For Many College Students, Hunger Can ‘Make It Hard To Focus In Class’

As students enter college this fall, many will hunger for more than knowledge. Up to half of college students report that they were either not getting enough to eat or were worried about it, according to published studies.

“Food insecurity,” as it’s called, is most prevalent at community colleges, but it’s common at public and private four-year schools as well. Student activists and advocates in the education community have drawn attention to the problem in recent years, and the food pantries that have sprung up at hundreds of schools are perhaps the most visible sign.

Some schools are also using the Swipe Out Hunger program, which allows students to donate their unused meal plan vouchers, or swipes, to other students to use at campus dining halls or food pantries.

Those “free dining passes have given me chances to eat when I thought I wouldn’t be able to,” one student wrote to the program. “I used to go hungry and that would make it hard to focus in class or study. [The passes] really helped my studying and may have helped me get my GPA up.”

Pantries and food passes are good band-aids, but more system-wide solutions are needed, advocates say.

“If I’m sending my kid to college, I want more than a food pantry,” said Sara Goldrick-Rab, professor of higher education policy and sociology at Temple University in Philadelphia, who founded the Hope Center for College, Community and Justice. “I want to know that they’re addressing high food prices on campus and taking steps to ensure no student goes hungry.”

Part of the disconnect may stem from a misperception about what today’s students are really like, said Katharine Broton, an assistant professor in educational policy and leadership studies at the University of Iowa who has published research on food and housing insecurity in colleges. Many of them don’t fit the profile of a “typical” student who attends a four-year institution full time and doesn’t have a job, Broton said. Rather, about 40 percent of students today are working in addition to going to school, and nearly 1 in 4 are parents.

The juggling act can be hard to maintain. “Most of the students, we find, are working and receiving financial aid, but still struggling with food insecurity,” Broton said.

Adding to the stress is the fact that while tuition and fees continue to rise, financial aid hasn’t kept pace. In the 2017-18 school year, after accounting for grant aid and tax benefits, full-time students at two-year colleges had to cover $8,070 in room and board on average, while those at four-year public institutions faced an average $14,940 in room, board, tuition and fees.

Anti-hunger advocates credit students with both sounding the alarm about hunger on campus and in some cases offering ingenious solutions.

Rachel Sumekh, who founded the Swipe Out Hunger program with friends at UCLA several years ago, said they wanted to do something useful with the unused credits from the meal plans that they were required to buy. The program now counts 48 schools as participants, and Sumekh said in the past year they’ve seen a “dramatic” increase in the number of colleges that are reaching out to them about getting involved.

The University of California-Berkeley is part of Swipes, as the program is known. It’s one element in a multipronged effort that targets students who may need extra support to meet their basic housing, food and other needs, said Ruben Canedo, a university employee who chairs the campus’s basic needs committee. (He also co-chairs a similar committee for all 10 UC campuses.)

According to a survey of Berkeley students, 38 percent of undergraduates and 23 percent of graduate students deal with food insecurity at some point during the academic year, Canedo said. The school targets particular types of students, including those who are first-generation college-goers, parents, low-income or LGBT.

Canedo said a key focus this fall will be to enroll eligible students in CalFresh, the California version of the federal Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps.

Under federal rules, students generally must work at least 20 hours a week to qualify for SNAP, something many cannot manage. But states have flexibility to designate what counts as employment and training programs, said Elizabeth Lower-Basch, director of income and work supports at CLASP, an anti-poverty advocacy organization. In California, for example, students who participate in certain educational programs at school are eligible for CalFresh.

“That’s our first line of defense,” Canedo said. “Students are being awarded about $192 per month.”

For students who don’t qualify for CalFresh, the school sponsors a parallel food assistance program that also provides benefits.

There’s a food pantry that offers regular cooking demonstrations. But what Canedo said he’s particularly proud of is a 15-week nutritional science course that students can take that teaches them about healthy eating, prepping food, budgeting and grocery shopping, among other things. Some of those skills can help students learn to manage their money and food to get them through their time at school without running short.

