The U.S. saw 111 deaths per 100,000 population, more than double the COVID mortality rate of other wealthy nations.
The United States would have averted 266,700 deaths during the Delta and Omicron spikes of the COVID-19 pandemic if the excess all-cause mortality rate nationally matched that of the 10-most vaccinated states, a new study shows.
The data, compiled in a research letter from Brown University School of Public Health, and Penn's Perelman School of Medicine, also showed that 122,304 deaths would have been averted if COVID-19 mortality rates matched those of the 10 most-vaccinated states between June 27, 2021 and March 26, 2022, the period covering outbreaks of the Delta (June 27, 2021-Dec. 25, 2021) and Omicron variants (December 26, 2021-March 26, 2022).
The rate of COVID mortality in the nation's 10 least-vaccinated states – 145 per 100,000 population -- was nearly double the COVID mortality rate of the 10 most-vaccinated states (74.5/100,000), according to the letter which was published Friday in JAMA Network.
"The U.S. continued to experience significantly higher COVID-19 and excess all-cause mortality compared with peer countries during 2021 and early 2022, a difference accounting for 150,000 to 470,000 deaths," the letter states.
When compared with 20 other wealthy nations that had ready access to vaccines, the United States excess all-cause mortality – 145 deaths per 100,000 population – was the highest. However, the 10 most-vaccinated states had excess all-cause mortality (65/100,000) comparable with or lower than other wealthy countries, such as Germany (63/100,000), the Netherlands (63/100,000), and Italy (71/100,000) over the Delta and Omicron outbreaks.
Comparisons of direct COVID-19 mortality in the United States with the peer nations were even more stark, with 111 deaths per 100,000 population, more than double the rate of most wealthy nations. Austria (65/100,000) led all peer nations.
"This difference was muted in the 10 states with highest vaccination coverage; remaining gaps may be explained by greater vaccination uptake in peer countries, better vaccination targeting to older age groups, and differences in health and social infrastructure," the letter said.
The initiative is developing admissions and application criteria, with the first apprentice program to begin in 2023.
In an effort to address Michigan's dire rural nursing shortage, the state has launched its first registered nurse apprentice program in a partnership with Corwell Health Ludington Hospital and West Shore Community College.
Stakeholders say the new program combine classroom instruction and practical experience with a nurse mentor for full-time apprentices at Corewell Health Ludington Hospital (formerly Spectrum Health Ludington Hospital) for a faster, less cumbersome path to RN licensure.
"The rural health workforce faces many challenges, including nursing shortages," Meleah Mariani, DNP, RN, NEA-BC, FACHE, CNO, at Corewell Health Ludington said at the launching ceremony this month in the city, located about 100 miles north of Grand Rapids on Lake Michigan.
Under the partnership, Corewell Health Ludington Hospital apprentices will enroll in the West Shore Community College nursing program for classroom instruction, lab, and clinical education. The apprentices also will be employed by Corewell Ludington with on-the-job training provided, which will expedite the time it takes to become practice-ready.
"The registered nurse apprenticeship can open doors for those who otherwise might not pursue a career in nursing," Mariani says. "So many times, I have heard someone say 'I always wanted to be a nurse,' but the need to work full-time, the demands of childcare, and other associated expenses create roadblocks.
"It is my hope that our RN apprenticeship and partnership with West Shore Community College and Michigan Works! West Central means that Corewell Health can inspire hope for those caring individuals who envision themselves as future nurses. We are incredibly grateful for this opportunity."
The partnership is developing admissions and application criteria, with the first apprentice program to begin in 2023.
"We are thrilled with this opportunity to allow working people a chance to take their skills and education to the next level," says Shelley Boes, MSN, RN, director of nursing and allied health at West Shore. "The nurse apprenticeship program will help nurses understand the role and job while they continue to learn and gain experience."
Not-for-profit Corewell Health West, formerly Spectrum Health, serves 13 counties in West Michigan. Corewell Health West is a region of Corewell Health, a 22-hospital system formerly known as Beaumont Health and Spectrum Health system.
