But physicians, dentists, ambulance companies, and other health care providers are still taking their patients to court, a Connecticut Mirror-Â鶹ŮÓÅ Health News investigation of state legal records shows.

Lawsuits by doctors and other nonhospital providers now dominate health care collections in Connecticut, the records show, accounting for more than 80% of cases filed against patients and their families in 2024.

That’s a major reversal from just five years earlier, when hospital system lawsuits made up three-quarters of health-related collection cases in the state’s courts.

The shift is moving medical debt collections into a less regulated realm. Most hospitals, because they are tax-exempt nonprofits, must make financial aid available to low-income patients and follow federal regulations that limit aggressive collection activities. Other medical providers, such as private medical groups, are generally exempt from these rules.

The lawsuits are typically over bills of less than $3,000, but the impact on patients can be devastating. Lawsuits are among the most ruinous byproducts of a health care debt problem that burdens an estimated 100 million people in the U.S.

Lawsuits can lead to garnished wages, liens on homes, and hundreds of dollars of added debt from interest and court fees. They also pile additional financial strains on struggling families, prevent patients from getting needed care, and sap trust in medical providers.

“It’s really messed up,” said Allie Cass-Wilson, a nurse in Bristol, Connecticut, who was sued over a $1,972 debt by an OB-GYN practice where she’d been a patient years earlier. “How can they do that to people?” She did not contest the lawsuit, court records show.

Cass-Wilson, who is 36 and lives in a small apartment just off an expressway on-ramp, said she learned of the outstanding debt only when she was sued. When she tried making an appointment, she said, she was told her doctor wouldn’t see her. “They said I was blacklisted,” Cass-Wilson said. “I was so confused. I couldn’t believe that my medical provider let my care be interrupted like this.”

Cass-Wilson ultimately sought medical care elsewhere.

Radiologists, Dentists, Ambulances

Overall, CT Mirror and Â鶹ŮÓÅ Health News identified more than 16,000 health care-related debt cases in Connecticut courts from 2019 to 2024. The database was assembled from online court records with the help of January Advisors, a data science consulting firm that helped extract and sort the data.

Over the six-year period, most of Connecticut’s more than 25,000 did not pursue patients in court for outstanding balances.

But records show that more than 400 medical providers, including several hospital systems, sued their patients. Among those filing lawsuits were radiologists, anesthesiologists, eye doctors, podiatrists, allergists, and pediatricians.

Dentists, periodontists, and other dental providers filed more than 1,000 lawsuits against patients. And ambulance companies sued more than 140 people.

Med-Aid, a company based outside New Haven, Connecticut, that provides orthopedic braces and other medical supplies to patients, sued more than 400 people, the court records show. The company’s president, Frank Dilieto, did not respond to repeated interview requests.

Cass-Wilson was sued by Briar Rose Network in Bristol, Connecticut, a member of a large network of OB-GYN practices across Connecticut called Physicians for Women’s Health. The network’s members sued close to 100 patients in 2024, records show.

Paula Greenberg, CEO of Women’s Health Connecticut, a private equity-backed company affiliated with Physicians for Women’s Health that manages business operations for the network, said the lawsuits represent a small fraction of the more than 300,000 patients the network sees every year.

“This is an organization committed to patients,” Greenberg said. She noted that the group offers options to help patients pay, including installment plans and financial aid.

Geoffrey Manton, president of Naugatuck Valley Radiological Associates, said his practice also will work with people who say they can’t pay. But, he said, patients sometimes stop responding to their bills.

“Hiding from your problems isn’t going to solve them,” Manton said. “If we didn’t take any action, there could be that person that is in that late-model Mercedes that just chooses not to pay any bills.” The group sued more than 125 patients from 2019 to 2024, according to the court records.

Many medical providers say that aggressive collections stem from the growing prevalence of high-deductible health plans that leave patients with thousands of dollars of bills before their coverage kicks in.

Greenberg and Manton said each of their physician groups must collect. “This is a business,” Greenberg said. “We have to look at our operating costs.”

Critics of medical collection lawsuits note that the patients are typically sued over relatively small debts that are likely to have little impact on multimillion-dollar medical practices.

The average patient debt that members of Physicians for Women’s Health sued over in 2024 was less than $1,100, court records show. The physician group’s annual revenues are typically in the tens of millions of dollars, according to Greenberg.

Even relatively small debts — which often include interest — can place substantial burdens on families struggling to keep up with their bills, especially while dealing with a serious illness, patient advocates say.

“We don’t have a realistic choice in using health care,” said Lisa Freeman, who heads the Connecticut Center for Patient Safety and has advocated for patients struggling with medical bills. “To then get sued for it, when people have less and less funds available for anything extra, that’s very disheartening.”

A Stroke, Then a Lawsuit

Matthew Millman, 54, lost his job as an IT support worker after having a stroke. Then Meriden Imaging Center sued him over an $1,891 bill.

Millman and his wife said they tried to explain their financial situation to the center, which is affiliated with Midstate Radiology Associates, a large physician group that operates imaging centers and doctors’ offices across Connecticut.

“It was very frustrating,” said Millman, who lives in an aging apartment owned by his wife’s family in New Britain. Millman, his wife, and their teenage daughter are barely getting by on his two part-time jobs — one bagging groceries, the other helping homebound seniors. Together, the jobs pay about $1,500 a month, he said.

The imaging center, after winning the collection case against Millman, tried to garnish his wages, though that was unsuccessful because Millman had lost his IT job.

“It’s all about money,” Millman said, shaking his head. “If you are trained in helping somebody with their health, it shouldn’t be about the money first. It should be about their health.”

Court records show that Midstate Radiology, Meriden Imaging Center and affiliates filed more than 1,000 collection lawsuits against patients from 2019 to 2024, making them the most litigious nonhospital providers in the state. As is common in medical debt lawsuits, the plaintiffs prevailed in most cases, records show.

Midstate president Gary Dee, a radiologist, didn’t respond to emails and messages left at his West Hartford office.

Across town from Millman’s apartment in New Britain, Joseph Lentz lives in a cramped apartment with his wife and daughter. He used to oversee operations at a Boy Scout camp but is now unemployed. Lentz lost his job during the pandemic. The family home went into foreclosure, he said.

In 2023, Orthopedic Associates of Hartford sued Lentz over a $3,644 bill the practice said he owed after having shoulder surgery in 2018.

“I’d pay it if I could, I guess,” said Lentz, 59. “But I don’t even know where next month’s rent is coming from. I’m trying to climb out as best I can. I guess this is just one more thing to shovel in.”

The orthopedic group filed more than 580 lawsuits against patients from 2019 to 2024, prevailing in most, records show.

The medical group declined interview requests. But chief executive David Mudano said in a statement: “As an independent physician practice, we strive to balance compassion for patients with the financial responsibility required to sustain our practice.”

Old Debts and Disputed Claims

Lentz, who did not contest the lawsuit, said he has no reason to doubt he owes the debt. But in many cases reviewed by CT Mirror and Â鶹ŮÓÅ Health News and in interviews, patients being sued questioned the accuracy of their medical bills, citing care they thought health insurance should have covered or, in some cases, bills for services they never received.

This reflects with aggressive collection tactics like lawsuits when disputes over the accuracy of medical bills and delayed or denied insurance claims are so widespread in American health care.

A by the federal Consumer Financial Protection Bureau found that nearly half of the medical debt complaints fielded by the agency involved bills that consumers said were erroneous in some way or that consumers said they’d already paid.

“We know people are billed incorrectly,” said Lester Bird, who studies debt collection lawsuits at the nonprofit Pew Charitable Trusts. Bird noted that courts are ill equipped to sort through disputed medical charges or insurance claims, especially when there is little documentation in most debt collection lawsuits.

“It’s complicated before it gets to the courts,” Bird said, “and it’s very complicated when it gets into the courts.”

This can create headaches for physicians and other providers. But billing problems ultimately affect patients and their families most, said Connecticut state Sen. Saud Anwar, a Democrat who is also a physician. “Patients are left to deal with it.”

Andrew Skolnick, an attorney in Milford, outside New Haven, was sued in 2023 by an imaging center where his wife had received services in 2020.

Skolnick said that when the couple, who were covered through his job-based insurance, originally received the bill from Diagnostic Imaging of Milford, he tried to tell the imaging center it had submitted the claim to the wrong insurance plan, but he said they wouldn’t speak with him.

The center later filed the lawsuit, alleging he owed more than $2,000, plus almost $300 in interest.

Despite interview requests, officials at Diagnostic Imaging of Milford did not comment for this article.

Unlike most patients who are sued, Skolnick had the resources and expertise to contest the suit. He said he offered to pay what would have been his responsibility under the plan if the imaging center had filed his claim correctly. He ultimately settled for $1,700, court records show.

“It wasn’t a tremendous amount, but I knew that they had made a mistake,” Skolnick said. “The system is not working.”

More Protections?

Anwar, the state lawmaker and physician, expressed concern that lawsuits undermine patients’ faith in their doctors.

“It’s a sacred relationship,” he said. “If your physician, who is taking care of you, is suing you for money, that’s a problem.

Many hospitals, facing bad publicity from suing patients, have stopped taking patients to court over unpaid bills. Hospital collection lawsuits identified by CT Mirror and Â鶹ŮÓÅ Health News in Connecticut court records plunged from more than 4,900 in 2019 to fewer than 300 in 2024.

Also, in recent years, several states, including Connecticut, have expanded protections for patients with bills they can’t pay.

Connecticut now from consumer credit reports, and legislators are pushing to get hospitals to provide more financial aid to patients. Other states have restricted the use of wage garnishment and property liens to collect medical debt.

But state efforts to rein in aggressive medical debt collections have mostly focused on hospitals. That may need to change, said Connecticut state Sen. Matt Lesser, a Democrat who co-chairs the legislature’s Human Services Committee.

He is a key backer of a bill that would bar hospitals from billing patients who receive public benefits like food assistance or who make less than twice the federal poverty level, about $32,000 for an individual.

The restriction would not apply to bills from physicians and other nonhospital providers, however. “We may have to go bigger if that’s where the heart of the matter is,” Lesser said.

Connecticut Gov. Ned Lamont, a Democrat who spearheaded an initiative to for more than 150,000 state residents, also expressed concern about physicians suing the people in their care.

“Everyone should do the right thing by patients,” he said.

This article was produced in partnership with , a statewide nonprofit newsroom that covers public policy and politics.

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One name repeatedly crops up in these discussions: Valley Medical Group.

With four locations in the Connecticut River Valley, the practice has been a mainstay of family medicine since the 1990s. Valley Medical’s flagship office in Florence can be found right on Main Street, next door to a pizza restaurant and near a Friendly’s.

Valley has 90 medical providers — including doctors, nurse practitioners, and physician assistants — and on-site labs, X-rays, and vision care. With tens of thousands of patients, it’s become one of the largest independent practices in western Massachusetts.

It forms a key part of the region’s health care infrastructure, yet Valley Medical has rarely been under more strain than it is now. In January, the practice laid off 40 employees — 10% of its 400-person staff — mostly in support positions.

Despite patient demand — there are waiting lists to be seen — primary care providers take on more clinical responsibilities, and for less pay, than most medical specialists, said the group’s CEO, primary care physician . Rates are outlined in the group’s contracts with insurance providers.

“It has to do with the fact that our contracts don’t pay as well as we think they should,” Carlan said. “The cost of everything is going up.”

Valley Medical Group is far from alone in this predicament. Thousands of primary care practices, a key gateway to the medical system, are fighting to remain financially viable — and independent.

In response, many are banding together to form or IPAs. The goal is to increase their market power, change the way they get paid, and retain control over how they treat patients.

Threats to Physician Autonomy

Primary care practices in the U.S. are in serious trouble, according to workforce surveys. The American Association of Medical Colleges of up to 86,000 primary care doctors by 2036, as more primary care doctors retire and fewer enter the field.

The number of people who can’t find a primary care doctor has grown by 20% in the past decade, according to a .

Lower relative salaries and higher professional stress are disincentives when medical students consider a career in primary care. Newly minted doctors can earn more in specialties such as cardiology or surgery.

Financial stresses in U.S. health care, exacerbated by the covid pandemic, have led to the closure of many primary care practices, according to the AAMC.

The released a report in 2025 partly blaming the crisis on the relatively low insurance reimbursement rates for primary care. The revenue problem for primary care is projected to get worse when the Republican-backed cuts to Medicaid start to take effect later this year.

As they seek financial security, many primary care practices have merged with large hospital systems, with doctors becoming employees of those systems.

But the doctors at Valley Medical Group were determined to avoid that fate. Joining a health system takes away the to make the best clinical decisions for their patients, Carlan said. It also siphons off income into the larger hospital system.

“Our priorities get muddled up,” he said. “And I think when you’re part of a health system, you’re constantly being asked to bend for the needs of the organization. Hospitals get paid when their beds are full.”

By contrast, primary care providers need time and money to manage or prevent illness, Carlan said, and their insurance reimbursement rates should take that into account.

In December, Valley Medical Group announced it would be . Like a union, an IPA combines individual primary care offices, giving them power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies.

“It’s a moment of transition,” said Lisa Bielamowicz, chief clinical officer of , an independent health care consultancy that works with health systems and physician groups.

IPAs are gaining momentum as older doctors retire, especially following the challenging years of the covid pandemic, Bielamowicz said. “As the baby boomers move out and younger physicians take leadership roles, these kinds of models become more attractive.”

The , a trade group, is hearing from practice owners who joined hospital systems but now want to break off and return to being a smaller practice.

“So if independent IPAs can create the infrastructure support to make independent practice viable, then that’s a good thing,” said , a vice president at AAFP.

