Opinion: Emergency Rooms Shouldn’t Be Parking Lots For Patients
Waits for inpatient beds are an important factor in ER overcrowding.
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On a good day in the emergency room where we work, patients who need to be admitted to the hospital might expect to wait four or five hours, including evaluation and treatment, before they are sent upstairs to a ready bed.
On a bad day, ER patients might wait two or three times as long, and sometimes much longer.
Recently, one of us cared for a bedridden patient with chest pain who spent 47 hours in an ER hallway before a spot became available in the cardiac unit.
Keeping patients in the ER while waiting for an inpatient bed — a practice known as boarding — isn’t unique to the busy teaching hospitals where we work. According to the Centers for Disease Control and Prevention, most American hospitals have boarded patients in the ER for more than two hours while waiting for an inpatient bed.
It’s a stubborn problem. A 2001 study suggested that as many as 1 in 5 ER patients is boarded. In 2006 the Institute of Medicine identified boarding as part of a “national crisis” affecting emergency care. In 2016, two-thirds of hospitals reported boarding patients in the ER or an observation unit for more than two hours, compared with 57% in 2009.
Waiting hours for a hospital bed can be maddening for patients and their families. Sometimes literally. Researchers recently found that long waits in ER hallway beds are associated with delirium, a medical condition defined by confusion and disorientation.
But boarding in the ER affects much more than patients’ state of mind. The American College of Emergency Physicians has identified boarding as one of the most important factors in ER overcrowding. And overcrowding, in turn, has been associated with everything from delays in administration of pain medication and antibiotics to longer inpatient stays, greater exposure to medical error, delayed treatment for heart attack and even increased mortality.
To understand why boarding can have so many negative consequences, think of a busy school cafeteria at lunch. No matter how efficient the cafeteria workers are at making and serving the food, processing payment and getting people through the line, no one can sit down to eat if all the tables are occupied with other students.
In our case, the emergency department can be remarkably effective at diagnosis and treatment. But if there’s nowhere for admitted patients to go, the whole operation gets bogged down and everyone’s care suffers.
If boarding is such a problem, why do hospitals allow it to continue?
The answer, as with so many things in our health care system, is complicated. But it has a lot to do with money.
Since 1975 the number of hospitals in America has declined by 30%. That’s more than 1,500 hospitals shuttered, with half a million beds lost.
Market forces have been largely responsible, as technology became more expensive, reimbursement rates were curtailed and hospitals either merged or went bankrupt. Meanwhile, annual ER visits have increased by nearly 50 million since 1995.
It looks like a basic supply and demand problem.
But here’s a curveball: Most hospitals operate, on average, at only about 65% of their total inpatient capacity — and this number has actually dropped since 1975.
How can that be?
Reimbursement is a key part of the puzzle.
Medicare, which provides insurance for about 60 million Americans, sets the bar for how much hospitals are paid, from treating pneumonia to neurosurgery. And those reimbursement rates have strongly favored invasive procedures like surgery, colonoscopy and cardiac catheterization.
Simply managing medical conditions in the hospital is much less lucrative.
Hospitals have a strong financial incentive to prioritize these procedures and to give latitude to the specialists performing them in setting their schedules. As a result, dozens of surgeries might be scheduled for a Monday morning, just a handful the following day and almost none over the weekend.
This approach creates wide variation in the number of postoperative patients needing admission to the hospital on any given day. But one thing’s for sure, a surge in post-op patients needing hospital beds means fewer beds for ER patients, which creates a bottleneck and leads to boarding. The variation in demand causes hospitals to swing between overcrowding and underutilization.
So even though we’re seeing more patients in fewer hospitals, limited capacity may not be the primary issue. It’s that we’re using existing capacity inefficiently.
A 2012 review identified inefficiency rather than insufficient beds as the root cause of boarding. Other sources of inefficiency include restricting certain beds to certain specialties, skeleton staffing during nights and weekends and poor discharge planning.
The silver lining is that efforts to improve efficiency are much less expensive than building a new hospital wing. Smoothing out surgical scheduling, for one, has been shown to yield major improvements. Cincinnati Children’s Hospital increased occupancy to 91% from 76%, made $137 million in extra revenue and avoided a $100 million expansion by rejiggering the surgical schedule and streamlining discharges.
Many hospitals are working on the problem. In the two teaching hospitals where we work in Boston, policies are in place to use observation units, affiliated community hospitals and even “home hospital,” where patients receive care from teams that visit them at home, to spare inpatient beds.
Even so, other hospitals may be falling short. Researchers found in 2012 that a majority of the most crowded hospitals had been slow to adopt the most effective measures to alleviate the bed crunch.
Could legislation be the answer? Perhaps.
In 2005, Britain instituted a maximum length of stay of four hours for all ER patients. It worked — 94% of patients were meeting that goal by 2014, although hospitals there have slipped more recently. Australia, New Zealand and Canada have had similar successes.
A legislative mandate seems far-fetched in the U.S., given the current state of Congress. Medicare has begun offering financial incentives for hospitals to address boarding, and the major accreditation organization for hospitals introduced guidelines on how to improve boarding in 2014. Neither of these measures requires action, though.
Ultimately, we suspect that what is really needed is an overhaul of the current system of financial incentives and reimbursement, coupled with penalties for hospitals that fail to act on the problem.
Until then, we’re sorry if you’re still waiting for that bed.
Clayton Dalton and Daniel Tonellato are resident physicians at Massachusetts General and Brigham & Women’s hospitals, both in Boston.
Toys R Us Reopens 2 Stores Under New Ownership After Painful Bankruptcy
Toys R Us has reopened just two stores after a painful bankruptcy. This Black Friday will be its first under new ownership.
ARI SHAPIRO, HOST:
Could Geoffrey the giraffe be back in business? For decades, a visit to Toys R Us was an indispensable part of holiday shopping for kids. That is, until last year, when the company announced it would be closing its doors for good.
NPR’s Darius Rafieyan paid a visit to its new flagship store.
DARIUS RAFIEYAN, BYLINE: Like many people, Jennifer Bain has fond memories of running around a Toys R Us store.
