Shaw, 56, who has been dependent on opioid painkillers since she injured her back in a fall a decade ago, said in both an interview with KFF Health News and in sworn courtroom testimony that the Tennessee clinic would write the prescriptions only if she first agreed to receive three or four “very painful” injections of another medicine along her spine.

The clinic claimed the injections were steroids that would relieve her pain, Shaw said, but with each shot her agony would grow. Shaw said she eventually tried to decline the shots, then the clinic issued an ultimatum: Take the injections or get her painkillers somewhere else.

“I had nowhere else to go at the time,” Shaw testified, according to a federal court transcript. “I was stuck.”

Shaw was among thousands of patients of Pain MD, a multistate pain management company that was once among the nation’s most prolific users of what it referred to as “tendon origin injections,” which normally inject a single dose of steroids to relieve stiff or painful joints. As many doctors were scaling back their use of prescription painkillers due to the opioid crisis, Pain MD paired opioids with monthly injections into patients’ backs, claiming the shots could ease pain and potentially lessen reliance on painkillers, according to federal court documents.

Now, years later, Pain MD’s injections have been proved in court to be part of a decade-long fraud scheme that made millions by capitalizing on patients’ dependence on opioids. The Department of Justice has successfully argued at trial that Pain MD’s “unnecessary and expensive injections” were largely ineffective because they targeted the wrong body part, contained short-lived numbing medications but no steroids, and appeared to be based on test shots given to cadavers — people who felt neither pain nor relief because they were dead.

Four Pain MD employees have pleaded guilty or been convicted of health care fraud, including company president Michael Kestner, who was found guilty of 13 felonies at an October trial in Nashville, Tennessee. According to a transcript from Kestner’s trial that became public in December, witnesses testified that the company documented giving patients about 700,000 total injections over about eight years and said some patients got as many as 24 shots at once.

“The defendant, Michael Kestner, found out about an injection that could be billed a lot and paid well,” said federal prosecutor James V. Hayes as the trial began, according to the transcript. “And they turned some patients into human pin cushions.”

The Department of Justice declined to comment for this article. Kestner’s attorneys either declined to comment or did not respond to requests for an interview. At trial, Kestner’s attorneys argued that he was a well-intentioned businessman who wanted to run pain clinics that offered more than just pills. He is scheduled to be sentenced on April 21 in a federal court in Nashville.

According to the transcript of Kestner’s trial, Shaw and three other former patients testified that Pain MD’s injections did not ease their pain and sometimes made it worse. The patients said they tolerated the shots only so Pain MD wouldn’t cut off their prescriptions, without which they might have spiraled into withdrawal.

“They told me that if I didn’t take the shots — because I said they didn’t help — I would not get my medication,” testified Patricia McNeil, a former patient in Tennessee, according to the trial transcript. “I took the shots to get my medication.”

In her interview with KFF Health News, Shaw said that often she would arrive at the Pain MD clinic walking with a cane but would leave in a wheelchair because the injections left her in too much pain to walk.

“That was the pain clinic that was supposed to be helping me,” Shaw said in her interview. “I would come home crying. It just felt like they were using me.”

‘Not Actually Injections Into Tendons at All’

Pain MD, which sometimes operated under the name Mid-South Pain Management, ran as many as 20 clinics in Tennessee, Virginia, and North Carolina throughout much of the 2010s. Some clinics averaged more than 12 injections per patient each month, and at least two patients each received more than 500 shots in total, according to federal court documents.

All those injections added up. According to Medicare data filed in federal court, Pain MD and Mid-South Pain Management billed Medicare for more than 290,000 “tendon origin injections” from January 2010 to May 2018, which is about seven times that of any other Medicare biller in the U.S. over the same period.

Tens of thousands of additional injections were billed to Medicaid and Tricare during those same years, according to federal court documents. Pain MD billed these government programs for about $111 per injection and collected more than $5 million from the government for the shots, according to the court documents.

More injections were billed to private insurance too. Christy Wallace, an audit manager for BlueCross BlueShield of Tennessee, testified that Pain MD billed the insurance company about $40 million for more than 380,000 injections from January 2010 to March 2013. BlueCross paid out about $7 million before it cut off Pain MD, Wallace said.

These kinds of enormous billing allegations are not uncommon in health care fraud cases, in which fraudsters sometimes find a legitimate treatment that insurance will pay for and then overuse it to the point of absurdity, said Don Cochran, a former U.S. attorney for the Middle District of Tennessee.

Tennessee alone has seen fraud allegations for unnecessary billing of urine testing, skin creams, and other injections in just the past decade. Federal authorities have also investigated an alleged fraud scheme involving a Tennessee company and hundreds of thousands of catheters billed to Medicare, according to The Washington Post, citing anonymous sources.

Cochran said the Pain MD case felt especially “nefarious” because it used opioids to make patients play along.

“A scheme where you get Medicare or Medicaid money to provide a medically unnecessary treatment is always going to be out there,” Cochran said. “The opioid piece just gives you a universe of compliant people who are not going to question what you are doing.”

“It was only opioids that made those folks come back,” he said.

The allegations against Pain MD became public in 2018 when Cochran and the Department of Justice filed a civil lawsuit against the company, Kestner, and several associated clinics, alleging that Pain MD defrauded taxpayers and government insurance programs by billing for “tendon origin injections” that were “not actually injections into tendons at all.”

Kestner, Pain MD, and several associated clinics have each denied all allegations in that lawsuit, which is ongoing.Scott Kreiner, an expert on spine care and pain medicine who testified at Kestner’s criminal trial, said that true tendon origin injections (or TOIs) typically are used to treat inflamed joints, like the condition known as “tennis elbow,” by injecting steroids or platelet-rich plasma into a tendon. Kreiner said most patients need only one shot at a time, according to the transcript.

But Pain MD made repeated injections into patients’ backs that contained only lidocaine or Marcaine, which are anesthetic medications that cause numbness for mere hours, Kreiner testified. Pain MD also used needles that were often too short to reach back tendons, Kreiner said, and there was no imaging technology used to aim the needle anyway. Kreiner said he didn’t find any injections in Pain MD’s records that appeared medically necessary, and even if they had been, no one could need so many.

“I simply cannot fathom a scenario where the sheer quantity of TOIs that I observed in the patient records would ever be medically necessary,” Kreiner said, according to the trial transcript. “This is not even a close call.”

Jonathan White, a physician assistant who administered injections at Pain MD and trained other employees to do so, then later testified against Kestner as part of a plea deal, said at trial that he believed Pain MD’s injection technique was based on a “cadaveric investigation.”

According to the trial transcript, White said that while working at Pain MD he realized he could find no medical research that supported performing tendon origin injections on patients’ backs instead of their joints. When he asked if Pain MD had any such research, White said, an employee responded with a two-paragraph letter from a Tennessee anatomy professor — not a medical doctor — that said it was possible to reach the region of back tendons in a cadaver by injecting “within two fingerbreadths” of the spine. This process was “exactly the procedure” that was taught at Pain MD, White said.

During his own testimony, Kreiner said it was “potentially dangerous” to inject a patient as described in the letter, which should not have been used to justify medical care.

“This was done on a dead person,” Kreiner said, according to the trial transcript. “So the letter says nothing about how effective the treatment is.”

Over-Injecting ‘Killed My Hand’

Pain MD collapsed into bankruptcy in 2019, leaving some patients unable to get new prescriptions because their medical records were stuck in locked storage units, according to federal court records.

At the time, Pain MD defended the injections and its practice of discharging patients who declined the shots. When a former patient publicly accused the company of treating his back “like a dartboard,” Pain MD filed a defamation lawsuit, then dropped the suit about a month later.

“These are interventional clinics, so that’s what they offer,” Jay Bowen, a then-attorney for Pain MD, told The Tennessean newspaper in 2019. “If you don’t want to consider acupuncture, don’t go to an acupuncture clinic. If you don’t want to buy shoes, don’t go to a shoe store.”

Kestner’s trial told another story. According to the trial transcript, eight former Pain MD medical providers testified that the driving force behind Pain MD’s injections was Kestner himself, who is not a medical professional and yet regularly pressured employees to give more shots.

One nurse practitioner testified that she received emails “every single workday” pushing for more injections. Others said Kestner openly ranked employees by their injection rates, and implied that those who ranked low might be fired.

“He told me that if I had to feed my family based on my productivity, that they would starve,” testified Amanda Fryer, a nurse practitioner who was not charged with any crime.

Brian Richey, a former Pain MD nurse practitioner who at times led the company’s injection rankings, and has since taken a plea deal that required him to testify in court, said at the trial that he “performed so many injections” that his hand became chronically inflamed and required surgery.