IPAs can bring more clout to the table when negotiating rates with insurance companies. Some insurers say they like working with these partnerships because they help stabilize primary care practices, maintaining access and options for insured patients.

Otherwise, some doctors shift their business model to “direct primary care,” which bypasses insurance altogether.

“We’re looking at independent practices that aren’t buoyed by …. these large health systems and can support members in the community in the ways that they want to be supported,” said , a vice president with .

A Different Payment Model

When those independent practices band together, Glenn said, Blue Cross can offer . Instead of getting a payment for each visit or procedure, the medical practice is given a budgeted amount for each patient’s care, which provides an incentive to keep them healthy so they need fewer treatments.

Medical providers “make different kinds of choices than they would if they’re paid for every procedure, every visit, every widget,” TrustWorks’ Bielamowicz said.

If there is money left at the end of the year, it’s split between the practice and the insurer.

The catch, Glenn said, is that a value-based contract works only if there’s a big enough pool of patients to spread out the risk, in case a few get really sick. Otherwise, she said, “the risk of ending up above or below the budget becomes somewhat subject to random variation rather than performance.”

Value-based contracts were supposed to be the next big thing when the Affordable Care Act passed in 2010, an innovative way to bring costs down for the health system as a whole.

But they were slow to catch on; the traditional fee-for-service payment model was too entrenched. Experts say that could still change, if enough primary care providers work together to build market power through IPAs.

“If we keep people out of the ER, keep them out of unnecessary hospitalizations, we save money for the system,” said Chris Kryder, CEO of in Cambridge, Massachusetts, the IPA specializing in value-based contracts that Valley Medical joined. “And we create more income for the PCPs [primary care providers], which is dreadfully needed.”

These contracts also allow more flexibility in staffing, Kryder said, because nurses, physical therapists, and medical assistants can take on some of the less complex medical tasks, saving the practice money.

IPAs Can Help, Depending on Who’s in Charge

But IPAs are not a panacea for primary care’s problems, according to some health care leaders.

There are hundreds of IPAs, but not all offer the independence and autonomy that many doctors crave. Some IPAs are actually owned by hospital systems, or even private equity companies, and they’re less focused on preventive care.

The American Academy of Family Physicians advises its members to seek out IPAs with “integrity,” ones that give doctors a strong role in decision-making.

“Who’s calling the shots, who’s making the decisions, and is it really focused on the best interests and long-term benefit of physicians in practice and their patients?” asked AAFP’s Johnson.

Arches Medical is owned entirely by physicians and focused specifically on primary care, Kryder said. But to be more effective, Arches needs to recruit more practices that want value-based contracts.

That can be a hard sell, said Glenn, of Blue Cross. Under that payment model, doctors might see a lag of more than a year from the time they provide care to the moment they realize savings.

“It doesn’t happen overnight, and it does take an investment,” she said.

That lag is one reason Valley Medical Group had to lay off staff after joining the Arches IPA, said CEO Carlan. But he has faith that, after some time, the practice will become more financially stable, be able to offer higher salaries, and, most important, keep the doctors in charge.

This article is from a partnership with and .

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Â鶹ŮÓÅ Health News senior correspondent Renuka Rayasam discussed excited delirium on Vox Media Podcast Network’s Criminal on March 6.

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On CBS News’ CBS Mornings on March 5, Céline Gounder, Â鶹ŮÓÅ Health News’ editor-at-large for public health, discussed the Massachusetts governor’s retort to comments by Health and Human Services Secretary Robert F. Kennedy Jr. about popular coffee chains.

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Â鶹ŮÓÅ Health News Southern California correspondent Claudia Boyd-Barrett discussed how family members and lawyers of those in Immigration and Customs Enforcement custody are struggling to find them in California hospitals on CapRadio’s Insight With Vicki Gonzalez on Feb. 25.

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Â鶹ŮÓÅ Health News chief rural correspondent Sarah Jane Tribble discussed major cuts to Medicaid on WBUR’s Here & Now on Feb. 19. Tribble also discussed Alabama’s plan for robotic ultrasounds on The Daily Yonder’s The Yonder Report on Feb. 19.

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Listen: More than 2 million Americans could benefit from PrEP, but only about a quarter of them are getting the HIV prevention medication. On Feb. 4, during WAMU’s “Health Hub,” Â鶹ŮÓÅ Health News reporter Zach Dyer shared tips for overcoming common hurdles to care.

Billing mistakes. Stigma. Doctors who aren’t keeping up with the latest research. Those are just some of the hurdles that for many Americans.

The Centers for Disease Control and Prevention estimates more than 2 million Americans could benefit from a treatment known as PrEP, but only a quarter of them are getting a form of the drug. Zach Dyer appeared on WAMU’s “Health Hub” on Feb. 4 to share tips patients can use to avoid those pitfalls and find a doctor who knows more about PrEP.

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During procedures, he seemed “hesitant, not sure of how to go on to the next step without being prompted” by assistants, said Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore.

The chief of surgery, concerned about the doctor’s cognition, “would not sign off on his credentials to practice surgery unless he went through an evaluation,” Katlic said.

Since 2015, when Sinai inaugurated a screening program for surgeons 75 and older, about 30 from around the country have undergone its comprehensive two-day physical and cognitive assessment. This surgeon “did not come of his own accord,” Katlic recalled.

But he came. The tests revealed mild cognitive impairment, often but not necessarily a precursor to dementia. The neuropsychologist’s report advised that the surgeon’s difficulties were “likely to impact his ability to practice medicine as he is doing presently, e.g. conducting complex surgical procedures.”

That didn’t mean the surgeon had to retire; a variety of accommodations would allow him to continue in other roles. “He retained a lifetime of knowledge that had not been impacted by cognitive changes,” Katlic said. The hospital “took him out of the OR, but he continued to see patients in the clinic.”

Such incidents are likely to become more common as America’s physician workforce ages rapidly. In 2005, more than 11% of doctors who were seeing patients were 65 or older, the American Medical Association said. Last year, the proportion reached 22.4%, with nearly 203,000 older practitioners.

Given physician shortages, especially in rural areas and key specialties like primary care, nobody wants to drive out veteran doctors with skills and experience.

Yet researchers have documented “a starting in their mid-60s,” said Thomas Gallagher, an internist and bioethicist at the University of Washington who has studied late-career trajectories.

At older ages, reaction times slow; knowledge can become outdated. Cognitive scores vary greatly, however. “Some practitioners continue to do as well as they did in their 40s and 50s, and others really start to struggle,” Gallagher said.

A few health organizations have responded by establishing mandating that older doctors be screened for cognitive and physical deficits.

UVA Health at the University of Virginia began its program in 2011 and has screened about 200 older practitioners. Only in four cases did the results significantly change a doctor’s practice or privileges.

Stanford Health Care launched its late-career program the following year. Penn Medicine at the University of Pennsylvania also put in place a testing program.

Nobody has tracked how many exist; Gallagher guesstimated as many as 200. But given that the United States has more than 6,000 hospitals, those with late-career programs constitute “a vast minority,” he said.

The number may actually have shrunk. A federal lawsuit, along with the profession’s lingering reluctance, appears to have put the effort to regularly assess older doctors’ abilities in limbo.

Late-career programs typically require those 70 and older to be evaluated before their privileges and credentials are renewed, with confirmatory testing for those whose initial results indicate problems. Thereafter, older doctors undergo regular rescreening, usually every year or two.

It’s fair to say such efforts proved unpopular among their intended targets. Doctors frequently insist that “‘I’ll know when it’s time to stand down,’” said Rocco Orlando, senior strategic adviser to Hartford HealthCare, which operates eight Connecticut hospitals and began its late-career practitioner program in 2018. “It turns out not to be true.”

When Hartford HealthCare published data from the first two years of its late-career program, it reported that of the 160 practitioners 70 and older who were screened, .

That mirrored results from Yale New Haven Hospital, which instituted mandatory cognitive screening for medical staff members starting at age 70. Among the first 141 Yale clinicians who underwent testing, that were likely to impair their ability to practice medicine independently,” a study reported.

Proponents of late-career screening argued that such programs could prevent harm to patients while steering impaired doctors to less demanding assignments or, in some cases, toward retirement.

“I thought as we got the word out nationally, this would be something we could encourage across the country,” Orlando said, noting that Hartford’s program cost only $50,000 to $60,000 a year.

Instead, he has seen “zero progress” in recent years. “Probably we’ve gone backward,” he said.

A key reason: In 2020, the federal over its testing efforts, charging age and disability discrimination. The legal action continues (the EEOC declined to comment on its status), as does the hospital’s late-career program.

But the suit led several other organizations to pause or shut down their programs, including those at Hartford HealthCare and at Driscoll Children’s Hospital in Corpus Christi, Texas, while few new ones have emerged.

“It made lots of organizations uncomfortable about sticking their necks out,” Gallagher said.

Instituting later-career programs has always been an uphill effort. “Doctors don’t like to be regulated,” Katlic acknowledged. Late-career programs have “in some cases been very controversial, and they’ve been blocked by influential physicians,” he said.

As health systems wait to see what happens in federal court, most national medical organizations have recommended only voluntary screening and peer reporting.

“Neither works very well at all,” Gallagher said. “Physicians are hesitant to share their concerns about their colleagues,” which can involve “challenging power dynamics.”

As for voluntary evaluation, since cognitive decline can affect doctors’ (or anyone’s) self-awareness, “they’re the last to know that they’re not themselves,” he added.

In a recent , Gallagher and his co-authors recommended procedural policies to promote fairness in late-career screening, based on an analysis of such programs and interviews with their leaders.

“How can we design these programs in a way that’s fair and that therefore physicians are more apt to participate in?” he said. The authors emphasized the need for confidentiality and safeguards, such as an appeals process.

“There are all sorts of accommodations” for doctors whose assessments indicate the need for different roles, Gallagher noted. They could adopt less onerous schedules or handle routine procedures while leaving complex six-hour surgeries to their colleagues. They might transition to teaching, mentoring, and consulting.

Yet a substantial number of older doctors head for the exits and retire rather than face a mandated evaluation, he said.

The future, therefore, might involve programs that regularly screen every practitioner. That would be inefficient (few doctors in their 40s will flunk a cognitive test) and, with current tests, time-consuming and consequently expensive. But it would avoid charges of age discrimination.

Faster reliable cognitive tests, reportedly in the research pipeline, may be one way to proceed. In the meantime, Orlando said, changing the culture of health care organizations requires encouraging peer reporting and commending “the people who have the courage to speak up.”

“If you see something, say something,” he continued, referring to health care professionals who witness doctors (of any age) faltering. “We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’”

The New Old Age is produced through a partnership with .

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Health policy changes in Washington will ripple through the country, resulting in millions of Americans losing their Medicaid or Affordable Care Act coverage. But there are still ways to find care.

Over the next decade, the GOP’s One Big Beautiful Bill Act is expected to slash nearly $1 trillion in spending from Medicaid, the state-federal program for people with low incomes and disabilities. The implementation of new work rules will cause some beneficiaries to lose their Medicaid coverage.

Millions of Americans are facing enormous increases in their out-of-pocket costs for ACA coverage. So far, 1.2 million fewer people have signed up for Obamacare plans compared with last year, and health policy analysts estimate more will lose coverage as they fail to pay their premiums.

Health costs are a top concern for Americans. Two-thirds of the public say they are somewhat or very worried about affording health care, more than express the same worries about utilities, food, housing, or gas, according to a , a health information nonprofit that includes Â鶹ŮÓÅ Health News.

“All of this pain just doesn’t have to be there,” said Cheryl Fish-Parcham, director of private coverage at the health consumer group Families USA.

Doctors and health policy researchers say health coverage, of any kind, is the best protection against major medical debt.

Caitlin Donovan, a senior director at the Patient Advocate Foundation, recommends exhausting every available option for health coverage before going uninsured.

Even a high-deductible plan can protect patients from medical bankruptcy “if the absolute worst-case scenario happens,” she said.

Here are five ways that the uninsured can find affordable care.

1. Don’t be afraid to talk with your doctor about money

Patients can be hesitant to tell their doctors they’re uninsured or be wary of expressing concern about being able to afford care.

But some hospitals, physicians, and other providers offer cheaper cash pay options, said Cynthia Cox, a senior vice president and the director of the Program on the ACA at Â鶹ŮÓÅ.

Often prices are negotiable. “Always ask,” she said.

Health care providers can make adjustments if they know patients are worried about money, said Ateev Mehrotra, a doctor and researcher at Brown University.

“If my patient tells me, ‘Doc, I’m gonna have to pay for this out-of-pocket,’ I’m gonna make a different risk calculus,” Mehrotra said.

That doesn’t mean a patient won’t get the care they need, he said. A doctor, for instance, might order an ultrasound instead of an MRI, which is more expensive.

2. Search for providers that specifically work with uninsured patients

If your usual provider won’t budge on prices, then search for providers that cater to patients without insurance.

Federally qualified health centers, or FQHCs, and other community clinics offer routine and non-emergency care, such as treatment for flu or infection, for low-income residents and the uninsured. Community health centers charge based on a sliding scale and see annually in some of the country’s most underserved areas, according to the National Association of Community Health Centers.

The Trump administration has made funding cuts that might lead some of the country’s approximately 1,500 FQHCs to close or cut services. But the administration still maintains .

Planned Parenthood also accepts uninsured patients. Its centers test for sexually transmitted diseases, provide birth control options, and offer postpartum and gender-affirming care .

And the National Association of Free & Charitable Clinics also offers to help people find free or low-cost care.

Most community clinics don’t offer specialty care, but they can usually refer patients who need more intensive services to providers willing to work with uninsured patients.

And academic medical centers tend to have more charity care programs that help uninsured patients lower their bills.

