The new coronavirus doesn't discriminate. But physicians in public health and on the front lines said they already can see the emergence of familiar patterns of racial and economic bias in the response to the pandemic.
In one analysis, it appears doctors may be less likely to refer African Americans for testing when they show up for care with signs of infection.
The biotech data firm Rubix Life Sciences, based in Lawrence, Massachusetts, reviewed recent billing information in several states and found that an African American with symptoms like cough and fever was less likely to be given one of the scarce coronavirus tests.
Delays in diagnosis and treatment can be harmful, especially for racial or ethnic minority groups that have higher rates of certain diseases, such as diabetes, high blood pressure and kidney disease. Those chronic illnesses can lead to more severe cases of COVID-19.
In Nashville, three drive-thru testing centers sat empty for weeks because the city couldn't acquire the necessary testing equipment and protective gear like gloves and masks. All of them are in diverse neighborhoods. One is on the campus of Meharry Medical College — a historically black institution.
"There's no doubt that some institutions have the resources and clout to maybe get these materials faster and easier," said Dr. James Hildreth, president of Meharry and an infectious disease specialist.
His school is in the heart of Nashville, where there were no screening centers until this week.
Most of the testing in the region took place at walk-in clinics managed by Vanderbilt University Medical Center, and those are primarily located in historically white areas like Belle Meade and Brentwood, Tennessee.
Hildreth said he has observed no overt bias on the part of health care workers and doesn't suspect any. But he said the distribution of testing sites shows a disparity in access to medical care that has long persisted.
'I Pray I'm Wrong'
If anyone should be prioritized, Hildreth said, it's minorities, whose communities already have more risk factors like diabetes and lung disease.
"We cannot afford to not have the resources to be distributed where they need to be," he said. "Otherwise, the virus will do great harm in some communities and less in others."
Data from late March show the location of coronavirus testing sites in Shelby County, Tennessee. It reveals that most screening is happening in the predominantly white and well-off Memphis suburbs, not the majority-black, lower-income neighborhoods.
The Rev. Earle Fisher has been warning his African American congregationthat the response to the pandemic may fall along the city's usual divides.
"I pray I'm wrong," Fisher said. "I think we're about to witness an inequitable distribution of the medical resources, too."
Around the nation, leaders are taking note of disproportionate health outcomes. In Wisconsin, African Americans accounted for all of Milwaukee County's first eight fatalities.
Gov. Tony Evers said he wants to know why black communities seem to be hit so hard. "It's a crisis within a crisis," the Democrat said in a video statement.
The Centers for Disease Control and Prevention is also on the ground on the north side of Milwaukee, as well as several other hot spots, looking into the outbreak in black neighborhoods.
Nationwide, it's difficult to know how minority populations are faring because the CDC isn't reporting data on race.
A few states are releasing more demographic data, but it's incomplete. Virginia is reporting race, yet the state's report is missing that information for two-thirds of confirmed cases.
Dr. Georges Benjamin, executive director of the American Public Health Association, has been pushing health officials to start monitoring race and income in the response to COVID-19.
"We want people to collect the data in an organized, professional, scientific manner and show who's getting it [appropriate care] and who's not getting it," Benjamin said. "Recognize that we very well may see these health inequities."
The Usual Disparities
Until he's convinced otherwise, Benjamin said he assumes the usual disparities are at play.
"Experience has taught all of us that if you're poor, if you're of color, you're going to get services second," he said.
The subjectivity of coronavirus symptoms is what worries Dr. Ebony Hilton the most.
"The person comes in, they're complaining of chest pain, they're complaining of shortness of breath, they have a cough — I can't quantify that," she said.
Hilton is an anesthesiologist at the University of Virginia Medical Center who has been raising concerns. She sees problems across the board, from the way social media is being used as a primary way of educating the public to the widespread reliance on drive-thru testing.
The first requires an internet connection. The second, a car.
Hilton said the country can't afford to overlook race, even during a swiftly moving pandemic.
"If you don't get a test, if you die, you're not going to be listed as dying from COVID," she said. "You're just going to be dead."
This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.
An initial study found cardiac damage in as many as 1 in 5 patients, leading to heart failure and death even among those who show no signs of respiratory distress.
This article was first published on Monday, April 6, 2020 inKaiser Health News.
While the focus of the COVID-19 pandemic has been on respiratory problems and securing enough ventilators, doctors on the front lines are grappling with a new medical mystery.
In addition to lung damage, many COVID-19 patients are also developing heart problems — and dying of cardiac arrest.
As more data comes in from China and Italy, as well as Washington state and New York, more cardiac experts are coming to believe the COVID-19 virus can infect the heart muscle. An initial study found cardiac damage in as many as 1 in 5 patients, leading to heart failure and death even among those who show no signs of respiratory distress.
That could change the way doctors and hospitals need to think about patients, particularly in the early stages of illness. It also could open up a second front in the battle against the COVID-19 pandemic, with a need for new precautions in people with preexisting heart problems, new demands for equipment and, ultimately, new treatment plans for damaged hearts among those who survive.
"It's extremely important to answer the question: Is their heart being affected by the virus and can we do something about it?" said Dr. Ulrich Jorde, the head of heart failure, cardiac transplantation and mechanical circulatory support for the Montefiore Health System in New York City. "This may save many lives in the end."
Virus Or Illness?
The question of whether the emerging heart problems are caused by the virus itself or are a byproduct of the body's reaction to it has become one of the critical unknowns facing doctors as they race to understand the novel illness. Determining how the virus affects the heart is difficult, in part, because severe illness alone can influence heart health.
"Someone who's dying from a bad pneumonia will ultimately die because the heart stops," said Dr. Robert Bonow, a professor of cardiology at the Northwestern University Feinberg School of Medicine and editor of the medical journal JAMA Cardiology. "You can't get enough oxygen into your system and things go haywire."
But Bonow and many other cardiac specialists believe a COVID-19 infection could lead to damage to the heart in four or five ways. Some patients, they say, might be affected by more than one of those pathways at once.
Doctors have long known that any serious medical event, even something as straightforward as hip surgery, can create enough stress to damage the heart. Moreover, a condition like pneumonia can cause widespread inflammation in the body. That, in turn, can lead to plaque in arteries becoming unstable, causing heart attacks. Inflammation can also cause a condition known as myocarditis, which can lead to the weakening of the heart muscle and, ultimately, heart failure.
But Bonow said the damage observed in COVID-19 patients could be from the virus directly infecting the heart muscle. Initial research suggests the coronavirus attaches to certain receptors in the lungs, and those same receptors are found in heart muscle as well.
Initial Data From China
In March, doctors from China published two studies that gave the first glimpse at how prevalent cardiac problems were among patients with COVID-19 illness. The larger of the two studies looked at 416 hospitalized patients. The researchers found that 19% showed signs of heart damage.And those who did were significantly more likely to die: 51% of those with heart damage died versus 4.5% who did not have it.
Patients who had heart disease before their coronavirus infections were much more likely to show heart damage afterward. But some patients with no previous heart disease also showed signs of cardiac damage. In fact, patients with no preexisting heart conditions who incurred heart damage during their infection were more likely to die than patients with previous heart disease but no COVID-19-induced cardiac damage.
It's unclear why some patients experience more cardiac effects than others. Bonow said that could be due to a genetic predisposition or it could be because they're exposed to higher viral loads.
Those uncertainties underscore the need for closer monitoring of cardiac markers in COVID-19 patients, Jorde said. If doctors in New York, Washington state and other hot spots can start to tease out how the virus is affecting the heart, they may be able to provide a risk score or other guidance to help clinicians manage COVID-19 patients in other parts of the country.
