Earlier this year, Grace Elizabeth Elliott got a mysterious hospital bill for medical care she had never received.

She soon discovered how far a clerical error can reach — even across a continent — and how frustrating it can be to fix.

During a college break in 2013, Elliott, then 22, began to feel faint and feverish while visiting her parents in Venice, Florida, about an hour south of Tampa. Her mother, a nurse, drove her to a facility that locals knew simply as Venice Hospital.

In the emergency department, Elliott was diagnosed with a kidney infection and held overnight before being discharged with a prescription for antibiotics, a common treatment for the illness.

“My hospital bill was about $100, which I remember because that was a lot of money for me as an undergrad,” said Elliott, now 31.

She recovered and eventually moved to California to teach preschool. Venice Regional Medical Center was bought by Community Health Systems, based in Franklin, Tennessee, in 2014 and eventually renamed ShorePoint Health Venice.

The kidney infection and overnight stay in the ER would have been little more than a memory for Elliott.

Then another bill came.

The Patients: Grace E. Elliott, 31, a preschool teacher living with her husband in San Francisco, and Grace A. Elliott, 81, a retiree in Venice, Florida.

Medical Services: For Grace E., an emergency department visit and overnight stay, plus antibiotics to treat a kidney infection in 2013. For Grace A., a shoulder replacement and rehabilitation services in 2021.

Service Provider: Venice Regional Medical Center, later renamed ShorePoint Health Venice.

Total Bill: $1,170, the patient’s responsibility for shoulder replacement services, after adjustments and payments of $13,210.21 by a health plan with no connection to Elliott. The initial charges were $123,854.14.

What Gives: This is a case of mistaken identity, a billing mystery that started at a hospital registration desk and didn’t end until months after the file had been handed over to a collection agency.

Early this year, Grace E. Elliott’s mother opened a bill from ShorePoint Health Venice that was addressed to her daughter and sought more than $1,000 for recent hospital services, Elliott said. She “immediately knew something was wrong.”

Months of sleuthing eventually revealed that the bill was meant for Grace Ann Elliott, a much older woman who underwent a shoulder replacement procedure and rehabilitation services at the Venice hospital last year.

Experts said that accessing the wrong patient’s file because of a name mix-up is a common error — but one for which safeguards, like checking a patient’s photo identification, usually exist.

The hospital had treated at least two Grace Elliotts. When Grace A. Elliott showed up for her shoulder replacement, a hospital employee pulled up Grace E. Elliott’s account by mistake.

“This is the kind of thing that can definitely happen,” said Shannon Hartsfield, a Florida attorney who specializes in health care privacy violations. (Hartsfield does not represent anyone involved in this case.) “All kinds of human errors happen. A worker can pull up the names, click the wrong button, and then not check [the current patient’s] date of birth to confirm.”

It was a seemingly obvious error: The younger Elliott was billed for a procedure she didn’t have by a hospital she had not visited in years. But it took her nearly a year of hours-long phone calls to undo the damage.

At first, worried that she had been the victim of identity theft, Grace E. Elliott contacted ShorePoint Health Venice and was bounced from one department to another. At one point, a billing employee disclosed to Elliott the birthdate the hospital had on file for the patient who had the shoulder replacement — it was not hers. Elliott then sent the hospital a copy of her ID.

It took weeks for an administrator at ShorePoint’s corporate office in Florida to admit the hospital’s error and promise to correct it.

In August, though, Grace E. Elliott received a notice that the corporate office had sold the debt to a collection agency called Medical Data Systems. Even though the hospital had acknowledged its error, the agency was coming after Grace E. Elliott for the balance due for Grace A. Elliott’s shoulder surgery.

“I thought, ‘Well, I’ll just work with them directly,’” Grace E. Elliott said.

Her appeal was denied. Medical Data Systems said in its denial letter that it had contacted the hospital and confirmed the name and address on file. The agency also included a copy of Grace A. Elliott’s expired driver license to Grace E. — along with several pages of the older woman’s medical information — in support of its conclusion.

“A collection agency, as a business associate of a hospital, has an obligation to ensure that the wrong patient’s information is not shared,” Hartsfield said.

In an email to KHN, Cheryl Spanier, a vice president of the collection agency, wrote that “MDS follows all state and federal rules and regulations.” Spanier declined to comment on Elliott’s case, saying she needed the written consent of both the health system and the patient to do so.

Elliott’s second appeal was also denied. She was told to contact the hospital to clear up the issue. But because the health system had long since sold the debt, Elliott said, she got no traction in trying to get ShorePoint Health Venice to help her. The hospital closed in September.

Resolution: In mid-November, shortly after a reporter contacted ShorePoint Health, which operates other hospitals and facilities in Florida, Grace E. Elliott received a call from Stanley Padfield, the Venice hospital’s outgoing privacy officer and director of health information management. “He said, ‘It’s taken care of,’” Elliott said, adding that she was relieved but skeptical. “I’ve heard that over and over.”

Elliott said Padfield told her that she had become listed as Grace A. Elliott’s guarantor, meaning she was legally responsible for the debt of a woman she had never met.

Elliott soon received a letter from Padfield stating that ShorePoint Health had removed her information from Grace A. Elliott’s account and confirmed that she had not been reported to any credit agencies. The letter said her information had been removed from the collection agency’s database and acknowledged that the hospital’s fix initially “was not appropriately communicated” to collections.

Padfield said the error started with a “registration clerk,” who he said had “received additional privacy education as a result of this incident.”

Devyn Brazelton, marketing coordinator for ShorePoint Health, told KHN the hospital believes the error was “an isolated incident.”

Using the date of birth provided by a hospital worker, Elliott was able to contact Grace A. Elliott and explain the mix-up.

“I’m a little upset right now,” Grace A. Elliott told KHN on the day she learned about the billing error and disclosure of her medical information.

The Takeaway: Grace E. Elliott said that when she asked Padfield, the Venice hospital’s outgoing privacy officer, whether she could have done something to fight such an obvious case of mistaken identity, he replied, “Probably not.”

This, experts said, is the dark secret of identity issues: Once a mistake has been entered into a database, it can be remarkably difficult to fix. And such incorrect information can live for generations.

