Covid no discrimina por edad: dramático aumento de casos en adultos jóvenes

Después de pasar gran parte del año pasado atendiendo a pacientes de edad avanzada, los médicos están viendo un cambio demográfico claro: los adultos jóvenes y de mediana edad constituyen una parte cada vez mayor de los pacientes en las salas de covid-19 de los hospitales.

Es tanto una señal del éxito del país en la protección de los adultos mayores con la vacunación como un recordatorio urgente de que las generaciones más jóvenes pagarán un alto precio si se permite que siga habiendo brotes en todo el país.

“Ahora vemos personas de 30, 40 y 50 años, jóvenes que están realmente enfermos”, dijo el doctor Vishnu Chundi, especialista en enfermedades infecciosas y presidente del grupo de trabajo de covid de la Sociedad Médica de Chicago. “La mayoría de ellos lo superan, pero algunos no… acabo de perder a un hombre de 32 años con dos hijos, es desgarrador”.

A nivel nacional, los adultos menores de 50 años representan ahora los pacientes con covid más hospitalizados en el país, alrededor del 36% de todas las admisiones. Las personas de 50 a 64 años representan el segundo grupo con más internaciones, alrededor del 31%. Las hospitalizaciones entre los adultos mayores de 65 años se han reducido significativamente.

Aproximadamente el 32% de la población de los Estados Unidos ya está completamente vacunada, pero la gran mayoría son personas mayores de 65 años, un grupo al que se le dio prioridad en la fase inicial de inmunización.

Aunque las nuevas infecciones están disminuyendo gradualmente en todo el país, algunas regiones han enfrentado un resurgimiento del coronavirus en los últimos meses, lo que algunos han llamado una “cuarta ola”, impulsado por la variante B.1.1.7, identificada por primera vez en el Reino Unido, que se estima que es entre un 40% y un 70% más contagiosa.

Como muchos estados abandonan las precauciones por la pandemia, esta cepa más virulenta todavía tiene un amplio margen para propagarse entre la población más joven, que sigue siendo ampliamente susceptible a la enfermedad.

La aparición de cepas más peligrosas del virus en el país, Incluidas las variantes descubiertas por primera vez en Sudáfrica y Brasil, ha hecho que el esfuerzo de vacunación sea aún más urgente.

“Estamos en un juego completamente diferente”, dijo Judith Malmgren, epidemióloga de la Universidad de Washington.

El aumento de las infecciones entre los adultos jóvenes crea un “reservorio de enfermedad” que eventualmente “se extiende al resto de la sociedad”, sociedad que aún no ha alcanzado la inmunidad colectiva, y presagia un aumento más amplio de casos, dijo.

Afortunadamente, la posibilidad de morir por covid sigue siendo muy pequeña para las personas menores de 50 años, pero este grupo de edad puede enfermarse gravemente o experimentar síntomas a largo plazo después de la infección inicial. Las personas con afecciones subyacentes, como obesidad y enfermedades cardíacas, también tienen más probabilidades de enfermarse gravemente.

“B.1.1.7 no discrimina por edad, y cuando se trata de jóvenes, nuestro mensaje al respecto sigue siendo demasiado suave”, dijo Malmgren.

En todo el país, la afluencia de pacientes más jóvenes con covid ha sorprendido a los médicos que describen salas de hospital llenas de pacientes, muchos de los cuales parecen estar más enfermos de lo que se vio durante las oleadas anteriores de la pandemia.

“Muchos de ellos requieren atención en terapia intensiva”, dijo la doctora Michelle Barron, jefa de prevención y control de infecciones en UCHealth, uno de los grandes sistemas hospitalarios de Colorado.

La edad promedio de los pacientes con covid en los hospitales de UCHealth ha disminuido en más de 10 años en las últimas semanas, de 59 a 48 años, agregó Barron.

“Creo que seguiremos viendo eso, especialmente si no hay mucha aceptación de la vacuna en estos grupos”, dijo.

Si bien la mayoría de los hospitales están lejos de la avalancha de casos durante el invierno, la explosión de casos en Michigan subraya las posibles consecuencias de flexibilizar las restricciones cuando una gran parte de los adultos aún no están vacunados.

Existe una fuerte evidencia de que las tres vacunas que se están utilizando en el país rindan una buena protección contra la variante del Reino Unido.

Un estudio sugiere que la variante B.1.1.7 no causa complicaciones graves, como se pensaba anteriormente. Sin embargo, los pacientes infectados con esta variante parecen tener más probabilidades de tener más virus en sus cuerpos que aquellos con la cepa que dominaba antes, lo que puede ayudar a explicar por qué se propaga más fácilmente.

“Creemos que esto puede estar causando más de estas hospitalizaciones en personas más jóvenes”, dijo la doctora Rachael Lee en el hospital de la Universidad de Alabama-Birmingham.

El hospital de Lee también ha observado un aumento en los pacientes más jóvenes. Al igual que en otros estados del sur, Alabama tiene una tasa baja de absorción de vacunas.

Pero incluso en el estado de Washington, donde gran parte de la población está optando por vacunarse, las hospitalizaciones han aumentado constantemente desde principios de marzo, especialmente entre los jóvenes. En el área de Seattle, actualmente se interna a más personas de 20 años por covid que personas de 70, según el doctor Jeff Duchin, director de salud pública de Seattle y el condado de King.

“Todavía no tenemos suficientes adultos jóvenes vacunados para contrarrestar la mayor facilidad con la que se propagan las variantes”, dijo Duchin en una conferencia de prensa reciente.

A nivel nacional, alrededor del 32% de las personas de 40 años están completamente vacunadas, en comparación con el 27% de las personas de 30 años. Esa proporción se reduce a aproximadamente el 18% para los jóvenes de 18 a 29 años.

“Tengo la esperanza de que la curva de muerte no aumente tan rápido, pero está ejerciendo presión sobre el sistema de salud”, dijo el doctor Nathaniel Schlicher, médico de emergencias y presidente de la Asociación Médica del Estado de Washington.

Schlicher, también de unos 30 años, recuerda con horror a dos de sus pacientes recientes, cercanos a su edad y previamente sanos, que ingresaron con insuficiencia cardíaca causada por covid.

“Lo he visto de cerca y eso es lo que más me asusta”, dijo.

“Entiendo que los jóvenes se sientan invencibles, pero lo que les diría es que no tengan miedo de morir, tengan miedo de la insuficiencia cardíaca, el daño pulmonar y no poder hacer las cosas que amas hacer”.

Los médicos y los expertos en salud pública esperan que el preocupante aumento de las hospitalizaciones entre la población más joven sea temporal, algo que las vacunas contrarrestarán pronto. Solo desde el 19 de abril todos los adultos se volvieron elegibles para la vacuna.

Pero algunas encuestas nacionales preocupantes indican que una parte considerable de los adolescentes y adultos de entre 20 y 30 años no necesariamente tienen planes de vacunarse.

“Solo tenemos que hacer que sea muy fácil, sin inconvenientes”, apuntó Malmgren, el epidemiólogo de Washington. “Tenemos que pensar un poco diferente”.

Esta historia es parte de una asociación que incluye a NPR y KHN.

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

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Covered California dice que el seguro de salud se ha vuelto demasiado barato como para ignorarlo

Una nueva ley federal podría hacer que sea mucho más barato comprar tu propio seguro si no tienes cobertura a través de un empleador o un programa del gobierno como Medicare o Medicaid.

La ley proporciona miles de millones de dólares federales para reducir las primas de las personas que compran cobertura a través de los mercados de seguros establecidos por la Ley de Cuidado de Salud a Bajo Precio (ACA).

Esta ayuda amplía un crédito fiscal federal creado por ACA que se puede recibir por adelantado como un descuento en tu prima, o como un reclamo en tus impuestos del año siguiente. Estos subsidios está disponible para quienes compran pólizas individuales o familiares en el mercado privado por fuera de los intercambios de ACA. Por lo tanto, si tienes un plan de salud por fuera de estos mercados, podrías ahorrar mucho dinero si cambias a uno que ofrezcan los mercados de ACA.

