Martin Khor, Third Worldist

3 Apr

PENANG, Apr 03 (IPS) – Martin Khor Kok Peng passed away just after the end of the first quarter of 2020. He leaves behind an unusually rich legacy. Atypically for people mainly working in the worldideas, he was also a very practical and pragmatic acti…

Overwhelmed Hospitals Face a New Crisis: Staffing Firms Are Cutting Their Doctors’ Hours and Pay

3 Apr

by Isaac Arnsdorf

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

The country’s top employers of emergency room doctors are cutting their hours — leaving clinicians with lower earnings and hospitals with less staff in the middle of a pandemic.

TeamHealth, a major medical staffing company owned by the private-equity giant Blackstone, is reducing hours for ER staff in some places and asking for voluntary furloughs from anesthesiologists, the company confirmed to ProPublica. Multiple ER providers working for a main competitor, KKR-owned Envision Healthcare, said their hours also are being cut.

Even as some hospitals risk running out of room to care for COVID-19 patients, demand for other kinds of health care is collapsing. This irony is straining the business models of hospitals and the companies that staff them with doctors and other medical professionals.

Most ER doctors aren’t direct employees of the hospitals where they work. Historically, the doctors belonged to practice groups that contracted with the hospitals. In recent years, private-equity investors started buying up and consolidating those practice groups into massive staffing companies.

Reduced hours are also hitting doctors employed by SCP Health, another medical staffing company backed by the investment firm Onex Corporation, according to internal memos obtained by ProPublica. US Acute Care Solutions, backed by the private-equity firm Welsh, Carson, Anderson & Stowe, said it’s cutting hours in some places while increasing staffing elsewhere.

The staffing companies said they’re responding to dropping revenue as non-coronavirus patients avoid the ER and hospitals cancel elective procedures. The companies also emphasize that they’re not cutting physicians’ hourly rates.

But by assigning fewer hours to doctors and other providers such as physician’s assistants and nurse practitioners, the companies are effectively paying them less. It also means that some hospitals have fewer clinicians working in the ER at a time.

“These actions are unacceptable and unnecessary,” Scott Hickey, president of the Virginia College of Emergency Physicians, said in a statement. “This is very likely the ‘calm before the storm’ of critically ill patients entering hospitals with COVID-19 symptoms. Who will be there waiting to save those lives?”

The steepest cuts so far have occurred at Alteon Health, whose private-equity backers are New Mountain Capital and Frazier Healthcare Partners. The company says ER visits are down as much as 40% nationwide. In addition to the benefits cuts that ProPublica first reported on Tuesday, Alteon is furloughing some clinicians for 30 days to six months and won’t guarantee any hours for part-time employees, according to company memos obtained by ProPublica.

“Anyone not willing or unable to share the burden will need to be terminated to preserve employment for those who really feel part of our team and care about their coworkers,” one manager wrote.

Alteon said its ER doctors and clinicians in places that are inundated with COVID-19 patients are working longer hours and being paid more. “We are doing all we can to provide the support to the people who are on the front lines of this fight right now and ensure we have resources for those who may be called on to do even more when surges come to their areas in the future,” the company said in a statement to ProPublica.

In an earlier statement posted on Alteon’s website, CEO Steve Holtzclaw said ProPublica’s earlier article “mischaracterized” Alteon’s actions, saying, “We have not cut clinical rates for providers in the field.” In fact, ProPublica reported that Alteon wasn’t cutting rates but was cutting hours, and fewer hours at the same rate amounts to lower earnings.

“It was worded in a way to make it sound like we weren’t affected by this, but by cutting our hours we are,” said an ER clinician who works for Alteon and has had hours reduced in a hospital with coronavirus patients. (The clinician, like others interviewed by ProPublica, spoke on the condition of anonymity because company policy prohibits their speaking publicly.) “When they’re saying clinician pay is not affected, it certainly is. That was a straight lie.”

The clinician added: “Health care workers are being applauded in the streets, and we are being stepped on by them.”

TeamHealth initially told ProPublica that it was “not instituting any reduction in pay or benefits.” However, the company is in fact paying some clinicians less in the form of reducing their hours. The company provided a new statement saying “we are not instituting any reduction in rate of pay or benefits as our emergency physicians face current challenges.”

An ER clinician who works for TeamHealth said, “I probably wouldn’t have complained as this situation is unprecedented, but to see TeamHealth blatantly lying is infuriating.”

TeamHealth said it has reduced hours in some markets but is maintaining staffing above current demand in anticipation of a future surge of COVID-19 patients. While the company is asking anesthesiologists to take furloughs that may be mandatory if there aren’t enough volunteers, TeamHealth said it’s also looking for ways for anesthesiologists to use their skills to help out in emergency rooms or intensive care units. Blackstone declined to comment.

