Smith-Bindman and like-minded colleagues have long pushed for federal policies aimed at improving safety for patients undergoing CT scans. Under new Medicare regulations effective this year, hospitals and imaging centers must start collecting and sharing more information about the radiation their scanners emit.

About 93 million CT scans are performed every year in the United States, according to IMV, a medical market research company that . More than half of those scans are for people 60 and older. Yet there is scant regulation of radiation levels as the machines scan organs and structures inside bodies. Dosages are erratic, varying widely from one clinic to another, and are too often unnecessarily high, Smith-Bindman and other critics say.

“It’s unfathomable,” Smith-Bindman said. “We keep doing more and more CTs, and the doses keep going up.”

One CT scan can expose a patient to 10 or 15 times as much radiation as another, Smith-Bindman said. “There is very large variation,” she said, “and the doses vary by an order of magnitude — tenfold, not 10% different — for patients seen for the same clinical problem.” In outlier institutions, the variation is even higher, according to research she and a team of international collaborators

She and other researchers estimated in 2009 that high doses could be responsible for 2% of cancers. Ongoing research shows it’s probably higher, since far more scans are performed today.

The cancer risk from CT scans for any individual patient is very low, although it rises for patients who have numerous scans throughout their lives. Radiologists don’t want to scare off patients who can benefit from imaging, which plays a crucial role in identifying life-threatening conditions like cancers and aneurysms and guides doctors through complicated procedures.

But the new data collection rules from the Centers for Medicare & Medicaid Services issued in the closing months of the Biden administration are aimed at making imaging safer. They also require a more careful assessment of the dosing, quality, and necessity of CT scans.

The requirements, rolled out in January, are being phased in over about three years , , and physicians. Under the complicated reporting system, not every radiologist or health care setting is required to comply immediately. Providers could face financial penalties under Medicare if they don’t comply, though those will be phased in, too, starting in 2027.

When the Biden administration issued the new guidelines, a CMS spokesperson said in an email that excessive and unnecessary radiation exposure was a health risk that could be addressed through measurement and feedback to hospitals and physicians. The agency at the time declined to make an official available for an interview. The Trump administration did not respond to a request for comment for this article.

The Leapfrog Group, an organization that tracks hospital safety, welcomed the new rules. “Radiation exposure is a very serious patient safety issue, so we commend CMS for focusing on CT scans,” said Leah Binder, the group’s president and CEO. Leapfrog has for to imaging radiation, “and we find significant variation among hospitals,” Binder added.

CMS contracted with UCSF in 2019 to research solutions aimed at encouraging better measurement and assessment of CTs, leading to the development of the agency’s new approach.

The American College of Radiology and three other associations involved in medical imaging, however, when they were under review, arguing in written comments in 2023 that they were excessively cumbersome, would burden providers, and could add to the cost of scans. The group was also concerned, at that time, that health providers would have to use a single, proprietary tech tool for gathering the dosing and any related scan data.

The single company in question, Alara Imaging, supplies free software that radiologists and radiology programs need to comply with the new regulations. The promise to keep it free is included in the company’s copyright. Smith-Bindman is a co-founder of Alara Imaging, and UCSF also has a stake in the company, which is developing other health tech products unrelated to the CMS imaging rule that it does plan to commercialize.

But the landscape has recently changed. ACR said in a statement from Judy Burleson, ACR vice president for quality management programs, that CMS is allowing in other vendors — and that ACR itself is “in discussion with Alara” on the data collection and submission. In addition, a company called Medisolv, which works on health care quality, said at least one client is working with another vendor, Imalogix, on the CT dose data.

Several dozen health quality and safety organizations — including some national leaders in patient safety, like the Institute of Healthcare Improvement — have supported CMS’ efforts.

Concerns about CT dosing are long-standing. A landmark study by a research team that included experts from the National Cancer Institute, the Department of Veterans Affairs, and universities estimated that CT scans were responsible for 29,000 excess cancer cases a year in the United States, about 2% of all cases diagnosed annually.

But the number of CT scans kept climbing. By 2016, , up 20% in a decade, though radiologists say dosages of radiation per scan have declined. Some researchers have noted that U.S. doctors order far more imaging than physicians in other developed countries, arguing some of it is wasteful and dangerous.

More recent studies, some looking at pediatric patients and some drawing on radiation exposure data from survivors of the atomic bomb attacks on Hiroshima and Nagasaki in Japan, have also identified CT scan risk.

Older people may face greater cancer risks because of imaging they had earlier in life. And scientists have emphasized the need to be particularly careful with children, who may be more vulnerable to radiation exposure while young and face the consequences of cumulative exposure as they age.

Max Wintermark, a neuroradiologist at the MD Anderson Cancer Center in Houston, who has been involved in the field’s work on appropriate utilization of imaging, said doctors generally follow dosing protocols for CT scans. In addition, the technology is improving; he expects artificial intelligence to soon help doctors determine optimal imaging use and dosing, delivering “the minimum amount of radiation dose to get us to the diagnosis that we’re trying to reach.”

But he said he welcomes the new CMS regulations.

“I think the measures will help accelerate the transition towards always lower and lower doses,” he said. “They are helpful.”

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

USE OUR CONTENT

This story can be republished for free (details).

In his mid-80s, he had a stroke. Then lymphoma. Then prostate cancer. He was fatigued, isolated, not all that steady on his feet.

Then Tsubaki took part in an innovative care initiative that, over four months, sent an occupational therapist, a nurse, and a handy worker to his home to help figure out what he needed to stay safe. In addition to grab bars and rails, the handy worker built a bookshelf so neither Tsubaki nor the books he cherished would topple over when he reached for them.

Reading “is kind of the back door for my cognitive health — my brain exercise,” said Tsubaki, a longtime community college teacher. Now 87, he lives independently and walks a mile and a half almost every day.

The program that helped Tsubaki remain independent, called Community Aging in Place: Advancing Better Living for Elders, , has been around for 15 years and is offered in about 65 places across 26 states. It helps people 60 and up, and some younger people with disabilities or limitations, who want to remain at home but have trouble with activities like bathing, dressing, or moving around safely. Several have found the program saves money and prevents falls, which the Centers for Disease Control and Prevention says contribute to the deaths of and cost Medicare about $50 billion each year.