“If you’re uninsured or even underinsured, you might be able to qualify for a significant discount on the cost of your care,” Cox said.

Still, be wary of heading to the emergency room, which is the most expensive place to get care. While ERs are federally required to stabilize all patients regardless of their ability to pay, they can still leave you with a big bill — and often do.

3. Call your local health department

Health services vary widely from county to county, but many offer free vaccinations, family planning services, and testing for sexually transmitted infections, as well as for flu, covid, and tuberculosis.

Some county health departments also offer more advanced care, such as dental services and mental health or substance abuse programs. And some states have consumer assistance programs that can guide residents in finding care, Fish-Parcham said.

In addition, the Centers for Disease Control and Prevention’s makes free or low-cost breast and cervical cancer screenings available to low-income women in all states and territories. And some states cover screenings for other types of cancer as well.

4. It’s easier to shop around for drugs than doctors

Don’t just fill your prescription at the closest pharmacy. Instead, research generic drug options and look around for the best price on brand names.

A handful of sites such as and offer comparison shopping tools and information on other ways to get drug discounts.

And some retailers offer low-cost access to common prescription drugs — at prices cheaper than you would find if you had insurance. Walmart, for instance, sells 90-day prescriptions of of drugs for $10. As do , , and a new site called the .

Many drugmakers also offer patient assistance programs, coupons, and rebates on some medications. Check their websites for details on how to apply.

States also offer drug assistance programs. The steps to qualify and types of drugs vary, but has a list of programs and how they work.

Joining a clinical trial is another way to access treatment. The and its have lists, but patients must first meet the criteria. Clinical trials aren’t necessarily free, even with insurance, Donovan said, so be sure to ask about any associated costs.

5. Your diagnosis might lead you to specialized resources

Patients with a specific diagnosis might have additional options for specialty treatment.

For example, someone with breast cancer should check with the and the nonprofit , Cox said.

The Patient Advocate Foundation hosts that can help offset the cost of medical bills and provide other resources such as transportation and lodging, Donovan said. Just type in basic information such as age, location, and diagnosis to see what is available.

Disorder-specific foundations, such as those for lupus or irritable bowel syndrome, can also steer patients to free or low-cost resources or cover some costs of care, Donovan said.

“Everything is out there,” she said.

As you research affordable care options, don’t be tricked by plans that look like health insurance but don’t offer guaranteed protection against big bills.

Some short-term plans and health care sharing ministries might seem like good deals, but read the fine print. Some red flags to look for: too-good-to-be-true monthly payments; no coverage for preexisting conditions; morality clauses such as those prohibiting the use of alcohol or drugs; or a lack of coverage for benefits such as mental health counseling that are required in ACA plans.

Â鶹ŮÓÅ Health News correspondent Sam Whitehead contributed to this report.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact Â鶹ŮÓÅ Health News and share your story.

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MacDonald wanted to find a new doctor right away. She needed refills for her blood pressure medications and wanted to book a follow-up appointment after a breast cancer scare. 

She called 10 primary care practices near her home in Westwood, Massachusetts. None of the doctors, nurse practitioners, or physician assistants was taking new patients. A few offices told her that a doctor could see her in a year and a half or two years.

“I was just shocked by that, because we live in Boston and we’re supposed to have this great medical care,” said MacDonald, who is in her late 40s and has private health insurance. “I couldn’t get my mind around the fact that we didn’t have any doctors.”

The shortage of primary care providers is a , but it’s particularly acute in Massachusetts. The state’s primary care workforce is shrinking faster than in most states, according to a .

Some health networks, including the state’s largest hospital chain, , are turning to artificial intelligence for solutions.

In September, right when MacDonald was running out of blood pressure medications, MGB launched a new AI-supported program, . MacDonald had received a letter from MGB, telling her no primary care providers in the network were taking new patients for in-person care. At the bottom of the letter was a link to Care Connect.

MacDonald downloaded the app and requested a telehealth appointment with a doctor. She then spent about 10 minutes chatting with an AI agent about why she wanted to see a physician. Afterward, the AI tool sent a summary of the chat to a primary care doctor who could see MacDonald by video.

“I think I got an appointment the next day or two days later,” she said. “It was just such a difference from being told I had to wait two years.”

Round-the-Clock Convenience

MGB says the AI tool can handle patients seeking care for colds, nausea, rashes, sprains, and other common urgent care requests, as well as mild to moderate mental health concerns and issues related to chronic diseases. After the patient types in a description of the symptoms or problem, the AI tool sends a doctor a suggested diagnosis and treatment plan.

Care Connect employs 12 physicians to work with the AI. They log in remotely from around the U.S., and patients can get help round-the-clock, seven days a week.

Care Connect is one of many AI-based tools that hospitals, doctors, and administrative staff are testing for a range of routine medical tasks, including note-taking, reviewing diagnostic results, billing, and ordering supplies.

Proponents argue that these AI programs can help relieve staff burnout and worker shortages by reducing time spent on medical records, referrals, and other administrative tasks. But there’s debate about and to use AI to improve diagnoses. Critics worry that AI agents miss important details about overlapping medical conditions.

Critics also point out that AI tools can’t assess whether patients can afford follow-up care or get to that appointment. They have no insight into family dynamics or caretaking needs, things that primary physicians come to understand through long-term personal relationships.

Since her first foray on the app in September, MacDonald has used Care Connect at least three more times. Two of those interactions led to an eventual conversation with a remote doctor, but when she went online to book an appointment for travel-related shots, she interacted only with the AI chatbot before visiting the travel clinic.

MacDonald likes the convenience.

“I don’t have to leave work,” she said. “And I gained some peace of mind, knowing that I have a plan between now and me finding another in-person doctor.”

So while she hunted for that person, MacDonald planned to stay with Care Connect.

“This is a logical solution in the short term,” MacDonald said. “At the end of the day, it’s the patient who’s feeling the aftermath of all of the bigger things going on in health care.”

Scarcity and Burnout

Many factors contribute to the shortage of providers. Many primary care doctors, such as pediatricians, internists, and family medicine physicians, are dissatisfied with their pay. They earn about , on average, than specialists such as surgeons, cardiologists, and anesthesiologists. 

At the same time, their workload has been increasing. Primary care doctors days packed with complex patient visits, followed by evenings spent updating medical records and responding to patient messages.

When MacDonald signed onto Care Connect, she was one of 15,000 patients in the Mass General Brigham system without a primary care provider. That number has grown as primary care doctors have left MGB for rival hospital networks.

, a primary care physician at an MGB health center in Chelsea, Massachusetts, said she’s staying at MGB for now, but she’s grown frustrated with the system’s leaders.

“They don’t make any effort to ease the shortage,” said Rao, who is also part of an MBG’s primary care doctors. “They put their money into specialties. Primary care feels like a peripheral part of the system, when it really should be a central part.”

Last year, MGB pledged to spend $400 million over five years on primary care services — though that includes the multiyear contract with Care Connect.

“Care Connect is just one solution among many in this broader strategy to alleviate the primary care capacity crisis,” , MGB’s chief operating officer, said in an emailed statement. “Our investment supports retaining our current physicians as well as recruiting new ones.”

Walls said MGB has increased staffing support for primary care physicians, implemented other AI tools, and hired a new executive for primary care. Some of these changes are based on recommendations from their own primary care doctors.

But some of those doctors say they would like other changes, and salary increases in particular.

Walls would not disclose the exact amount MGB is spending on Care Connect.

Bridge to Better Care or a ‘Band-Aid’?

MGB has rolled out other AI tools, including one that can transcribe a doctor’s in-person conversations with patients. Rao isn’t using that tool. She worries that patient information could be leaked and medical privacy violated, and she doesn’t want her conversations with patients to be used to help develop the next generation of AI medical tools.

“What if they’re just using my interactions with patients to train their AI and boot me out of my job?” she said.

That’s not the goal, said , a primary care physician who manages the program for MGB. All decisions about patient care are still made by real doctors, she said.

“We are not replacing our in-person primary care,” she said. “It’s still important, and the majority of patients still have in-person primary care.”

But the fear among some primary care doctors at MGB is that Care Connect will gradually erode access to in-person primary care visits. Of the $400 million pledged by MGB for primary care, they want less spent on AI and more used to attract and increase pay for primary care staffers.

, an MGB internist who is also involved in the unionizing effort, said the use of Care Connect can only fill a gap. “That sounds like a band-aid for a broken system to me,” he said.

Expanding AI Tools

As of mid-December, the Care Connect doctors were each seeing 40 to 50 patients a day. By February, the MGB network plans to make Care Connect available to all Massachusetts and New Hampshire residents who have health insurance, and to hire more doctors to staff the program as needed. 

Patients can use the program like an urgent care service, Ireland said. They can also decide to make one of the remote doctors their permanent primary care provider.

“Some patients want in-person care,” Ireland said. “But I do believe there’s a subset of patients who will appreciate the 24-hour, seven-day-a-week model and choose to be a part of this.”

Care Connect isn’t for patients who need emergency care or a physical exam, she said. And patients who need tests or imaging are referred to the network’s clinics or labs.

But the remote doctors can manage some of the same routine issues that all primary care doctors do, Ireland said, including moderate respiratory infections, allergies, and chronic conditions such as diabetes, high cholesterol, and depression. 

says only immediate, not ongoing, health problems should be on that list. Lin is chief of primary care at the Stanford University School of Medicine and founded Stanford’s Healthcare AI Applied Research Team.

“In its current state, the safest use of this tool is for more urgent care issues,” Lin said. “Your upper respiratory tract infections. Your urinary tract infections. Your musculoskeletal injuries. Your rashes.”

For patients with multiple chronic conditions such as high blood pressure and diabetes — or for patients with especially serious conditions like heart disease or cancer — Lin said nothing beats a human who sees you regularly.

Still, Lin agrees that the chat summary generated after an AI encounter can help a physician be more efficient. For patients, Lin understands the practical appeal of a virtual option.

“I would rather these patients get care, if that care can be safe,” he said, “than not get care at all.”

The company that developed the AI platform for Care Connect, , contends the program is delivering safe, effective care to patients with complex, chronic ailments — many of whom have no other option besides a hospital emergency room.

“America’s got a big problem with health care, issues with cost, quality, and access,” said , the company’s CEO. “To solve it, you need to start with primary care, and you have to use technology and AI.”

In addition to Mass General Brigham, K Health partners with five other health networks, including the highly ranked and Los Angeles-based .

In a funded by K Health, Cedars-Sinai researchers compared several hundred diagnosis and treatment recommendations made by AI with those made by physicians.

The researchers found the AI to be slightly better at identifying “critical red flags” and recommending care based on clinical guidelines, though the physicians were better at adjusting their treatment recommendations as they spoke more with the patient.

This article is from a partnership that includes , , and Â鶹ŮÓÅ Health News.

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Instead of typing on her computer keyboard during the exam, Urban’s primary care physician at the practice in Media, Pennsylvania, had an ambient artificial intelligence scribe take notes. At the end of the 30-minute visit, Urban’s doctor showed her the AI summary of the appointment, neatly organized into sections for her medical history, the physical exam findings, and an assessment and treatment plan for her rheumatoid arthritis and hot flashes, among other details.

The clinical note, which Urban could also review on the patient portal at home, was incredibly thorough, she said. It summarized all of her questions and concerns and the doctor’s responses. The scribe “made sure we didn’t miss anything,” Urban said.

Ambient AI scribes are being hailed by physicians as a game changer that helps free them to focus on their patients rather than their computer keyboard. By releasing doctors from the onerous and time-consuming task of documenting what happens during every patient encounter, , AI scribes may help reduce physician burnout and after-hours “pajama time” catching up on work in the evening.

The potential of AI to transform every aspect of the health care system — from patient care to clinical efficiency to medical innovation — is an area of intense focus, including by the Trump administration.

Last January, President Donald Trump issued an to remove barriers to American leadership in AI. Later in the year, a from the federal Department of Health and Human Services invited stakeholders to weigh in on how the department can accelerate the adoption of AI in health care.

Several startup vendors in recent years have introduced ambient AI scribe products that can be integrated into electronic health records. EHR market leader Epic is technology, which it expects to release widely early this year, according to , a family medicine physician who is chief medical officer and vice president of clinical informatics at Epic.

Health tech experts estimate that a third of providers have access to ambient AI scribe technology. As adoption looks likely to grow rapidly over the next few years, many expect it to become more of a recruiting tool, a minimum requirement for incoming clinicians, who are increasingly prioritizing work-life balance.

“It’s part of keeping doctors happy,” said , a professor and the chair of the Department of Medicine at the University of California-San Francisco, whose forthcoming book, , explores how AI is transforming health care. “Health systems that initially might have done a hard-nosed return-on-investment calculation — many are softening on that and realizing that the cost of recruiting and retaining doctors is pretty high.”

But many questions remain. Does the use of ambient AI scribes improve patient care and health outcomes? Will doctors use time they gain by employing an AI scribe to improve the quality of the time they spend with their patients or just boost the number of patients they see? To what extent will expanding the amount of detail available from a patient visit lead to bigger bills if the AI scribe is integrated with a coding app that optimizes provider charges?

For now, these questions remain mostly unanswered.

Urban said that the AI scribe didn’t change her experience as a patient very much. Typically, after a patient gives verbal permission, the AI scribe records the visit on a phone and organizes the conversation into the structure of a clinical note, filtering out small talk that isn’t pertinent to the medical visit but incorporating relevant details about a family member’s recent cancer diagnosis, for example. The scribe’s note is often then integrated into the provider’s EHR. The doctor later reviews the note and signs off on it.

Even though the visit may not feel very different to patients, some clinicians report that ambient AI scribes are changing patient encounters in unanticipated ways.