While some ERs in New York are overflowing with coronavirus patients, in many places people are staying home instead of going to the hospital. Studies have repeatedly shown that much of the care provided in the emergency room is for non-life-threatening issues.

“We always try to match our clinician coverage to our patient flow and we have done our best to do the same in this unpredictable time,” Amer Aldeen, US Acute Care Solutions’ chief medical officer, said in a statement. The company has not laid off, furloughed, reduced pay rates or cut benefits for any employees, Aldeen said.

Two clinicians working for Envision Healthcare said they were experiencing reduced hours. The company and its owner KKR did not respond to repeated requests for comment.

At SCP, salaries for nurse practitioners and physician’s assistants will decrease in line with reduced hours, the company said in a memo on Thursday. Employees who don’t accept the change will be terminated, the memo said.

“We know that this time is also difficult and uncertain for each of you, and we want all employees to be able to focus on getting through this time with as little worry as possible about their pay and benefits while avoiding unnecessary exposure to COVID-19,” SCP executives said in the memo. “SCP Health is using its reasonable best efforts to retain all team members at this time in light of this unforeseeable pandemic.”

SCP spokeswoman Maura Nelson said the company is dealing with a 30% drop in patients nationwide while the patients its providers are treating are more seriously ill. “We are calibrating our clinical coverage accordingly, so that we can address more flexibly the needs of our client hospitals,” Nelson said. “This was a necessary adjustment as we weather this crisis, together.”

Hickey of the Virginia physicians group called on staffing companies to take advantage of relief in the recent stimulus packages such as the Paycheck Protection Program and Medicare Accelerated and Advance Payment Program. But Alteon said it had already taken into account those relief measures before cutting compensation and benefits. “We have factored these actions into our plan,” Holtzclaw said in his message to employees on Monday.

The pandemic’s strain on the economics of the health care industry is not limited to private-equity-backed staffing companies. Hospital operators are also announcing layoffs and pay cuts. Dallas-based Tenet Healthcare said it would furlough 500 staff members and borrow money.

“We have this crisis going on where hospitals need as many people as possible, and at the same time hospitals have to cut their budgets,” said Brandon Jones, a nurse anesthetist and part-owner of a practice group called Greater Anesthesia Solutions in the Phoenix area. “Doctors are being sidelined or they’re being let go completely.”

While Jones’ colleagues are out of work for elective surgeries, he said they’re redeploying their skills to help treat COVID-19 patients — in particular by intubating them for breathing machines, which puts providers at a high risk to catch the virus. They’re wearing hazmat suits donated by a nearby nuclear power plant, Jones said, and they’re helping out even when they can’t bill for it or stand to make much less than normal.

“We’re going to do it because it’s right,” he said.

Maryam Jameel contributed reporting.


Along the Border, the Population Is High Risk for Coronavirus, but Testing Is In Short Supply

3 Apr

by Jeremy Schwartz and Lomi Kriel

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

This article is co-published with The Texas Tribune, as part of an investigative partnership.

On Monday afternoon, paramedic Theresa Fitzpatrick inched her Dodge Dart through a brand new drive-in testing center for COVID-19 in the small South Texas border city of Edinburg, a dozen miles from the Rio Grande. She had been wracked for a week with a dry, hacking cough ever since picking up a patient who had just crossed the international bridge with similar symptoms.

But she hadn’t been able to get a test since seeing her doctor last week, until a local university opened up drive-thru testing sites in her home county on Monday.

“They haven’t been testing people, that’s the problem,” said Fitzpatrick, a mother of four who earns $16 an hour as a paramedic for a private EMS company. “It just seems like the forgotten man down here.”

Hours earlier, Dr. Martin Garza, a pediatrician and former president of the Hidalgo-Starr County Medical Society, spent his lunch break drafting a plea to border-area lawmakers for help finding more testing kits.

Garza noted that at-risk areas such as South Texas, with lower numbers of confirmed cases, are precisely where enhanced testing is needed to detect and prevent a fatal spread of the virus, as is unfolding in New York City, New Orleans and smaller cities like Athens, Georgia.

“We have all heard, ‘If (only) we had been able to test sooner,’” he wrote. “Well the ‘sooner’ is still available in our community.”

While many places across the country are struggling to get enough testing, the problems are magnified in the Rio Grande Valley. It has among the highest poverty rates in the state, nearly half of its residents don’t have health insurance and chronic health conditions are rife.

Two weeks ago, Texas Gov. Greg Abbott promised that all those who need a coronavirus test “will get one,” but public health officials, politicians and doctors up and down the Rio Grande say that hasn’t happened and they are scrambling to assemble sufficient testing kits. Hidalgo County, the largest in the Valley, is only able to process 20 government tests a day, officials said this week.

