The California health care organization will create a new nonprofit that aims to acquire a half-dozen additional community health systems.The NewsKaiser Permanente, a large California-based health care group with 39 hospitals and 24,000 doctors, said on Wednesday that it expected to acquire Geisinger Health, a smaller East Coast group, in an effort to develop a new company that would operate nonprofit community health systems.“If we can take much of what is in our value-based care platform and extend that to these leading community health systems, then we extend our mission,” Greg A. Adams, Kaiser’s chairman and chief executive, said in an interview. “We reach more people, we drive greater affordability for health care in this country.” Both organizations are nonprofit.Kaiser will not absorb Geisinger, which will keep its name. Instead, Geisinger, which is headquartered in Danville, Pa., will be folded into Risant Health, a new nonprofit group that will operate independently. Geisinger’s chief executive, Dr. Jaewon Ryu, will serve as Risant’s chief executive when the deal is closed.Mike Blake/ReutersWhat’s Next: Regulatory ReviewFederal and state regulators must approve the deal. While Mr. Adams did not say what other health systems he might be talking to regarding acquisitions, Kaiser said it hoped to invest $5 billion in Risant over the next five years, in addition to its spending on Kaiser’s core operations. The company expects to add five or six health systems to Risant in that time.Why It Matters: Increasing ConsolidationKaiser, which serves 13 million people in eight states and the District of Columbia, has built a reputation for delivering high-quality care at low costs. The organization operates like a health maintenance organization, in which it is paid a fixed sum to care for someone through a closed network of hospitals and doctors. But it has not succeeded in offering its model broadly across the country.The creation of Risant Health represents an opportunity for Kaiser, which had $95 billion in revenue last year, to become an even bigger and more influential organization by working with other hospital groups and health plans.The formation of the company is also a response to the rapid changes taking place in the health care industry. Large for-profit companies like health insurers, pharmacy chains and other corporations are scooping up physician practices and urgent care centers and devouring more of the country’s health care dollars.In keeping with Kaiser’s model, the community health systems under Risant would invest in technology and preventive care to keep patients healthy, so they would need less expensive specialty and hospital care, Mr. Adams said.As national systems and new players grow larger, “they are pulling away in some respects from our communities and from our community health systems,” he said.The new venture “is a way to really ensure that not-for-profit, value-based community health is not only alive but is thriving in this country,” Mr. Adams added.Background: A Tough EnvironmentAs hospital groups emerge from the pandemic, many are struggling with higher expenses for supplies and labor. Both Kaiser and Geisinger reported operating losses in 2022.“Covid has really shown not having integrated, value-based relationships puts our health systems and our communities at risk,” Mr. Adams said.While Geisinger has long focused on improving care, Dr. Ryu said the health system would benefit from Kaiser’s ability to invest in the kind of technology and preventive care necessary to keep people healthier. “This model made sense to us as a way to accelerate and further bolster those capabilities and bring better health into our communities,” he said.Because it has specialized in providing care under arrangements where it is paid a fixed amount, Kaiser has become one of the largest insurers in the profitable Medicare Advantage market, where its private plans are sold as an alternative to traditional Medicare.But Kaiser has not been immune to criticism for overbilling the federal government, and some people say its financial model means it can be slow to refer patients for costly services. Kaiser has defended its billing practices and says its doctors work with patients to provide the most appropriate care.

Inflation and pressing household expenses are forcing some people to postpone health needs, an emerging trend that has health experts worried that conditions may only worsen.Megan Swanson has warily watched the erosion of her family’s savings as inflation chips away at a reserve for emergencies.She often postpones any regular doctor’s appointments, including her yearly dermatology appointment, even though annual skin checks are typically recommended for residents of sunny Florida, where she lives in Naples with her husband and their three children.“Each month we are seeing our costs go up, but not our bank account,” she said.Ms. Swanson, 37, is a part-time student and has not worked since she was laid off during the pandemic when the local Nordstrom store closed in 2020. Her husband, Brett, 37, is employed as the director of wellness at a retirement community.“I put the priority on the kids,” she said.Last March, the Swansons had to come up with $8,000 to cover their share of hospital bills after their baby daughter was hospitalized with a febrile seizure. “What if something happens again in the future, and how will we afford it?” she asked.Rising out-of-pocket costs are weighing heavily on the scale, pushing aside tests or procedures when troublesome symptoms emerge. And these days, the grocery list (and even the price of eggs) feel more pressing to many families. While some people avoided seeking medical care during the worst of the pandemic, worried about the risk of infection or unable to get an appointment because hospitals and doctors were overwhelmed, now many are finding that inflation and the uncertain economy have thrown up another barrier.