“Now, when I’m doing a physical exam, I have to say what I’m doing and what I’m finding out loud in order for the AI scribe to document it,” said , Urban’s primary care doctor. “People find that very interesting,” she said.

When Capalongo places her stethoscope over the carotid artery under a patient’s jaw, for example, she might say that she doesn’t hear a “bruit,” or vascular murmur, whose presence could indicate atherosclerosis. Patients have told her, “I never knew why a doctor would listen there,” she said.

Saying things out loud for the AI scribe that would typically appear only in a clinical note can create its own set of challenges, particularly during sensitive physical exams. Doctors may feel it’s important to adjust their conversation accordingly.

“Sometimes patients are anxious and scared and my saying things that they don’t understand or they may worry about during an uncomfortable examination does not help the situation and honestly is insensitive to what the patient is going through,” said , a professor in the Division of Colon and Rectal Surgery at the University of Minnesota, who is also chief health informatics and AI officer at Fairview Health Services in Minneapolis. “I’ll keep that top of mind and make sure I record it” after the visit.

“How we have conversations with patients about these tools is really important, in particular for maintaining trust and ensuring accurate information,” Melton-Meaux said.

Studies have found that, across a range of measures such as completeness, timeliness, and coherence, the notes created by ambient AI scribes are generally at least as good as, and sometimes better than, traditional documentation, said , a pediatrician who is vice president for applied informatics at the University of Pennsylvania Health System.

An ongoing concern is around AI “hallucinations,” in which false, sometimes fabricated information appears in an AI output.

Kaiser Permanente, an of ambient AI scribe technology, provides it to more than 25,000 doctors, advanced practice providers, and pharmacists systemwide. It has found hallucinations to be “quite rare,” said , an internist who is vice president of AI and emerging technologies at KP.

But they happen. An AI-scribe-generated note, for instance, might say that the doctor planned to refer someone to a neurologist or to follow up in two weeks. The problem? The doctor might not have said that.

“The technology is not perfect, and that’s why physicians are reviewing it,” Yang said. It’s learning from regular physician visits as it goes, he said. That’s why having a person check the work product is critical.

Still, even such a “human-in-the loop” system is fraught, Wachter said. “Humans stink at maintaining vigilance over time,” he said.

As the use of ambient AI scribes becomes routine, some clinicians worry that the technology will widen the divide between health care haves and have-nots.

Large health systems are able to move forward with the technology, Melton-Meaux said. But what about critical access hospitals or small private practices? “There need to be more resources,” she said.

Physicians’ enthusiasm for ambient AI scribes stands in sharp contrast to their negative reaction to electronic health record systems that have become widely adopted in recent years to replace paper charts.

“During the last 10 years, when EHRs became a thing, we all became very grumpy, overworked data scribes,” Wachter said.

The introduction of AI scribes makes physicians feel like technology is working for them rather than the other way around, health care AI experts said.

And AI scribes are “training wheels” for more consequential adoption of AI in health care, Wachter said.

To improve health care value and save costs, Wachter said, we need a system that makes it more likely that physicians will practice evidence-based medicine to order the right tests and prescribe the right medications.

“It’s a few years away, but it’s all AI-dependent,” he said.

Epic has introduced roughly 60 AI use cases for patients, clinicians, and administration, with over 100 more in the works.

“It’s so much bigger than a scribe,” said Epic’s Gerhart. “It’s literally listening and acting in a way that tees things up for me so that I can take action.”

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NEW ORLEANS — Elyse Stevens had a reputation for taking on complex medical cases. People who’d been battling addiction for decades. Chronic-pain patients on high doses of opioids. Sex workers and people living on the street.

“Many of my patients are messy, the ones that don’t know if they want to stop using drugs or not,” said Stevens, a primary care and addiction medicine doctor.

While other doctors avoided these patients, Stevens — who was familiar with the city from her time in medical school at Tulane University — sought them out. She regularly attended 6 a.m. breakfasts for homeless people, volunteered at a homeless shelter clinic on Saturdays, and, on Monday evenings, visited an abandoned Family Dollar store where advocates distributed supplies to people who use drugs.

One such evening about four years ago, Charmyra Harrell arrived there limping, her right leg swollen and covered in sores. Emergency room doctors had repeatedly dismissed her, so she eased the pain with street drugs, Harrell said.

Stevens cleaned her sores on Mondays for months until finally persuading Harrell to visit the clinic at University Medical Center New Orleans. There, Stevens discovered Harrell had diabetes and cancer.

She agreed to prescribe Harrell pain medication — an option many doctors would automatically dismiss for fear that a patient with a history of addiction would misuse it.

But Stevens was confident Harrell could hold up her end of the deal.

“She told me, ‘You cannot do drugs and do your pain meds,’” Harrell recounted on a Monday evening in October. So, “I’m no longer on cocaine.”

Stevens’ approach to patient care has won her awards and nominations in , , and . Instead of seeing patients in binaries — addicted or sober, with a positive or negative drug test — she measures progress on a spectrum. Are they showering daily, cooking with their families, using less fentanyl than the day before?

But not everyone agrees with this flexible approach that prioritizes working with patients on their goals, even if abstinence isn’t one of them. And it came to a head in the summer of 2024.

“The same things I was high-fived for thousands of times — suddenly that was bad,” Stevens said.

Flexible Care or Slippery Slope?

More than who need substance use treatment don’t receive it, national data shows. Barriers abound: high costs, lack of transportation, clinic hours that are incompatible with jobs, fear of being mistreated.

Some doctors had been trying to ease the process for years. Covid-19 accelerated that trend. Telehealth appointments, fewer urine drug tests, and medication refills that last longer became the norm.

The result?

“Patients did OK and we actually reached more people,” said , immediate past president of the American Society of Addiction Medicine. The organization supports continuing flexible practices, such as helping patients avoid withdrawal symptoms by of addiction medication and focusing on recovery goals .

But some doctors prefer traditional approaches that range from zero tolerance for patients using illegal drugs to setting stiff consequences for those who don’t meet their doctors’ expectations. For example, a patient who tests positive for street drugs while getting outpatient care would be discharged and told to go to residential rehab. Proponents of this method fear loosening restrictions could be a slippery slope that ultimately harms patients. They say continuing to prescribe painkillers, for example, to people using illicit substances long-term could normalize drug use and hamper the goal of getting people off illegal drugs.

Progress should be more than keeping patients in care, said , a Stanford psychologist, who has treated and researched addiction for decades and .

“If you give addicted people lots of drugs, they like it, and they may come back,” he said. “But that doesn’t mean that that is promoting their health over time.”

Flexible practices also tend to align with harm reduction, a divisive approach that proponents say keeps people who use drugs safe and that critics — — say enables illegal drug use.

The debate is not just philosophical. For Stevens and her patients, it came to bear on the streets of New Orleans.

‘Unconventional’ Prescribing

In the summer of 2024, supervisors started questioning Stevens’ approach.

In emails reviewed by Â鶹ŮÓÅ Health News, they expressed concerns about her prescribing too many pain pills, a mix of opioids and other controlled substances to the same patients, and high doses of buprenorphine, a medication considered to treat opioid addiction.

Supervisors worried Stevens wasn’t doing enough urine drug tests and kept treating patients who used illicit drugs instead of referring them to higher levels of care.

“Her prescribing pattern appears unconventional compared to the local standard of care,” the hospital’s chief medical officer at the time wrote to Stevens’ supervisor, . “Note that this is the only standard of care which would likely be considered should a legal concern arise.”

Springgate forwarded that email to Stevens and encouraged her to refer more patients to methadone clinics, intensive outpatient care, and inpatient rehab.

Stevens understood the general practice but couldn’t reconcile it with the reality her patients faced. How would someone living in a tent, fearful of losing their possessions, trek to a methadone clinic daily?

Stevens sent her supervisors of and backing her flexible approach. She explained that if she stopped prescribing the medications of concern, patients might leave the health system, but they wouldn’t disappear.

“They just wouldn’t be getting care and perhaps they’d be dead,” she said in an interview with Â鶹ŮÓÅ Health News.

Both University Medical Center and LSU Health New Orleans, which employs physicians at the hospital, declined repeated requests for interviews. They did not respond to detailed questions about addiction treatment or Stevens’ practices.

Instead, they provided a joint statement from Richard DiCarlo, dean of the LSU Health New Orleans School of Medicine, and Jeffrey Elder, chief medical officer of University Medical Center New Orleans.

“We are not at liberty to comment publicly on internal personnel issues,” they wrote.

“We recognize that addiction is a serious public health problem, and that addiction treatment is a challenge for the healthcare industry,” they said. “We remain dedicated to expanding access to treatment, while upholding the highest standard of care and safety for all patients.”

Not Black-and-White

Â鶹ŮÓÅ Health News shared the complaints against Stevens and the responses she’d written for supervisors with two addiction medicine doctors outside of Louisiana, who had no affiliation with Stevens. Both found her practices to be within the bounds of normal addiction care, especially for complex patients.

, an addiction medicine doctor and the , said doctors running pill mills typically have sparse patient notes that list a chief complaint of pain. But Stevens’ notes detailed patients’ life circumstances and the intricate decisions she was making with them.

“To me, that’s the big difference,” Loyd said.

Some people think the “only good answer is no opioids,” such as oxycodone or hydrocodone, for any patients, said , an addiction medicine doctor and associate professor at Michigan State University. But patients may need them — sometimes for things like cancer pain — or require months to lower their doses safely, she said. “It’s not as black-and-white as people outside our field want it to be.”

Humphreys, the Stanford psychologist, had a different take. He did not review Stevens’ case but said, as a general practice, there are risks to prescribing painkillers long-term, especially for patients using today’s lethal street drugs too.

Overprescribing fueled the opioid crisis, he said. “It’s not going to go away if we do that again.”

‘The Thing That Kills People’

After months of tension, Stevens’ supervisors told her on March 10 to stop coming to work. The hospital was conducting a review of her practices, they said in an email viewed by Â鶹ŮÓÅ Health News.

Overnight, hundreds of her patients were moved to other providers.

Luka Bair had been seeing Stevens for three years and was stable on daily buprenorphine.

After Stevens’ departure, Bair was left without medication for three days. The withdrawal symptoms were severe — headache, nausea, muscle cramps.

“I was just in physical hell,” said Bair, who works for the National Harm Reduction Coalition and uses they/them pronouns.

Although Bair eventually got a refill, Springgate, Stevens’ supervisor, didn’t want to continue the regimen long-term. Instead, Springgate referred Bair to more intensive and residential programs, citing Bair’s intermittent use of other drugs, including benzodiazepines and cocaine, as markers of high risk. Bair “requires a higher level of care than our clinic reasonably can offer,” Springgate wrote in patient portal notes reviewed by Â鶹ŮÓÅ Health News.

But Bair said daily attendance at those programs was incompatible with their full-time job. They left the clinic, with 30 days to find a new doctor or run out of medication again.

“This is the thing that kills people,” said Bair, who eventually found another doctor willing to prescribe.

Springgate did not respond to repeated calls and emails requesting comment.

University Medical Center and LSU Health New Orleans did not answer questions about discharging Stevens’ patients.

‘Reckless Behavior’

About a month after Stevens was told to stay home, Haley Beavers Khoury, a medical student who worked with her, had collected nearly 100 letters from other students, doctors, patients, and homelessness service providers calling for Stevens’ return.

One student wrote, “Make no mistake — some of her patients will die without her.” A nun from the Daughters of Charity, which ran , called Stevens a “lifeline” for vulnerable patients.

Beavers Khoury said she sent the letters to about 10 people in hospital and medical school leadership. Most did not respond.

In May, the hospital’s review committee determined Stevens’ practices fell “outside of the acceptable community standards” and constituted “reckless behavior,” according to a letter sent to Stevens.

The hospital did not answer Â鶹ŮÓÅ Health News’ questions about how it reached this conclusion or if it identified any patient harm.

Meanwhile, Stevens had secured a job at another New Orleans hospital. But because her resignation came amid the ongoing investigation, University Medical Center said it was required to inform the state’s medical licensing board.

The medical board began its own investigation — a development that eventually cost Stevens the other job offer.

In presenting her side to the medical board, Stevens repeated many arguments she’d made before. Yes, she was prescribing powerful medications. No, she wasn’t making clinical decisions based on urine drug tests. But national addiction organizations supported such practices and promoted tailoring care to patients’ circumstances, she said. Her response included a 10-page bibliography with 98 citations.

Liability

The board’s investigation into Stevens is ongoing. shows no action taken against her license as of late December.

The board declined to comment on both Stevens’ case and its definition of appropriate addiction treatment.

In October, Stevens moved to the Virgin Islands to work in internal medicine at a local hospital. She said she’s grateful for the welcoming locals and the financial stability to support herself and her parents.

But it hurts to think of her former patients in New Orleans.

Before leaving, Stevens packed away handwritten letters from several of them — one was 15 pages long, written in alternating green and purple marker — in which they shared childhood traumas and small successes they had while in treatment with her.

Stevens doesn’t know what happened to those patients after she left.

She believes the scrutiny of her practices centers on liability more than patient safety.

But, she said, “liability is in abandoning people too.”

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But physicians, dentists, ambulance companies, and other health care providers are still taking their patients to court, a Connecticut Mirror-Â鶹ŮÓÅ Health News investigation of state legal records shows.

Lawsuits by doctors and other nonhospital providers now dominate health care collections in Connecticut, the records show, accounting for more than 80% of cases filed against patients and their families in 2024.

That’s a major reversal from just five years earlier, when hospital system lawsuits made up three-quarters of health-related collection cases in the state’s courts.

