The COVID-19 Public Health Emergency is blamed for dramatic year-over-year reductions in healthcare services for children.
Health screenings and vaccinations fell dramatically for children enrolled in the Children's Health Insurance Program during the early months of the COVID-19 Public Health Emergency, the Centers for Medicare & Medicaid Services reported Wednesday.
When compared to data from March through May 2019, with the same three-month span in 2020, there were 1.7 million (22%) fewer vaccinations for beneficiaries up to age 2, 3.2 million (44%) fewer child screening services, 6.9 million (44%) fewer outpatient mental health services even after accounting for increased telehealth services, and 7.6 million (69%) fewer dental services, according to CHIP data released by CMS.
In a telehone call with media on Wednesday, CMS Administrator Seema Verma raised concerns that the drop in preventive and primary care services could have a long-term effect on the health outcomes for the 40 million children enrolled in CHIP, 75% of whom live in poverty.
"Today's analysis gives us a much better understanding of how children have been affected by the pandemic and we're releasing it today to raise awareness about this critical public health issue," Verma said.
The problem is further exacerbated by the limited in-person instruction at many schools, which normally would provide a venue for these physical, dental, and mental health screenings and other services such as speech, physical, and occupational therapy.
"The absence of these vital healthcare services may have lifelong consequences for these vulnerable children, and I call on states, pediatric providers, families, and schools to ensure children catch-up on overdue medical, behavioral health and dental appointments as well as childhood immunizations," Verma said.
Verma told reporters that the solution would not come solely from the federal government.
"From our perspective, we've provided a lot of flexibility to states around telehealth services. We've provided over 500 waivers to state Medicaid programs across the country," she said. "This is going to require state and local leadership on this is going to require local communities to put together a system of care for children. So we need to see collaboration between schools and health care providers, and also outreach to families."
CMS said that, for children to catch up on missed vaccinations, vaccination rates must not only approach those of 2019, but to be much higher, in order to mitigate the 22% dip during the early part of the COVID-19 Public Health Emergency.
"This has not begun to happen, and increases the risk of transmission of vaccine-preventable illnesses, such as measles, mumps, and Haemophilus influenza," CMS said.
Newer preliminary data cited by CMS also show a strong uptick in the use of telemedicine for children, but "it is still not enough to offset this decline in care for vulnerable children."
"Further, although telehealth remains an important part of care delivery for children, some services, such as vaccinations, cannot be provided through this vehicle, which contributes to the current gap in their healthcare," CMS said.
Providers also complain that the delayed release of the final rule cuts into the time ACOs and other APMs would have to implement the changes.
Citing concerns about mandating sweeping new reporting requirements in the middle of a pandemic, some of the nation's largest physician and hospital associations on Wednesday asked the federal government to drop changes on how Medicare accountable care organizations are assessed for quality.
"The ACO quality changes proposed are significant and come at a time when ACOs are continuing to deal with challenges and uncertainty caused by the COVID-19 pandemic," the American Medical Association, and nine other stakeholder groupswrote in a joint letter to Centers for Medicare & Medicaid Services Administrator Seema Verma.
"Just as CMS has proposed to delay moving forward with the MIPS Value Pathways approach due to concerns with COVID-19, CMS should also postpone such a drastic and significant change to the way ACO quality is measured, assessed, reported and scored for purposes of both the MSSP and MIPS programs," the letter said.
"The proposed rule, set to take effect in 20201, mandates of how ACOs and other alternative payment models are assessed on quality in the Medicare Shared Savings Program and Merit-Based Incentive Payment System.
The stakeholders also complain that the delayed release of the final rule cuts into the time ACOs and other APMs would have to implement the changes.
Specifically, the stakeholders urged Verma to reconsider:
Ending the use of the Web Interface reporting mechanism, which has been used since the MSSP's inception.
Removing the pay-for-reporting year currently provided to ACOs beginning an initial MSSP contract as well as individual measures that are newly introduced to the measure set.
Changes to the quality measure set ACOs must report under the APM Performance Pathway.
Replacing the existing MIPS APM Scoring Standard, which the stakeholders claim "allows each APM to have its own set of unique quality measures and scoring approaches that best fit the particular model."
The letter was signed by the AMA, American College of Physicians, America's Essential Hospitals, America's Physician Groups, AMGA, Association of American Medical Colleges, Federation of American Hospitals, Medical Group Management Association, National Association of ACOs, and Premier.