For patients, that means it’s crucial to review the information on patient portals — the online medical profiles many providers use to manage things like scheduling appointments, organizing medical records, and answering patient questions.

One downside of electronic medical records is that errors spread easily and repeat frequently. It is important to challenge and correct errors in medical records early and forcefully, with every bit of documentation available. That is true whether the problem is an incorrect name, a medication no longer (or never) taken, or an inaccurate diagnosis.

The process of amending a record can be “very involved,” Hartsfield said. “But with patients able now to see more and more of their medical records, they are going to want those amendments, and health systems and their related entities need to get prepared for that.”

Grace A. Elliott told KHN that she had received a call from ShorePoint Health in the previous few months indicating that she owed money for her shoulder replacement.

She asked for a copy of the bill, she told KHN. Months after she asked, it still hadn’t arrived.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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The federal system meant to stop health care business owners and executives from repeatedly bilking government health programs fails to do so, a KHN investigation has found.

That means people are once again tapping into Medicaid, Medicare, and other taxpayer-funded federal health programs after being legally banned because of fraudulent or illegal behavior.

In large part that’s because the government relies on those who are banned to self-report their infractions or criminal histories on federal and state applications when they move into new jobs or launch companies that access federal health care dollars.

The Office of Inspector General for the U.S. Department of Health and Human Services keeps a public list of those it has barred from receiving any payment from its programs — it reported excluding more than 14,000 individuals and entities since January 2017 — but it does little to track or police the future endeavors of those it has excluded.

The government explains that such bans apply to “the excluded person” or “anyone who employs or contracts with” them. Further, “the exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person,” according to the OIG.

Federal overseers largely count on employers to check their hires and identify those excluded. Big hospital systems and clinics typically employ compliance staff or hire contractors who routinely vet their workers against the federal list to avoid fines.

However, those who own or operate health care businesses are typically not subject to such oversight, KHN found. And people can sidestep detection by leaving their names off key documents or using aliases.

“If you intend to violate your exclusion, the exclusion list is not an effective deterrent,” said David Blank, a partner at Arnall Golden Gregory who previously was senior counsel at the OIG. “There are too many workarounds.”

KHN examined a sample of 300 health care business owners and executives who are among more than 1,600 on OIG’s exclusion list since January 2017. Journalists reviewed court and property records, social media, and other publicly available documents. Those excluded had owned or operated home health care agencies, medical equipment companies, mental health facilities, and more. They’d submitted false claims, received kickbacks for referrals, billed for care that was not provided, and harmed patients who were poor and old, in some cases by stealing their medication or by selling unneeded devices to unsuspecting Medicare enrollees. One owner of an elder care home was excluded after he pleaded guilty to sexual assault.

Among those sampled, KHN found:

• Eight people appeared to be serving or served in roles that could violate their bans;
• Six transferred control of a business to family or household members;
• Nine had previous, unrelated felony or fraud convictions, and went on to defraud the health care system;
• And seven were repeat violators, some of whom raked in tens of millions of federal health care dollars before getting caught by officials after a prior exclusion.

The exclusions list, according to Blank and other experts, is meant to make a person radioactive — easily identified as someone who cannot be trusted to handle public health care dollars.

But for business owners and executives, the system is devoid of oversight and rife with legal gray areas.

One man, Kenneth Greenlinger, pleaded guilty in 2016 to submitting “false and fraudulent” claims for medical equipment his California company, Valley Home Medical Supply, never sent to customers that totaled more than $1.4 million to Medicare and other government health care programs, according to his plea agreement. He was sentenced to eight months in federal prison and ordered to pay restitution of more than $1 million, according to court records. His company paid more than $565,000 to resolve allegations of false claims, according to the Justice Department website.

Greenlinger was handed a 15-year exclusion from Medicare, Medicaid, and any other federal health care program, starting in 2018, according to the OIG.

But this October, Greenlinger announced a health care business with government contracts for sale. Twice on LinkedIn, Greenlinger announced: “I have a DME [durable medical equipment] company in Southern California. We are contracted with most Medicare and Medi-Cal advantage plans as well as Aging in Place payers. I would like to sell,” adding a Gmail address.

Reached by phone, Greenlinger declined to comment on his case. About the LinkedIn post, he said: “I am not affiliated directly with the company. I do consulting for medical equipment companies — that was what that was, written representing my consulting business.”

His wife, Helene, who previously worked for Valley Home Medical Supply, is now its CEO, according to LinkedIn and documentation from the California Secretary of State office. Although Helene has a LinkedIn account, she told KHN in a telephone interview that her husband had posted on her behalf. But Kenneth posted on and commented from his LinkedIn page — not his wife’s.

At Valley Home Medical Supply, a person who answered the phone last month said he’d see whether Kenneth Greenlinger was available. Another company representative got on the line, saying “he’s not usually in the office.”

Helene Greenlinger said her husband may come by “once in a while” but “doesn’t work here.”

She said her husband doesn’t do any medical work: “He’s banned from it. We don’t fool around with the government.”

“I’m running this company now,” she said. “We have a Medicare and Medi-Cal number and knew everything was fine here, so let us continue.”

No Active Enforcement

Federal regulators do not proactively search for repeat violators based on the exclusion list, said Gabriel Imperato, a managing partner with Nelson Mullins in Florida and former deputy general counsel with HHS’ Office of the General Counsel in Dallas.

He said that for decades he has seen a “steady phenomenon” of people violating their exclusions. “They go right back to the well,” Imperato said.

That oversight gap played out during the past two years in two small Missouri towns.

Donald R. Peterson co-founded Noble Health Corp., a private equity-backed company that bought two rural Missouri hospitals, just months after he’d agreed in August 2019 to a five-year exclusion that “precludes him from making any claim to funds allocated by federal health care programs for services — including administrative and management services — ordered, prescribed, or furnished by Mr. Peterson,” said Jeff Morris, an attorney representing Peterson, in a March letter to KHN. The prohibition, Morris said, also “applies to entities or individuals who contract with Mr. Peterson.”

