The answer largely depends on whether Medicare and private health insurers will adequately cover virtual doctor visits once coronavirus outbreaks subside.
By Reed Abelson
Aug. 3, 2020
Telemedicine is having its moment. Over the last few months, millions of people have relied on video or telephone calls to talk to their doctors. But as the pandemic moves across the United States, and eventually recedes in some places, how long will the moment last?
While patients used virtual visits to avoid overcrowded and potentially infectious doctor’s offices or emergency rooms, many are returning to face-to-face appointments in cities where the threat has subsided.
And insurance payments for telehealth services, especially at full cost, may only be temporary.
Medicare’s coverage of a broad range of services is slated to end when the coronavirus no longer poses a public health emergency. Private insurers, which followed the federal government’s lead, could revert to paying doctors for virtual visits at a fraction of the cost for traditional visits, if anything at all.
Some of the nation’s biggest insurers, like UnitedHealthcare and Anthem, say they haven’t decided beyond September or October on whether to extend the policies they adopted that allowed for coverage in lieu of doctors’ visits during the coronavirus crisis.
“The concern everyone in the industry has is that reimbursement is in jeopardy,” said Dr. Mia Levy, the director of the cancer center at Rush University Medical Center in Chicago, which treated patients virtually during the height of the pandemic. “Because of telehealth, we were able to stay actively engaged with our patients,” she said.
While there is broad bipartisan support for telehealth coverage, Congress would have to pass specific legislation to make some of Medicare’s changes permanent.
“Reversing course would be a mistake,” said Seema Verma, the administrator for the federal program, which reimbursed doctors the same for virtual visits, including those over the telephone, as for in-person ones and relaxed rules about who can use telemedicine.
About nine million people under traditional Medicare used telemedicine services during the early months of the crisis. Early data does not show wide variations in use by race or ethnicity.
“It was really a no-brainer for us,” Ms. Verma said.
And spending on telemedicine services during the first peak of the coronavirus pandemic in the United States underscores the demand. In addition to federal spending through Medicare, nearly $4 billion was billed nationally for telehealth visits during March and April, compared to less than $60 million for the same two months of 2019, according to FAIR Health, a nonprofit group that analyzes private health insurance claims.
But to convince insurers they should continue paying for virtual care, doctors must demonstrate they can move beyond treating simple respiratory infections to caring for patients with chronic conditions like depression or diabetes. “From the perspective of managing the cost and quality, there’s a lot we don’t know about telemedicine,” said Dr. Rahul Rajkumar, the chief medical officer at Blue Cross Blue Shield of North Carolina.
BlueCross BlueShield of Tennessee says it is the first major insurer to make coverage of telehealth services permanent, but it has not yet determined how much it will eventually pay for the care. A few insurers, including Cigna and the Blue Cross plan in North Carolina, said they will continue to cover telehealth services at pandemic levels through the end of the year.
“We need to give providers time to get more comfortable,” said Dr. Scott Josephs, the chief medical officer for Cigna. To make remote medicine successful and worthwhile, doctors and medical groups need to invest in technology and train staff. “If they don’t have the time, they won’t make the investments,” he said.
The biggest hurdle to widespread adoption by both the government and insurers is the potential cost.
Lawmakers are reluctant to pass any bill that would significantly add to Medicare’s budget, with the government already spending a total of some $750 billion a year.
And private insurers see telemedicine as a way to save them money, said Sabrina Corlette, a research professor at Georgetown University, who helped author a recent report on how the companies responded to the pandemic. “Unless they are required to by the states or federal government, a lot of carriers will try to reimburse less for telehealth than an in-person visit,” she said.
For those at risk, telemedicine is particularly valuable. When a fever sent Susan Varak, 45, who has breast cancer, to the emergency room during the height of Chicago’s outbreak in April, she felt as if she were “walking into this war zone,” she said, because she was so terrified of catching the virus.
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She appreciates she still can see her oncologist remotely. “I don’t think it’s absolutely necessary to be face-to-face every couple of weeks,” she said.
