2020 in review: In health care, it wasn’t only about COVID - North Carolina Health News

By North Carolina Health News staff

Another year of mergers, acquisitions and hospital shifts

This year has been a tumultuous one for many hospitals across North Carolina. The pressure — and financial losses — of suspending elective procedures in early spring in order to make space for COVID patients upset the balance sheets of many hospitals in the state. Even with federal assistance through CARES Act funds, hospital leaders have said that recovery could take months or even longer.

In particular, the financial implications to rural hospitals, which already struggled financially before the pandemic, put a strain on already weakened institutions.

Hospital systems responded with belt-tightening measures, including layoffs and furloughs. At least two small hospitals in the state — Washington Regional and Randolph Health — sold to out-of-state private companies.

Larger hospitals were also affected. Cone Health, based in Greensboro, announced its intentions to merge with Sentara Healthcare. Novant and UNC have increased their foothold in the eastern part of the state, with UNC entering an agreement to manage the former Southeastern Health. The Charlotte-based Novant won its bid to purchase New Hanover Regional Medical Center, yet another hospital in the region. The transaction also included a partnership to enhance medical education in Wilmington with UNC and its medical school.

In the Charlotte and Triad areas, two giants, Atrium Health and Wake Forest Baptist, announced their intentions to combine. That partnership would net Charlotte a medical school.

With this year’s elections preserving the status quo at the General Assembly and the governor’s mansion, the chances for Medicaid expansion — a measure that would improve hospital finances in rural areas — are slim. The full financial ramification of the pandemic is likewise hazy, but secondary signs of strains, such as bankruptcy, layoffs and more hospitals changing hands could follow. –Liora Engel-Smith

‘Forever chemicals’ found at elevated levels in drinking water in the Cape Fear River basin

The New Year saw an old environmental nemesis in North Carolina, so-called “forever chemicals” that have been found at elevated levels throughout the Cape Fear River basin.

On Jan. 6, NC Health News reported that people in an area surrounding the Chemours chemical plant in Bladen County were buying homes unaware that their wells had been contaminated with per- and polyfluoroalkyl substances known as PFAS.

Chemours has been under a consent order since February 2019 to stop putting the potential carcinogen GenX and other PFAS into the air and the Cape Fear River. It was also required to provide filtration systems to homeowners surrounding the plant whose well water was found to contain PFAS exceeding levels specified in the consent order.

When the story was published, 1,673 homes had received filtration systems. Today, an estimated 4,000 homes have qualified for them. The story led to a disclosure document that real estate agents are expected to provide to buyers before a home with contaminated well water is sold.

In February, the state Department of Environmental Quality released data showing what one researcher called “incredibly high” levels of PFAS coming from municipal wastewater treatment plants in the river basin. Later in the year, the PFAS Testing Network, a collaboration of researchers from seven universities in the state, released data showing high levels of PFAS in drinking water in some cities and towns.

Meanwhile, Heather Stapleton, a researcher at Duke University, released a study showing that participating Pittsboro residents have levels of certain types of PFAS in their blood as much as four times higher than the U.S. population as a whole. The study says an estimated 1 million people whose drinking water comes from the Cape Fear River basin may have elevated levels of PFAS in their blood.

Last month, researchers in the state said people with elevated levels of PFAS in their bodies could be more susceptible to contracting COVID-19 and less responsive to the vaccines now being distributed to fight it.

Forever chemicals were not the only environmental health concerns making headlines in 2020. In December, a federal appeals court rejected most of Smithfield Foods’ arguments in a case that has pitted the pork behemoth against its mostly low-income neighbors.

Duke Energy had a tough year environmentally, as well, agreeing to a settlement in which it will excavate its unlined coal ash basins at six sites within the next 10 to 15 years. Duke Energy, along with Dominion Energy, also abandoned a years-long attempt to construct the Atlantic Coast Pipeline.

Climate change also made headlines in 2020 in the form of a 372-page report titled “North Carolina Climate Risk Assessment and Resilience Plan.” The plan comes with dire warnings on the effects climate change is expected to have on North Carolina if the state doesn’t act soon.

“By setting clear goals, taking action, and evaluating progress on a regular basis, North Carolina can ensure that our resilient state thrives amid changing conditions and challenges,” the report says. — Greg Barnes

A doctor’s tweet, a mother’s complaint, a loss for chronic pain patients.

In the spring, we had a popular story about a Raleigh doctor whose Twitter activity ultimately brought him under the scrutiny of the NC Medical Board. NC Health News reported that Thomas Kline gave up his license to prescribe narcotics when the board started investigating him.

Kline specializes in chronic, painful diseases. Over the last several years, he shifted his practice to treat a small group of complex pain patients who have struggled to find pain management amid the national crackdown on prescription painkillers.

Kline believes the narrative around the opioid crisis has some gaps in it. He asserts that illegal street drugs are the main problem and that patients prescribed opioids lawfully by physicians is not the driver behind the opioid crisis. Kline has long questioned the definition of addiction and contends that the rate of addiction hasn’t changed. More research into the genetics of addiction needs to be done to better understand this issue, he says.

Kline shares his sometimes controversial views about addiction, pain and the opioid crisis on Twitter and has a huge following.

