A “teachable moment” is one way to describe the  consternation that many uninsured people may feel when they file their taxes this spring and realize they owe a penalty for not having health insurance.

According to a new survey, the number of people who may need to be schooled is substantial: Forty-four percent of uninsured people who may be subject to the penalty say they know nothing or only a little about the penalty they may face.

The Urban Institute analysis was based on its December 2014 Health Reform Monitoring Survey of uninsured adults with incomes above the poverty level, a group that might be expected to owe a penalty for not having coverage.

For 2014, the penalty is the greater of $95 or 1 percent of annual income. In 2015, the penalty increases to 2 percent or $325, whichever is greater.

People who don’t become aware of the penalty until they file their 2014 taxes in March or April could end up owing penalties for both years. The open enrollment period to sign up for 2015 health insurance ended Feb. 15.

Consumer advocates have been strongly encouraging the Obama administration to create a special enrollment period for uninsured people who only realize the financial hit they’re facing after open enrollment has ended. While they probably can’t avoid a penalty for being uninsured last year, they could avoid getting dinged again in 2015 if they enrolled this spring.

“These results suggest that a special enrollment period could help a significant percentage of the uninsured get coverage,” says Stephen Zuckerman, co-director of the Urban Institute’s Health Policy Center and a co-author of the analysis.

In addition to being generally unaware of the penalties for not having insurance, 30 percent of those surveyed said they had not heard of the state health insurance marketplaces, while 29 percent said they knew about the marketplaces but didn’t know about the Feb. 15 enrollment deadline.

“There’s a general gap in knowledge,” Zuckerman says. “Looking across the years, there’s a surprising persistence of people who are not aware of the various provisions of the health law.”

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

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 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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