The CNA/NNU issued a 10-day notice on Nov. 10 following a near-unanimous strike authorization vote from rank and file.
More than 21,000 registered nurses and nurse practitioners at 21 Kaiser Permanente Hospitals in Northern California are planning a two-day strike on November 21 and 22 to protest what they say is the health system's "refusal to address ongoing concerns about workplace health and safety and chronic short staffing."
The California Nurses Association/National Nurses United issued a 10-day notice on Nov. 10 following a near-unanimous strike authorization vote from rank and file this month.
Nurses at Kaiser Permanente Los Angeles Medical Center will also join the two-day strike in what the union is calling the biggest private-sector nurses strike in U.S. history.
"We always want to give our patients the best care, but Kaiser refuses to provide the resources we need to do our jobs safely," says CNA President Cathy Kennedy, RN, in the neonatal ICU unit at Kaiser Permanente Roseville Medical Center. "We are chronically short-staffed, which means patients are waiting longer for care. This is unacceptable and unconscionable when Kaiser made more than $14 billion during the first two years of the pandemic."
The union and Kaiser have been negotiating a new contract since June but have made little headway. Among its demands, the union is calling for minimum staffing guidelines, increased hiring and training, and job protections against subcontractors and outsourcing.
The nurses' strike would come just one month after Kaiser Permanente in NorCal came to terms with more than 2,000 mental healthcare care workers following a 10-week walkout over chronic staffing shortages and long wait times for mental health services.
Kaiser Permanente calls the strike "counterproductive and distracts everyone from reaching agreement."
At its most-recent bargaining session last week, KP says it offered NorCal nurses "higher annual raises for our nurses than we have been able to offer for decades – 21.25% in wage increases over 4 years of the contract."
"Our proposal is driven by the changing economy, including inflation, significant changes in the marketplace and our commitment to providing our employees with excellent pay and benefits," KP says.
"In bargaining in Southern California, we are actively bargaining today. We hope to reach a mutually agreeable solution that recognizes the nursing wage rates in the Los Angeles market, our current economic realities, and the inflationary environment of today."
Our nurses’ dedication to providing expert, compassionate care, especially throughout the COVID-19 pandemic, has been nothing short of inspiring. We are committed to continuing to provide excellent compensation and a work environment committed to well-being, safety, and professional opportunities for our nurses.
KP's Statement
Kaiser Permanente issued the following statement in response to the strike threat.
"We have been in bargaining with the California Nurses Association (CNA) for months, and have been making steady progress towards these goals, including in a session Thursday (Nov. 10). We have already reached important agreements in bargaining on safety, diversity, and other important matters.
In Thursday's bargaining session in Northern California, we put an offer on the table, which includes higher annual raises for our nurses than we have been able to offer for decades – 21.25% in wage increases over 4 years of the contract. Our proposal is driven by the changing economy, including inflation, significant changes in the marketplace and our commitment to providing our employees with excellent pay and benefits. In bargaining in Southern California, we are actively bargaining today (Nov. 11). We hope to reach a mutually agreeable solution that recognizes the nursing wage rates in the Los Angeles market, our current economic realities, and the inflationary environment of today.
It is disappointing to receive a strike notice from CNA for a 2-day strike Nov. 21 and 22, as this tactic is counterproductive and distracts everyone from reaching agreement. Further, our nurses would prefer to be at the side of our patients as we once again manage through a time when flu and RSV illness are affecting so many patients and COVID-19 is still very real and sickening thousands every day.
We are committed to reaching an agreement, and do not believe there is any reason for a strike, given the many agreements we have already reached in bargaining, and the generous economic proposal we are putting on the table.
Right now, every health care provider in the nation is facing staffing shortages and fighting burnout, and Kaiser Permanente is not immune. In spite of the acute shortage of nurses in the state, our commitment to being the best place for nurses to work has enabled Kaiser Permanente Northern California to hire about 3,300 additional nurses since 2021 of which 650 were new graduates hired through our nurse residency program.