Other patients like the convenience. David Collins, 67, didn’t have a choice when he had a 20-minute video visit in March to rule out a diagnosis of coronavirus. Like many practices during the pandemic, the Kelsey-Seybold Clinic, a large physician group in Houston, was not allowing most patients to come in.
“I loved it because it saved me a lot of time.” he said, adding “I’d much rather do that than drive across town and look for parking.”
But, a few months later, he didn’t hesitate to go to the clinic for his checkup. “There’s a little more hands-on required,” he explained, like getting a physical exam and having his blood pressure taken. Not everything can be done virtually, he said. “If you break your arm, an e-visit isn’t going to help you at all,” he said.
After seeing about 90 percent of its patients virtually, Kelsey-Seybold has “almost flip-flopped back,” said Dr. Donnie Aga, an internist who oversees telehealth for the group. Most patients seem to prefer an in-person appointment. “You could really see that people missed coming in,” he said.
With coronavirus cases now at epidemic levels in Texas, the clinic wants to shift to dividing visits to half virtual, half in person. “You’ve got to have a balance, for sure,” Dr. Aga said.
But how doctors and insurers can do that is still unknown.
“We need to see where the equilibrium ends up,” said Dr. Andrea Gelzer, the corporate chief medical officer for AmeriHealth Caritas, a Medicaid managed care company. “If the total number of visits far exceeds pre-Covid, I don’t think that’s sustainable,” she said. Additional visits that do not improve patients’ health will only result in higher costs.
Doctors have to be more discriminating about which patients to see remotely, said Rita Numerof, a health care consultant.
Telemedicine “was a solution to an immediate problem,” she said, and doctors did not have clear criteria about who should be seen, under what circumstances and for which conditions.
Many in Congress are already convinced that Medicare should continue the current coverage. “The Covid-19 pandemic has been a trial by fire, but the experience to date has made clear that the health care system is ready for broader access to telehealth on a permanent basis,” said Sen. Ron Wyden of Oregon, a Democrat who introduced legislation earlier this month.
On Thursday, Sen. Lamar Alexander of Tennessee, a Republican and chair of the Senate health committee, introduced the Telehealth Modernization Act, which would also make some changes permanent. The experience of the previous four months “will likely mean that hundreds of millions of physician-patient visits will be remote or online that were in-person before,” he said.
Since May, nearly 20 telemedicine bills have been brought to the House floor and about the same number in the Senate, said Miranda Franco, a senior policy adviser for the law firm Holland & Knight. She thinks legislation will be passed by the end of the year.
While some lawmakers favor permanently expanding Medicare payment for a broad range of telemedicine services, others are concerned about the technology’s cost and potential for fraud. “Now you’re talking about reimbursing services we haven’t reimbursed before,” Ms. Franco said.
Some patients say telemedicine is not a substitute for in-person care. Jorge Cueto, who is in his mid-20s, said a virtual visit is often an additional step before going to the doctor’s office for, say, a sore throat.
“It’s another fee, it’s another gating mechanism,” he said.
His parents, who are not fluent in English, prefer going to the doctor’s office because they find it easier to communicate in person, he said, and they have difficulty setting up video calls. “I don’t think they would be willing opt for telehealth if they weren’t required to do it,” Mr. Cueto said.
Others may not have access to a computer or smartphone to connect for video visits, and insurers are particularly wary of doctors charging for phone calls to follow up on lab results or tell someone to come to the office.
Even patients who have cellphones may not be able to afford a lengthy consultation, Dr. Levy said. She and her colleagues discovered some people stopped answering their phones at the end of the month because they had run out of minutes. “That was very eye-opening to us,” she said.
Some proponents argue the goal of telemedicine should not be to lower health care costs over all. One of its main benefits is improving patients’ access to care, said Dr. Ateev Mehrotra, a professor of health care policy at Harvard Medical School, adding that it would be foolish to expect savings if more people also get treatment. “Those don’t reconcile,” he said.