Despite evidence and accolades, CAPABLE remains small, serving roughly 4,600 people to date. Insurance seldom covers it (although the typical cost of $3,500 to $4,000 per client is less than many health care interventions). Traditional Medicare and most Medicare Advantage private insurance plans don’t cover it. Only four states use funds from Medicaid,the federal-state program for low-income and disabled people. CAPABLE gets by on a patchwork of grants from places like state agencies for aging and philanthropies.

The payment obstacles are an object lesson in how insurers, including Medicare, are built around paying for doctors and hospitals treating people who are injured or sick — not around community services that keep people healthy. Medicare has billing codes for treating a broken hip, but not for avoiding one, let alone for something like having a handy person “tack down loose carpet near stairs.”

And while keeping someone alive longer may be a desirable outcome, it’s not necessarily counted as savings under federal budget rules. A 2017 found that CAPABLE had high satisfaction rates and some savings. But its limited size made it hard to assess the long-term economic impact.

It’s unclear how the Trump administration will approach senior care.

The barriers to broader state or federal financing are frustrating, said Sarah Szanton, who helped create CAPABLE while working as a nurse practitioner doing home visits in west Baltimore. Some patients struggled to reach the door to open it for her. One tossed keys to her out of a second-story window, she recalled.

Seeking a solution, Szanton discovered a program called ABLE, which brought an occupational therapist and a handy worker to the home. Inspired by its success, Szanton developed CAPABLE, which added a nurse to check on medications, pain, and mental well-being, and do things like help participants communicate with doctors. It began in 2008. Szanton since 2021 has been the dean of Johns Hopkins University School of Nursing, which coordinates research on CAPABLE. The model is participatory, with the client and care team “problem-solving and brainstorming together,” said Amanda Goodenow, an occupational therapist who worked in hospitals and traditional home health before joining CAPABLE in Denver, where she also works for the CAPABLE National Center, the nonprofit that runs the program.

CAPABLE doesn’t profess to fix all the gaps in U.S. long-term care, and it doesn’t work with all older people. Those with dementia, for example, don’t qualify. But studies show it does help participants live more safely at home with greater mobility. And one study that Szanton co-authored estimated Medicare savings of would continue for two years after a CAPABLE intervention.

“To us, it’s so obvious the impact that can be made just in a short amount of time and with a small budget,” said Amy Eschbach, a nurse who has worked with CAPABLE clients in the St. Louis area, where a Medicare Advantage plan covers CAPABLE. That St. Louis program caps spending on home modifications at $1,300 a person.

Both Hill staff and CMS experts who have looked at CAPABLE do see potential routes to broader coverage. One senior Democratic House aide, who asked not to be identified because they were not allowed to speak publicly, said Medicare would have to establish careful parameters. For instance, CMS would have to decide which beneficiaries would be eligible. Everyone in Medicare? Or only those with low incomes? Could Medicare somehow ensure that only necessary home modifications are made — and that unscrupulous contractors don’t try to extract the equivalent of a “copay” or “deductible” from clients?

Szanton said there are safeguards and more could be built in. For instance, it’s the therapists like Goodenow, not the handy workers, who put in the work orders to stay on budget.

For Tsubaki, whose books are not only shelved but organized by topic, the benefits have endured.

“I became more independent. I’m able to handle most of my activities. I go shopping, to the library, and so forth,” he said. His pace is slow, he acknowledged. But he gets there.

Kenen is the journalist-in-residence and a faculty member at Johns Hopkins University School of Public Health. She is not affiliated with the CAPABLE program.

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

USE OUR CONTENT

This story can be republished for free (details).

But Sanchez never had health insurance, and when she turned 65, she couldn’t enroll in Medicare. She has never had preventive care or screenings. No physicals. No cholesterol checks. No mammograms.

“Nada, nada, nada,” she said in an interview conducted in Spanish. Nothing, nothing, nothing.

When she did get sick, she delayed seeking care until she was so ill that she was twice hospitalized with pneumonia. She finally got covered last year under a landmark Illinois program for older people without legal residency that took effect in December 2020.

Democratic-led states such as Illinois are increasingly opening public insurance programs to immigrants lacking permanent legal status. A dozen had already covered children; even more provided prenatal coverage. But now more states are covering adults living in the country without authorization — and some are phasing in coverage for seniors, who are more expensive and a harder political sell than kids.

The expansions recognize the costs that patients living here illegally can otherwise impose on hospitals. But the policies are under harsh attack from former President Donald Trump and other Republicans who seek to make his opponent, Vice President Kamala Harris, the face of reckless immigration policies.

Republicans point to Harris’ home state of California’s to immigrants of all ages regardless of legal status, saying it comes at the expense of American citizens.

It’s a regular complaint for Trump. “She’ll go around saying, ‘Oh, Trump is going to do bad things to Social Security,’” he said of Harris at a . “No, she’s going to do it because she’s putting these illegal immigrants onto Social Security, onto Medicare, and she’s going to destroy those programs, and the people are going to have to pay.”

Harris’ choice of Minnesota Gov. Tim Walz as her running mate has added fuel to Republican attacks at the intersection of immigration and health policy.

Under a law Walz signed, immigrants living without authorization in Minnesota will be able to gain health coverage starting next year through the state’s for people with low incomes who aren’t eligible for Medicaid.

The issue is top of mind for some Americans. At an in Las Vegas, an audience member event host Univision identified as Ivett Castillo asked Harris what her administration would do about health care for people like her mother, who had immigrated from Mexico without authorization many years ago, worked her whole life, and died this year without ever receiving “the type of care and service that she needed or deserved.”

“What are your plans, or do you have plans, to support that subgroup of immigrants who have been here their whole lives, or most of them, and have to live and die in the shadows?” Castillo asked.

Harris noted her past support for a path to citizenship for unauthorized residents — and for a bipartisan border security bill that Senate Republicans killed earlier this year at the behest of Trump.

“This is one example of the fact that there are real people who are suffering because of an inability to put solutions in front of politics,” Harris said.

Even without such policies, immigrants can get free or inexpensive primary care at community clinics throughout the country — assuming they know it’s an option and feel safe at the facilities. But primary care can’t take care of all medical needs, particularly as people age and develop more complex health problems and chronic illnesses. So immigrants often rely on charity care, go into debt, or, like Sanchez, skimp. Some even return to their home countries for care.

Illinois, where Sanchez got covered, was a pioneer in extending insurance coverage to unauthorized migrants. Now, — all led by Democrats — cover at least some low-income older immigrants under Medicaid or Affordable Care Act waivers. Minnesota next year will become the seventh. State funds must be used for the expansions, as federal dollars generally can’t cover people lacking legal status.