We are committed to hiring hundreds more additional nurses, in addition to the hundreds we are already bringing on board through aggressive recruitment and hiring, to provide relief for our nurses and address staffing shortages. As a result of all this work, we are proud that Kaiser Permanente has one of the lower turnover rates for nurses in health care, and we don’t take that achievement for granted. The union’s claims of unsafe staffing levels are not correct. Kaiser Permanente meets or exceeds state-mandated staffing ratios.
Our first priority is always the care and safety of our members and patients. We have contingency plans in place to ensure patients receive the care they need in the event CNA carries out a strike.
Kaiser Permanente has a long and productive history with organized labor and we are proud of our ability to successfully reach agreements with our unions, which represent 160,000 Kaiser Permanente employees – more than any other health care organization in the nation. Labor unions have always played an important role in our efforts to give more people access to high-quality care and make care more affordable."
Ninety percent of the Californians in the plan receive financial assistance.
Gov. Gavin Newsom says that one million uninsured Californians could gain coverage in 2023 for as little as $10 a month through Covered California, the state's Affordable Care Act marketplace.
Two-thirds of the 1.7 million enrollees already are eligible for the low-cost coverage and some can get free coverage. Ninety percent of the Californians in the plan receive financial assistance.
"Millions of Californians now have access to affordable health coverage and now is the time to go sign up for health insurance to keep yourself and your family healthy," Newsom says. "We won't stop until every Californian – regardless of income or immigration status – has the health insurance they need and deserve."
According to Newsom, California leads the nation in lowering healthcare costs and improving access.
Other cost-reduction actions claimed by Newsom include:
Working with an outside partner to manufacture low-cost insulin, to reduce the cost of this life-saving medication, particularly for those who lack coverage for prescription drugs or who have a high level of cost sharing.
Expanding Medi-Cal to all income-eligible, undocumented Californians. By January 2024, all low-income Californians will be eligible for no-cost comprehensive healthcare coverage.
Eliminating Medi-Cal premiums for hundreds of thousands of Californians while improving quality and access. That includes reducing to zero the financial burden for approximately 500,000 pregnant women, children, and disabled working adult Medi-Cal enrollees.
Transforming Medi-Cal through CalAIM to provide better outcomes, expand access to services, and reduce disparities.
Only 16% Medi-Cal recipients estimated to be eligible for Community-Based Adult Services were served by the program in 2020.
Two Medi-Cal long-term care programs designed to keep seniors and disabled adults out of nursing homes are serving only a fraction of the eligible population, a UCLA Center for Health Policy Research study finds.
The study found high potential demand across the state for services offered by Medi-Cal's Multipurpose Senior Services Program, which provides health and social services for people 65 and older who would otherwise require institutional care, and Community-Based Adult Services, which provide professional care at licensed adult day health centers in the community for disabled people and others at risk of institutionalization.
However, only about 39,000, or 16%, of the roughly 243,400 Medi-Cal recipients estimated to be eligible for Community-Based Adult Services were served by the program in 2020, the study found.
Demand will only grow in coming years, with the need for such services increasing through 2025 and 2030 and into 2050, when people 65 and older are expected to make up some 25% of California's population, according to the study.
"Supportive programs provided to older adults and adults with disabilities at home and in the community are essential to maintaining physical and mental health," says Kathryn Kietzman, director of the center's Health Equity Program. "As the state continues to implement its Master Plan for Aging, it is critical that gaps in access to long-term services and supports are addressed."
The researchers also found wide disparities by race and ethnicity, age, and geography in the proportion of people estimated to be eligible and those currently receiving these long-term services and support.
Among the study's findings:
106,700 people were estimated to be eligible for the Multipurpose Senior Services Program in 2020 — almost 10 times more than the 10,324 people served.
Among those estimated to be eligible for Community-Based Adult Services, Black Americans and those who identified as two or more races were among the least likely to be receiving services, at 4% and 5%, respectively.
