Joanne Silberner, Author at ��ϳԹ�� News

Battle Brews Over Neutral Zone Where Border-Crossing Parties Rendezvous, Risking Infection

Joanne Silberner — Fri, 02 Apr 2021 09:00:00 +0000

BLAINE, Wash. — In the shadows of covid travel restrictions, a 42-acre park on the far western edge of the U.S.-Canadian dividing line has become a popular opening in an otherwise closed border, a place where Americans and Canadians can gather without needing permission to go through an official border crossing.

What is known as Peace Arch Park has lush green lawns, gardens and a white concrete arch erected in 1921 that spans the border. It’s an often muddy, sometimes idyllic place. But the pandemic has transformed this patch of historically neutral ground into a playing field for some fundamental public health questions.

Should people from Canada, which has a lower incidence of covid-19, risk mingling with people from the U.S.? Should families who’ve masked and distanced be able to reunite for a day without quarantining? Who decides?

On a recent sunny weekend, couples and groups of up to 15 people spaced themselves across a large central lawn and filled a dozen or so picnic tables. Some kept their distance of several feet, others huddled closely. Some wore masks, others didn’t. Sounds of laughter came from kids on the large playground. And all was quiet on the eastern edge of the park, where visitors had pitched dozens of tents, rumored to facilitate conjugal visits.

An American park ranger periodically made rounds and asked groups to stay physically distant from one another. Though dozens of surveillance cameras on tall poles kept watch throughout the parking lot, no police were in sight.

Canada closed its land borders a year ago to all but some select groups, and its side of the park has stayed shut since late. Even so, Canadians can freely hop across a small grass ditch that runs along 0 Avenue in Surrey, British Columbia, and Washington state’s side remains open after a brief closure earlier in the pandemic.

Royal Canadian Mounted Police officers stationed outside every few houses along 0 Avenue demand proof of citizenship as parkgoers exit, then suggest that returning Canadians quarantine.

That’s far different from the conventional passage through an immigration site like the one near the park, where anyone driving into Canada must sign up for a strictly enforced 14-day quarantine.

And most Americans need to be in an exempted group and have a negative covid test. Those who claim “family relationships” must be able to prove it to a border official. And, even then, they have that 14-day quarantine.

Immigration lawyer Len Saunders, who lives in Blaine, Washington, comes to the park most days to see his clients. “For many people, it’s a lifeline,” he said. “Without the park, people would be effectively separated from their spouses, fiancés and partners.”

He has two clients in that situation: Canadian Katrina Gurr, 29, and American Alexis Gurr, 32. They each live within an easy drive to the border and met online last March. “We just started talking, and then couldn’t stop,” said Alexis.

They married in July and today sometimes talk in unison.

The Zuidmeer family used to meet regularly at Peace Arch Park. Bill Zuidmeer was diagnosed in December with terminal kidney cancer. Bill and his grandson (above) had a final visit together before Bill passed away 12 days later. (Peter Zuidmeer)

The rules for travel are complex and changing, laxer for entering the U.S. and for air travel into Canada but still daunting. The Gurrs have visited each other for weeks-long stretches, but have spent most of their first year as newlyweds apart. Katrina has applied for a green card that would allow her to live and work in the U.S., a process she expects will take about a year.

In the meantime, Katrina walks across the ditch one day most weekends. Alexis brings a tent and a small propane tank.

“During football season, we watch the football game,” Alexis said.

“And we nap a lot, actually,” said Katrina, finishing her wife’s sentence.

For the Zuidmeer family, Peace Arch Park was a place to reunite. Father Bill and mother Denise traveled there many times in the past few months from their home 7 miles south to see their son, Peter, and his wife and child, who live north of the park. The visits became particularly important after Bill was diagnosed in December with terminal kidney cancer.