Si ya estás inscrito en un plan del mercado de seguros, podrías ver una cuenta más baja, en muchos casos mucho más baja, comenzando tan pronto como con tu prima de mayo.

Covered California, el mercado de seguros de salud de ACA del estado, abrió un período de inscripción especial el 12 de abril para las personas que quieran aprovechar la nueva ayuda al inscribirse o cambiar de cobertura. El período se extiende hasta diciembre. Los subsidios recientemente mejorados entran en vigencia con la cobertura que comienza el 1 de mayo. Para obtener cobertura el primer día de cualquier mes, solo necesitas inscribirte el día anterior.

Casi el 90% de los beneficiarios de Covered California ya reciben ayuda financiera, y muchos ahora recibirán más. Algunos afiliados que antes no calificaban para créditos fiscales ahora pueden ser elegibles.

Darci Gutiérrez, una agente de seguros en Dublin, California, dijo que un cliente con una familia numerosa ahorró $425 al mes en una PPO de Blue Shield en el nivel Plata, el segundo nivel más bajo de cobertura.

“Me sorprendió la cantidad de reducción de costos. Yo estaba como, ‘Santo cielo’”, dijo Gutiérrez.

Está previsto que la ayuda federal adicional se detenga después de 2022, lo que significa que tu seguro podría costarte más después.

La nueva ley también asigna dinero para brindar una cobertura prácticamente sin prima, solo en 2021, para cualquier persona que reciba beneficios por desempleo en cualquier momento durante el año.

Si ya estás inscrito en Covered California, puedes mantener tu plan y aprovechar los ahorros, o puedes comparar precios y ahorrar aún más, o cambiar a un nivel más alto de cobertura sin aumentar tu gasto mensual.

Si no cambias, Covered California calculará automáticamente tu prima más baja y verás un crédito de mayo en tu factura de junio. También obtendrás ese ahorro de manera retroactiva durante los primeros cuatro meses de 2021 en forma de una reducción adicional de la prima, en cuotas mensuales iguales, durante el resto del año.

Sin embargo, si no tienes seguro o tienes un plan de salud por fuera de los mercados de seguros de ACA, debes tomar medidas. Investiga tus opciones e inscríbete, o cambia de plan.

Para saber si reúnes los requisitos para recibir asistencia federal, inicia una sesión en el sitio www.coveredca.com/espanol.

Haz clic en el botón “busca y compara” para encontrar los planes de salud disponibles para tí en tu área, junto con la prima mensual que pagarás después que se descuento tu subsidio.

También puedes hacer clic en un botón para recibir una llamada de un agente de seguros de salud certificado que puede ayudarte a resolver todo, sin cobrarte. Si no tienes una computadora, llama a línea de Covered California en español, al 800-300-0213.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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

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Trouble Managing Money May Be an Early Sign of Dementia

After Maria Turner’s minivan was totaled in an accident a dozen years ago, she grew impatient waiting for the insurance company to process the claim. One night, she saw a red pickup truck on eBay for $20,000. She thought it was just what she needed. She clicked “buy it now” and went to bed. The next morning, she got an email about arranging delivery. Only then did she remember what she’d done.

This story also ran on The New York Times. It can be republished for free.

Making such a big purchase with no forethought and then forgetting about it was completely out of character for Turner, then a critical care nurse in Greenville, South Carolina. Although she was able to back out of the deal without financial consequences, the experience scared her.

“I made a joke out of it, but it really disturbed me,” Turner said.

It didn’t stop her, though. She shopped impulsively online with her credit card, buying dozens of pairs of shoes, hospital scrubs and garden gnomes. When boxes arrived, she didn’t remember ordering them.

Six years passed before Turner, now 53, got a medical explanation for her spending binges, headaches and memory lapses: Doctors told her that imaging of her brain showed all the hallmarks of chronic traumatic encephalopathy.CTE is a degenerative brain disease that in Turner’s case may be linked to the many concussions she suffered as a competitive horseback rider in her youth. Her doctors now also see evidence of Alzheimer’s disease and frontotemporal dementia, which affects the frontal and temporal lobes of the brain. These may have roots in her CTE.

Turner’s money troubles aren’t unusual among people who are beginning to experience cognitive declines. Long before they receive a dementia diagnosis, many people start losing their ability to manage their finances and make sound decisions as their memory, organizational skills and self-control falter, studies show. As people fall behind on their bills or make unwise purchases and investments, their bank balances and credit rating may take a hit.

Mental health experts say the covid pandemic may have masked such early lapses during the past year. Many older people have remained isolated from loved ones who might be the first to notice unpaid bills or unopened bank notices.

“That financial decision-making safety net may have been weakened,” said Carole Roan Gresenz, interim dean at Georgetown University’s School of Nursing and Health Studies, who co-authored a study examining the effect of early-stage Alzheimer’s disease on household finances. “We haven’t been able to visit, and while technology can provide some help, it’s not the same … as sitting next to people and reviewing their checking account with them.”

Even during times that aren’t complicated by a global health crisis, families may miss the signs that someone is struggling with finances, experts say.

“It’s not uncommon at all for us to hear that one of the first signs that families become aware of is around a person’s financial dealings,” said Beth Kallmyer, vice president for care and support at the Alzheimer’s Association.

Early in the disease, Kallmyer said, dementia robs people of the abilities they need to manage money: “executive functioning” skills like planning and problem-solving, as well as judgment, memory and the ability to understand context.

People who live alone may be the most likely to slip through the cracks, their lapses unnoticed, Kallmyer said. And many adult children may be reluctant to discuss personal finances with their parents, who often guard their independence.

About 6 million Americans are living with Alzheimer’s disease, the most common cause of dementia. Dementia is an umbrella term for a range of conditions associated with declines in mental abilities that are severe enough to interfere with daily life. There is no cure. Alzheimer’s, which killed more than 133,000 Americans in 2020, is the seventh-leading cause of death in the U.S.

Many people have mild symptoms for years before they are diagnosed. During this stage, before obvious impairment, they may make substantial errors managing their finances.

In Gresenz’s study, researchers linked data from Medicare claims between 1992 and 2014 with results from the federally funded Health and Retirement Study, which regularly surveys older adults about their finances, among other things. Her study, published in the journal Health Economics in 2019, found that during early-stage Alzheimer’s, people were up to 27% more likely than cognitively healthy people to experience a large decline in their liquid assets, such as savings and checking accounts, stocks and bonds.

Another study, published in JAMA Internal Medicinein November,linked Medicare claims data to the Federal Reserve Bank of New York/Equifax Consumer Credit Panel to track people’s credit card payments and credit scores. The study found that people with Alzheimer’s and related dementias were more likely to miss bill payments up to six years before they were diagnosed than were people who were never diagnosed. The researchers also noted that the people later diagnosed with dementia started to show subprime credit scores 2.5 years before the others.

“We went into the study thinking we might be able to see these financial indicators,” said Lauren Hersch Nicholas, an associate professor of public health at the University of Colorado, who co-authored the study. “But we were sort of surprised and dismayed to find that you really could. That means it’s sufficiently common because we’re picking it up in a sample of 80,000 people.”

For decades, Pam McElreath kept the books for the insurance agency that she and her husband, Jimmy, owned in Aberdeen, North Carolina. In the early 2000s, she started having trouble with routine tasks. She assigned the wrong billing codes to expenditures, filled in checks with the wrong year, forgot to pay the premium on her husband’s life insurance policy.

Everyone makes mistakes, right? It’s just part of aging, her friends would say.

“But it’s not like my friend that made that one mistake, one time,” saidMcElreath, 67. “Every month I was having to correct more mistakes. And I knew something was wrong.”

She was diagnosed with mild cognitive impairment in 2011, at age 56, and with early-onset Alzheimer’s two years later. In 2017, doctors changed her diagnosis to frontotemporal dementia.

Receiving a devastating diagnosis is hard enough, but learning to cope with it is also hard. Eventually both McElreath and Maria Turner put mechanisms in place to keep their finances on an even keel.

Turner, who has two adult children, lives alone. After her diagnosis, she hired a financial manager, and together they set up a system that provides Turner with a set amount of spending money every month and doesn’t allow her to make large withdrawals on impulse. She ditched her credit cards and removed eBay and Amazon from her phone.