Whether or how quickly more states follow remains to be seen, and if Trump wins the White House, his administration would likely try to thwart the trend, given that he has . Coverage for all immigrants is still a tough sell economically and politically — and the noncitizen population can’t vote its gratitude at the ballot box. Immigrant health have fizzled or been scaled back.

Maryland, for example, settled on opening its Obamacare exchange to people living in the state without authorization, starting in 2026 — but without taxpayer subsidies for their premiums.

Still, there’s enough activity in states to make advocates for immigrant health believe something has shifted. The pandemic’s severity and its uneven toll helped build support for covering older immigrants, said Lee Che Leong, the senior policy advocate at Northwest Health Law Advocates in Washington state.

“People are looking around and realizing that our health is interconnected, both globally and locally,” Leong said. “The pandemic really brought that home, that when you look at the disparities in who got covid, who was exposed to covid, and who died from covid.”

Access to U.S. health care has long been an obstacle for immigrants, even those in the country legally. People with green cards must wait five years for coverage under Medicaid or other government health programs. Some older green-card holders have to pay extra premiums for Medicare Part A — the portion that covers hospital care — if they haven’t been employed for at least 10 years in the U.S.

The new state health programs close those gaps, said Shelby Gonzales, vice president for immigration policy at the Center on Budget and Policy Priorities.

In July, Washington state started covering low-income immigrants in a Medicaid-like program called Apple Health Expansion, using a federal waiver. Enrollment is capped and the program filled quickly, but some slots were reserved for people 65 and older, Leong said. Earlier this year, the state opened its Obamacare exchange to immigrants living in the U.S. without authorization.

Oregon and Colorado now also offer some coverage to people in their states who lack legal status, though the Colorado program didn’t attract many older immigrants, according to data recently presented to the state Affordable Care Act exchange oversight committee.

New York has covered child immigrants lacking legal residency for years, and the state’s Medicaid program was opened in January to all adult immigrants regardless of status. About 25,000 people signed up in the first four months, according to New York Medicaid Director Amir Bassiri.

Back in Illinois, Maria Sanchez said her new coverage has been life-changing — and possibly lifesaving. Her bouts of pneumonia were severe, partly because she had delayed care. After her second hospitalization, she needed follow-up cardiac care. The hospital didn’t charge her for her stay.

But now, with her “tarjeta médica” — her medical card — she can see a doctor. Her heart condition is under control. She has seen a dentist. She’s getting her cataracts removed.

“With my medical card, I have peace of mind,” Sanchez said.

Illinois has gradually added coverage for other age groups; in summer 2022, it lowered eligibility to age 42. That means immigrants like Gaby Piceno, 45, can age more healthily.

“I don’t have to worry anymore,” she said, referring not just to herself but to her family.

But the coverage expansion has cost more than Illinois projected. People like Sanchez and Piceno, already on the rolls, remain covered, but new enrollment was paused this year. More people signed up than expected, and many continued seeking care in more costly hospital emergency departments rather than at doctors’ offices, said the state’s acting insurance commissioner, Ann Gillespie, who was an Illinois state senator when the program was established.

The state is now shifting covered immigrants into Medicaid managed-care plans, hoping to bring down the cost over time.

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

USE OUR CONTENT

This story can be republished for free (details).

Pero Sánchez nunca tuvo seguro médico, y cuando cumplió 65, no pudo inscribirse en Medicare. Nunca ha tenido atención preventiva ni exámenes. No ha tenido chequeos físicos, ni mediciones de colesterol, ni mamografías.

“Nada, nada, nada”, dijo.

Cuando enfermaba, tardaba en buscar atención médica hasta que estaba tan mal que fue hospitalizada dos veces por neumonía. Finalmente, el año pasado obtuvo cobertura a través de un programa pionero en Illinois para personas mayores indocumentadas que entró en vigencia en diciembre de 2020.

Estados liderados por demócratas, como Illinois, están abriendo cada vez más programas de seguros públicos a inmigrantes sin papeles. Una docena ya cubría a niños; aún más proporcionaban cobertura prenatal. Pero ahora, Ìýestán cubriendo a adultos que viven en el país sin autorización, y algunos están ampliando la cobertura para personas mayores, que son más costosos y representan un desafío político mayor que los niños.

Estas expansiones reconocen los costos que estos pacientes pueden imponer sobre los hospitales. Pero estas políticas están bajo dura crítica del ex presidente Donald Trump y otros republicanos, quienes buscan presentar a su oponente, la vicepresidenta Kamala Harris, como la cara de políticas de inmigración irresponsables.

Los republicanos señalan la en el estado natal de Harris, California, a inmigrantes de todas las edades independientemente de su estatus legal, argumentando que esto afecta a los ciudadanos estadounidenses.

Es una queja frecuente de Trump. “Ella va por ahí diciendo, ‘Oh, Trump va a hacer cosas malas con la Seguridad Social’”, dijo sobre Harris en el 13 de septiembre. “No, ella va a hacerlo porque está poniendo a estos inmigrantes ilegales en la Seguridad Social, en Medicare, y va a destruir esos programas, y la gente tendrá que pagar”.

La elección de Harris del gobernador de Minnesota, Tim Walz, como compañero de fórmula ha añadido combustible a los ataques republicanos en la intersección de la inmigración y la política de salud.

Con la esperanza de presentar a la candidata demócrata presidencial Kamala Harris como extrema en inmigración, el ex presidente Trump y sus partidarios han dicho que ella quería otorgar beneficios de salud gratuitos, pagados por los contribuyentes, a inmigrantes en el país sin permiso legal. Pero esta declaración omite detalles clave.

Bajo una ley firmada por Walz, los inmigrantes que viven sin documentos en Minnesota podrán obtener cobertura de salud a partir del próximo año a través del del estado para personas de bajos ingresos que no son elegibles para Medicaid.

El tema es de gran interés para algunos estadounidenses. En el 10 de octubre, una integrante del público identificada por Univision como Ivett Castillo le preguntó a Harris qué haría su administración respecto a la atención médica para personas como su madre, quien había emigrado de México sin autorización muchos años atrás, trabajado toda su vida ahasta su muerte este año sin haber recibido “el tipo de atención y servicio que necesitaba o merecía”.

“¿Cuáles son sus planes, o tienen planes, para apoyar a ese subgrupo de inmigrantes que han estado aquí toda su vida, o la mayoría de ellos, y tienen que vivir y morir en las sombras?”, preguntó Castillo.