“We are starting to see some individuals who are putting off some care, especially preventive care, due to the costs,” said Dr. Tochi Iroku-Malize, the president of the American Academy of Family Physicians and the chair of family medicine for Northwell Health in New York. Choosing between going to the doctor or paying for rent and food, “the health issue is no longer the priority,” she said.The inability to afford medical tests and treatment, a perennial concern in the United States, began emerging as a much more striking issue last year. Nearly four of 10 Americans said they had put off care in 2022 because of cost, the highest number since Gallup started asking people about delaying care more than 20 years ago. The percentage reporting they or a family member delayed health care because of cost rose to 38 percent from 26 percent in 2021.Megan and Brett Swanson playing a board game with their three children, Jojo, Gracie and Cam. Melanie Metz for The New York TimesWith the prices of prescription drugs, hospital stays and other treatments expected to increase significantly this year and next, some doctors expect families to have an even harder time affording medical care. A recent report from the Commonwealth Fund found that 29 percent of people with employer-based coverage were underinsured, because they had such high out-of-pocket costs even with insurance. The coming roll back of health coverage under the state-federal Medicaid program will very likely lead many people to become uninsured.About one-fourth of respondents in Gallup’s poll said they put off care last year for what they considered a “serious” condition. When Margaret Bell, 71, found that her cancer had returned four years ago, she hesitated to resume her chemotherapy because she could not afford it, and higher prices have made it even harder. She would regularly skip appointments near her home in Lancaster, S.C.“It is impacting patients’ access to care,” Ms. Bell’s oncologist, Dr. Kashyap B. Patel, said. As the chief executive of Carolina Blood and Cancer Care Associates in Rock Hill, S.C., he recently set up a nonprofit group, No One Left Alone, to help cancer patients like Ms. Bell and to connect them with local charities. The organization is covering the cost of her treatments, and Dr. Patel has assured her that his office will find the money for her visits.On a limited budget, “it’s been very difficult for me,” Ms. Bell said. Having her family over for dinner can be a strain because of high grocery bills, and she is faced with deciding which of her medical needs is the most urgent. She has postponed receiving a pacemaker.A new federal report suggests fewer Americans’ health bills are being sent to collection, but medical debt still accounts for more than half of all kinds of collection debt, exceeding unpaid credit card or cellphone bills. It remains a serious issue: about a fifth of Californians said they had medical debt of at least $5,000, according to another recent survey. A little over half of those asked said they had skipped some kind of care in the last year, with half of those reporting their condition got worse as a result.“This is about trade-offs that people have to think about that are really hard,” said Dr. Jay Bhatt, the executive director of the Deloitte Center for Health Solutions, a research unit of the consulting firm. He also sees patients at the Family Christian Health Center outside of Chicago. In a survey by Deloitte last year, 28 percent of respondents said they were less able to afford care than in the previous year.Some of the clinic’s patients are losing their jobs and insurance, he said. “We’ve seen this before, and we are going to see it in big numbers now,” Dr. Bhatt said.In Hammond, Ind., Tameaka Smith and her husband, Stevenson Lloyd, are coping with tighter finances and trying to save where they can. She is disabled and covered through Medicare, the federal insurance program, while her husband, who works at an auto parts factory, has private insurance through his employer.Still, they are skimping a bit on medicines they need. Her husband takes his thyroid medication every other day, and she sometimes uses her father’s asthma medicine. “We’re self-medicating, trying to stretch it out and doctor ourselves,” Ms. Smith said.With two children, their family has not recovered from the financial strains of the pandemic. “It’s hard catching up when you’re so pushed back,” Ms. Smith said.Her husband also weighs the merits of going to the doctor, knowing that if he doesn’t have to pay right away during the visit, “then next month we’re getting a big bill,” she said.“I put the priority on the kids,” Ms. Swanson said.Melanie Metz for The New York TimesAny turbulence in the economy has historically resulted in the loss of medical care for an increasing number of people, either because they no longer have health insurance or because they cannot afford their share of medical bills. During the Great Recession, millions of Americans lost their health coverage, and many people are predicting a similar wave in the coming months. Millions of people could lose Medicaid coverage as states begin the process of dropping individuals from the program now that states will no longer have to keep people enrolled and extra federal funds are going to disappear.The cost of treatments is also likely to rise next year as hospitals, many of whom reported losses in 2022, will raise their rates, said Sean Duffy, the co-founder and chief executive of Omada Health, a company in San Francisco that provides virtual care and coaching to people with chronic health conditions like diabetes. The company’s employees were already starting to see an increase in patients wrestling with how to pay for medicine and healthy food.“2024 is the reckoning, unfortunately,” Mr. Duffy said.In addition to medical bills, patients often cannot afford to take off work for a doctor’s visit, let alone find the funds to cover child care or the transportation needed to get there. A colonoscopy to determine why a patient may be bleeding could result in missing a day’s work and a medical bill equal to a week’s work, said Dr. Rajeev Jain, a gastroenterologist at Texas Digestive Disease Consultants. “We’re seeing an uptick in patients canceling for those reasons,” he said.“You have a finite number of dollars to spend on your family,” Dr. Jain said. When you’re worried about having enough food or stable housing, “at that moment, you’re not thinking of preventing something five years from now.”In 2021, a fifth of Americans either delayed or went without medical care because of the pandemic because of a lack of available appointments and fear of infection, according to a recent analysis by KFF, a nonprofit research group. Only 5 percent cited cost alone.The catch-up in visits and procedures by people who are now able to see the doctor and the increased number of people seeking care caused by the winter season’s respiratory illnesses could mask any recent declines in seeking out medical care.“It’s possible that this is the calm before the storm, especially since a lot of people are going to lose Medicaid coverage,” Cynthia Cox, a vice president at K.F.F., said.