“‘Over injecting killed my hand,’” Richey said on the witness stand, reading a text message he sent to another Pain MD employee in 2017, according to the trial transcript. “‘I was in so much pain Injecting people that didnt want it but took it to stay a patient.’”

“Why would they want to stay there?” a prosecutor asked.

“To keep getting their narcotics,” Richey responded, according to the trial transcript.

Throughout the trial, defense attorney Peter Strianse argued that Pain MD’s focus on injections was a result of Kestner’s “obsession” with ensuring that the company “would never be called a pill mill.”

Strianse said that Kestner “stayed up at night worrying” about patients coming to clinics only to get opioid prescriptions, so he pushed his employees to administer injections, too.

“Employers motivating employees is not a crime,” Strianse said at closing arguments, according to the court transcript. “We get pushed every day to perform. It’s not fraud; it’s a fact of life.”

Prosecutors insisted that this defense rang hollow. During the trial, former employees had testified that most patients’ opioid dosages remained steady or increased while at Pain MD, and that the clinics did not taper off the painkillers no matter how many injections were given.

“Giving them injections does not fix the pill mill problem,” federal prosecutor Katherine Payerle said during closing arguments, according to the trial transcript. “The way to fix being a pill mill is to stop giving the drugs or taper the drugs.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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His wife, Katherine Qualls, said his doctors offered little hope. In an interview and a written complaint to the Tennessee government, she said doctors at Holston Valley told her that her husband would not qualify for a heart transplant and shouldn’t be expected to recover.

Defiant, she insisted he be transferred hours away to a hospital in Nashville. Within days of leaving Holston Valley, Jerry Qualls was awake and sitting upright, his wife said, and he ultimately received a lifesaving heart transplant.

“How many families don’t know how to get a transfer and their loved one dies?” Katherine Qualls wrote in her complaint to the state. “My husband would have been dead within a few days if I didn’t get him out when I did.”

Holston Valley Medical Center is a flagship of Ballad Health, a 20-hospital system in northeastern Tennessee and southwestern Virginia that is the only option for hospital care in a large swath of Appalachia. Ballad formed six years ago when lawmakers in both states, in an effort to prevent hospital closures, waived federal antitrust laws so two rival health systems could merge. The merger created the largest state-sanctioned hospital monopoly in the nation.

Since then, Ballad has largely kept those hospitals open. But the monopoly has also fallen short of about three-fourths of the quality-of-care goals set by the states over the last three fiscal years, including failing to meet state benchmarks on infections, mortality, emergency room speed, and patient satisfaction, according to annual reports from the Tennessee Department of Health and Ballad itself.

Some local residents have become wary, afraid, or unwilling to seek care at Ballad hospitals and must drive over an hour to reach other options, according to written complaints to the Tennessee government and state lawmakers, public hearing testimony, and KFF Health News interviews conducted over the past year with patients, family members, local leaders, and some officials who once publicly supported the monopoly, including a former government consultant and one state lawmaker. Many of those who submitted complaints or were interviewed allege that paper-thin staffing at Ballad hospitals and ERs is the root cause of the monopoly’s quality-of-care woes.

In a two-hour interview vigorously defending the company, Ballad Health CEO Alan Levine said the hospitals are rapidly recovering from a quality-of-care slump caused by covid-19 and a subsequent rise in nursing turnover and staff shortages. These issues affected hospitals nationwide, Levine said, and were not related to the Ballad merger or the monopoly it created.

Levine declined to discuss specific complaints from patients. But he said that each of the complaints referenced in this article took issue with medical decisions made by doctors in Ballad hospitals — not “any policy or practice at Ballad.”

“I can understand if the patients, if the wife, was upset about the medical decisions they made if it turned out to be wrong,” Levine said. “But that has nothing to do with the merger, OK? That’s a completely different issue, and it happens in hospitals all over the country.”

In the interview with KFF Health News and in the days that followed, Levine flexed considerable connections to officials in the Tennessee government. As Levine spoke in a boardroom at Ballad’s hilltop headquarters, he was flanked by three local mayors who voiced support for the hospitals and said complaints came from a vocal minority of their constituents. Days later, Levine got two Tennessee state agency directors and a former state health commissioner to provide emails or text messages supporting statements he made during the interview.

Logan Grant, executive director of the Tennessee Health Facilities Commission, which processes complaints against hospitals for the state, said in a statement prompted by Levine that Ballad hospitals are “not an outlier in terms of substantiated survey findings.”

Joe Grandy, the mayor of Tennessee’s Washington County, where Ballad is headquartered, said most residents consider the quality of care in the area “about as good as it gets.”

Brenda Getaz certainly doesn’t.

Getaz, 76, who spent three decades as a hospital official specializing in quality standards before retiring to Washington County, said she plans to move to Atlanta if state governments do not take action to fix Ballad in the coming year. Getaz said local medical professionals she trusts have urged her to move away so she does not have to rely on Ballad for care.

“I’m frightened to be taken to a Ballad facility,” she said.

Glimpses of Government Concern

The Tennessee Department of Health, which has the most direct oversight over Ballad Health, over the past year has declined multiple interview requests to discuss the hospital monopoly. Department emails reviewed by KFF Health News, some of which were obtained through public record requests, offer glimpses of concern inside the agency.

Emails show the health department has attempted to hold Ballad more accountable for its quality of care in closed-door negotiations and is investigating Holston Valley’s treatment of a recent heart patient after receiving detailed complaints from his family. In a 2023 email, Tennessee Health Commissioner Ralph Alvarado reacted to a news story about low job satisfaction among Ballad nurses by writing: “Ouch. … What are they doing to address this?”

In another email from the same year, Alvarado praised an informal report submitted at a public hearing that concluded Ballad’s monopoly had caused more harm than good. The report was written by Wally Hankwitz, a retired health care executive who once led a physician management company in Kingsport. The report levied pages of criticism against Ballad’s “sub-par” performance and called for the monopoly to end.

“THIS communication from the COPA hearing is particularly good,” the health commissioner wrote to some of his staff. “Totally based on data. I would almost like to hear Ballad’s response to this.”

When asked to respond to the Hankwitz report, Levine said it was “full of errors” and that “no credible institution would pay attention to it.”

Despite concerns, Tennessee and Virginia have each year determined that the benefits of the Ballad monopoly outweigh any negative impacts, issuing stamps of approval that allow the monopoly to continue. This has occurred, at least in part, because both states grade Ballad against scoring rubrics that do not prioritize quality of care.

Larry Fitzgerald, a retired Tennessee consultant who monitored the monopoly for the state for more than five years and always gave Ballad high marks, said in an interview that his hands were tied by the state’s lenient grading system, which allowed Ballad to succeed on paper even when it failed to meet the state’s quality-of-care goals.

Fitzgerald said he is unconvinced that the state-sanctioned monopoly had prevented any hospital closures and said the merger had “probably not” benefited local residents overall.

When asked where he would get medical attention if he lived in northeastern Tennessee or southwestern Virginia, Fitzgerald immediately responded, “I’m not going to a Ballad hospital.”

In his interview, Levine alleged Fitzgerald had “basically defrauded the state” by not raising these criticisms of Ballad in his public reports on the monopoly and said it was “irresponsible” and “obscene” to express his concerns about quality of care after retiring.

‘Horror Stories’ From Ballad Patients

Tennessee House member Bud Hulsey, a Republican from Kingsport, wrote in a 2023 letter to the state health department that he “was an avid supporter of the merger” that created Ballad but since then had become “concerned” and “saddened” by the state of the local hospitals.

In a recent interview, Hulsey said that while his family has received excellent care from Ballad, his constituents have told him “horror stories” for years.

“I had people call me from the waiting room after they’ve sat there for 12 or 14 hours,” Hulsey said. “The scales have far more complaints on them than accolades.”

Others have soured on the monopoly, too. Joe Macione, who for years was on the board of Wellmont Health System, one of the rival companies that became Ballad, once publicly advocated for the merger.

In an interview, Macione said state leaders should have admitted years ago that the monopoly was a mistake.

“It has not worked,” said Macione, 87. “All my family knows that, if I have the time, I want to go to a highly graded hospital, either in Asheville or Knoxville.”

Ballad Health was created in 2018 after Tennessee and Virginia officials waived federal anti-monopoly laws and approved the nation’s biggest hospital merger, based on what’s called a Certificate of Public Advantage, or COPA, agreement. Ballad is now the only option for hospital care for most of the approximately 1.1 million people in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina.

In the years since, there have been multiple signs of discontent with and within Ballad hospitals. In 2019, protesters gathered daily for eight months outside Holston Valley to oppose the closure of the neonatal intensive care unit and the downgrading of a trauma center. (Ballad has said the NICU closure was necessary and benefited patients, and a study published this year said the trauma changes saved lives.)