Harris mencionó su apoyo anterior a un camino a la ciudadanía para residentes sin papeles, y a un proyecto de ley bipartidista de seguridad fronteriza que los republicanos del Senado bloquearon a principios de este año por insistencia de Trump.

“Este es un ejemplo de que hay personas reales que sufren debido a la incapacidad de anteponer soluciones a la política”, dijo Harris.

Incluso sin estas políticas, los inmigrantes pueden recibir atención primaria gratuita o económica en clínicas comunitarias en todo el país, asumiendo que saben que es una opción y se sienten seguros en las instalaciones.

Pero la atención primaria no puede cubrir todas las necesidades médicas, especialmente a medida que las personas envejecen y desarrollan problemas de salud y enfermedades crónicas más complejas. Así que los inmigrantes suelen depender de la atención caritativa, endeudarse o, como Sánchez, evadir al doctor. Algunos incluso regresan a sus países de origen para recibir atención.

Illinois, donde Sánchez obtuvo cobertura, fue pionero en la extensión de cobertura de seguros a migrantes no autorizados. Ahora, —todos liderados por demócratas— cubren al menos a algunos inmigrantes mayores de bajos ingresos bajo Medicaid o exenciones de la Ley de Cuidado de Salud a Bajo Precio (ACA).

Minnesota se convertirá en el séptimo el próximo año. Para estas expansiones se utilizan fondos estatales, ya que los fondos federales generalmente no pueden cubrir a personas sin estatus legal.

Queda por ver si más estados seguirán esta tendencia y cuán rápido, y si Trump gana la Casa Blanca, es probable que su administración intente frenar esta tendencia, dado que .

La cobertura para todos los inmigrantes sigue siendo una propuesta difícil tanto económica como políticamente, y la población no ciudadana no puede agradecer votando. Las iniciativas de salud para inmigrantes han fracasado o se han reducido.

Maryland, por ejemplo, decidió abrir su mercado del Obamacare a personas que viven en el estado sin autorización a partir de 2026, pero sin subsidios de los contribuyentes para sus primas.

Aun así, hay suficiente actividad en los estados para que defensores de la salud de los inmigrantes crean que algo ha cambiado. La gravedad de la pandemia y su impacto desigual ayudaron a generar el apoyo para cubrir a inmigrantes mayores, dijo Lee Che Leong, defensora principal de políticas en Northwest Health Law Advocates en el estado de Washington.

“La gente está mirando a su alrededor y se da cuenta de que nuestra salud está interconectada, tanto global como localmente”, dijo Leong. “La pandemia realmente mostró eso, cuando miras las disparidades en quién se contagió de covid, quién estuvo expuesto a covid y quién murió por covid”.

Durante mucho tiempo, el acceso a la atención médica en el país ha sido un obstáculo para los inmigrantes, incluso aquellos que tienen papeles. Las personas con tarjetas de residencia deben esperar cinco años para obtener cobertura bajo Medicaid u otros programas de salud del gobierno. Algunos personas mayores con residencia tienen que pagar primas adicionales para Medicare Parte A —la parte que cubre la atención hospitalaria— si no han trabajado al menos 10 años en Estados Unidos.

Los nuevos programas de salud estatales cierran estas brechas, dijo Shelby Gonzales, vicepresidenta de política de inmigración en el Center on Budget and Policy Priorities.

En julio, el estado de Washington comenzó a cubrir a inmigrantes de bajos ingresos en un programa similar a Medicaid llamado Apple Health Expansion, utilizando una exención federal.

La inscripción es limitada y el programa se llenó rápidamente, pero se reservaron algunos lugares para personas de 65 años o más, dijo Leong. A principios de este año, el estado abrió su mercado de Obamacare a inmigrantes que viven en los EE. UU. sin autorización.

Oregon y Colorado ahora también ofrecen alguna cobertura a personas en sus estados que carecen de estatus legal, aunque el programa de Colorado no atrajo a muchos inmigrantes mayores, según datos presentados hace poco al comité de supervisión del mercado de ACA.

Nueva York ha cubierto a niños inmigrantes sin documentos durante años, y el programa de Medicaid del estado se abrió en enero para todos los inmigrantes adultos independientemente de su estatus. Aproximadamente 25,000 personas se inscribieron en los primeros cuatro meses, según el director de Medicaid de Nueva York, Amir Bassiri.

De vuelta en Illinois, María Sánchez dijo que su nueva cobertura ha cambiado su vida, y posiblemente le ha salvado la vida. Sus episodios de neumonía fueron graves, en parte porque retrasó la atención. Después de su segunda hospitalización, necesitó atención cardíaca de seguimiento. El hospital no le cobró por su estadía.

Pero ahora, con su “tarjeta médica”, puede ver a un médico. Su condición cardíaca está bajo control. Ha visto a un dentista. Va a tener una operación de cataratas. “Con mi tarjeta médica, tengo paz mental”, dijo Sánchez.

llinois ha agregado gradualmente cobertura para otros grupos de edad; en el verano de 2022, redujo la elegibilidad a los 42 años. Eso significa que inmigrantes como Gaby Piceno, de 45, pueden envejecer de manera más saludable.

“Ya no tengo que preocuparme”, dijo, refiriéndose no solo a sí misma, sino a su familia.

Pero la expansión de la cobertura ha costado más de lo proyectado en Illinois. Personas como Sánchez y Piceno, ya inscritas, siguen cubiertas, pero este año se frenó la nueva inscripción. Se inscribieron más personas de lo esperado, y muchas continuaron buscando atención en salas de emergencia de hospitales más costosos en lugar de en consultorios médicos, dijo la comisionada interina de seguros del estado, Ann Gillespie, quien era senadora estatal en Illinois cuando se estableció el programa.

El estado ahora está transfiriendo a los inmigrantes cubiertos a planes de atención administrada de Medicaid, con la esperanza de reducir el costo con el tiempo.

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

USE OUR CONTENT

This story can be republished for free (details).

She was taking care of her father, now 86, who has been in and out of hospitals and rehabs after a worsening series of strokes in recent years.

Working from home for a rental property company, she could handle it. In fact, like most family caregivers during the early days of covid-19, she had to handle it. Community programs for the elderly had shut down.

Even when Beltré switched to a hybrid work role — meaning some days in the office, others at home — caring for her father was manageable, though never easy.