That case involved a company Peterson created called IVXpress, now operating as IVX Health with infusion centers in multiple states. Peterson left the company in 2018, according to his LinkedIn, after the settlement with the government showed a whistleblower accused him of altering claims, submitting false receipts for drugs, and paying a doctor kickbacks. He settled the resulting federal charges without admitting wrongdoing. His settlement agreement provides that if he violates the exclusion, he could face “criminal prosecution” and “civil monetary penalties.”

In January 2020, Peterson was listed in a state registration document as one of two Noble Health directors. He was also listed as the company’s secretary, vice president, and assistant treasurer. Four months later, in April 2020, Peterson’s name appears on a purchasing receipt obtained under the Freedom of Information Act. In addition to Medicare and Medicaid funds, Noble’s hospitals had received nearly $20 million in federal covid relief money.

A social media account with a photo that appears to show Peterson announced the launch of Noble Health in February 2020. Peterson identified himself on Twitter as executive chairman of the company.

It appears federal regulators who oversee exclusions did not review or approve his role, even though information about it was publicly available.

Peterson, whose name does not appear on the hospitals’ Medicare applications, said by email that his involvement in Noble didn’t violate his exclusion in his reading of the law.

He said he owned only 3% of the company, citing OIG guidance — federal regulators may exclude companies if someone who is banned has ownership of 5% or more of them — and he did not have a hand in operations. Peterson said he worked for the corporation, and the hospitals “did not employ me, did not pay me, did not report to me, did not receive instructions or advice from me,” he wrote in a November email.

A 2013 OIG advisory states that “an excluded individual may not serve in an executive or leadership role” and “may not provide other types of administrative and management services … unless wholly unrelated to federal health care programs.”

Peterson said his activities were apart from the business of the hospitals.

“My job was to advise Noble’s management on the acquisition and due diligence matters on hospitals and other entities it might consider acquiring. … That is all,” Peterson wrote. “I have expert legal guidance on my role at Noble and am comfortable that nothing in my settlement agreement has been violated on any level.”

For the two hospitals, Noble’s ownership ended badly: The Department of Labor opened one of two investigations into Noble this March in response to complaints from employees. Both Noble-owned hospitals suspended services. Most employees were furloughed and then lost their jobs.

Peterson said he left the company in August 2021. That’s the same month state regulators cited one hospital for deficiencies that put patients “at risk for their health and safety.”

If federal officials determine Peterson’s involvement with Noble violated his exclusion, they could seek to claw back Medicaid and Medicare payments the company benefited from during his tenure, according to OIG records.

Enforcement in a Gray Zone

Dennis Pangindian, an attorney with the firm Paul Hastings who had prosecuted Peterson while working for the OIG, said the agency has limited resources. “There are so many people on the exclusions list that to proactively monitor them is fairly difficult.”

He said whistleblowers or journalists’ reports often alert regulators to possible violations. KHN found eight people who appeared to be serving or served in roles that could violate their bans.

OIG spokesperson Melissa Rumley explained that “exclusion is not a punitive sanction but rather a remedial action intended to protect the programs and beneficiaries from bad actors.”

But the government relies on people to self-report that they are banned when applying for permission to file claims that access federal health care dollars through the Centers for Medicare & Medicaid Services.

While federal officials are aware of the problems, they so far have not fixed them. Late last year, the Government Accountability Office reported that 27 health care providers working in the federal Veterans Affairs system were on the OIG’s exclusion list.

If someone “intentionally omits” from applications they are an “excluded owner or an owner with a felony conviction,” then “there’s no means of immediately identifying the false reporting,” said Dara Corrigan, director of the center for program integrity at CMS. She also said there is “no centralized data source of accurate and comprehensive ownership” to check for violators.

The OIG exclusion list website, which health care companies are encouraged to check for offenders, notes that the list does not include altered names and encourages those checking it to vet other forms of identification.

Gaps in reporting also mean many who are barred may not know they could be violating their ban because exclusion letters can go out months after convictions or settlements and may never reach a person who is in jail or has moved, experts said. The exclusion applies to federal programs, so a person could work in health care by accepting only patients who pay cash or have private insurance. In its review, KHN found some on the exclusion list who were working in health care businesses that don’t appear to take taxpayer money.

OIG said its exclusions are “based largely on referrals” from the Justice Department, state Medicaid fraud-control units, and state licensing boards. A lack of coordination among state and federal agencies was evident in exclusions KHN reviewed, including cases where years elapsed between the convictions for health care fraud, elder abuse, or other health-related felonies in state courts and the offenders’ names appearing on the federal list.

ProviderTrust, a health care compliance group, found that the lag time between state Medicaid fraud findings and when exclusions appeared on the federal list averaged more than 360 days and that some cases were never sent to federal officials at all.

The NPI, or National Provider Identifier record, is another potential enforcement tool. Doctors, nurses, other practitioners, and health businesses register for NPI numbers to file claims to insurers and others. KHN found that NPI numbers are not revoked after a person or business appears on the list.

The NPI should be “essentially wiped clean” when the person is excluded, precluding them from submitting a bill, said John Kelly, a former assistant chief for health care fraud at the Department of Justice who is now a partner for the law firm Barnes & Thornburg.

Corrigan said the agency didn’t have the authority to deactivate or deny NPIs if someone were excluded.

The Family ‘Fronts’

Repeat violators are all too common, according to state and federal officials. KHN’s review of cases identified seven of them, noted by officials in press releases or in court records. KHN also found six who transferred control of a business to a family or household member.

One common maneuver to avoid detection is to use the names of “family members or close associates as ‘fronts’ to create new sham” businesses, said Lori Swanson, who served as Minnesota attorney general from 2007 to 2019.

Blank said the OIG can exclude business entities, which would prevent transfers to a person’s spouse or family members, but it rarely does so.

Thurlee Belfrey stayed in the home care business in Minnesota after his 2004 exclusion for state Medicaid fraud. His wife, Lanore, a former winner of the Miss Minnesota USA title, created a home care company named Model Health Care and “did not disclose” Thurlee’s involvement, according to his 2017 plea agreement.

“For more than a decade” Belfrey, his wife, and his twin brother, Roylee, made “millions in illicit profits by cheating government health care programs that were funded by honest taxpayers and intended for the needy,” according to the Justice Department. The brothers spent the money on a Caribbean cruise, high-end housing, and attempts to develop a reality TV show based on their lives, the DOJ said.