Insurers should evaluate whether telemedicine is more effective for treating conditions like depression than it is for, say, cancer. They could then make those distinctions in reimbursing for virtual visits, he said, just as they do for different prescription drugs.
“There should be no single telemedicine policy,” Dr. Mehrotra said.
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Please review this very important letter from the New York Department of Health regarding the measles outbreak.
Gov. Andrew Cuomo, in addressing a potential budget gap, said across-the-board cuts of $550 million to Medicaid funds were needed in his budget proposal. The governor said the revision is necessary to support the state's spending plan for fiscal 2020, which starts April 1. The decision reverses his position in January: that the industry needed support to fend off federal cuts.
Because of the federal matching funds that support Medicaid, the health care industry is projecting the total impact to be $1.1 billion less than they expected after Cuomo's proposal last month.
Cuomo blamed the federal government's changes to the deductibility of state and local taxes for the state's budget gap, saying that the higher tax burden has caused some of the state's wealthy residents to relocate—or at least change their residence for tax purposes.
Cuomo released a three-prong plan to achieve the savings. The state is diverting funds it had earmarked for "health care transformation" toward housing programs, reducing "indigent care" funding, which supports hospitals that provide a large percentage of services to Medicaid and uninsured patients, and levying a 0.8% across-the-board cut to Medicaid payments.
The decision drew swift condemnation from the Greater New York Hospital Association and the state's largest health worker union, 1199SEIU, two of Cuomo's closest political allies.
"As we seek to balance this budget, it cannot be done on the backs of our most vulnerable communities, and the dedicated workers who provide exceptional care," said George Gresham, president of 1199SEIU.
"Many hospitals would curtail vital services—and some would close their doors for good," GNYHA President Kenneth Raske said in a statement. "Tens of thousands of health care workers would lose their jobs. We will take our message to the public that these cuts would spell disaster for health care in New York, and we will do so with every resource at our disposal."
The hospital group and union backed Cuomo's re-election and helped orchestrate political rallies the governor held in 2017 in support of the Affordable Care Act. The two groups, which combine their lobbying efforts through the Healthcare Education Project, cheered last year when Cuomo announced a 2% increase in Medicaid payments to hospitals and 1.5% for nursing homes that went into effect Nov. 1. That support has been eliminated as the state lowers the growth in Medicaid costs to 3%, down from 3.6% in the governor's proposal last month.
Cuomo also said he plans to reconvene the Medicaid Redesign Team, a group created in 2011 to rein in spending. It was made up of leaders from the health care industry and helped save $17.1 billion in a five-year period.
CLARIFICATION: This article has been updated to reflect that the $550 million in cuts are a downward vision from Gov. Andrew Cuomo's fiscal 2020 budget proposal presented in January 2019.
Hidden from view: The complexity of the system comes with costs that aren’t obvious but that we all pay.
By Austin Frakt
It takes only a glance at a hospital bill or at the myriad choices you may have for health care coverage to get a sense of the bewildering complexity of health care financing in the United States. That complexity doesn’t just exact a cognitive cost. It also comes with administrative costs that are largely hidden from view but that we all pay.
Because they’re not directly related to patient care, we rarely think about administrative costs. They’re high.
A widely cited study published in The New England Journal of Medicine used data from 1999 to estimate that about 30 percent of American health care expenditures were the result of administration, about twice what it is in Canada. If the figures hold today, they mean that out of the average of about $19,000 that U.S. workers and their employers pay for family coverage each year, $5,700 goes toward administrative costs.
Such costs aren’t all bad. Some are tied up in things we may want, such as creating a quality improvement program. Others are for things we may dislike — for example, figuring out which of our claims to accept or reject or sending us bills. Others are just necessary, like processing payments; hiring and managing doctors and other employees; or maintaining information systems.
