Tag Archives: Hospital

Short on staff: Nursing crisis strains U.S. hospitals

Registered nurse Kara Salonga, pictured at nursing station at the West Virginia University Hospitals in Morgantown, West Virginia, U.S., September 6, 2017. Picture taken September 6, 2017. REUTERS/Mike Wood

By Jilian Mincer

MORGANTOWN, West Virginia (Reuters) – A shortage of nurses at U.S. hospitals hit West Virginia’s Charleston Area Medical Center at the worst possible time.

The non-profit healthcare system is one of the state’s largest employers and sits in the heart of economically depressed coal country. It faces a $40 million deficit this year as it struggles with fewer privately insured patients, cuts in government reimbursement and higher labor costs to attract a shrinking pool of nurses.

To keep its operations intact, Charleston Medical is spending this year $12 million on visiting or “travel” nurses, twice as much as three years ago. It had no need for travel nurses a decade ago.

“I’ve been a nurse 40 years, and the shortage is the worst I’ve ever seen it,” said Ron Moore, who retired in October from his position as vice president and chief nursing officer for the center. Charleston Area Medical’s incentives include tuition reimbursement for nursing students who commit to work at the hospital for two years.

“It’s better to pay a traveler than to shut a bed,” he said.

Hospitals nationwide face tough choices when it comes to filling nursing jobs. They are paying billions of dollars collectively to recruit and retain nurses rather than risk patient safety or closing down departments, according to Reuters interviews with more than 20 hospitals, including some of the largest U.S. chains.

In addition to higher salaries, retention and signing bonuses, they now offer perks such as student loan repayment, free housing and career mentoring, and rely more on foreign or temporary nurses to fill the gaps.

The cost nationwide for travel nurses alone nearly doubled over three years to $4.8 billion in 2017, according to Staffing Industry Analysts, a global advisor on workforce issues.

The burden falls disproportionately on hospitals serving rural communities, many of them already straining under heavy debt like the Charleston Area Medical Center.

These hospitals must offer more money and benefits to compete with facilities in larger metropolitan areas, many of them linked to well-funded universities, interviews with hospital officials and health experts show.

Along West Virginia’s border with Pennsylvania, university-affiliated J.W. Ruby Memorial Hospital in Morgantown is spending $10.4 million in 2017 compared with $3.6 million a year earlier to hire and retain nurses.

But these costs are part of the facility’s expansion this year, including adding more than 100 beds as it grows programs and takes over healthcare services from smaller rural providers that have scaled back or closed.

J.W. Ruby, the flagship hospital for WVU Medicine, offers higher pay for certain shifts, tuition reimbursement, $10,000 signing bonuses and free housing for staff who live at least 60 miles away.

Next year, the hospital is considering paying college tuition for the family members of long-time nurses to keep them in West Virginia.

“We’ll do whatever we need to do,” said Doug Mitchell, vice president and chief nursing officer of WVU Medicine-WVU Hospitals.

NOT LIKE OTHER SHORTAGES

Nursing shortages have occurred in the past, but the current crisis is far worse. The Bureau of Labor Statistics estimates there will be more than a million registered nurse openings by 2024, twice the rate seen in previous shortages.

A major driver is the aging of the baby boomer generation, with a greater number of patients seeking care, including many more complex cases, and a new wave of retirements among trained nurses.

Industry experts, from hospital associations to Wall Street analysts, say the crisis is harder to address than in the past. A faculty shortage and too few nursing school slots has contributed to the problem.

Hospitals seek to meet a goal calling for 80 percent of nursing staff to have a four-year degree by 2020, up from 50 percent in 2010. They also face more competition with clinics and insurance companies that may offer more flexible hours.

Healthcare experts warn that the shortfall presents risks to patients and providers. Research published in August in the International Journal of Nursing Studies found that having inadequate numbers of registered nurses on staff made it more likely that a patient would die after common surgeries.

UAB Hospital in Birmingham, Alabama, has invested millions to attract nurses, but still has 300 jobs to fill. At times, nursing vacancy rates in some of its departments has hit 20 percent or higher.

“We’ve rarely canceled a surgery or closed a bed because of lack of staffing,” said Terri Poe, chief of nursing at the hospital, the state’s largest, which serves many low income and uninsured residents.