Federal investigators deemed more than $18 million in claims Model Health Care had received were fraudulent because of Thurlee’s involvement. Meanwhile, Roylee operated several other health care businesses. Between 2007 and 2013, the brothers deducted and collected millions from their employees’ wages that they were supposed to pay in taxes to the IRS, the Justice Department said.

Thurlee, Lanore, and Roylee Belfrey all were convicted and served prison time. When reached for comment, the brothers said the government’s facts were inaccurate and they looked forward to telling their own story in a book. Roylee said he “did not steal people’s tax money to live a lavish lifestyle; it just didn’t happen.” Thurlee said he “never would have done anything deliberately to violate the exclusion and jeopardize my wife.” Lanore Belfrey could not be reached for comment.

Melchor Martinez settled with the government after he was accused by the Department of Justice of violating his exclusion and for a second time committing health care fraud by enlisting his wife, Melissa Chlebowski, in their Pennsylvania and North Carolina community mental health centers.

Previously, Martinez was convicted of Medicaid fraud in 2000 and was excluded from all federally funded health programs, according to DOJ.

Later, Chlebowski failed to disclose on Medicaid and Medicare enrollment applications that her husband was managing the clinics, according to allegations by the Justice Department.

Their Pennsylvania clinics were the largest providers of mental health services to Medicaid patients in their respective regions. They also had generated $75 million in combined Medicaid and Medicare payments from 2009 through 2012, according to the Justice Department. Officials accused the couple of employing people without credentials to be mental health therapists and the clinics of billing for shortened appointments for children, according to the DOJ.

They agreed, without admitting liability, to pay $3 million and to be excluded — a second time, for Martinez — according to court filings in the settlement with the government. They did not respond to KHN’s attempts to obtain comment.

‘Didn’t Check Anything’

In its review of cases, KHN found nine felons or people with fraud convictions who then had access to federal health care money before being excluded for alleged or confirmed wrongdoing.

But because of the way the law is written, Blank said, only certain types of felonies disqualify people from accessing federal health care money — and the system relies on felons to self-report.

According to the DOJ court filing, Frank Bianco concealed his ownership in Anointed Medical Supplies, which submitted about $1.4 million in fraudulent claims between September 2019 and October 2020.

Bianco, who opened the durable medical equipment company in South Florida, said in an interview with KHN that he did not put his name on a Medicare application for claims reimbursement because of his multiple prior felonies related to narcotics.

And as far as he knows, Bianco told KHN, the federal regulators “didn’t check anything.” Bianco’s ownership was discovered because one of his company’s contractors was under federal investigation, he said.

Kenneth Nash had been convicted of fraud before he operated his Michigan home health agency and submitted fraudulent claims for services totaling more than $750,000, according to the Justice Department. He was sentenced to more than five years in prison last year, according to the DOJ.

Attempts to reach Nash were unsuccessful.

“When investigators executed search warrants in June 2018, they shut down the operation and seized two Mercedes, one Land Rover, one Jaguar, one Aston Martin, and a $60,000 motor home — all purchased with fraud proceeds,” according to a court filing in his sentencing.

“What is readily apparent from this evidence is that Nash, a fraudster with ten prior state fraud convictions and one prior federal felony bank fraud conviction, got into health care to cheat the government, steal from the Medicare system, and lavishly spend on himself,” the filing said.

As Kelly, the former assistant chief for health care fraud at the Justice Department, put it: “Someone who’s interested in cheating the system is not going to do the right thing.”

KHN Colorado correspondent Rae Ellen Bichell contributed to this report.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Casi 1 de cada 7 adultos mayores muere dentro del año después de someterse a una cirugía mayor, según un nuevo estudio que arroja luz sobre los riesgos que enfrentan las personas mayores cuando tienen procedimientos invasivos.

Los pacientes mayores con probable demencia (33% mueren dentro del año) y fragilidad (28%), así como aquellos que se someten a cirugías de emergencia (22%) son los más vulnerables.

La edad avanzada también aumenta el riesgo: los pacientes de 90 años o más tienen seis veces más probabilidades de morir que los de 65 a 69.

El estudio, de investigadores de la Escuela de Medicina de Yale, publicado en JAMA Surgery, aborda una importante brecha: aunque en Estados Unidos los pacientes de 65 años y más representan casi el 40% de todas las cirugías, faltan datos nacionales detallados sobre los resultados de estos procedimientos.

“Como campo, hemos sido realmente negligentes al no comprender los resultados quirúrgicos a largo plazo para los adultos mayores”, dijo la doctora Zara Cooper, profesora de cirugía en la Escuela de Medicina de Harvard y directora del Centro de Cirugía Geriátrica en Brigham and Women’s Hospital de Boston.

La información sobre cuántas personas mayores mueren, desarrollan discapacidades, ya no pueden vivir de forma independiente o tienen una calidad de vida significativamente peor después de una cirugía mayor es crítica.

“Lo que los pacientes mayores quieren saber es: ‘¿cómo será mi vida?'”, dijo Cooper. “Pero no hemos podido responder antes con datos de calidad”.

En el nuevo estudio, el doctor Thomas Gill y sus colegas de Yale examinaron datos de reclamos de Medicare Tradicional y de encuestas del estudio Nacional de Tendencias de Salud y Envejecimiento que abarcan de 2011 a 2017.

Se contabilizaron como cirugías mayores los procedimientos invasivos que se realizan en quirófanos con pacientes bajo anestesia general. Los ejemplos incluyen cirugías para reemplazar caderas rotas, mejorar el flujo sanguíneo en el corazón, extirpar cáncer del colon, extirpar vesículas biliares, reparar válvulas cardíacas y hernias, entre muchas más.

Los adultos mayores tienden a experimentar más problemas después de la cirugía si tienen afecciones crónicas como enfermedades cardíacas o renales; si ya están débiles o tienen dificultad para moverse; si su capacidad para cuidar de sí mismos está comprometida; y si tienen problemas cognitivos, apuntó Gill, profesor de medicina, epidemiología y medicina de investigación en Yale.