"Today we mark a somber milestone as more than 200,000 people in the United States have died of COVID-19 over the course of the pandemic," the American Hospital Association, American Medical Association and American Nurses Association wrote.
The scale and raw numbers of deaths has had a devasting impact on the nation, the three associations wrote, "affecting Americans at a rate that represents a nearly worst-case scenario."
"Those lost include mothers and fathers, grandparents, children, teachers, and frontline workers. The steps required to stop the spread of this virus should be well known by now, but with more than 6 million COVID-positive Americans, we say again: wear your mask, wash your hands, and practice physical distancing," they wrote.
With the flu season approaching, the three associations urged the public to get a flu shot.
"With no end to COVID-19 in sight, a bad flu season has potential to cause additional strain on our health system that is still battling the pandemic. America’s physicians, nurses, and hospitals and health systems thank you for doing your part," they said.
NYU Langone's Center for Diabetes and Metabolic Health was among the nation's first outpatient diabetes practices to switch primarily to remote visits as the pandemic accelerated.
When government and private insurers this spring eased restrictions on telemedicine coverage in response to the pandemic, NYU Langone jumped to expand telemedicine access for the health system's diabetes patients.
"With diabetes emerging as a major risk factor for COVID-19, we felt it was crucial to spare our patients the potential exposures that in-person visits would entail," said Lauren H. Golden, MD, director of Langone's Center for Diabetes and Metabolic Health.
Pre-pandemic, Langone's outpatient diabetes practice had the technical infrastructure for video visits and was training patients to monitor their blood sugar and insulin dosing from personal devices to reduce office visits.
Because of that prearrangement, Golden said, the transition to virtual visits went smoothly.
"We sent patients links to software downloads, and most of them were able to figure out how to transmit readings to us online," she said. "We emailed logs to the others, so that they could fill them out and send them back."
The transition to virtual care came as many of the center's clinicians were working in the health system's "COVID Army," The video visits allowed the remaining clinicians to manage the outpatient services of their colleagues.
A small crew of clinicians and support staff stayed in the office part-time for occasional in-person visits, but by the last week of March, the vast majority of visits were taking place via video.
Langone's use of telemedicine for diabetes management relies on a multidisciplinary approach, Golden said, with endocrinologists, nurse practitioners, diabetes educators, and nutritionists focused on treating the whole patient. In fact, Golden said, video visits are a better access point for diabetes management because much of the regimen centers around lifestyle coaching.
"Because visits don't require travel, patients can check in more frequently than they would have before. Many have told us they're thankful for that enhanced access to care," Golden said.
The video visits also allowed Langone clinicians to support patients’ evolving needs and help them cope with emotional turmoil prompted by the pandemic and social isolation.
"One of the greatest stressors during the pandemic has been dealing with the unknown," Golden said. "We've found that patients benefit from focusing on what they can control, including their own role in staying healthy. It's empowering for them to understand that regulating their blood sugars not only mitigates their diabetes, but also puts them in a better position if they do become infected with the coronavirus."
"If people need a new exercise routine, we’ll send links to workout videos tailored to their age and fitness level," Golden said. "We talk to them about yoga, meditation, and other stress-relieving techniques, and help them find resources online. If they have unmet mental health needs, we try to arrange treatment for those issues as well."
The pandemic is waning in New York City – for now – but Golden said the lessons learned will not be forgotten. In-person visits are returning, but Golden expect telemedicine to remain a popular option with patients post-pandemic.
"The pandemic has shone a spotlight on the things that were or weren't working for people previously," she said. "We want every person we care for to take something positive from this crisis and use it to improve things when we return to whatever the new normal is going to be."
The Physicians Foundation survey of 2,334 physicians finds that the COVID-19 pandemic has significantly worsened the problem.
Nearly 1 in 4 physicians (22%) know a colleague who committed suicide and 58% of physicians say they've shown symptoms of burnout, according to a new survey released Thursday by The Physicians Foundation.
"Physician wellbeing was a public health crisis long before COVID-19. Now, we’re seeing the pandemic exacerbating this issue," said Gary Price, MD, president of The Physicians Foundation.
"With nearly half of physicians telling us that COVID-19 won’t be under control until mid-year 2021, it's critical we do more to support physicians who are fighting on the frontlines and putting their lives at risk to care for patients," Price said.