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FDA approves blood disorder drug made by Japan’s Shionogi

(Reuters) – The U.S. Food and Drug Administration on Tuesday approved Japan-based Shionogi & Co Ltd’s treatment for low blood-platelet count or thrombocytopenia in patients with chronic liver disease.

The treatment belongs to a new class of drugs called thrombopoietin receptor agonists (TPO RA), which stimulate platelet production. bit.ly/2LJJZPG

Its approval is the second for this class of drug for liver disease patients, following the FDA’s greenlight for U.S.-based Dova Pharmaceuticals’ rival treatment in May.

Reporting by Manas Mishra in Bengaluru

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Chipotle slumps 9 percent after Ohio outlet linked to food poisoning complaints

(Reuters) – More than 100 people said they had fallen sick after eating at a Chipotle Mexican Grill Inc (CMG.N) restaurant in Ohio, sending shares of the burrito chain down as much as 9 percent on Tuesday.

The customers said they suffered from food poisoning and diarrhea after eating dishes including tacos and burrito bowls at the Powell, Ohio restaurant over the past few days, according to food safety website iwaspoisoned.com.

The Delaware General Health District, which is investigating the food safety incident, told Reuters the county health department had got more than 100 calls since receiving the first complaint linked to the restaurant on Sunday.

Public information officer Traci Whittaker said the department was investigating food samples from the outlet, but is still not aware of the pathogen that caused the illnesses.

The reports come just after the agency had routinely inspected the restaurant on July 26 and found that lettuce and beans were not stored at the right temperature. However, the infractions were immediately corrected, Whittaker said.

FILE PHOTO: The logo of Chipotle Mexican Grill is seen at the Chipotle Next Kitchen in Manhattan, New York, U.S., June 28, 2018. REUTERS/Shannon Stapleton

Chipotle shut the restaurant on Monday after it received complaints of illness from two customers, Laurie Schalow, the company’s chief communications officer, said in an email.

“We acted quickly and closed this single restaurant out of an abundance of caution yesterday. We are working with the local health department and we plan to reopen this restaurant today,” Schalow said on Tuesday.

The Powell outlet said in a phone call that it was working to get the restaurant open by Tuesday afternoon.

The news is another setback to the company, which was recovering from a series of high-profile food safety lapses in 2015 that sickened more than 100 customers with E. coli and salmonella and bruised Chipotle’s reputation and stock price.

It is also the first major food safety issue under new Chief Executive Brian Niccol as he works to bring back customers to the Mexican food chain that once was an investor darling. The stock traded over $700 just two months before the 2015 food safety incidents.

“If this story gains traction, it might have more serious implications for the stock. It certainly, at this point, is a negative. I think it is something the CEO should address,” Maxim Group analyst Stephen Anderson said.

The company’s shares were down 5.6 percent at $439.60, erasing gains made since Chipotle reported stronger-than-expected profit and same-restaurant sales for its second quarter on Thursday.

Reporting by Siddharth Cavale, Uday Sampath Kumar and Nivedita Balu in Bengaluru; Editing by Anil D’Silva and Maju Samuel

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Mining A New Data Set To Pinpoint Critical Staffing Issues In Skilled Nursing Facilities

The Centers for Medicare & Medicaid Services is not known for linguistic playfulness. Nonetheless, at least one person there must have been chuckling when it named its rich new data source for nursing home staffing levels the Payroll-Based Journal, or PBJ.

Like that classic sandwich, the PBJ data set is irresistible. CMS created it to fulfill a requirement of the Affordable Care Act to improve the accuracy of its five-star staffing ratings on Medicare’s Nursing Home Compare website. The data set contains payroll records that nursing homes are required to submit to the government.

In April, Medicare began using them to rate staffing for more than 14,000 skilled nursing facilities (SNFs). The PBJ data gives a much better look at the how staffing relates to quality of care than the less precise — and too easy to inflate — staffing data Medicare had been using since 2008, which were based on two-week snapshots of staffing homes provided to inspectors. The data show staffing and occupancy on every day — an unprecedented degree of granularity that allows for new levels of inquiry.