Doctors fail to recognize serious conditions like stroke and sepsis in tens of thousands of patients each year, according to a new study.As many as 250,000 people die every year because they are misdiagnosed in the emergency room, with doctors failing to identify serious medical conditions like stroke, sepsis and pneumonia, according to a new analysis from the federal government.The study, released Thursday by the Agency for Healthcare Research and Quality, estimates roughly 7.4 million people are inaccurately diagnosed of the 130 million annual visits to hospital emergency departments in the United States. Some 370,000 patients may suffer serious harm as a result.Researchers from Johns Hopkins University, under a contract with the agency, analyzed data from two decades’ worth of studies to quantify the rate of diagnostic errors in the emergency room and identify serious conditions where doctors are most likely to make a mistake. Many of the studies were based on incidents in European countries and Canada, leading some officials of U.S. medical organizations to criticize the researchers’ conclusions.While these errors remain relatively rare, they are most likely to occur when someone presents with symptoms that are not typical, like stroke patients complaining the room is spinning.A doctor may not immediately think that a young woman with shortness of breath is having a heart attack or that someone who has back pain could have a spinal abscess.“This is the elephant in the room no one is paying attention to,” said Dr. David E. Newman-Toker, a neurologist at Johns Hopkins University and director of its Armstrong Institute Center for Diagnostic Excellence, and one of the study’s authors.The findings underscore the need to look harder at where errors are being made and the medical training, technology and support that could help doctors avoid them, Dr. Newman-Toker said. “It’s not about laying the blame on the feet of emergency room physicians,” he said.In reviewing the studies, the researchers also found that women and people of color had a roughly 20 to 30 percent higher risk of being misdiagnosed. While these results are not surprising, they point to the need to address how different patients are assessed in the emergency room as part of the effort to improve care, said Jennie Ward-Robinson, the chief executive of the Society to Improve Diagnosis in Medicine. “Equity must be core and must be fundamental,” she said.Medical societies representing emergency room doctors strongly criticized the study. “In addition to making misleading, incomplete and erroneous conclusions from the literature reviewed, the report conveys a tone that inaccurately characterizes and unnecessarily disparages the practice of emergency medicine in the United States,” Dr. Christopher S. Kang, the president of the American College of Emergency Physicians, said in a statement.“As with all medical specialties, there is room for improvement in the diagnostic accuracy of emergency care,” Dr. Kang added. “All of us who practice emergency medicine are committed to improving care and reducing diagnostic error.”Doctors say addressing diagnostic errors is challenging. While the National Academy of Medicine identified medical errors as a critical issue more than 20 years ago, most of the efforts to improve patient safety have focused on mistakes that are easier to identify, like when a patient gets the wrong medicine or develops an infection while in the hospital, said Dr. Robert Wachter, the chairman of medicine at the University of California, San Francisco, who had not seen the full report. “Diagnostic errors are a huge part of the problem,” he said.The deaths that the report suggests occur every year “is a very concerning number,” Dr. Wachter said. The study’s findings are higher than previous estimates, he noted.The researchers largely relied on studies conducted outside the United States, in countries like Canada, Spain and Switzerland, to come with up with their overall estimate of error and harm rates. But Dr. Kang argued the reliance on these studies may have distorted the findings and led the researchers to overestimate the number of mistakes. “While most medical specialties have similar training in Western nations, emergency medicine does not,” he said.The study’s authors acknowledged the need to do more research looking specifically at emergency rooms in the United States. “We need studies done in the United States,” said Dr. Susan M. Peterson, a Johns Hopkins emergency medicine physician who is also one of the study’s authors. “It’s a huge gap in the literature.”But she also emphasized the benefit of paying more attention when doctors tend to miss a crucial diagnosis. In recent years, she said, doctors have become much better at detecting heart attacks because of a concerted effort involving public health campaigns, better diagnostic testing, and collaboration between cardiologists and emergency medicine doctors to address the issue.Experts also emphasized that while the study focused on those mistakes made in emergency rooms, where a harried doctor, dealing with overcrowding, must make a quick decision about what is wrong with a patient, the issue of misdiagnosis is a common problem among all doctors.“The bottom line is diagnosis is hard,” said Dr. Doug Salvador, an infectious disease specialist who is the board president of the Society to Improve Diagnosis in Medicine and the chief quality officer at Baystate Health in Springfield, Mass.The researchers found that teaching hospitals were less prone to errors. Emergency room doctors working at an academic medical center may be able to consult with a specialist who is familiar with patients who have atypical symptoms, and they may have more resources to offer a wider range of tests or to keep patients longer while they figure out what’s wrong.The study also suggested that doctors were more likely to miss specific diseases. A patient with a spinal abscess, for example, is more frequently misdiagnosed than someone having a heart attack.Some doctors warn that the answer is not simply to do more testing. “This is a really complicated calibration problem,” Dr. Wachter said. “The answer can’t be let’s test everybody for all this stuff all the time,” he said.The Johns Hopkins researchers say there needs to be more effort to understand how to avoid the most deadly errors, including thinking about how doctors are trained and what kinds of technology could help alert them to a possible missed diagnosis. “This is going to have to be a sustained effort, and that requires resources and support,” Dr. Newman-Toker said.Not enough money is being spent on how to improve diagnosis despite its role in improving care, Dr. Peterson said. “A lot of research dollars are focused on treatment,” she said. “That’s a little more sexy than diagnosis.”

As inflation rises, assisted living and home health aides are becoming more expensive. We want to hear from people who are dealing with this type of financial stress.Many older Americans in need of long-term care are struggling to afford assisted living facilities, home health aides or nursing homes. Inflation is making these services even more expensive than before. Reporters from The New York Times and Kaiser Health News want to hear from people who are under financial strain because of long-term care.Have you or your relatives run out of money for long-term care? How are you coping financially and ensuring you or your loved ones get the necessary care?How has inflation made it harder or impossible to afford long-term care? How have higher prices affected how much you or your family can spend on an older person who needs assistance?Has an older person in your life had to leave a care facility or give up paid in-home care because of the rising costs or lack of funds? If so, how are you managing?Please fill out the form below, and a reporter may contact you to follow up. We won’t publish any part of your submission without contacting you first.How has the rising cost of long-term health care affected you?

Thank you for sharing your story with us! We may contact some respondents for a more in-depth conversation in the coming weeks.

