June 25, 2022

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Some medical tests, such as MRIs done early for uncomplicated low back pain and routine vitamin D tests “just to be thorough,” are considered “low-value care” and can lead to further testing that can cost patients thousands of dollars.

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Some medical tests, such as MRIs done early for uncomplicated low back pain and routine vitamin D tests “just to be thorough,” are considered “low-value care” and can lead to further testing that can cost patients thousands of dollars.

ER Productions Limited/Getty Images

Dr. Meredith Niess saw her patient was scared. He’d come to the Veterans Affairs clinic in Denver with a painful hernia near his stomach. Niess, a primary care resident, knew he needed surgery right away. But another doctor had already ordered a chest X-ray instead.

The test results revealed a mass in the man’s lung.

“This guy is sweating in his seat, [and] he’s not thinking about his hernia,” Niess said. “He’s thinking he’s got cancer.”

It was 2012, and Niess was upset. Though ordering a chest X-ray in a case like this was considered routine medical practice, Niess understood something her patient didn’t. Decades of evidence showed the chest X-ray was unnecessary and the “mass” was probably a shadow or a cluster of blood vessels. These non-finding findings are so common that doctors have dubbed them “incidentalomas.”

Niess also knew the initial X-ray would trigger more tests and delay the man’s surgery further.

In fact, a follow-up CT scan showed a clean lung but picked up another suspicious “something” in the patient’s adrenal gland.

“My heart just sank,” Niess said. “This doesn’t feel like medicine.”

A second CT scan finally cleared her patient for surgery — six months after he’d come for help.

Niess wrote about the case in JAMA Internal Medicine as an example of what researchers call a “cascade of care” — a seemingly unstoppable series of medical tests or procedures.

Cascades can begin when a test done for a good reason finds something unexpected. After all, good medicine often requires some sleuthing.

“Low-value care”

The most troubling cascades, though, start like Niess’ patient’s, with an unnecessary test — what Ishani Ganguli, a primary care physician who is an assistant professor of medicine at Harvard University, and other researchers, call “low-value services” or “low-value care.”

“A low-value service is a service for which there is little to no benefit in that clinical scenario, and potential for harm,” Ganguli said.

Over the past 30 years, doctors and researchers like Ganguli have flagged more than 600 procedures, treatments and services that are unlikely to help patients: Tests like MRIs done early for uncomplicated low back pain, prostate cancer screenings for men over 80 and routine vitamin D tests.

Research suggests low-value care is costly, with one study estimating that the U.S. health care system spends $75 billion to $100 billion annually on these services. Ganguli published a paper in 2019 that found the federal government

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3 min read

Claudia and Jesús Fierro of Yuma, Ariz., review their medical bills. They pay $1,000 a month for health insurance yet still owed more than $7,000 after two episodes of care at the local hospital.

Lisa Hornak for Kaiser Health News


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Lisa Hornak for Kaiser Health News


Claudia and Jesús Fierro of Yuma, Ariz., review their medical bills. They pay $1,000 a month for health insurance yet still owed more than $7,000 after two episodes of care at the local hospital.

Lisa Hornak for Kaiser Health News

The Fierro family of Yuma, Ariz., had a string of bad medical luck that started in December 2020.

That’s when Jesús Fierro Sr. was admitted to the hospital with a serious case of COVID-19. He spent 18 days at Yuma Regional Medical Center, where he lost 60 pounds. He came home weak and dependent on an oxygen tank.

Then, in June 2021, his wife, Claudia Fierro, fainted while waiting for a table at the local Olive Garden restaurant. She felt dizzy one minute and was in an ambulance on her way to the same medical center the next. She was told her magnesium levels were low and was sent home within 24 hours.

The family has health insurance through Jesús Sr.’s job, but it didn’t protect the Fierros from owing thousands of dollars. So when their son Jesús Fierro Jr. dislocated his shoulder, the Fierros — who hadn’t yet paid the bills for their own care — opted out of U.S. health care and headed south to the U.S.-Mexico border.

And no other bills came for at least one member of the family.

The patients: Jesús Fierro Sr., 48; Claudia Fierro, 51; and Jesús Fierro Jr., 17. The family has Blue Cross and Blue Shield of Texas health insurance through Jesús Sr.’s employment with NOV, formerly National Oilwell Varco, an American multinational oil company based in Houston.