Low staffing is a root cause of many injuries in nursing homes. As I wrote in the article published in The New York Times based on the data: “When nursing homes are short of staff, nurses and aides scramble to deliver meals, ferry bedbound residents to the bathroom and answer calls for pain medication. Essential medical tasks such as repositioning a patient to avert bedsores can be overlooked when workers are overburdened, sometimes leading to avoidable hospitalizations.”

Analyzing the files took time. To start with, the files were too large to analyze in Excel — a challenge with more and more health care data sets. I previously had taken classes in SQL at the National Institute for Computer-Assisted Reporting, but this was the first project in which I had to use SQL. Fortunately, KHN has two great data journalists who steered, taught and backstopped me: data editor Elizabeth Lucas and data correspondent Sydney Lupkin.

There were a lot of decisions to make in the analysis. Should we count nursing administrators in assessing staffing levels? How should we define best-staffed and worst-staffed days? How do we handle the fact that the data in its raw form wasn’t risk-adjusted — that is, that it didn’t tell you how comparatively frail and sick each nursing home’s residents were, making it dangerous to make comparisons. (You can read our decisions in our methodology, which accompanies the downloadable data.)

I guided myself with two intersecting principles: to reflect residents’ lived experience as accurately as possible, and to be fair to the facilities. When in doubt, I erred on the side of caution.

I bounced approaches off not only Liz and Sydney, but two of the top health care researchers who have published studies on staffing: David Stevenson at Vanderbilt University Medical Center and David Grabowski at Harvard Medical School. Both are straight shooters and rigorous in their methods. It was also invaluable to talk early on in the project to the nursing home industry’s trade group, the American Health Care Association, to solicit its views about the strengths and weaknesses of the data set.

I’ve been writing about nursing homes for a while, but until this story I didn’t know the source value of SNF resident and family councils. These councils are authorized by CMS, and facilities must let them meet on their premises and invite to their meetings anyone they want, including journalists.

The leaders of the council at Beechtree Center for Rehabilitation & Nursing, the Ithaca, N.Y., home that provided the anecdotes for the story, were a reporter’s dream: smart, dedicated and reasonable. They were able to see things from the facility administration’s position, but also were firm advocates for good care. They had educated themselves about the facility and the rules and regulations. Adam Chandler, whose mom was in Beechtree and whom I quoted in the story, had already been studying the PBJ data. The council’s president, Stan Hugo, carried around a tan notebook where he jotted down incidents of staffing problems he came across. He also kept a daily log of how many employees he observed when visiting his wife and how many the administration said were on duty in the sign Medicare requires them to post publicly.

Our story ultimately focused on the wide fluctuations in nursing home staffing day to day, with staffing consistently plummeting on weekends. Caitlin Hillyard, one of KHN’s web producers, created a terrific interactive graphic that reporters can use to see staffing patterns in nursing homes in your state. We encourage other reporters to download and use the data for their own stories. There’s no cost — just please credit KHN and provide a link back to us.


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Suicide details reported by the media may lead others to copy

(Reuters Health) – How the media reports on suicides may impact whether others decide to kill themselves in the days following the original death, a study suggests.

An international team of researchers analyzed newspaper reports and suicide patterns over a four-year period to determine if any sort of coverage was more – or less – likely to spark copycat attempts.

“We’re not saying that reporting about suicides is bad or that news organizations shouldn’t report on suicide issues,” said study coauthor Dr. Ayal Schaffer, a professor in the department of psychiatry at the University of Toronto. “But we know that specific aspects of reporting can have a significant effect on suicide contagion. This has been shown across many different groups and many different countries.”

It’s important to realize that certain features of a story can decrease or increase the likelihood that others will try to kill themselves afterward, Schaffer said. “There’s a 1 to 2 percent variance in suicide rates that are due to media reporting,” he explained. “Doing a quick calculation, in the world there are approximately 800,000 people who die each year by suicide – and that’s probably an underestimate. But even a change of 1 to 2 percent would be associated with a reduction of 8,000 to 16,000 deaths.”

As reported in CMAJ, the researchers gathered print and online reports published in the Toronto media market from 2011 to 2014. The 6,367 stories in which suicide was the major focus came from 12 major Canadian publications as well as one U.S. newspaper with high circulation in Toronto (The New York Times).