Many U.S. hospitals are postponing scans used to diagnose diseases after a Covid lockdown in China hobbled the main U.S. supplier of an imaging chemical.Doctors cannot seem to pinpoint what is wrong with Michael Quintos.Mr. Quintos, 53, a Chicago resident, has constant stomach pain. He has been hospitalized, and his doctors have tried everything including antibiotics, antacids, even removing his appendix. “I still don’t feel good,” Mr. Quintos said.His doctors recommend using a CT scan with contrast, imaging that relies on a special dye often injected into patients to better visualize their blood vessels, intestines and organs like the kidney and liver.But a nationwide shortage of the imaging agents needed for the procedure — the result of the recent lockdown in Shanghai to quell a Covid outbreak — has prompted hospitals to ration these tests except in emergencies.Like thousands of others in recent weeks, Mr. Quintos cannot get an exam using the contrast dye.And an alternative may not be enough to determine how to treat his illness.“The fact you can’t figure it out tells me you need more tools to figure it out,” he said.An estimated 50 million exams with contrast agents are performed each year in the United States, and as many as half the nation’s hospitals are affected by the shortage. Some are reserving much of their supply on hand for use in emergency rooms — where quick, accurate assessments are most dire.The shortage of a vital imaging agent is the latest example of the country’s vulnerability to disruptions in the global supply chain and its overreliance on a small number of manufacturers for such critical products. The Shanghai plant shuttered by the lockdown is operated by GE Healthcare, a unit of General Electric and one of two major suppliers of the iodinated contrast materials. The company supplies its dyes, Omnipaque and Visipaque, for the United States.Lawmakers expressed concern about the scarcity of imaging agents. “In the wealthiest nation on Earth, there should be no reason doctors are forced to ration lifesaving medical scans to compensate for a shortage of material,” Representative Rosa DeLauro, Democrat of Connecticut, said in a statement. “We are seeing supply chains break down because of consolidated industries experiencing manufacturing shortages and offshoring American jobs to China.”Shortages of the dye were reported to the U.S. Food and Drug Administration earlier this month, and the agency said it was working closely with manufacturers “to help minimize the impact on patients.” Yet even though GE Healthcare said this week that the situation was improving now that the plant had reopened, the shortages and patient delays could persist well into the summer because of a lag in how quickly replenished supplies could be distributed.Senator Patty Murray, Democrat of Washington, is pressing the agency to see what steps it is taking to address the shortage, according to a statement from her office. She has also introduced legislation, with Senator Richard Burr, Republican of North Carolina, to strengthen the supply chain.“The hits just keep on coming in this pandemic in the supply chain,” said Dr. Jamie McCarthy, the chief physician executive at Memorial Hermann Health System, a large hospital group in Houston.Health officials and doctors worry that the low supply and prolonged waits for tests will exacerbate earlier delays in care caused by the pandemic, when hospitals were overrun with Covid patients, they were facing sizable backlogs to get tests and elective procedures were canceled or postponed for months. Patients who overlooked troubling new symptoms or could not get follow-up appointments have suffered deteriorating health in many cases. Some doctors report more cancer patients with advanced-stage disease as a result.“We continue to be concerned about the impact of the delayed, deferred or ignored screening over the last few years,” said Dr. William Dahut, the chief scientific officer for the American Cancer Society.The lack of contrast dye in an exam can make it more difficult to diagnose cancer, he said, and can make it harder to see if a treatment is working. “Patients could be in a situation where clinical decisions are going to be negatively impacted,” Dr. Dahut said.In addition to using contrast with a CT angiogram to determine whether patients have a blood clot or internal bleeding, doctors often rely on CT scans with contrast to spot infections, bowel blockages or cancers. Doctors are also delaying some cardiac catheterizations.The shortage does not affect people undergoing mammograms and screenings for lung cancer because they do not require the imaging agents, and some patients may be able to have an M.R.I. in place of a CT scan or have the exam performed without contrast.But for many others, the shortage leaves them in limbo. “It’s definitely causing more stress for patients,” said Dr. Shikha Jain, an oncologist in Chicago. “There are patients who are getting frustrated because scans are delayed or canceled.”How long and to what extent the shortage will affect patient care is difficult to predict. For health care workers, for whom supply shortages and the pandemic have been so relentlessly taxing, “it feels like a never-ending marathon,” she said.Health care workers walked a residential street in lockdown in Shanghai on Monday. The city’s current covid precaution has affected a plant that manufactures the dyes.Aly Song/ReutersAt Memorial Hermann, the system has “throttled back” its use of contrast for elective procedures, Dr. McCarthy said, to preserve its supplies. The daily volume of CT scans being performed with contrast is about half of what it normally is, he says.At ChristianaCare, a Delaware-based hospital group, the supply depletion problem emerged in mid-May, and “became a serious issue very quickly,” said Dr. Kirk Garratt, the medical director for the group’s heart and vascular health center and a former president of the Society for Cardiovascular Angiography and Interventions. When other area hospitals began running out of dye, they started sending patients to ChristianaCare. “It impacted our burn rate,” he said.“We’re really worried here,” Dr. Garratt said. Explaining why elective procedures were being delayed, he added: “We feel we have to make this change now to ensure we have a supply so we can keep doing the urgent care we need.”A patient who fails an exercise stress test that may indicate a heart problem but is not in imminent danger is likely to wait for a scan and be treated with medications. But if a patient enters the emergency room and is sweating, with severe chest pain, an angiogram requiring contrast dye is immediately ordered to determine whether the person is suffering a heart attack.“We either fix that now, or in a few hours it will be too late to save you,” Dr. Garratt said.Hospitals generally rely on a single supplier for their contrast agents, and many facilities may have only a week or two of supply on hand, says Dr. Matthew Davenport, vice chair of the commission on quality and safety for the American College of Radiology and a professor at Michigan Medicine.He likens the situation to the current scarcity of baby formula, where only a handful of companies serve a critical market. “There is not a lot of redundancy in the system,” Dr. Davenport said.GE Healthcare said in a statement on Monday that its supply of iodinated contrast media products was increasing, although it did not provide an estimate for when the shortage would end. “We are working around the clock to expand production and return to full capacity as soon as possible and in line with local authorities” in China, the company said.“After having to close our Shanghai manufacturing facility for several weeks due to local Covid policies, we have been able to reopen and are utilizing our other global plants wherever we can,” the statement read.GE Healthcare said the plant was operating at 60 percent capacity and would be at 75 percent within the next two weeks. It also said it had taken other steps like increasing production of the products at its plant in Cork, Ireland, and flying some shipments to the United States.The company also said it was distributing the dye to hospitals based on their historical supply needs, which doctors said could prevent large hospital systems from stockpiling excessive amounts.Bracco Imaging, the other producer based in Milan, said in a statement that it was working to deliver supplies even to hospitals that were not customers to shore up use for “critical emergency procedures,” according to Fulvio Renoldi Bracco, the company’s chief executive. In a statement, he said that Bracco had also submitted a request to the F.D.A. for the potential importation of an equivalent agent that had not been approved for use in the United States. The agency declined to comment on the request.Nancy Foster, the vice president of quality and patient safety policy for the American Hospital Association, a trade group in Washington, likened the situation to the short supply of oxygen, among other treatment machines and remedies, during the pandemic. The group has urged G.E. to share more information about the shortage.“We need to figure out how to really create a much more robust, not as lean, supply system that has some give to it,” she said.