That New England Journal of Medicine study is still the only one on administrative costs that encompasses the entire health system. Many other more recent studies examine important portions of it, however. The story remains the same: Like the overall cost of the U.S. health system, its administrative cost alone is No. 1 in the world.
Using data from 2010 and 2011, one study, published in Health Affairs, compared hospital administrative costs in the United States with those in seven other places: Canada, England, Scotland, Wales, France, Germany and the Netherlands.
At just over 25 percent of total spending on hospital care (or 1.4 percent of total United States economic output), American hospital administrative costs exceed those of all the other places. The Netherlands was second in hospital administrative costs: almost 20 percent of hospital spending and 0.8 percent of that country’s G.D.P.
At the low end were Canada and Scotland, which both spend about 12 percent of hospital expenditures on administration, or about half a percent of G.D.P.
Hospitals are not the only source of high administrative spending in the United States. Physician practices also devote a large proportion of revenue to administration. By one estimate, for every 10 physicians providing care, almost seven additional people are engaged in billing-related activities.
It is no surprise then that a majority of American doctors say that generating bills and collecting payments is a major problem. Canadian practices spend only 27 percent of what U.S. ones do on dealing with payers like Medicare or private insurers.
Another study in Health Affairs surveyed physicians and physician practice administrators about billing tasks. It found that doctors spend about three hours per week dealing with billing-related matters. For each doctor, a further 19 hours per week are spent by medical support workers. And 36 hours per week of administrators’ time is consumed in this way. Added together, this time costs an additional $68,000 per year per physician (in 2006). Because these are administrative costs, that’s above and beyond the cost associated with direct provision of medical care.
In JAMA, scholars from Harvard and Duke examined the billing-related costs in an academic medical center. Their study essentially followed bills through the system to see how much time different types of medical workers spent in generating and processing them.
At the low end, such activities accounted for only 3 percent of revenue for surgical procedures, perhaps because surgery is itself so expensive. At the high end, 25 percent of emergency department visit revenue went toward billing costs. Primary care visits were in the middle, with billing functions accounting for 15 percent of revenue, or about $100,000 per year per primary care provider.
“The extraordinary costs we see are not because of administrative slack or because health care leaders don’t try to economize,” said Kevin Schulman, a co-author of the study and a professor of medicine at Duke. “The high administrative costs are functions of the system’s complexity.”
Costs related to billing appear to be growing. A literature review by Elsa Pearson, a policy analyst with the Boston University School of Public Health, found that in 2009 they accounted for about 14 percent of total health expenditures. By 2012, the figure was closer to 17 percent.
One obvious source of complexity of the American health system is its multiplicity of payers. A typical hospital has to contend not just with several public health programs, like Medicare and Medicaid, but also with many private insurers, each with its own set of procedures and forms (whether electronic or paper) for billing and collecting payment. By one estimate, 80 percent of the billing-related costs in the United States are because of contending with this added complexity.
“One can have choice without costly complexity,” said Barak Richman, a co-author of the JAMA study and a professor of law at Duke. “Switzerland and Germany, for example, have lower administrative costs than the U.S. but exhibit a robust choice of health insurers.”
An additional source of costs for health care providers is chasing patients for their portion of bills, the part not covered by insurance. With deductibles and co-payments on the rise, more patients are facing cost sharing that they may not be able to pay, possibly leading to rising costs for providers, or the collection agencies they work with, in trying to get them to do so.
Using data from Athenahealth, the Harvard health economist Michael Chernew computed the proportion of doctors’ bills that were paid by patients. For relatively small bills, those under $75, over 90 percent were paid within a year. For larger ones, over $200, that rate fell to 67 percent.
“It’s a mistake to think that billing issues only reflect complex interactions between providers and insurers,” Mr. Chernew said. “As patients are required to pay more money out of pocket, providers devote more resources to collecting it.”
A distinguishing feature of the American health system is that it offers a lot of choice, including among health plans. Because insurers and public programs have not coordinated on a set of standards for pricing, billing and collection — whatever the benefits of choice — one of the consequences is high administrative burden. And that’s another reason for high American health care prices.
Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health. He blogs at The Incidental Economist. @afrakt
Philadelphia, PA - January 24th, 2019 – vybe urgent care, the leading independent operator of
urgent care centers in greater Philadelphia, announces the opening today of its newest location
in the University City District of Philadelphia. This new center will be located in the heart of
West Philadelphia, nestled between the campuses of Drexel University and the University of
Pennsylvania and positioned amid the expanding commercial and residential development in
The center is located at 3550 Market St. and will be open from 8:00 a.m. to 8:00 p.m. Monday
through Friday and from 8:00 a.m. to 5:00 p.m. on the weekends.
The announcement marks another milestone in vybe’s expansion, as this location joins the
company’s current network of urgent care centers in Center City, South Philadelphia, Port
Richmond, Roxborough, Havertown and Ridley.
“We believe that everyone deserves great care – especially when they’re sick or injured,
nervous, and perhaps anxious about the cost of their treatment. vybe’s focus is easing those
concerns through everything we do, and we are pleased to expand our innovative model to
University City” said vybe urgent care President Peter Hotz. “We believe the diversity of West
Philadelphia is one of its greatest strengths, and we look forward to serving the diverse
healthcare needs of this community.”
While consumers typically rely upon urgent care centers for accessible, affordable, and
immediate healthcare service, vybe is committed to creating a truly patient-focused
atmosphere that eases the stress that comes with an illness or injury. vybe urgent care
provides patients with efficient walk-in, extended-hour medical attention with evening and
weekend hours. vybe is fully accredited by the Urgent Care Association (UCA), which is the
highest level of distinction for urgent care centers and ensures high levels of patient safety and
vybe urgent care operates the leading independent network of walk-in urgent care centers in
the greater Philadelphia region, with a focus on high-quality medical care and unparalleled
patient service. The Company’s vision is that everyone deserves great care, which is driving
development across the region and a unique focus on patient experience. Urgent care is rapidly
becoming the new way to be seen for many healthcare consumers. vybe provides a broad
range of injury and illness treatments, physical exams, and occupational health and workers’
compensation treatments. For more information, visit www.vybe.care.
By Sharon Otterman
Jan. 17, 2019
Through the fall, traveler after traveler arrived in the ultra-Orthodox Jewish communities of New York from areas of Israel and Europe where measles was spreading. They then spent time in homes, schools and shops in communities where too many people were unvaccinated.
Within months, New York State was facing its most severe outbreak of the disease in decades, with 177 cases confirmed by Tuesday, almost exclusively among ultra-Orthodox Jews. Health officials in New Jersey have reported 33 measles cases, mostly in Ocean County, driven by similar conditions.
In 2018, New York and New Jersey accounted for more than half the measles cases in the country.
Alarmed, health officials began a systematic effort to bring up vaccination rates and halt the disease’s spread.
But while there has been progress, the outbreak is not yet over. Health officials said part of the problem has been resistance among some people in ultra-Orthodox neighborhoods to fully cooperate with health workers, get vaccinations and promptly report infections.
“Sometimes they hang up and they don’t want to open the door,” said Dr. Patricia Schnabel Ruppert, the health commissioner of Rockland County, northwest of New York City, where the worst of the outbreak has been, with 114 confirmed cases. “It’s hard to break an outbreak if you are not getting cooperation.”
Dr. Ruppert said that health officials discovered that some religious schools, or yeshivas, in ultra-Orthodox communities in Rockland County had vaccination rates as low as 60 percent, far below the state average of 92.5 percent. Audits found that some schools were overreporting vaccination rates, she added.
Delayed vaccination also helped fuel the outbreak in the Orthodox communities of Williamsburg and Borough Park in Brooklyn, which had reported 55 cases as of last week, said Dr. Jane R. Zucker, head of the city health department’s Bureau of Immunization.
There have been no deaths in the outbreak, but there have been a few serious cases in young children that required hospitalization.