Schaffer’s team also obtained a list of people who died by suicide in Toronto between January 1, 2011 and December 31, 2014.

The researchers then looked for an association between certain features in the stories and an uptick in the number of people who killed themselves in the week after the accounts were published. Among the factors that appeared to create an uptick were: the suicide method appearing in the headline, reports that firearm suicides had the highest lethality, heavy detail on the suicide method, and statements that made suicide seem inevitable.

Certain features appeared to be protective, but the associations found by the researchers weren’t statistically significant, meaning the association might have been due to chance. People were less likely to try to copycat if the deceased was described in a negative light, for example.

“When people can really relate to the person in the story, they’re more likely to see themselves going down the same path,” Schaffer said. “Our hope is that stories will portray the death as a lost opportunity – if this person had gotten help he might have survived. Most people who try to kill themselves are ambivalent. They are suffering. And most just want relief. If we can provide them with relief they can get through the suicidal crisis.”

Schaffer and his colleagues hope that by studying the phenomenon in a scientific way, they’ll convince more journalists to handle stories about suicide with care.

The new study may actually be underestimating the effects of the media because it only looked at one week after the suicide, said Mark Reinecke, head of psychology at Northwestern University’s Feinberg School of Medicine in Chicago.

“I think we’ve known for a long time that media can have an impact on suicide contagion,” said Reinecke who is not affiliated with the new study. “They’ve unpacked that and shown the specific types of information included in media can have an impact on outcomes. I think they are quite right.”

Stories can have a positive effect if they shed light on the role of mental health issues, said Dr. David Brent, a professor of psychiatry and the Endowed Chair in Suicide Studies at the University of Pittsburgh. “And certainly you can say something about the devastating effect the suicide has on people,” said Brent who is not affiliated with the new research.

SOURCE: bit.ly/2K6WfUE and bit.ly/2vf8E3m CMAJ, online July 30, 2018.

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Meat allergy after tick bite may explain severe allergic reactions

(Reuters Health) – Meat allergies related to tick bites might be at the root of some unexplained severe, life-threatening allergic reactions, a new study suggests.

Researchers poring through records from a Tennessee clinic found that a large percentage of anaphylactic shock cases were sparked by an allergy to alpha-gal, a complex sugar found in red meat, according to a report in Annals of Allergy, Asthma and Immunology.

Even so, anaphylaxis due to alpha-gal is still pretty rare, said study coauthor Dr. Jay Lieberman of the University of Tennessee Health Science Center and Le Bonheur Children’s Hospital.

“I don’t want this to lead to hysteria,” said, Lieberman who is also vice chair of the American College of Allergy, Asthma and Immunology Food Allergy Committee. “The vast majority of people with a history of tick bites are not going to develop this allergy to meat and will continue to eat meat with no problem, even among those with positive antibody tests to alpha-gal. It’s just a small proportion who will actually have symptoms.”

Those symptoms can include hives; swollen lips, eyes, tongue and throat; trouble breathing; vomiting; diarrhea; increased heart rate and low blood pressure.

No one knows exactly how many Americans have developed a meat allergy from a tick bite. But “current estimates from multiple studies across institutions in the U.S. are that approximately 5,000 people have developed the alpha-gal red meat allergy,” said Dr. Scott Commins, an associate professor of medicine and pediatrics at the Thurston Research Center at the University of Carolina, Chapel Hill. Commins is not affiliated with the new research.

Lieberman’s team hopes the study will remind doctors and patients that the meat allergy could be the cause of unexplained anaphylaxis. Many are not aware because the tick-related allergy was only recently discovered.

About a decade ago, scientists figured out the connection between lone star tick bites and an allergy that some patients were developing to red meat. Current thinking is that ticks pick up alpha-gal, which is in all red meat, after biting a deer. When the tick bites a human, it passes along the alpha-gal. In some people, when the alpha-gal enters the bloodstream, the immune system flags the unfamiliar molecules as enemy invaders.

One big difference between alpha-gal sensitivity and other food allergies is how long it takes to react after eating. While typical food allergies may cause a reaction within minutes, the alpha-gal response can occur three to six hours after exposure, making it harder to connect the dots between the food and the body’s response to it.