Older Asian and Black adults were among the groups most underserved by the Multipurpose Senior Services Program.
All of California's geographic regions had significantly more people who were potentially eligible for both Community-Based Adult Services and the Multipurpose Senior Services Program than actually used them.
Los Angeles County served 38% of those potentially eligible for Community-Based Adult Services in 2020, while other Southern California regions, taken together, served 10%.
The lowest rates of participation in Community-Based Adult Services were seen in the Northern and Sierra region (2%) and the San Joaquin Valley (3%).
The greatest participation in the Multipurpose Senior Services Program was observed in the Northern and Sierra (65%) and Central Coast (38%) regions.
"Our hope is that these findings will inform and prioritize the implementation of strategies to increase access to care," Kietzman says. "Ideally, program planners and providers will find ways to improve communication about available programs, ease pathways to program information and enrollment, and streamline eligibility requirements."
Violators could get booted from the prestigious Boston hospital.
With violence against healthcare workers reaching epic proportions, Mass General Brigham Hospital has launched a campaign to curb abuse from patients and visitors.
Under a newly imposed Patient Code of Conduct, patients and visitors who disrupt care, make verbal or physical threats -- including racist, sexist, discriminatory or disrespectful comments about clinicians, other hospital staff, other patients and visitors -- could face a verbal reprimand, and even expulsion from the Boston hospital and possible suspension of future care access.
"Just as we expect all of our employees and clinicians to treat each other and every patient and visitor with courtesy and respect, we have the same expectations of all of you," Allison Bryant, MD, Mass General Brigham's senior medical director for health equity, says in a YouTube video on the health system's website.
"If there is a time where your actions violate the code, our staff will remind you of the expectations," Bryant says. "Depending on the situation, it is possible that family members or visitors who violate the code may be asked to leave the premises and future visitations may be restricted."
"If necessary patients who repeatedly act in disrespectful or discriminatory ways may be asked to make other arrangements for their care and obtaining future non-emergency care at MGB site may require review."
Mass General Brigham says it created the patient code of conduct in response to the alarming increases in violence and hostility directed against hospital staff across the nation, including encounters that have resulted in the deaths and harassment of clinicians.
In January, two dozen Neo-Nazis held a protest in front of Brigham and Women's Hospital and targeted for harassment two physician-advocates for health equity. In 2015, a Brigham cardiac surgeon was murdered by an angry patient.
A Bureau of Labor Statistics report found that injuries from violent attacks against medical professionals grew by 63% from 2011 to 2018. Hospital officials say the problem has intensified since the COVID-19 pandemic. A National Nurses United survey of more than 2,500 nurses in April found that nearly half (48%) reported an uptick in workplace violence – up from 22% in March 2021, a 119% increase.
"We are now more than three years into the pandemic and not only is staffing worse, but workplace violence is increasing," NNU President Zenei Triunfo-Cortez, RN, says. "Nurses are experiencing alarming levels of moral distress and moral injury due to the unsafe working conditions. Since our last survey in September 2021, even more nurses have reported feeling more stress and anxiety as well as feeling traumatized by their experiences caring for patients."
The threat of violence is one of several factors that are driving burned-out nurses from the profession, including chronic understaffing, an inability to manage surge capacity, and continued shortages of personal protection equipment, Triunfo-Cortez says.
Massachusetts Nurses Association President Katie Murphy, RN, says her union is "generally supportive of the new code of conduct, in the sense that we agree with the direction and goal of the policy and policies like it, but we may even want employers and the state to go further in some instances."
"We have pending workplace violence protection legislation for that purpose, which would require each MA healthcare facility to work with its staff to create threat/violence protections unique to its environment."
Murphy put some of the blame on the nation's healthcare delivery system, saying "we must also acknowledge that patients and healthcare workers are under tremendous stress created by a system that too often values profits at the expense of local services, safe staffing, and quality care."
"With healthcare violence rising during the pandemic, it is more important than ever that employers upgrade their policies in collaboration with nurses and other caregivers," Murphy says.