JENNIFER BAIN: I was a Toys R Us kid when I was younger. I definitely wanted to make sure that that was part of my daughter’s life, and I was really sad to see it go.
RAFIEYAN: I met Bain here at the new Toys R Us flagship store in Paramus, N.J. It’s part of a plan to open 10 new stores over the next year.
(SOUNDBITE OF NERF GUN FIRING, LAUGHTER)
RAFIEYAN: Her 5-year-old daughter Charlotte is standing inside a plexiglass enclosure trying out the latest Nerf blaster.
How do you like it?
CHARLOTTE: I loved it. Can I do it again, mommy?
BAIN: Absolutely.
RAFIEYAN: This Nerf target range is part of what Toys R Us is calling experience-driven retail. The idea is to encourage kids to actually pick up the toys and play with them. The company doesn’t have hundreds of stores like Walmart or same-day delivery like Amazon, so it’s trying to compete on fun. That strategy is the brainchild of Richard Barry, a former Toys R Us executive and the current CEO of Tru Kids Brands, which now owns the Toys R Us name.
RICHARD BARRY: I’m a 34-year Toys R Us employee, so hearing that the company was going through the troubles was extremely distressing.
RAFIEYAN: The original Toys R Us filed for bankruptcy back in 2017 and was ultimately forced to close all of its stores, some 700 of them. That company had been slow to adapt to online shopping, and it struggled to manage a sprawling real estate portfolio of hundreds of underperforming stores. And all of that was made worse by a disastrous private equity buyout that left the company billions of dollars in debt.
Barry is hoping that this smaller, more immersive retail concept will help the new company avoid some of those pitfalls.
BARRY: This is a very different store from those of the past. It’s extremely experiential. We’ve got a treehouse. We have a theater in the store. Every different spot in the store has a place where you can engage with toys and products.
RAFIEYAN: But Liz Dunn, a retail analyst at Pro4ma, is skeptical. She says many brick-and-mortar retailers are trying to reinvent the shopping experience. Delivering something that actually gets people to put down their phones and come into a store can be easier said than done.
LIZ DUNN: Just calling it experiential is not enough. You have to really, really wow consumers.
RAFIEYAN: The new store has its fans, though. For Stacey Wilkins, who spoke to me as her 7-year-old ran around the treehouse, this new Toys R Us is a godsend.
STACEY WILKINS: We needed a toy store like this, especially – my son is autistic. So being able to play and build and make things and let them be able to use their creativity is a wonderful thing.
RAFIEYAN: But if the company wants to avoid the fate of its predecessor, it still needs to show it can turn all that fun into actual sales.
Darius Rafieyan, NPR News, Paramus.
(SOUNDBITE OF PHOENIX’S “DEFINITIVE BREAKS”)
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NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
Why This Year Promises To Be A Big One For Cross Country Skiers
Jessie Diggins made history winning the first U.S. Olympic gold medal in cross country skiing in 2018. She and skiers at a season kickoff welcome the U.S.’s first World Cup race since 2001.
ARI SHAPIRO, HOST:
In Montana, Thanksgiving marks the traditional start of the cross-country ski season. This year promises to be a big one for the sport. For the first time since 2001, the Cross-Country World Cup includes a stop in the U.S. Yellowstone Public Radio’s Rachel Cramer takes us to the annual cross-country ski festival in West Yellowstone, where many athletes are training.
RACHEL CRAMER, BYLINE: Half a block from the west entrance to Yellowstone National Park, a local shop called Freeheel And Wheel is stocked with cross-country skis, poles and hand warmers. Co-owner Melissa Alder is in the back, waxing a pair of skis so they’ll glide more easily over the snow.
MELISSA ALDER: Once the wax has hardened, we’ll then scrape the excess wax off the base of the ski.
CRAMER: Alder is one of the people who helped the weeklong Yellowstone Ski Festival grow from a fall training camp for the U.S. Nordic ski team in the ’70s to a celebration with clinics, skier expos, talks from world-renowned athletes, even a fashion show. The festival now draws more than a thousand people every year.
ALDER: We have many skiers that return every year that are in their 80s. So we know that it’s a lifetime sport, and we really love promoting that and creating that enthusiasm behind it and opening up doors for people that may not have experienced cross-country skiing any other place.
CRAMER: American interest in cross-country skiing got a big boost a couple of winters ago when Jessica Diggins with the U.S. ski team won a gold medal in South Korea. Leveraging that success, she helped draw the Cross-Country World Cup tour away from Europe and Scandinavia, where fans fill stadiums to watch, and to hold a race in her home state of Minnesota this winter, only the third time ever in the U.S.
JESSICA DIGGINS: Skiers at any level can be right up alongside the fence to see their heroes ski in the highest-level competition in the entire world. This would be like – if you’re a basketball player, it’d be like, for $25 dollars, you get a front row seat to watch LeBron James play.
(SOUNDBITE OF SKIS GLIDING)
AMANDA SUSNIK: Now that the World Cup is going to be in Minnesota, it’s going to be so cool. I think everyone’s just, like, hyped about it.
CRAMER: Amanda Susnik is a Nordic skier for St. Olaf College in Minnesota. Beads of ice cling to her eyelashes after she’s just finished her morning workout here in West Yellowstone. She’s one of the hundreds of athletes who came to the trailhead at 8 a.m.
(CROSSTALK)
CRAMER: Rick Kapala, a coach from Sun Valley, Idaho, says a lot of people like cross-country skiing because it gets them out in nature and every trail is different.
RICK KAPALA: The festival sort of has mirrored the growth of cross-country skiing in the U.S. When we first started coming here, they’d be just a handful of people, a few teams. And now there are thousands of people here.
(SOUNDBITE OF SKIS GLIDING)
CRAMER: Kapala says his group alone brought out 60 athletes. He says West Yellowstone is one of the first places in the country to get good snow.
KAPALA: If you’re pursuing the sport at a higher level, you got to go where the best competitions are or where the skiing is.
CRAMER: Skiers don’t seem to mind that the temperature today is -10 degrees Fahrenheit. Gordon Lange, a former head coach for the U.S. Olympic team, is out here with the Park City Nordic Ski Club from Utah.