Lieberman and colleagues reexamined 218 cases of anaphylaxis treated between 2006 and 2016. Before their new review, the cause of anaphylaxis in nearly 60 percent of patients who came to the clinic couldn’t be diagnosed. After the review, that percentage dropped considerably, Lieberman said.

Eighty-five cases (39 percent) were classified as having a definitive cause. Among these, 28 cases (33 percent) were attributed to alpha-gal. Most of the others were attributed to food allergies (most often shellfish, followed by peanuts, tree nuts, fish, and milk). Causes for the rest included venom, medications, and other allergens.

Another 57 cases (26 percent) were classified as having a probable cause. In this group, 26 percent were most likely due to alpha-gal sensitivity, 35 percent to other food allergies, 23 percent to medication sensitivity, 5 percent to venom, and 11 percent to some other sensitivity.

Experts said the new study is an important heads-up to patients and the medical community. “Providers and patients – especially those living in tick-populated areas – should be aware of the delayed allergic reactions,” Commins said in an email.

Checking for alpha-gal sensitivity may soon become standard of care, said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security in Baltimore, Maryland.

“Patients who experienced anaphylactic shock and didn’t get a good explanation for it should take a look at the Centers for Disease Control and Prevention’s maps and if they live in an area where the lone star tick is common, they should talk to their doctor about investigating whether it was caused by alpha-gal sensitivity,” Adalja said. (bit.ly/2K8f7m2)

SOURCE: bit.ly/2K7zzU4 Annals of Allergy, Asthma and Immunology, online July 30, 2018.

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Shingrix vaccine makes shingles less severe, disruptive to quality of life

(Reuters Health) – The vaccine Shingrix prevents shingles, and if people do contract the virus, it reduces the severity of illness, two company-funded study suggests.

Shingles, also known as herpes zoster, typically develops in older adults who had chicken pox, or the varicella-zoster virus, when they were younger. Its hallmark is a painful rash, which clears up within a month in most cases. In some instances, however, it leads to nerve pain that can linger for much longer and make it harder for people to manage daily tasks.

“We knew that patients who had not received the shingles vaccine, and then suffered a shingles outbreak as well as the pain related to it, would have had their quality of life negatively impacted,” said Erin Adams, a researcher at the Bernard J. Dunn School of Pharmacy at Shenandoah University in Fairfax, Virginia.

“The first shingles vaccine, Zostavax, did show evidence that it reduced the burden of illness and postherpetic neuralgia if a patient ended up getting shingles post vaccination,” Adams, who wasn’t involved in the study, said by email. “It had been theorized that the Shingrix vaccine could lessen the symptoms of the virus itself, but we did not have evidence of how patients who received the Shingrix vaccine and still had a shingles outbreak would respond or what the impact would be on their quality of life before this study was published.”

For the study, a research team including several employees of GlaxoSmithKline, the company that sells Shingrix, compared how often people given Shingrix and or a placebo got shingles, how much pain they endured, and how much they felt the illness contributed to a worse quality of life.

In one late-stage trial, 9 of 7,340 people given Shingrix developed shingles, compared with 254 of 7,413 participants who received a placebo. In another late-stage trial, 25 of 8,250 people given Shingrix developed shingles, compared with 284 of 8,346 subjects who received a placebo.

Researchers calculated that the vaccine was 98 percent effective at reducing the burden of illness in people who did get shingles in one trial, and 92 percent effective at reducing the burden of illness from shingles in the other trial.

In adults 80 and older, the vaccine was just 82 percent effective at reducing the burden of illness, but the absolute amount of reduction was higher in these participants than it was for younger people in the trials.

People who got Shingrix and still developed the virus also reported lower pain over the first 28 days of infection than people who received a placebo, but the difference between the groups wasn’t statistically meaningful on all of the days studied.

One limitation of the study is that the high level of vaccine effectiveness may have left few too people with shingles to detect meaningful differences between outcomes for vaccinated and unvaccinated participants, the authors note in The Journals of Gerontology Series A. The study authors declined requests for comment.

