The University of Pennsylvania Health System had an operating profit of $189 million in the first six months of fiscal 2026, up from $117 million in the same period a year ago, the nonprofit reported to bond investors Friday.
Operating income increased, even after Penn put $43 million put into reserves for medical malpractice claims. Two years ago, Penn had recorded charges totaling $90 million for the same purpose.
Here are more details on Penn’s results:
Revenue: Penn had $6.76 billion in total revenue, up nearly 12% even adjusting for the inclusion of Doylestown Health in fiscal 2026. Penn acquired Doylestown last April.
“We’ve had good volume growth over the prior year, particularly in our outpatient activity,” the health system’s chief financial officer, Julia Puchtler, said in an interview.
The system has also had an increase in the acuity level on the inpatient side, she said. That translated into more revenue.
Expenses: The $43 million malpractice charge boosted overall malpractice expenses through December to $125 million, from $69 million in the same period a year ago.
It’s not that Penn is seeing more claims, Puchtler said. “It’s really the average reserve per claim that we’re seeing accelerate,” she said.
Notable: Excluding Doylestown, Penn saw a 5.9% increase in patient volumes, Puchtler said. “That’s mostly outpatient,” she said. “Outpatient surgery, endoscopy, and some of our other infusion therapy are all increased over the prior year.”
Editor’s note: This article has been updated to reflect an additional medical malpractice charge in 2024, bring the total to $90 million.
The University of Pennsylvania is getting $7.8 million over the next two years to study an overlooked aspect of human health: the lymphatic system.
Often described as the body’s sewer system, its main job is to maintain the body’s balance of fluid and filter out waste. Millions of Americans live with dysfunction in the system, often unknowingly.
The time to diagnose some lymphatic disorders is at least five years, said Maxim Itkin, an interventional radiologist who directs Penn’s center specializing in lymphatic disorders.
He’s even had a patient who experienced unexplained symptoms for 50 years before getting treatment.
“Right now, most healthcare providers simply aren’t equipped — or trained — to recognize lymphatic dysfunction, and the tools they need are virtually nonexistent,” said Kimberley Steele, a program manager at the Advanced Research Projects Agency for Health (ARPA-H), the federal agency organizing the research effort.
That’s why the government, through ARPA-H, is investing $135.7 million toward research headed by 11 institutions in the U.S. and Canada, including Penn, to improve detection of issues in the lymphatic system.
With its slice of funding, the team at Penn will develop ways to image the network and identify hidden signs of disease.
An inside look
Similar to plumbing, fluids in the lymphatic system can be flowing, obstructed, or leaking.
Doctors are able to “close” these leaks and even “open” obstructed areas, but the problem is knowing when those procedures are needed.
Existing contrast agents — substances used to increase visibility of tissues during imaging — for the lymphatic system are largely considered obsolete and offer poor resolution, said Itkin, who is leading the Penn project, which started last October.
When he began researching the system 20 years ago, he “started to realize that it’s of enormous importance, and it’s forgotten primarily because nobody can image [it] and do interventions,” he said.
Maxim Itkin, an interventional radiologist at the Hospital of the University of Pennsylvania, found a way to track the flow of lymphatic fluid using X-ray imaging equipment.
Itkin and his team have come up with ways of imaging by injecting dye into lymph nodes and tissues and tracing the dye’s location. This has enabled him to diagnose hidden conditions and develop new treatment methods.
The ARPA-H funding will allow them to go even further, developing imaging agents that focus on the parts of the lymphatic system in the liver and gut — organs that generate the majority of the network’s flow in the body.
These will be used for CT (computed tomography) and MRI (magnetic resonance imaging) scans.
One of the imagingcandidates is designed to be swallowed and absorbed in the intestine, so doctors can see the lymphatic system in the gut. The second imaging agent will be administered via IV to show the system in the liver.
“It was my dream to see the lymphatic system from inside by itself,” Itkin said.
They’ll be using an approach called AI-driven multi-omics, where AI will analyze samples for unique molecules being excreted by the lymphatic system in the liver.
Penn and several other funded groups are working with the New York-based nonprofit Lymphatic Education and Research Network to help with research and patient recruitment.
Current funding is for two years, with the potential to extend for another three years.
Itkin says seeing the lymphatic system in the liver will be a thrill.
Jefferson Health oncologist Jennifer Johnson had exhausted all the standard treatment options for her 49-year-old patient with esophageal cancer, who was likely to die within months.
Surgery, chemotherapy, radiation, and immunotherapy had kept the Northeast Philadelphia woman alive for six years after her diagnosis, but no longer were enough to stop her cancer from spreading.
Johnson knew her patient needed something novel. She recalled a presentation several years prior at a conference for head and neck cancers, where a doctor discussedan experimental treatment called T-cell receptor (TCR) therapy.
This type of cancer immunotherapy works by engineering the immune system to fight cancer, and falls into the same family of treatments as CAR-T, or chimeric antigen receptor (CAR) T cell therapy, an approach pioneered at the University of Pennsylvania that has revolutionized treatment for blood cancers.
She thought TCR therapy’s clever approach could work against solid tumors, where CAR-T had not been effective.
“I just remember sitting in the room and watching him present, thinking, I’m gonna use that one day,” the oncologist and cancer researcher recalled.
As it would happen, the approach was being tested in a phase II clinical trial at Rutgers Cancer Institute against tumors just like her patient’s: metastatic cancers driven by a virus called human papillomavirus 16. One of the most common strains, HPV16 causes roughly half of cervical cancer cases worldwide, as well as cancers of the head and neck area, anus, and genitals.
Cases that reach the metastatic stage like Johnson’s patient often run out of treatment options. Whether T-cell receptor therapy would work was unknown, but the alternatives were expected to fail.
“Anything that you might offer them would definitely not be expected to make their cancer go away completely and do it for a long time,” said Christian Hinrichs, the oncologist and scientist heading the trial whose presentation Johnson saw.
But interim results from the first half of the trial showed improvement in six out of 10 patients, whose tumors at least partially shrank. And two of them had no evidence of cancer after treatment.
Johnson’s patient, Maria Pascale, was one of thetwo whose promising early results were presented at a medical conference and highlighted in a research abstract in the Journal for ImmunoTherapy of Cancer in November.
She arrived at the health system in New Jersey in the summer of 2024 in such poor health thather lungs were starting to collapse.
