The bacterial outbreak at a Los Angeles hospital highlights shortcomings in the federal government’s efforts to avert the most lethal hospital infections, which are becoming increasingly impervious to treatment.

Government efforts are hobbled, infection control experts say, by gaps in monitoring the prevalence of these germs both within hospitals and beyond. The continued overuse of antibiotics — due to over-prescription by doctors, patients’ insistence and the widespread use in animals and crops — has helped these bacteria evolve into more dangerous forms and flourish.

In the outbreak at UCLA’s Ronald Reagan Medical Center, two patients have died and more than 100 may have been exposed to CRE, an antibiotic-resistant bacteria commonly found in the digestive tract. When this germ reaches the bloodstream, fatality rates are 40 percent. The government estimates about 9,000 infections leading to 600 deaths, are caused each year by CRE, which stands for carbapenem-resistant Enterobacteriaceae.

UCLA Health says the infections probably were passed around by inadequately sterilized scopes used to peer inside a body.

Previous CRE outbreaks have occurred elsewhere in the country, including hospitals in Illinois and Seattle.

The immediate public health response has focused on the safety of the scopes and tracking down people who may have been exposed. The U.S. Food and Drug Administration Thursday issued a warning about the devices. But the California outbreak comes amid the government’s broader struggle to spot and battle the swelling ranks of bacteria that are impervious to most, if not all, antibiotics.

CRE is one of three infectious agents that the Centers for Disease Control and Prevention categorized as the drug-resistant threats that require the most urgent monitoring and prevention. CRE is resistant to almost all antibiotics, including carbapenems, which doctors often deploy as a last resort. The remaining treatments are often toxic. A CDC report found that in the first six months of 2012, nearly 5 percent of hospitals reported at least one CRE infection.

Unlike another urgent threat, Clostridium difficile, known as C. diff, the federal government does not publicly report CRE infection rates at each hospital.

The federal government also does not monitor the prevalence of any of these antibiotic-resistant bacteria beyond health care facilities, although California, Georgia, Minnesota and seven other states do.

“That is an example of a world-class infections system, but it’s only in 10 states,” said Dr. Trish Perl, a senior epidemiologist at the Johns Hopkins Health System in Baltimore, Md.

“We have very targeted sources of information as opposed to an integrated and holistic system,” she said. “It’s like air control towers if you only had data from Chicago and Atlanta.”

People can often carry CRE in their gut without injury, but it can spread outside the gut quickly in people who are taking antibiotics for other ailments or in a weakened state. Lisa McGiffert, director of the Safe Patient Project at Consumers Union, said that the CDC recommends hospitals screen all new patients for CRE but “I find it highly unlikely that many hospitals are doing that.” She noted that UCLA this week notified patients who underwent procedures as long ago as October that they may have been infected.

The federal government has been trying for years to get doctors and hospitals to shrink their use of antibiotics, since their proliferation has helped create these new resistant bacteria strains. The CDC has encouraged hospitals to create antibiotic stewardship programs, where experts systemically try to insure that the bacteria-fighting drugs are the best resource and that there is evidence that they actually work on the specific infection the patient has.

For instance, stewardship programs can discourage doctors from bombarding patients with lots of different antibiotics. Instead, doctors can take an “antibiotic time out” until they get get lab results and reconsider their approach. (UCLA Health has a stewardship program in place.)

California last year mandated hospitals create stewardship programs, but the federal government considers them voluntary. Even the Infectious Diseases Society of America was unable to determine how many hospitals have such a program,  said John Billington, the society’s director of health policy.

The U.S. Centers for Medicare & Medicaid Services has been taking a tougher tactic against hospital infections. Since October, more than 700 hospitals have been receiving lower payments from Medicare if they have higher rates of infections and other injuries. However, that program only tracks two kinds of catheter-related infections, not CRE. It will be another two years before the penalties incorporate rates from two antibiotic-resistant germs that have been around for longer than CRE: C. diff, and methicillin-resistant Staphylococcus aureus, known as MRSA.