In 2020, Bristol Regional Medical Center CEO Greg Neal resigned after it was discovered he made the initial incision in a heart surgery despite not being a doctor, according to Tennessee state records. (Levine said in his interview that the resignation shows Ballad is holding employees accountable.)

In 2022, 14 cardiologists signed a letter warning of “severe limitations” in the Bristol Regional cardiac catheterization lab that were affecting patient safety and delaying procedures for weeks or months. (Ballad said in a letter to the Tennessee government that it worked with the cardiologists, who it said were partly to blame, to make the lab more efficient.)

In 2023, Ballad Health was ranked last among 200 large health care organizations in an analysis of nurse satisfaction published by an MIT business magazine. (Levine dismissed this analysis as unscientific.) This year, the Federal Trade Commission cited Ballad as a cautionary tale while opposing a similar hospital merger under consideration in Indiana, and a longtime Kingsport doctor took a parting shot at Ballad in his obituary. (Ballad declined to comment on either topic.)

And in August, the widow of a Tennessee sheriff filed a lawsuit alleging that Ballad caused her husband’s death and intentionally understaffed hospitals “to save money.” Brenda Tester, the wife of Johnson County Sheriff Eddie Tester, alleged in that lawsuit that Ballad put her husband on blood thinners and then gave him an unnecessary liver biopsy, causing “life ending internal blood loss” that led to “his cardiac arrest and ultimately his sudden death.”

Ballad has yet to respond to the Tester lawsuit in court. Levine said in his interview that the doctors who treated the sheriff were not employed by Ballad but merely contracted to work in its hospitals.

Some of Ballad’s most determined critics are family members of Anton Maki Jr., a former Holston Valley doctor who returned to the hospital as a patient in February. The family has filed complaints with multiple Tennessee agencies and the federal government and provided emails to KFF Health News showing that Tennessee is investigating Maki’s case.

In an interview and in those complaints, Maki’s family members allege Holston Valley gave Maki improper treatment, even though his symptoms and lab tests made it obvious that he was having a serious heart attack that required urgent attention.

The improper care did “permanent damage” to Maki’s heart, the family’s complaints allege. That damage required him to have a permanent mechanical heart pump surgically implanted at a non-Ballad hospital, said one of his daughters, Alexandra Maki, who is a surgeon in Kentucky. She said her father died after a fall three months later while still in a weakened state.

Alexandra Maki said that her father had been alarmed by the Ballad monopoly for years but that she didn’t fully appreciate his warnings until she witnessed his care at Holston Valley firsthand.

“I filed these complaints because it is my duty as a doctor to report what I saw,” Alexandra Maki said. “That was not care. It is a facade of a hospital. It is a well-oiled death machine.”

KFF Health News reporter Samantha Liss contributed to this article.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Then Carroll saw a TV commercial for another path: ClearChoice Dental Implant Centers. The company advertises that it can give patients “a new smile in as little as one day” by surgically replacing teeth instead of fixing them.

So Carroll saved and borrowed for the surgery, she said. In an interview and a lawsuit, Carroll said that at a ClearChoice clinic in New Jersey in 2021, she agreed to pay $31,000 to replace all her natural upper teeth with pearly-white prosthetic ones. What came next, Carroll said, was “like a horror movie.”

Carroll alleged that her anesthesia wore off during implant surgery, so she became conscious as her teeth were removed and titanium screws were twisted into her jawbone. Afterward, Carroll’s prosthetic teeth were so misaligned that she was largely unable to chew for more than two years until she could afford corrective surgery at another clinic, according to a sworn deposition from her lawsuit.

ClearChoice has denied Carroll’s claims of malpractice and negligence in court filings and did not respond to requests for comment on the ongoing case.

“I thought implants would be easier, and all at once, so you didn’t have to keep going back to the dentist,” Carroll, 52, said in an interview. “But I should have asked more questions … like, Can they save these teeth?”

Dental implants have been used for more than half a century to surgically replace missing or damaged teeth with artificial duplicates, often with picture-perfect results. While implant dentistry was once the domain of a small group of highly trained dentists and specialists, tens of thousands of dental providers now offer the surgery and place millions of implants each year in the U.S.

Amid this booming industry, some implant experts worry that many dentists are losing sight of dentistry’s fundamental goal of preserving natural teeth and have become too willing to remove teeth to make room for expensive implants, according to a months-long investigation by KFF Health News and CBS News. In interviews, 10 experts said they had each given second opinions to multiple patients who had been recommended for mouths full of implants that the experts ultimately determined were not necessary. Separately, lawsuits filed across the country have alleged that implant patients like Carroll have experienced painful complications that have required corrective surgery, while other lawsuits alleged dentists at some implant clinics have persuaded, pressured, or forced patients to remove teeth unnecessarily.

The experts warn that implants, for a single tooth or an entire mouth, expose patients to costs and surgery complications, plus a new risk of future dental problems with fewer treatment options because their natural teeth are forever gone.

“There are many cases where teeth, they’re perfectly fine, and they’re being removed unnecessarily,” said William Giannobile, dean of the Harvard School of Dental Medicine. “I really hate to say it, but many of them are doing it because these procedures, from a monetary standpoint, they’re much more beneficial to the practitioner.”

Giannobile and nine other experts say they are combating a false public perception that implants are more durable and longer-lasting than natural teeth, which some believe stems in part from advertising on TV and social media. Implants require upkeep, and although they can’t get cavities, studies have shown that patients can be susceptible to infections in the gums and bone around their implants.

“Just because somebody can afford implants doesn’t necessarily mean that they’re a good candidate,” said George Mandelaris, a Chicago-area periodontist and member of the American Academy of Periodontology Board of Trustees. “When an implant has infection, or when an implant has bone loss, an implant dies a much quicker death than do teeth.”

In its simplest form, implant surgery involves extracting a single tooth and replacing it with a metal post that is screwed into the jaw and then affixed with a prosthetic tooth commonly made of porcelain, also known as a crown. Patients can also use “full-arch” or “All-on-4” implants to replace all their upper or lower teeth — or all their teeth.

For this story, KFF Health News and CBS News sought interviews with large dental chains whose clinics offer implant surgery — ClearChoice, Aspen Dental, Affordable Care, and Dental Care Alliance — each of which declined to be interviewed or did not respond to multiple requests for comment. The Association of Dental Support Organizations, which represents these companies and others like them, also declined an interview request.

ClearChoice, which specializes in full-arch implants, did not answer more than two dozen questions submitted in writing. In an emailed statement, the company said full-arch implants “have become a well-accepted standard of care for patients with severe tooth loss and teeth with poor prognosis.”

“The use of full-arch restorations reflects the evolution of modern dentistry, offering patients a solution that restores their ability to eat, speak, and live comfortably — far beyond what traditional dentures can provide,” the company said.

Carroll said she regrets not letting her dentist try to fix her teeth and rushing to ClearChoice for implants.

“Because it was a nightmare,” she said.

‘They Are Not Teeth’

Dental implant surgery can be a godsend for patients with unsalvageable teeth. Several experts said implants can be so transformative that their invention should have contended for a Nobel Prize. And yet, these experts still worry that implants are overused, because it is generally better for patients to have their natural teeth.

Paul Rosen, a Pennsylvania periodontist who said he has worked with implants for more than three decades, said many patients believe a “fallacy” that implants are “bulletproof.”

“You can’t just have an implant placed and go off riding into the sunset,” Rosen said. “In many instances, they need more care than teeth because they are not teeth.”

Generally, a single implant costs a few thousand dollars while full-arch implants cost tens of thousands. Neither procedure is well covered by dental insurance, so many clinics partner with credit companies that offer loans for implant surgeries. At ClearChoice, for example, loans can be as large as $65,000 paid off over 10 years, according to the company’s website.

Despite the price, implants are more popular than ever. Sales increased by more than 6% on average each year since 2010, culminating in more than 3.7 million implants sold in the U.S. in 2022, according to a 2023 report produced by iData Research, a health care market research firm.

Some worry implant dentistry has gone too far. In 10 interviews, dentists and dental specialists with expertise in implants said they had witnessed the overuse of implants firsthand. Each expert said they’d examined multiple patients in recent years who were recommended for full-arch implants by other dentists despite their teeth being treatable with conventional dentistry.

Giannobile, the Harvard dean, said he had given second opinions to “dozens” of patients who were recommended for implants they did not need.

“I see many of these patients now that are coming in and saying, ‘I’ve been seen, and they are telling me to get my entire dentition — all of my teeth — extracted.’ And then I’ll take a look at them and say that we can preserve most of your teeth,” Giannobile said.