Hace dos años, el equipo de Gill realizó una investigación que mostró que 1 de cada 3 adultos mayores no había vuelto a su nivel básico de funcionamiento a los seis meses de una cirugía mayor. Los más propensos a recuperarse fueron los adultos mayores que se sometieron a cirugías electivas para las que podían prepararse con anticipación.

En otro estudio, publicado el año pasado en Annals of Surgery, su equipo encontró que se realizan 1 millón de cirugías mayores en personas de 65 años o más cada año, incluido un número significativo cerca del final de la vida.

“Esto abre todo tipo de preguntas: ¿estas cirugías se hicieron por una buena razón? ¿Cómo se define la cirugía adecuada? ¿Se consideraron las metas del paciente?”, dijo el doctor Clifford Ko, profesor de cirugía en la Escuela de Medicina de UCLA y director de la División de Investigación y Atención Óptima del Paciente en el Colegio Estadounidense de Cirujanos.

Como ejemplo de este tipo de toma de decisiones, Ko describió a un paciente que, a los 93 años, se enteró que tenía cáncer de colon en etapa temprana además de una enfermedad preexistente del hígado, el corazón y los pulmones. Después de una discusión en profundidad y de que se le explicara que el riesgo de malos resultados era alto, el paciente decidió no realizar un tratamiento invasivo.

Pero la mayoría de los pacientes eligen la cirugía. La doctora Marcia Russell, cirujana del Sistema de Atención de Salud del Área de Asuntos de Veteranos de Los Ángeles, describió a un paciente de 90 años que recientemente se enteró de que tenía cáncer de colon durante una internación prolongada por una neumonía.

“Hablamos con él sobre la cirugía y su meta era vivir el mayor tiempo posible”, dijo Russell. Para prepararlo en casa para la futura cirugía, le recomendó que hiciera fisioterapia y comiera más alimentos ricos en proteínas, para fortalecerse.

“Es posible que necesite de seis a ocho semanas para prepararse para la cirugía, pero está motivado para mejorar”, dijo Russell.

Las decisiones que toman las personas mayores acerca de someterse a una cirugía mayor tienen amplias implicaciones sociales.

A medida que crece la población de más de 65 años, “cubrir la cirugía va a ser un desafío fiscal para Medicare”, señaló el doctor Robert Becher, profesor asistente de cirugía en Yale y colaborador de investigación de Gill.

Un poco más de la mitad del gasto de Medicare se deriva a la atención quirúrgica para pacientes hospitalizados y ambulatorios, según un análisis de 2020.

Además, “casi todas las subespecialidades quirúrgicas experimentarán escasez de profesionales en los próximos años”, dijo Becher. Señaló que en 2033 habrá casi 30,000 cirujanos menos de los necesarios para satisfacer la demanda esperada.

Estas tendencias hacen que los esfuerzos por mejorar los resultados quirúrgicos para los adultos mayores sean aún más críticos. Sin embargo, el progreso ha sido lento. El Colegio Estadounidense de Cirujanos lanzó un importante programa de mejora de la calidad en julio de 2019, ocho meses antes de la pandemia de covid-19.

Requiere que los hospitales cumplan con 30 estándares para lograr una experiencia reconocida en cirugía geriátrica. Hasta ahora, están participando menos de 100 de los miles de hospitales elegibles.

Uno de los sistemas más avanzados del país, el Centro de Cirugía Geriátrica del Brigham and Women’s Hospital, ilustra lo que es posible. Allí, se examina a los adultos mayores candidatos y, aquellos a los que se considera frágiles se someten a una evaluación geriátrica exhaustiva y se reúnen con una enfermera que ayudará a coordinar la atención después del alta.

También se evalúa a los seniors tres veces al día en busca de delirio (un cambio agudo en el estado mental que a menudo afecta a los pacientes mayores hospitalizados), y se usan analgésicos no narcóticos. “El objetivo es minimizar los daños de la hospitalización”, dijo Cooper, quien dirige el esfuerzo.

Cooper comentó sobre una paciente a quien describió como una “mujer sociable de poco más de 80 años que todavía usaba jeans ajustados e iba a cócteles”. Esta mujer llegó a la sala de emergencias con diverticulitis aguda y delirio. Se llamó a un geriatra antes de la cirugía para ayudarla a controlar sus medicamentos y su ciclo de sueño y vigilia, y para recomendar intervenciones no farmacéuticas.

Con la ayuda de los miembros de la familia que la atendieron, “ella está muy bien”, dijo Cooper. “Es el tipo de resultado que trabajamos muy duro para lograr”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Envy for-profit US healthcare? Check out this MD whose wife is a medical billing expert who spent over a year challenging an egregious billing error. After it all they still paid $1200. These are resourceful knowledgeable people who got taken for a ride. https://t.co/fnlUz3KTJb

— Raghu Venugopal MD (@raghu_venugopal) October 26, 2022

— Dr. Raghu Venugopal, Toronto

A Plea for Sane Prices

I just read your story about the emergency room billing for a procedure that was not done (“A Billing Expert Saved Big After Finding an Incorrect Charge in Her Husband’s ER Bill,” Oct. 25). We too had a similar experience with an emergency room and a broken arm that was coded at a Level 5, and it was a simple break. No surgery needed, and it took them only 10 minutes to set and wrap the broken arm but charged us over $9,000. I disputed the charges, and it took six months to get them to reduce the bill but they never admitted that they coded a simple break incorrectly to jack up the price of the bill. If it had been a Level 5 issue, we would not have sat in the waiting room for six hours before being seen. It was a horrible experience, and I think ERs all over the nation are doing this to make up for the non-payers they treat every day. It is robbery.