“A lot of patients are walking around with CRE and don’t know about it,” said Dr. Anthony Harris, president of the Society for Healthcare Epidemiology of America. “At this point CRE is still a fairly rare event, but this is the time to intervene so you don’t have the magnitude of the problem we have with MRSA.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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In Medical Park hospital in Winston-Salem, North Carolina, Angela Koons is still a little loopy and uncomfortable after wrist surgery. Nurse Suzanne Cammer jokes around with her. When Koons says she’s itchy under her cast, Cammer laughs and says, “Do not stick anything down there to scratch it!”  Koons smiles and says, “I know.”

Cammer is wearing charm-bracelets and jangly earrings, so she literally jingles as she works around Koons. Her enthusiasm for her job puts Koons at ease and is making her hospital stay more comfortable.

“They’ve been really nice, very efficient. Gave me plenty of blankets because it’s really cold in this place,” she says.

A reporter takes a quick informal poll, asking Koons and her stepfather, Raymond Zwack, to rate their satisfaction with the hospital on a 10-point scale.  They both give Medical Park the same rating: a perfect 10.

Other patients — Karen Siburt, George Stilphen and Emily Willard — all agreed. They would rate the hospital a 9 or a 10.

Hospitals take more formal surveys from Medicare very seriously because the Affordable Care Act ties some hospital payments each year to how patients rate the facilities. Medical Park received a $22,000 bonus from Medicare in part because of sterling patient satisfaction surveys.

Novant Health is Medical Park’s parent company, and none of their dozen or so other hospitals even come close to rating that high on patient satisfaction.  Figuring out why Medical Park did so well is complicated.

First, says staff surgeon Scott Berger, this isn’t your typical hospital.

“It kind of feels, almost like a mom-and-pop shop,” he says.

Medical Park is really small, only two floors. Doctors just do surgeries, like fixing shoulders and removing prostates, and mostly for people with insurance.

Another key is that no one at Medical Park was rushed to the hospital in an ambulance or waited a long time in the emergency room; in fact, the hospital doesn’t even have an emergency room. The vast majority of the surgeries done at Medical Park are elective.

“They’re choosing to come here,’’ says Chief Operating Officer Chad Setliff. “They’re choosing their physician.”

These are the built-in advantages small, specialty hospitals have on patient satisfaction, says Chas Roades, a consultant with The Advisory Board Company.

“A lot of these metrics that the hospitals are measured on, the game is sort of rigged against [large hospitals] in a sense just because of the kind of facility they are,” he says.

This is the third year hospitals can get bonuses or pay cuts from Medicare in part because of those scores. They can add up to hundreds of thousands of dollars.

Hospitals that handle many more patients – often massive, noisy and hectic places – are more likely to get penalized, says Roades.

“In particular, the big teaching hospitals, urban trauma centers, those kind of facilities don’t tend to do as well in patient satisfaction because they’re just busy, crowded, [and] there’s a lot of different caregivers that interact with the patients,” he says.

Roades says the patient surveys aren’t perfect, but they are fair: “In any other part of the economy, if you and I were getting bad service somewhere – if we weren’t happy with our auto mechanic or we weren’t happy with where we went to get our haircut – we’d go somewhere else.”.

In health care, patients rarely have that choice. So Roades says hospitals should be assessed in part by patients.

And Medical Park executives say there are ways big hospitals can seem smaller – and raise their scores.

Nurse Gennie Tedder is walking patient Jeremy Silkstone through a pre-surgical visit.  It’s a chance a week or two before surgery to connect with patients and prepare them for what can be a painful process.

“It’s very important that you have realistic expectations about pain after surgery. It’s realistic to expect some versus none,” she explains to Silkstone.

Medical Park now handles this part of surgery prep for some of its parent company’s other, bigger hospitals. Silkstone, for example, will have surgery at the huge hospital right across the street, Forsyth Medical Center.

Medical Park Nursing Director Carol Smith says when her staff took over pre-surgical, “Forsyth’s outpatient surgical scores increased by 10 percent.”

But some doctors and patients who’ve been to both hospitals agree that the smaller one is sure to have higher scores. It’s just warmer and fuzzier, one patient says.