Last year, the medical center covered nearly $200 million in unreimbursed medical costs for patients. It spent $4.5 million for visiting nurses during fiscal 2016, including $3 million for post-surgery services, compared with $858,000 in 2012.

Healthcare labor costs typically account for at least half of a facility’s expenses. They jumped by 7.6 percent nationally last year, after climbing at a rate closer to 5 percent annually in recent years, said Beth Wexler, vice president non-profit healthcare at Moody’s. The spending has proven a boon for medical staffing companies like AMN Healthcare and Aya Healthcare.

Missouri’s nursing shortage reached a record high in 2017, with almost 16 percent – or 5,700 – of positions vacant, up from 8 percent last year. Thirty-four percent of Missouri registered nurses are 55 or older.

“Our biggest challenge is getting the pipeline of experienced nurses,” said Peter Callan, director of talent acquisition and development at the University of Missouri Health Care in Columbia, which is expanding. “There are fewer and fewer as people retire.”

Last year, the academic medical center hired talent scouts to identify candidates, Callan said. It spends $750,000 a year on extras to attract and keep nurses, including annual $2,000 bonuses to registered nurses who remain in hard-to-fill units and up to five years of student loan repayment assistance. It offers employee referral bonuses and a chance to win a trip to Hawaii.

Smaller hospitals find it much harder to compete in this climate. More than 40 percent of rural hospitals had negative operating margins in 2015, according to The Chartis Center for Rural Health.

In rural Missouri, 25-bed Ste. Genevieve County Memorial Hospital had to offer signing bonuses, tuition reimbursement and pay differentials when staffing is “critically low” in units such as obstetrics.

They haven’t closed beds, but have hired less experienced nurses, raised salaries and turned away at least one patient who would have been in its long term care program.

“We’ve had to try whatever it takes to get nurses here,” said Rita Brumfield, head of nursing at the hospital. “It’s a struggle every day to get qualified staff.”

To see the entire graphic on the U.S. nursing shortage, click http://tmsnrt.rs/2xQ9Y0K

(Editing by Michele Gershberg and Edward Tobin)

Charlie Gard’s parents say hospital denied their ‘final wish’ for dying son

Charlie Gard's parents Connie Yates and Chris Gard read a statement at the High Court after a hearing on their baby's future, in London. REUTERS/Peter Nicholls

LONDON (Reuters) – The parents of Charlie Gard, a terminally ill baby who a judge ordered should be sent to a hospice to die, said Britain’s top pediatric hospital had denied them their final wish to decide the arrangements for their son’s death.

After a harrowing legal battle that prompted a global debate over who has the moral right to decide the fate of a sick child, a judge on Thursday ordered that Charlie be moved to a hospice where the ventilator that keeps him alive will be turned off.

His parents had sought first to take him home but Great Ormond Street Hospital (GOSH) said that was not possible due the ventilation Charlie needs, they then asked for several days in a hospice to bid farewell to their son.

But they were unable to find doctors to oversee such an extended period of time and so a judge ruled that Charlie be moved to a hospice to die.

“GOSH have denied us our final wish,” his mother, Connie Yates, was quoted as saying by the BBC.

“Despite us and our legal team working tirelessly to arrange this near impossible task, the judge has ordered against what we arranged and has agreed to what GOSH asked,” she said. “This subsequently gives us very little time with our son.”

Great Ormond Street Hospital, a pioneering pediatric center, said that it deeply regretted the breakdown in relations with Charlie’s parents, in a case that has involved months of legal wrangling and has even drawn comment from U.S. President Donald Trump and Pope Francis.

“Most people won’t ever have to go through what we have been through, we’ve had no control over our son’s life and no control over our son’s death,” Charlie’s mother said.

“We just want some peace with our son, no hospital, no lawyers, no courts, no media, just quality time with Charlie away from everything, to say goodbye to him in the most loving way.”

(Reporting by Guy Faulconbridge; Editing by Louise Ireland)

More hospital closings in rural America add risk for pregnant women

Dr. Nicole Arthur (R), visits Tariyana Wiggins, a high school teacher, shortly after the birth of Troy O’Brien Williams in the hospital room at the North Baldwin Infirmary, a 70-bed hospital in rural Bay Minette, Alabama, U.S. on June 22, 2017. REUTERS/Jilian Mincer

By Jilian Mincer

Bay Minette, Alabama (Reuters) – Dr. Nicole Arthur, a family practice physician, was trained to avoid Cesarean deliveries in child-birth, unless medically necessary, because surgery increases risks and recovery time.