GORDON LANGE: I love it. I complain a little bit because it’s cold and I’m old, but once you’re out there and you’re skiing on good tracks and everything, it’s really nice.
(SOUNDBITE OF SKIS GLIDING)
CRAMER: Dozens of long, lean athletes in colorful Lycra ski wear stride past, pushing forward with long poles, skis whispering as they disappear into the trees. The Yellowstone Ski Festival ends this weekend with races and a party.
For NPR News, I’m Rachel Cramer in West Yellowstone, Mont.
Copyright © 2019 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
When Teens Abuse Parents, Shame and Secrecy Make It Hard to Seek Help
Hokyoung Kim for NPR and KHN
Nothing Jenn and Jason learned in parenting class prepared them for the challenges they’ve faced raising a child prone to violent outbursts.
The couple are parents to two siblings whom they first fostered as toddlers and later adopted. (NPR has agreed not to use the children’s names or the couple’s last names because of the sensitive nature of the family’s story.)
In some ways, the family today seems like many others. Jenn and Jason’s 12-year-old daughter is into pop star Taylor Swift and loves playing outside with her older brother. He’s 15, and his hobbies include running track and drawing pictures of superheroes. The family lives on a quiet street in central Illinois, with three cats and a rescued pit bull named Sailor.
Jenn describes their teenage son as a “kind, funny and smart kid,” most of the time.
Drawings made by Jenn and Jason’s 15-year-old son lie on the family’s dining room table in their home in central Illinois. Though his angry outbursts reveal a violent side, his parents say that most of the time he is “kind, funny and smart” — a teen who enjoys drawing pictures of superheroes.
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But starting when he was around 3 or 4 years old, even the smallest things — like being told to put on his swimsuit when he wanted to go to the pool — could set off an hours-long rage.
“In his room, his dresser would be pushed across the other side of the room,” Jason says. “His bed would be flipped up on the side. So, I mean, very violent. We’ve always said it was kind of like a light switch: It clicked on and clicked off.”
Jenn and Jason say their son’s behavior has gotten more dangerous as he has gotten older. Today he’s 6 feet tall — bigger than both of his parents.
Most of the time, Jenn says, her son directs his initial anger and aggression toward her. But when the 15-year-old has threatened to hit her, and Jason has intervened, the teen has hit his father or thrown things at him.
“The way he will look at me is just evil,” Jenn says. “He has threatened to slap me in the face. He’s called me all sorts of horrible names. After an incident like that, it’s hard to go to sleep, thinking, ‘Is he going to come in and attack us while we’re sleeping?’ “
Help Is Available
If you are experiencing abuse and need help, you can call the National Domestic Violence Hotline at 1-800-799-7233 or visit its page for an online chat.
People who are victims of domestic violence are advised to seek help. But when the abuse comes from your own child, some parents say, there’s a lack of support, understanding and effective interventions to keep the entire family safe.
While research is limited, a 2017 review of the literature found child-on-parent violence is likely a major problem that’s underreported.
Jenn says she’s concerned about everyone’s safety and worries about her 12-year-old daughter being exposed to constant violence in their home.
The stress has taken a significant mental and emotional toll on Jenn. She sees a therapist to cope with the abuse at home and to deal with her anxiety.
“There are days when it’s hard to breathe,” Jenn says. “You just feel it in your chest — like, I need a breath of air, I’m drowning. We say to each other all the time, ‘This is insanity. How can we live like this? This is out of control.’ “
Parents feel blamed and shamed into silence
It’s hard to know exactly how common Jenn and Jason’s experience is, since research is sparse. In one nationally representative survey in the mid-1970s of roughly 600 U.S. families, about 1 in 11 reported at least one incident of an adolescent child acting violently toward a parent in the previous year. In about a third of those cases, the violence was severe — ranging from punching, kicking or biting to the use of a knife or gun.
Other more recent estimates of the prevalence of child-on-parent violence range from 5% to 22% of families, which means several million U.S. families could be affected.
A 2008 study by the U.S. Justice Department found that while most domestic assault offenders are adults, about 1 in 12 who come to the attention of law enforcement are minors. In half of those cases, the victim was a parent, most often the mother.
While most children who are abused or witness domestic violence do not go on to become violent themselves, and while most people with mental illness are not violent, those life experiences have been identified as risk factors for children who abuse their parents.
Lily Anderson is a clinical social worker in the Seattle area who has worked with hundreds of families dealing with a violent child. Along with her colleague Gregory Routt, she developed a family violence intervention program for the juvenile court in King County, Wash., called Step-Up.
Anderson says, in her experience, many parents feel ashamed about their situation.
“They don’t want to tell their friends or their family members,” Anderson says. “They do feel a lot of self-blame around it: ‘I should be able to handle my child. I should be able to control this behavior.’ “
Anderson says many of the incidents take place at home, where the assaults are hidden from the public eye. That contributes to the lack of public awareness about the issue and makes it even harder for affected parents to find support.
“The whole issue becomes perceived as being the parent’s problem and the parent is to blame for the youth’s behavior,” Anderson says. “I think the main issue is that we need to talk about this. We need to talk — be willing to put it out there and make it an important issue and bring resources together for it.”
When therapy doesn’t fix it
Jenn says that she has talked to her son’s therapists about why he has such trouble regulating his emotions, and they’ve told her it could be linked to the severe trauma he experienced as a baby and toddler.
When the couple began fostering the siblings in late 2007, the boy was 3 and his sister younger than 1. They had been removed from the home of their birth parents, where police were regularly called for drug and domestic violence issues. Jenn says her son remembers being beaten by men in his home and watching as his biological mom cut herself.
Jenn, Jason and their kids together at home last spring. Before they were adopted, the kids experienced or witnessed significant abuse in their birth family, Jenn says. That severe trauma, according to therapists, is likely a source of their son’s difficulty in regulating his emotions.
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Jenn and Jason started their son in therapy at a young age, and he has been diagnosed with reactive attachment disorder, PTSD, ADHD and autism.