The email survey of 2,334 physicians – COVID-19’s Impact on Physician Wellbeing – is the second in the Foundation's three-part series, 2020 Survey of America’s Physicians, that looks at how COVID-19 is affecting physicians. It was conducted in mid-August by physician recruiters Merritt Hawkins.
Physician burnout rates were already at an all-time high before the pandemic but have increased dramatically within the past six months. The Physicians Foundation's 2018 Survey of America's Physicians found that 40% of physicians often or always experienced feelings of burnout.
In the latest survey, 50% of physicians said they experienced anger, crying or anxiety because of COVID-19's effects on their practice. To cope with the anxiety caused by the pandemic, 18% of physicians said they increased their use of medications, alcohol, or illegal drugs, while 13% sought medical attention for a mental health problem.
Robert Seligson, CEO of The Physicians Foundation, said the finding that only 13% of physicians are seeking mental health care is a giant red flag that underscores the importance of a nationwide effort to address physician burnout.
"There are two main reasons that so few physicians seek help – stigma and fearing a loss of their license," Seligson said. "But just like anyone else, physicians are people and should feel comfortable seeking help without worry of being judged or losing their right to practice."
The survey also found that:
22% of physicians know a doctor who committed suicide.
26% of physicians know a colleague who has considered suicide and 15% know colleague who has attempted suicide.
8% of physicians have had thoughts of self-harm as a result of COVID-19's effects on their practice. Younger physicians report thoughts of self-harm at a higher rate than older physicians.
30% cited feelings of hopelessness or having no purpose due to the changes of their practice because of COVID-19.
78% cited a lack of population compliance with COVID-19 distancing and mask-wearing protocols as their number one source of frustration during the pandemic and 70% cite lack of reliable COVID-19 tests.
90% of physicians cite their family as integral in supporting their wellbeing, followed by friends (83%) and colleagues (73%).
56% said their medical practice or group has been helpful to their mental health and wellbeing during the pandemic, 40% said their hospital or health system has been helpful, 34% said their specialty society has been helpful and 23% said their state medical society has been helpful.
The bond rating agency credited the for-profit hospital sector for its "rapid and aggressive responses to the pandemic" that included cost cuts to labor and supplies to limit cash burn.
For-profit hospital margins will continue to strain over the next 18 months as federal aid wanes, higher unemployment hurts the payer mix, and volume instability and cost management remain a challenge, Moody's Investors Service says.
The bond rating agency credited the for-profit hospital sector for its "rapid and aggressive responses to the pandemic" that included cost cuts to labor and supplies to limit cash burn and emerge from Q2 with much of funding provided by the Coronavirus Aid, Relief, and Economic Security Act.
"Some hospitals have said that for every lost dollar of revenue, they were able to cut about 50 cents in costs," Moody's said, but warned that "these levels of cost cuts are not sustainable."
Median same hospital revenue in Q2 for Moody's-rated for-profit hospitals fell 10%, but Earnings Before Interest, Taxes, Depreciation, and Amortization increased 18%. However, without the federal aid, EBITDA declined by 37.5%.
The bottom-line benefits of the $175 billion in CARES Act relief will dwindle in Q3, Moody's said, even as COVID-related costs persist.
"These include operating COVID and non-COVID areas; buying expensive personal protective equipment (PPE); and educating communities on hospital safety and the risks of deferring care," Moody's said.
"As a result, hospitals will operate less efficiently in the wake of the pandemic, although their early experiences in treating COVID-19 patients will enable them to provide care more efficiently than in the early days of the pandemic," Moody's said.
That newfound efficiency should help hospitals free up bed capacity and avoid widespread shutdown for profitable elective surgeries.
Volume Uncertainty
Barring a second wave of the COVID-19 pandemic, Moody's expects patient volumes in Q4 to exceed 90% of pre-pandemic levels, with the remaining 10% to return gradually in 2021. Those volumes could come back faster if a vaccine becomes widely available.
Inpatient surgeries fell 35%-45% in April but recovered somewhat in May and June. Emergency room and other urgent care volumes also fell by 50%-70% because of shelter-at-home orders. They are still down 15%-20% because of patient apprehension.
The pent-up demand for elective surgeries, and the patient apprehension about hospital safety pushed many procedures to outpatient venues, Moody's said, which will also weaken earnings, particularly for hospitals that don’t have a sizeable outpatient presence.
Further, CMS's proposal to eliminate 300 musculoskeletal-related services from its "in-patient only list" will send money making orthopedic surgeries to outpatient settings.