— Terrence Campbell, Pocatello, Idaho

It would be great if the vaulted @KHNews would clearly distinguish between the ED pro fee billing & hospital charges as it is not entirely clear here w/ in network svs.—Billing Expert Saved Big After Finding an Incorrect Charge in Her Husband’s ER Bill https://t.co/jRFAYb5F0P

— Ed Gaines (@EdGainesIII) October 25, 2022

— Ed Gaines, Greensboro, North Carolina

As you said, CPT codes should always be examined. This case is probably more than “just an error.” As a retired orthopedic surgeon, chief of surgery, and chief of staff at a North Carolina hospital, I have seen care such as this coded exactly like this with the rationale that, “Hey, this was a fractured humerus and it was manipulated and splinted.” 24505 is correct IF that is the definitive treatment, which it was not here. Even code 24500 would indicate definitive treatment without manipulation. This was just temporary care until definitive care could be done later. It should be billed as a visit and a splint. The visit for this, if it was an isolated problem (no other injury or problems), would qualify only as a Level 2 visit. That frequently gets upcoded as well by adding a lot of non-pertinent family, medical, and social history and a complete physical exam (seven systems at least) and a whole lot of non-pertinent “medical decision making.” All of that should be documented in the medical records even if the hospital stonewalls on the CPT codes.

Look closely at medical records and you will find frequent upcoding, if you are familiar with the requirements for different levels of treatment.

— Dr. Charles Beemer, Arvada, Colorado

Never attribute to Baumol's cost disease that which is adequately explained by malice. https://t.co/RbKOlBgCmp

— Shashank Bhat (@shashank_ps) October 26, 2022

— Shashank Bhat, San Francisco

A number of years ago, I was billed using a code that described a treatment that was not carried out. In similar fashion, I talked with my insurance company, which basically said it did not care whether the treatment took place or not as all it required was for a valid code to appear. I also contacted the Virginia Bureau of Insurance, which approves the various policies, and it said it had no jurisdiction over claims. I decided to let the hospital sue me for the disputed amount and defended myself in district court. Despite their attorney and four “witnesses,” the case was thrown out because the hospital was both unwilling and unable to justify the charges to the satisfaction of the judge. They did not want anybody in power to testify because of the questions they would have been asked, so they left it to people who were completely clueless. The takeaways from this were:

• Hospitals make up the numbers and leave them grossly inflated so they can claim that they are giving away care when they give discounts on the made-up numbers.
• Hospitals turn employees into separate billing entities so they can double-charge.
• Hospitals open facilities such as physical therapy in hospital locations because insurance companies will pay higher amounts when treatment is carried out in a hospital environment.
• Insurance companies and state insurance agencies do not act as gatekeepers to protect their clients/taxpayers.
• The insurance companies and the providers have a shared interest in the highest possible ticket prices and outrageous charges because the providers get to claim how generous they are with “unremunerated care,” and if the prices were affordable then they could not justify the high prices for insurance premiums and the allowed administration/profit share of 20% would be based on a far smaller amount.

In any other industry, this would have resulted in multiple antitrust suits. U.S. health care is a sad example of government, health care industry, and insurers all coming together against the interests of consumers. After this court case, I wanted to form a nonprofit to systematically challenge every outrageous charge against people who, unlike myself, did not believe or know how to defend themselves. If hospitals and other providers were forced to go to court to justify their charges on a systematic basis, pricing sanity would eventually prevail.

— Philip Solomon, Richmond, Virginia

The obvious solution to prosecute the hospital for fraud followed by a civil suit"A hospital charged nearly $7,000 for a procedure that was never performed" https://t.co/wPNNZ5cZey

— Barry Ritholtz (@ritholtz) October 31, 2022

— Barry Ritholtz, New York City

Patients as Watchdogs

Thank you for the article on Lupron Depot injections (Bill of the Month: “$38,398 for a Single Shot of a Very Old Cancer Drug,” Oct. 26). Last year, I was diagnosed with prostate cancer, though my case is not anywhere as severe as that experienced by Mr. Hinds.

Last month my urologist scheduled an MRI update for me at a facility owned by Northside Hospital Atlanta. At the suggestion of my beloved wife, I called my insurance company, UnitedHealthcare, to make sure the procedure was covered. Fortunately, it was. That being said, the agent from UnitedHealthcare mentioned that Northside Hospital’s fee was “quite a bit higher than the average for your area.” It was. Before insurance, the charge for an MRI at Northside was $6,291. I canceled the appointment at Northside and had the MRI done by a free-standing facility. Their charge, before insurance, was $1,234.

Every single encounter that I have with the health care system involves constant vigilance against price-gouging. When I have a procedure, I have to make sure that the facility is in-network,. that each physician is in-network, that any attending specialist such as an anesthesiologist or radiologist is in-network (and their base-facility as well). If I have a blood test, I have to double-check if the cost is included in a procedure or if it is separate. If it is a separate fee, I have to ensure that the analysis is also covered, and, if it is not, that it is not done through a hospital-owned facility but instead through a free-standing operation.

I have several ongoing conditions in addition to my prostate cancer — Dupuytren’s contracture, a rare bleeding disorder similar to thrombocytopenia, and arthritis. Needless to say, navigating our byzantine, inefficient, and profit-driven health care system is a total nightmare.

Health care in the United States has become so exceedingly outrageous. I cannot understand why it is not an issue that surfaces during election years or something that Congress is willing to address.

Again, thank you for your excellent reporting.

— Karl D. Lehman, Atlanta

Why capitalism without guardrails is a pipedream. Own the patent, control the pricing, and this is the result: $38,398 for a Single Shot of a Very Old Cancer Drug https://t.co/BLes77QN7F via @khnews

— Brian Murphy (@NorwoodCDI) October 26, 2022

— Brian Murphy, Austin, Texas

I was a medical stop-loss underwriter and marketer for over 30 years. Most larger (company plans for 100-plus employees) are self-funded, meaning the carrier — as in this case, UnitedHealthcare — is supplying the administrative functions and network access for a fee, while using the employer’s money to pay claims.

Every administrator out there charges a case management fee, either as a stand-alone charge or buried in their fees. Either way, they all tout how they are looking out for both the employer and the patient.

Even if this plan was fully insured, wouldn’t it have been in the best interest of all parties when they became aware of the patient’s treatment (maybe after the first payment) to reach out to the patient and let them know there are other alternatives?

The question in these cases is who is minding the store for both the patient and the employer. The employer, the insurer, and the patient could have all saved a lot of money and pain, if someone from case management had actually questioned the first set of charges.