Medical services: For Jesús Sr., 18 days of inpatient care for a severe case of COVID-19. For Claudia, fewer than 24 hours of emergency care after fainting. For Jesús Jr., a walk-in appointment for a dislocated shoulder.

Total bills: Jesús Sr. was charged $3,894.86. The total bill was $107,905.80 for COVID-19 treatment. Claudia was charged $3,252.74, including $202.36 for treatment from an out-of-network physician. The total bill was $13,429.50 for less than one day of treatment. Jesús Jr. was charged $5 (70 pesos) for an outpatient visit that the family paid in cash.

Service providers: Yuma Regional Medical Center, a 406-bed nonprofit hospital in Yuma, Ariz. It’s in the Fierros’ insurance network. And a private doctor’s office in Mexicali, Mexico, which is not.

What gives: The Fierros were trapped in a situation in which more and more Americans find themselves. They are what some experts term “functionally uninsured.” They have insurance — in this case, through Jesús Sr.’s job, which pays $72,000 a year. But their health plan is expensive, and they don’t have the liquid savings to pay their share of

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2 min read

While Sean Deines and his wife, Rebekah, were traveling in Wyoming in 2020, Sean got very ill and was diagnosed with an aggressive leukemia. A huge air ambulance bill added to their stress.

Maddy Alewine/Kaiser Health News


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Maddy Alewine/Kaiser Health News


While Sean Deines and his wife, Rebekah, were traveling in Wyoming in 2020, Sean got very ill and was diagnosed with an aggressive leukemia. A huge air ambulance bill added to their stress.

Maddy Alewine/Kaiser Health News

Sean Deines and his wife, Rebekah, were road-tripping after he lost his job as a bartender when the pandemic hit. But while visiting his grandfather in a remote part of Wyoming, Sean started to feel very ill.

Rebekah insisted he go to an urgent care center in Laramie.

“Your white blood count is through the roof. You need to get to an ER right now,” Deines, 32, recalls a staffer saying. The North Carolina couple initially drove to a hospital in Casper but were quickly airlifted to the University of Colorado Hospital near Denver, where he was admitted on Nov. 28, 2020.

There, specialists confirmed his diagnosis: acute lymphoblastic leukemia, a fast-growing blood cancer.

“Literally within 12 hours, I needed to figure out what to do with the next step of my life,” said Deines.

So, after he was started on intravenous treatments, including steroids and antibiotics, to stabilize him, the couple decided it was prudent to return to North Carolina, where they could get help from his mother and mother-in-law. They selected Duke University Medical Center in Durham, which was in his insurance network.

His family called Angel MedFlight, part of Aviation West Charters of Scottsdale, Ariz., which told Rebekah Deines that it would accept whatever the couple’s insurer would pay and that they would not be held responsible for any remaining balance.

Sean Deines was flown to North Carolina on Dec. 1, 2020, and taken by ground ambulance to Duke, where he spent the next 28 days as an inpatient.

By his discharge, he felt better and things were looking up.

Then the bills came.

The patient: Sean Deines, 32, who purchased coverage through the Affordable Care Act marketplace with Blue Cross Blue Shield of North Carolina.

Medical service: A 1,468-mile air ambulance flight from Colorado to North Carolina, along with ground transportation between the hospitals and airports.

Service provider: Aviation West Charters, doing business as Angel MedFlight, a medical transport company.

Total bill: $489,000, most of which was for the flight from Denver, with approximately $70,000 for the ground ambulance service to and from the Denver and Raleigh-Durham airports.

What gives: Insurers generally get to decide what care is “medically necessary” and therefore covered. And that is often in the eye of the beholder. In this case, the debate revolved first around whether Deines would have been stable enough to safely take a three-plus-hour commercial flight to North Carolina during a pandemic or did he require the intensive care the air ambulance provided.

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3 min read

Dhaval Bhatt plays Monopoly with his children, Hridaya (left) and Martand, at their home in St. Peters, Missouri. Martand’s mother took him to a children’s hospital in April after he burned his hand, and the bill for the emergency room visit was more than $1,000 — even though the child was never seen by a doctor.

Whitney Curtis for Kaiser Health News


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Whitney Curtis for Kaiser Health News


Dhaval Bhatt plays Monopoly with his children, Hridaya (left) and Martand, at their home in St. Peters, Missouri. Martand’s mother took him to a children’s hospital in April after he burned his hand, and the bill for the emergency room visit was more than $1,000 — even though the child was never seen by a doctor.