Proponents of the expansion says the expense to the state is justified financially.
More than a quarter-million undocumented income-eligible adults age 50 and older in California are enrolled in Medi-Cal, as a result of Gov. Gavin Newsom’s 2021 initiative to expand the healthcare access regardless of immigration status, the California Department of Health Services has announced.
"We’re making sure that universal access to healthcare coverage becomes a reality here in California, and this expansion has gotten us one step closer – more than a quarter million undocumented Californians aged 50 and older now have good, quality health care," Newsom says.
DHCS implemented the older adult expansion to provide state-funded full scope Medi-Cal to people 50 years of age or older who are ineligible for federally-funded full scope Medi-Cal because of their immigration status. This includes those who were enrolled in restricted scope Medi-Cal before implementation of the older adult expansion on May 1.
Proponents of the expansion says the expense to the state is justified financially, because people who have access to preventive services and regular healthcare and home-based care tend to stay healthier, and out of emergency rooms and nursing homes.
In May 2016, children under 19 years of age became eligible for full scope Medi-Cal benefits, and in January 2020, full scope Medi-Cal was extended to young adults ages 19 through 25, regardless of immigration status.
Starting January 1, 2024, Newsom’s Healthy California for All initiative will expand full scope Medi-Cal coverage to more than 700,000 undocumented adults ages 26 through 49 who are ineligible for federally funded Medi-Cal.
The California Department of Health Care Services agrees with the audit findings.
Federal watchdogs are asking Medi-Cal to refund $15.7 million in unallowable capitation payments made to managed care organizations on behalf of beneficiaries with multiple Client Index Numbers.
The U.S. Department of Health and Human Services Office of the Inspector General audited $112.1 million ($56.1 million federal share) in Medi-Cal capitation payments made to MCOs from July 1, 2015, through June 30, 2019, for 12,686 beneficiary matches.
Based on a random sample of 100 beneficiaries, OIG found that Medi-Cal made improper capitation payments in 76 cases totaling $657,057 ($328,529 federal share).
"On the basis of our sample results, we estimated that California made unallowable capitation payments totaling approximately $31.4 million ($15.7 million Federal share) on behalf of beneficiaries with multiple CINs during our audit period," OIG says.
The California Department of Health Care Services agrees with the audit findings, attributes the improper payments to "human error" at the county level, and says it is implementing a correction plan.
"Specifically, during the file clearance process, California county staff made data entry errors that included misspelling beneficiaries' names," OIG says. "Also, staff transposed Social Security numbers, failed to identify and link multiple records, and did not always identify and resolve variations in beneficiaries' names."
OIG says that the algorithm that CDHS used to create the Beneficiary Name and Date of Birth Match Report was too broad and ineffective, and that CDHS did not require county staff to review training materials.
OIG recommends that CDHS: refund the $15.7 million federal share in unallowable payments, review capitation payments that fell outside the OIG audit period and refund any unallowable payments; ensure that the algorithm used to in its revised Beneficiary Name and DOB Match Reports is effective at detecting individuals with multiple records; require training for county staff to prevent issuing multiple CINs; and enhance internal controls to ensure that no beneficiary is issued multiple CINs.
The survey commissioned by Elevance Health found that convenience and accessibility were top draws for telehealth consumers.
An overwhelming majority (94%) of adults who've used telehealth to access primary care say they're satisfied with the virtual experience, which 79% say "has allowed them to take charge of their health."
The online poll of more than 5,000 people, 32% of whom say they've accessed virtual primary care, was commissioned by Elevance Health (formerly Anthem, Inc.,) and conducted in March by The Harris Poll.
The poll also found that convenience and accessibility were top draws for telehealth among consumers.
"Consumers are using digital technologies at an accelerating pace, and consistent with this, we're seeing at Elevance Health use of telehealth that is nearly 20 times greater than pre-pandemic levels," says Rajeev Ronanki, president of digital platforms at Elevance.