The shift is moving medical debt collections into a less regulated realm. Most hospitals, because they are tax-exempt nonprofits, must make financial aid available to low-income patients and follow federal regulations that limit aggressive collection activities. Other medical providers, such as private medical groups, are generally exempt from these rules.

The lawsuits are typically over bills of less than $3,000, but the impact on patients can be devastating. Lawsuits are among the most ruinous byproducts of a health care debt problem that burdens an estimated 100 million people in the U.S.

Lawsuits can lead to garnished wages, liens on homes, and hundreds of dollars of added debt from interest and court fees. They also pile additional financial strains on struggling families, prevent patients from getting needed care, and sap trust in medical providers.

“It’s really messed up,” said Allie Cass-Wilson, a nurse in Bristol, Connecticut, who was sued over a $1,972 debt by an OB-GYN practice where she’d been a patient years earlier. “How can they do that to people?” She did not contest the lawsuit, court records show.

Cass-Wilson, who is 36 and lives in a small apartment just off an expressway on-ramp, said she learned of the outstanding debt only when she was sued. When she tried making an appointment, she said, she was told her doctor wouldn’t see her. “They said I was blacklisted,” Cass-Wilson said. “I was so confused. I couldn’t believe that my medical provider let my care be interrupted like this.”

Cass-Wilson ultimately sought medical care elsewhere.

Radiologists, Dentists, Ambulances

Overall, CT Mirror and Â鶹ŮÓÅ Health News identified more than 16,000 health care-related debt cases in Connecticut courts from 2019 to 2024. The database was assembled from online court records with the help of January Advisors, a data science consulting firm that helped extract and sort the data.

Over the six-year period, most of Connecticut’s more than 25,000 did not pursue patients in court for outstanding balances.

But records show that more than 400 medical providers, including several hospital systems, sued their patients. Among those filing lawsuits were radiologists, anesthesiologists, eye doctors, podiatrists, allergists, and pediatricians.

Dentists, periodontists, and other dental providers filed more than 1,000 lawsuits against patients. And ambulance companies sued more than 140 people.

Med-Aid, a company based outside New Haven, Connecticut, that provides orthopedic braces and other medical supplies to patients, sued more than 400 people, the court records show. The company’s president, Frank Dilieto, did not respond to repeated interview requests.

Cass-Wilson was sued by Briar Rose Network in Bristol, Connecticut, a member of a large network of OB-GYN practices across Connecticut called Physicians for Women’s Health. The network’s members sued close to 100 patients in 2024, records show.

Paula Greenberg, CEO of Women’s Health Connecticut, a private equity-backed company affiliated with Physicians for Women’s Health that manages business operations for the network, said the lawsuits represent a small fraction of the more than 300,000 patients the network sees every year.

“This is an organization committed to patients,” Greenberg said. She noted that the group offers options to help patients pay, including installment plans and financial aid.

Geoffrey Manton, president of Naugatuck Valley Radiological Associates, said his practice also will work with people who say they can’t pay. But, he said, patients sometimes stop responding to their bills.

“Hiding from your problems isn’t going to solve them,” Manton said. “If we didn’t take any action, there could be that person that is in that late-model Mercedes that just chooses not to pay any bills.” The group sued more than 125 patients from 2019 to 2024, according to the court records.

Many medical providers say that aggressive collections stem from the growing prevalence of high-deductible health plans that leave patients with thousands of dollars of bills before their coverage kicks in.

Greenberg and Manton said each of their physician groups must collect. “This is a business,” Greenberg said. “We have to look at our operating costs.”

Critics of medical collection lawsuits note that the patients are typically sued over relatively small debts that are likely to have little impact on multimillion-dollar medical practices.

The average patient debt that members of Physicians for Women’s Health sued over in 2024 was less than $1,100, court records show. The physician group’s annual revenues are typically in the tens of millions of dollars, according to Greenberg.

Even relatively small debts — which often include interest — can place substantial burdens on families struggling to keep up with their bills, especially while dealing with a serious illness, patient advocates say.

“We don’t have a realistic choice in using health care,” said Lisa Freeman, who heads the Connecticut Center for Patient Safety and has advocated for patients struggling with medical bills. “To then get sued for it, when people have less and less funds available for anything extra, that’s very disheartening.”

A Stroke, Then a Lawsuit

Matthew Millman, 54, lost his job as an IT support worker after having a stroke. Then Meriden Imaging Center sued him over an $1,891 bill.

Millman and his wife said they tried to explain their financial situation to the center, which is affiliated with Midstate Radiology Associates, a large physician group that operates imaging centers and doctors’ offices across Connecticut.

“It was very frustrating,” said Millman, who lives in an aging apartment owned by his wife’s family in New Britain. Millman, his wife, and their teenage daughter are barely getting by on his two part-time jobs — one bagging groceries, the other helping homebound seniors. Together, the jobs pay about $1,500 a month, he said.

The imaging center, after winning the collection case against Millman, tried to garnish his wages, though that was unsuccessful because Millman had lost his IT job.

“It’s all about money,” Millman said, shaking his head. “If you are trained in helping somebody with their health, it shouldn’t be about the money first. It should be about their health.”

Court records show that Midstate Radiology, Meriden Imaging Center and affiliates filed more than 1,000 collection lawsuits against patients from 2019 to 2024, making them the most litigious nonhospital providers in the state. As is common in medical debt lawsuits, the plaintiffs prevailed in most cases, records show.

Midstate president Gary Dee, a radiologist, didn’t respond to emails and messages left at his West Hartford office.

Across town from Millman’s apartment in New Britain, Joseph Lentz lives in a cramped apartment with his wife and daughter. He used to oversee operations at a Boy Scout camp but is now unemployed. Lentz lost his job during the pandemic. The family home went into foreclosure, he said.

In 2023, Orthopedic Associates of Hartford sued Lentz over a $3,644 bill the practice said he owed after having shoulder surgery in 2018.

“I’d pay it if I could, I guess,” said Lentz, 59. “But I don’t even know where next month’s rent is coming from. I’m trying to climb out as best I can. I guess this is just one more thing to shovel in.”

The orthopedic group filed more than 580 lawsuits against patients from 2019 to 2024, prevailing in most, records show.

The medical group declined interview requests. But chief executive David Mudano said in a statement: “As an independent physician practice, we strive to balance compassion for patients with the financial responsibility required to sustain our practice.”

Old Debts and Disputed Claims

Lentz, who did not contest the lawsuit, said he has no reason to doubt he owes the debt. But in many cases reviewed by CT Mirror and Â鶹ŮÓÅ Health News and in interviews, patients being sued questioned the accuracy of their medical bills, citing care they thought health insurance should have covered or, in some cases, bills for services they never received.

This reflects with aggressive collection tactics like lawsuits when disputes over the accuracy of medical bills and delayed or denied insurance claims are so widespread in American health care.

A by the federal Consumer Financial Protection Bureau found that nearly half of the medical debt complaints fielded by the agency involved bills that consumers said were erroneous in some way or that consumers said they’d already paid.

“We know people are billed incorrectly,” said Lester Bird, who studies debt collection lawsuits at the nonprofit Pew Charitable Trusts. Bird noted that courts are ill equipped to sort through disputed medical charges or insurance claims, especially when there is little documentation in most debt collection lawsuits.

“It’s complicated before it gets to the courts,” Bird said, “and it’s very complicated when it gets into the courts.”

This can create headaches for physicians and other providers. But billing problems ultimately affect patients and their families most, said Connecticut state Sen. Saud Anwar, a Democrat who is also a physician. “Patients are left to deal with it.”

Andrew Skolnick, an attorney in Milford, outside New Haven, was sued in 2023 by an imaging center where his wife had received services in 2020.

Skolnick said that when the couple, who were covered through his job-based insurance, originally received the bill from Diagnostic Imaging of Milford, he tried to tell the imaging center it had submitted the claim to the wrong insurance plan, but he said they wouldn’t speak with him.

The center later filed the lawsuit, alleging he owed more than $2,000, plus almost $300 in interest.

Despite interview requests, officials at Diagnostic Imaging of Milford did not comment for this article.

Unlike most patients who are sued, Skolnick had the resources and expertise to contest the suit. He said he offered to pay what would have been his responsibility under the plan if the imaging center had filed his claim correctly. He ultimately settled for $1,700, court records show.

“It wasn’t a tremendous amount, but I knew that they had made a mistake,” Skolnick said. “The system is not working.”

More Protections?

Anwar, the state lawmaker and physician, expressed concern that lawsuits undermine patients’ faith in their doctors.

“It’s a sacred relationship,” he said. “If your physician, who is taking care of you, is suing you for money, that’s a problem.

Many hospitals, facing bad publicity from suing patients, have stopped taking patients to court over unpaid bills. Hospital collection lawsuits identified by CT Mirror and Â鶹ŮÓÅ Health News in Connecticut court records plunged from more than 4,900 in 2019 to fewer than 300 in 2024.

Also, in recent years, several states, including Connecticut, have expanded protections for patients with bills they can’t pay.

Connecticut now from consumer credit reports, and legislators are pushing to get hospitals to provide more financial aid to patients. Other states have restricted the use of wage garnishment and property liens to collect medical debt.

But state efforts to rein in aggressive medical debt collections have mostly focused on hospitals. That may need to change, said Connecticut state Sen. Matt Lesser, a Democrat who co-chairs the legislature’s Human Services Committee.

He is a key backer of a bill that would bar hospitals from billing patients who receive public benefits like food assistance or who make less than twice the federal poverty level, about $32,000 for an individual.

The restriction would not apply to bills from physicians and other nonhospital providers, however. “We may have to go bigger if that’s where the heart of the matter is,” Lesser said.

Connecticut Gov. Ned Lamont, a Democrat who spearheaded an initiative to for more than 150,000 state residents, also expressed concern about physicians suing the people in their care.

“Everyone should do the right thing by patients,” he said.

This article was produced in partnership with , a statewide nonprofit newsroom that covers public policy and politics.

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One name repeatedly crops up in these discussions: Valley Medical Group.

With four locations in the Connecticut River Valley, the practice has been a mainstay of family medicine since the 1990s. Valley Medical’s flagship office in Florence can be found right on Main Street, next door to a pizza restaurant and near a Friendly’s.

Valley has 90 medical providers — including doctors, nurse practitioners, and physician assistants — and on-site labs, X-rays, and vision care. With tens of thousands of patients, it’s become one of the largest independent practices in western Massachusetts.

It forms a key part of the region’s health care infrastructure, yet Valley Medical has rarely been under more strain than it is now. In January, the practice laid off 40 employees — 10% of its 400-person staff — mostly in support positions.

Despite patient demand — there are waiting lists to be seen — primary care providers take on more clinical responsibilities, and for less pay, than most medical specialists, said the group’s CEO, primary care physician . Rates are outlined in the group’s contracts with insurance providers.

“It has to do with the fact that our contracts don’t pay as well as we think they should,” Carlan said. “The cost of everything is going up.”

Valley Medical Group is far from alone in this predicament. Thousands of primary care practices, a key gateway to the medical system, are fighting to remain financially viable — and independent.

In response, many are banding together to form or IPAs. The goal is to increase their market power, change the way they get paid, and retain control over how they treat patients.

Threats to Physician Autonomy

Primary care practices in the U.S. are in serious trouble, according to workforce surveys. The American Association of Medical Colleges of up to 86,000 primary care doctors by 2036, as more primary care doctors retire and fewer enter the field.

The number of people who can’t find a primary care doctor has grown by 20% in the past decade, according to a .

Lower relative salaries and higher professional stress are disincentives when medical students consider a career in primary care. Newly minted doctors can earn more in specialties such as cardiology or surgery.

Financial stresses in U.S. health care, exacerbated by the covid pandemic, have led to the closure of many primary care practices, according to the AAMC.

The released a report in 2025 partly blaming the crisis on the relatively low insurance reimbursement rates for primary care. The revenue problem for primary care is projected to get worse when the Republican-backed cuts to Medicaid start to take effect later this year.

As they seek financial security, many primary care practices have merged with large hospital systems, with doctors becoming employees of those systems.

But the doctors at Valley Medical Group were determined to avoid that fate. Joining a health system takes away the to make the best clinical decisions for their patients, Carlan said. It also siphons off income into the larger hospital system.

“Our priorities get muddled up,” he said. “And I think when you’re part of a health system, you’re constantly being asked to bend for the needs of the organization. Hospitals get paid when their beds are full.”

By contrast, primary care providers need time and money to manage or prevent illness, Carlan said, and their insurance reimbursement rates should take that into account.

In December, Valley Medical Group announced it would be . Like a union, an IPA combines individual primary care offices, giving them power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies.

“It’s a moment of transition,” said Lisa Bielamowicz, chief clinical officer of , an independent health care consultancy that works with health systems and physician groups.

IPAs are gaining momentum as older doctors retire, especially following the challenging years of the covid pandemic, Bielamowicz said. “As the baby boomers move out and younger physicians take leadership roles, these kinds of models become more attractive.”

The , a trade group, is hearing from practice owners who joined hospital systems but now want to break off and return to being a smaller practice.

“So if independent IPAs can create the infrastructure support to make independent practice viable, then that’s a good thing,” said , a vice president at AAFP.

IPAs can bring more clout to the table when negotiating rates with insurance companies. Some insurers say they like working with these partnerships because they help stabilize primary care practices, maintaining access and options for insured patients.

Otherwise, some doctors shift their business model to “direct primary care,” which bypasses insurance altogether.

“We’re looking at independent practices that aren’t buoyed by …. these large health systems and can support members in the community in the ways that they want to be supported,” said , a vice president with .

A Different Payment Model

When those independent practices band together, Glenn said, Blue Cross can offer . Instead of getting a payment for each visit or procedure, the medical practice is given a budgeted amount for each patient’s care, which provides an incentive to keep them healthy so they need fewer treatments.