Measles is one of the most contagious infections and can live for up to two hours in the airspace where an infected person breathed, coughed or sneezed. It usually affects children, and symptoms include high fever and a rash of red spots all over the body, as well as a cough and runny nose. Some 90 percent of unvaccinated people exposed in proximity to an infected person will get it.
But the vaccine, when given in two doses — typically around age 1 and age 5 — is about 97 percent effective.
Health officials and sociologists say the reasons for low vaccination rates among the ultra-Orthodox are complex.
In part they are tied to the wider anti-vaccination movement globally, including concerns that the measles vaccine, which also protects against mumps and rubella, causes autism or other diseases. The idea has been widely debunked but persists in some circles.
Rabbi Yakov Horowitz, founder of Darchei Noam yeshiva in Monsey in Rockland County, said that some parents considering admission to his school agonized over giving their children vaccines because they had heard they were dangerous. His yeshiva insisted on them, he said, though he knew of others that did not.
“Good people, great parents were terrified,” he said. “They felt that I was asking to give their children something that would harm them.”
There have been more than 200 measles cases in New York and New Jersey in recent months, accounting for half of the cases in the country.CreditSchneyder Mendoza/Agence France-Presse — Getty Images
Alexandra Khorover, general counsel for Refuah Health Center, one of the largest health providers in the Rockland community of Spring Valley, said her health workers had encountered “a small pocket of people who are anti-vaccine who have been peddling this information, fostering confusion and fear.”
Part of the reluctance to vaccinate or allow a government health worker to enter the home, though, is cultural.
Samuel Heilman, a Queens College sociology professor who studies the ultra-Orthodox, said that there is a “fear of interference from the outside” rooted in the community’s origins in pre-World War II Europe. More recently, the ultra-Orthodox have fought back against other health department efforts, such as New York City’s efforts to limit a controversial circumcision practice, metzitzah b’peh, because of warnings from health officials that it causes herpes in infants.
“They have accepted the idea that they live by different rules than others in the outside community,” Mr. Heilman said.
While this insularity allowed the measles to spread, it has also had a protective effect on wider public health, at least so far. In part because ultra-Orthodox Jews tend to attend their own religious schools and patronize their own shops and restaurants, the disease has remained in Orthodox circles, save for several infections among non-Jewish workers linked to their communities, health officials said.
The outbreak in New York and New Jersey can be traced to the rise of measles in Israel, where some 2,700 cases and two deaths were reported in 2018, centered in Jerusalem.
In Europe, which was the source of at least some of the Brooklyn infections, some 65,000 cases were reported in the year ending October 2018, with high concentrations in Balkan countries and Ukraine.
A flier distributed in ultra-Orthodox Jewish communities by the New York City Health Department.
A flier distributed in ultra-Orthodox Jewish communities by the New York City Health Department.CreditNew York City Department of Health & Mental Hygiene
As measles spread in New York, public health officials swung into action. Some 40,000 fliers were printed in English, Yiddish, Spanish and other languages warning of the Israeli outbreak and calling for people to be vaccinated. Health officials met with rabbis and pediatricians, who sounded the alarm to their congregations and patients.
“We are telling people the health department is looking out for your health,” said Rabbi David Niederman, a community leader and executive director of the United Jewish Organizations of Williamsburg. “They are the experts and you should take the vaccinations.”
In Rockland County, which includes the large ultra-Orthodox community of New Square, the authorities put 59 schools under “exclusion orders,” forbidding unvaccinated children to attend even if they had a valid religious or medical exemption to the vaccine. The orders are lifted when a school’s vaccination rate reaches 95 percent, which state authorities consider protective of public health. Eighteen schools have had the orders lifted, officials said.
In Brooklyn, some children have been out of school for months because of similar exclusion orders by health officials, said Rabbi David Zwiebel, the executive director of Agudath Israel, an ultra-Orthodox umbrella organization. Tensions are high, with some parents still refusing to vaccinate because of health fears, and others relenting.