Tim Kosinski, who is a representative of the Academy of General Dentistry and said he has placed more than 19,000 implants, said he examines as many as five patients a month who have been recommended for full-arch implants that he deems unnecessary.

“There is a push in the profession to remove teeth that could be saved,” Kosinski said. “But the public isn’t aware.”

Luiz Gonzaga, a periodontist and prosthodontist at the University of Florida, said he, too, had turned away patients who wanted most or all their teeth extracted. Gonzaga said some had received implant recommendations that he considered “an atrocity.”

“You don’t go to the hospital and tell them ‘I broke my finger a couple of times. This is bothering me. Can you please cut my finger off?’ No one will do that,” Gonzaga said. “Why would I extract your tooth because you need a root canal?”

Jaime Lozada, director of an elite dental implant residency program at Loma Linda University, said he’d not only witnessed an increase in dentists extracting “perfectly healthy teeth” but also treated a rash of patients with mouths full of ill-fitting implants that had to be surgically replaced.

Lozada said in August that he’d treated seven such patients in just three months.

“When individuals just make a decision of extracting teeth to make it simple and make money quick, so to speak, that’s where I have a problem,” Lozada said. “And it happens quite often.”

When full-arch implants fail, patients sometimes don’t have enough jawbone left to anchor another set. These patients have little choice but to get implants that reach into cheekbones, said Sohail Saghezchi, an oral and maxillofacial surgeon at the University of California-San Francisco.

“It’s kind of like a last resort,” Saghezchi said. “If those fail, you don’t have anywhere else to go.”

‘It Was Horrendous Dentistry’

Most of the experts interviewed for this article said their rising alarm corresponded with big changes in the availability of dental implants. Implants are now offered by more than 70,000 dental providers nationwide, two-thirds of whom are general dentists, according to the iData Research report.

Dentists are not required to learn how to place implants in dental school, nor are they required to complete implant training before performing the surgery in nearly all states. This year, Oregon started requiring dentists to complete 56 hours of hands-on training before placing any implants. Stephen Prisby, executive director of the Oregon Board of Dentistry, said the requirement — the first and only of its kind in the U.S. — was a response to dozens of investigations in the state into botched surgeries and other implant failures, split evenly between general dentists and specialists.

“I was frankly stunned at how bad some of these dentists were practicing,” Prisby said. “It was horrendous dentistry.”

Many dental clinics that offer implants have consolidated into chains owned by private equity firms that have bought out much of implant dentistry. In health care, private equity investment is sometimes criticized for overtreatment and prioritizing short-term profit over patients.

Private equity firms have spent about $5 billion in recent years to buy large dental chains that offer implants at hundreds of clinics owned by individual dentists and dental specialists. ClearChoice was bought for an estimated $1.1 billion in 2020 by Aspen Dental, which is owned by three private equity firms, according to PitchBook, a research firm focused on the private equity industry. Private equity firms also bought Affordable Care, whose largest clinic brand is Affordable Dentures & Implants, for an estimated $2.7 billion in 2021, according to PitchBook. And the private equity wing of the Abu Dhabi government bought Dental Care Alliance, which offers implants at many of its affiliated clinics, for an estimated $1 billion in 2022, according to PitchBook.

ClearChoice and Aspen Dental each said in email statements that the companies’ private equity owners “do not have influence or control over treatment recommendations.” Both companies said dentists or dental specialists make all clinical decisions.

Private equity deals involving dental practices increased ninefold from 2011 to 2021, according to an American Dental Association study published in August. The study also said investors showed an interest in oral surgery, possibly because of the “high prices” of implants.

“Some argue this is a negative thing,” said Marko Vujicic, vice president of the association’s Health Policy Institute, who co-authored the study. “On the other hand, some would argue that involvement of private equity and outside capital brings economies of scale, it brings efficiency.”

Edwin Zinman, a San Francisco dental malpractice attorney and former periodontist who has filed hundreds of dental lawsuits over four decades, said he believed many of the worst fears about private equity owners had already come true in implant dentistry.

“They’ve sold a lot of [implants], and some of it unnecessarily, and too often done negligently, without having the dentists who are doing it have the necessary training and experience,” Zinman said. “It’s for five simple letters: M-O-N-E-Y.”

Hundreds of Implant Clinics With No Specialists

For this article, journalists from KFF Health News and CBS News analyzed the webpages for more than 1,000 clinics in the nation’s largest private equity-owned dental chains, all of which offer some implants. The analysis found that more than 70% of those clinics listed only general dentists on their websites and did not appear to employ the specialists — oral surgeons, periodontists, or prosthodontists — who traditionally have more training with implants.

Affordable Dentures & Implants listed specialists at fewer than 5% of its more than 400 clinics, according to the analysis. The rest were staffed by general dentists, most of whom did not list credentialing from implant training organizations, according to the analysis.

ClearChoice, on the other hand, employs at least one oral surgeon or prosthodontist at each of its more than 100 centers, according to the analysis. But its new parent company, Aspen Dental, which offers implants in many of its more than 1,100 clinics, does not list any specialists at many of those locations.

Not everyone is worried about private equity in implant dentistry. In interviews arranged by the American Academy of Implant Dentistry, which trains dentists to use implants, two other implant experts did not express concerns about private equity firms.

Brian Jackson, a former academy president and implant specialist in New York, said he believed dentists are too ethical and patients are too smart to be pressured by private equity owners “who will never see a patient.”

Jumoke Adedoyin, a chief clinical officer for Affordable Care, who has placed implants at an Affordable Dentures & Implants clinic in the Atlanta suburbs for 15 years, said she had never felt pressure from above to sell implants.

“I’ve actually felt more pressure sometimes from patients who have gone around and been told they need to take their teeth out,” she said. “They come in and, honestly, taking a look at them, maybe they don’t need to take all their teeth out.”

Still, lawsuits filed across the country have alleged that dentists at implant clinics have extracted patients’ teeth unnecessarily.

For example, in Texas, a patient alleged in a 2020 lawsuit that an Affordable Care dentist removed “every single tooth from her mouth when such was not necessary,” then stuffed her mouth with gauze and left her waiting in the lobby as he and his staff left for lunch. In Maryland, a patient alleged in a 2021 lawsuit that ClearChoice “convinced” her to extract “eight healthy upper teeth,” by “greatly downplay[ing] the risks.” In Florida, a patient alleged in a 2023 lawsuit that ClearChoice provided her with no other treatment options before extracting all her teeth, “which was totally unnecessary.”

ClearChoice and Affordable Care denied wrongdoing in their respective lawsuits, then privately settled out of court with each patient. ClearChoice and Affordable Care did not respond to requests for comment submitted to the companies or attorneys. Lawyers for all three plaintiffs declined to comment on these lawsuits or did not respond to requests for comment.

Fred Goldberg, a Maryland dental malpractice attorney who said he has represented at least six clients who sued ClearChoice, said each of his clients agreed to get implants after meeting with a salesperson — not a dentist.

“Every client I’ve had who has gone to ClearChoice has started off meeting a salesperson and actually signing up to get their financing through ClearChoice before they ever meet with a dentist,” Goldberg said. “You meet with a salesperson who sells you on what they like to present as the best choice, which is almost always that they’re going to take out all your natural teeth.”

Becky Carroll, the ClearChoice patient from New Jersey, told a similar story.

Carroll said in her lawsuit that she met first with a ClearChoice salesperson referred to as a “patient education consultant.” In an interview, Carroll said the salesperson encouraged her to borrow money from family members for the surgery and it was not until after she agreed to a loan and passed a credit check that a ClearChoice dentist peered into her mouth.

“It seems way backwards,” Carroll said. “They just want to know you’re approved before you get to talk to a dentist.”

CBS News producer Nicole Keller contributed to this report.

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Government documents obtained by KFF Health News reveal that Tennessee officials, in closed-door negotiations, are attempting to hold the monopoly more accountable after years of complaints and protests from patients and their families.

Ballad, a 20-hospital system in northeastern Tennessee and southwestern Virginia, was created six years ago through monopoly agreements negotiated with both states. Since then, Ballad has consistently fallen short of the quality-of-care goals, according to annual reports released by the Tennessee Department of Health.

Despite these failures, Tennessee has given “A” grades and annual stamps of approval to Ballad that allow the monopoly to continue. This has occurred, at least in part, because Ballad is graded against a scoring rubric that largely ignores how its hospitals actually perform.

Now that may change. In an ongoing renegotiation of Tennessee’s monopoly agreement, the state health department has pushed for an eightfold increase in the importance of hospital performance, making it “the most heavily weighted” issue on which Ballad would be judged, according to state documents obtained through a public records request. The negotiations appear to be the state’s most substantial response to residents who sound alarms about Ballad hospitals.

