Verma calls for "a more tailored and flexible approach" with input from local leaders.
The Centers for Medicare & Medicaid Services is offering recommendations for how hospitals in areas with low incidences of COVID-19 can re-open for non-emergency procedures.
"Today, some areas of the country are experiencing fewer cases and lower incidence of the virus, necessitating a more tailored and flexible approach," CMS Administrator Seema Verma said.
"Every state and local official will need to assess the situation on the ground to determine the best course forward, but these guidelines provide a gradual process for restarting non-COVID-19 essential care while keeping patients safe," she said.
The recommendations, released Sunday, target communities that are in Phase 1 of the Guidelines for Opening Up America Again with low incidence or relatively low and stable incidence of COVID-19 cases.
CMS is calling for a "gradual transition," with providers coordinating with state and local public health officials, and accounting for the availability of personal protective equipment and other supplies, workforce availability, facility readiness, and testing capacity.
To get to Phase 1, states or regions need to pass gating criteria regarding symptoms, cases, and hospitals. However, CMS said recommendations are just that, and are not meant to be implemented by every state, county, or city right now. Ultimately, governors and local leaders will make decisions on whether re-openings are appropriate.
Emergency designations on care venues means that the now-empty, 185-bed hospital will treat only COVID-19 patients until the pandemic declaration has lifted.
Beaumont Hospital, Wayne "temporarily paused" this week in anticipation of a "second surge" of COVID-19 patients that the health system said could occur if social distancing restrictions are eased.
"Beaumont Hospital, Wayne is important to Beaumont Health and is not permanently closing. Rumors to that effect are false," the Royal Oak, Michigan-based health system said.
Wayne's "few remaining patients" were either discharged or transferred from the 185-bed, acute-care hospital this week, and staff were redeployed to other Beaumont hospitals or temporarily laid off.
Beaumont said the region was expecting a surge in COVID-19 patients two weeks ago and gained state approval to designate Wayne as a COVID-19-only hospital.
"Fortunately, the surge was more moderated, likely due to aggressive social distancing, the stay at home order and other factors mitigating the spread of the disease," Beaumont said.
However, Beaumont said, strict state designations on care venues means that the now-empty Wayne hospital will remain under the COVID-19-only status until the pandemic declaration has been lifted.
"This is in preparation for a second surge that could occur after the stay at home restrictions end," Beaumont said. "The pandemic remains very unpredictable. Beaumont Health is committed to responding to potential ongoing COVID-19 surges by relying upon our Wayne hospital and other resources."
"Beaumont is committed to reopening Beaumont, Wayne and making sure the services provided there both meet the community's needs and fit within our system’s overall strategic plan. However, we will only do that when it is safe to do so and when we have more clarity about the pandemic."
As of Friday afternoon, Michigan had reported 29,263 COVID-19 cases and 2,093 deaths.
Medicare's reimbursement for automated tests will increase from $51 to $100.
In an attempt to reduce lag times for COVID-19 diagnoses and get a better sense of the scope of the pandemic, Medicare said it will nearly double its payments for high-throughput commercial lab tests.
"CMS has made a critical move to ensure adequate reimbursement for advanced technology that can process a large volume of COVID-19 tests rapidly and accurately," CMS Administrator Seema Verma said. "This is an absolute game-changer for nursing homes, where risk of Coronavirus infection is high among our most vulnerable."
The higher $100 payment – an increase from $51 – will be paid to private sector labs, such as Roche, Hologic, Abbott and Cepheid, that have developed highly automated processes to increase testing capacity and achieve faster and more accurate results.
The high-throughput labs can process more than 200 tests each day.
A lack of testing kits and long delays in getting the results of COVID-19 tests were citied as a major reason for backups in hospital patient throughput in March, according to a study released this month by the Office of the Inspector General for the Department of Health and Human Services.
The scarcity of the tests, and the subsequent wait for results for patients and staff, which often took a week or longer, had a snowball effect on patient throughput, OIG said in its report.
MedPAC asks CMS not to use 2020 data to calculate baseline year spending for future benchmarks.
The Medicare Payment Advisory Commission is recommending that the Centers for Medicare & Medicaid Services scrap pandemic-skewed 2020 performance benchmarks for at-risk accountable care organizations.
"The COVID-19 public health emergency has likely affected—and will continue to affect, at least through 2020—Medicare spending in ways that are yet to be fully understood," MedPAC Chairman Francis J. Crosson, MD,said in a letter this week to CMS Administrator Seema Verma.