Then she was ordered back to the office full time in 2022. By then, Medicaid was covering 17 hours of home care a week, up from five. But that was not close to enough. Beltré, now 61, was always rushing, always worrying. There was no way she could leave her father alone so long.

She quit. “I needed to see my dad,” she said.

In theory, the national debate about remote or hybrid work is one great big teachable moment about the demands on the 53 million Americans taking care of an elderly or disabled relative.

But the “return to office” debate has centered on commuting, convenience, and child care. That fourth C, caregiving, is seldom mentioned.

That’s a missed opportunity, caregivers and their advocates say.

Employers and co-workers understand the need to take time off to care for a baby. But there’s a lot less understanding about time to care for anyone else. “We need to destigmatize it and create a culture where it’s normalized, like birth or adoption,” said Karen Kavanaugh, chief of strategic initiatives at the Rosalynn Carter Institute for Caregivers. For all the talk of cradle to grave, she said, “mostly, it’s cradle.”

After her stepmother died, Beltré moved her father into her home in Fort Myers, Florida, in 2016. His needs have multiplied, and she’s been juggling, juggling, juggling. She’s exhausted and, now, unemployed.

She’s also not alone. About , and nearly a third have quit a job because of their caregiving responsibilities, according to a report from the Rosalynn Carter Institute. Others cut back their hours. The Rand Corp. has estimated that caregivers in family income each year — an amount that’s almost certainly gone up since the report was released nearly a decade ago.

Beltré briefly had a remote job but left it. The position required sales pitches to people struggling with elder care, which she found uncomfortable. She rarely gets out — only to the grocery store and church, and even then she’s constantly checking on her dad.

“This is the story of my life,” she said.

Workplace flexibility, however desirable, is no substitute for a national long-term care policy, a viable long-term care insurance market, or paid family leave, none of which are on Washington’s radar.

President Joe Biden gave family caregivers a shoutout in his State of the Union address in February and followed up in April with an executive order aimed at supporting caregivers and incorporating their needs in planning federal programs, including Medicare and Medicaid. Last year, his Department of Health and Human Services released a outlining how federal agencies can help and offering road maps for the private sector.

Although Biden checked off priorities and potential innovations, he didn’t offer any money. That would have to come from Congress. And Congress right now is locked in a battle over cutting spending, not increasing it.

So that leaves it up to families.

Remote work can’t fill all the caregiving gaps, particularly when the patient has advanced disease or dementia and needs intense round-the-clock care from a relative who is also trying to do a full-time job from the kitchen table.

But there are countless scenarios in which the option to work remotely is an enormous help.

When a disease flares up. When someone is recuperating from an injury, an operation, or a rough round of chemo. When a paid caregiver is off, or sick, or AWOL. When another family caregiver, the person who usually does the heavy lift literally or metaphorically, needs respite.

“Being able to respond to time-sensitive needs for my dad at the end of his life, and to be present with my stepmother, who was the 24/7 caregiver, was an incredible blessing,” said Gretchen Alkema, a well-known expert in aging policy who now runs a consulting firm and was able to work from her dad’s home as needed.

That flexibility is what Rose Garcia has come to appreciate, as a small-business owner and a caregiver for her husband.

Garcia’s husband and business partner, Alex Sajkovic, has Lou Gehrig’s disease. Because of his escalating needs and the damage the pandemic wrought on their San Francisco stone and porcelain design company, she downsized and redesigned the business. They cashed in his retirement fund to hire part-time caregivers. She goes to work in person sometimes, particularly to meet architects and clients, which she enjoys. The rest of the time she works from home.

As it happened, two of her employees also had caregiving obligations. Her experience, she said, made her open to doing things differently.

For one employee, a hybrid work schedule didn’t work out. She had many demands on her, plus her own serious illness, and couldn’t make her schedule mesh with Garcia’s. For the other staff member, who has a young child and an older mother, hybrid work let her keep the job.

A third worker comes in full time, Garcia said. Since he’s often alone, his dogs come too.

In Lincoln, Nebraska, Sarah Rasby was running the yoga studio she co-owned, teaching classes, and taking care of her young children. Then, at 35, her twin sister, Erin Lewis, had a sudden cardiac event that triggered an irreversible and ultimately fatal brain injury. For three heartbreaking years, her sister’s needs were intense, even when she was in a rehab center or nursing home. Rasby, their mother, and other family members spent hour after hour at her side.

Rasby, who also took on all the legal and paperwork tasks for her twin, sold the studio.

“I’m still playing catch-up from all those years of not having income,” said Rasby, now working on a graduate degree in family caregiving.

Economic stress is not unusual. Caregivers are disproportionately women. If caregivers quit or go part time, they lose pay, benefits, Social Security, and retirement savings.

“It’s really important to keep someone attached to the labor market,” the Rosalynn Carter Institute’s Kavanaugh said. Caregivers “prefer to keep working. Their financial security is diminished when they don’t — and they may lose health insurance and other benefits.”

But given the high cost of home care, the sparse insurance coverage for it, and the persistent workforce shortages in home health and adult day programs, caregivers often feel they have no choice but to leave their jobs.

At the same time, though, more employers, facing a competitive labor market, are realizing that flexibility regarding remote or hybrid work helps attract and retain workers. Big consultant companies like BCG offer advice on “.”

Successful remote work during the pandemic has undercut bosses’ abilities to claim, “You can’t do your job like that,” observed Rita Choula, director of caregiving for the AARP Public Policy Institute. It’s been more common in recent years for employers to offer policies that help workers with child care. Choula wants to see them expanded “so that they represent a broad range of caregiving that occurs across life.”

Yet, even with covid’s reframing of in-person work, telecommuting is still not the norm. A March report from the Bureau of Labor Statistics private businesses had some or all of their workforce remote last summer — a dropoff from 40% in 2021, the second pandemic summer. Only about 1 in 10 workplaces are fully remote.

And remote and hybrid work is mostly for people whose jobs are largely computer-based. A restaurant server can’t refill a coffee cup via Zoom. An assembly line worker can’t weld a car part from her father-in-law’s bedside.

But even in the service and manufacturing sectors, willing employers can explore creative solutions, like modified shift schedules or job shares, said Kavanaugh, who is running pilot programs with businesses in Michigan. Cross-training so workers can fill in for one another when one has to step into caregiving is another strategy.

New approaches can’t come soon enough for Aida Beltré, who finds joy in caregiving along with the burden. She’s looking for work, hybrid this time. “I am a people person,” she said. “I need to get out.”