"We have to assume, maybe, that the virus affects the heart directly," Jorde said. "But it's essential to find out."
Facing Obstacles
Gathering the data to do so amid the crisis, however, can be difficult. Ideally, doctors would take biopsies of the heart to determine whether the heart muscle is infected with the virus.
But COVID-19 patients are often so sick it's difficult for them to undergo invasive procedures. And more testing could expose additional health care workers to the virus. Many hospitals aren't using electrocardiograms on patients in isolation to avoid bringing additional staff into the room and using up limited masks or other protective equipment.
Still, Dr. Sahil Parikh, an interventional cardiologist at Columbia University Irving Medical Center in New York City, said hospitals are making a concerted effort to order the tests needed and to enter findings in medical records so they can sort out what's going on with the heart.
"We all recognize that because we're at the leading edge, for better or for worse, we need to try to compile information and use it to help advance the field," he said.
Indeed, despite the surge in patients, doctors continue to gather data, compile trends and publish their findings in near real time. Parikh and several colleagues recently penned a compilationof what's known about cardiac complications of COVID-19, making the article available online immediately and adding new findings before the article comes out in print.
Cardiologists in New York, New Jersey and Connecticut are sharing the latest COVID-19 information through a WhatsApp group that has at least 150 members. And even as New York hospitals are operating under crisis conditions, doctors are testing new drugs and treatments in clinical trials to ensure that what they have learned about the coronavirus can be shared elsewhere with scientific validity.
That work has already resulted in changes in the way hospitals deal with the cardiac implications of COVID-19. Doctors have found that the infection can mimic a heart attack. They have taken patients to the cardiac catheterization lab to clear a suspected blockage, only to find the patient wasn't really experiencing a heart attack but had COVID-19.
For years, hospitals have rushed suspected heart attack patients directly to the catheterization lab, bypassing the emergency room, in an effort to shorten the time from when the patient enters the door to when doctors can clear the blockage with a balloon. Door-to-balloon time had become an important measure of how well hospitals treat heart attacks.
"We're taking a step back from that now and thinking about having patients brought to the emergency department so they can get evaluated briefly, so that we could determine: Is this somebody who's really at high risk for COVID-19?" Parikh said. "And is this manifestation that we're calling a heart attack really a heart attack?"
New protocols now include bringing in a cardiologist and getting an EKG or an ultrasound to confirm a blockage.
"We're doing that in large measure to protect the patient from what would be an otherwise unnecessary procedure," Parikh said, "But also to help us decide which sort of level of personal protective equipment we would employ in the cath lab."
Sorting out how the virus affects the heart should help doctors determine which therapies to pursue to keep patients alive.
Jorde said that after COVID-19 patients recover, they could have long-term effects from such heart damage. But, he said, treatments exist for various forms of heart damage that should be effective once the viral infection has cleared.
Still, that could require another wave of widespread health care demands after the pandemic has calmed.
As city leaders across the country scramble to find space for the expected surge of COVID-19 patients, some are looking at a seemingly obvious choice: former hospital buildings, sitting empty, right downtown.
This article was first published on Thursday, April 2, 2020 in Kaiser Health News.
As city leaders across the country scramble to find space for the expected surge of COVID-19 patients, some are looking at a seemingly obvious choice: former hospital buildings, sitting empty, right downtown.
In Philadelphia, New Orleans, and Los Angeles, where hospitalizations from COVID-19 increase each day, shuttered hospitals that once served the city's poor and uninsured sit at the center of a public health crisis that begs for exactly what they can offer: more space. But reopening closed hospitals, even in a public health emergency, is difficult.
Philadelphia, the largest city in America with no public hospital, is also thepoorest. There, Hahnemann University Hospital shut its doors in September after its owner, Philadelphia Academic Health System, declared bankruptcy. While not public, the 496-bed safety-net hospital mainly treated patients on public insurance. Philadelphia Mayor Jim Kenney began talks with the building's owner, California-based investment banker Joel Freedman, as soon as his administration saw projections that the demand for hospital beds during the pandemic would outpace the city's capacity. Not long after negotiations started, city officials announced the talks were going badly.
"Mr. Freedman was difficult to work with at times when he was the owner of the hospital, and he is still difficult to work with as the owner of the shuttered hospital," said Brian Abernathy, who is Philadelphia's managing director and heading the city's COVID-19 response.
In New Orleans, where the soaring COVID-19 infection rate is disproportionately high compared with its population, Charity Hospital sits vacant in the middle of town. The former public hospital never reopened after Hurricane Katrina in 2005. The Louisiana State University System, which owns the building, incorporated Charity Hospital into the city's new medical center, but the original building remains vacant. Instead of using it during the pandemic, the New Orleans Convention Center is being convertedto a "step-down" facility with the capacity to treat up to 2,000 patients after they no longer need critical care.
Elsewhere, city governments have struck deals with the owners of empty hospital buildings to lease their space. At St. Vincent Medical Center in Los Angeles, the city is paying $236 per night per bed, for a total of $2.6 million each month.
In Philadelphia, Freedman offered the Hahnemann building to the city for $27 per bed per night, plus taxes, maintenance and insurance, which the city would pay directly. All told, that added up to just over $900,000 per month.
"I think he is looking at how to turn an asset that is earning no revenue into an asset that earns some revenue, and isn't thinking through what the impacts are on public health," Abernathy said of Freedman. "I think he's looking at this as a business transaction rather than providing an imminent and important aid to the city and our residents."
This isn't the first time Freedman has come under fire by Philadelphians for his handling of the hospital. Its closure sparked protests from city officials, health care unions, and even presidential hopeful Bernie Sanders. Critics speculated that Freedman, whose private equity firm bought the struggling hospital in 2018, didn't try in earnest to save it and planned to flip it for its valuable downtown real estate. Notably, Hahnemann's real estate was parsed out into a separate company, Broad Street Healthcare Properties, also owned by Freedman, and not included in Philadelphia Academic Health System's Chapter 11 bankruptcy petition.
A representative for Freedman said the building has an interested buyer, and that is one reason Broad Street Healthcare will not let the city use the building at cost.
"We're offering this facility because of the public benefit in a health crisis, but it comes at a cost to the property owner," said Broad Street representative Sam Singer.
As urban hospitals have struggled in recent years, it's become increasingly common for private equity to get involved: Big firms buy struggling medical centers with the promise of financial support and to improve their operations and business strategy. When things go right, the business succeeds, and the private equity firm sells it in a public offering or to another bidder for more than it paid.
In other cases, though, the firms load companies up with debt, take dividends out for themselves, sell off valuable real estate and charge fees and high-interest loans, leaving a company in a much weaker position than it would have been otherwise, and often on the verge of bankruptcy.
"The house never loses," said Eileen Appelbaum, co-director at the Center for Economic and Policy Research. "The private equity firm makes money whether the company succeeds or it doesn't."
For instance, Steward Health Care was able to expand from its base in Massachusetts to a 36-hospital network nationwide with backing from Cerberus Capital Management. Now, said Appelbaum, the chain of community hospitals is stuck paying rent to a separate real estate company, on all its properties, while also struggling to stay in the black. The network announced last weekit would furlough non-clinical workers across nine states because the requirement to cancel elective surgeries caused too great a financial strain.
Freedman's private equity firm is called Paladin Healthcare, and it has previously bought and managed hospitals in California and Washington, D.C., where it helped the struggling Howard University Hospital out of the red. Paladin then sold the hospital to Adventist HealthCare last summer.