The teen has attended art therapy and equine therapy regularly for years. He also participated in a mentorship program and attended a school designed for children with behavioral health needs. Jenn and Jason participated in family therapy sessions with their son, where they learned coping skills and practiced de-escalating situations at home.
The teen was also prescribed medication to help regulate his emotions.
Jenn says her son enjoyed going to therapy and seemed to be making some progress, but his anger remained unpredictable.
During the worst of the conflicts, the teen has kicked holes in walls and broken appliances. He has attempted to run away from home and even created weapons to try to hurt his parents and himself. About once a month, in recent years, Jenn and Jason have had to call police to their house for help restraining their son and sometimes had to have him admitted to the hospital for a brief psychiatric stay.
“Seems like it’s not enough”
Keri Williams is a writer in North Carolina who advocates for parents raising children who have trauma-related behavioral issues, including attachment disorders that can manifest as intentional violence directed toward parents.
Williams’ own son became so violent that her family had to place him in a residential facility at age 10. He’s now 18.
“I actually thought I was the only person going through it,” Williams says. “I had no idea that this was actually a larger issue than myself.”
Williams manages a blog and Facebook page where she says parents like herself, who are often isolated and unsure of where to turn, can find others who can relate.
Many parents she meets online struggle to accept that they’re dealing with a serious domestic violence issue, she says.
“You just don’t want to think like that,” Williams says. “That’s just not how our culture is and how parents perceive things. And that denial actually is what keeps parents from getting their kids help.”
Jenn — the mother of the 15-year-old in Illinois — says parenting her son often feels like being stuck in an abusive relationship.
“But it’s different when it’s your son,” she says. “I don’t have a choice. I can’t just, you know, shove him away or break up with him.”
Jenn says any time she sees a news story about a child who has killed a parent, she worries. Such events are extremely rare, and Jenn doesn’t want to think her son is capable of that.
“But, unfortunately, the reality is, when he is in those rages and in those meltdowns, he really isn’t thinking straight, and he’s very impulsive,” Jenn says. “So, it’s very scary.”
Despite all the challenges, she and her husband both say that adopting their son has brought them a lot of joy.
“It’s made me a better, stronger person, a better and stronger wife and teacher,” Jenn says.
But, she adds, she wishes there were more effective treatments that could help kids like her son live safely in the community and more places where traumatized parents could turn to find help.
“I feel like we’re doing everything that we can for him, but it just seems like it’s not enough,” Jenn says.
A difficult decision
Right before the current school year started, Jenn and Jason made the difficult decision to send their son to a residential facility for children with severe behavioral health issues. He’s living there now.
The couple wrestled with that choice for some time. The boy had already spent almost three years in residential treatment all told, starting when he was 10. He’d moved back home last year because they thought he was ready.
But the family continued to deal with almost-daily standoffs involving verbal threats, angry outbursts and property destruction.
The boy’s 12-year-old sister says she has mixed feelings about her brother leaving home again to reenter residential treatment.
“It makes me feel happy and sad,” she says, “because, well, I love my brother. And I know he’ll be getting the help he needs.”
She’s comforted knowing her parents will be safe but says she’ll miss her brother a lot.
“I just love him,” she says. “And I don’t want to see him go through that.”
This story is part of NPR’s reporting partnership with Side Effects Public Media, Illinois Public Media and Kaiser Health News. Christine Herman is a recipient of a Rosalynn Carter Fellowship for Mental Health Journalism. Follow her on Twitter: @CTHerman.
Future Of Surprise Medical Billing Legislation Remains Uncertain
The summer kicked off with a blitz of government activity to end surprise medical billing, but lobbying, impeachment, and policy arguments have left the future of the legislation up in the air.
ARI SHAPIRO, HOST:
Surprise medical billing was supposed to be the easy health care fix that Washington could get done this year. In May, President Trump urged Congress to come up with a solution.
(SOUNDBITE OF ARCHIVED RECORDING)
PRESIDENT DONALD TRUMP: No American mom or dad should lay awake at night worrying about the hidden fees or shocking, unexpected medical bills to come.
SHAPIRO: Bills were introduced and advanced. Democrats, Republicans, senators, House members – practically everyone agreed the practice was bad and it should stop. Now Congress is getting ready to wrap up the year and still hasn’t passed legislation. NPR’s Selena Simmons-Duffin explains what’s going on.
SELENA SIMMONS-DUFFIN, BYLINE: This is an easy thing to get worked up about. It just seems so unfair. The classic scenario is this – you go to an emergency room, even one that’s in your insurance company’s network. A doctor working there is not in your network and consults with you or treats you. That doctor can bill you what’s called a balance bill. So the insurance company tells the doctor, we’ll pay $1,000. The doctor says, well, I’m going to charge $5,000, and you are on the hook for that difference.
ERIN FUSE BROWN: There’s a lot of agreement that this is a broken part of the health care system that everyone agrees the market can’t fix by itself.
SIMMONS-DUFFIN: Erin Fuse Brown is a law professor at Georgia State University. Because so many members of Congress in both parties agree that it’s outrageous and a place where the government needs to step in, this seemed doable.
FUSE BROWN: Absolutely doable. It’s not fixing the whole health care system.
SIMMONS-DUFFIN: It’s like low-hanging fruit.
FUSE BROWN: Yes.
SIMMONS-DUFFIN: But there are two problems – agreeing on how to get it done and getting passed a flood of lobbying money. Anna Massoglia is a researcher with the Center for Responsive Politics. And she says, at the end of July, a group with the friendly sounding name Doctor Patient Unity came out of nowhere.
ANNA MASSOGLIA: Doctor Patient Unity, practically overnight, spent about $28 million on ads.
SIMMONS-DUFFIN: Ads like this one.
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UNIDENTIFIED PERSON: Congress is working to end surprise medical billing, and that’s a good thing. But that fix cannot include government rate setting, a slippery slope toward doctor shortages…
SIMMONS-DUFFIN: Massoglia says it was clear this was a front group for industry, but there was very little information about who was funding it. The mystery lasted until September, when the group revealed themselves to reporters at The New York Times. It turns out…
MASSOGLIA: Private equity-backed firms were some of the entities bankrolling the operation.