In the border city of Laredo, 80 miles upriver from the Rio Grande Valley, a cluster of residents died on four consecutive days starting Sunday, bringing the city’s COVID-19 death toll to five, just below that of the state’s largest city Houston as of Friday morning. The first four were women in their 60s to 97. The latest was a 43-year-old man. Health authorities say all five suffered from underlying health conditions.

Also troubling to local health leaders is that the highest percentage of the city’s 65 positive cases is the result of some form of community contact.

As Laredo reeled from the deaths, its Mexican sister city, Nuevo Laredo, announced its first two positive cases this week, including a 56-year-old man who had recently traveled to Dallas. Health experts believe cases in Mexico are vastly underreported because of almost nonexistent testing there.

Responding to the threat, some border cities took drastic steps, including setting up roadblocks to catch people violating orders to shelter in place and requiring masks inside public buildings.

In many ways, the situation along the Texas border reflects the chaotic manner that the second-largest state in the country, with the highest percentage of people lacking health insurance, has approached the issue of testing — and the pandemic itself. Unlike some governors, Abbott, a Republican, had declined to impose a mandatory statewide shelter-in-place order, instead urging counties to make their own decisions. On Tuesday, he did issue such an order urging most people to stay home.

Texas as a whole also has lagged when it comes to testing. It’s completed more than 50,600 tests so far, more than double what it had less than a week ago, but it still ranks among the lowest in the nation in per-capita testing, well behind other large states such as New York and California, according to a ProPublica analysis. At least 70 people have died in Texas.

Abbott’s spokesman, John Wittman, referred questions to the state’s Division of Emergency Management.

Seth Christensen, that agency’s spokesman, said in a statement that the state is available to assist “every mayor and county judge” across Texas. He said that swabs are in short supply nationally, but that the state is trying to procure more from the federal government and private companies.

He said private health care providers should also make an effort to obtain testing supplies through the private sector to “ensure we are leveraging every available avenue.”

To ward off the virus spreading across international borders, President Donald Trump has largely closed border crossings to “nonessential” travel, but epidemiologists say that’s not the solution to an epidemic that has likely already taken root on both sides of the Rio Grande.

“The answer is not closing the border,” said epidemiologist Benjamin King of the University of Texas at Austin. “It’s aggressive testing on both sides.”

Population at Risk

The Rio Grande Valley is a world away from the state’s largest regions, Houston and Dallas, which have seen the most cases. It is a sprawling mix of rural farmland and urban spread that is home to more than 1.3 million mostly Hispanic residents and shares river frontage with a bustling Mexican border region of factories, busy land crossings and outbreaks of drug cartel violence.

The Valley’s population is particularly vulnerable to the virus, experts say. About half a million Texas border residents live in so-called colonias across the U.S. side of the border, which often lack basic amenities such as running water. Roughly one in three people in the Rio Grande Valley is diabetic, a major risk factor for complications from COVID-19. And one in 10 of the state’s undocumented population lives in the region, with potential immigration consequences often making them fearful to seek help.

“My concern is not only that it is circulating without our knowledge, but we also have a population at high risk for severe disease,” said Dr. Joseph McCormick, an epidemiologist at the Brownsville campus of the University of Texas Health Science Center at Houston. “I don’t think it will take very long at all to overwhelm the facilities at our hospitals.”

Hidalgo County, the largest in the Rio Grande Valley, has about 2,000 hospital beds, compared with about 14,000 in Houston.

McCormick, who helped investigate the first-recorded Ebola outbreak in 1976, blamed the lack of testing on the state and federal government.

“The state is depending on the federal government to bring tests in and that hasn’t happened. … I don’t know why the state hasn’t done more,” he said. “Our folks are now relying more on private labs.”

“Some Very Sick People”

On Monday, UT Health RGV, which is part of the University of Texas Rio Grande Valley School of Medicine, began drive-thru testing in Brownsville and Edinburg.

In a few days, its hotline received almost a thousand calls and health workers were seeing “some very sick people,” said Dr. Linda Nelson, senior director of clinical operations heading the initiative. “Some of them can’t even talk on the phone without coughing.”

Dr. Rosemary Recavarren, a pathologist who oversees four hospital laboratories in the Rio Grande Valley, has been worried about this for weeks. She and her staff have been reaching out to the state health department and private testing companies since February, but they were told they were not a priority and that testing kits were allocated to areas much harder hit.

“We are not going to get testing for our machines until probably the end of April,” she said.

Eddie Olivarez, chief administrative officer for Hidalgo County’s health department, said only about 20% of COVID-19 testing in the region was being conducted by public labs, compared with 80% done through private institutions, because of capacity and because state criteria is more stringent on who can qualify for testing. Patients must have traveled and had known exposure to a confirmed case to be eligible for state tests, whereas private institutions allow more flexibility from each physician in recommending testing.

Olivarez said the Harlingen public health laboratory through which his county does testing can only process about 40 tests a day.