This story is part of a reporting partnership between NPR, WFAE and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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After Pam Durocher was diagnosed with breast cancer, she searched her insurer’s website for a participating surgeon to do the reconstructive surgery.

Having done her homework, she was stunned to get a $10,000 bill from the surgeon.

“I panicked when I got that bill,” said the 60-year-old retired civil servant who lives near Roseville, Calif.

Like Durocher, many consumers who take pains to research which doctors and hospitals participate in their plans can still end up with huge bills.

Sometimes, that’s because they got incorrect or incomplete information from their insurer or health-care provider. Sometimes, it’s because a physician has multiple offices, and not all are in network, as in Durocher’s case. Sometimes, it’s because a participating hospital relies on out-of-network doctors, including emergency room physicians, anesthesiologists and radiologists.

Consumer advocates say the sheer scope of such problems undermine promises made by proponents of the Affordable Care Act that the law would protect against medical bankruptcy.

“It’s not fair and probably not legal that consumers be left holding the bag when an out-of-network doctor treats them,” said Timothy Jost, a law professor at Washington and Lee University. Jost said it’s a different matter if a consumer knowingly chooses an out-of-network doctor.

Durocher learned only after getting her surgeon’s bill that just one of his two offices participated in her plan and she had chosen the wrong one.  She said the doctor’s staff later insisted that they had raised the issue during her initial consultation, but she doesn’t recall that, possibly because she was distracted by her cancer diagnosis.

Adding insult to injury, insurers are not required to count out-of-network charges toward the federal health law’s annual limit on how much of their medical costs patients can be asked to pay out of their own pockets.

Efforts by doctors, hospitals and other health providers to charge patients for bills not covered by their insurers are called “balance billing.” The problem pre-dates the federal health law and has long been among the top complaints filed with state insurance regulators.

Because the issue is complex and pits powerful rivals against one another— among them, hospitals, doctors and insurers— relatively few states have addressed it.  What laws do exist are generally limited to specific situations, such as emergency room care, or certain types of insurance plans, such as HMOs.

The federal health law largely sidesteps the issue as well. It says insurers must include coverage for emergency care and not charge policyholders higher copayments for ER services at non-network hospitals, because patients can’t always choose where they go. While the insurer will pay a portion of the bill, in such cases, doctors or hospitals may still bill patients for the difference between that payment and their own charges.

That means that in spite of having insurance, a consumer involved in a car wreck and taken to a non-network hospital might receive additional bills, not just from the hospital, but from the radiologist who read his X-rays, the surgeon who repaired his broken leg and the laboratory that processed his blood tests.

Networks Get Narrower

Advocates believe a growing number of consumers are vulnerable to balance billing as insurance networks grow smaller in the bid to hold down costs.

For example, there were no in-network emergency room physicians or anesthesiologists in some of the hospitals participating in plans offered by three large insurers in Texas in 2013 and 2014, according to a survey of state data by the Center for Public Policy Priorities, a Texas advocacy group.

Smaller networks are also becoming more common in employer-based insurance: About 23 percent of job-based plans had so-called “narrow networks” in 2012, up from 15 percent in 2007, according to a May report from the Urban Institute and Georgetown University Center on Health Insurance Reforms.

To protect consumers, advocacy groups, including Consumers Union and the American Cancer Society Cancer Action Network, want regulators to strictly limit balance billing when an insured person gets care in a medical facility that is part of an insurer’s network.

“Without protection from balance billing, the cost of out-of-network care can be overwhelming,” wrote Consumers Union in a recent letter to the National Association of Insurance Commissioners (NAIC), which is updating a model law that states could adopt to regulate insurance networks.

NAIC’S current draft does not directly address the issue of balance billing and consumer efforts have drawn sharp opposition from insurers, hospitals and doctors.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

FORT COLLINS, Colo. — When Pavel Poliakov’s small clothing shop in this picturesque college town closed last year, he felt lucky to be able to sign up for Medicaid just as Colorado expanded the program under President Barack Obama’s health law.