— Fred Burkacki, Sarasota, Florida 

I did a few rounds of Lupron in my 20s for severe #endometriosis, and I had to fight my insurance company to get approved. Now, this is how much it costs for some people. https://t.co/UlB1TTtW40 #healthcare #prostatecancer

— Amanda Oglesby 🌊 (@OglesbyAPP) October 26, 2022

— Amanda Oglesby, Neptune, New Jersey

‘Bill of the Month’ Pays Off

I received a $1,075 refund on a colonoscopy bill I paid months earlier after listening to the KHN-NPR “Bill of the Month” segment “Her First Colonoscopy Cost Her $0. Her Second Cost $2,185. Why?” (May 31) and finding out the procedure should be covered under routine health care coverage. Thank you!

— Cynthia McBride, University Place, Washington

We have to close legal loopholes to make sure that cancer diagnostic procedures have the same insurance coverage as screening. Colonoscopies must be fully covered whether a polyp is found or not #ACA #colorectalcancer #CancerScreening https://t.co/slE6p3FvHe

— Erica Warner, ScD (@ewarner_12) May 31, 2022

— Erica Warner, Boston

Removing Barriers to Benefits

In the story “People With Long Covid Face Barriers to Government Disability Benefits” (Nov. 9), you stated: “Many people with long covid don’t have the financial resources to hire a lawyer.” This is incorrect. When applying for disability, you don’t need financial resources. There are law firms that specialize in disability claims and will not charge you until you win your claim. And, according to federal law, those law firms can charge only a certain percentage of the back pay you would get once the claim has been won. Also, if you lose the claim, and the law firm has appealed as many times as possible, you don’t owe anything. Please don’t make it more difficult for those who are disabled with misinformation.

— Lorrie Crabtree, Los Angeles

People unable to work due to Long Covid are facing barriers to obtaining government disability benefits.https://t.co/zWQfW5CkOS

— Ron Chusid (@RonChusid) November 10, 2022

— Ron Chusid, Muskegon, Michigan

Vaccine Injuries Deserve Attention, Too

I read your long-covid article with interest because many of the barriers and some of the symptoms faced by people with long covid are similar to those experienced by people with vaccine injuries. I’m really concerned about how there is even less attention and support for people who suffered adverse vaccine reactions.

Long covid and vaccine injuries are both issues of justice, mercy, and human rights as much as they are a range of complex medical conditions.

It’s nearly 20 months since someone I know sustained a serious adverse reaction, and it is heartbreaking how hard it has been for her to find doctors who will acknowledge what happened and try to help. There’s no medical or financial support from our government, and the Countermeasures Injury Compensation Program is truly a dead end, even as other countries such as Thailand, Australia, and the United Kingdom have begun to acknowledge and financially support people who sustained vaccine injuries.

I’ve contacted my congressional representatives dozens of times asking for help and sharing research papers about vaccine injuries, but they have declined to respond in meaningful ways. Similarly, my state-level representatives ignore questions about our vaccine mandate, which remains in place for state employees, despite at least one confirmed vaccine-caused fatality in a young mother who fell under the state mandate in order to volunteer at school.

There have been a few articles, such as …

• Why Is It So Hard to Compensate People for Serious Vaccine Side Effects?
• Feds Pay Zero Claims for Covid-19 Vaccine Injuries/Deaths
• Covid Vaccine Injury Plaintiffs Face Long Odds in U.S. Compensation Program
• Covid-19: Is the US Compensation Scheme for Vaccine Injuries Fit for Purpose?

… but no new ones have come to my attention recently, and it is concerning that the media and our political and public health leaders seem OK with leaving people behind as collateral damage.

Please consider writing a companion piece to highlight this need and the lack of a functional safety net or merciful response. My hope is that if long covid and vaccine injuries were both studied vigorously, new understanding would lead to therapeutics and treatments to help these people.

— Kathy Zelenka, Port Angeles, Washington

Given how long it took Congress to eventually approve "Agent Orange" and "Burn Pit" benefits for disabled veterans, it is at least a 15-20 year time frame and they don't have the backing or societal standing that veterans do. https://t.co/idt6tSioHc

— Matthew Guldin (@MRG_1977) November 11, 2022

— Matthew Guldin, West Chester, Pennsylvania

More on Mammograms

The article “Despite Katie Couric’s Advice, Doctors Say Ultrasound Breast Exams May Not Be Needed” (Oct. 28) does a disservice to women and can cause harm. An ultrasound is saving my life. I had two mammograms with ultrasounds this year. Although the first mammogram showed one cyst that was diagnosed as “maybe benign,” I knew it wasn’t. Why? Because I could feel the difference. I insisted on a second, and sure enough a large-enough cyst that’s definitely malignant was found. I had breast surgery on Oct. 31, followed by radiation treatment and, if needed, chemotherapy later. This article will deprive other, less aggressive and experienced women who do not have health care credentials or a radiologist for a husband to be harmed by being lulled into complacency.

— Digna Irizarry Cassens, Yucca Valley, California

Why do some women with dense breasts get additional screening while others do not? ⁦@CNN⁩ explains. ⁦@IronwoodCancer⁩ https://t.co/uFZZKo6RO4

— Patricia Clark (@patriciaclarkmd) October 27, 2022

— Patricia Clark, Scottsdale, Arizona

Your article on breast cancer screening neglected to present the supplemental option of Abbreviated Breast MRI (AB-MRI). The out-of-pocket cost at many clinics ranges from $250 to $500. For a national listing of clinics that offer this supplemental screening option, please go to https://timetobeseen.org/self-pay-ab-mri. For benefits, just Google “Abbreviated Breast MRI.”

— Elsie Spry, Wexford, Pennsylvania

Why didn’t more #SeniorCitizens leave for safer havens during Hurricane Ian as recommended? ⁦@judith_graham⁩ rightfully suggests that learning why is critical as the population of older people grows and #NaturalDisasters become more frequent. https://t.co/7k8bvNQxug

— Donald H. Polite (@DonaldPolite) November 2, 2022

— Donald H. Polite, Milwaukee

Preparation Plans for Seniors: All for One and One for All

At least 120 people died from Hurricane Ian, two-thirds of whom were 60 or older. This is a tragedy among our most vulnerable population that should have been prevented (“Hurricane Ian’s Deadly Impact on Florida Seniors Exposes Need for New Preparation Strategies,” Nov. 2).