"This is particularly problematic for providers participating in ACOs, whose 2020 performance will be assessed using benchmarks established before the current emergency," Crosson said. "Given the dramatic shifts in care delivery that have occurred in 2020, attempting to adjust 2020 spending and benchmarks for COVID-19 will be impractical. It also may be inequitable."
Specifically, Crosson asked CMS to:
Not use 2020 data to determine ACO quality, bonuses and penalties; not use 2020 data to calculate baseline year spending for future benchmarks; and consider extending existing ACO agreement periods by one year.
Not use 2020 claims data to assign beneficiaries, because the use of telehealth could distort ACO assignment. Instead, MedPAC is recommending that CMS consider using 2019 and/or 2021 claims data to assign beneficiaries in 2021.
Provide an extension of the NextGen ACO model through 2023, which will give ACOs already in the model time to continue in the program without having to adapt to a new model during the pandemic.
Delay the start of the Center for Medicare & Medicaid Innovation Direct Contracting model, by at least one year, to give providers a change to understand the new model before committing to it.
NAACOS Objects
The MedPAC recommendations brought down the ire of the National Association of ACOs, which said "ignoring shared savings in 2020 would devastate Medicare ACO programs."
"In 2018, Medicare paid ACOs back roughly $900 million of the $1.7 billion they saved. ACOs used that money to pay for quality improvement programs, care coordinators, health IT, analytics and other infrastructure," NAACOS said.
"Without those funds, ACOs will no longer have resources to focus on improving quality and addressing chronic disease, which help improve patient care. The impact of the pandemic will play out differently from region to region and market to market. To gut the savings opportunity before the data are in is presumptuous at best."
Instead, NAACOS said, MedPAC should consider other options, such as holding at-risk ACOs harmless, allowing ACOs to forego less shared savings in exchange for less risk, or extending the dropout deadline to give ACOs the chance "to understand how COVID-19 will playout in the coming months.
"MedPAC has consistently underplayed the value ACOs bring to Medicare payment reform.," NAACOS said. "Let's hope CMS doesn't accept this advice that would have detrimental effects on Medicare's overall shift to value."
A poll released this week shows that 54% of ACOs in Medicare's Shared Savings Program would likely leave the program amid fears of getting stuck with massive financial losses to cover the cost of the COVID-19 pandemic.
The National Association of ACOs estimates that the COVID-19 pandemic could cost Medicare between $38.5 billion and $115.4 billionover the next year.
A separate study released last week by America's Health Insurance Plans estimated the cost of the pandemic for the nation's healthcare system at between $56 billion and $556 billion
Almost 80% of Medicare risk-bearing ACOs said they were "very concerned" about their financial performance this year.
More than half of accountable care organizations in Medicare's Shared Savings Program say they'll likely leave the program amid fears of getting stuck with massive financial losses to cover the cost of the COVID-19 pandemic.
That's according to a new online survey conducted this month by the National Association of Accountable Care Organizations, which asked 2020 Medicare Shared Savings Program and Next Generation ACO Model participants across the nation to gauge their experience in handling the ongoing pandemic.
Almost 80% of the 225 ACOs that responded to the five-question survey, conducted between April 3-8, said they were "very concerned" about their financial performance this year.
Further, 56% of respondents they would leave the payment model, including 21% who said they were "very likely," 14% who were "likely" and 21% who said they were "somewhat likely."
"When ACOs made a commitment to assume risk, they didn't expect they'd be handling the risk of a global pandemic," said NAACOS President and CEO Clif Gaus.
"Rather than be forced to pay enormous losses resulting from the pandemic, these groups of providers may sadly quit the program, which they can do without penalty by May 31," he said. "Medicare's decade-long effort to change how we pay for health care to better reward quality and outcomes may be lost unless Washington acts quickly to throw these providers a lifeline."
In mid-March, NAACOS cosigned a letter with the American Hospital Association, the American College of Physicians, and seven other stakeholder organizations, askingthe Centers for Medicare & Medicaid Services to hold harmless Shared Savings participants from performance-related penalties for 2020. CMS has yet to respond.
"CMS has yet to adequately mitigate the costs and disruptions of the pandemic," Gaus said. "ACOs are telling us that they will leave the program unless there is protection from the losses of the pandemic, and it would be a tragedy for millions of Medicare beneficiaries to lose the access to care coordination and quality improvement that ACOs offer."
NAACOS estimates that the COVID-19 pandemic could cost Medicare between $38.5 billion and $115.4 billionover the next year. A separate study released last week by America's Health Insurance Plans estimated the cost of the pandemic for the nation's healthcare system at between $56 billion and $556 billion
Because of the pandemic, about 25% of ACOs said they expect spending to increase by more than 10%, another 25% say they expected spending to increase between 5% and 10%, while 10% said they expect spending to remain the same or fall, and 37% said they "don’t know."