She also needs to be in. “Every night, he says, ‘Thank you for all you do,’” she said of her father. “I tell him, ‘I do this because I love you.’”

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

USE OUR CONTENT

This story can be republished for free (details).

Families can access it from birth – sometimes even before a baby is born, if a serious problem is detected in utero – through the course of an illness, whether it lasts weeks, months or years. Care can be at home, in the hospital, or in both settings.

More on Palliative Care

• Palliative Care Can Help Children And Families Navigate Bewildering Medical Terrain
• What Is Palliative Care?

Palliative care teams work with children with many serious diseases such as cancer, major organ failures, HIV/AIDS, serious heart conditions, cystic fibrosis, progressive genetic, neurological or metabolic disorders, kidney failure, or severe cerebral palsy. Sometimes they are involved with children who are awaiting, or who have had, transplants.

For more information nationwide, contact , a consumer site of the Center to Advance Palliative Care, or the helpline at of the National Hospice and Palliative Care Organization at 800-658-8898.

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

USE OUR CONTENT

This story can be republished for free (details).

Hospice is an interdisciplinary approach to health care for people who are likely to die within six months. Most hospice care takes place in the patient’s home.Ìý It became part of the Medicare system in the early 1980s, and programs are also usually available for end-of-life care through Medicaid and private insurance.

But hospice generally requires that the patient give up care aimed at curing or at least halting the progression of the disease.Ìý But it can be very hard for patients, families and doctors to know when the time has come to stop aggressive treatment – or to surrender hope for a cure.

More on Palliative Care

• Palliative Care Can Help Children And Families Navigate Bewildering Medical Terrain
• Who Should Get Pediatric Palliative Care?

That’s one reason palliative care has emerged in the past decade. It takes that interdisciplinary approach – doctors, nurses, social workers and often chaplains – and blends it with curative care for seriously ill people.Ìý While palliative care is for people who are very sick, they don’t have to have a six-month life expectancy.Ìý Some palliative care programs operate in hospitals; others treat people living at home. Growing numbers of community-based hospices also have palliative care services now.

Pediatric palliative care is not available everywhere, although it’s becoming more common at the major children’s hospitals, according to Dr. Joanne Wolfe, director of pediatric palliative care at Children’s Hospital Boston. In addition, hospices nationwide, which traditionally were often unwilling to treat dying children, have also become more open to pediatric care. The new health reform law allows dying children on Medicaid or the state Children’s Health Insurance Program to get hospice or palliative care without halting other treatment.

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

USE OUR CONTENT

This story can be republished for free (details).

Nicky Nault, and her son Avery sit in the pediatric palliative care program at Children’s Hospital Boston in March. (Suzanne Kreiter/The Boston Globe)

“Then I got home, and I thought, ‘huh?’ ” said Diane Norton, who cares for her disabled daughter at home. She turned to PACT.

PACTÌý– the at Children’s Hospital Boston and the Dana-Farber Cancer Institute — has worked with the Norton family for nine years. The doctors, nurses, and social workers, trained in the relatively new specialty of pediatric palliative care, manage complex pain and symptoms while supporting families as they navigate bewildering medical terrain, set goals of care, and make tough decisions that match those goals.

See Video

See video of the Pediatric Advanced Care Team at work:

• Special Needs, Special Care: Palliative Care at Children’s Hopsital BostonÌý

Lindsay suffered seizures as a newborn, and the family knew early on that she would have limitations. It wasn’t until she was 4 that they learned that her rare neuromuscular condition was degenerative. She cannot speak, has a feeding tube and is in a wheelchair. Her mother is profoundly grateful that Lindsay has lived 13 years. She knows the future is unknowable.

“I just want to make the best decisions,” she said, stroking the long hair of her daughter, meticulously groomed down to her polished fingernails, during an outpatient appointment with Children’s palliative care director, Dr. Joanne Wolfe, and social worker Marsha Joselow. Their hour-plus meeting included an assessment of the gurgling sounds in Lindsay’s chest, a review of her many medications, a quick check on how big brother Craig was coping with the stressful college application season.

Norton’s instinct, supported by Wolfe, was to go slow on the scoliosis surgery. She would go back to the orthopedist, accompanied by a PACT professional, so that everyone would have a more nuanced picture of Lindsay’s likely trajectory, with or without the operation. They would consult with an anesthesiologist, for more insight into how her fragile body would hold up during surgery and the recuperation. Then they would pause, reflect and reassess. The final decision would be Diane Norton’s.

Getting Help While Continuing Treatment

About 1.3 million babies, children, and adolescents live with serious or life-limiting illness, such as cerebral palsy, heart defects, metabolic disorders, and cancer, Children’s Hospice International has . Around 53,000 die each year, according to the .

Hospice can and does help dying children (although not all hospices work with dying children.) Palliative care arose, in part, because many of these children and their families need an interdisciplinary approach for months or years, not just at the close of a child’s life. Teams such as PACT can address complex and distressing symptoms, including shortness of breath, nausea, anxiety, and hard-to-control pain.

Palliative Care

• What Is Palliative Care?Ìý
• Who Should Get Pediatric Palliative Care?

Hospice usually requires that patients stop curative care. But parents can’t always bring themselves to give up that last slender thread of hope that one more treatment, one more surgery, one more hospital stay could bring forth a miracle. doesn’t force that stark choice on families. They can have both palliative and curative care.

Massachusetts, as part of its health insurance overhaul in 2006, required that dying children have access to both hospice and other care and built a statewide palliative care network for kids, according to Margaret Murphy, executive director of the Hospice & Palliative Care Federation of Massachusetts.

The year-old federal health law terminally ill children in Medicaid and the state-based Children’s Health Insurance Program to have hospice or palliative care, without having to stop chemotherapy or other disease-fighting therapies. Medicare will test similar concurrent care models for adults. With adults, palliative care can save money. With children, people don’t talk much about the cost, just about the need.

‘We Want To Get Out Of Here’

Some children with life-threatening illnesses will be cured or stabilized. Others are not so lucky.

Nicky and Rick Nault have three children. The oldest, Janessa, is healthy. Their two sons have disorders that affect a part of cells in their bodies called mitochondria. Isaiah, the older, is doing OK. Little Avery, 4, is not. He lies in his hospital bed at Children’s, encircled by his big toy dragon, making funny faces with a favorite nurse, looking a bit suspiciously at strangers in case, his mother explained, they’ve come to suction his respiratory secretions.