Investigators urged increased oversight of the program, saying that insurers deny tens of thousands of authorization requests annually.Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published on Thursday.The investigators urged Medicare officials to strengthen oversight of these private insurance plans, which provide benefits to 28 million older Americans, and called for increased enforcement against plans with a pattern of inappropriate denials.Advantage plans have become an increasingly popular option among older Americans, offering privatized versions of Medicare that are frequently less expensive and provide a wider array of benefits than the traditional government-run program offers.Enrollment in Advantage plans has more than doubled over the last decade, and half of Medicare beneficiaries are expected to choose a private insurer over the traditional government program in the next few years.The industry’s main trade group claims people choose Medicare Advantage because “it delivers better services, better access to care and better value.” But federal investigators say there is troubling evidence that plans are delaying or even preventing Medicare beneficiaries from getting medically necessary care.The new report, from the inspector general’s office of the Health and Human Services Department, looked into whether some of the services that were rejected would probably have been approved if the beneficiaries had been enrolled in traditional Medicare.Tens of millions of denials are issued each year for both authorization and reimbursements, and audits of the private insurers show evidence of “widespread and persistent problems related to inappropriate denials of services and payment,” the investigators found.The report echoes similar findings by the office in 2018 showing that private plans were reversing about three-quarters of their denials on appeal. Hospitals and doctors have long complained about the insurance company tactics, and Congress is considering legislation aimed at addressing some of these concerns.In its review of 430 denials in June 2019, the inspector general’s office said that it had found repeated examples of care denials for medical services that coding experts and doctors reviewing the cases determined were medically necessary and should be covered.Based on its finding that about 13 percent of the requests denied should have been covered under Medicare, the investigators estimated as many as 85,000 beneficiary requests for prior authorization of medical care were potentially improperly denied in 2019.Advantage plans also refused to pay legitimate claims, according to the report. About 18 percent of payments were denied despite meeting Medicare coverage rules, an estimated 1.5 million payments for all of 2019. In some cases, plans ignored prior authorizations or other documentation necessary to support the payment.These denials may delay or even prevent a Medicare Advantage beneficiary from getting needed care, said Rosemary Bartholomew, who led the team that worked on the report. Only a tiny fraction of patients or providers try to appeal these decisions, she said.“We’re also concerned that beneficiaries may not be aware of the greater barriers,” she said.Kurt Pauker, an 87-year-old Holocaust survivor in Indianapolis who has kidney and heart conditions that complicate his care, is enrolled in a Medicare Advantage plan sold by Humana.In spite of recommendations from Mr. Pauker’s doctors, his family said, Humana has repeatedly denied authorization for inpatient rehabilitation after hospitalization, saying at times he was too healthy and at times too ill to benefit. Kurt Pauker with his daughter, Robyn, at her graduation from law school in 2017.via Robyn PaukerLast March, after undergoing hip surgery, Mr. Pauker was again told that he did not qualify for inpatient rehab but would be sent back to a skilled nursing center to recover, his family said.During his previous stay at a skilled nursing center, he received little in the way of physical or occupational therapy, the family said. He has so far lost his appeals, and relatives have chosen to pay for care privately while continuing to pursue his case.People “should know what they’re giving up,” said David B. Honig, a health care lawyer and Mr. Pauker’s son-in-law. People signing up for Medicare Advantage are surrendering their right to have a doctor determine what is medically necessary, he said, rather than have the insurer decide.Humana, which reported strong earnings on Wednesday, said it could not comment specifically on Mr. Pauker’s case, citing privacy rules. But the insurer noted that it was required to follow the standards set by the Centers for Medicare and Medicaid Services. “While every member’s experience and needs are unique, we work to provide health coverage that is consistent with what we believe C.M.S. would require in each instance and supports our members in achieving their best health,” Humana said in a statement.Medicare officials said in a statement that they are reviewing the findings to determine the appropriate next steps, and that plans found to have repeated violations will be subject to increasing penalties. The agency “is committed to ensuring that people with Medicare Advantage have timely access to medically necessary care,” officials said.The federal government pays private insurers a fixed amount per Medicare Advantage patient. If the patient’s choice of hospital or doctor is limited, and if he or she is encouraged to get services that are less expensive but effective, then the insurer stands to profit.Under traditional Medicare, there may be an incentive for hospitals and doctors to overtreat patients because they are paid for each service and test performed. But the fixed payment given to private plans provides “the potential incentive for insurers to deny access to services and payment in an attempt to increase their profits,” the report concluded.Dr. Jack Resneck Jr., the president-elect of the American Medical Association, said the plans’ denials had become widespread. The organization has been aggressively lobbying lawmakers to impose stricter rules.Prior authorization, intended to limit very expensive or unproven treatments, has “spread way beyond its original purpose,” Dr. Resneck said. When patients cannot get approval for a new prescription, many do not fill it and never tell the doctor, he added.Appeals end up unfairly burdening patients and often take precious time, some doctors said.“We are able to reverse this some of the time,” said Dr. Kashyap Patel, a cancer specialist who serves as chief executive of Carolina Blood and Cancer Care and president of the Community Oncology Alliance. But his efforts to “fight like a hawk” to get approvals for the care he recommends also leave him less time to tend to patients, he added.The most frequent denials found by the investigators included those for imaging services like M.R.I.’s and CT scans. In one case, an Advantage plan refused to approve a follow-up M.R.I. to determine whether a lesion was malignant after it was identified through an earlier CT scan because the lesion was too small. The plan reversed its decision after an appeal.In another case, a patient had to wait five weeks before authorization to get a CT scan to assess her endometrial cancer and to determine a course of treatment. Such delayed care can negatively affect a patient’s health, the report noted.But Advantage plans also denied requests to send patients recovering from a hospital stay to a skilled nursing center or rehabilitation center when the doctors determined that those places were more appropriate than sending a patient home.A patient with bedsores and a bacterial skin infection was denied a transfer to a skilled nursing center, investigators found. A high-risk patient recovering from surgery to repair a fractured femur was denied admission to a rehab center, although doctors said the patient needed to be under the supervision of a physician.In some cases, the investigators said Medicare rules — like whether a plan can require a patient to have an X-ray before getting an M.R.I. — needed to be clarified.The plans may use their own clinical criteria to judge whether a test or service should be reimbursed, but they have to offer the same benefits as traditional Medicare and cannot be more restrictive in paying for care.The investigators urged Medicare officials to beef up oversight of Advantage plans and provide consumers “with clear, easily accessible information about serious violations.”