Urban hospitals like Hahnemann have struggled to stay afloat in recent years, in part due to their lack of privately insured patients. Hospitals often finance the care of uninsured patients or those on Medicaid by treating those with private insurance, which reimburses the hospitals faster and at a higher rate. At Hahnemann, two-thirds of patients were on Medicaid or Medicare. While a financially struggling public or nonprofit hospital might continue serving a poorer community, a for-profit hospital has different incentives, said Vickie Williams, a former law professor for Gonzaga University.
"If your urban hospital is purchased by a for-profit company and it doesn't perform sufficiently, they don't have the same necessarily mission-driven directives to keep that hospital functioning for the good of the community at a loss," said Williams, who is now senior counsel for CommonSpirit Health in Tacoma, Washington.
Freedman has said that he tried to sell the Hahnemann property to a nonprofit and requested money from the city and state to keep it open, but neither option worked.
Following news that Philadelphia had abandoned negotiations with Freedman, calls to seize the property in order to save lives came pouring in, including from elected officials.
"Eminent Domain was created for situations like #Hahnemann," City Council member Helen Gym wrote on Twitter. "This is a public health emergency and Philly is the largest city in the nation WITHOUT a public hospital. We cannot allow unconscionable greed to get in the way of saving lives. Eminent domain this property." Legal experts say the lengthy process of eminent domain and the requirement to pay the owner fair market value for the building make it an unlikely mechanism for an instance like this.
But in public health emergencies, local, state and federal governments do have broad authority to commandeer private property, such as hotels, convention centers, university dormitories or even defunct hospitals for disaster response. Williams, whose research has focused on preserving hospital infrastructure during a pandemic, said that so far in the United States, that hasn't had to happen ― at least not in the traditional sense.
In Pennsylvania, the governor's emergency declaration gives him the authority to "commandeer or utilize any private, public or quasi-public property if necessary to cope with the disaster emergency." A health department representative said all options remain on the table in the event that the city's hospital bed capacity is overrun.
In the interim, the mayor made a deal with Temple University to use its basketball arena, which would have the capacity to treat 250 non-critical patients, at no cost to the city.
This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.
[Correction: This article was revised at 5:30 p.m. ET on April 2, 2020, to clarify Steward Health Care's real estate situation.]
California's hospitals thought they were ready for the next big disaster.
They've retrofitted their buildings to withstand a major earthquake and whisked patients out of danger during deadly wildfires. They've kept patients alive with backup generators amid sweeping power shutoffs and trained their staff to thwart would-be shooters.
But nothing has prepared them for a crisis of the magnitude facing hospitals today.
"We're in a battle with an unseen enemy, and we have to be fully mobilized in a way that's never been seen in our careers," said Dr. Stephen Parodi, an infectious disease expert for Kaiser Permanente in California. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)
As California enters the most critical period in the state's battle against COVID-19, the state's 416 hospitals — big and small, public and private — are scrambling to build the capacity needed for an onslaught of critically ill patients.
Hospitals from Los Angeles to San Jose are already seeing a steady increase in patients infected by the virus, and so far, hospital officials say they have enough space to treat them. But they also issued a dire warning: What happens over the next four to six weeks will determine whether the experience of California overall looks more like that of New York, which has seen an explosion of hospitalizations and deaths, or like that of the San Francisco Bay Area, which has so far managed to prevent a major spike in new infections, hospitalizations and death.
Some of their preparations share common themes: Postpone elective surgeries. Make greater use of telemedicine to limit face-to-face contact. Erect tents outside to care for less critical patients. Add beds — hospital by hospital, a few dozen at a time — to spaces like cafeterias, operating rooms and decommissioned wings.
But by necessity — because of shortages of testing, ventilators, personal protective equipment and even doctors and nurses — they're also trying creative and sometimes untried strategies to bolster their readiness and increase their capacity.
In San Diego, hospitals may use college dormitories as alternative care sites. A large public hospital in Los Angeles is turning to 3D printing to manufacture ventilator parts. And in hard-hit Santa Clara County, with a population of nearly 2 million, public and private hospitals have joined forces to alleviate pressure on local hospitals by caring for patients at the Santa Clara Convention Center.
Yet some hospitals acknowledge that, despite their efforts, they may end up having to park patients in hallways.
"The need in this pandemic is so different and so extraordinary and so big that a hospital's typical surge plan will be insufficient for what we're dealing with in this state and across the nation," said Carmela Coyle, president and CEO of the California Hospital Association.
Across the U.S., more than 213,000 cases of COVID-19 have been confirmed, and at least 4,750 people have died. California accounts for more than 9,400 cases and at least 199 deaths.
Health officials and hospital administrators are singling out April as the most consequential month in California's effort to combat a steep increase in new infections. State Health and Human Services Secretary Mark Ghaly said Wednesday that the number of hospitalizations is expected to peak in mid-May.
Gov. Gavin Newsom said there were 1,855 COVID-19 cases in hospitals Wednesday, a number that had tripled in six days, and 774 patients in critical care. By mid-May, the number of critical care patients is expected to climb to 27,000, he said.
Newsom said the state needs nearly 70,000 more hospital beds, bringing its overall capacity to more than 140,000 — both inside hospitals and also at alternative care sites like convention centers. The state also needs 10,000 more ventilators than it normally has to aid the crush of patients needing help to breathe, he said, and so far has acquired fewer than half.
Newsom and state health officials worked with the Trump administration to bring a naval hospital ship to the Port of Los Angeles, where it is already treating patients not infected with the novel coronavirus. The state is working with the Army Corps of Engineers to deploy eight mobile field hospitals, including one in Santa Clara County. And it is bringing hospitals back online that were shuttered or slated to close, including one each in Daly City, Los Angeles, Long Beach and Costa Mesa.
The governor is also drafting a plan to make greater use of hotels and motels and nursing homes to house patients, if needed.
But the size of the surge that hits hospitals depends on how well the public follows social distancing and stay-at-home orders, said Newsom and hospital administrators. "This is not just about health care providers caring for the sick," said Dr. Steve Lockhart, the chief medical officer of Sutter Health, which has 22 hospitals across Northern California.
While hospitals welcomed the state assistance, they're also undertaking dramatic measures to prepare on their own.
"I'm genuinely very worried, and it scares me that so many people are still out there doing business as usual," said Chris Van Gorder, CEO of Scripps Health, a system with five major hospitals in San Diego County. "It wouldn't take a lot to overwhelm us."
Internal projections show the hospital system could need 8,000 beds by June, he said. It has 1,200.
In addition to taking precautions to protect its health care workers — such as using baby monitors to observe patients without risking infection — it is working with area colleges to use dorm rooms as hospital rooms for patients with mild cases of COVID-19, among other efforts, he said.
"Honestly, I think we should have been better prepared than we are," Van Gorder said. "But hospitals cannot take on this burden themselves."
Van Gorder and other hospital administrators say a continued shortage of COVID-19 tests has hampered their response — because they still don't know exactly which patients have the virus — as has the chronic underfunding of public health infrastructure.
Kaiser Permanente wants to double the capacity of its 36 California hospitals, Parodi said. It is also working with the garment industry to manufacture face masks, and eyeing hotel rooms for less critical patients.
Harbor-UCLA Medical Center, a 425-bed safety-net hospital in Los Angeles, is working to increase its capacity by 200%, said Dr. Anish Mahajan, the hospital's chief medical officer.
Harbor-UCLA is using 3D printers to produce ventilator piping equipped to serve two patients per machine. And in March it transformed a new emergency wing into an intensive care unit for COVID-19 patients.