But what became Bill’s last visit to the park was nearly a failure. The rules in Canada had changed — the Mounties warned Peter that to return to Canada he’d need to show his real passport, not just the photo on his phone. The round trip to retrieve it would take an hour and a half. His father was already exhausted from the trip, and Denise needed to return the specialized medical vehicle known as a cabulance she’d rented to get him there.

Denise begged the Mounties for dispensation. For her, this was all about her husband having a chance to have what might be a final reunion, safe because it was outdoors and all involved had been careful about physical distancing. “This isn’t tourism,” she said later. “It’s families.”

The Mounties ultimately allowed Peter across for a brief and emotional hug, and Peter’s 3-year-old got to sit on his grandfather’s lap for the last time.

Bill died at home 12 days later, on March 11, after his son made one last visit the formal way involving a strict 14-day quarantine on his return.

Katrina (left) and Alexis Gurr stand outside their tent on the American side of Peace Arch Park in Blaine, Washington. Katrina is Canadian. Alexis is American. They met online last spring and married in July. (Joanne Silberner)

Most of the park reunions are happier. Saunders, the immigration lawyer, said he’s seen a lot of weddings.

Some of the Canadians who live on 0 Avenue or thereabouts object to the gatherings. Canadian John Kageorge is concerned mostly about security issues, people smuggling things like guns or drugs. In addition, he said, “people need to follow public health guidelines, and they are not doing that at the park.”

Fear of covid is prevalent in Canada, so much so that “covid shaming” — social media outing and threatening of covid-positive people — has become , according to The New York Times. And Americans are often blamed. “There’s a big stigma in Canada that you guys aren’t the best,” said Katrina Gurr.

The U.S. has an appreciably higher rate of covid infections and deaths — more than people compared with Canada’s 26,000 per million as of Wednesday. But whether SARS-CoV-2 is being spread outdoors or in the tents of Peace Arch Park is anybody’s guess. After the issue was raised by the Canadian media in February, the British Columbia premier responded that his chief health official had told him no outbreaks were attributable to the park.

The Public Health Agency of Canada cases to international travel. But that estimate is likely to be low, said Kelley Lee and Anne-Marie Nicol, global health policy experts at Simon Fraser University. In an in The Conversation, an online news site, they note that only air travelers are monitored. That leaves out the people in Peace Arch Park and essential workers like truckers and health care workers who regularly drive across the border.

“Essential travelers remain untested so we cannot know what risk they pose,” Lee wrote in an email.

Tents abound on the eastern side of Peace Arch Park, even though park rules clearly state that no tents are allowed. (Joanne Silberner)

In the absence of clear information about spread, the fight over the park remains a political one. Two Liberal Party of Canada members of the provincial legislature British Columbia’s premier, a member of the New Democratic Party, to ask Washington Gov. Jay Inslee, a Democrat, to close the American side. But the premier turned them down, saying that international borders were an issue for the federal government in Ottawa.

Inslee spokesperson Mike Faulk said Washington discourages people from gathering but did not indicate any action was imminent. Last October, Prime Minister Justin Trudeau said the border closures would last “as long as we feel that they need to last.”

The Canadian side of the arch says: “Brethren Dwelling Together in Unity.” For now, at least, that’s true in the park, but not along the rest of the 4,000 miles of border between the Atlantic and Pacific oceans. Saunders, the Gurrs and Zuidmeers plus many other border watchers are not expecting any changes soon.

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Head Of Major HMO Sees Openings For Accountable Care Organizations-The KHN Interview

Joanne Silberner — Mon, 25 Jul 2011 04:30:00 +0000

Long before the sweeping health law was even a notion on Capitol Hill, HMOs were a force in American medicine. The business model of patients having a primary care doctor, who coordinated care with specialists and hospitals in an established network, was designed to apply best and most effective practices in medicine while controlling spending.

Then, when the law was written, a key provision called for insurers, hospitals, doctors’ groups and other providers to form accountable care organizations. The goal: to offer patients unified care systems with electronic health records, quality measurements and best-practices medicine.

knows a lot about how to do that. As the chairman and CEO of Kaiser Permanente’s hospitals and health plans (which is not affiliated with KHN), he says, “With more than $40 billion a year in revenue, we’re bigger than 42 states and 135 countries relative to our care delivery system and the population we care for.” And he’s also proud of the awards it has won for delivering high-quality care.