But she has adjusted her approach since arriving last year at the 70-bed North Baldwin Infirmary in rural, southern Alabama.

Low patient admissions and high costs mean the hospital does not have doctors on site around-the-clock to administer anesthesia in the case of an unexpected emergency Cesarean.

As a result, Dr. Arthur performs the surgery if there are any signs of complication, rather than waiting and running the risk that comes with the 20 to 30 minutes it takes for an anesthesiologist to arrive in the middle of the night.

“It’s better for me to do a C-section when I suspect that something may happen,” she said of her new strategy. “Getting the baby out healthy and happy outweighs some of the risk.”

Physicians in rural communities across America are facing the same tough choices as Dr. Arthur. Hospitals are scaling back services, shutting their maternity wards or closing altogether, according to data from hospitals, state health departments, the federal government and rural health organizations.

Nationally, 119 rural hospitals that have shut since 2005, with 80 of those closures having occurred since 2010, according to the most recent data from the North Carolina Rural Health Research Program.

To save on insurance and staffing costs, maternity departments are often among the first to get shuttered inside financially stressed rural hospitals, according medical professionals and healthcare experts.

“It’s been a slow and steady decline,” said Michael Topchik, the National Leader for the Chartis Center for Rural Health, about maternity ward closings. “It’s very expensive care to offer, especially when it’s lower volume.”

More than 200 maternity wards closed between 2004 and 2014 because of higher costs, fewer births and staffing shortages, leaving 54 percent of rural counties across the United States without hospital-based obstetrics, data from the University of Minnesota’s Rural Health Research Center show.

The trend has escalated recently even though the national healthcare law, known as Obamacare, was designed in part to help rural hospitals thrive. But unpaid patient debt has risen among rural hospitals by 50 percent since the Affordable Care Act was passed, according to the National Rural Health Association, especially in states that decided not to expand Medicaid – the state and federal insurance program for the poor.

The outlook for these hospitals was not poised to improve had Congress approved legislation to replace Obamacare. Senate Republicans’ proposed cuts to Medicaid would have pushed about 150 more rural hospitals into the red, according to the Chartis Center for Rural Health, mainly in states that voted Republican in the last election.

But late on Monday, Senate Majority Leader Mitch McConnell said the Republican effort to repeal and immediately replace Obamacare will not be successful, after two of McConnell’s Senate conservatives announced that they would not support the bill.

PAIN FELT BEYOND THE BELTWAY

The consequences go beyond politics.

When local doctors and midwives leave town, rural women lose access to essential services. Many skip or delay prenatal care that could prevent complications, premature birth or even death. The U.S. infant mortality rate is among the highest in developing countries at 5.8 deaths per 1,000 births.

Pregnant woman in rural areas are more likely to have their deliveries induced or by Cesarean section that, while potentially life-saving, are more expensive and risky than a normal vaginal birth, according to patients, medical professionals and researchers.

Almost a year after her second son’s birth, Courtney Cross is still repaying money she borrowed because of the smaller paychecks and larger gas bills she had from driving 60 minutes each way to a specialist in Mobile, Alabama.

“There were some days I had to reschedule because of the money factor,” said Cross, a medical technician and mother of two, who some months made the trip multiple times. “I had to make money.”

Cross is not alone. The most common reasons for the hospital closures are people and money. More and more people are moving to urban areas in pursuit of work and a better paycheck. And in most states, lower revenue from insurance and U.S. government payments are pushing these hospitals into financial stress, particularly in states that did not build out their Medicaid programs as Obamacare allowed.

“The majority of births in rural America are paid for by Medicaid, and Medicaid is not the most generous payer,” said Diane Calmus, government affairs and policy manager for the National Rural Health Association. “For most hospitals it is a money losing proposition.”

This is the main reason why Connie Trujillo shuttered her midwife practice this spring in Las Vegas, New Mexico. The local hospital had closed its maternity ward, and the closest hospital to deliver babies was at least 60 miles away. She sees more elective inductions because the patients live far away and can’t afford to go back and forth.

“Some of them just don’t have the resources,” she said. A year after shuttering, the hospital is trying to hire additional staff to reopen the ward.