Medical providers “make different kinds of choices than they would if they’re paid for every procedure, every visit, every widget,” TrustWorks’ Bielamowicz said.

If there is money left at the end of the year, it’s split between the practice and the insurer.

The catch, Glenn said, is that a value-based contract works only if there’s a big enough pool of patients to spread out the risk, in case a few get really sick. Otherwise, she said, “the risk of ending up above or below the budget becomes somewhat subject to random variation rather than performance.”

Value-based contracts were supposed to be the next big thing when the Affordable Care Act passed in 2010, an innovative way to bring costs down for the health system as a whole.

But they were slow to catch on; the traditional fee-for-service payment model was too entrenched. Experts say that could still change, if enough primary care providers work together to build market power through IPAs.

“If we keep people out of the ER, keep them out of unnecessary hospitalizations, we save money for the system,” said Chris Kryder, CEO of in Cambridge, Massachusetts, the IPA specializing in value-based contracts that Valley Medical joined. “And we create more income for the PCPs [primary care providers], which is dreadfully needed.”

These contracts also allow more flexibility in staffing, Kryder said, because nurses, physical therapists, and medical assistants can take on some of the less complex medical tasks, saving the practice money.

IPAs Can Help, Depending on Who’s in Charge

But IPAs are not a panacea for primary care’s problems, according to some health care leaders.

There are hundreds of IPAs, but not all offer the independence and autonomy that many doctors crave. Some IPAs are actually owned by hospital systems, or even private equity companies, and they’re less focused on preventive care.

The American Academy of Family Physicians advises its members to seek out IPAs with “integrity,” ones that give doctors a strong role in decision-making.

“Who’s calling the shots, who’s making the decisions, and is it really focused on the best interests and long-term benefit of physicians in practice and their patients?” asked AAFP’s Johnson.

Arches Medical is owned entirely by physicians and focused specifically on primary care, Kryder said. But to be more effective, Arches needs to recruit more practices that want value-based contracts.

That can be a hard sell, said Glenn, of Blue Cross. Under that payment model, doctors might see a lag of more than a year from the time they provide care to the moment they realize savings.

“It doesn’t happen overnight, and it does take an investment,” she said.

That lag is one reason Valley Medical Group had to lay off staff after joining the Arches IPA, said CEO Carlan. But he has faith that, after some time, the practice will become more financially stable, be able to offer higher salaries, and, most important, keep the doctors in charge.

This article is from a partnership with and .

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Â鶹ŮÓÅ Health News senior correspondent Renuka Rayasam discussed excited delirium on Vox Media Podcast Network’s Criminal on March 6.

• Read Rayasam’s ““

On CBS News’ CBS Mornings on March 5, Céline Gounder, Â鶹ŮÓÅ Health News’ editor-at-large for public health, discussed the Massachusetts governor’s retort to comments by Health and Human Services Secretary Robert F. Kennedy Jr. about popular coffee chains.

Â鶹ŮÓÅ Health News California correspondent Christine Mai-Duc discussed Affordable Care Act premium increases on CapRadio’s Insight With Vicki Gonzalez on March 2.

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Â鶹ŮÓÅ Health News rural health reporter Andrew Jones discussed how younger doctors are struggling to diagnose measles on KMOX’s Total Information AM on Feb. 27.

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Â鶹ŮÓÅ Health News South Dakota correspondent Arielle Zionts discussed the $50 billion Rural Health Transformation Program on Marketplace’s Make Me Smart podcast on Feb. 19.

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Â鶹ŮÓÅ Health News Southern California correspondent Claudia Boyd-Barrett discussed how family members and lawyers of those in Immigration and Customs Enforcement custody are struggling to find them in California hospitals on CapRadio’s Insight With Vicki Gonzalez on Feb. 25.

• Click here to hear Boyd-Barrett on .
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Céline Gounder, Â鶹ŮÓÅ Health News’ editor-at-large for public health, discussed the neurodegenerative disease ALS on CBS News’ CBS Mornings on Feb. 20.

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Â鶹ŮÓÅ Health News senior correspondent Aneri Pattani discussed Elyse Stevens, a New Orleans doctor who faced investigation because of her patient-centered approach to substance use disorders, on The Lens’ Behind The Lens podcast on Feb. 20.

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Â鶹ŮÓÅ Health News chief rural correspondent Sarah Jane Tribble discussed major cuts to Medicaid on WBUR’s Here & Now on Feb. 19. Tribble also discussed Alabama’s plan for robotic ultrasounds on The Daily Yonder’s The Yonder Report on Feb. 19.

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Listen: More than 2 million Americans could benefit from PrEP, but only about a quarter of them are getting the HIV prevention medication. On Feb. 4, during WAMU’s “Health Hub,” Â鶹ŮÓÅ Health News reporter Zach Dyer shared tips for overcoming common hurdles to care.

Billing mistakes. Stigma. Doctors who aren’t keeping up with the latest research. Those are just some of the hurdles that for many Americans.

The Centers for Disease Control and Prevention estimates more than 2 million Americans could benefit from a treatment known as PrEP, but only a quarter of them are getting a form of the drug. Zach Dyer appeared on WAMU’s “Health Hub” on Feb. 4 to share tips patients can use to avoid those pitfalls and find a doctor who knows more about PrEP.

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During procedures, he seemed “hesitant, not sure of how to go on to the next step without being prompted” by assistants, said Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore.

The chief of surgery, concerned about the doctor’s cognition, “would not sign off on his credentials to practice surgery unless he went through an evaluation,” Katlic said.

Since 2015, when Sinai inaugurated a screening program for surgeons 75 and older, about 30 from around the country have undergone its comprehensive two-day physical and cognitive assessment. This surgeon “did not come of his own accord,” Katlic recalled.

But he came. The tests revealed mild cognitive impairment, often but not necessarily a precursor to dementia. The neuropsychologist’s report advised that the surgeon’s difficulties were “likely to impact his ability to practice medicine as he is doing presently, e.g. conducting complex surgical procedures.”

That didn’t mean the surgeon had to retire; a variety of accommodations would allow him to continue in other roles. “He retained a lifetime of knowledge that had not been impacted by cognitive changes,” Katlic said. The hospital “took him out of the OR, but he continued to see patients in the clinic.”

Such incidents are likely to become more common as America’s physician workforce ages rapidly. In 2005, more than 11% of doctors who were seeing patients were 65 or older, the American Medical Association said. Last year, the proportion reached 22.4%, with nearly 203,000 older practitioners.

Given physician shortages, especially in rural areas and key specialties like primary care, nobody wants to drive out veteran doctors with skills and experience.

Yet researchers have documented “a starting in their mid-60s,” said Thomas Gallagher, an internist and bioethicist at the University of Washington who has studied late-career trajectories.

At older ages, reaction times slow; knowledge can become outdated. Cognitive scores vary greatly, however. “Some practitioners continue to do as well as they did in their 40s and 50s, and others really start to struggle,” Gallagher said.

A few health organizations have responded by establishing mandating that older doctors be screened for cognitive and physical deficits.

UVA Health at the University of Virginia began its program in 2011 and has screened about 200 older practitioners. Only in four cases did the results significantly change a doctor’s practice or privileges.

Stanford Health Care launched its late-career program the following year. Penn Medicine at the University of Pennsylvania also put in place a testing program.

Nobody has tracked how many exist; Gallagher guesstimated as many as 200. But given that the United States has more than 6,000 hospitals, those with late-career programs constitute “a vast minority,” he said.

The number may actually have shrunk. A federal lawsuit, along with the profession’s lingering reluctance, appears to have put the effort to regularly assess older doctors’ abilities in limbo.

Late-career programs typically require those 70 and older to be evaluated before their privileges and credentials are renewed, with confirmatory testing for those whose initial results indicate problems. Thereafter, older doctors undergo regular rescreening, usually every year or two.

It’s fair to say such efforts proved unpopular among their intended targets. Doctors frequently insist that “‘I’ll know when it’s time to stand down,’” said Rocco Orlando, senior strategic adviser to Hartford HealthCare, which operates eight Connecticut hospitals and began its late-career practitioner program in 2018. “It turns out not to be true.”

When Hartford HealthCare published data from the first two years of its late-career program, it reported that of the 160 practitioners 70 and older who were screened, .

That mirrored results from Yale New Haven Hospital, which instituted mandatory cognitive screening for medical staff members starting at age 70. Among the first 141 Yale clinicians who underwent testing, that were likely to impair their ability to practice medicine independently,” a study reported.

Proponents of late-career screening argued that such programs could prevent harm to patients while steering impaired doctors to less demanding assignments or, in some cases, toward retirement.

“I thought as we got the word out nationally, this would be something we could encourage across the country,” Orlando said, noting that Hartford’s program cost only $50,000 to $60,000 a year.

Instead, he has seen “zero progress” in recent years. “Probably we’ve gone backward,” he said.

A key reason: In 2020, the federal over its testing efforts, charging age and disability discrimination. The legal action continues (the EEOC declined to comment on its status), as does the hospital’s late-career program.

But the suit led several other organizations to pause or shut down their programs, including those at Hartford HealthCare and at Driscoll Children’s Hospital in Corpus Christi, Texas, while few new ones have emerged.

“It made lots of organizations uncomfortable about sticking their necks out,” Gallagher said.

Instituting later-career programs has always been an uphill effort. “Doctors don’t like to be regulated,” Katlic acknowledged. Late-career programs have “in some cases been very controversial, and they’ve been blocked by influential physicians,” he said.

As health systems wait to see what happens in federal court, most national medical organizations have recommended only voluntary screening and peer reporting.

“Neither works very well at all,” Gallagher said. “Physicians are hesitant to share their concerns about their colleagues,” which can involve “challenging power dynamics.”

As for voluntary evaluation, since cognitive decline can affect doctors’ (or anyone’s) self-awareness, “they’re the last to know that they’re not themselves,” he added.

In a recent , Gallagher and his co-authors recommended procedural policies to promote fairness in late-career screening, based on an analysis of such programs and interviews with their leaders.

“How can we design these programs in a way that’s fair and that therefore physicians are more apt to participate in?” he said. The authors emphasized the need for confidentiality and safeguards, such as an appeals process.

“There are all sorts of accommodations” for doctors whose assessments indicate the need for different roles, Gallagher noted. They could adopt less onerous schedules or handle routine procedures while leaving complex six-hour surgeries to their colleagues. They might transition to teaching, mentoring, and consulting.

Yet a substantial number of older doctors head for the exits and retire rather than face a mandated evaluation, he said.

The future, therefore, might involve programs that regularly screen every practitioner. That would be inefficient (few doctors in their 40s will flunk a cognitive test) and, with current tests, time-consuming and consequently expensive. But it would avoid charges of age discrimination.

Faster reliable cognitive tests, reportedly in the research pipeline, may be one way to proceed. In the meantime, Orlando said, changing the culture of health care organizations requires encouraging peer reporting and commending “the people who have the courage to speak up.”

“If you see something, say something,” he continued, referring to health care professionals who witness doctors (of any age) faltering. “We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’”

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Health policy changes in Washington will ripple through the country, resulting in millions of Americans losing their Medicaid or Affordable Care Act coverage. But there are still ways to find care.

Over the next decade, the GOP’s One Big Beautiful Bill Act is expected to slash nearly $1 trillion in spending from Medicaid, the state-federal program for people with low incomes and disabilities. The implementation of new work rules will cause some beneficiaries to lose their Medicaid coverage.

Millions of Americans are facing enormous increases in their out-of-pocket costs for ACA coverage. So far, 1.2 million fewer people have signed up for Obamacare plans compared with last year, and health policy analysts estimate more will lose coverage as they fail to pay their premiums.

Health costs are a top concern for Americans. Two-thirds of the public say they are somewhat or very worried about affording health care, more than express the same worries about utilities, food, housing, or gas, according to a , a health information nonprofit that includes Â鶹ŮÓÅ Health News.

“All of this pain just doesn’t have to be there,” said Cheryl Fish-Parcham, director of private coverage at the health consumer group Families USA.

Doctors and health policy researchers say health coverage, of any kind, is the best protection against major medical debt.

Caitlin Donovan, a senior director at the Patient Advocate Foundation, recommends exhausting every available option for health coverage before going uninsured.

Even a high-deductible plan can protect patients from medical bankruptcy “if the absolute worst-case scenario happens,” she said.

Here are five ways that the uninsured can find affordable care.

1. Don’t be afraid to talk with your doctor about money

Patients can be hesitant to tell their doctors they’re uninsured or be wary of expressing concern about being able to afford care.

But some hospitals, physicians, and other providers offer cheaper cash pay options, said Cynthia Cox, a senior vice president and the director of the Program on the ACA at Â鶹ŮÓÅ.

Often prices are negotiable. “Always ask,” she said.

Health care providers can make adjustments if they know patients are worried about money, said Ateev Mehrotra, a doctor and researcher at Brown University.

“If my patient tells me, ‘Doc, I’m gonna have to pay for this out-of-pocket,’ I’m gonna make a different risk calculus,” Mehrotra said.

That doesn’t mean a patient won’t get the care they need, he said. A doctor, for instance, might order an ultrasound instead of an MRI, which is more expensive.

2. Search for providers that specifically work with uninsured patients

If your usual provider won’t budge on prices, then search for providers that cater to patients without insurance.

Federally qualified health centers, or FQHCs, and other community clinics offer routine and non-emergency care, such as treatment for flu or infection, for low-income residents and the uninsured. Community health centers charge based on a sliding scale and see annually in some of the country’s most underserved areas, according to the National Association of Community Health Centers.