"This was a shocking thing to do," Mahajan said of the unprecedented move to create extra space.
He said some measures are untested, but hospitals across the state are facing extreme pressure to do whatever they can to meet their greatest needs.
In March, Stanford Hospital in the San Francisco Bay Area launched a massive telemedicine overhaul of its emergency department to reduce the number of employees who interact with patients in person. This is the first time the hospital has used telemedicine like this, said Dr. Ryan Ribeira, an emergency physician who spearheaded the project.
Stanford also did some soul-searching, thinking about which of its staff might be at highest risk if they catch COVID-19, and has assigned them to parts of the hospital with no coronavirus patients or areas dedicated to telemedicine. "These are people that we might have otherwise had to drop off the schedule," Ribeira said.
Nearby, several San Francisco hospitals that were previously competitors have joined forces to create a dedicated COVID-19 floor at Saint Francis Memorial Hospital with four dozen critical care beds.
The city currently has 1,300 beds, including 200 ICU beds. If the number of patients surges as it has in New York, officials anticipate needing 5,000 additional beds.
But the San Francisco Bay Area hasn't yet seen the expected surge. UCSF Health had 15 inpatients with COVID-19 Tuesday. Zuckerberg San Francisco General Hospital and Trauma Center had 18 inpatients with the disease Wednesday.
While hospital officials are cautiously optimistic that local and state stay-at-home orders have worked to slow the spread of the virus, they are still preparing for what could be a major increase in admissions.
"The next two weeks is when we're really going to see the surge," said San Francisco General CEO Susan Ehrlich. "We're preparing for the worst but hoping for the best."
Health care businesses will get billions of dollars in additional funding not directly related to the pandemic, because Congress agreed to reverse scheduled cuts in the rates paid by Medicaid and Medicare.
This article was first published on Monday, March 30, 2020 in Kaiser Health News.
The coronavirus stimulus package Congress rushed out last week to help the nation's hospitals and health care networks hands the industry billions of dollars in windfall subsidies and other spending that has little to do with defeating the COVID-19 pandemic.
The $2 trillion legislation, which President Donald Trump signed Friday, includes more than $100 billion in emergency funds to compensate hospitals and other health care providers for lost revenue and other costs associated with COVID-19. The measure also calls for spending up to $16 billion to replenish the nation's depleted stockpile of medical gear, such as ventilators, medicines and personal protective equipment, or PPE.
But health care businesses will get billions of dollars in additional funding not directly related to the pandemic, in some cases because Congress agreed to reverse scheduled cuts in the rates paid by Medicaid and Medicare, which the federal government had tried for years to impose.
"Anything that could tangentially be related to the crisis lobbyists tried to get stuffed in this bill ― particularly health-care-related items," said Steve Ellis, vice president of Taxpayers for Common Sense, a nonpartisan watchdog group. While the stimulus package is "not as big" a "Christmas tree" as some other bills, Ellis said, "I'm sure we'll find a few baubles and gifts along the way."
Hospitals have won widespread praise as their doctors and other medical staffs labor under perilous conditions, including shortages of protective gear. And, perhaps not surprisingly, the industry emerged as a big winner in the stimulus negotiations. Not only can hospitals draw on the $100 billion fund to stem their losses and cover other costs, but they will also see a boost in one stream of revenue as Congress overturned some planned rate cuts.
More than 3,000 hospitals that treat outsize numbers of Medicaid or uninsured patients, for instance, will share in an $8 billion windfall through the stimulus provision that reverses cuts in their Medicaid payments for 2020 and 2021.
Separately, hospitals will rake in at least $3 billion more because of a temporary suspension of a 2% cut in Medicare fees, according to the Federation of American Hospitals, which represents more than 1,000 for-profit hospitals and health systems. The infusion of cash also benefits doctors, nursing homes, home health companies and others.
"That's welcome news during this time of crisis," said Joanne Cunningham, executive director of the Partnership for Quality Home Healthcare.
Also tucked into the stimulus: a rollback of planned rate cuts to clinical laboratories and some medical equipment suppliers.
At this stage, it is unclear how much these measures will add to the COVID-19 tab ― or if far more stimulus would be required for the health care industry to rebound.
Take the 2% rate cut known as "the sequester." The Office of Management and Budget expected it would save Medicare $16.2 billion in fiscal 2021. But the stimulus bill rescinds that rate cut from May 1 through the end of this year. As part of the legislation, Congress said it would, in effect, recoup the payments later by adding another year to the sequester. Whether lawmakers will follow through on that is anyone's guess.
Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA), expects the sequester relief to translate to a "huge" financial boost for more than 15,000 medical practices his group represents.
"This would never have been done under any other circumstances," Gilberg said. "The situation was recognized as dire."
Dr. Patrice Harris, president of the American Medical Association, said the stimulus offers "needed financial relief to hard-hit workers, health systems and physician practices. At this critical moment, physician practices need significant financial support to sustain themselves and continue to meet the health care needs of all Americans during this time."
Similarly, American Hospital Association CEO Rick Pollack calledthe legislation "an important first step forward. But, he added, "more will need to be done to deal with the unprecedented challenge of this virus."
In a nod to clinical laboratories, which have helped bail out the federal government's early failure to supply enough COVID-19 tests, the stimulus delayed planned rate cuts in 2021 likely to amount to tens of millions of dollars in revenue. Medicare officials have been at odds with the lab industry for years over rates for lab tests.
While other health care interests praised the bill, the laboratory trade association said it comes up short.
Just before the Senate passed the stimulus bill Wednesday, American Clinical Laboratory Association President Julie Khani slammed Congress for not designating funding to support labs. She said labs were in "an untenable situation, absorbing growing, uncompensated costs for testing specimens with no assurance that they will be appropriately or fairly reimbursed for all the tests they are performing."
She added a not-so-veiled threat, saying: "If Congress fails to designate essential emergency funding for clinical laboratories to support our efforts, labs will be soon be forced to make difficult decisions about whether they can keep building the [testing] capacity our nation needs."
The lab association, in a statement to Kaiser Health News, said labs have absorbed "stunning" Medicare reimbursement cuts of as much as 30% for many common tests in recent years.
In public securities filings this year, lab giants QuestDiagnostics Inc. and Laboratory Corp of America Holdings, known as LabCorp, reported they expected rate cuts in 2020 totaling more than $150 million. LabCorp said it supported the views of the lab association. Quest did not respond to a request for comment.
While labs processing COVID-19 tests missed out on direct funding, they could be eligible for some of the $100 billion allocated for hospitals and other providers to cover their losses, congressional aides said.
And the stimulus measure states that even in the event a lab is out-of-network, health plans are expected to pay the price it sets — as long as the lab publishes that price online — or negotiate with the lab.
Given that laws in some states ban surprise billing in particular, this provision seems to favor the labs, said Katie Keith, a Georgetown University law professor and health policy expert. "No one just lets the provider set the price," she said.
The lab association disputes that, saying that many health plans are expected to pay them less than the $51.50 government recommended for a COVID-19 test.
Just how the $100 billion in health care funding will be distributed and how much oversight will occur is another unknown.
Health and Human Services Secretary Alex Azar has the authority to decide how long the emergency provisions remain in effect. Tracking all that money will be a challenge as well.
Ellis, the taxpayer advocate, noted that no government agency "is ready to handle the rush of extra funding." He said that the stimulus grants extra resources to inspector general offices to monitor spending.
"There will be waste, there will be abuse," he said. "It's about exposing and rooting it out."