The therapy has enabled her to celebrate two birthdays, start martial arts classes, reunite with old friends visiting from Argentina, and see her 23-year-old son get engaged.
“Imagine the wedding, then later the grandkids, I’m always thinking about [that],” she said.
What is a T-cell receptor therapy?
In the immune system, T cells act as frontline defenders against viruses, bacteria, and other threats.
Sometimes, these cells aren’t great at their jobs.
In the face of cancer, T cells can become exhausted over time, and fail to recognize invaders or mount attacks.
The idea behind immunotherapy is to transform these regular immune cells into cancer-fighting super-soldiers.
The Rutgers approach, an engineered TCR therapy, involves collecting T cells from a patient’s blood and genetically engineering them to better target a cancer cell for attack.
Afterward, the scientists grow more of the enhanced T cells in the lab and infuse them back into the patient.
The “prototype” for this style of therapy is CAR-T, a treatment that has saved tens of thousands of lives since the first FDA approval in 2017. Scientists have not yet been able to replicate the therapy’s success in blood cancers in solid cancers, although some early stage trials have shown potential.
TCR therapy is thought to be more promising against the latter cancer type — which is what’s being treated in the Rutgers trial — due to differences in the way the engineered T cells identify cancer cells.
CAR-T therapy uses what’s called a chimeric antigen receptor, a protein that recognizes a cell as cancer based on what’s on the outside of the cell.
It’s like knowing you’re at your friend’s house because of a specific doormat or set of house numbers on the exterior.
TCR therapy uses what’s called a T-cell receptor, which can recognize cancer cells based on what’s inside the cell.
It’s like knowing you’re at your friend’s house because you can see your friend inside.
Sometimes cancer cells have more unique identifiable elements on the outside, but other times they don’t. Imagine if multiple houses had the same doormat.
“That target would be on other cells that aren’t cancer cells and cause lots of toxicity,” said Carl June, the pioneering cancer scientist at Penn who developed the first FDA-approved CAR-T therapy and was not involved in the Rutgers trial.
That’s been the problem that’s held back CAR-T’s use in solid tumors.
The target in the Rutgers trial is a protein called HPV16 E7, found inside the cell. In tumors driven by the virus HPV16, it plays a key role in turning a cell into cancer.
“That’s like going after its Achilles’ heel,” June said.
Swarming the cancer
Pascale first arrived at Thomas Jefferson University Hospital in Center City in 2018 after suffering injuries in a car accident.
Doctors found a mass in the 43-year-old’s neck that turned out to be cancer.
Surgeons removed the mass,and she was fine until 2021 when doctors, including Johnson, found the cancer at the top of her esophagus.
They treated her with a combination of chemotherapy and radiation, which worked until March of 2022, when the cancer started appearing in Pascale’s lungs.
“All bets were off,” Johnson said.
Doctors gave Pascale chemotherapy and immunotherapy over the next couple of years, but in the spring of 2024, she developed an allergy to one of her chemotherapy drugs.
Around the same time, the cancer spread to the skin on Pascale’s back.
That’s when Johnson transferred her care to Hinrichs’ team at Rutgers.
Pascale started preparations for the treatment in July 2024, spending a couple weeks in the hospital.
The Rutgers team took T cells from her blood, gave her chemotherapy to knock her immune system down, and then transfused the engineered cells back into her body.
Within 48 hours, Pascale started feeling horrible.
“It was painful. It was my whole body, like I had pneumonia,” she said.
She had trouble breathing as the cells fought the cancer in her lungs. Hinrichs described it as “the T cells swarming the cancer,” leading to an inflammatory reaction.
The same thing occurred on her back. When Pascale’s sister came over, she saw one of the tumors in her skin was suddenly the size of a lemon.
Another one appeared red and felt like someone was burning a cigarette on her back.
The pain continued for three days, and then she felt well enough to go home. Pascale and her sister could see and feel the nodules on her back get smaller, until eventually they were gone.
Roughly five months later, Pascale’s scans showed no evidence of cancer. As of last month, a year and a half after she received the treatment, that was still true.
“What’s three days of pain compared with the opportunity that I have to live a lot of beautiful things with my family and friends?” Pascale said.
Maria Pascale walks with her sister Maria Durante and her doctor Christian Hinrichs at Rutgers.
The future of the treatment
Hinrichs said his team is working to figure out why two of the patients, including Pascale and a patient with anal cancer, responded better to the treatment.
He cautioned that it’s too early to draw sweeping conclusions since the sample size is small. (Researchers will seek to recruit another 10 patients for the ongoing trial.)
The patients who had complete responses will need follow-up scans every few months to make sure their cancers have not returned.
It will still take years to finish evaluating safety and efficacy. Treatments tested in clinical trials often do not advance to become standard practice.
June, the Penn scientist, called the trial’s early results promising and noted that there weren’t any major safety problems reported.
Adverse effects seen in the trial were mainly those caused by the chemotherapy.
However, the drawback of using TCR therapy is that patients need a certain genetic background for it to work, June said. This is similar to how not every organ donor would be a good match for a recipient.
The genetic profile chosen for the Rutgers therapy is the most common in America. However, it is less common in Black and Asian people compared to white people.
Scientists hope it could one day be possible to manufacture the therapy witha warehouse approach, where TCR therapies that work across genetic backgrounds could be mixed and matched.
“It’s a practical issue that the drug companies face,” June said.
CAR-T, in comparison, canbe used more broadly across different genetic backgrounds.
What matters most, since the treatment is expensive to make, is that the responses hold up over time, June said.
(The TCR therapy’s cost has not yet been set, Hinrichs said, since it is currently manufactured individually for each patient.)
“If they’re long lasting, then it’s really going to be a huge advance because nothing else works in the patients he’s treated,” June said.
At Jefferson, Johnson is cautiously optimistic about the treatment that has kept her patient alive.
If the therapy makes it through the rest of the trial process and proves effective, she hopes it could become “another thing in our armamentarium against this type of cancer.” (A type that doctors would hope to see less of since the introduction of the HPV vaccine in 2006.)
“I can’t tell you how wonderful it is to have a patient responding and living well when you saw things going the wrong way,” Johnson said.
Editor’s note: This story has been updated to clarify where the research has been presented and a reference to the prevalence of the genetic profile used in TCR therapy.