SIMMONS-DUFFIN: Private equity had been buying up physician groups. Surprise bills were part of their business model to bring in profits for investors, and they jumped in to defend that business model. While social media and TV got bombarded, Dan Auble, who’s also from the Center for Responsive Politics, says Congress was getting bombarded, too. Last year, only a few dozen groups lobbied on surprise billing. This year?
DAN AUBLE: We’ve seen 340 groups mention it on their lobbying reports, and they’ve hired 1,200 lobbyists to do that work.
SIMMONS-DUFFIN: But the lobbying and ads are not the whole story here. The other big issue is how to fix the surprise billing problem, says Fuse Brown.
FUSE BROWN: The disagreement really comes down to how to determine the amount that the health insurance company is going to pay the out-of-network provider.
SIMMONS-DUFFIN: So remember – if the doctor wants to charge $5,000 and the insurer wants to pay $1,000, how do you settle on the amount?
FUSE BROWN: There’s this hot debate about where do you set the payment amount and what role does the government have in actually setting it or does it just sort of set up a mechanism for some third party to decide?
SIMMONS-DUFFIN: There are bipartisan bills in the House and the Senate. There was momentum in the summer. In the fall, things seemed stalled. But congressional meetings are starting up again. So now the state of play is this – the White House and lawmakers mostly say they’re optimistic this can get done by Christmas. But there are still hurdles to clear. So even this low-hanging health policy fruit might not get picked this year.
Selena Simmons-Duffin, NPR News.
(SOUNDBITE OF JELLIS AND SUBSET’S “KYOTO”)
Copyright © 2019 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
Supreme Court Hears Case Involving Blackbeard’s Ship, State And Property Rights
The Supreme Court recently heard arguments in a case that involved both a 300-year-old pirate ship — and a contemporary fight between two powerful forces: states’ rights and property rights.
ARI SHAPIRO, HOST:
The Supreme Court recently heard arguments in a case that involved both a 300-year-old pirate ship and a contemporary fight between two powerful forces in American law. Jacob Goldstein from our Planet Money podcast explains.
JACOB GOLDSTEIN, BYLINE: The ship belonged to the pirate Blackbeard. It sunk off the coast of North Carolina in the early 18th century. The person who brought the case to the Supreme Court is an underwater videographer named Rick Allen. Allen started filming the excavation of Blackbeard’s ship in the late 1990s.
RICK ALLEN: The first time I went down, it was like climbing into a washing machine, filling it with tea or coffee and then turning it on. There’s a lot of current. The visibility’s terrible. So I didn’t see a lot of the wreck. I just pretty much hung on for dear life.
GOLDSTEIN: But year after year for more than a decade, Allen kept diving and filming there.
ALLEN: We’re probably talking about 1,000, 2,000 hours on the wreck site.
GOLDSTEIN: The rights to the ship were owned by the state of North Carolina. Rick Allen had signed a deal where he would pay for the filming out of his own pocket, and he would own the copyright to the footage so he could license it to museums and for documentaries. The legal trouble started in 2013 when, Allen says, the state started posting his pictures and videos without his permission. The fight wound up in the Supreme Court this fall.
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JOHN ROBERTS: We’ll hear argument next in Case 18-877, Allen v. Cooper.
GOLDSTEIN: Allen’s argument relied heavily on a law Congress passed in 1990. It was called the Copyright Remedy Clarification Act. And the law said that federal copyright law applies to state governments just the same way it applies to everybody else. In other words, if a state posts your videos without permission, you can sue the state for damages just like you can sue anybody else.
North Carolina’s counterargument came down to this. That federal law Allen is relying on – it is unconstitutional, and the Supreme Court should strike it down. The state’s lawyer, Ryan Park, articulated the basis for North Carolina’s case in the first three words of his argument.
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RYAN PARK: State sovereign immunity is a fundamental feature of our Constitution’s structure.
GOLDSTEIN: State sovereign immunity – that’s it. That is North Carolina’s whole case, and it is a pretty strong case – strong enough to make it all the way to the Supreme Court. So here is what state sovereign immunity means. State just means any state in the union. Sovereign immunity means in most circumstances, you are not allowed to sue the federal government or state governments for money damages.
Ryan Park, North Carolina’s lawyer, suggested that sovereign immunity really does come down to money.
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PARK: I think the important understanding that the founders had is that when you sue a sovereign, on the opposite side of the judgment are the people and the people’s money.
GOLDSTEIN: When you’re suing the state, you are suing the people. You’re suing for taxpayer dollars. And Park is saying we, the people of North Carolina – not the federal government – should be allowed to decide when and whether we are on the hook for damages in court.
In the end, this case comes down to a fight between states’ rights – North Carolina’s sovereign immunity – and property rights – Rick Allen’s copyrights on the videos of Blackbeard’s ship. A decision in the case is expected sometime before the end of the court’s term next June.
Jacob Goldstein, NPR News.
(SOUNDBITE OF DAWN AVERY’S “ZUSESKA (SNAKE) BATTLE”)
Copyright © 2019 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
Following Backlash, Twitter Offers to ‘Memorialize’ Accounts Of The Deceased
Twitter announced Wednesday it will allow relatives to archive the accounts of deceased loved ones.
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Jeff Chiu/AP
Twitter will allow people to permanently archive and memorialize the accounts of deceased loved ones. The company received backlash this week after news broke that it would delete accounts that had not been logged in to in over six months.
A company spokesperson originally said inactive accounts would be removed from the platform starting in December as part of its “commitment to serve the public conversation.”
The announcement sparked a mass panic.
Numerous inactive users returned to the platform for the sole purpose of saving their accounts. Popular K-pop star Taeyang tweeted twice Wednesday, his first tweets since 2016. His messages were simple: One was a photo of a sun-shape balloon; the other just said, “Hello.”
Hello
— TAEYANG (@Realtaeyang) November 27, 2019
However, to many, the initial plan to delete inactive accounts wasn’t about losing a handle. It meant they might lose a digital remnant of their loved ones.
Harris Wittels, a comedian and television writer, died four years ago, yet his Twitter account was active Tuesday. His sister, Stephanie Wittels, logged on after she read that inactive accounts would be culled.