Still, the overall efficacy of the vaccine in reducing the burden of illness, interferences in activities of daily living was greater than 90 percent in patients 50 and older and in a pooled analysis of patients 70 and older, Adams noted.

“The study results are important to note for patients because not only does the vaccine help prevent shingles but it also shows that for patients who get shingles, despite receiving the vaccine (since no vaccine is 100% effective), that their quality of life is less impacted and pain scales are lower in patients compared to those who didn’t get the Shingrix vaccine,” Adams said.

Shingrix won U.S. regulatory approval in 2017 to help prevent shingles in adults 50 and older.

SOURCE: bit.ly/2uQy73N The Journals of Gerontology Series A, online June 27, 2018.

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Teen drivers take more risks after trading learner permits for licenses

(Reuters Health) – Adolescents may be cautious while they’re learning to drive, but a new study suggests they get downright dangerous once their license allows them to hit the road without a grownup in the car.

Teen drivers have long been synonymous with risky maneuvers on the road and plenty of previous research has also found novice drivers have higher crash rates than people with more experience. The current study helps pinpoint when teen driving may be riskiest by using cameras and sensors inside cars to examine driving habits for parents and children over almost two years, starting when teens got their learner’s permits.

While teens only had permits, their chance of being in a crash or nearly missing a collision as well as their odds of exhibiting risky driving behavior like speeding, swerving, and slamming the brakes were similar to the adults, the study found.

In the first year after teens had their licenses, however, they were more than six times more likely to crash or narrowly escape collisions than the adults, and they were also almost four times more likely to exhibit risky driving behaviors.

“Parents are in the vehicle during the learner phase and this makes all the difference,” said lead study author Pnina Gershon, a researcher at the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health in Bethesda, Maryland.

Among other things, parents can help teen drivers stay focused on the road, offer tips on how to drive safely, and help these new drivers avoid dangerous situations, Gershon said by email.

“Even during independent driving, when parents are passengers and presumably are not in the teaching role, teens drive more safely than when they drive alone,” Gershon added. “But on their own, without a parent or adult present, we find that teens’ risky driving behaviors, crash and near crash rates increase dramatically.”

Adolescent drivers have disproportionately higher crash rates than other driver age groups, accounting for six percent of licensed drivers in the U.S. but nine percent of fatal crashes, researchers note in the Journal of Adolescent Health.

The current study included 49 girls and 41 boys who were about 16 years old on average.

During the study, teens drove an average of 5,445 miles and a total of about 490,000 miles. Their parents, meanwhile, drove more than twice as many miles.

As a group, teens had a total of 148 near crashes, 69 collisions, and 9 crashes that were reported to the police. This translated into an average of 2.4 incidents per driver.

By contrast, parents had a total of 84 close calls, 28 collisions, and 2 crashes that were reported to the police. This translated into an average of 1.2 incidents per driver.

Teens also had a total of 18,378 incidents of risky driving, which translated into roughly 108 events per driver. The parents, meanwhile, had 5,272 incidents of risky driving, or about 59 per driver.

For young drivers, the highest rates of crashes, near misses and risky driving occurred in the months immediately after they got licenses and started hitting the road without a parent in the car.

Beyond its small size, the study also wasn’t a controlled experiment designed to prove whether or how parents’ presence in the car might directly improve teen driving safety. Researchers also didn’t follow teens long enough to see how their driving records might change with a few more years of experience.

Even so, the results underscore the importance of parents modeling the behavior they want their teens to have behind the wheel, said Despina Stavrinos, an injury prevention researcher at the University of Alabama at Birmingham who wasn’t involved in the study.

If parents drive recklessly, speed, text while on the road, or fail to buckle up, teens will probably follow suit, Stavrinos said by email.

“Kids are watching and learning and developing their own ideas about what is acceptable driving behavior,” Stavrinos added. “They might be thinking – if mom or dad does it, then it must be safe for me to do it.”

SOURCE: bit.ly/2uV6BSv Journal of Adolescent Health, online July 10, 2018.

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Community Frets As Buyer For Cherished Rural Hospital Slips From View

Confusion is growing in the remote Surprise Valley region of northeastern California as locals wonder whether a Denver entrepreneur will make good on his pledge to save their bankrupt rural hospital.