Though not a micromanager, Turner’s financial adviser keeps an eye on her spending and questions her when something seems off.

“Did you realize you spent X?” she’ll ask, Turner said.

“And I’ll be like, ‘No, I didn’t.’ And that’s the thing. I’m aware but I’m not aware,” she added.

In 2017, Pam and Jimmy McElreath sold their insurance agency to spend more time together and moved west to Sugar Grove, in the Blue Ridge Mountains. They worked with a therapist to figure out how to ensure Pam is able to continue to do as much as possible.

These days, Pam still signs their personal checks, but now Jimmy looks them over before sending them out. The system is working so far.

“At first I was mad, and I went through this dark time,” Pam said, adding: “But the more that you come to accept your problem, the easier it is to say, ‘I need help.’”

Jimmy’s gentle approach helped. “He was so good about telling me when I did something wrong but doing it in such a kind way, not blaming me for making mistakes. We’ve been able to work it out.”

Tips for Helping a Loved One

It’s not easy to broach financial management issues with an elderly parent or other relative experiencing cognitive trouble. Ideally, you and they will have these conversations before problems develop.

As an adult child, you might mention you’ve been talking with a financial adviser about managing your own finances to ease into a conversation about what your elder is doing, said Beth Kallmyer of the Alzheimer’s Association.

Or suggest that allowing a shared financial management arrangement would eliminate the hassle of tracking and paying bills.

“Often people are open to the idea of making their lives easier,” Kallmyer said.

Whatever the approach, it’s important to plan and take steps to protect assets.

“Part and parcel of any legal or estate planning is protecting oneself in the event of incapacity,” said Jeffrey Bloom, an elder law attorney at Margolis & Bloom in the Boston area.

Specific steps depend on the family and their financial situation, but here are some to consider:

Encourage the parent in need of help to sign a financial power of attorney.

These legal documents authorize you or another person to act on a parent’s behalf in financial matters. The terms may be narrow or broad, allowing you to make all financial decisions or to perform specific duties like paying bills, making account transfers or filing taxes.

A “durable” power of attorney allows you to make decisions even if your parent becomes incapacitated. In some states, power of attorney documents are automatically considered durable.

Put assets in a trust.

A trust is a legal vehicle that can hold a range of assets and property. It can spell out how those assets are managed and distributed while people are alive or after they die.

“We do believe in the power of attorney, but we believe in the trust as an even better tool in the event of incapacity,” Bloom said.

Trusts can be tailored to a client’s concerns and provide more guidance than a power of attorney document about what money can be spent on and who has access under what circumstances, among other things.

You might be a co-trustee on major distributions, for example, or there may be rules that provide for you or others to review and be notified of any changes, Bloom said.

The Alzheimer’s Association recommends working with an attorney who specializes in trusts to ensure all laws and regulations are followed, Kallmyer said.

Have your name added as another user on a parent’s bank accounts, credit cards or other financial accounts.

This may be a convenient way to make payments or monitor activity. But a shared account can be problematic if children are sued, for example, or wish to withdraw the money for their own use.

The funds typically belong to all parties whose names are on the account. Unlike a power of attorney, the child isn’t obligated to act in a parent’s best interest.

Each of these setups may help protect a parent’s assets. But parents may not welcome what they see as interference, no matter how well meaning family members are. Typically, they can refuse to permit children’s access to their financial information or revoke permission previously granted.

Finding a balance between protecting someone and usurping their rights is hard, said Bloom. The only way to ensure financial control is to go to court to establish guardianship or conservatorship. But that is a serious step not to be taken lightly.

“You only want to do that if there’s a major risk.”

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

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Hit by Higher Prices for Gear, Doctors and Dentists Want Insurers to Pay

SACRAMENTO — Treating patients has become more expensive during the pandemic, and doctors and dentists don’t want to be on the hook for all the new costs.

This story also ran on Los Angeles Times. It can be republished for free.

For instance, the box of 100 gloves that cost $2.39 in February 2020 costs $30 now, said Dr. Judee Tippett-Whyte, president of the California Dental Association, who has a private dental practice in Stockton.

Her practice used to rely on surgical masks that cost 20 cents each but has upgraded to N95 masks at $2.50 a pop. On top of that, her office is scheduling two or three fewer patients each day to accommodate physical distancing and give staff members time to disinfect between patients, she said.

“We’ve sustained a lot of financial costs,” Tippett-Whyte said. “We shouldn’t have to bear the cost of this for ourselves.”

Her argument raises a fundamental covid question: Who should pay for pandemic expenses? Should it be health care providers contending with new pandemic-era protocols or insurance companies, which may pass on their additional costs to customers in the form of higher premiums?

California’s dentist and doctor lobbies say insurance companies are flush with cash after collecting premiums during the pandemic but paying fewer claims than usual — and should foot the bill. The California Medical Association, which represents doctors, has sponsored legislation that would require insurers to reimburse medical and dental practices for pandemic-related expenses like personal protective equipment, disinfectant and the staff time required to screen patients for symptoms before an appointment.

A request by doctors to bill Medicaid and Medicare for supplies and other pandemic-related costs recently failed at the federal level. But in Washington state, a new law sponsored by the state doctors’ lobby requires private health insurers to reimburse a portion of those costs.

Insurance trade groups have opposed both state measures.

Reimbursing the cost of nonmedical supplies isn’t typically the responsibility of insurers, said Mary Ellen Grant, spokesperson for the California Association of Health Plans.

“Here we are with treatment and office levels back at pre-pandemic levels. Now they want additional payment from plans to pay for nonmedical expenses,” Grant said.

The insurance industry also points out that doctors and dentists haven’t had to fend for themselves when it comes to PPE and other pandemic-related expenses. Since April 2020, the U.S. Department of Health and Human Services has distributed $9.9 billion to more than 50,000 California medical providers through the Provider Relief Fund, out of $178 billion available nationally.

And more than 900,000 businesses in the “health care and social assistance” category — including some medical practices and dentists — have gotten Paycheck Protection Program loans from the Small Business Administration since March 2020.

A letter from insurance groups opposing California’s bill points to other assistance, such as advance payments on insurance claims from the federal government and insurance plans, state-based grants and loans, and programs that distributed free PPE to some practices.

“They’ve gotten plenty of help from the feds to cover these costs,” Grant said.

Health insurance companies saw their margins and profits skyrocket at the beginning of the pandemic when they were collecting premiums while patients put off non-urgent medical care. Those tapered off when people started returning to the doctor. Still, the nation’s largest medical insurer, UnitedHealth Group, recently announced its net income for the first quarter of 2021 was 44% higher than in the same quarter last year.

Allison Hoffman, a professor who researches health policy at the University of Pennsylvania’s law school, said she has little sympathy for health insurance companies that “made a fortune over the past year” by collecting premiums without paying for the typical number of treatments and doctors’ visits.

“We’re starting to see a kind of broader definition of what health insurance might pay for in order to keep people healthy,” Hoffman said. “There’s nothing like a public health emergency to shine a light on the fact that sometimes it’s not a prescription drug or surgical procedure that’s going to improve health.”

Late last year, the American Medical Association lobbied the federal Centers for Medicare & Medicaid Services to approve a procedure code doctors could use to bill those public insurance programs for PPE, disinfecting materials, office modifications to keep people apart, and staff time spent instructing patients before their visits and checking their symptoms. Often, when federal regulators approve a new billing code for Medicare and Medicaid, private insurers start reimbursing for the corresponding costs as well.

Allowing doctors to bill for that code would help them follow infection control protocols without further cutting into revenues, the association wrote to the federal agency.

But CMS denied the request, saying it considers payment for those costs part of the payment for the rest of the appointment, according to an agency spokesperson.

In the wake of that decision, two state medical associations took up the cause themselves.

The Washington State Medical Association backed a law, which took effect April 16, that allows health care providers to bill state-regulated private insurance companies $6.57 when they see a patient in person — on top of billing for whatever services they provide — to cover the cost of extra PPE, staff time, and materials to conduct and transport covid tests. The new rules last through the rest of the federally declared public health emergency.