“Twitter is going to start deleting inactive accounts in December, and it would be a goddamn tragedy if this account got sucked into oblivion,” Wittels tweeted from her brother’s account. “So I’m tweeting to ensure that doesn’t happen.”
For others, it wasn’t possible to log on and tweet again. Drew Olanoff wrote in TechCrunch that he doesn’t have his late father’s password and thus cannot preserve his “quirky nerdy tweets.”
“It’s my way, odd or not, of remembering him. Keeping his spirit alive. His tweets are timestamped moments that he shared with the world,” Olanoff wrote.
Horrified and scared to think I’ll lose traces of my dead partner, or my dead friends. It should be possible to free up usernames without eradicating the work and words of those who are no longer around.
— General Elainovision 2019 (@scattermoon) November 26, 2019
Twitter CEO Jack Dorsey tweeted Wednesday the company miscommunicated and is working to clarify its message.
Later, the company’s support account apologized for the confusion. It said the account removals will only occur in the European Union and only after a way to archive accounts is created.
“We’ve heard you on the impact that this would have on the accounts of the deceased,” the company tweeted. “This was a miss on our part. We will not be removing any inactive accounts until we create a new way for people to memorialize accounts.”
It is not clear when this function will become available.
Until then, Internet historians are offering solutions to those worried about their loved ones. Volunteers with The Internet Archive, a nonprofit digital library, created a public form that will collect the Twitter handles of deceased people and archive their accounts to the best of their abilities.
Paolo Zialcita is an intern on NPR’s Newsdesk.
Stephen F. Austin Defeats No. 1 Ranked Duke In Huge Upset
Stephen F. Austin University beat No. 1 ranked Duke in one of the biggest men’s college basketball upsets ever on Tuesday night.
AILSA CHANG, HOST:
Last night, a college basketball game had an ending that seemed pulled straight from your favorite cheesy sports movie. Stephen F. Austin State University, the pride of Nacogdoches, Texas, and ranked 222nd in the nation, faced the top-ranked team, Duke.
ARI SHAPIRO, HOST:
Duke had not lost at home to a non-conference opponent in 150 games almost 20 years ago. So this was supposed to be an early season warm-up game against a completely outmatched opponent.
CHANG: Everyone expected the Lumberjacks of Stephen F. Austin to get crushed and then go home. Nathan Bain had other ideas.
SHAPIRO: With seconds left in overtime and the game tied up, Duke lost the ball. The Lumberjacks recovered. And suddenly, forward Nathan Bain had the ball at half court and a clear path to the basket.
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UNIDENTIFIED SPORTS ANNOUNCER #1: They’ve got a timeout. They don’t use it – Bain – yes. The Lumberjacks have done it.
CHANG: As you heard on the ACC Network, Bain’s layup with one-tenth of a second left sealed the stunning Lumberjack victory. Duke fans will spend Thanksgiving wondering what the heck happened.
SHAPIRO: And for at least the next few days, Nathan Bain is one of the biggest names in college basketball.
(SOUNDBITE OF ARCHIVED RECORDING)
UNIDENTIFIED SPORTS ANNOUNCER #2: Nathan Bain, this is your life. Wow.
CHANG: And about that life – Nathan Bain is from the Bahamas and the son of a minister.
SHAPIRO: His family pretty much lost everything when Hurricane Dorian ravaged the country two months ago. His father’s church was wrecked.
CHANG: Bain had all of that on his mind during a post-game interview.
(SOUNDBITE OF ARCHIVED RECORDING)
NATHAN BAIN: Man, it’s just – I’m trying real hard not to get emotional. You know, my family lost a whole lot this year. I’m not going to cry on TV. My family lost a whole lot this year, and I’m just playing this game for them, you know, just playing for my SFA family, my family back home in the Bahamas. I just want to make my country proud.
SHAPIRO: I just want to make my country proud. A GoFundMe to support his family had about $2,000 in donations before the game. As of this afternoon, not even 24 hours later, it was at $66,000 and counting.
CHANG: To be fair, almost every college basketball fan outside of Duke hates Duke. So at least some of this generosity is coming from a less-than-noble place.
SHAPIRO: One person donated $5 with the message, Duke sucks and nothing else.
CHANG: But even some Duke fans will admit this is sports hate for a good cause.
Copyright © 2019 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
737 Max Scandal Cuts Boeing’s Once Rock-Solid Image
A Boeing 737 MAX aircraft owned by Ryanair parked at Boeing’s Renton, Washington factory in October. All 737 Max planes remain officially “grounded” worldwide.
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In air travel, reputation is everything. The Boeing Company continues to find this out the hard way as it struggles through one of the worst crises in its 103-year history– the crashes of two its new 737 Max airplanes within five months that killed 346 people.
For decades, Boeing’s reputation among airline pilots was second to none.
“I’ve been (flying) on Boeing aircraft for over 33 years,” says Captain Dennis Tajer, a 737 pilot for American Airlines. Boeing planes saved his life when he flew in the military, he says. Pilots had a saying that showed their faith in the company’s aircraft– “If it ain’t Boeing, I ain’t going.”
But that high level of confidence is in the past. Ask Tajer about his trust in Boeing now, and he says, “Oh, it’s been shaken. Absolutely. Boeing is still an incredible company but they horridly fouled up this aircraft.”
Tajer, who is a spokesman for American’s pilots union, says it’s not just that Boeing installed a flawed flight control system that forced both planes into uncontrollable nose dives, but pilots are outraged because the company never told pilots the system even existed. That outrage only grew when Boeing initially defended the design and suggested pilot errors were more to blame for the crashes. This was compounded by revelations that Boeing officials knew about the systems flaws before the crashes and appeared to have downplayed safety concerns.
“These are just toxic liquids poured over the trust relationship,” says Tajer. “It doesn’t mean we can’t get there (and have faith in Boeing again). It just means that it’s more than ‘trust but verify,’ we’re down to ‘show me.'”
Flyers Faith Rattled
With pilots’ faith in Boeing shaken, who can blame frequent flyers like Wendy Rheault who before boarding a recent flight from Chicago’s O’Hare airport to Sacramento said she doubts she’ll fly on a 737 Max even if aviation regulators recertify the planes as safe.