Dani Cook, a community organizer who has led efforts against Ballad for years, including an eight-month protest outside a Ballad hospital in 2019, said a renegotiated monopoly agreement could be a first step toward progress that locals have long sought, but only if it is enforced by the state.

Cook also questioned why Tennessee took years to prioritize something as fundamental as good care.

“That’s what baffles me about this entire relationship: Ballad seems to never be held to account,” Cook said. “And that’s why, when I look at this, I say, ‘Oh that sounds great.’ But let’s see what happens.”

Ballad Health was created in 2018 after Tennessee and Virginia officials waived federal anti-monopoly laws and approved the nation’s biggest hospital merger based on what’s called a Certificate of Public Advantage, or COPA, agreement. Despite the warnings of the Federal Trade Commission, the region’s rival hospital systems became a single system without competition. Ballad is now the only option for hospital care for most of about 1.1 million people in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina.

In an effort to offset the perils of the monopoly, Ballad was required to enter agreements with the states that set expectations for the company and limited its ability to raise prices or close hospitals. Each year, Tennessee grades Ballad against this agreement on a 100-point scale. If the company performs poorly, Tennessee could in theory revoke the COPA, and then enforce a plan to split Ballad into separate companies, according to the monopoly agreement.

The new negotiation documents offer a snapshot of how Tennessee hopes to reshape this agreement, detailing more than a dozen changes the health department proposed in February and a counterproposal from Ballad in May. It is unclear if or how these proposals may have changed in the subsequent months.

Tennessee Department of Health spokesperson Dean Flener said the agency would not comment on Ballad or the ongoing negotiations.

In a written statement, Ballad did not comment directly on the negotiations but said the company “enthusiastically agrees that the most important thing to our patients is the quality of care they receive.” The company said in 2023 that its hospital quality slipped due to the pressure of the coronavirus pandemic and that it was in the process of rebounding.

“We strongly support a shared focus on quality of care as it relates to the COPA,” Molly Luton, a Ballad spokesperson, said in the statement.

Historically, quality of care has been just a small part of how Ballad is held accountable. Twenty percent of Ballad’s annual COPA score comes from measurements of hospital quality, but the company gets full credit on three-fourths of those measurements if it reports any value — even a terrible one. Only 5% of the annual score is determined by real-world hospital performance.

If quality was weighted more, Ballad would have scored much worse in past years. Annual reports released by the Tennessee Department of Health over the last two years show that Ballad failed to meet more than 74% of the state’s quality-of-care benchmarks, including some about mortality rates, readmission rates, emergency room speed, surgery-related infections, and patient satisfaction.

Under Tennessee’s proposed changes, all these metrics would matter much more. But Tennessee would also lower the overall standards for Ballad’s monopoly and ease a charity care obligation that Ballad has repeatedly not met, according to the negotiation documents. Ballad has said it hasn’t met the charity care obligation because changes to Medicaid programs have left fewer patients uninsured and in need of charity.

The documents show that:

• Tennessee has proposed increasing the share of Ballad’s annual score that is attributable to real-world quality of care from 5% to 40% and no longer giving Ballad any points for merely reporting quality statistics. In a counteroffer, Ballad proposed raising this percentage to 34%, with some points still awarded to the company just for reporting.
• Tennessee proposed lowering the minimum overall score that Ballad needs to obtain each year for its monopoly to be considered a “clear and convincing public advantage.” If Ballad falls below this threshold, the COPA agreement could be modified or “terminated.” Tennessee wants to lower the threshold from 85 out of 100 to 75. In its counteroffer, Ballad proposed 70.
• Tennessee would reduce or weaken a requirement for Ballad charity care spending that is largely moot. Ballad has been required to provide more than $100 million in free or discounted charity care to low-income patients each year under the current monopoly agreement, but it has failed to do so five years in a row, falling short by about $194 million in total. Tennessee has waived the requirement each year.

Cook, who described the new documents as a rare glimpse into closed-door dealings that Ballad patients never get to see, said it was striking to witness the company push for lower standards.

“Why would they be pushing back on improving the quality of care that people receive?” Cook said. “If they are really among the nation’s best — because that’s what they tell the entire region — why do you need the standards lowered?”

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For more than three decades, Tennessee’s “aggravated prostitution” laws have made prostitution a misdemeanor for most sex workers but a felony for those who are HIV-positive. Tennessee toughened penalties in 2010 by reclassifying prostitution with HIV as a “violent sexual offense” with a lifetime registration as a sex offender — even if protection is used.

At least 83 people are believed to be on Tennessee’s sex offender registry solely because of these laws, with most living in the Memphis area, where undercover police officers and prosecutors most often invoked the statute, commonly against Black and transgender women, according to a lawsuit filed last year by the American Civil Liberties Union and four women who were convicted of aggravated prostitution. The Department of Justice challenged the law in a separate suit earlier this year.

Both lawsuits argue that Tennessee law does not account for evolving science on the transmission of HIV or precautions that prevent its spread, like use of condoms. Both lawsuits also argue that labeling a person as a sex offender because of HIV unfairly limits where they can live and work and stops them from being alone with grandchildren or minor relatives.

“Tennessee’s Aggravated Prostitution statute is the only law in the nation that treats people living with HIV who engage in any sex work, even risk-free encounters, as ‘violent sex offenders’ subjected to lifetime registration,” the ACLU lawsuit states.

“That individuals living with HIV are treated so differently can only be understood as a remnant of the profoundly prejudiced early response to the AIDS epidemic.”

In a settlement agreement signed by Tennessee Gov. Bill Lee on July 15 and filed in both lawsuits on July 17, the Tennessee Bureau of Investigation said it would comb through the state’s sex offender registry to find those added solely because of aggravated prostitution convictions, then send letters alerting those people that they can make a written request to be removed. The language of the settlement suggests that people will need to request their removal from the registry, but the agency said in the agreement it will make “its best effort” to act on the requests “promptly in the order in which they are received.”

The Tennessee attorney general’s office, which represents the state in both the ACLU and DOJ lawsuits and approved the settlement agreement, said in an email statement it would “continue to defend Tennessee’s prohibition on aggravated prostitution.”

In an email statement, the ACLU celebrated the settlement as “one step toward remedying the harms by addressing the sex offender registration,” but said its work in Tennessee was not done because aggravated prostitution remained a felony charge that it would “fight to overturn.”

Molly Quinn, executive director of LGBTQ+ support organization OUTMemphis, another plaintiff in the ACLU lawsuit, said both organizations would help eligible people with the paperwork to get removed from the registry.

“We would not have agreed to settle if we did not feel like this was a process that would be extremely beneficial,” Quinn said. “But, we’re sad that the statute existed as long as it did and sad that there is any process at all that folks have to go through after living with this extraordinary burden of being on the sex offender registry for really an irrelevant reason.”

Michelle Anderson, a Memphis resident who is one of the plaintiffs in the ACLU lawsuit, said in court records that since being convicted of aggravated prostitution, the sex offender label has made it so difficult to find a home and a job that she was “unhoused for about a year” and has at times “felt she had no option but to continue to engage in sex work to survive.”

Like the other plaintiffs, Anderson said her conviction kept her minor relatives at a distance.

“Ms. Anderson has a nephew she loves, but she cannot have a close relationship with him,” the lawsuit states. “Even though Ms. Anderson’s convictions had nothing to do with children, she cannot legally be alone with her nephew.”

The Tennessee settlement comes months after state lawmakers softened the law so no one else should be added to the sex offender registry for aggravated prostitution. Lawmakers removed the registration requirement and made convictions eligible for expungement if the defendant testifies they were a victim of human trafficking.

State Sen. Page Walley (R-Savannah), who supported the original aggravated prostitution law passed in 1991 and co-sponsored the recent bill to amend it, said on the floor of the legislature that the changes do not prevent prosecutors from charging people with a felony for aggravated prostitution. Instead, he said, the amendments undo the 2010 law that put those who are convicted on the registry “along with pedophiles and rapists for a lifetime, with no recourse for removal.”

“Having stood, as I mentioned, in 1991 and passed this,” Walley said, “it is a particular gratifying moment for me to see how we continue to evolve and seek what’s just and what’s right and what’s best.”

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Nothing has helped. Tallant, 51, of Knoxville, Tennessee, said she lives in agony and cannot eat any food that must be chewed. Despite spending a small fortune on treatment, she can barely open her mouth enough to squeeze in a toothbrush.

Tallant estimates she has paid at least $200,000 for TMJ care. She provided medical records showing more than $60,000 in out-of-pocket spending in just the past decade. She has exhausted her savings and borrowed money, she said, and her family sold a plot of land to help pay the bills.

Tallant will need another jaw surgery later this year, which could cost as much as $75,000. Her insurance is unlikely to pay for any of it, she said.