For a law that put the state’s medical association and insurance association on opposite sides of the bargaining table, it was remarkably uncontentious, said state Sen. David Frockt (D-Seattle), who introduced the bill.

California’s legislation, which is still being debated, is more open-ended than Washington’s.

SB 242 doesn’t specify a dollar amount but would require private health plans regulated by the state to reimburse dental and medical practices for the “medically necessary” business expenses associated with a public health emergency.

The California Medical Association said physician practice revenues fell by one-third while PPE costs rose by 14% in the first six months of the pandemic, according to an October 2020 survey of its members. Of the survey respondents, 87% said they were worried about their financial viability.

“When you look at the record profits on some of these publicly traded companies and what they’re showing their shareholders, this would be a drop in the bucket,” association spokesperson Anthony York said of health insurers. “We’re not surprised plans don’t want to pay more, but ultimately this is a fight we’ll have in the legislature.”

The bill is intended to keep small and medium-sized practices from closing their doors in the face of rising costs, said its author, state Sen. Josh Newman (D-Fullerton). The state medical and dental associations warn that anything that adds costs and cuts into revenues could force smaller practices to close or consolidate, exacerbating physician and dentist shortages around the state.

“What I’m doing, as a legislator, is to deliberately offset some of these burdensome costs so we don’t lose physicians and practices,” Newman said. “It would be a shame if those communities lost access to health care.”

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

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

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Covid Shot in the Arm Not Enough to Keep Pharmacies in Business

Tobin’s pharmacy and department store had already stocked its shelves with Easter and Mother’s Day items last spring, and the staff had just placed the Christmas orders. The shop in Oconomowoc, Wisconsin, had been operating on a razor’s edge as retail sales moved online and mail-order pharmacies siphoned off its patients. It was losing money on 1 out of 4 pill bottles filled, so the front of the store, where it sold clothing, cosmetics and jewelry, had been compensating for pharmacy losses for years.

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“And then covid hit,” said Dave Schultz, who co-owned the store with his brother. “And that was the final straw.”

The covid-19 pandemic sank many businesses in 2020, particularly those relying on in-person sales to stay afloat. For pharmacies — especially independent pharmacies — the pandemic lockdowns exacerbated long-standing economic pressures. Many small owner-operated pharmacies adapted quickly, delivering their traditional amenities in safer ways or capitalizing on new services created by the pandemic, such as covid testing and vaccinations. But others, like Tobin’s, became casualties of the pandemic, closing their doors for good.

It’s too early to quantify just how many pharmacies succumbed to covid and assess how patients will be affected. The total number of pharmacies has declined less than 1% over the past five years, as pharmacy chains get larger while independent community pharmacies — often the last place left to fill a prescription in some small towns — go under. The Rural Policy Research Institute found that 1,231 independently owned rural pharmacies, about 16%, closed for good from 2003 to 2018, well before the pandemic pinch. And according to the Drug Channels Institute, after five years of declines, the number of urban and rural independent pharmacies dipped below 20,000 for the first time in 2020.

Revenue from covid testing and vaccinations may help keep some independents afloat, but that comes with added costs and logistical challenges.

“Pharmacies are struggling,” said Harry Lattanzio, president of PRS Pharmacy Services, a consulting firm in Latrobe, Pennsylvania. “We’re getting calls from a lot more pharmacy owners that want to sell their stores. They’ve had enough.”

Most pharmacies, he said, saw a decline in prescriptions last year as customers hesitated to visit their doctors for anything but emergencies. That drop in business also meant fewer sales of over-the-counter medicines and ancillary items sold by the stores. Meanwhile, pharmacies had to buy protective equipment to keep staffers and customers safe and beef up their technology to address the new reality.

Lattanzio said some independent pharmacies, which had always preferred the personal touch of having staff members answer the phones, have had to invest in new systems to handle thousands of calls a day from people seeking vaccines. Costs rose even as revenues dropped.

“For the most part, they lost money,” Lattanzio said. “If you didn’t lose money, you did something really right.”

When Lattanzio opened his first pharmacy 20 years ago, he saw gross profit margins of 36%. Now independent pharmacies are fortunate to see margins of 3% to 5%, if they survive the pandemic at all. Much of that decline comes from the impact of pharmacy benefit managers, which manage commercial and public health plans’ prescription drug reimbursements to pharmacies. Those PBMs, often aligned with large drugstore chains, systematically squeezed the profits out of independent pharmacies. That left many smaller chains or unaffiliated pharmacies unable to bear the added hit from the pandemic.

“I’m afraid to see the outcome,” said Joe Moose, co-owner of Moose Pharmacy, a chain of seven drugstores on the outskirts of Charlotte, North Carolina. “The delay in payments, the increased cost to keep operating in the early days of this, combined with the fact that reimbursement is so poor already — covid may be the final nail in the coffin for some of us.”

Moose Pharmacy is trying to adapt. When it had to stop in-store purchases during the pandemic, the chain expanded curbside services and hired additional drivers. Home deliveries tripled. Workers ferried food, toilet paper, paper towels and shampoo to customers.

“We had to build out our website. We put in technology so that people could text us from the parking lot. It had to be HIPAA-compliant,” said Moose, who owns the chain with his brother. “And keep in mind that all of that is happening at no change in reimbursement.”

Covid also interrupted the medication supply chain. In normal times, the pharmacy’s supply of drugs is automated, so when it dispenses medicines, replacements show up in the next day’s delivery. But Moose and his staff had to resort to the old way of calling up five or six wholesalers to see who had the drugs in stock.

When covid testing was scarce, the pharmacies taught their employees to perform rapid tests. Once vaccines arrived, Moose sought out patients who couldn’t make an appointment on a smartphone, who couldn’t drive to mass vaccination clinics, or who were just afraid to leave their home.

Staffers delivered vaccines to one elderly man with cancer, whose wife had died a year earlier. He and his disabled adult son didn’t want to risk going out and contracting the virus.

“But he trusts us, and so we deliver medication to him probably every other week,” Moose said. “So it made sense that we bring the vaccine to him.”

Tripp Logan, a pharmacist in Charleston, Missouri, said one of his three pharmacies is in rural Mississippi County, which has no hospital or chain pharmacy for the 14,000 residents. There, four independent pharmacies and the county health department formed a consortium to help distribute covid vaccines.

“It started with a group text, and the next thing you know, we’re vaccinating hundreds of people a week collectively,” Logan said.

Because pharmacies can make up to $70 per covid test and $40 for each vaccination,  many pharmacies are earning new revenue to offset some of the retail losses, said Owen BonDurant, president of Independent Rx Consulting in Centerville, Ohio.

“So that has brought a significant increase in profit margins for the short term,” BonDurant said. “Covid has probably saved a lot of pharmacies. Because PBM pressure has been so hard, especially on some of these rural and inner-city pharmacies, a lot of them still are on the verge of going out of business.”

The cash infusion from the federal Paycheck Protection Program also kept many pharmacies afloat, and allowed some to make investments that better position them for the future.

“We would have had to shut down or sell because the PBMs were brutal last year, and they killed off a lot of our friends in Wisconsin,” said Dan Strause, president and chief executive officer of Hometown Pharmacy in Madison, Wisconsin. “Without the PPP, there would have been far more facing the same fate.”

Some of the changes born of necessity could stick. In a recent survey by the National Community Pharmacists Association, 3 in 5 community pharmacists said they expect more pharmacies to offer point-of-care testing after the pandemic, and more than half said additional pharmacies will give immunizations.

Hashim Zaibak, CEO of Hayat Pharmacy in Milwaukee, said his pharmacy is considering testing for the flu, strep and hemoglobin A1C levels for those with diabetes, and it will continue providing vaccinations.

“Those changes are here to stay,” Zaibak said.

Tobin’s owners considered selling their pharmacy, but finding no buyers, they shut down for good in September. Schultz said it’s unclear whether they could have survived had covid not happened — or if the vaccine revenue might have helped. He knows of two other independent pharmacies in Wisconsin that closed in the past 18 months.

“The real crux of the matter is you’re getting paid, in some cases, $60 under the cost that we end up paying for the medication,” he said. “How do you justify that portion of your business?”