“We want to get out of here in the next few days,” Nicky Nault told Joselow. At home, the little boy can sleep in his own bed, laugh with his brother, sister, and dog. But when they tried to take Avery home a few weeks ago, they got only as far as a service station down the block from the hospital before turning around. Avery was having trouble breathing.

Last summer, when Avery was hospitalized for six weeks and needed a ventilator to breathe, his parents faced a difficult situation. “We began to realize we could lose him,” Nicky Nault said. “Do we have a year? Two years? We don’t know. We had to step back and make a lot of decisions.” The palliative care team keeps Avery comfortable and pain-free while they help the family grapple with how much is too much — when do the burdens of modern medicine outweigh the blessings.

“It is what it is,” she said, “a nasty disease that will take him from us.”

Kevin “AJ” Amaral, 15, hasn’t even gotten as far as that gas station.

He was born with a metabolic disorder but was able to function well and enjoy life. He walked, talked -– and laughed. He attended school. According to a sign posted on his hospital door, he loved wrestling, Sponge Bob, silly jokes and rude digestive noises.

In the fall of 2009, he came down with the H1N1 flu. Complications included a stroke. He was hospitalized with ferocious full-body spasms. His mother, Ann Gauthier, calls them “torture.” He passes his days in a wheelchair or in bed and can’t speak much, only in a whisper, struggling to be understood.

He has spent every day and every night in a hospital or rehab room since Nov. 6, 2009, almost 17 months ago. The blue-eyed kitten his mother chose to greet him at home is no longer a kitten.

Gauthier seldom leaves his side. With each infection, each complication, each disappointment, the family has had to adjust to what one PACT team member called a “new reality.”

“He gets up every day and tries. Every day,” said Dr. Rick Goldstein, who left his more traditional pediatric practice to take care of these seriously ill children. Earlier this month, Goldstein scheduled a PACT meeting “so everyone can come together and think about getting AJ home.”

That will require taming the spasms, a special wheelchair, setting up home care, and coordinating with all the other doctors treating the problems that ricochet from one vital organ to the next.

Mark Toro, 15, a beautiful child with deep brown eyes and chiseled cheekbones, was diagnosed at age 4 with neuroblastoma, a rare cancer of the nerve tissue. He had one year of treatment, followed by three good years. But the cancer came back. Working alongside oncologists, PACT helped get Mark through years of physical and emotional pain of cancer treatment, when there was hope for a cure, and when that hope faded.

A few weeks ago he came from his home in Amherst for an appointment at Dana-Farber. His disease was advancing; pain control was a challenge, which the palliative care team attacked with pills, patches, and pumps. His mom, Ana Rosa, had filled her freezer with Fudgsicles. They didn’t upset his stomach and gave him a few moments of frozen chocolate pleasure.

Mark understood but didn’t want to talk to a reporter. He gestured to his mother to speak for him.

“We have emotional moments, family conversations,” she said. “When we’re alone, him and I, he tells me he’s not afraid, he’s not afraid to die, that I don’t need to be so emotional, that he’s going to be OK.”

PACT had accompanied them every step of the way; Rosa had a rock-solid certainty that they would be there for the difficult steps to come. She wondered aloud how she would get through it.

“This is all I know. What am I going to do right after?”

She turned to her son with her answer. “You will be on my right shoulder,” she said. “My little angel.”

Last Friday afternoon, Mark died in his parents’ arms.

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

USE OUR CONTENT

This story can be republished for free (details).

Melanie Bella’s new job is to help fix that.

Bella once ran the Indiana Medicaid program and most recently worked at the Center for Health Care Strategies, a nonprofit focusing on quality care for people with complex conditions. There, she worked on improving care for vulnerable populations with complex health needs. In September, she was named the of the Federal Coordinated Health Care Office (CHCO), known as the “office of the duals.” Established under the new health care law, the office will work closely with the Center for Medicare and Medicaid Innovation to streamline care for people who are . The office will address some of the cost-shifting and inconsistencies that can contribute to fragmentation of care, particularly as patients move back and forth from hospital, home, rehab and long-term care – with some services and settings under Medicare’s purview and some under Medicaid’s. A major focus will be to improve the federal-state relationship.

According to the SCAN Foundation, a California nonprofit organization dedicated to improving seniors’ health care options, Medicare spends five times more on dual eligibles than on individuals only on Medicare. Although dual eligibles make up fewer than one in five Medicaid beneficiaries, they account for nearly half of all Medicaid spending.

Joanne Kenen interviewed Bella for Kaiser Health News. Here is an edited and condensed account.

Q: Can you explain your goals – how you see the problem?

A: It’s really two main themes. Improve the beneficiaries’ experience and make it easier for them to understand and navigate the system, so they can expect to get good care. And address ways in which the system is highly uncoordinated, the need to improve the relationship between the federal government and the states. These programs were never designed with the idea of people getting both (Medicare and Medicaid). They were not designed to work together, and we are seeing that. There are different systems for enrollment, grievances, financing, misaligned incentives, cost shifting. All these things can result in poor care, poor outcomes.

Q: Where do you start?

A: We’re cataloguing. What order are we going to go in and make the fixes? We want to be transparent, and get feedback. We’re a small office, but the list is long.

Q: Can you give an example of how a patient experiences some of this lack of coordination?

A: Think about the different coverage and benefit standards, just with home care. For Medicare, you have to meet the definition of being homebound to get home care. Not for Medicaid. This creates problems. Someone who hasn’t met the Medicare homebound definition, (but has qualified for services through Medicaid) and then something happens (often after hospitalization), and he or she meets the (Medicare) definition. Then Medicare has to provide the home care, so you switch them over. And there’s a different formulary and there’s a new payer, new rules, there are all sorts of problems.

Q: You have had experience at the state level – as Indiana’s Medicaid director, and you directed a leadership training institute for Medicaid directors. What does that tell you about improving federal-state coordination for this population, and will it differ in “red” and “blue” states?

A: We are open for business to help states move beneficiaries into more seamless systems. We don’t prescribe a one size fits all approach. We want beneficiaries to receive certain types of things but there may be different systems – an accountable care organization, PACE (Program of All-inclusive Care for the Elderly, a SNP (special needs plan).

The states have common sets of need. They need help integrating and analyzing data. They need actuarial help. They need help in putting together best practices, what works, what hasn’t worked. There is a core set of needs they all have, regardless of the political underpinnings. I think that all the states – most of the states – are interested in access to data, and all states would like to have an ability to share in savings.