The Trump administration has made funding cuts that might lead some of the country’s approximately 1,500 FQHCs to close or cut services. But the administration still maintains .

Planned Parenthood also accepts uninsured patients. Its centers test for sexually transmitted diseases, provide birth control options, and offer postpartum and gender-affirming care .

And the National Association of Free & Charitable Clinics also offers to help people find free or low-cost care.

Most community clinics don’t offer specialty care, but they can usually refer patients who need more intensive services to providers willing to work with uninsured patients.

And academic medical centers tend to have more charity care programs that help uninsured patients lower their bills.

“If you’re uninsured or even underinsured, you might be able to qualify for a significant discount on the cost of your care,” Cox said.

Still, be wary of heading to the emergency room, which is the most expensive place to get care. While ERs are federally required to stabilize all patients regardless of their ability to pay, they can still leave you with a big bill — and often do.

3. Call your local health department

Health services vary widely from county to county, but many offer free vaccinations, family planning services, and testing for sexually transmitted infections, as well as for flu, covid, and tuberculosis.

Some county health departments also offer more advanced care, such as dental services and mental health or substance abuse programs. And some states have consumer assistance programs that can guide residents in finding care, Fish-Parcham said.

In addition, the Centers for Disease Control and Prevention’s makes free or low-cost breast and cervical cancer screenings available to low-income women in all states and territories. And some states cover screenings for other types of cancer as well.

4. It’s easier to shop around for drugs than doctors

Don’t just fill your prescription at the closest pharmacy. Instead, research generic drug options and look around for the best price on brand names.

A handful of sites such as and offer comparison shopping tools and information on other ways to get drug discounts.

And some retailers offer low-cost access to common prescription drugs — at prices cheaper than you would find if you had insurance. Walmart, for instance, sells 90-day prescriptions of of drugs for $10. As do , , and a new site called the .

Many drugmakers also offer patient assistance programs, coupons, and rebates on some medications. Check their websites for details on how to apply.

States also offer drug assistance programs. The steps to qualify and types of drugs vary, but has a list of programs and how they work.

Joining a clinical trial is another way to access treatment. The and its have lists, but patients must first meet the criteria. Clinical trials aren’t necessarily free, even with insurance, Donovan said, so be sure to ask about any associated costs.

5. Your diagnosis might lead you to specialized resources

Patients with a specific diagnosis might have additional options for specialty treatment.

For example, someone with breast cancer should check with the and the nonprofit , Cox said.

The Patient Advocate Foundation hosts that can help offset the cost of medical bills and provide other resources such as transportation and lodging, Donovan said. Just type in basic information such as age, location, and diagnosis to see what is available.

Disorder-specific foundations, such as those for lupus or irritable bowel syndrome, can also steer patients to free or low-cost resources or cover some costs of care, Donovan said.

“Everything is out there,” she said.

As you research affordable care options, don’t be tricked by plans that look like health insurance but don’t offer guaranteed protection against big bills.

Some short-term plans and health care sharing ministries might seem like good deals, but read the fine print. Some red flags to look for: too-good-to-be-true monthly payments; no coverage for preexisting conditions; morality clauses such as those prohibiting the use of alcohol or drugs; or a lack of coverage for benefits such as mental health counseling that are required in ACA plans.

Â鶹ŮÓÅ Health News correspondent Sam Whitehead contributed to this report.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact Â鶹ŮÓÅ Health News and share your story.

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MacDonald wanted to find a new doctor right away. She needed refills for her blood pressure medications and wanted to book a follow-up appointment after a breast cancer scare. 

She called 10 primary care practices near her home in Westwood, Massachusetts. None of the doctors, nurse practitioners, or physician assistants was taking new patients. A few offices told her that a doctor could see her in a year and a half or two years.

“I was just shocked by that, because we live in Boston and we’re supposed to have this great medical care,” said MacDonald, who is in her late 40s and has private health insurance. “I couldn’t get my mind around the fact that we didn’t have any doctors.”

The shortage of primary care providers is a , but it’s particularly acute in Massachusetts. The state’s primary care workforce is shrinking faster than in most states, according to a .

Some health networks, including the state’s largest hospital chain, , are turning to artificial intelligence for solutions.

In September, right when MacDonald was running out of blood pressure medications, MGB launched a new AI-supported program, . MacDonald had received a letter from MGB, telling her no primary care providers in the network were taking new patients for in-person care. At the bottom of the letter was a link to Care Connect.

MacDonald downloaded the app and requested a telehealth appointment with a doctor. She then spent about 10 minutes chatting with an AI agent about why she wanted to see a physician. Afterward, the AI tool sent a summary of the chat to a primary care doctor who could see MacDonald by video.

“I think I got an appointment the next day or two days later,” she said. “It was just such a difference from being told I had to wait two years.”

Round-the-Clock Convenience

MGB says the AI tool can handle patients seeking care for colds, nausea, rashes, sprains, and other common urgent care requests, as well as mild to moderate mental health concerns and issues related to chronic diseases. After the patient types in a description of the symptoms or problem, the AI tool sends a doctor a suggested diagnosis and treatment plan.

Care Connect employs 12 physicians to work with the AI. They log in remotely from around the U.S., and patients can get help round-the-clock, seven days a week.

Care Connect is one of many AI-based tools that hospitals, doctors, and administrative staff are testing for a range of routine medical tasks, including note-taking, reviewing diagnostic results, billing, and ordering supplies.

Proponents argue that these AI programs can help relieve staff burnout and worker shortages by reducing time spent on medical records, referrals, and other administrative tasks. But there’s debate about and to use AI to improve diagnoses. Critics worry that AI agents miss important details about overlapping medical conditions.

Critics also point out that AI tools can’t assess whether patients can afford follow-up care or get to that appointment. They have no insight into family dynamics or caretaking needs, things that primary physicians come to understand through long-term personal relationships.

Since her first foray on the app in September, MacDonald has used Care Connect at least three more times. Two of those interactions led to an eventual conversation with a remote doctor, but when she went online to book an appointment for travel-related shots, she interacted only with the AI chatbot before visiting the travel clinic.

MacDonald likes the convenience.

“I don’t have to leave work,” she said. “And I gained some peace of mind, knowing that I have a plan between now and me finding another in-person doctor.”

So while she hunted for that person, MacDonald planned to stay with Care Connect.

“This is a logical solution in the short term,” MacDonald said. “At the end of the day, it’s the patient who’s feeling the aftermath of all of the bigger things going on in health care.”

Scarcity and Burnout

Many factors contribute to the shortage of providers. Many primary care doctors, such as pediatricians, internists, and family medicine physicians, are dissatisfied with their pay. They earn about , on average, than specialists such as surgeons, cardiologists, and anesthesiologists. 

At the same time, their workload has been increasing. Primary care doctors days packed with complex patient visits, followed by evenings spent updating medical records and responding to patient messages.

When MacDonald signed onto Care Connect, she was one of 15,000 patients in the Mass General Brigham system without a primary care provider. That number has grown as primary care doctors have left MGB for rival hospital networks.

, a primary care physician at an MGB health center in Chelsea, Massachusetts, said she’s staying at MGB for now, but she’s grown frustrated with the system’s leaders.

“They don’t make any effort to ease the shortage,” said Rao, who is also part of an MBG’s primary care doctors. “They put their money into specialties. Primary care feels like a peripheral part of the system, when it really should be a central part.”

Last year, MGB pledged to spend $400 million over five years on primary care services — though that includes the multiyear contract with Care Connect.

“Care Connect is just one solution among many in this broader strategy to alleviate the primary care capacity crisis,” , MGB’s chief operating officer, said in an emailed statement. “Our investment supports retaining our current physicians as well as recruiting new ones.”

Walls said MGB has increased staffing support for primary care physicians, implemented other AI tools, and hired a new executive for primary care. Some of these changes are based on recommendations from their own primary care doctors.

But some of those doctors say they would like other changes, and salary increases in particular.

Walls would not disclose the exact amount MGB is spending on Care Connect.

Bridge to Better Care or a ‘Band-Aid’?

MGB has rolled out other AI tools, including one that can transcribe a doctor’s in-person conversations with patients. Rao isn’t using that tool. She worries that patient information could be leaked and medical privacy violated, and she doesn’t want her conversations with patients to be used to help develop the next generation of AI medical tools.

“What if they’re just using my interactions with patients to train their AI and boot me out of my job?” she said.

That’s not the goal, said , a primary care physician who manages the program for MGB. All decisions about patient care are still made by real doctors, she said.

“We are not replacing our in-person primary care,” she said. “It’s still important, and the majority of patients still have in-person primary care.”

But the fear among some primary care doctors at MGB is that Care Connect will gradually erode access to in-person primary care visits. Of the $400 million pledged by MGB for primary care, they want less spent on AI and more used to attract and increase pay for primary care staffers.

, an MGB internist who is also involved in the unionizing effort, said the use of Care Connect can only fill a gap. “That sounds like a band-aid for a broken system to me,” he said.

Expanding AI Tools

As of mid-December, the Care Connect doctors were each seeing 40 to 50 patients a day. By February, the MGB network plans to make Care Connect available to all Massachusetts and New Hampshire residents who have health insurance, and to hire more doctors to staff the program as needed. 

Patients can use the program like an urgent care service, Ireland said. They can also decide to make one of the remote doctors their permanent primary care provider.

“Some patients want in-person care,” Ireland said. “But I do believe there’s a subset of patients who will appreciate the 24-hour, seven-day-a-week model and choose to be a part of this.”

Care Connect isn’t for patients who need emergency care or a physical exam, she said. And patients who need tests or imaging are referred to the network’s clinics or labs.

But the remote doctors can manage some of the same routine issues that all primary care doctors do, Ireland said, including moderate respiratory infections, allergies, and chronic conditions such as diabetes, high cholesterol, and depression. 

says only immediate, not ongoing, health problems should be on that list. Lin is chief of primary care at the Stanford University School of Medicine and founded Stanford’s Healthcare AI Applied Research Team.

“In its current state, the safest use of this tool is for more urgent care issues,” Lin said. “Your upper respiratory tract infections. Your urinary tract infections. Your musculoskeletal injuries. Your rashes.”

For patients with multiple chronic conditions such as high blood pressure and diabetes — or for patients with especially serious conditions like heart disease or cancer — Lin said nothing beats a human who sees you regularly.

Still, Lin agrees that the chat summary generated after an AI encounter can help a physician be more efficient. For patients, Lin understands the practical appeal of a virtual option.

“I would rather these patients get care, if that care can be safe,” he said, “than not get care at all.”

The company that developed the AI platform for Care Connect, , contends the program is delivering safe, effective care to patients with complex, chronic ailments — many of whom have no other option besides a hospital emergency room.

“America’s got a big problem with health care, issues with cost, quality, and access,” said , the company’s CEO. “To solve it, you need to start with primary care, and you have to use technology and AI.”

In addition to Mass General Brigham, K Health partners with five other health networks, including the highly ranked and Los Angeles-based .

In a funded by K Health, Cedars-Sinai researchers compared several hundred diagnosis and treatment recommendations made by AI with those made by physicians.

The researchers found the AI to be slightly better at identifying “critical red flags” and recommending care based on clinical guidelines, though the physicians were better at adjusting their treatment recommendations as they spoke more with the patient.

This article is from a partnership that includes , , and Â鶹ŮÓÅ Health News.

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Instead of typing on her computer keyboard during the exam, Urban’s primary care physician at the practice in Media, Pennsylvania, had an ambient artificial intelligence scribe take notes. At the end of the 30-minute visit, Urban’s doctor showed her the AI summary of the appointment, neatly organized into sections for her medical history, the physical exam findings, and an assessment and treatment plan for her rheumatoid arthritis and hot flashes, among other details.

The clinical note, which Urban could also review on the patient portal at home, was incredibly thorough, she said. It summarized all of her questions and concerns and the doctor’s responses. The scribe “made sure we didn’t miss anything,” Urban said.

Ambient AI scribes are being hailed by physicians as a game changer that helps free them to focus on their patients rather than their computer keyboard. By releasing doctors from the onerous and time-consuming task of documenting what happens during every patient encounter, , AI scribes may help reduce physician burnout and after-hours “pajama time” catching up on work in the evening.

The potential of AI to transform every aspect of the health care system — from patient care to clinical efficiency to medical innovation — is an area of intense focus, including by the Trump administration.

Last January, President Donald Trump issued an to remove barriers to American leadership in AI. Later in the year, a from the federal Department of Health and Human Services invited stakeholders to weigh in on how the department can accelerate the adoption of AI in health care.

Several startup vendors in recent years have introduced ambient AI scribe products that can be integrated into electronic health records. EHR market leader Epic is technology, which it expects to release widely early this year, according to , a family medicine physician who is chief medical officer and vice president of clinical informatics at Epic.

Health tech experts estimate that a third of providers have access to ambient AI scribe technology. As adoption looks likely to grow rapidly over the next few years, many expect it to become more of a recruiting tool, a minimum requirement for incoming clinicians, who are increasingly prioritizing work-life balance.

“It’s part of keeping doctors happy,” said , a professor and the chair of the Department of Medicine at the University of California-San Francisco, whose forthcoming book, , explores how AI is transforming health care. “Health systems that initially might have done a hard-nosed return-on-investment calculation — many are softening on that and realizing that the cost of recruiting and retaining doctors is pretty high.”

But many questions remain. Does the use of ambient AI scribes improve patient care and health outcomes? Will doctors use time they gain by employing an AI scribe to improve the quality of the time they spend with their patients or just boost the number of patients they see? To what extent will expanding the amount of detail available from a patient visit lead to bigger bills if the AI scribe is integrated with a coding app that optimizes provider charges?

For now, these questions remain mostly unanswered.