Oconomowoc has one independent drugstore, two grocery store pharmacies and a Walgreens to serve its 17,000 residents. But Schultz worries about many of the older, sicker customers who relied on the personalized care his pharmacy provided. One of his former pharmacists now works at a drugstore outside of town but delivers medications to some of Tobin’s most vulnerable former customers on her way home.

“She just didn’t think they would survive going someplace else,” he said.

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

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A Primary Care Physician for Every American, Science Panel Urges

The federal government must aggressively bolster primary care and connect more Americans with a dedicated source of care, the National Academies of Sciences, Engineering and Medicine warn in a major report that sounds the alarm about an endangered foundation of the U.S. health system.

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The urgently worded report, which comes as internists, family doctors and pediatricians nationwide struggle with the economic fallout of the coronavirus pandemic, calls for a broad recognition that primary care is a “common good” akin to public education.

The authors recommend that all Americans select a primary care provider or be assigned one, a landmark step that could reorient how care is delivered in the nation’s fragmented medical system.

And the report calls on major government health plans such as Medicare and Medicaid to shift money to primary care and away from the medical specialties that have long commanded the biggest fees in the U.S. system.

“High-quality primary care is the foundation of a robust health care system, and perhaps more importantly, it is the essential element for improving the health of the U.S. population,” the report concludes. “Yet, in large part because of chronic underinvestment, primary care in the United States is slowly dying.”

The report, which is advisory, does not guarantee federal action. But reports from the national academies have helped support major health initiatives over the years, such as curbing tobacco use among children and protecting patients from medical errors.

Strengthening primary care has long been seen as a critical public health need. And research dating back more than half a century shows that robust primary care systems save money, improve people’s health and even save lives.

“We know that better access to primary care leads to more timely identification of problems, better management of chronic disease and better coordination of care,” said Melinda Abrams, executive vice president of the Commonwealth Fund, a New York-based foundation that studies health systems around the world.

Recognizing the value of this kind of care, many nations — from wealthy democracies like the United Kingdom and the Netherlands to middle-income countries such as Costa Rica and Thailand — have deliberately constructed health systems around primary care.

And many have reaped significant rewards. Europeans with chronic illnesses such as diabetes, high blood pressure, cancer and depression reported significantly better health if they lived in a country with a robust primary care system, a group of researchers found.

For decades, experts here have called for this country to make a similar commitment.

But only about 5% of U.S. health care spending goes to primary care, versus an average of 14% in other wealthy nations, according to data collected by the Organization for Economic Co-operation and Development.

Other research shows that primary spending has declined in many U.S. states in recent years.

The situation grew even more dire as the pandemic forced thousands of primary care physicians — who didn’t receive the government largesse showered on major medical systems — to lay off staff members or even close their doors.

Reversing this slide will require new investment, the authors of the new report conclude. But, they argue, that should yield big dividends.

“If we increase the supply of primary care, more people and more communities will be healthier, and no other part of health care can make this claim,” said Dr. Robert Phillips, a family physician who co-chaired the committee that produced the report. Phillips also directs the Center for Professionalism and Value in Health Care at the American Board of Family Medicine.

The report urges new initiatives to build more health centers, especially in underserved areas that are frequently home to minority communities, and to expand primary care teams, including nurse practitioners, pharmacists and mental health specialists.

And it advocates new efforts to shift away from paying physicians for every patient visit, a system that critics have long argued doesn’t incentivize doctors to keep patients healthy.

Potentially most controversial, however, is the report’s recommendation that Medicare and Medicaid, as well as commercial insurers and employers that provide their workers with health benefits, ask their members to declare a primary care provider. Anyone who does not, the report notes, should be assigned a provider.

“Successfully implementing high-quality primary care means everyone should have access to the ‘sustained relationships’ primary care offers,” the report notes.

This idea of formally linking patients with a primary care office — often called empanelment — isn’t new. Kaiser Permanente, consistently among the nation’s best-performing health systems, has long made primary care central. (KHN is not affiliated with Kaiser Permanente.)

But the model, which was at the heart of managed-care health plans, suffered in the backlash against HMOs in the 1990s, when some health plans forced primary care providers to act as “gatekeepers” to keep patients away from costlier specialty care.

More recently, however, a growing number of experts and primary care advocates have shown that linking patients with a primary care provider need not limit access to care.

Indeed, a new generation of medical systems that rely on primary care to look after elderly Americans on Medicare with chronic medical conditions has demonstrated great success in keeping patients healthier and costs down. These “advanced primary care” systems include ChenMed, Iora Health and Oak Street Health.

“If you don’t have empanelment, you don’t really have continuity of care,” said Dr. Tom Bodenheimer, an internist who founded the Center for Excellence in Primary Care at the University of California-San Francisco and has called for stronger primary care systems for decades.

Bodenheimer added: “We know that continuity of care is linked to everything good: better preventive care, higher patient satisfaction, better chronic care and lower costs. It is really fundamental.”

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

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In Appalachia and the Mississippi Delta, Millions Face Long Drives to Stroke Care

Debbie Cook was in her pajamas on a summer morning in 2019 when she got a call from her son: “Something bad is wrong with Granny.”

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The fear in his voice told Cook it was serious. She dialed 911 immediately, knowing it could take time for an ambulance to navigate the country roads in Fentress County, Tennessee.

She got dressed and made the short drive across the family farm, over two bridges and a creek, to her mother’s house. Cook prayed that one of the three ambulances covering their roughly 500-square mile county was near.

When Cook arrived, she found her mother, Lottie Crouch, in the bathroom, unable to stand or walk. Cook, a licensed practical nurse, quickly recognized the signs: lopsided face, one side of the mouth drooping.

Her mama was having a stroke.

“I was petrified,” Cook recalled. She started her career working with stroke rehab patients and knew that getting the right care fast could mean life or death. Or a big difference in her mother’s quality of life. Crouch was 75 and still energetic and loved doing things like firing up a kettle of soup for herself. To continue living the life Crouch knew, each step toward getting care in a rural area had to go right.

But when the paramedics arrived, one of the biggest questions was: Where would they take Crouch for care?

Across the nation, nearly 800,000 people suffer strokes each year. The issue is particularly acute across the regions of Appalachia and the Mississippi Delta, where more than 80% of counties have stroke death rates above the national average. Many of these counties also face high rates of poverty and are home to vulnerable elderly populations. They have a shortage of medical providers or have seen local hospitals shutter.

In Tennessee, 2 million people — nearly one-third of the state — are people like Crouch who live more than 45 minutes from a hospital that is stroke-certified and able to provide the most advanced care, according to a new analysis by KHN and InvestigateTV. And rates are even higher in Delta states such as Arkansas and Mississippi, where more than half of residents must drive longer than 45 minutes to those specialized stroke centers.

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The analysis is part of a yearlong project called Bridging the Great Health Divide, in which KHN and Gray Television’s national investigative team, InvestigateTV, are digging into health issues that have historically plagued these regions. Strokes are chief among them. Despite medical advancements in stroke care, routing patients from rural parts of Appalachia and the Delta to the appropriate facility is an intricate jigsaw puzzle.

“There’s not the same one correct answer for all patients,” said Dr. Raul Nogueira, an interventional neurologist at Grady Memorial Hospital in Atlanta. Where a patient should be taken for care “really depends on travel time,” he said. “It’s all about time.”

For years, the advice for stroke patients has been to get to the nearest hospital as soon as possible. A stroke cuts off blood flow to part of the brain, and the sooner that blood flow can be restored the better. So, the idea has been to get patients to a doctor — any doctor — quickly.

But that advice is now evolving. Research shows some stroke patients benefit more from advanced procedures typically done by specialists at large medical centers. The new goal is to get patients to the right doctor at the right hospital as soon as possible.

In some cases, that means skipping the closest facility. For patients with severe strokes, in which a clot is blocking one of the brain’s major arteries, the American Heart and Stroke associations recommend traveling up to an additional 30 minutes in urban areas and 60 minutes in rural areas to reach a hospital with more advanced stroke capabilities.