Whitney Curtis for Kaiser Health News

Martand Bhatt’s parents weren’t sure he needed immediate medical care when the energetic toddler burned his hand on the kitchen stove one April morning.

Dhaval Bhatt, Martand’s father, said he’d been warned about hospital emergency rooms after he arrived in the U.S. from his native India.

“People always told me to avoid the ER in America unless you are really dying,” said Bhatt, a research scientist and pharmacologist at Washington University in St. Louis.

But after seeing a photo, the family’s pediatrician directed them the next day to the local children’s hospital.

Dhaval Bhatt was traveling at the time. So Martand’s mother, Mansi Bhatt, took their son to the hospital and was sent to the emergency room. A nurse took the toddler’s vitals and looked at the wound. She said a surgeon would be in to inspect it more closely.

When the surgeon didn’t appear after more than an hour, Mansi Bhatt took her son home. The hospital told her to make a follow-up appointment with a doctor, which turned out to be unnecessary because the burn healed quickly.

Then the bill came.

The patient: Martand Bhatt, a toddler covered by a UnitedHealthcare insurance plan provided by the employer of his father, Dhaval Bhatt.

Medical service: An emergency room visit for a burn sustained when Martand touched an electric stove.

Total bill: $1,012. UnitedHealthcare’s negotiated rate was $858.92, all of which the Bhatts were responsible for because their plan had a $3,000 deductible.

Service provider: SSM Health Cardinal Glennon Children’s Hospital, one of 23 hospitals owned by SSM Health, a Catholic nonprofit health system with more than $8 billion in annual revenue.

What gives: Many patients don’t understand that they can rack up huge bills almost as soon as they walk through the doors of an ER.

Unlike a restaurant or a mechanic that won’t charge if someone gets tired of waiting for a table or an inspection of a rattling engine, hospital emergency rooms almost invariably charge patients as soon as they check in.

And once they register, patients will be billed — often a lot — whether treatment was rendered or not.

Martand received almost no medical service. A nurse practitioner looked over

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3 min read

People wait in line at a testing site to receive a free COVID-19 PCR test in Washington, D.C. On Monday, the CDC announced that people can isolate for five days, instead of 10, after they’ve tested positive for the coronavirus and have no symptoms.

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People wait in line at a testing site to receive a free COVID-19 PCR test in Washington, D.C. On Monday, the CDC announced that people can isolate for five days, instead of 10, after they’ve tested positive for the coronavirus and have no symptoms.

Anna Moneymaker/Getty Images

More than 200,000 people are testing positive for COVID-19 in the U.S. each day. Until this week, a positive test meant you should stay home for 10 days to avoid infecting others. Now, those who don’t have symptoms after five days can go back to their regular activities as long as they wear a mask, according to updated guidance from the Centers for Disease Control and Prevention.

The change in guidance released Monday was “motivated by science demonstrating that the majority of SARS-CoV-2 transmission occurs early in the course of illness,” according to the CDC.

CDC director Dr. Rochelle Walensky says the change was also motivated by economic and societal concerns. “With a really large anticipated number of cases [from omicron], we also want to make sure we can keep the critical functions of society open and operating,” she told NPR on Tuesday. “We can’t take science in a vacuum. We have to put science in the context of how it can be implemented in a functional society.”

Public health experts say a shorter isolation period may be reasonable at this point in the pandemic, but they say the agency’s new guidance is problematic because it relies on people’s self-judgment to assess their transmission risk — and could lead to more spread and more COVID-19 cases if people aren’t careful.

“The CDC is right. The vast majority of the transmissions happen in the first couple of days after the onset of symptoms … but the data shows that about 20 to 40% of people are still going to be able to transmit COVID after five days,” says Dr. Emily Landon, an infectious disease specialist at UChicago Medicine. “Is that person [leaving isolation after five days] really safe to carpool with or have close contact with or have them take care of your unvaccinated kids?”

Dr. Anthony Fauci, who is the White House chief medical adviser and director of the NIAID, and Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention. Walensky defends the new CDC isolation and quarantine guidelines, saying she “trusts” the public to follow them.

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Dr. Anthony Fauci, who is the White House chief medical adviser and director of the NIAID, and Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention. Walensky defends the new CDC isolation and quarantine guidelines, saying

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