In a recent conversation with Joanne Silberner, Halvorson took a look at the future of health care under the 2010 Affordable Care Act, including the role ACOs are likely to play. An edited excerpt follows.

Q. From what you’re seeing in your visits to Washington, what’s the future of the health law?

A. All the things related to care — coordinated care, care safety — are pretty much going to survive because people really want hospitals to report their infection rates, people want databases about cancer care. The only part of the bill I think is in jeopardy legally at the Supreme Court level is the consumer mandate; the betting is 50/50 either way. If it doesn’t survive, we’re going to have to figure out another mechanism for making sure the risk pool isn’t just comprised of people who are the equivalent of buying your car insurance after your car has crashed. On the insurance side, there are going to be some questions on how well the exchanges work.

Q. You run what is essentially an accountable care organization. From your viewpoint, can an ACO not only give integrated care but also save money?

A. I think that the very best way to save money in health care is to make care more accountable and effective and to focus on the right level of care. We at KP have cut the number of broken bones in our seniors by about 40 percent by delivering team care to them, and identifying all the seniors at high risk and making sure they get the right prescriptions, the right follow-up and the right coaching. And we save hundreds of millions of dollars a year by not having those bones break.

Q: Can private insurance provide integrated care now?

A: Private care delivery can do this. The problem is they’re not paid for it. At KP we do six things for seniors that help keep bones from breaking, and three of the six do not appear on a Blue Cross or Medicare or Medicaid fee schedule. For example, we have the nurse and the pharmacist sit down together to figure out the right prescriptions and do follow-up care to make sure the patients are filling their prescriptions. A pharmacist and nurse in any other setting who did that work would have to do it for free.

Q: What do you see happening with ACOs as envisioned by the Affordable Care Act?

A: For Medicare, it means that even though (the program isn’t) going to pay for what the pharmacist and nurse do, if as a result of this you save money on broken bones providers get half the savings. Right now the caregivers who do that work get absolutely no reward and actually lose revenue.

But the version of ACOs that was written into the law for Medicare is complex and the law wasn’t as well drafted as it could have been. (The main ACO program) is probably going to have very few people signing up and is going to be almost a non-starter. But Medicare is creating some pilot programs with ACOs, and I think there are going to be a few dozen of these that are going to figure out ways of dealing with the patient population more directly.

There’s a third version of ACOs for the commercial health care insurance market; it’s to help them work with sets of caregivers to figure out how to create team care. I think there’s going to be a lot of energy in that area. The care systems are much more interested in doing that work than they were before, inspired in part by the act.

Q. ACOs depend on electronic health records. It took some work to get your electronic record system up and going. What kind of lessons have you learned that others might benefit from?

A. One of the lessons that we learned is that if you think of it as an end in itself, that’s a mistake. But if you say once the information is on a computer and it’s accessible and available, you can use it to make care better if you do particular things, then it’s very workable. We know which of our patients have asthma, which allows us to check to see which of them are getting the right asthma drugs and following the right asthma protocols. If you don’t do step 2, just putting that information in the computer doesn’t do any good.

Our overall medical cost trend since the medical record system has been installed has been about 20 to 30 percent lower than the cost trend of anybody else in health care, and we have 23 categories where we’re the number one scorer in the country on quality scores.

Q. What about the R word rationing? Will ACOs lead to rationing?

A. When doctors join an ACO, if they do the ACO right, they will figure out what’s the very best care for patients, what are the tests, what are the follow-ups, what are the treatments. If they function well as an ACO team, they’ll have that information available and the patients will get the right care. If you do it right, there’s no need for a “no” anywhere in the process.

Dr. Halvorson’s title has been corrected in this article.