While that’s easy enough in a city where multiple hospitals are clustered together, in rural areas like Fentress County the question of where to take a patient has become increasingly fraught.

Big Decisions, Little Time

When Lottie Crouch had her stroke, what would have been the nearest hospital, less than 20 minutes away, had closed two months earlier. It’s one of 136 rural hospitals nationwide that have shuttered since 2010, including nearly three dozen across Appalachia and the Delta. That meant the closest in-state hospital for Crouch was nearly 45 minutes away by car, and medical centers with the most advanced care were more than an hour’s drive. That left EMS services stretched thin trying to transport patients farther away.

Each step in the process to get someone who’d had a stroke to the right care within the right amount of time had become more complex.

The decisions along the way are rarely clear-cut, Nogueira said. If a patient has a severe stroke, they might benefit from getting to a large medical center where they can undergo surgery right away, he said. Stopping at a smaller hospital that can’t perform that procedure might unnecessarily delay care.

But if the stroke is less severe, the person might benefit more from first going to a closer facility that can offer medications to break up the clot sooner, Nogueira said. Then the patient could avoid unnecessary medical bills from a long trip, anything from $500 for a ride in the back of a regular ambulance to $50,000 for a helicopter. And their family could save the time and money needed to visit them in a faraway hospital.

The problem is that first responders can’t necessarily tell how severe a stroke is just by looking at someone. So, they rely on an evaluation of the patient’s symptoms to make the best choice.

The gravity of these decisions weighs on Jamey Beaty, a paramedic in Fentress County, who responded to Lottie Crouch’s home.

“When you’re in the back of a truck and all alone and you have a patient actively dying on you, the only thing you can think about is: How can I keep this patient alive until I can get them somewhere?” Beaty said. “That’s all that crosses your mind.”

Anytime Beaty gets a call about a stroke, his first response is to look at the sky.

Since the local hospital closed, an air ambulance is how he quickly gets people to treatment. The day Lottie Crouch had her stroke, luckily the Tennessee sky was clear blue. Crouch was taken nearly 100 miles to a hospital in Knoxville with advanced stroke services.

Long Journeys to Advanced Care

Over the past two decades, two main treatments have advanced care for strokes caused by a blockage — the most common type of stroke in America. The first is a medication delivered through an IV to break up clots in patients’ blood vessels. The medicine has to be given within 4½ hours of when symptoms start. The second is a procedure using a catheter to physically remove the clot from a patient’s vessels. This treatment can be done up to 24 hours after symptoms start but is generally used only for severe strokes.

Across the country, hospitals are certified by tiers, largely based on their ability to regularly provide these treatments. Some hospitals have no certification. Among stroke-certified hospitals, the first level is acute stroke-ready hospitals, which can assess stroke patients, keep them stable and provide clot-busting medications. At the other end of the spectrum are comprehensive stroke centers, which have specialized teams of neurologists and neurosurgeons. In addition to giving the clot-busting drugs, these centers can physically remove clots.

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The big question is: Which facility can and should stroke patients be taken to first to get the right care within the right time span?

In Appalachia, about 11% of residents must drive more than 45 minutes to reach any kind of stroke center, according to the KHN and InvestigateTV analysis. That proportion is even higher in the Delta, where nearly a third of residents have to drive more than 45 minutes to a stroke center. Another third of Delta residents have only basic-care stroke centers within that distance and would need to drive farther for advanced stroke surgeries.

And in the most rural parts of both these regions, people are less likely to be near an advanced-care stroke facility.

Rural and Largely African American

While reaching appropriate stroke care in time is difficult for many rural Americans, such as Crouch, who is white, the concerns are compounded for places with a large Black population.

Black Americans have strokes more often and at younger ages than their white counterparts. They’re also less likely to receive clot-busting medications because they often arrive at the hospital outside the window of treatment.

In Sumter County, Alabama, several people interviewed — from a business owner to a college professor to the district judge — were able to name someone off the top of their heads who has had a stroke. The county is more than 70% Black, and it is one of the poorest areas of the state.

The only hospital within county lines has no stroke certification. Loretta Wilson, the CEO of Hill Hospital of Sumter County, wishes her facility could do more for stroke patients. But clot-busting medications can cost $8,000 per dose, and the hospital can’t always afford to keep them on hand, she said.

Most stroke patients are taken to larger hospitals at least 30 or 40 minutes away. That can be a long and expensive journey for many residents, Wilson said.

Understanding that, Wilson focuses largely on prevention efforts. She runs a nonprofit that tackles issues like high blood pressure, obesity and diabetes, all of which increase a person’s risk of stroke. Her organization partners with churches to teach people about healthy eating and exercise, and passes around blood pressure monitors so congregants can screen themselves after services.

“We have a high African American population,” said Wilson, who is African American too, “and those are the ones who really need the services.”

Other organizations in the county also work to educate people about heart health and when to call 911. The local college’s nursing program has a scholarship aimed at bringing more medical providers to the area.

Using Telestroke to Boost Rural Care

In rural hospitals, even if doctors have access to clot-busting drugs, they may hesitate to administer them for fear of harming the patient. In rare instances — about 2% to 7% of cases — the drugs can cause bleeding in the brain.

But not using the drugs can also have consequences. A national study published in 2020 found stroke patients were less likely to receive those medications in rural hospitals than urban ones, and stroke patients were more likely to die in rural hospitals.

Telestroke programs can help bridge that gap, said Dr. Amelia Adcock, a neurologist at WVU Medicine in West Virginia and head of the system’s telestroke network.

By connecting doctors from smaller, often rural, hospitals with an on-call specialist at a large medical center, the programs allow people “to share the burden of decision-making,” Adcock said. And the liability.

Dr. Michael Gould is an emergency medicine doctor at the 25-bed Potomac Valley Hospital in rural northern West Virginia. His hospital is not stroke-certified and does not have a neurologist on staff. He said giving clot-busting drugs is “one of the decisions in medicine that makes me the most nervous.”

But consulting with neurologists at WVU Medicine’s hub about 80 miles away in Morgantown has given him more confidence, he said. Gould estimated he now administers the drugs once or twice a month.

A study of WVU Medicine’s telestroke network found the number of stroke patients receiving clot-busting medications nearly doubled over the first three years of the program.

Last fall, Christopher Green was picking up groceries when he suddenly developed a severe headache and lost his peripheral vision. Green, a longtime paramedic, immediately recognized what was happening. “Oh, my God, I’m having a stroke,” he remembers thinking. He was brought to Gould’s hospital, and the ER staff immediately fired up the telestroke program.

Within 30 minutes, Green got drugs to break up the blockage in his vessels. "A textbook outcome," said Green, who has responded to many 911 calls for stroke.

Looking back, Green said he probably would have taken a patient in his situation to a farther hospital that was stroke-certified. But experiencing the telestroke program firsthand changed his outlook.

”Now I see that delaying that treatment 20 to 30 minutes makes a difference on whether you have a full resolution or some kind of residual effects,” he said.

‘What Could It Have Been?’

Back in Tennessee, Debbie Cook was grateful her mother was taken to the advanced-care stroke center in Knoxville. It allowed Lottie Crouch to get the treatment she needed so she can still lead a mostly independent life.

But there were trade-offs. The distance took a toll on the family. Cook, her sister and her daughter took turns driving nearly two hours each way to watch over Crouch in the hospital each night.

After 10 days, when Crouch was transferred to a rehab facility closer to home, the family felt a sense of relief. They could bring her meatloaf and wild blackberry dumplings for dinner. And “a lot of peppermint candy,” Crouch recalled — her favorite.

Although Crouch is now healthy and at home, her 27-year-old granddaughter, Haelee Stockton, is still haunted by the possibility of what could have happened that day. If the paramedics hadn’t made it in time or if bad weather had prevented the helicopter from flying, her granny might not be alive.

“What could it have been?” Stockton said. “How lucky was she? And how many people are going to get that lucky in the future?”

Aneri Pattani led the reporting and writing for this story. Hannah Recht led the data analysis and graphics. InvestigateTV’s Daniela Molina contributed to this report.

Read the methodology to learn how we did this analysis and visit the Github repository to see the code.