Jefferson Health had an operating loss of $201 million in the six months that ended Dec. 31, compared to a $55 million loss the year before, the nonprofit health system said in a notice to bondholders Friday.
The $201 million loss included a $64.7 million restructuring charge related to severance for 600 to 700 people laid off in October and other changes designed to improve efficiency in the 32-hospital system that stretches from South Jersey to Scranton.
Excluding the restructuring expenses, Jefferson’s operating loss was $136.3 million in the first half of fiscal 2026.
Jefferson said in a statement that it continues facing significant financial headwinds, like health systems nationwide, citing rising pharmaceutical costs.
“We remain focused on driving efficiency, advocating for reimbursement rates that better reflect the true cost of care in Pennsylvania, and advancing the long-term stability of our academic health system,” the health system’s chief financial officer Michael Harrington said.
Here are some details:
Revenue: Patient revenue reached nearly $6 billion in the first half of fiscal 2026. The figure for the previous year is not comparable because it does not include Lehigh Valley Health Network for the full six months. Jefferson acquired the system on Aug. 1, 2024.
Jefferson’s total revenue of $8.6 billion included $145.9 million of investment income that directly boosted operating income. Competitors who use heath-system reporting rules do not include investment income in revenue. Jefferson, by contrast, follows rules for higher-education reporting.
Insurance business: Jefferson noted improvement in its health insurance arm. Jefferson Health Plans’ loss in the six months ended Dec. 31 was $90.7 million, compared to a $118.5 million loss in the same period the year before. The number of people insured in the plans climbed to 371,005 from 359,662. Medicaid recipients account for most of that enrollment.
Notable: Both Moody’s Ratings and Standard & Poor’s Ratings Service in December and January revised their outlooks on Jefferson to negative, which means the agencies could downgrade the organization’s credit rating if Jefferson’s finances don’t improve over the next two years.
“The negative outlook reflects the magnitude of current operating losses as well as anticipated difficulties in returning to or near operating profitability for several years,” Standard & Poor’s said.
Tower Health had an operating loss of $16 million in the first six month of fiscal 2026, according to its report to bondholders Friday. In the same period a year ago, the Berks County nonprofit’s loss was $16.1 million.
Here are some details:
Revenue: Revenue from patient care rose less than 1% to $889.3 million, while total revenue climbed 4.3% to $1.03 billion, thanks to a 34% increase in other revenue.
Cash reserves: Tower reported $244 million in cash reserves on Dec. 31. That translates into enough money to keep operating for 44 days without any new revenue. Both of those figures were at their highest levels since 2022.
The quarterly low was in March 2024, when Tower reported $153 million in cash. That amounted to 30 days of cash on hand. Financially strong systems often have 200 days in reserve.
Family Practice & Counseling Services Network won a $3.4 million federal health center grant that will allow the nonprofit to continue providing medical and mental healthcare in Southwest Philadelphia and other low-income Philadelphia neighborhoods, officials confirmed this week.
The clinic had been part of Resources for Human Development, a Philadelphia human services agency that a fast-growing Reading nonprofit called Inperium Inc. acquired in late 2024. As a federally qualified health clinic since 1992, the clinic had received an annual federal grant, higher Medicaid rates, and other benefits.
Federal rules prohibited the clinic from continuing to retain that status and those benefits under a parent company. That meant Family Practice & Counseling Network had two options: close or spin out into a new entity that would reapply to be a federally qualified clinic.
With financial and operational help from the University of Pennsylvania Health System, Family Practice & Counseling formed a new legal entity last July and reapplied for the grant. Last week, the organization’s CEO Emily Nichols learned that the federal agency that oversees federal health centers awarded it the grant.
A new sign with orange letters outside a former Rite Aid in Germantown announces the arrival of a primary care model new to the Philadelphia region.
ArchWell Health recently opened its first three of eight planned primary care centers here for people with Medicare Advantage, promising convenient and personalized care in neighborhoods with a relative lack of doctors.
Two others have opened on North Broad Street, near Stenton and Susquehanna Avenues, also in former Rite Aid stores.
A privately held company based in Nashville, Tenn., ArchWell says it can offer patients greater access to healthcare throughlower patient-provider ratios.
Itplans to limit each of itsphysicians to no more than 500 patients — about a fifth of the patient load for typical primary care doctors. Nurse practitioners working under the doctors will manage a maximum of 250 patients,officials said.
The approach is built around a financial model that differentiates ArchWell from Medicare-focused competitors already in Philadelphia like Oak Street Health and ChenMed’s Dedicated Senior Medical Centers. ArchWell only accepts patients who have private Medicare or are willing to switch to it. Oak Street and ChenMed also accept traditional Medicare.
Privately run Medicare Advantage plans are increasingly popular among people ages 65 and older who qualify for government-funded Medicare coverage. Advantage plans appeal to people bycovering services, such as dental and vision care, left out of traditional Medicare, but have come under scrutiny for exaggerating how sick patients are to rack up more revenue.
ArchWell sees exclusively working with Medicare Advantage plans as helping doctors to focus solely on the best outcomes for patients, rather than on providing more services to bring in more revenue, a criticism of traditional Medicare, said Doron Schneider, its medical director for the Philadelphia market.
Melissa A. Herd, community relations specialist for ArchWell Health in Philadelphia, is shown outside the company’s Germantown location, which is in a former Rite Aid building.
“You have different incentives, you have different care models, you have different case management models, you have different ways to treat one person versus the other,” Schneider said.
Before starting at ArchWell in late 2024, Schneider worked at Tandigm Health, an Independence Health Group company founded in 2014 with the goal of helping primary care doctors manage costs and improve care for their patients. He learned there how hard it is for doctors to work with different types of insurers and the varied incentives that go with them.
How ArchWell conducts business
ArchWell, which opened its first clinic in 2021 in Birmingham, Ala., operates under contracts with Medicare Advantage plans. The plans give ArchWell a portion of the monthly payment they get from Medicare for each patient. That money is supposed to cover all of the person’s medical costs.
Aetna, UnitedHealthcare, and Devoted Health have contracts with ArchWell to cover the Philadelphia market. ArchWell is close to getting contracts with HealthSpring and Humana, Schneider said. Those five companies had more than 90,000 people in their plans in December, according to federal data.
Aetna and UnitedHealthcare said they work with clinics like ArchWell’s around the country to improve health outcomes and leave patients more satisfied with their experience.