The HHS Office of Inspector General expects to receive $4 million to support this oversight, according to spokesman Donald White.
Some groups aren't waiting to compete over the $100 billion. The MGMA sent a letterMarch 27 to Azar and the Centers for Medicare & Medicaid Services chief Seema Verma asking for more direct help. Gilberg noted that some medical practices, such as doctors who perform colonoscopies, have not been able to continue their work.
"Doctors and physician practices are having a lot of trouble right now," Gilberg said. "They are literally shut down, and they are having financial troubles. Their operations have come to a full halt."
KHN correspondents Rachana Pradhan and Emmarie Huetteman contributed to this report.
Hospitals need to clear out patients who no longer need acute care. Nursing homes don't want to take discharged patients for fear they'll bring the coronavirus with them.
This article was first published on Monday, March 30, 2020 in Kaiser Health News.
A wrenching conflict is emerging as the COVID-19 virus storms through U.S. communities: Some patients are falling into a no man's land between hospitals and nursing homes.
Hospitals need to clear out patients who no longer need acute care. But nursing homes don't want to take patients discharged from hospitals for fear they'll bring the coronavirus with them.
"It's a huge and very difficult issue," said Cassie Sauer, president of the Washington State Hospital Association, whose members were hit early by the coronavirus.
Each side has legitimate concerns. Hospitals in coronavirus hot spots need to free up beds for the next wave of critically ill patients. They are canceling elective and nonessential procedures. They are also trying to move coronavirus patients out of the hospital as quickly as possible.
The goal is to "allow hospitals to reserve beds for the most severely ill patients by discharging those who are less severely ill to skilled nursing facilities," Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said a few weeks ago as the federal agency relaxed rules restricting which Medicare patients can receive nursing home care.
Nursing homes are alarmed at the prospect of taking patients who may have coronavirus infections. The consequences could be dire. The first nursing home known to have COVID-19, the Life Care Center in Kirkland, Washington, saw the virus spread like wildfire. It killed 37 people.
"We're looking at case fatality rates of 30, 40, 50% in nursing homes when coronavirus gets introduced," said Christopher Laxton, executive director of AMDA — the Society for Post-Acute and Long-Term Care Medicine, which represents nursing home medical directors.
Fears extend to patients with other conditions, such as strokes or heart attacks, who've been in the hospital and do not have COVID-19 symptoms but could harbor the virus.
In its most recent guidance, the American Health Care Association, an industry trade group, said nursing homes can accept patients "who are COVID negative or do not have symptoms." If someone has symptoms such as a dry cough or fever, they "should be tested for COVID-19 before being admitted to the facility." If someone is COVID positive, they should be kept only "with other COVID positive residents."
But nursing home doctors worry this doesn't go far enough. According to a resolution by the California Association of Long Term Care Medicine, nursing homes should not have to take patients known to have the coronavirus unless "they have two negative tests that are 24 hours apart, OR 10 days after admission AND no fever for 72 hours." A new AMDA resolution echoes this caution.
"We have an obligation to our patients to draw the line," said Dr. Michael Wasserman, president of the California association. "Increasing the number of COVID-19 positive residents in facilities — whether these facilities have patients with the virus or not — raises the risk of infecting the uninfected and dramatically increasing the number of deaths."
For their part, hospital leaders say an emphasis on testing before discharging patients is impractical, given the shortage of tests and delays in receiving results.
"Many nursing homes are requiring a negative COVID-19 test even for patients who were in the hospital for nothing to do with COVID," said Sauer in Washington state. "We don't agree with this. It's using up very limited testing resources."
Nowhere are tensions higher than in New York, where Gov. Andrew Cuomo has said 73,000 extra hospital beds will be needed within weeks to treat a surge of COVID-19 patients. Hospitals in the state have 53,000 beds.
On Wednesday, the New York State Department of Health issued an advisory noting: "No resident shall be denied re-admission or admission to the NH [nursing home] solely based on a confirmed or suspected diagnosis of COVID-19."
Speaking on behalf of nursing home physicians, AMDA voiced strong opposition, calling the policy "over-reaching, not consistent with science, unenforceable, and beyond all, not in the least consistent with patient safety principles" in astatement.
Some nursing homes are sending residents with suspected coronavirus to hospitals for evaluation and then refusing to take them back until tests confirm their negative status.
"Essentially, they're dumping patients on hospitals and saying, 'Too bad — you're stuck with them now,'" said a consultant who works closely with hospitals and spoke on the condition of anonymity.
Others want to do their part to serve COVID-19 patients. "It is our obligation to keep the health care system flowing," said Scott LaRue, president of ArchCare, the health care system of the Archdiocese of New York.
LaRue has no illusions about keeping the coronavirus out of ArchCare's five nursing homes, which, combined, have 1,700 beds.
"In New York City the virus is everywhere," he said. That means it has to be managed, not avoided. "Our intention is to take COVID-19 stable patients" and move them to a single floor at each nursing home, he said.
That will happen under two conditions, LaRue said. First, ArchCare will need sufficient personal protective equipment — gowns, masks and face shields — for its staff. Currently, the system can't get face shields. It was due to run out of gowns by Wednesday.
Second, ArchCare will need to test whether its protocols for managing COVID-positive patients are working. Those include putting patients in isolation, monitoring them more closely, limiting the number of people who can go in, and ensuring that staff use personal protective equipment and are trained properly.
So far, only one of its nursing home patients is known to have COVID-19.
"We won't know for 14 days if the steps we're taking are working," LaRue said.
But it's unrealistic to expect other nursing homes to follow suit.
"I would be surprised if 10% to 15% of skilled nursing facilities in the U.S. could take a COVID-positive patient and treat that patient safely while ensuring that other residents in the home are safe," said David Grabowski, a professor of Health Care Policy at Harvard Medical School.
In a new commentary in the Journal of the American Medical Association, Grabowski calls for establishing "centers of excellence" to care for patients recovering from COVID-19 and building "temporary capacity" in hot spots where the need for post-hospital services is likely to surge.
That's beginning to happen. On Tuesday, Cuomo announced that a field hospital being built by the U.S. Army Corps of Engineers to house overflow coronavirus patients at the Jacob K. Javits Convention Center in New York City would include 1,000 beds for patients who don't need acute care services.
On Wednesday, a unit of Partners HealthCare, a large Massachusetts health care system, announced a new center for patients recovering from COVID-19 on the fourth floor of Spaulding Hospital for Continuing Care, a long-term care hospital in Cambridge. The center, set to open soon, will have 60 beds and accept patients from Massachusetts General Hospital and Brigham and Women's Hospital.
In the Twin Cities area of Minnesota, Allina Health, which operates 11 hospitals, is partnering with Presbyterian Homes & Services to convert a 50-bed skilled nursing home to a "step-down site," said Dr. Emily Downing, a vice president of Allina Health. The goal is to help COVID-19 patients recover so they can return to nursing homes or senior living communities.
Katie Smith Sloan, president of LeadingAge, which represents not-for-profit nursing homes, home care agencies and assisted living centers, said she was hearing about nascent plans to reopen closed nursing homes for COVID-19 patients. Government agencies need to make financing available to build extra capacity to care for these patients, she said.
As for patients who need less intensive care or who need to be quarantined after the hospital to ensure they aren't infectious, other options exist.
"King County has bought a hotel and is leasing another and is looking at what are now empty ambulatory surgery centers or a Christian summer camp in the area," said Sauer of the Washington State Hospital Association.
This article was first published on Friday, March 27, 2020 in Kaiser Health News.