MORE SCHEDULED DELIVERIES

The number of induced U.S. deliveries nationally has doubled since 1990 to about 23.3 percent, but rates are significantly higher in rural areas, where it is routinely offered to women traveling long distances, especially if the weather is bad.

Induced labor and surgery come at a high cost. Commercial insurance and Medicaid paid about 50 percent more for Cesarean than vaginal births, according to a 2013 Truven Health Analytics report. The report said Medicaid payments for maternal and newborn care for a vaginal birth was $9,131 versus $13,590 for a C-section.

In largely rural West Virginia – where the Summersville Regional Medical Center became the latest hospital to stop delivering newborns earlier this year – elected inductions for first time mothers rose to 28.7 percent in 2015 from 24.1 percent in 2011, according to data provided to Reuters by the West Virginia Perinatal Partnership, a statewide effort to improve care.

“Inductions allow the physicians to manage their case loads and timing of deliveries,” said Amy Tolliver, director of the Perinatal Partnership. “We know that inductions are happening in small hospitals that have difficulty with staffing.”

To address staffing issues at Dr Arthur’s hospital in Alabama, the facility paid temporary doctors for a year to keep the department open when one of its two maternity doctors stopped doing deliveries.

“It’s important to have access (to obstetrics),” said hospital president Benjamin Hansert, who also organized a group of doctors from Mobile about 40 minutes away to cover some of the shifts so that staff doctors would not always be on call. “Where the mother goes for care, the rest of the family will follow.”

For the full graphic on hospital closures, click http://tmsnrt.rs/2us7qDM

(Editing by Caroline Humer and Edward Tobin)

U.S. lawmaker wounded in shooting has surgery for infection: hospital

FILE PHOTO - Representative Steve Scalise (R-LA) is pictured sitting at the controls in the drilling shack on BP's Thunder Horse Oil Platform in the Gulf of Mexico, 150 miles from the Louisiana coast, May 11, 2017. REUTERS/Jessica Resnick-Ault

WASHINGTON (Reuters) – U.S. Representative Steve Scalise, who was shot and wounded during a baseball practice last month, has undergone surgery to treat an infection and remains in serious condition, the hospital said on Thursday.

Scalise, the No. 3 Republican leader in the U.S. House of Representatives, had been readmitted to MedStar Washington Hospital Center’s intensive care unit because of concerns about the infection, the hospital said on Wednesday night.

Scalise, 51, tolerated the latest surgery well and remained in serious condition, the hospital said in a statement on Thursday.

A gunman opened fire on Scalise and other Republican lawmakers as they practiced on June 14 in a Washington suburb for a charity baseball game. Scalise, from Louisiana, was shot in the hip.

Scalise had been improving in recent weeks following surgeries to repair internal organs and broken bones.

Gunman James Hodgkinson, 66, had a history of posting angry messages against Republican President Donald Trump. He died after being wounded by police at the Alexandria, Virginia, ballpark.

(Reporting by Eric Beech; Editing by Peter Cooney)

Republican lawmaker Steve Scalise’s condition worsens after June shooting

FILE PHOTO: House Majority Whip Steve Scalise (R-LA) speaks to reporters at the U.S. Capitol, hours before an expected vote to repeal Obamacare in Washington, D.C., U.S., May 4, 2017. REUTERS/Kevin Lamarque

WASHINGTON (Reuters) – U.S. Representative Steve Scalise, shot and wounded during a baseball practice last month, developed an infection and was readmitted to an intensive care unit, MedStar Washington Hospital Center said on Wednesday.

Scalise, the No. 3 Republican leader in the U.S. House of Representatives, had been improving in recent weeks following surgeries to repair internal organs and broken bones.

The hospital, which downgraded his condition to “serious” from “fair,” said it would provide another update on Thursday.

A gunman opened fire on Scalise and other Republican lawmakers as they practiced on June 14 in a Washington, D.C., suburb for a charity baseball game. Scalise, from Louisiana, was shot in the hip.

Gunman James Hodgkinson, 66, had a history of posting angry messages against Republican President Donald Trump. He died after being wounded by police at the Alexandria, Virginia, ballpark.