Urban said that the AI scribe didn’t change her experience as a patient very much. Typically, after a patient gives verbal permission, the AI scribe records the visit on a phone and organizes the conversation into the structure of a clinical note, filtering out small talk that isn’t pertinent to the medical visit but incorporating relevant details about a family member’s recent cancer diagnosis, for example. The scribe’s note is often then integrated into the provider’s EHR. The doctor later reviews the note and signs off on it.

Even though the visit may not feel very different to patients, some clinicians report that ambient AI scribes are changing patient encounters in unanticipated ways.

“Now, when I’m doing a physical exam, I have to say what I’m doing and what I’m finding out loud in order for the AI scribe to document it,” said , Urban’s primary care doctor. “People find that very interesting,” she said.

When Capalongo places her stethoscope over the carotid artery under a patient’s jaw, for example, she might say that she doesn’t hear a “bruit,” or vascular murmur, whose presence could indicate atherosclerosis. Patients have told her, “I never knew why a doctor would listen there,” she said.

Saying things out loud for the AI scribe that would typically appear only in a clinical note can create its own set of challenges, particularly during sensitive physical exams. Doctors may feel it’s important to adjust their conversation accordingly.

“Sometimes patients are anxious and scared and my saying things that they don’t understand or they may worry about during an uncomfortable examination does not help the situation and honestly is insensitive to what the patient is going through,” said , a professor in the Division of Colon and Rectal Surgery at the University of Minnesota, who is also chief health informatics and AI officer at Fairview Health Services in Minneapolis. “I’ll keep that top of mind and make sure I record it” after the visit.

“How we have conversations with patients about these tools is really important, in particular for maintaining trust and ensuring accurate information,” Melton-Meaux said.

Studies have found that, across a range of measures such as completeness, timeliness, and coherence, the notes created by ambient AI scribes are generally at least as good as, and sometimes better than, traditional documentation, said , a pediatrician who is vice president for applied informatics at the University of Pennsylvania Health System.

An ongoing concern is around AI “hallucinations,” in which false, sometimes fabricated information appears in an AI output.

Kaiser Permanente, an of ambient AI scribe technology, provides it to more than 25,000 doctors, advanced practice providers, and pharmacists systemwide. It has found hallucinations to be “quite rare,” said , an internist who is vice president of AI and emerging technologies at KP.

But they happen. An AI-scribe-generated note, for instance, might say that the doctor planned to refer someone to a neurologist or to follow up in two weeks. The problem? The doctor might not have said that.

“The technology is not perfect, and that’s why physicians are reviewing it,” Yang said. It’s learning from regular physician visits as it goes, he said. That’s why having a person check the work product is critical.

Still, even such a “human-in-the loop” system is fraught, Wachter said. “Humans stink at maintaining vigilance over time,” he said.

As the use of ambient AI scribes becomes routine, some clinicians worry that the technology will widen the divide between health care haves and have-nots.

Large health systems are able to move forward with the technology, Melton-Meaux said. But what about critical access hospitals or small private practices? “There need to be more resources,” she said.

Physicians’ enthusiasm for ambient AI scribes stands in sharp contrast to their negative reaction to electronic health record systems that have become widely adopted in recent years to replace paper charts.

“During the last 10 years, when EHRs became a thing, we all became very grumpy, overworked data scribes,” Wachter said.

The introduction of AI scribes makes physicians feel like technology is working for them rather than the other way around, health care AI experts said.

And AI scribes are “training wheels” for more consequential adoption of AI in health care, Wachter said.

To improve health care value and save costs, Wachter said, we need a system that makes it more likely that physicians will practice evidence-based medicine to order the right tests and prescribe the right medications.

“It’s a few years away, but it’s all AI-dependent,” he said.

Epic has introduced roughly 60 AI use cases for patients, clinicians, and administration, with over 100 more in the works.

“It’s so much bigger than a scribe,” said Epic’s Gerhart. “It’s literally listening and acting in a way that tees things up for me so that I can take action.”

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NEW ORLEANS — Elyse Stevens had a reputation for taking on complex medical cases. People who’d been battling addiction for decades. Chronic-pain patients on high doses of opioids. Sex workers and people living on the street.

“Many of my patients are messy, the ones that don’t know if they want to stop using drugs or not,” said Stevens, a primary care and addiction medicine doctor.

While other doctors avoided these patients, Stevens — who was familiar with the city from her time in medical school at Tulane University — sought them out. She regularly attended 6 a.m. breakfasts for homeless people, volunteered at a homeless shelter clinic on Saturdays, and, on Monday evenings, visited an abandoned Family Dollar store where advocates distributed supplies to people who use drugs.

One such evening about four years ago, Charmyra Harrell arrived there limping, her right leg swollen and covered in sores. Emergency room doctors had repeatedly dismissed her, so she eased the pain with street drugs, Harrell said.

Stevens cleaned her sores on Mondays for months until finally persuading Harrell to visit the clinic at University Medical Center New Orleans. There, Stevens discovered Harrell had diabetes and cancer.

She agreed to prescribe Harrell pain medication — an option many doctors would automatically dismiss for fear that a patient with a history of addiction would misuse it.

But Stevens was confident Harrell could hold up her end of the deal.

“She told me, ‘You cannot do drugs and do your pain meds,’” Harrell recounted on a Monday evening in October. So, “I’m no longer on cocaine.”

Stevens’ approach to patient care has won her awards and nominations in , , and . Instead of seeing patients in binaries — addicted or sober, with a positive or negative drug test — she measures progress on a spectrum. Are they showering daily, cooking with their families, using less fentanyl than the day before?

But not everyone agrees with this flexible approach that prioritizes working with patients on their goals, even if abstinence isn’t one of them. And it came to a head in the summer of 2024.

“The same things I was high-fived for thousands of times — suddenly that was bad,” Stevens said.

Flexible Care or Slippery Slope?

More than who need substance use treatment don’t receive it, national data shows. Barriers abound: high costs, lack of transportation, clinic hours that are incompatible with jobs, fear of being mistreated.

Some doctors had been trying to ease the process for years. Covid-19 accelerated that trend. Telehealth appointments, fewer urine drug tests, and medication refills that last longer became the norm.

The result?

“Patients did OK and we actually reached more people,” said , immediate past president of the American Society of Addiction Medicine. The organization supports continuing flexible practices, such as helping patients avoid withdrawal symptoms by of addiction medication and focusing on recovery goals .

But some doctors prefer traditional approaches that range from zero tolerance for patients using illegal drugs to setting stiff consequences for those who don’t meet their doctors’ expectations. For example, a patient who tests positive for street drugs while getting outpatient care would be discharged and told to go to residential rehab. Proponents of this method fear loosening restrictions could be a slippery slope that ultimately harms patients. They say continuing to prescribe painkillers, for example, to people using illicit substances long-term could normalize drug use and hamper the goal of getting people off illegal drugs.

Progress should be more than keeping patients in care, said , a Stanford psychologist, who has treated and researched addiction for decades and .

“If you give addicted people lots of drugs, they like it, and they may come back,” he said. “But that doesn’t mean that that is promoting their health over time.”

Flexible practices also tend to align with harm reduction, a divisive approach that proponents say keeps people who use drugs safe and that critics — — say enables illegal drug use.

The debate is not just philosophical. For Stevens and her patients, it came to bear on the streets of New Orleans.

‘Unconventional’ Prescribing

In the summer of 2024, supervisors started questioning Stevens’ approach.

In emails reviewed by Â鶹ŮÓÅ Health News, they expressed concerns about her prescribing too many pain pills, a mix of opioids and other controlled substances to the same patients, and high doses of buprenorphine, a medication considered to treat opioid addiction.

Supervisors worried Stevens wasn’t doing enough urine drug tests and kept treating patients who used illicit drugs instead of referring them to higher levels of care.

“Her prescribing pattern appears unconventional compared to the local standard of care,” the hospital’s chief medical officer at the time wrote to Stevens’ supervisor, . “Note that this is the only standard of care which would likely be considered should a legal concern arise.”

Springgate forwarded that email to Stevens and encouraged her to refer more patients to methadone clinics, intensive outpatient care, and inpatient rehab.

Stevens understood the general practice but couldn’t reconcile it with the reality her patients faced. How would someone living in a tent, fearful of losing their possessions, trek to a methadone clinic daily?

Stevens sent her supervisors of and backing her flexible approach. She explained that if she stopped prescribing the medications of concern, patients might leave the health system, but they wouldn’t disappear.

“They just wouldn’t be getting care and perhaps they’d be dead,” she said in an interview with Â鶹ŮÓÅ Health News.

Both University Medical Center and LSU Health New Orleans, which employs physicians at the hospital, declined repeated requests for interviews. They did not respond to detailed questions about addiction treatment or Stevens’ practices.

Instead, they provided a joint statement from Richard DiCarlo, dean of the LSU Health New Orleans School of Medicine, and Jeffrey Elder, chief medical officer of University Medical Center New Orleans.

“We are not at liberty to comment publicly on internal personnel issues,” they wrote.

“We recognize that addiction is a serious public health problem, and that addiction treatment is a challenge for the healthcare industry,” they said. “We remain dedicated to expanding access to treatment, while upholding the highest standard of care and safety for all patients.”

Not Black-and-White

Â鶹ŮÓÅ Health News shared the complaints against Stevens and the responses she’d written for supervisors with two addiction medicine doctors outside of Louisiana, who had no affiliation with Stevens. Both found her practices to be within the bounds of normal addiction care, especially for complex patients.

, an addiction medicine doctor and the , said doctors running pill mills typically have sparse patient notes that list a chief complaint of pain. But Stevens’ notes detailed patients’ life circumstances and the intricate decisions she was making with them.

“To me, that’s the big difference,” Loyd said.

Some people think the “only good answer is no opioids,” such as oxycodone or hydrocodone, for any patients, said , an addiction medicine doctor and associate professor at Michigan State University. But patients may need them — sometimes for things like cancer pain — or require months to lower their doses safely, she said. “It’s not as black-and-white as people outside our field want it to be.”

Humphreys, the Stanford psychologist, had a different take. He did not review Stevens’ case but said, as a general practice, there are risks to prescribing painkillers long-term, especially for patients using today’s lethal street drugs too.

Overprescribing fueled the opioid crisis, he said. “It’s not going to go away if we do that again.”

‘The Thing That Kills People’

After months of tension, Stevens’ supervisors told her on March 10 to stop coming to work. The hospital was conducting a review of her practices, they said in an email viewed by Â鶹ŮÓÅ Health News.

Overnight, hundreds of her patients were moved to other providers.

Luka Bair had been seeing Stevens for three years and was stable on daily buprenorphine.

After Stevens’ departure, Bair was left without medication for three days. The withdrawal symptoms were severe — headache, nausea, muscle cramps.

“I was just in physical hell,” said Bair, who works for the National Harm Reduction Coalition and uses they/them pronouns.

Although Bair eventually got a refill, Springgate, Stevens’ supervisor, didn’t want to continue the regimen long-term. Instead, Springgate referred Bair to more intensive and residential programs, citing Bair’s intermittent use of other drugs, including benzodiazepines and cocaine, as markers of high risk. Bair “requires a higher level of care than our clinic reasonably can offer,” Springgate wrote in patient portal notes reviewed by Â鶹ŮÓÅ Health News.

But Bair said daily attendance at those programs was incompatible with their full-time job. They left the clinic, with 30 days to find a new doctor or run out of medication again.

“This is the thing that kills people,” said Bair, who eventually found another doctor willing to prescribe.

Springgate did not respond to repeated calls and emails requesting comment.

University Medical Center and LSU Health New Orleans did not answer questions about discharging Stevens’ patients.

‘Reckless Behavior’

About a month after Stevens was told to stay home, Haley Beavers Khoury, a medical student who worked with her, had collected nearly 100 letters from other students, doctors, patients, and homelessness service providers calling for Stevens’ return.

One student wrote, “Make no mistake — some of her patients will die without her.” A nun from the Daughters of Charity, which ran , called Stevens a “lifeline” for vulnerable patients.

Beavers Khoury said she sent the letters to about 10 people in hospital and medical school leadership. Most did not respond.

In May, the hospital’s review committee determined Stevens’ practices fell “outside of the acceptable community standards” and constituted “reckless behavior,” according to a letter sent to Stevens.

The hospital did not answer Â鶹ŮÓÅ Health News’ questions about how it reached this conclusion or if it identified any patient harm.

Meanwhile, Stevens had secured a job at another New Orleans hospital. But because her resignation came amid the ongoing investigation, University Medical Center said it was required to inform the state’s medical licensing board.

The medical board began its own investigation — a development that eventually cost Stevens the other job offer.

In presenting her side to the medical board, Stevens repeated many arguments she’d made before. Yes, she was prescribing powerful medications. No, she wasn’t making clinical decisions based on urine drug tests. But national addiction organizations supported such practices and promoted tailoring care to patients’ circumstances, she said. Her response included a 10-page bibliography with 98 citations.

Liability

The board’s investigation into Stevens is ongoing. shows no action taken against her license as of late December.

The board declined to comment on both Stevens’ case and its definition of appropriate addiction treatment.

In October, Stevens moved to the Virgin Islands to work in internal medicine at a local hospital. She said she’s grateful for the welcoming locals and the financial stability to support herself and her parents.

But it hurts to think of her former patients in New Orleans.

Before leaving, Stevens packed away handwritten letters from several of them — one was 15 pages long, written in alternating green and purple marker — in which they shared childhood traumas and small successes they had while in treatment with her.

Stevens doesn’t know what happened to those patients after she left.

She believes the scrutiny of her practices centers on liability more than patient safety.

But, she said, “liability is in abandoning people too.”

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