Dr.Jessica Kiss’ twin girls cry most mornings when she goes to work. They’re 9, old enough to know she could catch the coronavirus from her patients and get so sick she could die.
Kiss shares that fear, and worries at least as much about bringing the virus home to her family — especially since she depends on a mask more than a week old to protect her.
“I have four small children. I’m always thinking of them,” said the 37-year-old California family physician, who has one daughter with asthma. “But there really is no choice. I took an oath as a doctor to do the right thing.”
Kiss’ concerns are mirrored by dozens of physician parents from around the nation in an impassioned letter to Congress begging that the remainder of the relevant personal protective equipment be released from the Strategic National Stockpile, a federal cache of medical supplies, for those on the front lines. They join a growing chorus of American health care workers who say they’re battling the virus with far too little armor as shortages force them to reuse personal protective equipment, known as PPE, or rely on homemade substitutes. Sometimes they must even go without protection altogether.
“We are physically bringing home bacteria and viruses,” said Dr. Hala Sabry, an emergency medicine physician outside Los Angeles who founded the Physician Moms Group on Facebook, which has more than 70,000 members. “We need PPE, and we need it now. We actually needed it yesterday.”
The danger is clear. A March 21 editorial in The Lancetsaid 3,300 health care workers were infected with the COVID-19 virus in China as of early March. At least 22 died by the end of February.
The virus has also stricken health care workers in the United States. On March 14, the American College of Emergency Physicians announced that two members — one in Washington state and another in New Jersey — were in critical condition with COVID-19.
At the private practice outside Los Angeles where Kiss works, three patients have had confirmed cases of COVID-19 since the pandemic began. Tests are pending on 10 others, she said, and they suspect at least 50 more potential cases based on symptoms.
Ideally, Kiss said, she’d use a fresh, tight-fitting N95 respirator mask each time she examined a patient. But she has had just one mask since March 16, when she got a box of five for her practice from a physician friend. Someone left a box of them on the friend’s porch, she said.
When she encounters a patient with symptoms resembling COVID-19, Kiss said, she wears a face shield over her mask, wiping it down with medical-grade wipes between treating patients.
As soon as she gets home from work, she said, she jumps straight into the shower and then launders her scrubs. She knows it could be devastating if she infects her family, even though children generally experience milder symptoms than adults. According to the Centers for Disease Control and Prevention, her daughter’s asthma may put the girl at greater risk of a severe form of the disease.
Dr. Niran Al-Agba of Bremerton, Washington, said she worries “every single day” about bringing the COVID-19 virus home to her family.
“I’ve been hugging them a lot,” the 45-year-old pediatrician said in a phone interview, as she cuddled one of her four children on her lap. “It’s the hardest part of what we’re doing. I could lose my husband. I could lose myself. I could lose my children.”
Al-Agba said she first realized she’d need N95 masks and gowns after hearing about a COVID-19 death about 30 miles away in Kirkland last month. She asked her distributor to order them, but they were sold out. In early March, she found one N95 mask among painting gear in a storage facility. She figured she could reuse the mask if she sprayed it down with a little isopropyl alcohol and also protected herself with gloves, goggles and a jacket instead of a gown. So that’s what she did, visiting symptomatic patients in their cars to reduce the risk of spreading the virus in her office and the need for more protective equipment for other staffers.
Recently, she began getting donations of such equipment. Someone left two boxes of N95s on her doorstep. Three retired dentists dropped off supplies. Patients brought her dozens of homemade masks. Al-Agba plans to make these supplies last, so she’s continuing to examine patients in cars.
In the March 19 letter to Congress, about 50 other physicians described similar experiences and fears for their families, with their names excluded to protect them from possible retaliation from employers. Several described having few or no masks or gowns. Two said their health centers stopped testing for COVID-19 because there is not enough protective gear to keep workers safe. One described buying N95 masks from the Home Depot to distribute to colleagues; another spoke of buying safety glasses from a local construction site.
“Healthcare workers around the country continue to risk exposure — some requiring quarantine and others falling ill,” said the letter. “With emergency rooms and hospitals running at and even over capacity, and as the crisis expands, so does the risk to our healthcare workers. And with a shortage of PPE, that risk is even greater.”
Besides asking the government to release the entire stockpile of masks and other protective equipment — some of which has already been sent to states — the doctors requested it be replenished with newly manufactured equipment that is steered to health care workers before retail stores.
They called on the U.S. Government Accountability Office to investigate the distribution of stockpile supplies and recommended ways to ensure they are distributed as efficiently as possible. They said the current system, which requires requests from local, state and territorial authorities, “may create delays that could cause significant harm to the health and welfare of the general public.”
At this point, Sabry said, the federal government should not be keeping any part of the stockpile for a rainy day.
“It’s pouring in the United States right now,” she said. “What are they waiting for? How bad does it have to get?”
As the coronavirus sweeps the nation, a new survey reveals widespread medical shortages while hospitals give up on a fractured supply chain and take matters into their own hands with planes sprinting past cargo ships.
This article was first published on Thursday, March 26, 2020 in Kaiser Health News.
Hospitals in the New York City area are turning to a private distributor to airlift millions of protective masks out of China. The U.S. military is flying specialized swabs out of Italy. And a Chicago-area medical supply firm is taking to the skies as well — because a weekslong boat trip across the ocean just won't do.
The race to import medical supplies reflects a nationwide panic over a dwindling supply of the masks, gowns and other protective gear that health care workers need amid the growing coronavirus pandemic. Demand is outstripping what's available due to a damaged supply chain heavily reliant on China and a struggling Strategic National Stockpile. U.S. manufacturing giants like 3M have not yet made up the difference.
A sweeping national survey out Wednesday drives home that nearly a quarter of hospitals have fewer than 100 N95 masks on hand and 20% report an immediate need for ventilators. In the hardest-hit areas, like New York City, the shortages are potentially life-threatening to patients as well as health care workers.
About 260 health systems representing 990 major hospitals responded to the March 16-20 survey by Premier Inc., a group purchasing organization that negotiates with suppliers for discounts. While the survey provides a fresh picture of nationwide hospital operations, the number of U.S. COVID-19 cases has soared tenfold since the survey began ― from fewer than 5,000 to more than 55,000 as of Wednesday afternoon.
"Absent additional interventions from the government or private sector, we don't foresee the current status quo changing," said Soumi Saha, senior director of advocacy for Premier. "And the current status quo is not acceptable."
Saha said the national stockpile "is intended to be a band-aid, not a long-term solution." Premier called on the Trump administration to either further implement the Defense Production Act to ramp up domestic manufacturing or provide more clear direction on which medical supplies are needed and streamline distribution. FEMA announced Tuesday it did not use the Defense Production Act for test kits after previously stating it would.
The alarm bells ringing from the hospital community come in contrast to a more subdued message from FEMA, which is helping hospitals procure needed goods.
"The private sector can directly purchase [personal protective equipment] from manufacturers and distributors, as they normally do," FEMA press secretary Lizzie Litzow said in a statement. "The private sector can also accept donations from other private sector entities." The statement pointed to a "how to help" document that outlines how individuals and companies can share supplies or other resources.
In recent days, volunteer efforts have ramped up to help health providers who've taken to Twitter and other social media with pleas for more protective gear. Grassroots efforts have sprung up, with veterinary, computer, constructionand industrial businesses donating goods while sewing circles churn out cloth masks.
During a White House press briefing Tuesday, President Donald Trump said FEMA is distributing more than 8 million N95 respirators, 14 million surgical masks and 2.4 million face shields.
"The federal government is using every resource at its disposal to acquire and distribute critical medical supplies," the president said.