Chris Van Deusen, a spokesman for the Texas Department of State Health Services, said the agency had shipped more tests to the Rio Grande Valley on Wednesday and was working to start a “high-throughput” testing platform that would allow tests at a faster pace.

Most metropolitan areas in Texas rely on private hospitals for some in-house analysis of testing, but almost no hospitals in the Rio Grande Valley currently have that ability, Recavarren, the pathologist, said. They must either send swabs to public health laboratories, which comply with the state’s stricter criteria, or to private companies.

But as demand has skyrocketed across the country, companies are now overwhelmed and many Texas health workers said it can take days for results back from Quest Diagnostics and up to two weeks for LabCorp.

Quest Diagnostics said in a statement this week that between March 9 and April 1 it performed more than 400,000 COVID-19 tests across the country, “a sharp influx of test orders that continued to outpace our growing capacity.”

But it has since implemented a “higher throughput” diagnostic test at laboratories across the country, reducing the national backlog from 160,000 to 115,000 in a week.

“While we are more confident now in our ability to meet demand and report results for COVID-19 testing than in mid-March, when we were still ramping up capacity, this crisis is fluid and unpredictable, and so is the demand for COVID-19 testing,” the company said.

LabCorp said in a statement that it was also working “tirelessly” to increase capacity.

The lack of testing and delay in labs has even metropolitan areas with far more physicians and hospitals struggling.

Bexar County Judge Nelson Wolff, who oversees the state’s second-largest city of San Antonio, said its public laboratories can get results in a day, but when they send tests to Quest Diagnostics, it takes up to five days. More than 220 cases have been confirmed there with at least nine deaths, including a nursing home outbreak this week that killed one resident and infected at least 66 of the 84 residents.

In Harris County, home to Houston, the fourth-largest city in the nation, officials have struggled to open enough testing centers, receiving only enough supplies from the federal government for two publicly run sites in the county, testing 500 a day — far fewer than the 10 sites sought by Harris County Judge Lina Hidalgo, the region’s chief executive. The city of Houston has another two public testing sites able to jointly run another 500 tests daily.

The metropolitan area is also home to one of the country’s biggest medical centers, with many hospitals running in-house testing and analysis, including Houston Methodist, which can test about 250 patients in-house a day.

By Friday morning, at least 955 people in Houston and Harris County had tested positive — the most in the state — and at least 10 had died. The county is home to about 16% of the state’s 29 million residents.

Dr. Peter Hotez, a vaccine researcher and dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston, has predicted Houston could follow New Orleans as a hot spot in the South. He thinks the Rio Grande Valley is also at risk, due to its high percentage of people living in poverty with diabetes and hypertension.

“Testing is crucial in poor neighborhoods, both on the border or in the urban core, that’s the most vulnerable populations,” Hotez said. “Wherever there is crowding and poverty, those are the areas I worry about the most.”

“A Tsunami Coming”

Starr County, an isolated, mostly rural county with one of the highest poverty rates in the state, bucked the border trend and was the first south of San Antonio to establish a drive-thru testing site in early March, thanks to a partnership between the county, university and a local businessman.

“Our testing here has not been short of anything,” Starr County Judge Eloy Vera said. “Anyone who needs to be tested is getting tested.”

The effort has paid off, local officials believe. The businessman is footing the first month’s bill, and the site has done about 300 tests, with just five people testing positive.

This week, Webb County, slammed with five deaths in four days, finalized a deal to bring 5,000 rapid tests to the Laredo area through a partnership with a local ER provider, Clear Choice ER.

City officials hoped to have the tests up and running by the end of this week, but on Friday announced they had determined the tests were not reliable and that Laredo police would investigate the validity of the kits’ FDA certification. Officials said they would continue “scouring the world for testing kits.”

Officials are feeling the pressure to slow the virus.

“We only have one shot at this,” Laredo City Manager Robert Eads said. “We have to get this right now.”

As testing increases and cases rise by the day, border officials brace for what lies ahead.

On Thursday, as 17 more people tested positive in Hidalgo County, including four children under the age of 5, county officials said there was now “clear evidence” of community spread. More than 630 in the county have now been tested, with at least 79 confirmed cases.

Fitzpatrick, the paramedic in Edinburg who struggled to get tested, learned Thursday she was not among them. She plans to return to her ambulance this weekend and hopes her department will receive more of the personal protective gear it needs.

“If we don’t do it, who’s going to do it?” she said. “There’s a lot more down here who will get sick.”

A University of Texas at Austin model of potential new COVID-19 hospitalizations released this week showed that depending on the measures taken by local officials, overall cases could reach between roughly 95,000 and 335,000 combined in the metro areas of Laredo, Brownsville and McAllen.

Hidalgo County Judge Richard Cortez, in his strongest words yet, warned “there is a tsunami coming. It hasn’t hit us yet.”