Q: There is talk of having states assume full financial and programmatic responsibility for managing dual eligibles’ care. How is that different than block grants?

A: We’ve had many, many demos in Massachusetts, Minnesota and Wisconsin of blended funding and it’s not a block grant. The funding – from Medicare and Medicaid – went to the health plan, that’s where it was blended [not in state government.]. It was integrated at the plan level, with the ability to have flexibility, to provide the types of services that keep people at home or in the community, rather than in the institution. One entity gets the funding – but they have accountability along with the flexibility.

Q: We tend to think of dual eligibles as elderly people with chronic disease but about a third – 3.4 million in 2008 – were younger people with disabilities. How do they fit in?

A: That’s a priority population for us — particularly the under 65 with serious mental illness. Who are they? We know at a high level but we want to drill down. Under 65, the presence or absence of mental illness is a game changer. We have a group of folks whose needs are long-term-care driven, some in institutions and some in the community. They need home care, personal care attendants, respite care. They need better care management at home, prevention of costly institutionalizations down the road. It’s very different than the older folks who have physical morbidities.

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

USE OUR CONTENT

This story can be republished for free (details).

She decided to put up with the pain a bit longer — at least until the Average White Band finished its set.

When she did get to Ochsner Medical Center, she was stunned. The whole visit took less than an hour – including X-rays, pain medication, a soft cast and discharge instructions to tide her over until she got home to Cary, Illinois.Ìý

“I was absolutely amazed,” said Foley, who said she is about 60 years old.

Ochsner is one of a growing number of emergency departments trying new approaches to ease crowding. The efforts have added urgency as some experts predict the problem could worsen in coming years. They worry that as millions of people suddenly gain health coverage in 2014 under the new federal health law, they may have trouble finding primary care doctors and will turn to hospital emergency departments instead.

For both patients and hospitals, crowding involves more than inconvenience. Some patients get so tired of waiting that they leave without being seen. That’s bad medicine, because they can end up sicker within hours or days.

And it’s bad business, because the hospital is left with lost revenue and unsatisfied customers.

“It’s not only the person with a minor illness . . . who leaves,” said Mark McClelland, a George Washington University health policy expert working with the Robert Wood Johnson Foundation’s Ìýemergency care project. “Someone who is very, very sick, who is at risk for significant problems, can be leaving. They came to you for help, and you failed your mission if they leave.”

The hospital efforts to address the problem have ranged from high-tech options such as smart phone programs that let patients compare waiting times at local hospitals to something as mundane as staggering nursing shifts to better match patient traffic. “Fast tracks,” or clinics for patients with simple complaints, are also common.

But some hospitals, such as Ochsner, are looking at more fundamental routines, shaking up and re-engineering their procedures. Ochsner, for instance, created an emergency department protocol called “qTrack.” The sickest patients still go back immediately to the emergency department’s traditional beds, but patients such as Foley go quickly into separate treatment areas with a nice comfortable recliner or to a procedure room for stitches or a cast. They await test results and discharge instructions in a post-treatment waiting room.

Treatment there can move faster and cost less. Foley never had to change into a hospital gown and or get in an expensive hospital bed with high tech monitors. She just had to show the doctor her arm.

“Beds are the most squandered and overutilized resource in emergency departments,” said Dr. Joseph Guarisco, chairman of the department of emergency medicine at Ochsner.

The Banner hospital system based in Phoenix uses a similar approach and was by the federal Agency for Healthcare Research and Quality as an instructive case study for other hospitals.

Among the changes some other hospitals have tried:

–The emergency department at Stony Brook University Medical Center in Long Island, N.Y., grew tired of having the hallways lined with patients on gurneys who needed to be admitted to the regular medical or surgical floors. But it now has procedures to send some patients upstairs anyway, even if it means they lie on a gurney in the hallway near the nursing station. That has helped the rest of the hospital become more attuned to the needs of the emergency department – and much faster at finding the needed beds, according to Dr. Peter Viccellio, clinical director of emergency medicine.

“It’s like a fire alarm that goes on at the institutional level – everyone knows there’s a problem in the emergency department, we’re at capacity,” he said.

–Doctors at Providence Hospital in Washington, D.C., used community health workers to identify emergency patients who with a little guidance could get their needs met in a community setting such as a primary care, HIV/AIDS or mental health clinic.

“They did a fantastic job of decreasing the return revisits,” said Dr. Kim Bullock, the hospital’s assistant director for the emergency department. But the project ended when the year-long grant ran out. Under traditional fee-for-service payment plans, Providence has no way of getting reimbursed for the work. The hospital is looking for another grant – or waiting to see whether payment changes expected under health reform make programs like this more viable in the next few years.

–Emergency physicians at Good Samaritan Hospital in West Islip, N.Y., on the South Shore of Long Island, take over one of the hospital’s walk-in surgery units after it empties out around 4 p.m. – just in time, because the emergency room generally starts getting crowded by mid-afternoon.

In addition to offering space, the program focuses on patients who score in the middle of the five-point triage scale, whose risk is just not clear cut and who are often at risk for leaving without being seen. For example, does that patient have severe stomach flu – or is it an ectopic pregnancy or a bowel obstruction? An intense migraine – or a brain bleed?

It’s not clear that initiatives such as these can keep up with the growing number of patients in emergency departments, especially as some hospitals close and demand continues to grow from the ranks of people newly insured and an aging population. In addition, there is no one easy answer for hospitals–sometimes projects that are hugely successful in one hospital flop somewhere else.

Yet even as emergency departments work on new initiatives, some experts argue that attention should be focused instead on the hospital as a whole. Dr. Art Kellermann, a Rand Corp. scholar and an emergency care physician, says such “workarounds” let hospitals off the hook. “The reality,” he said, “is the rest of the hospital doesn’t want to deal with the fact that the overcrowded ER is a sure absolute sign of a poorly managed hospital.”

Not all experts share that view. “It all depends on where you create bottlenecks,” in the inpatient side or in the ED itself, said Dr. Joseph “Jody” Crane, an emergency physician at Mary Washington Hospital in Fredericksburg, Va., and a faculty member of the Institute of Healthcare Improvement. “It doesn’t make sense to point fingers,” he said.

Foley came away a believer. “I thought it would be five or six hours — two hours to get in, another few to get out.” Instead “I iced and elevated my arm like they told me to – but I stayed for the rest of the JazzFest.”

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

USE OUR CONTENT

This story can be republished for free (details).