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Study: Back Pain Too Often Treated With Expensive Surgery

Joanne Silberner — Wed, 07 Apr 2010 00:00:00 +0000

This story comes from our partner

Ruptured disc, spinal stenosis or degenerating spinal joints? See three common and chronic spine problems. (Graphic: NPR)

Too many complex back surgeries are being done and people are suffering as a result, according to a study in the current issue of the Journal of the American Medical Association. The general tendency noted in the study – that many patients and doctors think more medical care is always better – has implications for the new health overhaul law.

Back pain associated with aging can be treated in one of numerous ways: rest and physical therapy, surgery to remove the bony growths that can push on nerves, fusing two vertebrae together, or fusing many vertebrae together.

In the past few years, several studies have failed to show a big advantage for surgery – especially for complex surgery. Researchers from Oregon Health and Science University and several other places looked at Medicare billing records to see whether the rates or type of back surgeries went down as a result.

They found the number of surgeries has gone down very slightly. But when they looked specifically at complex surgeries, they found a big difference.

“The most complex type of back surgery has increased dramatically between 2002 and 2007, with a 15-fold increase,” says co-author Richard Deyo. In 2002, the rate of complex surgery was 1.4 per 100,000 people in Medicare. It jumped to 19.9 per 100,000 just five years later.

Deyo and his colleagues also checked the rate of complications. “This more complex form of surgery is associated with a higher risk of life threatening complications,” he says. Among people who just had the bony growths removed (a surgery called decompression), 2.3 percent had problems associated with their treatment, such as a heart attack, stroke or pneumonia. The complication rate was 5.6 percent among people who had multiple vertebrae fused together.

Deyo says there’s no reason to think people suddenly started developing the spinal deformities that justify the complex surgeries. He offers several possibilities for the upswing. “Many surgeons genuinely believe that the more invasive procedures offer some benefits,” he says. “But certainly there are important financial incentives at play as well.” Surgical fees for simple decompressions are about $600 to $1,000. The complex surgeries earn surgeons as much as 10 times more. He says another possible factor is the tendency for both doctors and patients to go for a new, more expensive approach just because it sounds better.

Orthopedist Eugene Carragee, a professor at Stanford University School of Medicine, wrote an editorial accompanying the research, saying that financial incentives are part of the problem. There’s also a problem with how new technologies are introduced, he says. In surgery, someone can just introduce a new procedure.

“The burden of proof in the system as it is now is that researchers have to go out to try and prove that what this guy wants to do doesn’t work, and that’s a backwards kind of thinking,” he says.

It’s far better to have to prove that something works before it becomes common practice, he says.

JAMA study researcher Deyo would like his study to alter the practice of medicine. “The effect I would hope it would have is to have surgeons and patients choose the least invasive procedure that would accomplish the surgical aim,” he says. But he’s pessimistic about it, unless there’s a change in the financial incentives.

James Weinstein is also calling for a rejiggering of financial incentives. Weinstein is an orthopedic surgeon and the director of the Dartmouth Institute for Health Policy and Clinical Practice. He did some of the original studies showing that most back surgeries make a minimal difference, if any. He says Deyo’s study shows one thing clearly. “The practice of medicine doesn’t always follow the best evidence,” he says.

The new health overhaul law sets up a new institute that would do studies like Deyo’s, comparing the risks and benefits of various treatments for various conditions. The law explicitly says the information can’t be used by insurers or government to set reimbursement policies, but Weinstein says the institute could make a big difference.

“I think if patients were well informed, they would choose the right thing,” Weinstein says. “We’ve done lots of studies with shared decision-making. Where patients are given good information they generally choose the least invasive, less risky procedure.”

He says health overhaul plans need to go beyond what’s in the new law. “Right now we have health insurance reform,” he says. “We need health care delivery reform, we need to change how we’re delivering practice and how we’re reimbursing for it.” What he’d like to see is a system that pays doctors and hospitals based on overall patient care, not separately for individual procedures.

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