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

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En los Apalaches y el delta del Mississippi, millones deben viajar lejos para recibir atención por accidentes cerebrovasculares

Una mañana de verano en 2019, Debbie Cook estaba todavía en pijamas cuando recibió una llamada de su hijo: “Algo malo le pasa a la abuela”.

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Por el miedo en la voz de su hijo supo que se trataba de algo serio. Marcó el 911 de inmediato, sabiendo que una ambulancia podría tardar un buen tiempo en recorrer las carreteras rurales del condado de Fentress, en Tennessee.

Se vistió y condujo a través de la granja familiar, dos puentes y un riachuelo, hasta la casa de su madre. Cook rezó para que una de las tres ambulancias que cubrían su condado de aproximadamente 500 millas cuadradas estuviera cerca.

Cuando llegó, encontró a su madre, Lottie Crouch, en el baño, incapaz de pararse o caminar. Cook, quien es enfermera licenciada, reconoció rápidamente los signos: cara torcida, un lado de la boca caído.

Su mamá estaba sufriendo un accidente cerebrovascular (ACV, también llamado ataque cerebral).

“Me quedé petrificada”, recordó Cook, quien comenzó su carrera trabajando con pacientes en rehabilitación tras accidentes cerebrovasculares, y sabía que obtener la atención adecuada rápidamente podría hacer la diferencia entre la vida o la muerte. O una gran diferencia en la calidad de vida de su madre. Crouch tenía 75 años, todavía estaba enérgica y le encantaba hacer cosas como prepararse sopa. Para seguir viviendo la vida que Crouch conocía, cada paso hacia la atención adecuada, en un área rural, tenía que salir bien.

Cuando llegaron los paramédicos, la pregunta crucial fue: ¿A dónde llevarían a Crouch para que recibiera atención?

En todo el país, cerca de 800,000 personas sufren accidentes cerebrovasculares cada año. El problema es particularmente grave en las regiones de los Apalaches y el delta del Mississippi, donde más del 80% de los condados tienen tasas de muerte por ACV superiores al promedio nacional. Muchos de estos condados también enfrentan altos índices de pobreza y albergan a poblaciones de adultos mayores vulnerables. Tienen escasez de proveedores médicos o han visto cerrar hospitales locales.

En Tennessee, 2 millones de personas, casi un tercio del estado, están en la situación de Crouch: viven a más de 45 minutos de un hospital certificado para el tratamiento de accidentes cerebrovasculares y capaz de brindar la atención más avanzada, según un nuevo análisis de KHN e InvestigateTV.

Y las tasas son aún más altas en los estados del delta como Arkansas y Mississippi, donde más de la mitad de los residentes deben conducir más de 45 minutos hasta estos centros especializados.

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El análisis es parte de un proyecto de un año llamado Bridging the Great Health Divide, durante el cual KHN y el equipo de investigación nacional de Gray Television, InvestigateTV, investigan los problemas de salud que históricamente han plagado a estas regiones. Y los accidentes cerebrovasculares son los principales. A pesar de los avances médicos en la atención de estos ataques, enviar a los pacientes de las zonas rurales de los Apalaches y el delta del Mississippi a las instalaciones adecuadas es un intrincado rompecabezas.

"No existe una única respuesta correcta para todos los pacientes", dijo el doctor Raul Nogueira, neurólogo intervencionista del Grady Memorial Hospital en Atlanta, Georgia. El lugar donde se debe cuidar a un paciente "realmente depende del tiempo de viaje", dijo. "Todo es cuestión de tiempo".

Durante años, el consejo para los pacientes con ACV ha sido llegar al hospital más cercano lo antes posible. Esta emergencia interrumpe el flujo sanguíneo a una parte del cerebro y, cuanto antes se lo pueda restaurar, mejor. Entonces, la idea ha sido llevar a los pacientes a un médico, cualquier médico, rápidamente.

Pero ahora, ese consejo está evolucionando. Investigaciones muestran que algunos pacientes con ACV se benefician más de los procedimientos avanzados que suelen realizar especialistas en grandes centros médicos. Por eso, el nuevo objetivo es llevar a los pacientes al médico adecuado en el hospital adecuado lo antes posible.

En algunos casos, eso no significa la instalación más cercana. Para los pacientes con accidentes cerebrovasculares graves, en los que un coágulo está bloqueando a una de las arterias principales del cerebro, las asociaciones médicas recomiendan viajar hasta 30 minutos adicionales en áreas urbanas y 60 minutos en áreas rurales para llegar a un hospital con capacidad de tratar un ataque cerebral con técnicas avanzadas.

Si bien eso es bastante fácil en una ciudad donde hay muchos hospitales, en áreas rurales como el condado de Fentress, la cuestión de dónde llevar a un paciente se ha vuelto cada vez más complicada.

Grandes decisiones, poco tiempo

Cuando Lottie Crouch tuvo su accidente cerebrovascular, el que habría sido el hospital más cercano, a menos de 20 minutos, había cerrado dos meses antes. Es uno de los 136 hospitales rurales en todo el país que han cerrado desde 2010, incluidos casi tres docenas en Appalachia y el delta.

Eso significaba que, para Crouch, el hospital estatal más cercano estaba a casi 45 minutos en auto, y los centros médicos con la atención más avanzada estaban a más de una hora. Eso hizo que los servicios de emergencias médicas se esforzaran por transportar a los pacientes más lejos.

Cada paso en el proceso para conseguir que alguien que había sufrido un derrame cerebral recibiera la atención adecuada en el tiempo adecuado se había vuelto más complejo.

Las decisiones del momento rara vez son claras, dijo Nogueira. Si un paciente tiene un accidente cerebrovascular severo, podría beneficiarse de ir a un centro médico grande donde pueda someterse a una cirugía de inmediato, agregó. Detenerse en un hospital más pequeño que no puede realizar ese procedimiento podría retrasar innecesariamente la atención.

Pero si el ataque es menos grave, podría ser mejor ir primero a un centro más cercano en donde el paciente podría recibir medicamentos para disolver el coágulo antes, dijo Nogueira. Así, evitaría facturas médicas innecesarias por un viaje largo, desde $500 por un viaje en la parte trasera de una ambulancia regular hasta $50,000 por un helicóptero. Y la familia podría ahorrar el tiempo y el dinero que implica visitar al paciente en un hospital lejano.

El problema es que los socorristas no necesariamente pueden saber qué tan grave es un derrame cerebral con solo mirar a alguien. Por lo tanto, se basan en una evaluación de los síntomas del paciente para tomar la mejor decisión.

A Jamey Beaty, un paramédico en el condado de Fentress que respondió a la casa de Lottie Crouch, le pesan la gravedad de estas decisiones.

"Cuando estás solo en la parte trasera de una ambulancia y tienes un paciente que se está muriendo, lo único en lo que puedes pensar es: ¿Cómo puedo mantener vivo a este paciente hasta que pueda llevarlo a alguna parte?", dijo Beaty. "Eso es todo lo que se te pasa por la cabeza".

Cada vez que Beaty recibe una llamada por un ataque cerebral, su primera respuesta es mirar al cielo.

Desde que cerró el hospital local, una ambulancia aérea es la forma más rápida para que el paciente llegue al lugar del tratamiento. Afortunadamente, el día que Lottie Crouch tuvo su ataque, el cielo de Tennessee estaba azul claro. Crouch fue trasladada casi 100 millas a un hospital en Knoxville con servicios avanzados para accidentes cerebrovasculares.

Viajes largos hacia la atención avanzada

Durante las últimas dos décadas, dos tratamientos principales han hecho que avanzara la atención de los accidentes cerebrovasculares causados ​​por un bloqueo, el tipo de ataque más común en Estados Unidos.

El primero es un medicamento administrado por vía intravenosa para disolver los coágulos en los vasos sanguíneos de los pacientes. El medicamento debe administrarse dentro de las 4½ horas posteriores al inicio de los síntomas. El segundo es un procedimiento que utiliza un catéter para remover físicamente el coágulo de los vasos de un paciente. Este tratamiento se puede realizar hasta 24 horas después del comienzo de los síntomas, pero generalmente se usa solo para accidentes cerebrovasculares graves.