But when Poliakov developed such a severe toothache that he couldn’t eat on one side of his mouth, he was unable to find a dentist — even though Colorado had just extended dental benefits to adults on Medicaid.  Eventually, he turned to a county taxpayer-supported clinic that holds a monthly lottery for new patients.

Poliakov, 40, was a three-time lottery loser before his name was chosen in September.  “It was horrible” living with the pain so long, he said as the second of his seven cavities was filled at the dental clinic run by the Health District of Northern Larimer County.

Colorado was one of five states last year to begin offering routine dental coverage to millions of low-income adults in Medicaid — an unprecedented expansion. But like Poliakov, many have had trouble finding dentists willing to treat them because of Medicaid’s low reimbursements, according to providers, advocates and patients.

The upshot is that many Medicaid enrollees continue to live with the pain and discomfort of tooth decay and gum disease, which can exacerbate other health problems, such as heart disease, diabetes and rheumatoid arthritis. Eventually, some go to costly emergency rooms, which can do little but provide short-term pain relief.

“Translating Medicaid coverage into care is a significant problem,” said David Jordan, who directs the dental access project at Community Catalyst, a national consumer advocacy group based in Boston.

“The number of adults on Medicaid who are able to see a dentist is woefully short of where it needs to be.”

Many dentists are reluctant to participate in the government program for low-income Americans because it typically pays as little as half of what they get from patients with private insurance. For example, Medicaid in Colorado pays $87 for a filling on a back tooth and $435 for a crown, compared to the $150 and $800 that private patients typically pay.

While federal law requires states to provide dental coverage to children in Medicaid, adult dental coverage is optional. To save money, almost half the states either don’t provide any dental coverage for adults or cover only emergencies.

In addition to Colorado, California, Illinois and Washington added or restored adult dental benefits last year as they expanded Medicaid eligibility under the health law to those making up to 138 percent of the federal poverty level. The federal government pays the full cost of expansion through 2016, and then no less than 90 percent. The fifth state, South Carolina did not expand Medicaid eligibility, but added adult dental services to improve benefits.

Yet advocates in all five states say providers are struggling to keep up with demand.

“Getting oral health care is difficult, if not impossible, for many of Colorado’s Medicaid clients,” said a report released this month by the nonpartisan Colorado Health Institute, a health policy research organization.  The study found that in the past year, the number of Coloradans eligible for Medicaid dental coverage, including children, tripled to nearly 1 million, while the number of dentists who say they treat Medicaid patients increased by only 17 percent — to 877 practitioners.

Nationally, children on Medicaid also face a shortage of dentists willing to treat them, though the problem is typically not as severe.

Safety net providers in Colorado, such as federally funded community health centers, have tried to fill the gap, but in many places appointments for new patients are gone within hours of becoming available. Eight Colorado counties lack any dentists and seven more don’t have a private dentist who accepts Medicaid or a safety net clinic offering dental services, the study found.

Colorado Medicaid officials say they have enough dentists in most places. “We’ve not had calls from legislators or stakeholders that we flat out can’t get people into dental services,” said Bill Heller, director of the state’s Medicaid dental program.

Still, the state last summer proposed paying dentists a $1,000 bonus for taking five new Medicaid clients and seeing them at least twice a year. But the Obama administration has yet to approve federal incentive money

With little political support to increase reimbursements to dentists, advocates have looked at other ways to boost care. The Colorado Dental Association has urged members to take new Medicaid dental patients to alleviate waits, but it’s unclear how many have done so.

“The economic realities make it difficult,” said Greg Hill, association executive director.

Seeking other alternatives, Alaska and Minnesota have enacted regulations that allow dental therapists with two years of training to perform basic services, such as filling cavities, if they work under a dentist’s supervision. The therapists in those states are much more willing to see Medicaid patients.

But efforts to expand their use in other states have been opposed by the American Dental Association, which raises questions about patient safety.  Dental therapist legislation is pending in Washington and South Carolina, along with several other states.

Meanwhile, patients with Medicaid continue to struggle to get care.

Officials at Promise Healthcare, a community health center in Champaign, Ill., say demand for dental services is so great they frequently turn clients away. Last month, more than 150 people called for one of 12 new patient appointments, said Executive Director Nancy Greenwalt.  “Patients are desperate.”