Yes, coming together and developing preparedness plans is one way to protect seniors and avoid these kinds of tragedies in the future, but since this is not a one-size-fits-all situation, organizations that help seniors across the country must first look internally and be held accountable by making sure their teams always have a plan in place and are prepared to activate them at a moment’s notice.

During Hurricane Ian, I saw firsthand what can happen when teamwork and effective planning come together successfully to protect and prepare seniors with chronic health conditions like chronic obstructive pulmonary disease who require supplemental oxygen to breathe.

Home respiratory care providers and home oxygen suppliers worked tirelessly to ensure our patients received plenty of supplies to sustain them throughout the storm, and when some patients faced situations where their oxygen equipment wasn’t working properly inside their homes, staff members were readily available to calmly talk the patient through fixing the problem. After the winds receded, mobile vans were quickly stationed in safe spaces for patients or their family members to access the oxygen tanks and supplies they needed. If patients were unable to make it to these locations, staff members were dispatched to deliver tanks to their homes personally and check in on the patient.

Patients were also tracked down at shelters, and a team of volunteers was formed around the country to find patients who could not be reached by calling their emergency backup contacts, a friend, or family member. Through these established systems, we were able to remain in contact with all of our patients in Ian’s path to ensure their care was not impeded by the storm.

Organizations should always be ready and held accountable for the seniors they care for in times of disaster. I know my team will be ready. Will yours?

— Crispin Teufel, CEO of Lincare, Clearwater, Florida

Understanding the impact of #Climatechange on older people is critically important as the population expands and #naturaldisasters become more frequent and intense.https://t.co/RKB7pA28nr

— Ashley Moore, MS, BSN Health Policy (@MooreRNPolicy) November 2, 2022

— Ashley Moore, San Francisco

The Tall and the Short of BMI

I am amazed that in your article about BMI (“BMI: The Mismeasure of Weight and the Mistreatment of Obesity,” Oct. 12) you never mentioned anything about the loss of height. If a person goes from 5-foot-2 to 4-foot-10, the BMI changes significantly.

— Sue Robinson, Hanover, Pennsylvania

I've been against this since after gastric bypass surgery I got down to 164 pounds but at 5'7" BMI still considered me overweight. How an overreliance on BMI can stand between patients and treatment https://t.co/OawzhO0aOk

— Steve Clark (@blindbites) October 10, 2022

— Steve Clark, Lee’s Summit, Missouri

Caring for Nurses’ Mental Health

During the pandemic, when I read stories about how brave and selfless health care heroes were fighting covid-19, I wondered who was taking care of them and how they were processing those events. They put their own lives on the line treating patients and serving their communities, but how were these experiences affecting them? I am a mother of a nurse who was on the front lines. I constantly worried about her as well as her mental and physical well-being (“Employers Are Concerned About Covering Workers’ Mental Health Needs, Survey Finds,” Oct. 27). I was determined to find a way to honor and support her and her colleagues around the country.

I created a large collaborative art project called “The Together While Apart Project” that included the artwork of 18 other artists from around the United States. It originated during the lockdown phase of the pandemic, a time when we were all physically separated yet joined by a collective mission to create one amazing art installation to honor front-line workers, especially nurses. Upon its completion, this collaboration was recognized by the Smithsonian Institute, Channel Kindness (a nonprofit co-founded by Lady Gaga) and NOAH (National Organization of Arts in Medicine). After traveling around the Southeast to various hospitals for the past year on temporary exhibit, the artwork now hangs permanently in the main lobby at the University of Virginia Medical Center in Charlottesville, Virginia.

I wanted to do something philanthropic with this art project to honor and thank health care heroes for their dedication over the past two years. It was important to find a way to help support them and to ensure they are not being forgotten. Using art project as my platform, I partnered with the American Nurses Association and created a fundraiser. This campaign raises money for the ANA’s Well-Being Initiative programs, which support nurses struggling from burnout and post-traumatic stress disorder and who desperately need mental and physical wellness care. Fighting covid has taken a major toll on too many nurses. Some feel dehumanized and are not receiving the time off or the mental and physical resources needed to sustain them. Many are suffering in silence and have to choose between caring for themselves or their patients. They should not have to make this choice. Nurses are the lifeline in our communities and the backbone of the health care industry. When they suffer, we all suffer. Whether they work in hospitals, doctors’ offices, assisted living facilities, clinics or schools, every nurse has been negatively impacted in some way by the pandemic. They are being asked to do so much more than their jobs require in addition to experiencing greater health risks, less pay, and longer hours. Nurses under 35 and those of color are struggling in larger numbers.

The American Nurses Foundation offers many forms of wellness care at no charge. They rely heavily on donations to maintain the quality of their offerings as well as the ability to provide services to a growing number of nurses. I am an artist, not a professional fundraiser, and I have never raised money before. But I feel so strongly about ensuring that nurses receive the support and care they deserve, that I am willing to do whatever it takes to advocate and elevate these health care heroes.

The Together While Apart Project’s “Thank You Nurses Campaign” goal is $20,200, an amount chosen to reflect the numbers 2020, the year nurses became daily heroes. So far, I have raised over $15,500 through gifts in all amounts. For example, a $20 donation provides a nurse with a free one-hour call with a mental health specialist. That $20 alone makes a big difference and can change the life of one nurse for the better. The campaign has provided enough funding (year to date) to enable 940 nurses to receive free one-hour wellness calls with mental health specialists.

The online fundraiser can be found at https://givetonursing.networkforgood.com/projects/159204-together-while-apart-fundraiser.

— Deane Bowers, Seabrook Island, South Carolina

CEAPs, is it time to offer more #mentalhealth services? Nearly 1/2 of employers (w/ 200 workers) report a growing share of workers using mental health services. Yet 56% report they lack #behavioralhealth providers for employees to access to timely care. https://t.co/Vpkkwlq6C6

— EAPA (@EAPA) October 27, 2022

— Employee Assistance Professionals Association, Arlington, Virginia

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).