Median same facility revenue per adjusted admission grew by 9.3% during the Q2 largely due to medically necessary and costly surgeries. However, hospitals are also expected to see a drop in those higher-acuity surgeries, while seeing more of the lower-acuity and less-costly procedures that were deferred in the first months of the pandemic, Moody's said.
"As patients suffering from lower acuity issues regain comfort in going to hospital emergency rooms in the quarters ahead, we expect revenue per adjusted admission to return to a low-single digit growth rate," Moody's said. "It is unclear whether the upcoming flu season, in concert with the coronavirus, will result in significantly higher rates of acuity."
Widespread efforts to curtail the spread of COVID-19, including masks and social distancing, could hurt hospitals' earnings by diminishing the severity of the flu season, Moody's said.
Weaker Payer Mix
The pandemic-related recession has put millions of people out of work, many of whom have consequently lost their employer-sponsored health insurance.
Moody's notes that some of the newly jobless will be able to buy coverage on Affordable Care Act exchanges, while others will transition to Medicaid and the Children's Health Insurance Program.
"This will hinder hospitals' earnings growth over the next 12-18 months. Employer-provided health insurance pays significantly higher reimbursement rates than government-based programs, like Medicaid and Medicare," Moody's said.
Positive Offsets
It's not all bad news for the for-profit hospital sector.
Moody's notes that while federal grants will peter out in Q3, hospitals will still receive a 20% add on for treating Medicare COVID-19 patients. The CARES Act also suspends sequestration cuts through the end of 2020, and provides other benefits that will improve liquidity, including accelerated Medicare payments, and the deferral of the employer portion of the Social Security payroll tax.
In addition, CMS has proposed a 2.6% increase in Medicare outpatient rates for 2021, and final in-patient rates for 2021 will include a 2.9% increase for acute care hospitals in the quality reporting program that are "meaningful users" of electronic health records.
The public health emergency loosens restrictions on HIPAA and EMTALA mandates, physician licensing, and self-referrals for providers operating 'in good faith.'
The wildfires sweeping through Oregon prompted the Department of Health and Human Services on Wednesday to declare a public health emergency in the state.
The emergency declarationandwaiver, which follow President Donald Trump's emergency declaration for the state, will give healthcare providers and suppliers more flexibility to meet the care needs of Medicare and Medicaid beneficiaries affected by the wildfires, HHS Secretary Alex Azar said.
Among other things, the waiver loosens restrictions on the Health Insurance Portability and Accountability Act (HIPAA), and the Emergency Medical Treatment and Labor Act (EMTALA), physician licensing, and on self-referrals for clinicians and hospitals operating "in good faith."
"We are working closely with Oregon health authorities and monitoring the needs of healthcare facilities to support their efforts to save lives and protect health during these dangerous wildfires," Azar said. "With this declaration and waiver, the Trump Administration is helping to ensure that Oregonians who rely on Medicare and Medicaid have continuous access to the care they need during this disaster and as communities recover."
The wildfires up and down the West Coast and the choking haze they've created have raised concerns about respiratory ailments for millions of people and the stresses that can create for healthcare systems; a concern exacerbated by the COVID-19 pandemic.
Oregon's air quality index in many areas has been reported at or above 300 which can cause health problems even among otherwise healthy people.
HHS also sent an Incident Management Team to Oregon and regional emergency coordinators to the state's emergency operations centers to coordinate with state and local health and emergency response authorities.
The Centers for Medicare & Medicaid Services will also share with state and local officials information on the numbers of Medicare beneficiaries who rely on electricity dependent medical devices and healthcare services such as home dialysis and home oxygen in the event that the fires threaten at-risk patients.
The partnership aims to save $400 million over the next seven years using proactive care and improving access to care for minority communities.
Maryland's CareFirst BlueCross BlueShield and MedStar Health said Wednesday their partnering to create a value-based collaborative that will emphasize cost-effective preventive care.
"This partnership between MedStar Health and CareFirst allows for creativity, innovation and unprecedented collaboration between our two organizations to help transform healthcare," said Kenneth A. Samet, president and CEO of MedStar Health.
"Working together to remove barriers and solve challenges will provide our patients with more convenient access to manage their health and experience better outcomes, while helping to make care more affordable," Samet said. "This important new partnership will benefit the communities we already serve together.”