(Reporting by Richard Cowan; Editing by Howard Goller)

Gunman kills doctor, wounds six others in Bronx hospital rampage

Police vehicles line the streets outside the hospital after an incident in which a gunman fired shots inside the Bronx-Lebanon Hospital in New York City, U.S. June 30, 2017. REUTERS/Brendan Mcdermid

By Laila Kearney and Melissa Fares

NEW YORK (Reuters) – A doctor who had lost his job at a New York City hospital opened fire with an assault rifle inside the building on Friday, killing another physician and wounding six other people before taking his own life in a burst of apparent workplace-related violence, officials said.

The gunman, wearing a white medical lab coat, stalked two floors of the Bronx-Lebanon Hospital Center, in the New York borough of the Bronx, and tried to set himself on fire before police searching the building found him dead of a self-inflicted gunshot, Police Commissioner James O’Neill said.

One female physician was shot to death, and six other people were wounded, five seriously, including one who was shot in the leg, O’Neill said at a news conference.

Mayor Bill de Blasio characterized the shooting as an “isolated incident” that appeared to be “a workplace-related matter.” He said that it was “not an act of terrorism.”

“One doctor is dead, and there are several doctors who are fighting for their lives right now amongst those who are wounded,” de Blasio told reporters. “This is a horrific situation unfolding in the middle of a place that people associate with care and comfort.”

O’Neill said the gunman was armed with an assault rifle.

Neither the mayor nor police immediately identified the suspect or any of the victims. O’Neill said the gunman was a former employee of the 972-bed hospital.

Bronx Borough President Ruben Diaz, in an interview with WABC News, identified the gunman as Dr. Henry Bello and said he had been fired by the hospital. Other media reports said Bello was 45 years of age.

The New York Times and the New York Daily News reported, citing unnamed sources, that Bello had resigned from the hospital rather than face termination over accusations of sexual harassment.

NYPD officers work outside Bronx-Lebanon Hospital, after an incident in which a gunman fired shots inside the hospital in New York City, U.S. June 30, 2017. REUTERS/Brendan McDermid

NYPD officers work outside Bronx-Lebanon Hospital, after an incident in which a gunman fired shots inside the hospital in New York City, U.S. June 30, 2017. REUTERS/Brendan McDermid

FROM NIGERIA TO CARIBBEAN MEDICAL SCHOOL

Bello had received a limited permit to practice as an international medical graduate in order to gain experience so he could be fully licensed, but that permit expired a year ago, the Times reported. It said he also had a pharmacy technician license from California. The Daily News said he had been a pharmacy tech at the hospital before he quit in 2015.

A native of Nigeria, Bello earned a medical degree from Ross University on the Caribbean island nation of Dominica and later worked briefly as a pharmacy technician for Metropolitan Hospital Center in Manhattan in 2012, according to David Wims, a lawyer who represented Bello in an unemployment insurance claim against that hospital.

In a telephone interview, Wims told Reuters Bello was injured on the job at Metropolitan a few months after being hired, then went on leave and never returned. In a decision upheld by the state’s appellate court division, Bello ultimately was denied unemployment benefits on grounds he quit without good cause.

Wims said he remembered Bello as “an even-keeled, respectful, humble person” and knew nothing of his history at the Bronx hospital.

Details about the shooting were still sketchy.

Authorities said the rampage unfolded shortly before 3 p.m. when the gunman went on a rampage on the 16th and 17th floors of the hospital. He and the slain physician both were found on the 17th floor, while the six other victims were found on the 16th floor, O’Neill said.

The incident sent waves of panic throughout the hospital, and police swarmed the building searching for the gunman.

“People were running. People were afraid,” said Jane Vachara, 50, a clerical associate on the ninth floor, who said she huddled with colleagues in a locker room for about an hour.

Adding to the pandemonium was the gunman’s attempt to set himself ablaze, which apparently triggered the hospital’s fire alarm system and halted elevator service, hampering efforts by first responders to reach victims and evacuate the building.

One ambulance worker, Robert Maldonado, told WCBS television that he and his partner had to carry a bleeding patient down nine flights of stairs to safety, applying pressure to the man’s wound on the way down.

Bronx-Lebanon Hospital Center, located about one mile (1.6 km) north of Yankee Stadium, is the largest voluntary, non-profit health care system serving the South and Central Bronx, as well as one of the city’s biggest providers of outpatient services.