“It’s a bottomless pit,” Tallant said, choking up, as she leafed through a pile of medical records splayed on her dining table. “It has consumed so much of my life that there is not much left.”

Temporomandibular joint disorders, known as TMJ or TMD, cause pain and stiffness in the face and jaw and are believed to afflict as many as 33 million Americans. Scientific studies have found that women experience TMJ disorders two to nine times as often as men, and while minor symptoms may not require treatment, severe symptoms can include disabling pain that makes it challenging to eat, work, talk, or sleep.

Despite the commonness of TMJ disorders, treatments are often not covered by medical or dental insurance, leaving patients with out-of-pocket bills that can range from a few hundred dollars to tens of thousands of dollars. Many medical insurers consider TMJ treatment too dental-focused for medical insurance, while dental insurers consider it too medical for dental insurance, leaving patients stuck in a “medical-dental divide” that hinders care and increases cost, according to the National Academies of Science, Engineering, and Medicine.

Worse still, researchers warn that the meager insurance coverage available for TMJ often excludes the safest forms of care while steering patients toward surgery — a riskier and irreversible option that the National Institutes of Health recommends “staying away” from.

Terrie Cowley, a longtime TMJ patient who leads the TMJ Association, an advocacy group, has spoken with patients who refinanced their homes and cashed out retirement accounts to afford the out-of-pocket costs for their care.

“It bankrupts them,” Cowley said. “But it isn’t nearly as horrible as when the treatments go wrong.”

Insurance woes are just one facet of the problems with TMJ care in the United States. In April, a joint investigation by KFF Health News and CBS News found that TMJ disorders have been widely misunderstood by many dentists for decades, so some patients fall into a spiral of ineffective care and futile surgeries that do more harm than good. Dentistry has tried to correct course in recent years with the promising new specialty of orofacial pain, which treats TMJ disorders with a more conservative approach, but these specialists are few and rarely covered by insurance, so their services remain beyond the reach of many patients.

Tony Schwartz, president of the American Board of Orofacial Pain, said the specialty is still fighting for widespread acceptance from insurance companies and some dentists, who cling to “old, debunked theories” that TMJ disorders are caused by misaligned teeth or a bad bite.

“This is the basis for why insurance companies have been so reluctant to, over the years, pay for any treatment,” Schwartz said. “Because there has been so much controversy about what works and what doesn’t work.”

For this article, KFF Health News and CBS News interviewed 10 patients with severe TMJ disorders who have been in treatment for years, if not decades. Almost all the patients described spending thousands of dollars out-of-pocket at every stage of their care, usually because treatment fell outside their medical and dental insurance coverage. Some patients said their medical bills mounted just as debilitating pain forced them to leave jobs or abandon careers. Some underwent expensive TMJ surgeries offered by only a small group of surgeons who generally do not accept insurance.

Kyra Wiedenkeller, 45, of New York state, said she worked as a manager in the music industry, including on “American Idol,” before her “unrelenting pain” became too great.

Wiedenkeller, who is now on disability, said she’s spent at least $100,000 out-of-pocket on TMJ treatment and provided medical documents showing she had been billed for at least that much.

“Every doctor I’ve seen has made me progressively worse,” Wiedenkeller said. “I paid an exorbitant amount of money. I wiped out my 401(k) for these treatments in hopes of getting better time and time again. And just get worse and worse. I feel like there is no end.”

Wiedenkeller’s story echoes findings of the national academies, which conducted a comprehensive study of TMJ in 2020 that included input from more than 110 patients. The study found that TMJ patients are “often harmed” during “overly aggressive” treatment, which frequently falls into a chasm between medical and dental insurance, leaving most bills paid out-of-pocket at costs of up to tens of thousands of dollars.

As an example, the study describes how dental splints — a common TMJ treatment — have been considered to be medical care by some dental insurers and considered dental care by some medical insurance programs, and are “therefore not covered” by either.

And when TMJ is covered by insurance, it tends to exclude “low-risk, effective treatments,” like those used by orofacial pain specialists, but covers “higher-risk” options, like jaw surgery, according to the national academies study. This leads to patients receiving “the care that is best reimbursed, rather than the care that is best,” the study said.

Other researchers have come to the same conclusion.

James Fricton, an orofacial pain specialist who studies the lack of insurance coverage for TMJ care, said that even though surgery is appropriate for few patients, it is the only treatment covered by most insurance plans in most states.

“Patients will assume that insurance companies know what they’re doing,” Fricton said. “If that’s all that’s covered, what do you think they are going to get? Surgery.”

In contrast, insurance coverage appears to be weakest at the other end of the treatment spectrum.

“Orofacial pain,” officially recognized by the American Dental Association in 2020, is now taught in residency programs at a dozen U.S. colleges at least, including the universities of Michigan, Minnesota, and North Carolina. The specialty avoids making irreversible changes to the bite or jaw and instead treats TMJ disorders with tools like counseling, dietary changes, medication, physical therapy, and removable dental splints. Many TMJ patients can be treated by orofacial pain specialists for a few thousand dollars.

The national academies study describes this approach as one of the few promising options for TMJ patients, citing studies that showed improvement among patients who are taught how to manage their pain. But the national academies also said it is a “particular challenge” that this treatment is “often not considered reimbursable by insurance.”

In separate interviews, six orofacial pain specialists with clinics around the country said insurance coverage for this specialty care is patchy, poor, or nonexistent. Several said their specialty is often absent from dropdown menus on standard insurance forms. Most said the insurance industry had fallen behind on the evolving science of TMJ, missing a chance to help patients and cut costs.

“It’s a no-brainer,” said Jeffrey Okeson, dean of the University of Kentucky’s College of Dentistry. “If I was an insurance person, I’d want to supply $1,000 to a patient to do conservative treatment … instead of $15,000 or $30,000 for surgery. Think of the money that can be saved there.”

Okeson and the other orofacial pain specialists said unreliable insurance coverage has hamstrung the specialty by making it less attractive to the next generation of dentists.

Currently there are fewer than 300 certified orofacial pain specialists in the United States, according to a database maintained by the American Board of Orofacial Pain. At least 20 states have no certified specialists, and eight other states have only one or two.

Deepika Jaiswal, the only certified specialist in Iowa, said some patients with TMJ disorders drive across the state to see her.

However, most of her patients — and many of her fellow dentists — remain unaware of the orofacial pain specialty, Jaiswal said, so insurance companies likely feel little pressure to include it in their coverage.

“People don’t even know around the area that we exist,” Jaiswal said. “When there are more providers providing this service, I think at that point there will be more insurance.”

CBS News producer Nicole Keller contributed to this article.

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Peggy A. Randolph, a social worker who was licensed in Florida and Tennessee and formerly worked for Brightside Health, a nationwide online therapy company, is accused of helping her wife impersonate her in online sessions, according to an investigation report from the Florida Department of Health.

The Florida report says the couple “defrauded” patients through a “coordinated effort”: As Randolph treated patients in person, her wife pretended to be her in telehealth sessions with Brightside patients. The deceit was discovered after the wife died last year and a patient realized they’d been talking to the wrong person, according to a Tennessee Department of Health settlement agreement.

Records from both states identify Randolph’s wife only by her initials, T.R., but her full name is in her obituary: Tammy G. Heath-Randolph. Therapists are generally expected to have at least a master’s degree, but Randolph’s wife was “not licensed or trained to provide any sort of counseling services,” according to the Tennessee agreement.

“[Randolph] denies knowing that T.R. was using her Brightside Health Therapist Portal log-in credentials or treating clients under her account. However, [she] received compensation for the sessions conducted,” the agreement states.

The alleged ruse has not been previously reported and its details and scope were only recently glimpsed in a few pages of public documents released by the state agencies. The Tennessee settlement, released in May, states that Randolph was supposed to provide online therapy to “hundreds of clients” while working for Brightside Health from January 2021 to February 2023. However, a Brightside internal investigation found it was actually Heath-Randolph who was “seeing all her patients and had been for a long time,” according to the Florida investigation report.

Randolph declined to comment.

The Florida and Tennessee records say Randolph voluntarily surrendered her social worker’s licenses in both states. This resulted in the health departments dropping their investigations, which limited the case details and documents available in the public record. Brightside’s internal investigation report has not been made public.

Brightside Health, a San Francisco company that offers nationwide online psychiatry and therapy sessions, declined to make an official available for an interview.

Company spokesperson Hannah Changi said in an email that as soon as Brightside learned of the allegations, it audited its security, fired Randolph, and reported her to state licensing authorities. Changi said Brightside can’t say how many patients were seen by Randolph’s wife “due to the nature of the incident and ongoing legal proceedings,” but said the company notified and refunded all “potentially impacted patients.”