He transformed a small company into a corporation focused on providing health insurance under government programs. It now insures 25 million people.Michael F. Neidorff, who built the Centene Corporation from a small Milwaukee health plan into the nation’s largest insurer for the government’s Medicaid program and a stalwart of the Obamacare markets, died on April 7 in St. Louis. He was 79.His family said the cause was an infection.Mr. Neidorff indicated in December that he would retire as chief executive in 2022, and he took a medical leave of absence in February. Centene, which is headquartered in St. Louis, appointed Sarah London, who had been vice chairwoman, as its chief executive in March.When Mr. Neidorff joined Centene as chief executive in 1996, the insurer, then known as Coordinated Care, offered a single health plan and had $40 million in sales. Over the next 25 years, he transformed it into a corporation that focused on providing health insurance under government programs like Medicaid and Medicare. Centene now provides coverage to 25 million people and had $126 billion in revenues last year.“The company he built provides health care for nearly one in 15 vulnerable Americans,” Ms. London said in a statement.Under Mr. Neidorff’s leadership, Centene chose to concentrate on government-sponsored insurance through Medicaid for low-income individuals and Medicare for older people and the disabled.“Michael was very clever from a strategic standpoint,” said Dr. J. Mario Molina, the former chief executive of Molina Healthcare, one of Centene’s main rivals. Early on, he said, Mr. Neidorff recognized that fewer people were likely to be insured through their employer while “the government programs were growing,”When a new market for insurance was created under the Affordable Care Act — the federal law, known as Obamacare, that helps provide private insurance to people who do not qualify for Medicaid but who are not covered by their employers — Mr. Neidorff positioned Centene as a major provider of low-cost plans. He persevered even after many large insurers lost money and stopped offering coverage.“He stayed with Obamacare in the exchanges when many of the other companies pulled out,” Ana Gupte, a former Wall Street analyst who now runs her own advisory company, recalled.“They grew remarkably in Obamacare,” she said. “They took advantage of the fact that other companies were risk averse and exiting.”When state officials and government regulators were concerned that some counties in the United States would be left without a carrier willing to sell insurance under the Affordable Care Act, Mr. Neidorff agreed to provide coverage in some of those markets, said Jesse Hunter, a former chief strategy officer for Centene, and “there was never any hesitation.”“We want to help out where we are able to,” Mr. Neidorff told The New York Times in 2017.He was born in 1942 in Altoona, Pa., to A. Harvey Neidorff, a physician, and Shirley Rubin Neidorff, a nurse. He had considered going into medicine but decided instead to major in political science at Trinity University in San Antonio. He later earned a master’s degree from St. Francis College in Brooklyn.He is survived by his wife, Noémi; his brother, Robert; his sister, Susan Neidorff Reinglass; and his son, Peter. His daughter, Monica Neidorff, died in 2021.Mr. Neidorff had worked for a unit of UnitedHealthcare when he was recruited to be chief executive of Coordinated Care, the small managed-care company that would become Centene. “It was obvious they needed a complete change,” said Robert Ditmore, a longtime Centene board member who was involved in the company.Mr. Neidorff expanded aggressively into the Medicaid market, despite concerns about whether it would be a successful venture. “I had questions about Medicaid; is it going to work?” Mr. Ditmore said. But, he added, Mr. Neidorff persuaded him: “It was obviously a big market, so we said let’s go for it.”Mr. Neidorff took the company public in 2001. In 2016, he acquired a California insurer, Health Net, which offered private plans for another government program, Medicare.When the Affordable Care Act provided an opportunity to sell low-cost private insurance through the state markets set up by the federal government, Mr. Ditmore recalled, Mr. Neidorff was eager to become a major player, despite uncertainty about how insurers should price their policies in the new market. “He kept pushing for it,” Mr. Ditmore said. “He was a bulldog with a bone in his mouth.”Mr. Neidorff made several key acquisitions to add to Centene’s depth. In 2020 he bought WellCare, a Florida Medicare Advantage insurer. This year the company completed the purchase of Magellan Health, which specialized in providing mental health benefits.Centene’s stock price had underperformed in recent years, and the company found itself under pressure from an activist investor, Politan Capital Management. In December, the company agreed to change the composition of its board, and Mr. Neidorff announced that he would retire as chief executive in 2022.He was also active in philanthropy. He was chairman of the National Urban League’s board of trustees and a board member of the St. Louis Symphony Orchestra, the Opera Theater of Saint Louis and the Manhattan School of Music, among other organizations. Last September, he donated $25 million to Trinity for the Michael F. Neidorff School of Business.