“We are pleased that they are now an option for Aetna Medicare Advantage members in the Philadelphia area,” Aetna said in a statement.
ArchWell declined to provide financial details, such as annual revenue from the more than 80 clinics it had in a dozen states before coming to Philadelphia or how much it spends to open each center. ArchWell representatives also did not disclose who its owners are.
The interior of Archwell Health’s Germantown primary care clinic has Philadelphia-centric images painted on the walls.
Company founder Carl Whitmer worked at Clayton, Dubilier & Rice, a global private equity firm, before founding ArchWell.
“We have partners that are focused on our sustainability and growth,” said Christina Cober, ArchWell’s vice president of marketing.
But companies focused on primary care for seniors haven’t always been as successful as anticipated.
Oak Street, founded in Chicago in 2012, grew rapidly and now services 450,000 patients at 230 centers across the country. It declined to say how many patients it has in Philadelphia. Oak Street arrived here in 2018.
CVS Health bought Oak Street in 2023 for $10.6 billion, anticipating that it would expand to more than 300 centers by this year. Last fall, CVS announced it was closing 16 centers and taking a $5.7 billion write-down on its health-services business, largely because of slower anticipated growth at Oak Street.
ArchWell says itslowerpatient-provider ratios allow more frequent interactions with patients. If a patient is diagnosed with high blood pressure, Schneider said, the message to the patient is: “We’ll see you back in a week. We’ll see you back in two weeks.”
The repeat visits happen with no cost to the member and no extra revenue to ArchWell because all care is supposed to be covered by a monthly payment per member.
ArchWell expects to add about 300 patients per year at each center, said Cober. Staffing at the centers starts out with a physician, a nurse-practitioner, two care navigators, two medical assistants, and a center manager.
Among the early patients at ArchWell’s center on Germantown Avenue is Marcella James, 69, who lives across the street from the clinic and watched as the building was transformed from a shuttered Rite Aid.
“I walked over there one day just to see what it was like and what they offer, and I signed up right away,” James said. James likes her doctor at Temple Health, but ArchWell was irresistibly convenient.
“If I can get the same help or better help from ArchWell is to be seen because I just started with them,” she said.
Each night, Louis-Hunter Kean spiked a fever as high as 104.5. He would sweat through bedsheets and shiver uncontrollably. By morning, his fever wouldease but his body stillached; even his jaw hurt.
He had been sick like this for months. Doctors near his South Jersey home couldn’t figure out why a previously healthy 34-year-old was suffering high fevers plus a swollen liver and spleen. In early 2023, they referred Kean to Penn Medicine.
Louis-Hunter Kean visiting a winery in the Tuscany region of Italy in September 2021. He first spiked a mysterious and persistent fever about a year later in August 2022.
“These doctors are very sharp, and there are a lot of teams working on it,” Kean texted a friend after being admitted to the Hospital of the University of Pennsylvania (HUP) in West Philadelphia.
Was it an infection? An autoimmune disease? A blood cancer? Over the next six months, at least 34 HUP doctors — rheumatologists, hematologist-oncologists, gastroenterologists, infectious disease and internal medicine specialists — searched for an answer.
Kean was hospitalized at HUP five times during a six-month period in 2023. His electronic medical chart grew to thousands of pages.
Along the way, doctors missed critical clues, such as failing to obtain Kean’s complete travel history. They recommended a pair of key tests, but didn’t follow up to make sure they got done, medical records provided to The Inquirer by his family show.
Doctors involved in Kean’s care, including at Penn, prescribed treatments that made him sicker, said four infectious disease experts not involved in his care during interviews with a reporter, who shared details about his treatment. Penn doctors continued to do so even as his condition worsened.
Louis-Hunter Kean receives a kiss from bride Ashley Greyson at the October 2021 wedding of his close friend, Joshua Green. Green and Kean graduated from Haddonfield High School in 2007.
“No one was paying attention to what the doctor before them did or said,” Kean’s mother, Lois Kean, said.
“They did not put all the pieces together,” she said. “It was helter-skelter.”
Kean’s family is now suing Penn’s health system for medical malpractice in Common Pleas Court in Philadelphia. The complaint identifies nearly three dozen Penn doctors, accusing them of misdiagnoses and harmful treatments. These physicians are not individually named as defendants.
In court filings, Penn says its doctors did not act recklessly or with disregard for Kean’s well-being, and his case is not indicative of any systemic failures within its flagship hospital. A Penn spokesperson declined further comment on behalf of both the hospital and the individual doctors involved in Kean’s care, citing the pending lawsuit.
The puzzle of Kean’s diagnosis finally came together in November 2023 after a Penn doctor, early in his career, sought help from the National Institutes of Health (NIH).
An NIH doctor recommended a test that identified the cause: a parasite prevalent in countries bordering the Mediterranean Sea. Kean likely got infected while vacationing in Italy, four parasitic disease experts told The Inquirer.
The infection, which is treatable when caught early, is so rare in the U.S. that most doctors here have never seen a case, the experts said.
By the time Penn doctors figured it out, Kean’s organs were failing.
Louis-Hunter Kean and his then-girlfriend Zara Gaudioso at a friend’s wedding in Tuscany in September 2021. Kean and Gaudioso got engaged in early 2023. Gaudioso was smitten by Kean’s good looks and sense of humor.While vacationing in Italy in September 2021, Louis-Hunter Kean and his friends hiked in the foothills of the Apennine Mountains and visited Gran Sasso and Monti della Laga National Park.
A missed clue
When a patient has an ongoing and unexplained fever, an infectious disease doctor will routinely start by takinga thorough travel history to screen for possible illnesses picked up abroad.
A medical student took Kean’s travel history during his initial workup at HUP in June 2023. An infectious disease specialist reviewed the student’s notes and added a Cooper University Hospital doctor’s earlier notes into Kean’s electronic medical chart at Penn.
Those records show Kean had traveled to Turks and Caicos with his fiancée in May 2022. The next month, he took a work trip out West, including to California, where he visited farms, but didn’t interact with livestock.
This was not unusual for Kean, who worked with fruits and vegetables imported from around the world at his family’s produce distribution center on Essington Avenue in Southwest Philadelphia.
Kean’s fiancée, Zara Gaudioso, said she repeatedly told doctors about another trip: In September 2021, about a year before his fevers began, they traveled to Italy for a friend’s wedding in Tuscany.