(Additional reporting by Peter Szekely; Writing by Steve Gorman; Editing by Mary Milliken and Stephen Coates)

Representative Scalise, wounded in Virginia shooting, is out of ICU

FILE PHOTO: House Majority Whip Steve Scalise (R-LA) speaks at a news conference on "Taxpayers Protection Alliance on Trade Promotion Authority" on Capitol Hill in Washington, June 10, 2015. REUTERS/Yuri Gripas/File Photo

WASHINGTON (Reuters) – Steve Scalise, the Louisiana lawmaker shot last week at a U.S. congressional baseball team practice, is no longer in the intensive care unit of the hospital where he is being treated and remains in fair condition, the hospital said on Friday.

Scalise was shot in the hip on June 14 when a lone gunman opened fire on Republican lawmakers practicing for an annual charity game against the Democrats. He entered the hospital in critical condition and has undergone several surgeries.

“Congressman Steve Scalise’s continued good progress allowed him to be transferred out of the Intensive Care Unit (ICU) on Thursday,” said MedStar Washington Hospital Center.

“He remains in fair condition as he continues an extended period of healing and rehabilitation,” the hospital said in a statement posted on its web site.

Matt Mika, a lobbyist wounded in the same shooting at an Alexandria, Virginia ball field, has been released from George Washington University Hospital, his family said in a statement on Friday.

Local media reported that Mika, a Tyson Foods lobbyist, was visited before leaving in his hospital room by Jayson Werth, a Washington Nationals star player.

Scalise, 51, is the No. 3 Republican in the House. He, Mika and others were shot or otherwise injured in a mass shooting carried out by James Hodgkinson, 66, of Belleville, Illinois, who later died in the hospital of gunshot wounds.

The FBI, which investigated the incident, said on Wednesday that Hodgkinson did not post online any threats against or references to members of Congress before the attack.

The agent said authorities found a laptop computer, a cell phone and a digital camera in Hodgkinson’s car after the incident, and 200 rounds of ammunition in a storage locker Hodgkinson had rented in April in Alexandria.

The shooting occurred as 25 to 30 Republican members of the House and Senate had gathered for an early morning practice a day before the annual charity game, which was played on June 15.

With many players on both teams wearing hats to honor Scalise, the game was won by the Democrats, 11-2, but they loaned the trophy to the Republicans until Scalise is better.

As the game was about to begin, Senate Majority Leader Mitch McConnell, Senate Minority Leader Chuck Schumer, House Speaker Paul Ryan and House Minority Leader Nancy Pelosi stood side by side at Washington’s Nationals Park to shout: “Let’s play ball!”

(Reporting by Rick Cowan; Additional reportng by Jon Herskovitz; Writing by Tim Ahmann; Editing by Kevin Drawbaugh and Simon Cameron-Moore)

Man’s body, seen tossed from plane, found on roof of Mexican hospital

Police officers stand guard near a crime scene where the body of a man, who witnesses said was tossed from a plane, landed on a hospital roof in Culiacan, in Mexico's northern Sinaloa state April 12, 2017. REUTERS/Jesus Bustamante

By Gabriel Stargardter

MEXICO CITY (Reuters) – The body of a man, who witnesses said was tossed from a plane, landed on a hospital roof in Mexico’s northern Sinaloa state on Wednesday, according to a public health service official in the region, which is home to notorious drug traffickers.

The body landed on the roof of an IMSS hospital in the town of Eldorado, around 7:30 a.m. local time, said the official, who was not authorized to give his name.

Witnesses standing outside the health center reported a plane flying low over the hospital and a person thrown out, the health official said.

Later on Wednesday, Sinaloa’s Deputy Attorney General Jesus Martin Robles said a body, found on the hospital roof, showed injuries that appeared to be related to a strong impact. He did not confirm that it had been thrown from a plane.

The public health service official said two more bodies were reported to have been found in the town, about 60 kilometers (40 miles) south of Culiacan, the state capital. Local media reported that those two bodies were thrown from the same plane as the body that landed on the hospital.

The official did not know if the man was alive when he was thrown from the plane. Officials from the state prosecutor’s office were at the scene, he said.

“This is an agricultural area and planes are regularly used for fumigation,” the official said, adding that the IMSS hospital was operating normally.

Local media reported that suspected gang members had picked up the two other corpses.

Sinaloa is the home state of Joaquin “Chapo” Guzman, who ran the Sinaloa drug cartel until his arrest in 2016. He was extradited to the United States earlier this year.