“I think I would be uncomfortable flying it,” says the health care executive. “I would have to kind of wait for a while (after it’s flying again).” She says she thinks she’d have trouble trusting that the plane is safe.
Jay Hanmantgad of London, who was passing through O’Hare on his way to Ottawa says he would fly on a Max but only after European, Canadian and other international regulators recertify it to fly.
And he says his once high opinion of Boeing has changed.
“Yes, it certainly has,” says Hanmantgad. It appears to him that the company hurried the plane through the development and certification process in an effort to keep costs down and reap higher profits, “which is clearly a criminal offense, I would say. So they need to be held accountable for that.”
A recent survey of about two thousand air travelers shows that more than 80-percent say they would avoid flying on a 737 Max in its first six months back, and more than half say they’d pay a higher fare just to avoid flying on a Max.
Even if the FAA and other aviation regulators recertify the 737 Max as safe to fly again, airlines and their flight crews can refuse to fly the plane if they’re not convinced.
A Storied Safety Reputation In Jeopardy
“I think it’s a really critical moment for Boeing as a corporation,” says Tim Calkins, an expert in branding and crisis management and a professor at Northwestern University’s Kellogg School of Management. He says Boeing needs pilots, flight attendants and their airlines to vouch for the plane’s safety because Boeing’s own credibility is lacking.
“The hard part right now is that there’s very little Boeing can say that people will really believe,” says Calkins. “If Boeing says the plane is safe, I’m not sure I believe that because they were saying that before.”
To that end, Boeing officials have been regularly meeting with aviation regulators, airlines, pilots and other key groups as they continue to develop and test software fixes for the Max planes. The company is reaching out in other ways, too, taking out full page newspaper ads to express condolences to the families of those who died in the two crashes, and with promotional videos featuring a diverse array of Boeing employees offering testimonials to the company’s safety culture.
“When I take a 737 Max for a test flight, it’s deeply important that I do my job right,” says Boeing’s chief 737 test pilot Jennifer Henderson in one of the videos. “When the 737 Max returns to service I will absolutely put my family on this airplane.”
But many people in aviation circles aren’t convinced, with some commenting in social media forums where the videos are posted that the employees probably had little choice but to sing their employer’s praises.
“Well, I think she could not say it would be unsafe,” quipped one poster on a Facebook page for Boeing enthusiasts.
A Public Relations Disaster
Despite hiring the heavyweight PR firm Edelman to bolster crisis communications efforts, the campaign to win back the trust of air travelers thus far appears to have fallen flat. CEO Dennis Muilenburg’s recent testimony before two Congressional committees has been widely criticized as he struggled to answer questions that many industry insiders felt he should have been prepared for.
“I think Boeing needs a come to Jesus moment and I haven’t seen it happen yet,” says Christine Negroni, an aviation writer and author of book about plane crash investigations called “The Crash Detectives.”
She says Muilenburg and other Boeing officials haven’t been fully forthcoming in explaining their missteps in the development of the 737 Max and what the company knew about the potential problems with the plane before the crashes. Negroni says they still won’t acknowledge deeper and systemic problems inside the company.
“Boeing’s in a pickle and Boeing needs to recognize it’s in a pickle and that might be the hardest part,” Negroni says. “I said it’s a ‘come to Jesus’ moment. It’s (also) a, ‘do you realize you’re a sinner and what are you going to do to fix it’ moment.”
Despite its problems, Northwestern’s Tim Calkins says the company can still reclaim its once sterling reputation..
“If you take the right steps today, I think Boeing can come across as a brand that is still strong, is still trusted, and maybe is better for all of this,” Calkins says. “But if you don’t (take the right steps), it creates deep, long term problems for the company.”
Boeing may be able to fix the problems that brought down two of its 737 MAX planes, but as it tries to win regulatory approval to return the Max to service early next year, the company faces the additional challenge of rebuilding its once lauded reputation for safety.
Bill Of The Month: Extraction Of Doll Shoes In Girl’s Nose Cost $2,659
A 4-year-old girl was playing with her dolls and next thing you know, she had two tiny doll shoes stuck in her nose. A trip to urgent care, then the emergency room left her parents with a giant bill.
MARY LOUISE KELLY, HOST:
If you’re in the emergency room with your kid, it’s scary, and the bill is probably not the first thing on your mind. But a visit to the emergency room can end up getting pretty pricey.
Each month, NPR takes a medical bill to sort through why they can be so confusing and confounding. Today, we look at the case of a pretty big bill for what seems like a pretty simple medical service. It only took a minute or so.
We’re joined by Dr. Elisabeth Rosenthal. She’s editor-in-chief of our partner Kaiser Health News. Welcome back.
ELISABETH ROSENTHAL: Hi. That’s quite a story.
KELLY: Quite a story. So who are we hearing from? What’s the story?
ROSENTHAL: Today, we’re meeting the Branson family from Las Vegas. They’re a young couple with two little girls, Emma and Lucy. And the bill involves a Polly Pocket doll and an emergency room visit.
KELLY: OK. Looking forward to hearing where this one goes. And our guide is going to be reporter Stephanie O’Neill, who visited the Bransons. Let’s hear what happened.
STEPHANIE O’NEILL, BYLINE: For the Bransons of Las Vegas, the story of Lucy and the tiny doll shoes is one no one in this family will ever forget. It happened last April. Lucy was just 3 1/2. And on this particular evening, her parents, Katy and Michael, were getting ready for a long-awaited concert. It was to be a special evening, one given to them by Katy’s parents.
KATY BRANSON: We had a babysitter coming in, like, less than an hour. We had these tickets. We were really excited. And Lucy comes up the stairs, and I hear (imitating coughing). And I was like, what is going on? And Michael said, why are you coughing?
O’NEILL: But Lucy wouldn’t answer them beyond gesturing at her nose, Michael says.
MICHAEL BRANSON: Well, I kind of pulled her back and kind of lifted her head up and put her on our bed. And that’s when I could see something up her nose.