The partnership between Maryland's largest not-for-profit health system and largest non-for-profit health insurer, which will be led by a joint management team, aims to improve affordability, accessibility, quality, and patient experience while also reducing care costs by $400 million over the next seven years.
In particular, the partners said they will focus on removing disparities in care access for minority communities.
CareFirst President and CEO, Brian D. Pieninck noted that the health insurer and MedStar serve the same region and the same people and "have a shared responsibility to ensure members and employers are getting maximum value for their healthcare dollar."
"Through this unique partnership, we will help to transform the healthcare landscape to deliver on our shared missions to increase access to quality, affordable care," Pieninck said.
CareFirst provides coverage and administrative services to 3.3 million people in Maryland.
MedStar has 10 hospitals and more than 300 care venues across Maryland, with 4,700 affiliated physicians and 30,000 employees.
The bond rater said the repayments would only be problematic for hospitals "if there is a significant rise in infections that results in another round of elective procedure curtailment."
The looming repayment of billions of dollars in federal pandemic emergency loans is not expected to "materially affect" the finances of not-for-profit healthcare providers, Fitch Ratings says.
The money, essentially six months of advanced payments under the Medicare Accelerated and Advance Payment Programs, is part of the massive $2.2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act, a stopgap for hospitals that saw nonemergency procedures and services grind to a halt this spring because of the pandemic.
"Providers' ratings are supported by ample liquidity and Fitch's expectations are for a long-term volume recovery due to the essential nature of services," the bond rating agency said in a brief Tuesday.
"Liquidity will gradually decline as advances are repaid but full and timely repayment is part of our rating assumptions for all issuers and we anticipate most providers will ultimately maintain liquidity profiles consistent with current rating levels based on our expectations for continued volume recovery in the hospital sector," Fitch said.
The Medicare payment advances under the AAP account for about 10% of unrestricted liquidity for some hospitals, Fitch said, "although this increases to almost 30% for some issuers with lower levels of liquidity.
"In terms of total revenues, funds under the AAP range from a low of around 5% of total revenues to around 15%, depending on a hospital’s commensurate amount of Medicare revenue," Fitch said.
The pandemic shut down nonessential care delivery in most parts of the United States, robbing hospitals of revenue from money-making elective procedures and shredding patient volumes to ration personal protective equipment and prepare for a surge of COVID-19 patients.
Fitch said the repayments, which would come in the form of reduced Medicare reimbursements, would only be problematic for hospitals "if there is a significant rise in infections that results in another round of elective procedure curtailment."
That does not seem to be a problem right now. Fitch notes that not-for-profit hospitals are already seeing a strong recovery in elective patient volumes that are about 80% to 90% of pre-pandemic levels.
"While there is still some patient hesitancy to seek non-coronavirus medical care, particularly visits to the emergency department, we believe that a return to near pre-coronavirus levels are possible by year’s end," Fitch said, adding that "downside risks remain given the volatile nature of the coronavirus itself."
The repayment timeline for the Medicare advances was extended by Congress and may be extended again. Some lawmakers have suggested forgiving the loans and converting them into grants under a new federal coronavirus aid package.
However, Congress is at loggerheads over a new pandemic relief package, and loan repayments are expected to begin soon, Fitch said.
Turnovers have hovered at around 18% for the past eight years, as many hospital leaders reach retirement age.
Hospital CEO positions turned over at a rate of 17% in 2019, a small drop from turnover rates over the last five years that have held steady at 18%, the American College of Healthcare Executives reports.
Still, the ACHE survey finds that hospital leaders are continuing their nomadic ways, with the last eight years representing the longest period during which hospital CEO turnover rates were 17% or higher since the study began in the early 1980s.
"Despite the slight drop in 2019, turnover rates in recent years remain at higher levels than in the past," ACHE President and CEO Deborah J. Bowen, FACHE, CAE, said.
Bowen said the turnover comes as hospitals continue to adapt to a rapidly changing healthcare environment and the movement of CEOs to different positions within healthcare systems.
"In addition, more CEOs are reaching retirement age," Bowen says. "Our turnover data underline the importance of organizations maintaining a focus on succession planning and developing our new healthcare leaders."
ACHE's CEO turnover rates are based on changes reported to the American Hospital Association and confirmed from ACHE data.
Delaware had the highest CEO turnover, at 40% in 2019, while South Dakota had the lowest turnover, at 2%, among the 50 states, Puerto Rico, and Washington, D.C., ACHE's report shows.