The couple hiked remote foothills, danced all night in a courtyard, dined by candlelight surrounded by a sunflower farm, and slept in rustic villas with the windows flung open.
“We told everybody,” Gaudioso said. “A lot of Americans go to Italy — it’s not like a third-world country, so I could see how it could just go in one ear and out the other.”
But notes in Kean’s medical record from the Penn infectious disease specialist don’t mention Italy. Neither do the ones the specialist copied over from Kean’s infectious disease doctor at Cooper.
Kean “does not have known risk factors” for exposure to pathogens, the Penn specialist concluded, except possibly from farm animals or bird and bat droppings.
Still, the specialist listed various diseases that cause unexplained fever: Tick-borne diseases. Fungal infections. Tuberculosis. Bacteria from drinking unpasteurized milk.
The possible culprits included a parasitic disease, called visceral leishmaniasis, transmitted by a bite from an infected sandfly. It can lie dormant for a lifetime — or, in rare cases, activate long after exposure, so it’s important for doctors to take extensive past travel histories, parasitic experts say.
The parasite is widely circulating in Southern European countries, including Spain, Greece, Portugal, and Italy.
“Mostly, people living there are the ones who get it. But it’s just a lottery sandwich, and there’s no reason that travelers can’t get it,” said Michael Libman, a top parasitic disease expert and former director of a tropical medicine center at McGill University in Canada.
But few cases become severe. Hospitals in Italy reported only 2,509 cases of active infection between 2011 and 2016, affecting fewer than one in 100,000 people. Infections requiring hospital care in Italy began to decline after 2012, according a 2023 European study by the Public Library of Science (PLOS) journal Neglected Tropical Diseases.
Caught early, visceral leishmaniasis is treatable. Without treatment, more than 90% of patients will die.
In addition to fever, other telltale symptoms are swelling of the liver and spleen and low blood cell counts. Kean had all of those.
A missed test
The infectious disease specialist requested a test to examine tissue biopsied from Kean’s liver, which was damaged and enlarged. Lab results showed that immune cells there had formed unusual clusters — another sign that his body might be fighting off an infection.
In her notes, the specialist identified “visceral leish” as a possible diagnosis, which repeated — via copy and paste — seven times in his medical record. Her request to “please send biopsy for broad-range PCR” repeated five times.
That is a diagnostic (polymerase chain reaction) test that looks for the genetic fingerprint of a range of pathogens.
The test comes in different versions: One looks broadly for bacteria. The other is for fungi. The broad fungal test candetect leishmania, even though it’s not a fungus. However, it’s not always sensitive enough to identify the parasite and can produce a false negative, experts said.
The specialist’s chart note doesn’t specify which type she wanted done.
It’s not clear if anyone asked. The test wasn’t done.
Louis-Hunter Kean (right, with wine glass and tambourine) leads a wedding procession through the small stone village of Santo Stefano di Sessanio in Italy’s Abruzzo region in September 2021.
She did not order a low-cost rapid blood test that screens specifically for leishmaniasis by detecting antibodies made by the immune system after fighting it. She also didn’t order a leishmania-PCR, which is highly targeted to detect the exact species of the parasite.
Nor did the medical record show that the specialist followed up on the results of the broader test she requested, even though she saw Kean on nine of the 13 days of his first hospitalization at HUP in June 2023.
Penn has a policy that a lead doctor on the patient’s case is responsible for making sure that recommended tests get done. The specialist was called in as a consultant on Kean’s case. During that June hospitalization alone, his medical chart grew to 997 pages.
Patient safety experts have warned for years that electronic medical record systems — designed for billing and not for care — can become so unwieldy that doctors miss important details, especially with multiple specialists involved, or repeat initial errors.
A seemingly innocuous step in charting — copying and pasting previous entries and layering on new ones— can add to the danger, patient safety experts say.
That’s how the specialist’s mention of “visceral leish” and her test recommendation got repeated in Kean’s chart.
Marcus Schabacker, president of ECRI, a nonprofit patient-safety organization based in Plymouth Meeting, said “copy and paste” in electronic medical records puts patients at risk of harm.
“The reality is if you are reading something over and over again, which seems to be the same, you’re just not reading it anymore. You say, ‘Oh, yeah, I read that, let’s go on,’” said Schabacker, speaking generally about electronic medical record systems and not specifically about Kean’s case.
Louis-Hunter Kean plays guitar in his younger years. He loved music and shared eclectic playlists with his friends.
When treatments harm
Penn doctors believed Kean had a rare,life-threatening disorder, known as hemophagocytic lymphohistiocytosis (HLH), in which the immune system attacks the body. Instead of fighting infections, defective immune cells start to destroy healthy blood cells.
In most adults, the constellation of symptoms diagnosed as HLH gets triggered when an underlying disease sends the body’s immune system into overdrive. Triggers include a blood cancer like lymphoma, an autoimmune disease like lupus, or an infection.
Penn doctors across three specialties — hematology-oncology, rheumatology, and infectious disease — were searching for the cause within their specialties.
“His picture is extremely puzzling,” one doctor wrote in Kean’s chart. “We are awaiting liver biopsy results. I remain concerned about a possible infectious cause.”
As HUP doctors awaited test results, they treated Kean’s HLH symptoms with high doses of steroids and immunosuppressants to calm his immune system and reduce inflammation.
The treatments, however, made Kean highly vulnerable to further infection.And defenseless against another possible trigger of HLH: visceral leishmaniasis.
At the time, a Penn rheumatologist involved in Kean’s care before his first hospitalization warned about steroids “causing harm” to Kean if it turned out he had an infection. He wrote, “please ensure all studies requested by” infectious disease are done, medical records show.
Steroid treatments would allow the parasites to proliferate unchecked, experts said.
“It’s unfortunately exactly the wrong treatment for parasitic disease,” said Libman, the leishmania disease expert at McGill University.
As Kean grew sicker, he was readmitted to HUP for a third time in September 2023. He texted a friend: “I’m on more medications than I’ve ever been on and my condition is worse than it’s ever been.”
A sampling of Louis-Hunter Kean’s electronic medical records, which ballooned to thousands of pages over five HUP hospitalizations within six months in 2023.
Handoffs between doctors
No single doctor seemed to be in charge of Kean’s care, his family said. And the number of specialists involved worried them.