O’NEILL: That something was a pair of tiny, pink, plastic doll shoes, one perfectly lodged in each of Lucy’s little nostrils. Michael says panic overtook him, while Katy, who was in the midst of readying herself for the date, sprung into full-on mom mode.
K BRANSON: And so I went up with my little tweezers, and I get one little pink shoe out, and I put it on the counter. It’s maybe about the size of a Q-tip head.
O’NEILL: Easy peasy, she thought. So she takes a deep breath and reaches into the other nostril. But as Lucy, now 4 years old, explains, it didn’t work.
LUCY: The other one was stuck in my nose, and I couldn’t – and my mom couldn’t get it out.
O’NEILL: Big sister Emma says…
EMMA: And it was hard for her to breathe.
O’NEILL: Emma’s 7.
EMMA: It was scary. Lucy, was it scary?
LUCY: Yes.
EMMA: That’s what I was thinking.
O’NEILL: Have you ever done anything like that?
EMMA: Never in my life.
O’NEILL: But it is pretty common for kids to stick things up their noses, with some items even requiring surgical extraction. Still, Katy wasn’t too worried, even when her tweezers couldn’t reach the second shoe.
K BRANSON: I’m thinking, OK, well, I can’t get this out. I don’t want to hurt her. So I say, OK, Lucy, you need to blow. Like – and then I kind of do the motion of blow. And she goes (imitating inhaling).
O’NEILL: That was a giant sniff.
K BRANSON: And I was like, oh, shoot (laughter).
O’NEILL: After that, Katy knew it was time for the professionals.
K BRANSON: So I said, OK, Michael, you need to go to the urgent care. They should have the tweezers. All we need is – are – is tweezers that are, like, maybe a half an inch or an inch longer than my standard day-to-day tweezers.
O’NEILL: But urgent care didn’t have a long enough pair. Next stop, the hospital emergency room. And voila – the ER doc easily plucked the shoe out of little Lucy’s nostril.
M BRANSON: And it was probably less than one second – the time they put it up her nose, latched on it, pulled it out. She was out.
O’NEILL: Lucy got a lollipop. Katy and Michael got to the concert. It seemed like their lucky day.
Then they got the bill – almost $2,000 for the ER and almost another grand for the ER doc. And because the Bransons have a high-deductible plan, they’re responsible for all of it.
K BRANSON: I thought it was simply an error. I was like, there is no way.
O’NEILL: What’s the most you’ve ever paid for a pair of shoes?
K BRANSON: Oh, my gosh – probably $178. Yeah. They were normally 228, and I had a coupon. I was very proud of it.
O’NEILL: So you’ve never had a pair of shoes anything close to the cost of these shoes.
K BRANSON: No, I haven’t – never had a $3,000 pair of shoes.
O’NEILL: Still, Katy Branson says she remains hopeful that Lucy has learned her lesson.
K BRANSON: But she has said she will never put shoes up her nose again. She’s promised.
O’NEILL: And her parents hope that also means she won’t be sticking anything else up her nostrils ever again.
For NPR News, I’m Stephanie O’Neill in Las Vegas.
KELLY: Oh, wow. I am in full-on mom myself right there with those poor parents. Elisabeth Rosenthal, you were an ER doc before you moved to Kaiser Health News. Is that right? How common is this – kids in the ER with something they have managed to shove up their nose?
ROSENTHAL: Well, I worked in an adult ER, and grown-ups have mostly learned not to do this kind of thing. But pediatricians say it’s very common and very easy to treat if you have long tweezers, which they call forceps – medical lingo. As a kid, I myself put pussy willows in both ears, so I’ve been there.
KELLY: In your ear. OK. I have been there with – yes – with kids for many things, including things up the nose. But I have never been presented with a $3,000 bill for something that took less than a minute to get out. What’s going on here?
ROSENTHAL: What’s going on here is that today, everything and anything will be billed and billed a lot. The doctor charged over $900. Katy Branson very smartly negotiated that into half right away. But the hospital charged more than 1,700. And so far, they aren’t budging.
KELLY: They aren’t. And I’m sure the parents have asked for them to budge. Why aren’t they?
ROSENTHAL: Well, their attitude seems to be, an ER visit is an ER visit, and you could’ve gone to urgent care.
KELLY: They did go to urgent care, though.
ROSENTHAL: Right. And it was a Friday night, and they didn’t want to leave Lucy uncomfortable all weekend. And plus, what layperson knows whether or not it’s dangerous to leave Polly Pocket shoes up your kid’s nose for the weekend.
KELLY: Yeah, you don’t want her to keep sniffing in, and they end up in her lungs. And then…
ROSENTHAL: Right. They made a rational decision.
KELLY: So their insurance did not pick up any of this. Explain.
ROSENTHAL: Well, lots of families these days, like the Bransons, opt for a high-deductible plan. That means, in the Bransons’ case, they had to spend $6,000 before insurance kicked in. They’re pretty savvy. They made a decision that they would set this money aside for, like, a medical crisis. They just never imagined that they’d have to spend this money for a little shoe up the nose.
KELLY: Yeah. And what is the takeaway here? What should they have done differently, particularly – as we said, it’s a – it was a Friday night. The pediatrician wasn’t there.
ROSENTHAL: Well, a pediatrician might have told them it could safely wait until Monday morning or at least look for other options the next day. So it’s important, I think, to have a primary care doctor who can say, beware; there are other options. But they did one really smart thing that others should follow. Instead of getting angry when they saw this bill, they began to push back right away and got a discount from the doctor, at least.
KELLY: A minor point, but I have to ask – whatever happened to the Polly Pocket shoes?
ROSENTHAL: The hot pink ones that caused the trouble disappeared into the playroom vortex. But Lucy and Emma had lots of other Polly Pocket shoes to show us when we visited.
KELLY: (Laughter) It’s a danger lurking in every corner.
ROSENTHAL: Yes. Be careful.
KELLY: You can see those pictures, if you dare, at NPR’s Shots blog.
Elisabeth Rosenthal, thank you so much for being here today.
ROSENTHAL: Thanks for having me.
(SOUNDBITE OF ISOTOPE 127’S “LA JETEE”)
Copyright © 2019 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
