi-Cal, California’s Medicaid program, which insures low-income people. “But when one does, another does, and then next week another does, and it becomes like a connective tissue.”

    These groups can offer essential support in a public system beset by workforce shortages, Cordero said. Two are run entirely by peer leaders, who help build trust by sharing personal experiences, said Cheryl Akoni, a marriage and family therapist who works for Solano County and leads Holding Hope alongside Cordero.

    “You’re amongst your peers,” Akoni said. “You’re amongst people who have lived and shared experiences that you often might not get with your therapist because we have to keep our boundaries.”

    In California, mental health care for Medi-Cal enrollees is provided by managed care insurers and county mental health plans. Among its services, Solano County Behavioral Health provides case management and appointments with therapists and psychiatrists, plus five groups, ranging from Holding Hope to a journaling collective.

    In 2022, California started allowing counties to use Medicaid dollars to pay peer support leaders for their work, a benefit 51 of the state’s 58 counties have adopted, according to the state Department of Health Care Services. To qualify, individuals must undergo training and get certified by the California Mental Health Services Authority.

    Cordero isn’t yet getting paid for his work with Holding Hope. He said he’s building experience as a volunteer and plans to seek his certification when the next training takes place.

    Cordero’s family immigrated to California from the Philippines, and the tension between his American and Filipino identities caused anxiety as a child, he said. He first thought about killing himself around age 13 and didn’t feel he could be honest about his mental health with his family.

    “I had American problems for my parents and family who had a traditional Filipino paradigm,” he said.

    Cordero was diagnosed with borderline personality disorder in his 20s and was addicted to marijuana and methamphetamine throughout his adult life. Amid these challenges, Cordero took human services courses at Solano Community College and started to speak to high school classes about mental health and addiction. When that program ended, the loss of structure was destabilizing, he said.

    “I just dove headlong into substance abuse,” Cordero said.

    He missed his daughters’ school graduations. His diabetes went untreated, and his addiction grew more severe.

    During the covid-19 pandemic, social distancing restrictions made it difficult for Cordero to obtain illegal drugs. He experienced severe withdrawal symptoms, along with a blood infection and complications from his untreated diabetes. This resulted in a series of hospital visits — and it was during one of these that Cordero was enrolled in Medi-Cal.

    After he recovered, Cordero contacted Solano County seeking mental health treatment. He was told there would be a wait for a therapist due to covid-19 and staffing shortages but was encouraged to attend Holding Hope in the meantime.

    He quickly took to sharing in the group, and after about a year of his attending, its former leader encouraged Cordero to assume a bigger role, he said.

    “It was great to talk, and I can ramble forever,” Cordero recalled. “She said, ‘I think you can do better than that.’”

    He started leading the group with Akoni in January.

    Not every person who seeks mental health help is ready for or needs a therapist, but for those who do, groups and peer support can provide connection and community as they wait, said Emery Cowan, director of Solano County Behavioral Health.

    At least 90% of the city and county behavioral health agencies who responded to a survey commissioned by the County Behavioral Health Directors Association of California in 2021 reported difficulty recruiting psychiatrists, licensed clinical social workers, and licensed marriage and family therapists.

    The counties pointed to multiple staffing challenges: They generally can’t offer salaries comparable to the private sector; don’t appeal to applicants who want to work remotely or have flexible schedules; and have trouble finding and keeping providers with the training and experience to handle the complex patient population.

    Cordero was paired with a psychiatrist right after his intake appointment. He finally added his name to the waitlist for a therapist in 2022 and said it took about a year to get matched with someone.

    Solano County Behavioral Health relies on Medi-Cal-certified peer leaders and volunteer peer leaders, like Cordero, who run groups, help clients prepare for appointments, and craft wellness recovery plans.

    “They’ve lived that experience, they know how hard it is, they’re more willing to do it because they want to help people just like them,” Cowan said. “They were that person.”

    Cowan and Cordero acknowledge that group therapy isn’t for everyone. Discussing personal challenges or traumatic incidents in front of a group can be intimidating, and some people need more individualized care.

    But for those who are a good fit, there is community to be found.

    At the recent gathering of Holding Hope, participants discussed relationships and loneliness. Cordero shared that he still finds it difficult to maintain close bonds with family and friends, and that he feels lonely.

    He repeatedly encouraged his peers to reframe negative thoughts and experiences, explaining that anguish can start feeling comfortable, almost like a routine, and that breaking out of that routine can feel challenging.

    To emphasize his point, Cordero circled back to a particular phrase several times over the hour: “The path to pain is a well-carved path.”

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




    Kaiser Health NewsThis article was reprinted from khn.org, 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.

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