Since our story in March, the NC Medical Board completed its investigation and alleged several problems with Kline’s medical practice in its report. Kline — who is in his late 70s — disputes the board’s findings, but decided not to contest them in an official hearing.

The case was resolved by Kline retiring from medicine. Instead, he’s decided to redirect his efforts to help found a group called the National Pain Council. The first goal of the council is to restore treatment for pain patients, he said.

“We fear that there will be a point where pain patients won’t be able to get opioids,” Kline said.

There is anecdotal evidence of pain patients taking their lives because they cannot find relief. Researchers at the University of Alabama at Birmingham are attempting to quantify this sad trend. Stefan Kertesz, UAB professor of medicine, said he’s concerned about the pattern of suicide attempts after a patient’s pain medication is reduced.

“Several federal agencies have acknowledged a link between suicide and changes in opioid prescriptions, but no really one understands what is happening,” Kertesz said in a press release. “We don’t know why some people wind up dead and others don’t, and that’s why research is needed.”

He’s actively recruiting pain patients and their loved ones for his study here. – Taylor Knopf

NC hygienists gain some ground in long tug-of-war with dentists

It’s difficult to look back on 2020 and remember what it was like before COVID-19 upended all sense of time.

Way back in January and February, though, dental hygienists were able to loosen a very tight lid on scope of practice laws that are among the most restrictive in the country.

In January, the legislative rules commission adopted an amendment to North Carolina law to make it possible for hygienists in this state to do cleanings and screenings in some public schools, as well as elder care and special needs facilities even if a supervising dentist has not examined the patient in person.

Through fledgling public-private partnerships with dentists, hygienists can be deemed public health practitioners and have a slightly broader scope of practice.

Though North Carolina law limits each dentist in a private practice to the oversight of no more than two hygienists, the rule change allows those in public-private partnerships to supervise more.

The impetus for the change came as many parts of North Carolina, particularly the rural areas, suffer from a persistent shortage of oral health professionals.

Hygienists, who have long lobbied to broaden their scope of practice, have not been able to set up practices of their own to help with teeth cleanings and other basic oral health needs.

The rule change was heralded as “a big step” by Crystal Adams, a past president of the North Carolina Dental Hygienists’ Association. Still, she added, North Carolina has “many steps to go.”

When the rule change took effect on Feb. 1, oral health care advocates were uncertain how quickly such partnerships would be created, making it difficult to measure how much of an impact the slightly broader scope of practice would have in shortage areas.

Then North Carolina announced its first lab-confirmed case of COVID-19 in March and many dental businesses closed their doors for all but emergency service for at least a month.

As practices see patients again with protective measures in place, and COVID-19 vaccine distribution begins, it could be well into 2021 before dentists and hygienists turn their attention to new models for doing business. — Anne Blythe

Even as COVID dominated the conversation, other health policy moved forward at the NCGA

For observers of the North Carolina General Assembly at the beginning of 2020, the prognosis was that it would be another year of gridlock. In 2019, a standoff between Gov. Roy Cooper and the legislature over funding for teacher raises and the fate of Medicaid expansion meant that North Carolina moved into the 2019-2020 fiscal year without an overall state budget.

That budget gridlock also created the need to push back the rollout of the state’s new Medicaid managed care system, as money for the conversion had been caught up in the budget fight.

With a Democratic governor and Republican-dominated legislative chambers, 2020 was shaping up to be another year without large legislative initiatives moving forward in health care.

Then came COVID, and in Raleigh, lawmakers’ focus turned almost completely to addressing the gaping needs created by the pandemic.

Legislators and Cooper came together largely to address the huge needs created by the pandemic. Armed with dollars from Congress flowing as a result of the CARES Act and other bills, money flowed for testing, contact tracing for COVID patients, personal protective equipment, rural hospitals, broadband and a host of other health care priorities.

As the spring – and the legislative session – progressed, lawmakers found themselves preoccupied with needs generated by COVID. But lawmakers also found the focus to move on one non-COVID priority: scheduling the rollout of the new Medicaid managed care regimen.

Senate Bill 808 obligates the Department of Health and Human Services to flip the switch on the changeover to managed care on July 1, 2021, but the final version of the bill took out penalties totaling about $20 million per month that would have been levied on DHHS had they missed that deadline. The bill allocates money to hire contractors, complete IT work on the initiative and beef up fraud detection in the program.

It remains to be seen whether DHHS can get all the pieces in place to change to managed care during the summer, even as the department has been preoccupied with managing the deepening COVID pandemic. Getting things back up and moving towards transformation amidst multiple priorities could be a challenge, said Medicaid head Dave Richard.

“We’ve had this massive shift in how we’ve done our business,” Richard said. “We have had to shift resources significantly to address COVID.”

But when it comes to expanding the Medicaid program to sweep in more than a half-million low-income workers, legislators took a pass.

“We tried once in the budget, we tried twice with [NC Health Care for Working Families Act],” Rep. Josh Dobson (R-Nebo) told NC Health News. Dobson had been one of a group of Republican House members who ran multiple bills to expand the program over the course of four years, but none ever made it out of that chamber.

“If we did the same thing, again, we were going to get the same result,” he said. – Rose Hoban