3M, a major American manufacturer of the N95 masks, said on March 20 it had doubled its global output of the crucial N95 respirators and plans to further increase output. Currently, over 30 million industrial and health care specific N95s are being produced for U.S. health care use by the company each month. Shipments totaling half a million 3M masks were scheduled tostart arriving in New York and Seattle on Monday from itsSouth Dakota plant.
The influx of goods comes as health care providers are now using four to 10 times more protective gear once a COVID-19 patient enters their doors than they typically use. This has forced hospitals already dealing with cases to scramble even more than health care facilities yet to get any cases, though shortages are crippling allareas of the health care industry.
"It's a total change in what we are used to as a society around availability," said Cathy Denning, senior vice president of sourcing operations for Vizient, an analytics and advisory firm that also does health care group purchasing. "From our perspective, it's this unbelievable place we find ourselves in — realizing we have a vulnerable supply chain."
As the coronavirus crippled China, the center of commerce for low-margin products like face masks and sanitizing wipes, the U.S. supply chain began to fall apart. With global competition for the same safety gear, the crisis deepened, and big national suppliers aren't coming up with enough products to meet the crushing demand.
And waiting about a month for a cargo ship of supplies to arrive from China is a luxury of time that hospitals cannot afford ― even though ships can carry over 10 times more supplies than a cargo plane could.
Medline, a Chicago-area medical supplier, started delivering face masks by airplane last week after manufacturing resumed in China. According to spokesperson Stacy Rubenstein, flying the supplies in will shorten the "manufacturing-to-dock" time by three to four weeks, and the firm will not be passing along the "significant increase in cost" to customers.
But the demand is still 300% higher than traditional inventory levels, Rubenstein said in an email.
Elsewhere, hospitals are reaching out to Michael Einhorn, president of Dealmed, the medical products distributor and supplier working with 12 New York metro area hospitals — desperate for products he cannot always secure.
"Does it cost the hospitals a lot of money? No question about it. But right now, that's what they need to do to secure product," Einhorn said. "We can't wait for it to come overseas."
He's paying up to $40,000 for shipments arriving on multiple planes from Shanghai to New York's John F. Kennedy International Airport and Los Angeles International Airport — and sometimes losing money due to the high shipping costs.
The other backstop for hospitals was the national stockpile, which has come up far short.
Despite receiving 49,200 N95 masks, 115,000 surgical masks, 21,420 surgical gowns, 21,800 face shields and 84 coveralls from the national stockpile, the Colorado Department of Public Health and Environmentestimated in a press release Monday that those supplies would last approximately one full day of statewide operations.
Einhorn said that hospitals are panicking, having lost faith in the supply chain as they cannot find products they so desperately need.
"The strategic national stockpile, with all due respect, was a failure," he said.
The hospitals reported in the survey that their supply of N95 masks are their chief concern, with the best-supplied hospitals having about a 10-day supply on hand.
Hospitals identified hand sanitizer as the second-most pressing shortage, with 64% of respondents saying they were already running out. Next was surgical masks, which provide less protection than the N95 masks. Nearly half of hospitals had fewer than 1,000 on hand; a quarter of them reported going through 1,000 per day.
To keep up with that kind of demand, Einhorn said, more needs to be done to secure the products from China.
"One of the things we have been asking for is assistance getting these products quickly from China to here," said Einhorn. "Instead, we're doing drives of people dropping off three boxes of face masks."
As the caseload of patients with the new coronavirus grows, masks and other personal protective equipment are in short supply — and nurses in Washington state are resorting to workarounds to try to stay safe.
Wendy Shaw, a charge nurse for an emergency room in Seattle, said her hospital and others have locked up critical equipment like masks and respirators to ensure they don't run out.
Shaw is the de facto gatekeeper, and is now required to run through a list of questions when anyone comes to get a mask: "What are you using it for? What patient? What's the procedure?"
"I have become a 'jailer' in a sense of these masks," she said.
"We now have to learn how to work with less, and how to be good stewards of the resources that we have," Shaw said.
For Shaw, there's a very personal stress driving her to be careful. She has Type 1 diabetes, and so does her young son, which puts her at high risk for complications if she were to be infected.
"I am cleaning like I have never cleaned before. I am hyperaware of what I touch, who has brushed up against me," said Shaw. "We think about this all the time. Every day I wake up without a fever or a cough is a win for me."
At some hospitals, nurses and doctors said they are being told that, contrary to standard protocol of disposal after a single use, they should try to clean and reuse their N95 masks, a respirator that protects the face from airborne particles and contaminated liquid.
Meanwhile, office staff at the corporate headquarters of Providence St. Joseph Health in Renton, Washington, have opened an ad hoc workshop where they are assembling masks and face shields on their own, to bolster resources.
"At any given time, we are days away from running out of personal protective equipment," said Melissa Tizon, with Providence St. Joseph Health.
Tizon said the health system has already delivered 500 face shields to Providence-affiliated hospitals in Seattle and Everett, Washington, and plans to start sewing masks in the coming days.
Some nurses are even crowdsourcing masks.
Bobbie Habdas, an ICU nurse at Swedish Medical Center, took to Facebook asking for help from her community.
"I never thought that we'd necessarily be doing this," said Habdas.
Her post gained lots of attention, and she collected more than a hundred masks to share with co-workers.
"Honestly, it shocked me and it really touched me — it's extremely appreciated," she said.
The outpouring was a bright spot, but Habdas wonders why nurses have to scrounge for supplies, in addition to their regular duties.
"There is a huge feeling of panic, not only externally, but also internally within the hospital," said Habdas.
She said spending time looking for supplies during her shift doesn't help with the stress of responding to the coronavirus pandemic. Patients have died from the disease in Washington, with at least 74 COVID-19 deaths recorded across the state as of Thursday afternoon.
Sally Watkins, executive director of the Washington State Nurses Association, said nurses are being forced to make do with less.
"They are not being protected at the level that they should be," said Watkins. She hopes the region will get more supplies from the federal stockpile soon.
Communication Breakdowns
After 39 years as an intensive care nurse, Mary Mills has dealt with other infectious disease crises, but her hospital's response to the coronavirus outbreak feels different. She remembers helping to intubate HIV patients in the early days of the AIDS crisis, when there was still a lot of fear and unknowns about that illness.
"Everybody was on the same page," Mills said. "There was clear communication."
Mills works at one of the five hospitals run by Swedish Medical Center in the Seattle area. "I hate to say I don't feel particularly supported now," she said.
Like many health care workers, Mills feels frustrated because the guidance on when to use personal protective equipment, or PPE, keeps shifting, sometimes daily.
"What they decide I need, in terms of my safety, is being changed based on availability of product, rather than the science," Mills said.
"This is super contagious. We can spread it to our kids, our parents and grandparents," she added.
Worries About Health Care Worker Exposure
Mills believes that hospital managers have not been taking nurses' concerns seriously enough, especially when it came to testing patients and staff in the early days of the outbreak.
She said two nurses she works with have already become sick with what seemed to be COVID-19.
"One went out with a cough and a fever, all the classic five symptoms," Mills said. "On the eighth day, they finally agreed to have her tested for COVID-19."
Mills said this type of response only erodes nurses' trust in hospital leadership, harming a relationship that is critical as the entire Seattle-area health care workforce is called upon to care for an increasing number of patients with the disease.
Health care workers being exposed to coronavirus is a central concern throughout the region. Multiple hospitals in the Seattle area have reported cases among staff at their facilities. An emergency room doctor in Kirkland was hospitalized after being infected.