The wide variance in cost estimates depends upon how many people are infected by the virus, the availability of testing, and compliance with preventative measures such as social distancing.
The federal government is making available more than $100 billion to cover costs for the nation's hospitals under the $2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act.
That $100 billion averages about $108,000 per hospital bed. Is it enough?
Moody's Investors Service doesn’t think so, particularly if the pandemic extends for months. The rating agency called the federal aid "extraordinary" but also "unlikely to fully cover the material revenue decline facing hospitals as a result of the pandemic."
Moody's Vice President Dan Steingart said the $100 billion "provides some relief to hospitals by supporting their operations and providing access to critical supplies."
"However, it is unlikely to fully compensate the sector for the two main financial challenges facing providers as a result of the coronavirus outbreak," he said.
"The first is a material decline in revenue and cash flow as profitable elective surgeries, procedures and other services are postponed to preserve resources and avoid spreading the virus," he said. "The second is difficulty curbing expenses as surge preparation costs offset any expense reductions from postponed or canceled services."
Citing anecdotal evidence, Moody's estimates that postponed elective services will reduce hospital revenues by as much as 40% per month and strain cash flow. These reductions are occurring, Moody's said, even at hospitals and areas of the country that have not seen that many COVID-19 patients.
That's because many states have suspended nonessential hospital services indefinitely, creating uncertainty for hospitals about when they can resume providing these money-making elective services, Moody's said.
Up to $556B Over 2 Years
A study released Wednesday by America's Health Insurance Plans offers a canyon-wide estimate of the pandemic's cost for commercial health plans, ranging from $56 billion to $556 billion over the next two years.
The wide cost variance in the study, conducted by Wakely Consulting Group, depends upon how many people are infected by the virus, the availability of testing, and compliance with preventative measures such as social distancing.
Assuming a 20% infection rate among the study population, for example, Wakely estimates that more than 50 million people will become infected, with at least 5.5 million requiring hospitalization – of which 1.3 million will require intensive care, with average ICU costs per patient exceeding $30,000.
"This new data provides us with better insight to help policymakers, private sector leaders, and other stakeholders understand the investments required to successfully care for every American subjected to this life-threatening virus," AHIP President and CEO Matt Eyles said.
Wakely estimates enrollee cost sharing would average approximately 14%-18% of annual allowed costs and would range from $10 billion to $78 billion. That estimate does not take into account decisions by some payers to waive out-of-pocket costs for COVID-19 testing and treatment.
Treating the Uninsured
A study this week by Kaiser Family Foundation estimates that providing care for up to two million uninsured Americans infected with the virus could cost between $13 billion and $42 billion, consuming more than 40% of the CARES Act funding for hospitals.
The variance of the estimate is owing to uncertainty about how may people will become infected.
"Covering COVID-19 hospital costs for patients who are uninsured would give them peace of mind that their inpatient costs will be covered," KFF President and CEO Drew Altman said. "While the details are spotty, uninsured patients could still be on the hook if they test negative for coronavirus and if they receive care outside hospitals."
Altman said the KFF analysis raises questions about how the federal government will help offset the bills of uninsured patients, and whether it reimburses physicians who treat uninsured COVID-19 patients.
The payment advances, essentially loans that will have to be paid back, were distributed under CMS's Accelerated and Advance Payment Program.
The Centers for Medicare & Medicaid Services said it used a streamlined approval process this week to distribute $34 billion in Medicare advanced payments to 17,000 providers and suppliers battling COVID-19
The payment advances – essentially loans that will have to be paid back – were distributed under CMS's Accelerated and Advance Payment Program, which is funded by the Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B) trust funds, which are the same fund used to pay Medicare claims.
The $34 billion outlay is separate from the $100 billion provided in the Coronavirus Aid, Relief, and Economic Security Act, which distributes funds that do not need to be repaid.
CMS Administrator Seema Verma said the new streamlined process reduced the processing time from three or four weeks to four to six days.
"Healthcare providers are making massive financial sacrifices to care for the influx of coronavirus patients," Verma said in a media release.
"Many are rightly complying with federal recommendations to delay non-essential elective surgeries to preserve capacity and personal protective equipment," she said. "They shouldn't be penalized for doing the right thing."
CMS this month has received more than 25,000 requests from providers and suppliers for expedited payments and has approved more 17,000 requests in the past week.
Before the pandemic, CMS had approved about 100 requests for advanced payments in the past five years, mostly for natural disasters such as hurricanes and tornadoes.