Deaths at American nursing home residents from Covid appear to be at their lowest levels since the coronavirus first swept the United States more than two years ago, according to the most recent data from the Centers for Disease Control and Prevention.Some 67 residents died during the week ending March 27. While that number could be adjusted in the coming weeks, it mirrors the lows last reached during June 2021 before facilities were hit with the Delta and Omicron variants. Although cases among residents climbed much more sharply in the fall and winter, deaths still reached roughly 1,500 in January before steadily dropping.But experts say there is little reason for complacency. Nursing home residents remain highly vulnerable to the virus because of their age and underlying medical conditions. While booster shots proved to be protective against severe illness during the latest surge, federal regulators already authorized second booster shots of the Pfizer-BioNTech and Moderna coronavirus vaccines last week. There is also growing concern over a highly contagious subvariant of Omicron, known as BA.2.Getting the second booster shot to nursing home residents “is a real policy priority,” said David Grabowski, a health policy researcher at Harvard Medical School who studies nursing homes. “We know this is protective.”While there was a significant push by the federal government and the large pharmacy chains to vaccinate nursing home residents when the initial shots first became available, many facilities were slow to roll out booster shots last fall even as there began to be outbreaks. About 88 percent of residents are fully vaccinated, and about 76 percent have received a booster shot, according to the latest federal data.Immunizing staff members has been harder, with the federal mandate to require health care workers to be vaccinated facing legal challenges. While 86 percent of staff are fully vaccinated, only 43 percent have received a booster shot. In 13 states, fewer than a third of employees have received the added immunizations.“We have a lot of nursing homes around the country that lag behind,” said Dr. Grabowski, adding that he was concerned about residents in facilities that serve predominantly people on Medicaid and people of color. “I think there are going to be real issues of equity here,” he said.The gap between those who received the initial vaccinations and those who receive additional doses could continue to widen, said Brendan Williams, the chief executive of the New Hampshire Health Care Association, a state nursing home trade group. People appear more skeptical over the need for additional shots. “I worry there has been a lot of mixed messages from the federal government,” he said.While many nursing homes say they will provide the additional doses to their staff and residents, there does not seem to be significant urgency, Dr. Grabowski said. In Connecticut, which this year had issued an executive order mandating booster shots for workers in nursing homes, state health officials were reported to have indicated a similar directive for second boosters was not imminent.Mr. Williams remains cautious. “Right now, there doesn’t appear to be a crisis,” he said. “There’s not that attention being paid, but things can always change. It’s concerning.”

With the federal requirement in limbo because of legal challenges, some major multistate hospital systems have stopped enforcing their own policies.The legal uncertainty over a federal requirement that the nation’s 17 million health care workers be vaccinated against the coronavirus has led some well-known hospital chains to drop their own mandates — at least temporarily.The Cleveland Clinic, HCA Healthcare and Intermountain Healthcare, among others, have said they are no longer requiring employees to be vaccinated until the courts sort out whether the federal mandate can go into effect. The hospitals’ decisions were first reported by The Wall Street Journal.The moves are likely to slow down efforts to quell the latest surge in infections, potentially worsening by holiday traveling, large gatherings indoors and the introduction of the Omicron variant. Public health officials are renewing their pleas for more people to get vaccinations and booster shots as this latest wave of Covid cases threatens to again overwhelm hospitals. Some 66,000 Americans are now hospitalized with Covid.Suspending the localized requirements will also make it harder for hospitals to meet the federal government’s deadline of early January for vaccinating all eligible staff if the courts uphold the mandate. Federal officials are appealing a Louisiana judge’s decision to halt the rule, and the case is likely to go to the Supreme Court. The court on Monday allowed New York State’s vaccine requirement for health care workers to continue, and the justices have previously rejected challenges to other vaccine requirements.Exactly how many hospitals are abandoning the policy is unclear. Many states, like California and New York, and local governments, like Philadelphia’s, adopted their own edicts. HCA specified that it would continue the requirement at hospitals in places where there is a state mandate.Several large hospital groups imposed their own requirements earlier this year after experiencing a sharp rise in cases from the Delta variant. About 40 percent of the nation’s hospitals mandated vaccinations for staff members, and the Centers for Medicaid and Medicare Services, which issued the new rule, says many facilities have already succeeded in getting workers protected.Decisions on enforcement “have varied across the board,” said Erin J. McLaughlin, a labor and employment lawyer for Buchanan, Ingersoll & Rooney. She said an equal number of her health care clients had scrapped the requirement as had continued it.An I.C.U. pharmacist at St. Peter’s Health in Helena, Mont., received a shot. About 40 percent of the nation’s hospitals mandated vaccinations for staff members, but some have now suspended enforcing their policies. Thom Bridge/Independent Record, via The Associated Press“We do not think most hospitals are changing their mandates,” the American Hospital Association, a trade group, said in a statement. “While the current C.M.S. vaccine requirement may be delayed, hospitals and health systems are not delaying their efforts to vaccinate staff,” the group said.But the legal landscape is confusing at best, with states and local governments often running counter to the federal efforts. In Florida, where AdventHealth, HCA and UF Health Jacksonville have all paused their requirements, Gov. Ron DeSantis prohibited vaccine mandates by private employers shortly after the federal government issued its rule for health care workers.Exactly how many health care workers still need to get vaccinated is also unclear. While a study by federal researchers found that 30 percent of hospital workers were not fully vaccinated as of mid-September, overall immunization rates have climbed in the last few months. HCA, which employs about 275,000 workers and operates in 20 states, said most of its workers were fully vaccinated, but it would not provide specifics. Neither AdventHealth nor UF Health Jacksonville would say how many of its employees were vaccinated. Unlike nursing homes, hospitals are not required to publicly report their vaccination rates.But many hospitals insist they are continuing efforts to persuade workers. “Based on scientific evidence and what we see in our hospitals every day, Covid-19 vaccines are safe and effective at reducing both the risk of becoming infected and the level of harm in the case of a breakthrough infection,” AdventHealth said in a statement.Hospitals “are totally committed to having their work force vaxxed,” said Chip Kahn, the chief executive of the Federation of American Hospitals, which represents for-profit chains like HCA.Much of the opposition to the requirements is over concerns that workers who object to the vaccine will leave. Many hospital chains said departures had not been numerous, but Mr. Kahn emphasized that even a small number of resignations can be disruptive. “Those small numbers can really be a problem,” he said.Some hospital companies said they would pursue alternatives to keep patients and employees safe. The Cleveland Clinic, which estimated that nearly 85 percent of its employees were fully vaccinated, said it was adding more measures, “including periodic testing for those providing direct clinical care.”Hospitals that do not want to insist on immunizations are focusing on testing their employees, said Ann Marie Pettis, the president of the Association for Professionals in Infection Control and Epidemiology, which supports a mandate for health care workers. “It’s not like they are just throwing up their hands and saying it is a free-for-all,” she said.Other hospitals already have high numbers of vaccinated workers. Intermountain, along with other Utah hospitals, is pausing its requirement and said 98 percent of its staff was already vaccinated.