“We take our patient experience seriously and hold ourselves to a high ethical code of conduct,” Changi said. “We’re extremely disappointed that a single provider was willing to violate the trust that Brightside and, most importantly, her patients had placed in her.”

Brightside was also required to alert the U.S. Department of Health and Human Services, which investigates data breaches that expose private medical information. In this breach, an “unauthorized individual” accessed the info of 767 people, including Social Security numbers and diagnoses, according to the agency’s online database.

Neither Florida nor Tennessee health officials answered questions about the case.

Dean Flener, a spokesperson for the Tennessee Department of Health, said details of Randolph’s case remain confidential under state law.

Jae Williams, a Florida Department of Health spokesperson, said a full investigation was not completed because Randolph surrendered her license, which has the same effect as the state revoking it but allowed her to keep “what dignity she had left.”

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Peggy A. Randolph, trabajadora social con licencia en Florida y Tennessee, quien trabajaba para Brightside Health, una empresa nacional de terapia en línea, está acusada de ayudar a su esposa a hacerse pasar por ella en sesiones de internet, según el informe de una investigación del Departamento de Salud de Florida.

El informe de Florida indica que la pareja “estafaba” a los pacientes mediante un “esfuerzo coordinado”: mientras Randolph trataba a pacientes en persona, su esposa se hacía pasar por ella en sesiones de telesalud con pacientes de Brightside. El engaño se descubrió después que la esposa impostora muriera el año pasado, y un paciente se diera cuenta de que había estado hablando con la persona equivocada, según un acuerdo de conciliación del Departamento de Salud de Tennessee.

Los registros de ambos estados identifican a la esposa de Randolph sólo por sus iniciales, T.R., pero su nombre completo figura en su obituario: Tammy G. Heath-Randolph. Tradicionalmente, se espera que los terapeutas tengan al menos una maestría, pero la esposa de Randolph “no tenía licencia ni formación para prestar ningún tipo de servicios de consejería”, según revela el acuerdo de Tennessee.

Según consta en el acuerdo: “[Randolph] niega saber que T.R. estuviera utilizando sus credenciales de acceso al portal de terapeutas de Brightside Health o tratando a clientes con su cuenta. Sin embargo, [ella] recibió compensación por las sesiones realizadas”.

La presunta artimaña no había sido denunciada anteriormente y sus detalles y alcance salieron a la luz recientemente en las páginas de unos documentos públicos divulgadas por los agencias estatales.

El acuerdo de Tennessee, publicado en mayo, indica que Randolph debió haber proporcionado terapia en línea a “cientos de clientes” mientras trabajaba para Brightside Health desde enero de 2021 hasta febrero de 2023. Sin embargo, una investigación interna de Brightside descubrió que en realidad era Heath-Randolph quien “veía a todos los pacientes y lo estuvo haciendo durante mucho tiempo”, según el informe de la investigación de Florida.

Randolph declinó hacer comentarios.

Los registros de Florida y Tennessee dicen que Randolph renunció voluntariamente a sus licencias de trabajadora social en ambos estados. Esto dio lugar a que los departamentos de salud abandonaran sus investigaciones, lo que limitó los detalles del caso y los documentos disponibles en el registro público.

El informe de la investigación interna de Brightside no se ha divulgado.

Brightside Health, una empresa de San Francisco que ofrece sesiones de psiquiatría y terapia en línea en todo el país, declinó hacer ningún tipo de declaración por medio de una entrevista.

La vocera de la empresa, Hannah Changi, dijo en un correo electrónico que en cuanto Brightside se enteró de las acusaciones, hizo una auditoría de su seguridad, despidió a Randolph y la denunció ante las autoridades estatales que concede las licencias. Changi señaló que Brightside no puede decir cuántos pacientes fueron atendidos por la esposa de Randolph “debido a la naturaleza del incidente y los procedimientos legales en curso”, pero aseguró que la compañía notificó y reembolsó a todos los “pacientes potencialmente afectados”.

“Nos tomamos muy en serio la experiencia de nuestros pacientes y tenemos un elevado código ético de conducta”, dijo Changi. “Nos decepciona profundamente que uno de nuestros proveedores haya traicionado la confianza que Brightside y, más importante, sus pacientes habían depositado en ella”.

Además, Brightside se vio obligada a alertar al Departamento de Salud y Servicios Humanos de Estados Unidos, que investiga la filtración de datos que exponen información médica privada. En esta filtración, un “individuo no autorizado” accedió a la información de 767 personas, incluidos números de seguro social y diagnósticos, según la base de datos en línea de la agencia.

Ni las autoridades de salud de Florida ni las de Tennessee respondieron a las preguntas sobre el caso.

Dean Flener, vocero del Departamento de Salud de Tennessee, dijo que los detalles del caso de Randolph siguen siendo confidenciales en virtud de la ley estatal.

Jae Williams, vocero del Departamento de Salud de Florida, señaló que no se llevó a cabo una investigación completa porque Randolph renunció a su licencia, lo que tiene el mismo efecto que la revocación por parte del estado, pero le permitió conservar “la dignidad que le quedaba”.

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Ballad Health, a 20-hospital system in northeast Tennessee and southwest Virginia, has received A grades and an annual stamp of approval from the Tennessee Department of Health. This has occurred as Ballad hospitals consistently fall short of performance targets established by the state, according to health department documents.

Because the state’s scoring rubric largely ignores the hospitals’ performance, only 5% of Ballad’s final score is based on actual quality of care, and Ballad has suffered no penalty for failing to meet the state’s goals in about 50 areas — including surgery complications, emergency room speed, and patient satisfaction.

“It doesn’t make any sense,” said Ron Allgood, 75, of Kingsport, Tennessee, who said he had a heart attack in a Ballad ER in 2022 after waiting for three hours with chest pains. “It seems that nobody listens to the patients.”

Ballad Health was created six years ago after Tennessee and Virginia lawmakers waived federal anti-monopoly laws so two competing hospital companies could merge. The monopoly agreement established two quality measures to compare Ballad’s care against the state’s baseline expectations: about 17 “target” measures, on which hospitals are expected to improve and their performance factors into their grade; and more than 50 “monitoring” measures, which Ballad must report, but how the hospitals perform on them is not factored into Ballad’s grade.

Ballad has failed to meet the baseline values on 75% or more of all quality measures in recent years — and some are not even close — according to reports the company has submitted to the health department.

Since the merger, Ballad has become the only option for hospital care for most of about 1.1 million residents in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina. Critics are vocal. Protesters rallied outside a Ballad hospital for months. For years, longtime residents like Allgood have alleged Ballad’s leadership has diminished the hospitals they’ve relied on their entire lives.

“It’s a shadow of the hospital we used to have,” Allgood said.

And yet, every year since the merger, the Tennessee health department has reported that the benefits of the hospital merger outweigh the risks of a monopoly, and that Ballad “continues to provide a Public Advantage.” Tennessee has also given Ballad an A grade in every year but two, when the scoring system was suspended due to the covid-19 pandemic and no grade issued.

The department’s latest report, released this month, awarded Ballad 93.6 of 100 possible points, including 15 points just for reporting the monitoring measures. If Tennessee rescored Ballad based on its performance, its score would drop from 93.6 to about 79.7, based on the scoring rubric described in health department documents. Tennessee considers scores of 85 or higher to be “satisfactory,” the documents state.

Larry Fitzgerald, who monitored Ballad for the Tennessee government before retiring this year, said it was obvious the state’s scoring rubric should be changed.

Fitzgerald likened Ballad to a student getting 15 free points on a test for writing any answer.

“Do I think Ballad should be required to show improvement on those measures? Yes, absolutely,” Fitzgerald said. “I think any human being you spoke with would give the same answer.”

Ballad Health declined to comment. Tennessee Department of Health spokesperson Dean Flener declined an interview request and directed all questions about Ballad to the Tennessee Attorney General’s Office, which also has a role in regulating the monopoly. Amy Wilhite, a spokesperson for the AG’s office, directed those questions back to the health department and provided documents showing it is the agency responsible for how Ballad is scored.

The Virginia Department of Health, which is also supposed to perform “active supervision” of Ballad as part of the monopoly agreement, has fallen several years behind schedule. Its most recent assessment of the company was for fiscal year 2020, when it found that the benefits of the monopoly “outweigh the disadvantages.” Erik Bodin, a Virginia official who oversees the agreement, said more recent reports are not yet ready to be released.

Ballad Health was formed in 2018 after state officials approved the nation’s biggest so-called Certificate of Public Advantage, or COPA, agreement, allowing a merger of the Tri-Cities region’s only two hospital systems — Mountain States Health Alliance and Wellmont Health System. Nationwide, COPAs have been used in about 10 hospital mergers over the past three decades, but none has involved as many hospitals as Ballad’s.