Surprise Valley Community Hospital, located in Cedarville, Calif., was featured in a June 6 California Healthline story illustrating the plight of strapped rural hospitals and controversial efforts by some to stay solvent through laboratory billing for patients never treated on-site.

Beau Gertz, who owns Denver-based Cadira Labs and other health-related businesses, proposed such a plan, saying faraway patients could be treated through telemedicine. Hospital district residents voted in June to approve his purchase of the 26-bed public hospital for $4 million.

But Gertz hasn’t been seen around town since late spring and websites for his Denver businesses have been shut down, including those for his labs that would presumably do the billing. Four ex-employees, who spoke on condition of anonymity for fear of retaliation, said they and the rest of his Colorado-based staff were laid off.

The entrepreneur’s landlord, David North, said earlier this month that Gertz’s Denver office building has been empty for weeks. Gertz did not respond to emails, texts or phone calls.

Gertz’s low profile in recent weeks has perplexed residents, some of whom struggled over the decision to sell the hospital to an outsider. Some had been suspicious because plans by a previous “white knight” — and former business associate of Gertz’s — to save the hospital through remote lab billing fell through last summer. Also, some were frustrated when Gertz said in a public meeting that he was under no obligation to provide the community with his “financials.”

“I’ve never met a businessman who operated the way he would, investing in something that’s losing money,” said Amy Beller, 63, a retired graphic designer who lives in Cedarville and had talked with Gertz at a town hall meeting. “There was nothing there to make me think he was there to help Surprise Valley. I thought he was disingenuous.”

Members of the hospital district board, which planned to meet Wednesday, have declined to comment on the status of the sale. Hospital administrator Bill Bostic said he had spoken to Gertz several times and that the sale is “on track,” but would not elaborate on the timetable or Gertz’s whereabouts.

“We’re going through a process. It’s complicated, it’s legitimate,” Bostic said. “We’re just trying to keep open, we’re not doing anything underhanded. All we’re trying to do is save our hospital.”

State officials said they have received no application from Surprise Valley to transfer ownership or management of the hospital. The state Department of Public Health must approve all such changes, a process that can take months.

Enticed by out-of-town investors, Surprise Valley and other struggling rural hospitals around the country have embraced lab billing for faraway patients as a rescue plan. That’s because Medicare and commercial insurers tend to pay more for tests to sustain endangered rural hospitals, compared with how much they pay urban hospitals and especially outpatient labs.

In general, this kind of remote billing is controversial and legally murky, and it recently has resulted in allegations of fraud in several states, according to government documents and media reports.

In the run-up to the vote, Gertz described his plan as perfectly legal. He said the hospital, after taking over one of his Denver labs, could legitimately bill for patients treated remotely through video and other telemedicine technology. The idea appealed to many Surprise Valley residents, desperate to save a facility facing imminent closure. Without a buyer, experts said, property owners in the district could have been responsible for repaying the hospital’s mounting debts — estimated at up to $4 million.

The hospital is considered crucial by many residents, largely because of its 24-hour emergency room. These days, all but two of its beds are dedicated to nursing home patients. The next nearest hospital with an ER is about 25 miles away over a mountain pass.

Janna Bennett, 61, a public health nurse who once worked for the hospital, said she still hopes Gertz will deliver on his ideas for a world-class “destination hospital” that he had promised in community meetings.

“If the deal falls through, I’ll be disappointed. I’ll be angry,” she said.

It is not clear whether one of Gertz’s investors, the Knights Genesis Group with offices in New York City, Shanghai and Beijing, continues to back him financially. Eric Cho, who answered the telephone at the firm’s New York office in late June, confirmed that Knights Genesis was working with Gertz but declined to elaborate. No one else from the company since has responded to calls or emails.

If the deal collapses and the hospital cannot find another buyer, residents say it will be a sad end for a facility that opened in 1952 and once was the pride of the community, according to Jim Laacke, a retired forester from Cedarville who once served on the hospital’s board.

“This hospital is an idea, generated by the people who were here and a doctor who was much-loved. It is a thing the community created,” Laacke said. “It’s hard to think about it just disappearing.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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