Federal officials point to the city’s mandate as a success story and a shield against new Covid outbreaks at hospitals and nursing homes.While the national vaccine mandate for health care workers remains mired in the federal courts, government officials say there is ample proof that requirements work — and do not cause a mass exodus of employees that some critics had feared.Philadelphia, which issued a vaccine mandate in August, would seem to be a case in point. Virtually all hospital employees there are now fully vaccinated against Covid-19, according to a group of local hospitals that met last week with officials from the Centers for Medicare and Medicaid Services, which issued the national rule. About 95 percent of nursing home employees are also fully vaccinated, according to the city health department, compared with an average of 75 percent across the country.With several states, including Pennsylvania, reporting sharp increases in Covid cases and hospitalizations and the arrival of the new Omicron variant, vaccine protection for health care workers is once again a critical tool.Pennsylvania now has one of the country’s highest hospitalization rates. “Covid continues to rage on,” Dr. Jaewon Ryu, the chief executive of one of the state’s largest hospital groups, Geisinger, said at a news conference. Its intensive-care units are overwhelmed, he said.In Philadelphia alone, 366 people were hospitalized in early December, compared with around 200 before Thanksgiving, according to city data.The city’s hospitals and nursing homes were able to achieve high vaccination rates without significant staff departures. “At the end of the day, very few people quit,” Chiquita Brooks-LaSure, the agency’s administrator, said in an interview after the meeting.Ms. Brooks-LaSure said it was important that hospitals and nursing homes educate their workers about the benefits of the vaccine and address safety concerns, although she added that local and workplace orders clearly influenced higher vaccination rates.About 40 percent of the nation’s hospitals have vaccine requirements, and numerous states and cities imposed them for health care workers. In New York, which issued a mandate in late August, about 96 percent of hospital and nursing home workers are fully vaccinated, according to state data.See How Vaccinations Are Going in Your County and StateSee where doses have gone, and who is eligible for a shot in each state.In California, which also required workers to get vaccinated, about 94 percent of nursing home employees have done so, and outbreaks have fallen, according to state data.In states without mandates, like Oklahoma, about a third of nursing home workers are not fully vaccinated, and there have been thousands of recent cases among residents and staff.At Crozer Health, a hospital group based in Springfield, Pa., the vaccination rate among workers climbed to 98 percent from 65 percent, largely because the area’s hospitals all had similar requirements and faced the looming federal mandate, Conlen Booth, Crozer’s senior director of emergency preparedness, said. “Staff understood there was no other alternative,” he said.Crozer asked infectious disease specialists to directly address employees who were hesitant, including first responders like paramedics whose jobs did not typically put them in direct contact with someone who could answer their questions authoritatively. “They had never been spoken to by a physician,” Mr. Booth said.Even nursing home executives acknowledged that the city’s requirement resulted in fewer departures than predicted. Philadelphia’s 47 nursing homes reported an average of about seven staff departures related to the vaccine requirement, according to the Pennsylvania Health Care Association, which represents the state’s nursing homes.Zach Shamberg, the group’s chief executive, said Philadelphia remained “a cautionary tale” given that some employees did leave. Because a widespread staffing shortage is already hindering the ability of nursing homes to care for residents, “we cannot afford to lose one more worker,” he said.There was some disagreement among hospital executives on the panel, which explored techniques employed to get all their workers vaccinated. One administrator warned that mandates could smack of “Big Brother,” while another defended the federal requirement as crucial leverage.Officials from the Centers for Medicare and Medicaid Services also emphasized the unique role of individuals who care for the public, pointing to cases where patients were uncomfortable with nurses or aides who were not immunized.“Health care workers have a special ethical and professional duty to protect the patients,” Dr. Lee Fleisher, the agency’s chief medical officer, said at the meeting with the hospitals. “There is no question that in any health care setting, the unvaccinated pose a direct and indirect threat to patient safety and, from our perspective, population health.”The future of President Biden’s vaccine mandates for health care workers and private employees in other sectors is unclear. Federal judges have blocked the C.M.S. rule, which required health care providers to get their workers — an estimated 17 million — fully vaccinated by early January or risk losing federal funding.The judge in the U.S. District Court for the Western District of Louisiana ruled that the agency had overstepped its authority by issuing an emergency regulation. He said the mandate “is something that should be done by Congress, not a government agency,” and added that “it is not clear that even an act of Congress mandating a vaccine would be constitutional.”The administration has appealed, and the rule is on hold. “While C.M.S. remains confident in its authority to protect the health and safety of patients in facilities certified by the Medicare and Medicaid programs, it has suspended activities related to the implementation and enforcement of this rule pending future developments in the litigation,” the agency informed health care providers early this month.The Coronavirus Pandemic: Key Things to KnowCard 1 of 5The Omicron variant.