“There has been some harsh language exchanged on both sides,” Rabbi Zwiebel said.
The information campaign has had an impact. In Rockland County alone, more than 13,000 vaccines have been given since October.
While the rate of infection has slowed regionwide, Rockland has recorded an uptick — 18 new cases in January, after a drop in December.
Dr. Ruppert advised caution for all residents of Rockland County, particularly for parents of young infants and others who are not immunized, because just about everyone in the county shops at the same malls and box stores.
“Rockland is a small county, and I consider everyone potentially exposed,” she said.
In New York City, health officials sounded a hopeful note: No new cases in Brooklyn have been confirmed since Jan. 8. Orange County cases have crept up in recent weeks to eight.
“I’m sort of holding my breath,” Dr. Zucker said. “I think we have promising news, but I don’t want to be optimistic too soon.”
Liz Robbins contributed reporting.
“This could become a truly major epidemic,” said one pediatrician.
By Maggie Fox
At Clarkstown Pediatrics in Nanuet, New York, babies are on an accelerated measles vaccination schedule, getting their first shots six months early and their second dose right away.
It’s part of a statewide effort to stop several outbreaks of measles from turning into an epidemic. The state has had 170 cases of the highly infectious virus since September, making it the worst year for measles since the 1990s.
Pockets of unvaccinated children have provided fertile ground for the measles virus to take hold. Although measles was eliminated in the U.S. the virus has been brought back by travelers to Israel, which has been battling an epidemic of measles for months. The victims: mostly members of close-knit Orthodox Jewish communities across the state.
“It’s a clear and present danger right here in our community,” said Dr. Douglas Puder, a pediatrician at Clarkstown Pediatrics. His practice is right in the middle of the biggest outbreak, in New York’s Rockland County. As of Jan. 10, county reported 108 cases of measles since the fall. More than 80 percent on average had not been vaccinated and just three cases had received both recommended doses of measles vaccine.
Europe's measles outbreak sparks concern over what could happen in U.S.
Local, state and federal health officials are battling to fight the outbreaks, which they believe have been fueled by a combination of anti-vaccine propaganda, lax enforcement of school requirements to vaccinate, and a growing trend among some families to turn away from standard medical care. As a result, some private schools in the county reported vaccination rates had fallen to as low as 50 percent. It takes a vaccination rate of 95 percent or higher to prevent outbreaks of disease.
Thus, the full-court press to get children vaccinated. “We have made an incredibly aggressive effort to address this,” said New York state health commissioner Dr. Howard Zucker. “This has been the worst measles outbreak in recent history in New York state.”
More than 13,000 people, mostly young children, have been vaccinated over the past three months at state and county clinics. More than 40,000 educational flyers have been distributed to homes in the hardest-hit communities, and more than two dozen schools and daycare centers closed because of low vaccination rates. Unvaccinated children have been required to stay home for their own protection until they get the shots.
“To date there are more than 30 schools, daycares, and nursery schools in Rockland county that have been required to enact exclusion policies to help stop the spread of measles as permitted by New York State Public Health Law,” the county says on its website.
And individual clinics are making their own efforts.
“We have brought in every child six months and older to give them an MMR (measles, mumps and rubella vaccine),” Puder told NBC News.
A child usually receives the first MMR vaccine at the age of one year, and a second dose by age four. But to protect local kids in the face of a spreading, highly contagious virus, the schedule has been accelerated. “We have been bringing the one-year-olds back at 13 months to get a second dose,” Puder said. “It’s up to us to keep this from spreading. This could become a truly major epidemic.”
It took years for the pile of dry tinder to build. Three things have to happen to before a measles outbreak can take hold in the U.S., where homegrown measles has been eliminated: A population must have substantial numbers of unvaccinated or under-vaccinated people; some of those unvaccinated people must travel to an area where measles is spreading and then must themselves get infected and bring it back.
Health officials have struggled to get a handle on how this happened. Statewide, New York has good vaccination rates. More than 92 percent of children in New York have received at least one dose of the MMR vaccine, according to the Centers for Disease Control and Prevention.