En todo el país, los hospitales están certificados por niveles, en gran parte en función de su capacidad para proporcionar estos tratamientos con regularidad. Algunos hospitales no tienen certificación. Entre los hospitales certificados para accidentes cerebrovasculares, el primer nivel son los que están preparados para accidentes cerebrovasculares agudos, que pueden evaluar a los pacientes con accidente cerebrovascular, mantenerlos estables y proporcionar medicamentos anticoagulantes.

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En el otro extremo del espectro están los centros integrales de accidentes cerebrovasculares, que cuentan con equipos especializados de neurólogos y neurocirujanos. Además de administrar los medicamentos anticoagulantes, estos centros pueden remover los coágulos con cirugía.

La gran pregunta es ¿a qué centro se puede y se debe llevar primero a los pacientes con ACV para que reciban la atención adecuada en un tiempo adecuado?

En Appalachia, aproximadamente el 11% de los residentes deben conducir más de 45 minutos para llegar a cualquier tipo de centro de accidentes cerebrovasculares, según el análisis de KHN e InvestigateTV. Esa proporción es aún mayor en el delta, donde casi un tercio de los residentes tienen que conducir más de 45 minutos para llegar a uno de estos centros. Otro tercio solo tiene centros de atención básica para accidentes cerebrovasculares dentro de esa distancia y necesitaría conducir más lejos para cirugías avanzadas.

Y en las partes rurales más remotas de estas dos regiones, es menos probable que las personas estén cerca de un centro de atención avanzada para accidentes cerebrovasculares.

Rural y mayoritariamente afroamericano

Si bien para muchos estadounidenses rurales como Crouch, que es blanca no hispana, es difícil llegar a tiempo al lugar adecuado para recibir la atención, las preocupaciones se agravan en los lugares con una gran población de raza negra.

Los afroamericanos tienen accidentes cerebrovasculares con más frecuencia y a edades más tempranas que sus contrapartes caucásicas. También es menos probable que reciban medicamentos anticoagulantes porque generalmente llegan al hospital fuera de la ventana del tratamiento.

En el condado de Sumter, Alabama, varias personas entrevistadas, desde el dueño de un negocio local hasta un profesor universitario y el juez de distrito, pudieron nombrar a alguien que había tenido un ataque cerebral. Más del 70% de la población del condado es de raza negra, y es una de las áreas más pobres del estado.

El único hospital dentro de las fronteras del condado no tiene certificación para ACV. Loretta Wilson, directora ejecutiva del Hospital Hill del condado de Sumter, quisiera que su centro pudiera hacer más por los pacientes con ACV. Pero los medicamentos anticoagulantes pueden costar $8,000 por dosis y el hospital no siempre puede permitirse el lujo de tenerlos a mano, dijo.

A la mayoría de los pacientes con accidente cerebrovascular se los traslada a hospitales más grandes, al menos a 30 o 40 minutos de distancia. Ese puede ser un viaje largo y costoso para muchos residentes, agregó Wilson.

Por eso, Wilson se centra principalmente en los esfuerzos de prevención. Dirige una organización sin fines de lucro que aborda problemas como la presión arterial alta, la obesidad y la diabetes, que aumentan el riesgo de una persona de sufrir un ACV. Su organización tiene alianzas con iglesias para educar a las personas sobre alimentación saludable y ejercicio, y distribuye monitores de presión arterial para que los feligreses puedan tomarse la presión ellos mismos.

"Tenemos una alta población afroamericana", dijo Wilson, quien también es afroamericana, "y esos son los que realmente necesitan los servicios".

Otras organizaciones en el condado también trabajan para educar a las personas sobre la salud cardíaca y cuándo llamar al 911. El programa de enfermería de la universidad local tiene una beca destinada a atraer a más proveedores médicos al área.

Usando telestroke para impulsar la atención rural

En los hospitales rurales, incluso si los médicos tienen acceso a medicamentos anticoagulantes, pueden dudar en administrarlos por temor a dañar al paciente. En raras ocasiones, alrededor del 2% al 7% de los casos, los medicamentos pueden causar sangrado cerebral.

Pero no usar las drogas también puede tener consecuencias. Un estudio nacional publicado en 2020 encontró que los pacientes con accidente cerebrovascular tenían menos probabilidades de recibir esos medicamentos en hospitales rurales que en los urbanos, y los pacientes con estos ataques tenían más probabilidades de morir en hospitales rurales.

Los programas de telestroke pueden ayudar a cerrar esa brecha, explicó la doctora Amelia Adcock, neuróloga de WVU Medicine en West Virginia y jefa de la red de telestroke del sistema.

Al conectar a médicos de hospitales más pequeños, a menudo rurales, con un especialista de guardia en un gran centro médico, los programas permiten que las personas “compartan la carga de la toma de decisiones”, dijo Adcock. Y la responsabilidad.

El doctor Michael Gould es médico de medicina de emergencia en el Hospital Potomac Valley de 25 camas en la zona rural del norte de West Virginia. Su hospital no está certificado para accidentes cerebrovasculares y no cuenta con un neurólogo de planta. Dijo que administrar medicamentos anticoagulantes es "una de las decisiones de la medicina que me pone más nervioso".

Pero consultar con neurólogos en el centro de Medicina de WVU a unas 80 millas de distancia en Morgantown le ha dado más confianza, dijo. Gould estimó que ahora administra los medicamentos una o dos veces al mes.

Un estudio de la red de telestroke de WVU Medicine halló que el número de pacientes con accidente cerebrovascular que recibieron medicamentos anticoagulantes casi se duplicó durante los primeros tres años del programa.

El otoño pasado, Christopher Green estaba haciendo las compras cuando de repente sintió un fuerte dolor de cabeza y perdió la visión periférica. Green, un veterano paramédico, reconoció de inmediato lo que estaba sucediendo. "Oh, Dios mío, estoy sufriendo un ataque cerebral", recuerda haber pensado. Lo llevaron al hospital de Gould y el personal de emergencias inmediatamente puso en marcha el programa de telestroke.

En 30 minutos, Green consiguió medicamentos para disolver el coágulo en sus vasos. "Un resultado de libro de texto", dijo Green, quien ha respondido a muchas llamadas al 911 por accidentes cerebrovasculares.

Rememorando, Green dijo que probablemente habría llevado a un paciente en su situación a un hospital más lejano que estuviera certificado para accidentes cerebrovasculares. Pero experimentar el programa de telestroke en carne propia cambió su perspectiva.

"Ahora veo que retrasar el tratamiento de 20 a 30 minutos marca la diferencia entre tener una solución completa o algún tipo de efecto residual", dijo.

“¿Qué pudo haber sido?”

De vuelta en Tennessee, Debbie Cook estaba agradecida de que a su madre la hubieran llevado al centro de atención avanzada para accidentes cerebrovasculares en Knoxville. Le permitió a Lottie Crouch recibir el tratamiento que necesitaba para poder llevar una vida mayormente independiente.

Pero la distancia le pasó factura a la familia. Cook, su hermana y su hija se turnaron para conducir casi dos horas de ida y dos de vuelta para pasar la noche con Crouch en el hospital.

Después de 10 días, cuando Crouch fue trasladada a un centro de rehabilitación más cercano a su casa, la familia sintió una sensación de alivio. Podrían llevarle pastel de carne y dumplings de moras silvestres para la cena. Y "un montón de caramelos de menta", recuerda Crouch, su favorito.

Aunque Crouch ahora está sana, y en casa, su nieta de 27 años, Haelee Stockton, todavía está obsesionada de solo pensar lo que podría haber sucedido ese día. Si los paramédicos no hubieran llegado a tiempo o si el mal tiempo hubiera impedido que el helicóptero volara, es posible que su abuela no estuviera viva.

"¿Qué pudo haber sido?", se preguntó Stockton. “¿Qué tanta suerte tuvo? ¿Y cuántas personas van a tener esa suerte en el futuro?".

Aneri Pattani lideró las entrevistas y la redacción de esta historia. Hannah Recht lideró el análisis de datos y los gráficos. Daniela Molina de InvestigateTV colaboraron con la historia.

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

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