“Everyone just kept being like, ‘We don’t know. Go see this specialist. Go see that specialist,’” Kean’s sister, Priscilla Zinsky, said.
By fall 2023, rheumatologists hadn’t found a trigger of Kean’s symptoms within their specialty. They turned to doctors specializing in blood cancer.
During the handoff, three doctors noted that they didn’t see the results of the test requested by the infectious disease specialist back in June. They still thought it was possible that Kean had an infection, records show.
“An additional consideration to rule out infectious cause would be blood-based Karius testing (though this would be fraught with false positives),” wrote that doctor, who was still training as a hematologist-oncologist.
A supervising physician reviewed the Sept. 8, 2023, note and signed off on it. The medical records don’t show any follow-up with infectious disease doctors, and the test wasn’t done at the time.
In the coming days, blood cancer specialists struggled to find a link between Kean’s symptoms and an underlying disease.
They thought he might have a rare form of leukemia, but tests weren’t definitive, Kean texted friends.
Untreated HLH symptoms can lead to rapid organ failure, so doctors often start patients on treatment while trying to figure out the underlying cause, said Gaurav Goyal, a leading national expert on HLH, noting that it can take days to get test results.
“You have to walk and chew the gum. You have to calm the inflammation so the patient doesn’t die immediately, and at the same time, try to figure out what’s causing it by sending tests and biopsies,” said Goyal, a hematologist-oncologist at the University of Alabama at Birmingham.
Medical records show that Penn doctors feared Kean was at “significant risk” of “irreversible organ failure.”
They suggested a more aggressive treatment: a type of chemotherapy used to treat HLH that would destroy Kean’s malfunctioning immune cells.
In his medical record, a doctor noted that beginning treatment without a clear diagnosis was “not ideal,” but doctors thought it was his best option.
Four parasitic disease experts told The Inquirer that chemotherapy, along with steroids and immunosuppressants, can be fatal to patients with visceral leishmaniasis.
“If that goes on long enough, then they kill the patient because the parasite goes out of control,” Libman said, explaining that ramping up the HLH treatments weakens the immune system. “The parasite has a holiday.”
A sample of text messages from Louis-Hunter Kean to friends during separate HUP hospitalizations over a six-month period in 2023.
Chemo as last resort
Kean banked his sperm, because chemo infusions can cause infertility. He told friends he trusted his Penn team and hoped to make a full recovery.
“Started chemo last night. It really feels like finally there is a light at the end of the tunnel,” he texted a friend on Oct. 7, 2023.
“I’m gonna get to marry my best friend, and I think I’m going to be able to have children,” Kean wrote in another text to a different friend.
Kean spent nearly all of October at HUP getting chemo infusions. He rated his pain as a nine out of 10. His joints throbbed. He couldn’t get out of bed. He started blacking out.
Doctors added a full dose of steroids on top of the IV chemo infusion. By the end of the month, Kean told a friend he feared he was dying.
A year had passed since Kean first spiked a fever. He no longer could see himself returning to his former life — one filled with daily exercise, helping run his family’s produce store, nights out with friends at concerts and bars, and vacations overseas.
Lethargic and weak, he could barely feed himself. His sister tried to spoon-feed him yogurt in his hospital bed.
He started texting reflections on his life to friends and family, saying his illness had given him a “polished lens” through which he could see clearly. He wrote that their love felt “like a physical thing, like it’s a weighted blanket.”
“I’ve lived an extremely privileged life. I don’t think it’s possible for me to feel bad for myself,” he said in a text. “And I don’t want anyone else to either.”
Louis-Hunter Kean enjoying dinner out with his sister, Jessica Kean, in Manhattan in 2014. Friends and family described him as a “foodie” and health food advocate prior to the onset of his illness in August 2022.
Puzzle solved
One doctor involved in Kean’s care had seen him at Penn’s rheumatology clinic in early June 2023, just before his first HUP hospitalization. The doctor, a rheumatology fellow,urged him to go to HUP’s emergency department, so he could be admitted for a medical workup.
The fellowremained closely involved in Kean’s care, medical records show. Also in his 30s, this doctor shared Kean’s interests in music, fashion, and the city’s restaurant scene, according to Kean’s family.
“They had a rapport,” Kean’s father, Ted Kean, said. “Louis thought a lot of him, and he seemed to think a lot of my son.”
By early November 2023, the rheumatology fellow was extremely concerned, medical records show.
The chemo infusions weren’t helping. Kean still was running a fever of 103. The fellow wrote in his chart that he was worried Kean needed a bone-marrow transplant to replace his failing immune system.
And doctors still didn’t know the root of his symptoms.
The fellowcontacted the NIH, medical notes show.
An NIH doctor recommended a test to check for rare pathogens, including parasites that cause visceral leishmaniasis,according to family members present when the testing was discussed.
The NIH-recommended Karius test was the same one suggested two months earlier by the Penn hematologist-oncologist in training, but with no follow-up.
File of sign on front of Hospital of the University of Pennsylvania (HUP) taken on Tuesday, March 19, 2024.
On Nov. 16, the fellow got the results. He went to Kean’s bedside.
After five HUP hospitalizations over six months, a single test had revealed the cause of his illness: visceral leishmaniasis.
Kean cried with relief and hugged the fellow, joined by his mother and sister.
“‘You saved my life,’” Kean’s sister, Jessica Kean, recalled her brother telling the doctor. “‘Finally, we know what this is, and we can treat it.’”
Kean’s medical chart was updated to note that he traveled to “Italy in the past,” also noting he had visited Nicaragua and Mexico. A HUP infectious disease doctor consulted with the Centers for Disease Control and Prevention on antiparasitic medications.
Meanwhile, Kean’s nose wouldn’t stop bleeding. He felt light-headed and dizzy, with high fever. Even on morphine for his pain, his joints ached.
“I’ve been struggling, buddy,” he texted a friend on Nov. 20. “This might be the worst I’ve ever been.”
By Nov. 22, he stopped responding to text messages. He began hallucinating and babbling incoherently, family members recalled. “Things went downhill very, very quickly, like shockingly quickly,” his sister, Priscilla Zinsky, said.
When she returned on Thanksgiving morning, he was convulsing, thrashing his head and arms. “It was horrifying to see,” Zinsky said.