"Virtual primary care gives individuals the opportunity to work with innovative services that make healthcare more convenient, accessible, and fit into their increasingly busy schedules," Ronanki says. "The study's findings reiterate the desires of consumers to use digital technology – along with using traditional in-person care options – to take control of their health."
While the popularity of telehealth has grown substantially during and after the pandemic, the poll found that only 48% of respondents said they were familiar with the technology, although 73% of respondents said that virtual primary care was appealing to them, primarily for convenience (35%), accessibility (31%), and overall ease of use (30%).
For those who haven't used virtual primary care, 31% say that physicians need to see them in person to diagnose ailments, while 21% say they're not sure if telehealth is covered by their insurance and that it may cost more.
Telehealth advocates point to studies that have shown that virtual care is effective to help manage chronic conditions, such as diabetes, high blood pressure, and asthma, and for urgent minor health issues such as allergies, cold, and skin rashes.
"As we develop the future of consumer-centered healthcare, it is important that we create a digital care network that gives individuals access to a spectrum of connected services, which includes virtual primary care as well as in-office, in-home, and digital services," Ronanki says.
While 82% of Americans feel their health is excellent or good, in reality 63% are living with or managing chronic health conditions. Two-thirds (62%) of poll respondents managing chronic conditions say virtual primary care could help them take charge of their health.
The poll also found that:
People with a chronic health condition are more likely to be familiar with virtual primary care (52% vs. 42%).
41% of people with a primary healthcare doctor want to see more use of digital communication, such as text messages or emails.
52% with a primary care physician say they would use virtual primary care in addition to the care they receive from their current primary healthcare provider within the next year, while 59% are likely to do so within the next two to five years, and 62% beyond the next five years.
84% of people who have accessed virtual primary care say it has been very useful during the pandemic and that they plan to continue using it as pandemic conditions improve.
Large majorities of respondents say they want to use virtual primary care for prescription refills (76%), referrals to specialists (72%), non-urgent (67%) and/or urgent issues (58%).
71% say that the nation's care delivery system is improving with the use of telehealth.
83% say it's a great way to increase access to healthcare for people who may otherwise be unable to visit a provider in person.
The PBM lobby has called the states' push for oversight "both misplaced and irrelevant."
California Attorney General Rob Bonta has joined 35 attorneys general who've filed an amicus brief with a federal appeals court in support of Oklahoma's authority to regulate pharmacy benefit managers.
"Ensuring access to affordable and regulated prescription medication is essential to the health and well-being of Californians," Bonta says.
"The expanded power of PBMs in the pharmaceutical industry has had an outsized, negative impact on drug pricing and the availability of pharmacies in vulnerable communities. States have a responsibility to regulate PBMs to curb the rising cost of lifesaving prescription drugs."
The AGs brief, filed with the U.S. Court of Appeals for the 10th Circuit in Denver, notes that PBMs over the years have expanded into a multi-billion-dollar industry that does nothing to lower drug prices paid by health plans to drug makers.
The growth and consolidation of PBMs with major retail pharmacies like CVS and health plans such as Aetna, has resulted in below-market reimbursements for smaller, independent pharmacies that are often driven out of business, the AGs say.
In response, Oklahoma and other states have bolstered oversight of PBMs to protect consumers, who ultimately pay for the higher drug costs.
A 2021 study in Health Affairs found that the closure of neighborhood pharmacies in California disproportionately occurs in communities of color.
'Unsupported Attacks on PBMs'
The Pharmaceutical Care Management Association, the lobbying group for PBMs, has called the "unsupported attacks on PBMs…. both misplaced and irrelevant" and argued that the Oklahoma law "interferes with health plans' ability to design benefits for Oklahomans that are flexible, cost-effective, and high-quality."
"The law would increase health care costs and threaten access to prescription drugs for Oklahoma's businesses, employees, and Medicare beneficiaries," PCMA says.
"Furthermore, the core argument presented by Oklahoma and rehashed in amicus briefs filed by the independent pharmacy lobby and certain attorneys' general has been rejected in nearly every court that has considered it, including the Supreme Court."