But New York is one of 47 states that still allow parents to refuse to vaccinate their children for religious reasons, and confusion over that may have led some parents to opt out, Zucker said. That’s even though no organized religious group forbids its member to vaccinate children, and Jewish law specifically instructs followers to protect their own health as well as the health of their children and community.
“I have been out to the community many times now and met with the rabbis there,” Zucker said. He said religious leaders have been puzzled by some of the vaccine skepticism and are advising their congregations to vaccinate.
One issue: Private schools don’t necessarily follow state guidelines for vaccinating students as a prerequisite for enrollment, and Rockland County has a large number of private schools, said John Lyon, a spokesman for the county.
“People usually wait until the school or the doctor makes them get vaccinated,” Lyon said. “In many cases, it seems like they didn’t have to do it so they chose not to do it.” Enforcing school vaccination requirements appears to have helped encourage more vaccinations, Lyon said.
“There is also a strong movement by the anti-vaccination community to get into this community,” Zucker said. Some groups have complained that they were targeted for years by an anti-vaccine group called PEACH, or Parents Teaching and Advocating for Children’s Health — including with pamphlets and robo-calls.
Measles is extremely infectious. An unvaccinated person has a 90 percent chance of becoming ill if exposed to the virus and the virus itself is unusually transmissible. It can hang in the air and infect people even hours after an infectious person has left a room.
Puder said parents are often vague about their fears. “Parents will say things ‘like so many vaccines’ or ‘my child is too small to get so many vaccines’,” he said. “When the fear is not put into words ... it’s hard to respond.”
Many of the cases are among people who have skipped regular medical visits, Puder said. “I know in our group, it’s the kids you don’t see that don’t get vaccinated,” he said. "It's the group that is interested in alternative medicine."
And some pediatricians have enabled the vaccine-shy. “There are a few pediatricians who are more tolerant of vaccine-refusing parents,” he said. “I know who they are and I am not going to say their names.”
Although some people consider measles a benign childhood illness, it can kill. Measles causes encephalitis and pneumonia and before mass vaccination began in the 1980s, measles killed nearly 2.6 million people a year, according to the World Health Organization. It still kills more than 100,000 people a year, mostly children under five.
So every time a case is identified, public health workers must track down everyone else that patient was in contact with over the preceding days and weeks and check to make sure they do not become infected. “Whenever you get a confirmed case of measles, you have to interview the person and find out everywhere they have been and every person they met during the communicable period,” Lyon said.
But efforts are slowly working.
“It’s a clear and present danger right here in our community."
“I think we are on top of the outbreaks. The issue is to get all these kids vaccinated and to get a very strong campaign to raise public awareness,” Zucker said.
According to the CDC, 2018 was not worst recent year on record for measles in the U.S. As of Dec. 1, 292 cases were reported nationwide. In 2014, 667 cases were reported, fueled in large part by an outbreak traced to travelers returning from the Philippines and linked to Disneyland, as well as unvaccinated Amish communities in Ohio.
And anti-vaccine propagandists helped set the stage for an outbreak of measles among Somali immigrants in Minnesota in 2017.
CityMD, the fast-growing urgent care chain, has reached a contract to remain in the network of UnitedHealthcare, the country's largest health insurer, just before the companies' agreement was set to expire at the end of the year, CityMD said.
If a deal had not been reached, members of United and its subsidiary Oxford Health Plans, would have faced higher charges when seeking care at one of CityMD's locations. A letter dated Nov. 26 warned members that they might need to seek out other providers.
"Utilizing an out-of-network provider may result in higher costs for you," United wrote.
CityMD has more than 120 locations in New York, New Jersey and Washington. In Manhattan, the urgent-care chain dots the map like subway stops, with 22 clinics. Private-equity firm Warburg Pincus acquired a majority stake in CityMD for an undisclosed price in 2017.
Crain's New York
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