"Amid a public health storm of unprecedented fury, these payments are helping providers and suppliers – so critical to defeating this terrible virus – stay afloat," Verma said.
The expedited payments are available to Part A providers, including hospitals, and Part B suppliers, including doctors, non-physician practitioners and durable medical equipment suppliers.
Most of the stakeholders can get an advance on three months of their Medicare reimbursements, and some providers can get up to six months.
CMS will apply claims payments to offset the accelerated/advance payments four months after the pay-out.
Most hospitals will have up to one year from the date the accelerated payment was made to repay the balance. Other Part A providers and Part B suppliers will have up to 210 days to complete repayments.
Trump disparaged the report at a Monday press availability, where he baselessly suggested it was politically motivated.
The American Hospital Association is defending federal auditors who've drawn the wrath of President Donald Trump for a scathing new report detailing hospital disarray and a slapdash federal response to the coronavirus pandemic.
The Department of Health and Human Services' Office of the Inspector General conducted a telephone survey on March 23-27 of 323 randomly selected hospitals across the nation. The survey found widespread shortages of vital medical equipment and a backlog of COVID-19 testing that was creating a bottleneck in patient throughput.
The report also detailed confusing and conflicting guidance given to hospitals from various federal agencies.
AHA President and CEO Rick Pollack called the OIG's report "important and timely" and said it "accurately captures the crisis that hospitals and health systems, physicians and nurses on the front lines face of not having enough personal protective equipment, medical supplies and equipment in their fight against COVID-19."
"The OIG report also highlights the tremendous strain – both physical and emotional – that this pandemic is putting on the shoulders of heroic physicians, nurses and other caregivers and their families, and why they need our support during this critical time," Pollack said.
Trump disparaged the report at a Monday press availability, where he baselessly suggested it was politically motivated.
"It's just wrong. Did I hear the word 'inspector general,' really? It's wrong," Trump said, adding later, "Well where did he come from, the inspector general? What's his name? So, give me the name of the inspector general. Could politics be entered into that?"
Trump did not provide any evidence to affirm his suggestions that the report was incorrect or politically motivated. HHS OIG is an independent arm of the department, that is led by Christi Grimm, a woman, who has worked for the office since 1999. The auditors who wrote the report have served Republican and Democratic administrations.
He also deflected blame for a shortage of COVID-19 testing kits and the backlog of test results away from the federal response, saying "states are supposed to be doing testing. Hospitals are supposed to be doing testing."
"We're the federal government. We're not supposed to be standing on street corners doing testing," he said. "They go to doctors. They go to hospitals."
Trump continued to disparage the auditors and question the motivation for the report in a tweet on Tueday.
"Why didn’t the I.G., who spent 8 years with the Obama Administration (Did she Report on the failed H1N1 Swine Flu debacle where 17,000 people died?), want to talk to the Admirals, Generals, V.P. & others in charge, before doing her report. Another Fake Dossier!"
Assistant Secretary for Health Adm. Brett Giroir, who attended the Monday briefing, said he doesn’t know the inspector general, but said the auditors should have come forward with their dire findings earlier.
"I'll tell you one thing I have a problem with: If there was such a problem that she knew about or he knew about on March 23 and 24, why did I find out about the test from them on the news media at 8 o'clock this morning," he said. "But that's a discussion for the future."
In defending the auditors, Pollack was careful not to dispute Trump directly, and even praised "certain agencies within the Administration (that) have responded to many of our concerns, particularly CMS, which has cleared regulatory red tape to allow hospitals the flexibility to take quick and decisive action in this rapidly changing situation to better care for patients."
Also Tuesday, without explanation, Trump removed Gerald Fine, a careeer employee, as the federal watchdog over the $2 trillion coronavirus emergency funding package, and named the the EPA inspector general as a temporary replacement.
An inability to quickly diagnose COVID-19 patients in a timely manner meant that hospitals had to assume that all symptomatic patients and staff were infected until results showed otherwise.
A shortage of COVID-19 testing kits, and lengthy waits for test results were identified as root problems that created bottlenecks for the nation's hospitals as the coronavirus pandemic gained momentum late last month, a new federal audit shows.
The scarcity of the tests, and the subsequent wait for results for patients and staff, which often took a week or longer, had a snowball effect on patient throughput, according to a survey and analysis by the Department of Health and Human Services' Office of the Inspector General.
The inability to quickly diagnose COVID-19 patients in a timely manner meant that hospitals had to assume that all symptomatic patients and staff were infected until results showed otherwise.