Ever since Chapo’s arrest, security in the state has deteriorated, as the Sinaloa cartel struggles to adapt to infighting and fresh threats from rival groups.

(Additional Reporting by Noe Torres; Editing by Frank Jack Daniel and Leslie Adler)

Iraqi troops retreat after Mosul hospital battle

Iraqi forces backed by tribal militias during battle to retake a village from the Islamic State on the eastern bank of the river Tigris, Iraq

By Ahmed Rasheed and Saif Hameed

BAGHDAD (Reuters) – Iraqi troops who seized a hospital deep inside Mosul believed to be used as an Islamic State military base have retreated after a fierce counter-attack, giving up some of their biggest gains in a hard-fought seven-week campaign to recapture the city.

The soldiers seized Salam hospital, less than a mile (1.5 km) from the Tigris river running through central Mosul, on Tuesday but pulled back the next day after they were hit by six suicide car bombs and “heavy enemy fire”, according to a statement by the U.S.-led coalition supporting Iraqi forces.

Coalition warplanes, at Iraq’s request, also struck a building inside the hospital complex from which the militants were firing machine guns and rocket-propelled grenades, it said.

Tuesday’s rapid advance into the Wahda neighborhood where the hospital is located marked a change of tactics after a month of grueling fighting in east Mosul, in which the army has sought to capture and clear neighborhoods block by block.

The soldiers are part of a U.S.-backed 100,000-strong coalition of Iraqi forces including the army, federal police, Kurdish peshmerga fighters and mainly Shi’ite Popular Mobilization forces battling to crush Islamic State in Mosul.

Defeating the militants in their Iraq stronghold would mark a major step in rolling back the caliphate declared by the jihadists in parts of Syria and Iraq when they took over Mosul in mid-2014.

But with two years to dig themselves into northern Iraq’s largest city, retreating fighters have waged a lethal defence, deploying hundreds of suicide car bombers, mortar barrages and snipers against the advancing soldiers and exploiting a network of tunnels to ambush them in residential areas.

“GATES OF HELL”

Soldiers from the army’s Ninth Armored division were left exposed on Tuesday after punching into the Wahda neighborhood.

“When we advanced first into Wahda, Daesh (Islamic State) showed little resistance and we thought they had fled,” an officer briefed on the operation told Reuters by telephone. “But once we took over the hospital, the gates of hell opened wide”.

“They started to appear and attack from every corner, every street and every house near the hospital,” said the officer who declined to be identified because he was not authorized to speak to the media. He said insurgents may also have used a tunnel network reaching into the hospital complex itself.

Iraqi military spokesmen have said little about the fighting around the hospital, stressing instead gains they said were being made in other parts of east Mosul, including the Ilam neighborhood a few districts northeast.

Brigadier-General Yahya Rasoul, a spokesman for Iraq’s joint operations command, said on Wednesday “operations are continuing” around Wahda. He could not immediately be contacted on Thursday.

The statement by the coalition said Iraqi troops “fought off several counter-attacks and six VBIEDs (car bombs) … before retrograding a short distance, under heavy enemy fire”.

The Iraqi officer said that when the troops were inside the hospital complex, fighting off the militants, they came under attack from suicide bombers who he said either infiltrated through tunnels or had been hiding in the hospital grounds.

“We don’t know, they were like ghosts,” he said.

Iraq does not give casualty figures or report on its equipment losses, but the officer said 20 soldiers were killed and around 20 armored vehicles were destroyed or damaged.

Those figures could not be confirmed. Islamic State’s Amaq news agency said more than 20 vehicles were destroyed and dozens of soldiers killed, and that they had been forced to retreat.

Alongside those figures it showed a picture of a smouldering tank, its turret blown off, next to a crater in the road.

Around 280 km (175 miles) southwest of Mosul dozens of people, mainly civilians, were killed on Wednesday in air strikes which hit a western Iraqi town close to the border with Syria, local parliamentarians and hospital sources said.

They said the strikes hit a busy market area in the Islamic State-held town of Qaim, in the overwhelmingly Sunni Muslim province of Anbar. Among the victims were 12 women and 19 children.

An Iraqi military statement said Iraqi air force planes conducted air strikes “on a terrorist hideout” in the area shortly after noon on Wednesday, as well as a second attack an unspecified location.

It said at least 50 terrorists were killed. It gave no details of civilian casualties, but said that the region – and all information coming out of it – was controlled by Islamic State.