The Federal Trade Commission has warned that hospital monopolies lead to increased prices and decreased quality of care. To offset the perils of Ballad’s monopoly, officials required the new company to agree to more robust regulation by state health officials and a long list of special conditions, including the state’s quality-of-care measurements.

Ballad failed to meet the baseline on about 80% of those quality measures from July 2021 to June 2022, according to a report the company submitted to the health department. The following year, Ballad fell short on about 75% of the quality measures, and some got dramatically worse, another company report shows.

For example, the median time Ballad patients spend in the ER before being admitted to the hospital has risen each year and is now nearly 11 hours, according to the latest Ballad report. That’s more than three times what it was when the monopoly began, and more than 2.5 times the state baseline.

And yet Ballad’s grade is not lowered by the lack of speed in its ERs.

Fitzgerald, Tennessee’s former Ballad monitor, who previously served as an executive in the University of Virginia Health System, said a hospital company with competitors would have more reason than Ballad to improve its ER speeds.

“When I was at UVA, we monitored this stuff passionately because — and I think this is the key point here — we had competition,” Fitzgerald said. “And if we didn’t score well, the competition took advantage.”

Midwest correspondent Samantha Liss contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Police were pushing into the camp after an hours-long standoff. Chan, 31, a medical tent volunteer, said protesters limped in with severe puncture wounds, but there was little hope of getting them to a hospital through the chaos outside. Chan suspects the injuries were caused by rubber bullets or other “less lethal” projectiles, which police have confirmed were fired at protesters.

“It would pierce through skin and gouge deep into people’s bodies,” she said. “All of them were profusely bleeding. In OB-GYN we don’t treat rubber bullets. … I couldn’t believe that this was allowed to be [done to] civilians — students — without protective gear.”

The UCLA protest, which gathered thousands in opposition to Israel’s ongoing bombing of Gaza, began in April and grew to a dangerous crescendo this month when counterprotesters and police clashed with the activists and their supporters.

In interviews with KFF Health News, Chan and three other volunteer medics described treating protesters with bleeding wounds, head injuries, and suspected broken bones in a makeshift clinic cobbled together in tents with no electricity or running water. The medical tents were staffed day and night by a rotating team of doctors, nurses, medical students, EMTs, and volunteers with no formal medical training.

At times, the escalating violence outside the tent isolated injured protesters from access to ambulances, the medics said, so the wounded walked to a nearby hospital or were carried beyond the borders of the protest so they could be driven to the emergency room.

“I’ve never been in a setting where we’re blocked from getting higher level of care,” Chan said. “That was terrifying to me.”

Three of the medics interviewed by KFF Health News said they were present when police swept the encampment May 2 and described multiple injuries that appeared to have been caused by “less lethal” projectiles.

Less lethal projectiles — including beanbags filled with metal pellets, sponge-tipped rounds, and projectiles commonly known as rubber bullets — are used by police to subdue suspects or disperse crowds or protests. Police drew widespread condemnation for using the weapons against Black Lives Matter demonstrations that swept the country after the killing of George Floyd in 2020. Although the name of these weapons downplays their danger, less lethal projectiles can travel upward of 200 mph and have a documented potential to injure, maim, or kill.

The medics’ interviews directly contradict an account from the Los Angeles Police Department. After police cleared the encampment, LAPD Chief Dominic Choi said in a post on the social platform X that there were “no serious injuries to officers or protestors” as police moved in and made more than 200 arrests.

In response to questions from KFF Health News, both the LAPD and California Highway Patrol said in emailed statements that they would investigate how their officers responded to the protest. The LAPD statement said the agency was conducting a review of how it responded, which would lead to a “detailed report.”

The Highway Patrol statement said officers warned the encampment that “non-lethal rounds” may be used if protesters did not disperse, and after some became an “immediate threat” by “launching objects and weapons,” some officers used “kinetic specialty rounds to protect themselves, other officers, and members of the public.” One officer received minor injuries, according to the statement.

Video footage that circulated online after the protest appeared to show a Highway Patrol officer firing less lethal projectiles at protesters with a shotgun.

“The use of force and any incident involving the use of a weapon by CHP personnel is a serious matter, and the CHP will conduct a fair and impartial investigation to ensure that actions were consistent with policy and the law,” the Highway Patrol said in its statement.

The UCLA Police Department, which was also involved with the protest response, did not respond to requests for comment.

Jack Fukushima, 28, a UCLA medical student and volunteer medic, said he witnessed a police officer shoot at least two protesters with less lethal projectiles, including a man who collapsed after being hit “square in the chest.” Fukushima said he and other medics escorted the stunned man to the medical tent then returned to the front lines to look for more injured.

“It did really feel like a war,” Fukushima said. “To be met with such police brutality was so disheartening.”

Back on the front line, police had breached the borders of the encampment and begun to scrum with protesters, Fukushima said. He said he saw the same officer who had fired earlier shoot another protester in the neck.

The protester dropped to the ground. Fukushima assumed the worst and rushed to his side.

“I find him, and I’m like, ‘Hey, are you OK?’” Fukushima said. “To the point of courage of these undergrads, he’s like, ‘Yeah, it’s not my first time.’ And then just jumps right back in.”

Sonia Raghuram, 27, another medical student stationed in the tent, said that during the police sweep she tended to a protester with an open puncture wound on their back, another with a quarter-sized contusion in the center of their chest, and a third with a “gushing” cut over their right eye and possible broken rib. Raghuram said patients told her the wounds were caused by police projectiles, which she said matched the severity of their injuries.

The patients made it clear the police officers were closing in on the medical tent, Raghuram said, but she stayed put.

“We will never leave a patient,” she said, describing the mantra in the medical tent. “I don’t care if we get arrested. If I’m taking care of a patient, that’s the thing that comes first.”

The UCLA protest is one of many that have been held on college campuses across the country as students opposed to Israel’s ongoing war in Gaza demand universities support a ceasefire or divest from companies tied to Israel. Police have used force to remove protesters at Columbia University, Emory University, and the universities of Arizona, Utah, and South Florida, among others.

At UCLA, student protesters set up a tent encampment on April 25 in a grassy plaza outside the campus’s Royce Hall theater, eventually drawing thousands of supporters, according to the Los Angeles Times. Days later, a “violent mob” of counterprotesters “attacked the camp,” the Times reported, attempting to tear down barricades along its borders and throwing fireworks at the tents inside.

The following night, police issued an unlawful assembly order, then swept the encampment in the early hours of May 2, clearing tents and arresting hundreds by dawn.

Police have been widely criticized for not intervening as the clash between protesters and counterprotesters dragged on for hours. The University of California system announced it has hired an independent policing consultant to investigate the violence and “resolve unanswered questions about UCLA’s planning and protocols, as well as the mutual aid response.”

Charlotte Austin, 34, a surgery resident, said that as counterprotesters were attacking she also saw about 10 private campus security officers stand by, “hands in their pockets,” as students were bashed and bloodied.

Austin said she treated patients with cuts to the face and possible skull fractures. The medical tent sent at least 20 people to the hospital that evening, she said.

“Any medical professional would describe these as serious injuries,” Austin said. “There were people who required hospitalization — not just a visit to the emergency room — but actual hospitalization.”

Police Tactics ‘Lawful but Awful’

UCLA protesters are far from the first to be injured by less lethal projectiles.

In recent years, police across the U.S. have repeatedly fired these weapons at protesters, with virtually no overarching standards governing their use or safety. Cities have spent millions to settle lawsuits from the injured. Some of the wounded have never been the same.

During the nationwide protests following the police killing of George Floyd in 2020, at least 60 protesters sustained serious injuries — including blinding and a broken jaw — from being shot with these projectiles, sometimes in apparent violations of police department policies, according to a joint investigation by KFF Health News and USA Today.

In 2004, in Boston, a college student celebrating a Red Sox victory was killed by a projectile filled with pepper-based irritant when it tore through her eye and into her brain.

“They’re called less lethal for a reason,” said Jim Bueermann, a former police chief of Redlands, California, who now leads the Future Policing Institute. “They can kill you.”

Bueermann, who reviewed video footage of the police response at UCLA at the request of KFF Health News, said the footage shows California Highway Patrol officers firing beanbag rounds from a shotgun. Bueermann said the footage did not provide enough context to determine if the projectiles were being used “reasonably,” which is a standard established by federal courts, or being fired “indiscriminately,” which was outlawed by a California law in 2021.

“There is a saying in policing — ‘lawful but awful’ — meaning that it was reasonable under the legal standards but it looks terrible,” Bueermann said. “And I think a cop racking multiple rounds into a shotgun, firing into protesters, doesn’t look very good.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).