That delay sideline staff suspected of contracting the virus, who were quarantined; which strained remaining staff; kept patients in acute care hospital beds longer, and delayed transfer to nursing homes or other post-acute care settings until a diagnosis could be verified; directed more scarce resources, such as personal protective equipment, for patients in diagnostic limbo; which also made it harder for hospitals to free up bed capacity in anticipation of a surge in new patients, the survey found.
"Sitting with 60 patients with presumed positives in our hospital isn't healthy for anybody," one administrator told OIG in its March 23-27 telephone survey of 323 randomly selected hospitals across the nation.
"Hospitals reported that their most significant challenges centered on testing and caring for patients with known or suspected COVID-19 and keeping staff safe" OIG said. "Hospitals said that severe shortages of testing supplies and extended waits for test results limited hospitals' ability to monitor the health of patients and staff."
"They also reported that widespread shortages of personal protective equipment (PPE) put staff and patients at risk. In addition, hospitals said that they were not always able to maintain adequate staffing levels or to offer staff adequate support," OIG said.
"Administrators also expressed concern that fear and uncertainty were taking an emotional toll on staff, both professionally and personally," OIG said.
'We are all competing for the same items.'
The hospitals described a mad scramble to acquire testing kits, PPE, no-touch infrared thermometers, ventilators, and other supplies, and often found themselves competing with other hospitals and the general public for the scare resources. "We are all competing for the same items and there are only so many people on the other end of the supply chain," one administrator told auditors.
Hospitals also complained of little coordination or oversight – and sometimes conflicting guidance – from the federal government.
"Hospitals often stated that they were in competition with other providers for limited supplies, and that government intervention and coordination could help reconcile this problem at the national level to provide equitable distribution of supplies throughout the country," OIG said.
Another administrator told OIG that the hospital normally used 200 masks daily, but was now using 2,000 per day. Another hospital administrator said the "fear factor" prompted all staff to wear masks, not just those clinicians treating COVID-19 patients. Another administrator reported that a box of 2,500 N95 masks obtained from a state strategic reserve was unusable because the elastic straps had dry-rotted. Another administrator said that masks that usually cost 50 cents now cost $6 apiece.
When supplies could not be found and staffing shortages threatened care, OIG said hospitals improvised "a range of strategies to maintain or expand their capacity to care for patients and to keep staff safe," including "sometimes un-vetted, and non-traditional sources of supplies and medical equipment."
That included reusing disposable PPE, using homemade or construction face masks, and "jerry-rigging" anesthesia machines as ventilators.
To alleviate clinician shortages, hospitals trained anesthesiologists, hospitalists, and nurses to operate ventilators.
To support staff, hospitals provided childcare, laundry and grocery services, and hotel rooms to promote separation from elderly family members.
To manage patient flow and hospital capacity, some hospitals provided outpatient or telehealth care for patients with less-severe symptoms, and set up alternate care venues at fairgrounds, college dorms, and even empty jails.
On top of all this, hospital administrators reported that the increased costs of care, coupled with the decreased revenues from the postponement of lucrative elective surgeries and other procedures, posed "a threat to their financial viability," OIG said.
The administrators who spoke with OIG frequently expressed concerns about ongoing staffing and equipment shortages if the pandemic stretches into the summer and beyond.
"Unlike a disaster where the surge is over in a matter of days, with this situation we have to prepare for this to last many months," one administrator said. "We have to scale up in equipment and staff, and prepare for this to last a long, long time. This is very challenging for staff."
Since the survey was taken, OIG noted that the federal government has taken steps to address the shortages and concerns raised by hospitals, which includes a $110 billion aid package passed by Congress in late March.
The collaborative was created under a coronavirus emergency response initiative led by FEMA and HHS.
The Department of Justice says it will not launch an antitrust challenge against five medical supply companies collaborating to expedite the manufacturing and delivery of personal protective equipment and other coronavirus-related supplies.
The companies – McKesson Corp., Owens & Minor Inc., Cardinal Health Inc., Medline Industries Inc., and Henry Schein Inc. – are working collaboratively as Medical Supplies Distributors under a coronavirus emergency response initiative from the Federal Emergency Management Agency (FEMA) and the Department of Health and Human Services.
"These Medical Supplies Distributors should be applauded for their efforts to both assist the United States in responding to the COVID-19 pandemic and stay within the bounds of antitrust law," Assistant U.S. Attorney General Makan Delrahim said in a media release.
Medical Supplies Distributors has developed Project Airbridge, which works with FEMA and HHS and logistics companies to expedite and airlift PPE and other supplies and medications to pandemic "hotspots" across the country.
Medical Supplies Distributors submitted their collaborative for DOJ review on March 24. DOJ approved the request on Saturday.