Her brother had suffered brain bleeds that caused a stroke. His organs were failing. He had a fungal infection with black mold growing throughout his right lung, medical records show.
Kean was put on life support, with a doctor noting the still-preliminary diagnosis: “Very medically ill with leishmaniasis.”
“Prognosis is poor,” read the note in his Nov. 29, 2023, medical records.
A few hours later, Kean’s family took him off life support. He died that day.
“All of his organs were destroyed,” said Kean’s mother, Lois Kean. “Even if he had lived, he had zero quality of life.”
Portraits of Lois and Ted Kean’s four children decorate a wall at their home in Haddonfield. Their son, Louis-Hunter, died after contracting visceral leishmaniasis, a parasitic infection he likely picked up in Italy. When caught early, it’s treatable with medication. It’s deadly without treatment.
It’s not clear why the parasites began to attack Kean a year after his return from Italy. Healthy people rarely develop severe disease from exposure to the deadly form of the parasite circulating outside the U.S., experts said.
Most people infected by a sandfly “are probably harboring small amounts of the parasite” in their organs, according to Naomi E. Aronson, a leishmania expert and director of infectious diseases at the Uniformed Services University of the Health Sciences in Bethesda, Md.
“Most of the time, you don’t have any problem from it,” Aronson said.
Children under age 5, seniors, and people who are malnourished or immunodeficient are most susceptible to visceral leishmaniasis. Aronson said she worries about people who might harbor the parasite without problems for years, and then become immunocompromised.
Libman, the parasitic expert from McGill, said he’s seen six to 10 patients die from visceral leishmaniasis because doctors unfamiliar with the disease mistakenly increased immunosuppressants to treat HLH during his 40 years specializing in parasite disease.
“That’s a classic error,” he said.
Kean’s case “should be a real clarion call” for infectious disease specialists and other doctors in the U.S., said Joshua A. Lieberman, an infectious disease pathologist and clinical microbiologist who pioneered the leishmania-PCR test at the Washington state lab.
“If you’re worried about an unexplained [fever], you have to take a travel history that goes back pretty far and think about Southern Europe, Iraq, Afghanistan, India, and maybe even Brazil,” Lieberman said.
In the wake of Kean’s death, his family was told that Penn doctors held a meeting to analyze his case so they could learn from it.
An infectious disease doctor called Zinsky, Kean’s sister, to let her know about the postmortem review and shared that doctors discussed that Kean had likely picked up the parasite in Tuscany.
“Why didn’t you guys have this meeting,” she asked, ”while he was alive?”
Editor’s note: This story has been updated to clarify that ECRI President Marcus Schabacker was not speaking specifically on Kean’s case.
At Roxborough Memorial Hospital in Philadelphia, surgeon Piotr Krecioch has his hands full launching a program offering surgical interventions to treat obesity.
One in three Philadelphians are living with obesity, putting them at higher risk of chronic conditions like diabetes and heart disease, but these days fewer are seeking the bariatric surgical procedures long considered a leading medical treatment for the condition.
“I’m trying to start a bariatric program at probably the worst possible time you can ever imagine because everybody’s losing patients, and I don’t even have a patient to begin with,” Krecioch said.
Tower Health’s Reading Hospital recently closed its bariatric surgery program, and other local health systems have seen declines in weight-loss operations approach 50%.
Independence Blue Cross, the Philadelphia region’s largest insurer, said the number of bariatric surgeries it paid for dropped by half in the five years ended June 30.
Those shifts in the bariatric surgery landscape have followed the meteoric national rise in the use of GLP-1s and related drugs for weight loss.
So far, the drugs havebenefited patients by allowing them to avoid an invasive surgery.With bariatric surgery, people lose weight because the procedures restrict the amount of food a person can eat. Drugs in a class known asGLP-1s make people feel full longer.
For hospitals, the upheaval in treatment options cuts into a profitable business line and adds to the financial pressure health systems have been experiencing since the pandemic.
Despite the ever-increasing popularity of GLP-1s for weight loss like Novo Nordisk’s Ozempic and Wegovy and Eli Lilly’s Mounjaro and Zepbound, it’s too soon to write off bariatric surgery as an option, some doctors say.
Insurers are imposing limits on coverage because of the long-term cost of the drugs compared to surgery, and doctors are watching for side effects that may emerge as more people take the drugs for longer periods of time.
It’s not the first time a new technology has reduced surgical volumes.
Whenever a less-invasive treatment has come along, “surgical volumes always have taken a beating,” said Prashanth R. Ramachandra, a bariatric and general surgeon at Trinity Health Mid-Atlantic’s Mercy Fitzgerald Hospital. Declines in peptic ulcer and open heart surgeries are past examples of the phenomenon, he said.
Such industrywide moves away from profitable procedures can create financial challenges for individual clinics or independent hospitals, said Daniel Steingart, who leads the nonprofit healthcare practice at Moody’s, a major credit ratings agency.
“But I also see it as an opportunity, because there’s other patients out there, there’s other services that can be provided. This is a matter of the management team being nimble,” he said.
Sharp decline in bariatric surgeries
National data show a 38% decline in bariatric surgeries from the beginning of 2024 through September, according to data firm Strata Decision Technology. Comparable local data were not available.
A substantial portion of the drop is from patients who previously had bariatric surgery but regained weight, physicians say. In the past, they would have had a type of surgery called a revision. Now, those patients are more likely to start taking GLP-1s, local doctors said.
Prashanth R. Ramachandra is a general and bariatric surgeon at Trinity Health Mid-Atlantic’s Mercy Fitzgerald Hospital in Darby.
Only two Philadelphia-area health systems provided details on changes in bariatric surgery volumes in recent years as GLP-1s for weight loss took off.
At the University of Pennsylvania Health System’s three Philadelphia hospitals, the annual number of bariatric surgeries has fallen by more than half, from a peak of 850 three or four years ago to around 400 in the year that ended June 30, said Noel Williams, a physician who leads Penn’s bariatric surgery program.
At Mercy Fitzgerald in Darby, the number fell from an annual peak in the 220-230 range to about 125 last year, Ramachandra said.
The volume at Mercy Fitzgerald was likely buoyed by the closure of the bariatric surgery program at nearby Crozer-Chester Medical Centerin Upland.
Tower did not provide details on the Reading closure, which was part of cutbacks Tower announced in early November. The program closed last month after a 60-day notice tothe state health department.