Iraq’s speaker of parliament, the country’s most senior Sunni Muslim politician, called on Thursday for a government inquiry into the air strikes.

(Writing by Dominic Evans, editing by Peter Millership)

In-patient or not? Medicare requires hospitals to tell you

An entrance sign to a hospital is seen in Dallas, Texas,

By Mark Miller

CHICAGO (Reuters) – You are in the hospital for tests after experiencing dizziness. You are nervous about what the tests will show, but at least you do not have to worry about hospital bills – you have Medicare, so you can relax about healthcare coverage. Or can you?

Not if you are in the hospital under “observation status” – a Medicare designation applied to patients deemed insufficiently ill for formal admission, but still too sick to be allowed to go home. Observation status can result in thousands of dollars in higher costs – especially if you need post-hospital nursing care.

Medicare covers care in skilled nursing facilities, but only for patients who were first formally admitted to a hospital for three consecutive days.

Federal data shows that the number of Medicare patients classified as under observation has jumped sharply in recent years, and it has stirred a great deal of pushback from Medicare enrollees and advocacy groups. A new law – the Notice Act – requires hospitals to at least notify patients if they stay in the hospital more than 24 hours without being formally admitted. Patients will receive the warnings starting in January, but advocates argue the new protection does not go far enough.

“It does half of what we would like to see,” said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy. “The notice should also allow patients to appeal their status.”

Hospitals have been motivated to use the status to avoid costly penalties from Medicare for improper admissions under a well-intentioned effort by Medicare to control costs through a program that audits hospitals for possible overpayments. The program began during the George W. Bush administration.

The number of patients cared for under observation status doubled to nearly 1.9 million in 2014 compared with 2006, according to figures from the Centers for Medicare & Medicaid Services (CMS). The majority (54 percent) were for observation stays of less than 24 hours; another 38 percent of the stays were 48 hours or less, CMS reports.

FACING HIGHER COSTS

The new notifications will require hospitals to inform patients orally and in writing if they are on observation status for more than 24 hours. The written notification, developed by CMS, is called the Medicare Outpatient Observation Notice (MOON). The MOON also explains the cost implications of receiving hospital services as an outpatient.

The costs of observation status can affect any enrollee on traditional fee-for-service Medicare. (Beneficiaries using Medicare Advantage, which provide all-in-one care, will also receive the MOON, but some Medicare Advantage plans will cover a stay in a skilled nursing facility without first requiring that patients have a three-day inpatient hospital stay.)

Medicare normally covers up to a maximum of 100 days of care in a skilled nursing facility following a hospital admission – it pays 100 percent for the first 20 days, and patients are responsible for a daily $161 co-pay for the next 80 days. But patients leaving the hospital for a nursing facility after an observation pay the full cost out of pocket.

RISING NURSING HOME COSTS

The cost of skilled nursing care is substantial, and rising quickly. This year, the national median monthly cost of a private nursing room is $7,698, according to a Genworth survey, and it runs much higher in states such as New York ($11,330 per month) and California ($9,338).

Medicaid would cover the stay if the patient meets the program’s low-income requirements (a status called “dual-eligible”). A commercial long-term care policy might provide some coverage, although many of these policies have “elimination” features (deductibles) that require patients to pay the first 90 days out of pocket.

Observation status also affects coverage of drug usage in the hospital. Medicare Part B would cover drug usage for the specific problem related to the hospitalization, subject to Part B’s typical 20 percent copay); for routine drugs that you take at home (say, a statin for high cholesterol), practices vary. Some hospitals allow patients to bring their own drugs from home, others do not, and charge much more than you would pay at a typical pharmacy.

Some – but not all – Part D drug plans will cover some of these prescription drug costs.

A broader fix to the observation status has garnered broad support from organizations ranging from AARP to the American Medical Association, elder law groups and Medicare advocacy groups. Legislation that has bipartisan support has been introduced in the U.S. House and Senate that would require that time spent in observation be counted toward meeting the three-day prior inpatient stay that is necessary to qualify for Medicare coverage.

“The bill is simple,” said Edelman of the Center for Medicare Advocacy. “Count the time in hospital, no matter what. If you are in the hospital for three midnights, you have met this requirement.”

(The writer is a Reuters columnist. The opinions expressed are his own.)

(Editing by Matthew Lewis)