Christina Peters, of the Washington Children’s Health Alliance, said only about 15 percent of adult Medicaid enrollees in that state received dental care last year after the benefit began.

In Hartsville, S.C., CareSouth , a community health center, has one dentist who’s seen 60 new dental patients in the past month— but more than 400 have sought care.

Alfredo Rodriguez, 51, a Longmont, Colo. landscaper, visited a dentist at the Salud Family Health Center in February with several loose and broken front teeth that made it hard to eat. “I’m so thankful to be here,” he said while waiting to get three teeth pulled and to be fitted for a partial denture.

The North Larimer County Health District dental clinic gets between 150 and 300 people entering its lottery each month, hoping to qualify for 50 or 60 slots.  Over half the clinic’s 5,000 patients are on Medicaid.

Rob Gartland, a clinic dentist, says the value of Medicaid is that patients can afford more expensive procedures, such as crowns and root canals, rather than just extractions.

In Fort Collins at least, Medicaid patients will soon get more help when Salud’s clinic here adds a dentist later this winter.

Sitting in the center’s waiting area recently, Tiffany Rickman, 23, said she would definitely use the service. She says she feels pain every time she eats, but has been unable to get care. “I would really like to get into a dentist and have a place where I can be a regular patient,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Obama administration often touts the health benefits women have gained under the Affordable Care Act, including the option to sign up for coverage outside of open enrollment periods if they’re “having a baby.”

But advocates complain the special insurance enrollment period begins only after a birth. As a result, uninsured women who learn they are pregnant outside of the regular three-month open enrollment period, which this year ended Sunday, can get stuck paying thousands of dollars for prenatal care and a delivery — or worse, going without  care.

The advocacy groups, including the March of Dimes, Planned Parenthood and Young Invincibles, are asking the administration to allow women to sign up whenever they become pregnant – a change opposed by the insurance industry. They say they’ve sought the change unsuccessfully for several years.

Cynthia Pellegrini, senior vice president of March of Dimes, notes that about half of pregnancies are unintended. And women often can’t predict when they will have a challenging pregnancy requiring more services.

The advocates have applauded the health law for including maternity coverage among the list of “essential benefits.” But they say that allowing women to get covered as soon as they’re pregnant would give them and their unborn children greater protection. It would also allow those with high-risk pregnancies to change plans to get more comprehensive coverage that might include access to certain hospitals and doctors.

The health insurance industry contends that allowing reproductive-age women to enroll any time they become pregnant would give women an incentive to wait to buy coverage.

“If you only create incentives for people to enroll when they have a health need, it poses a tremendous risk to the risk pool and affordability for everyone else,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, the industry’s trade group.  She said insurers would have more difficulty setting their prices because it would be harder to predict who would buy coverage.

Before the Affordable Care Act, individual insurance policies rarely included maternity coverage — and women could not buy policies after they became pregnant. Today, they can buy such coverage during open enrollment.

A spokesman from the Department of Health and Human Services declined to comment.

The Obama administration allows people to enroll outside of the regular enrollment period in several circumstances, including after adopting or having a child, losing other coverage, moving out of a plan’s service area or getting married. The list of so-called “qualifying events” is similar to the circumstances that allow people with employer-sponsored insurance to change their coverage outside of open enrollment. The administration last week said it was considering adding a special enrollment period for people who discover they owe a tax penalty due to lack of coverage.

“If you have to spend $10,000 to $20,000 out of pocket on maternity care, it certainly puts women in a difficult position and insurance coverage [after a child’s birth] would be coming too late for them,” said Christina Postolowski, health policy manager for Young Invincibles, the nonprofit which has worked with the administration to boost enrollment.

The group is releasing a report Wednesday that looks at the economic and health consequences of not making pregnancy “a qualifying event” to sign up for coverage any time.

Without access to a health plan, women may be more likely to forgo prenatal care because they can’t afford it, which can put them at higher risk for conditions than can affect their own health as well as that of their child, such as pregnancy-related diabetes and high blood pressure, the report said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.