Main Line Health, which only offers bariatric surgery at Bryn Mawr Hospital, said surgeries have declined, but provided no details.
Virtua Health did not provide comparable data but said that its Virtua Complete Weight Management Program, which opened in spring 2024 to expand into medication treatments, experienced a 35% increase in visits last year.
The number of bariatric procedures is also down at Temple University Health System, but patients with complex conditions and more severe obesity are still coming to Temple for surgery, said David Stein, who is surgeon-in-chief at Temple University Hospital.
To adapt to this rapid change in medicine, Temple is adopting a multidisciplinary approach to the disease, building on what is done in cancer care, Stein said.
Jefferson Health did not respond to requests for information about its bariatric surgery program.
How health systems are responding
While full-scale closures like Reading’s are unusual, cutbacks are occurring broadly.
When the bariatric surgeon at Penn Presbyterian Medical Center retired amid declining numbers of surgeries across the entire system, Penn did not replace him, Williams said.
Penn does the procedures locally at the Hospital of the University of Pennsylvania and at Pennsylvania Hospital.
“If the numbers were to continue the way they are now,” Williams said, “we may want to consolidate into one of our hospitals in the city.”
Outside of Philadelphia, Penn has bariatrics programs at Lancaster General Hospital and Penn Princeton Medical Center.
After Jefferson Health acquired Einstein Healthcare Network in late 2021, it consolidated bariatric procedures at Jefferson Abington Hospital, according an Inquirer analysis of inpatient data through 2024 from the Pennsylvania Health Cost Containment Council.
Jefferson did not respond to a request for information about the changes.
Piotr Krecioch is a bariatric and general surgeon at Roxborough Memorial Hospital in Philadelphia.
Not the end for bariatric surgery
GLP-1s don’t mean the end of bariatric surgery, even though the procedures are not likely to return to previous peaks, physicians said.
Some patients don’t respond to GLP-1s and others can’t tolerate them, which means they remain candidates for surgery, Williams said. Surgery is still recommended forpatients who are considered severely obese,with body-mass indexes over 50,he added.
Outcomes cannot yet be compared over the long-term. Ramachandra and other doctors are keeping their eye on the ratio of fat loss and muscle loss in patients taking GLP-1s compared to those who have bariatric surgery. Losing muscle can lead to falls and fractures.
A study published last month in the Journal of the American Medical Association found that bariatric surgery is associated with a favorable ratio of fat loss.
At Roxborough Memorial Hospital, Krecioch, who also works as a general surgeon, sounds optimisticas he works on his new program.He became a Roxborough employee in April 2024 after eight years at Mercy Fitzgerald, where he worked with Ramachandra.
Krecioch’s strategy for years has been to offer weight management services in addition to surgery. Patients come for a GLP-1, giving him a chance to build a long-term relationship.
“I have a feeling that these people are going to come back to my office,” he said. ”I’m gonna keep seeing them, and that they will actually convert to bariatric surgery at some point.”
Editor’s note: This article has been updated with information from Temple University Health System.
Philadelphia biotechs are worried about losing a key source of federal funding for early-stage innovation.
Known as “America’s seed fund,” the Small Business Innovation Research (SBIR) and Small Business Technology Transfer (STTR) programs helpsmall companies develop innovative technologies. In recent years, they’ve allocated $4 billion annually to more than 4,000 businesses nationwide. However, after Congress failed to reauthorize the decades-old programs last fall, their funding officially expired in September.
The fallout has affected more than a dozen local life sciences companies, raising concerns about whether they can maintain staffing and make up for thedelay in funds promised months ago, said Heath Naquin, senior vice president of innovation and new ventures at University City Science Center, a nonprofit commonly known as the Science Center that provides startup support.
For many, staffing and financing plans could be disrupted by funding shortfalls, as companies either haven’t gotten their payment yet or can’t get their funding for next year approved, he said.
An exact figure is unknown, but Naquin estimated that some affected companies could be short up to a million dollars for the year.
At the same time, the city of Philadelphialaunched last spring a new program that provides additional funding to those who have already earned SBIR/STTR grants. The 21 awardees who will share $450,000 from the city were announced publicly in January.
The citymoney is earmarked for technical assistance, such as the cost of attorneys, marketing, and anything else needed for commercialization, while SBIR/STTR money normally goes toward research and development.
“There is no overnight solution to SBIR right now,” said Tiffany Wilson, chief executive officer of the Science Center, which is partnering with the city to implement the program. “It’s just another layer of uncertainty that we’ve got to navigate through.”
New city-led program
Pennsylvania is not one of the dozens of states that offer matching programs to supplement the federal SBIR/STTR funds.
To fill that gap, Philadelphia launched its new city-level program, which is one of the first in the nation and the only one of its kind in the state.
The idea was to boost companies already vetted by the federal government that could still benefit from smaller amounts of money.
“Life science companies need millions of dollars, but this was a way that we could help Philadelphia-based companies thrive,” said Rebecca Grant, who runs the program and serves as senior director of life sciences and innovation for the city.
This year, the city offered funding to all eligible applicants.
The $450,000 is doled out in three tiers: companies with the earliest stage grants received $20,000 while those in the next phase received $40,000. Those whose grants were no longer active received $2,500.
The program is still a pilot, and city leaders hope to run it on an annual basis, Grant said.
Naquin has heard from at least three companies in the last six months that are formally considering moving to Philadelphia as a result of the program’s existence.
The SBIR/STTR grants are valuable to early-stage biotechs for two reasons: They provide funding without asking for ownership or equity in return, and signal to potential investors that the company is less risky, Wilson explained.
The programs traditionally have been reauthorized every few years without major lapses. However, recent debates over reforms have created a deadlock.
Policymakers from both parties want to address companies that are repeatedly going back for more funding, concerns over foreign involvement, and how to better support commercialization, Naquin said.
“We’re still in a waiting game,” he said, adding that the programs were not reauthorized in the latest government funding bill passed this week.
With the SBIR/STTR pipeline stalled, the Science Center has had to pivot. Federal support for science has been particularly precarious under President Donald Trump’s second administration, with widespread cuts and pauses to millions of dollars worth of programs and grants.
Late last year, the center launched aninitiative to help startups figure out which agencies still have available funding opportunities.
The aim is to help them better shop around for the grants that they can apply to, Wilson said.