Dr. Chris Dale, the chief quality officer for Swedish, said his hospital system is focused on caregiver safety.
"We cannot effectively provide safe care for patients if our caregivers first aren't safe," said Dale.
The hospital just launched pop-up clinics where staff and patients can get tested. He said that testing around Washington has improved significantly as more labs have come online in recent days. Currently, results are coming back within three to four days, he said, compared with earlier, when it took a week.
He said the number of Swedish Medical Center health care workers who have contracted COVID-19 remains "low," but did not give specific numbers.
"With this extraordinary pandemic, and the squeeze that we are seeing on supplies, we need to balance both supply and the very real need to keep caregivers safe," said Dale.
Swedish follows the World Health Organization guidance when treating patients with suspected or confirmed cases of COVID-19, he said.
Staffing Issues
Nurses from Swedish Medical Center began confronting this pandemic at a time when they were already locked in a divisive labor dispute, related to staffing levels. In January, thousands of health care workers from their unionwent on a three-day strike, unrelated to the coronavirus crisis. The nurses contend that chronic understaffing inside the hospitals can negatively affect patient safety.
Dale said Swedish has recently hired about 300 temporary nurses, called travel nurses, and is actively recruiting more. But Mills still worries there won't be enough nurses to handle the surge in patients.
"It is not just about physical beds or ventilators," said Mills. "A room and a ventilator don't mean anything if you don't have a nurse."
Mills said she hopes management starts dealing with these urgent issues. After decades of working in the ICU, she said her No. 1 commitment is to her patients. Already, she has treated some patients with COVID-19 who died in isolation — sometimes with no family members there in-person.
The hospital's policy currently does not allow any visitors to COVID-19 patients for safety reasons, though the hospital said it makes exceptions "in extreme circumstances."
"The tragedy of not having family there to support the super sick … you feel a greater burden to deliver some form of compassion to these people who are totally isolated," said Mills. "The only people there are the ICU nurses."
This story is part of a partnership that includes NPR and Kaiser Health News.
Public health officials are just beginning to grapple with the fallout from that early bungling of testing, which is likely to haunt the country in the months to come.
This article was first published on Monday, March 23, 2020 in Kaiser Health News.
As the novel coronavirus snaked its way across the globe, the Centers for Disease Control and Prevention in early February distributed 200 test kits it had produced to more than 100 public health labs run by states and counties nationwide.
Each kit contained material to test a mere 300 to 400 patients. And labs, whether serving the population of New York City or tiny towns in rural America, apparently received the same kits.
The kits were distributed roughly equally to locales in all 50 states. That decision presaged weeks of chaos, in which the availability of COVID-19 tests seemed oddly out of sync with where testing was needed.
A woman in South Dakota with mild symptoms and no fever readily got the test and the results. Meanwhile, politicians in places like New York, Boston, Seattle and the San Francisco Bay Area — all in the throes of serious outbreaks ― couldn't get enough tests to screen ill patients or, thereby, the information they needed to protect the general public and stem the outbreak of the virus, whose symptoms mimic those of common respiratory illnesses.
Rapid testing is crucial in the early stages of an outbreak. It allows health workers and families to identify and focus on treating those infected and isolate them.
Yet health officials in New York City and such states as New York, Washington, Pennsylvania and Georgia confirmed to Kaiser Health News that they each initially got one test kit, calling into question whether they would have even stood a chance to contain the outbreaks that would emerge. They would soon discover that the tests they did receive were flawed, lacking critical components and delivering faulty results.
During those early weeks, the virus took off, infecting thousands of people and leading to nationwide social distancing and sheltering in place. Public health officials are just beginning to grapple with the fallout from that early bungling of testing, which is likely to haunt the country in the months to come.
Too Little Too Late
The first shipment to Washington state arrived more than two weeks after officials there announced the first U.S. case of coronavirus, and at a moment when deadly outbreaks of the disease were already festering in places like the Life Care Center in Kirkland. Within weeks, three dozen people infected with COVID-19 would die at the nursing home in the suburbs of Seattle.
The spread of COVID19 would not take long to overwhelm the state, which as of Friday had more than 1,300 cases.
The Trump administration in recent days has attempted to speed testing for the virus after early missteps hampered the government's response to contain the contagion, and officials have had to respond to a barrage of criticism from public health experts, state officials and members of Congress.
Federal health officials have eased the process for university and commercial labs to perform their own tests, and they are ramping up their capacity. As of March 16, public and private labs in the U.S. had the ability to test more than 36,000 people a day, according to estimates compiled by the American Enterprise Institute, a conservative-leaning think tank in Washington, D.C., a figure expected to rapidly escalate in coming weeks. That figure, however, can vary considerably by state and does not indicate how many tests are actually given to patients.
"We are now beginning to see that they have spread out in a prioritized way. We asked them to prioritize the regions that were mostly affected," Deborah Birx, the coronavirus response coordinator for the White House Coronavirus Task Force, said Wednesday of private labs' testing, without elaboration.
The scaling up of testing is set to take place after weeks of faltering and hundreds, if not thousands, of undiagnosed people spreading the virus. For example, New York's state health department received a faulty CDC test kit on Feb. 8 for 800 patient specimens, an amount that's consistent with other states, according to a spokesperson. It later began testing patients with a test that state officials developed based on the CDC protocol and has significantly increased testing — as of Friday, more than 7,200 people had tested positive statewide.
In New York City, the first batch was obtained on Feb. 7.
"The other state and local public health laboratories got test kits as they became available," said Eric Blank, chief program officer of the Association of Public Health Laboratories.
Places in the middle of the country with no outbreaks had the luxury of time to plan. For example, Missouri officials have had about 800 tests to work with, leading to only 395 performed so far in the region by public health labs ― 26 of which were positive. When private lab tests are accounted for, as of Friday there were 47 confirmed cases.
Health care providers and public health staff in the state, however, benefited from the fact that there is less international travel to the region, according to infectious disease expert Dr. Steven Lawrence of Washington University in St. Louis.
"This is very similar to 1918 with the influenza pandemic — St. Louis had more time to prepare and was able to put measures in place to flatten the curve than, say, Philadelphia," Lawrence said. "Seattle didn't have an opportunity to prepare as much in advance."
While commercial labs are coming online, strict restrictions are limitingtesting capabilities, Lawrence said.
"The state has had their hands tied," he added.
Waiting And Wondering
Because of a widespread lag in testing, it is still a mystery for thousands of people to know whether they've come into contact with an infected person until well after it happens. As of Friday, the pandemic had killed more than 11,000 globally. More than 16,000 Americans were confirmed infected and at least 216 have died.
"CDC will distribute tests based on where they can do the most good. But without hospital-based testing and commercial testing, it will not be possible to meet the need," said Tom Frieden, who led the CDC during the Obama administration and is a former commissioner of the New York City Health Department.
In California, public school teacher Claire Dugan, whose state was among the hardest hit in the initial wave of U.S. coronavirus cases, was told she didn't qualify for testing because she had not traveled abroad to any country with an outbreak of the virus or been in contact with an infected person. Dugan, who lives in the San Francisco Bay Area and is already medically fragile after a stray bullet nearly killed her while driving four years ago, sought a test from her doctor after registering a temperature of 100.7 degrees earlier this month.
"There are a lot of layers as to why this is so messed up," said Dugan, who relies on a feeding tube and said she sought a test not only to protect herself but her students. "It's community spreading right now, so it's kind of silly we're still insisting on [the early criteria for testing]. How would I know?"
Since the CDC's initial distribution, states have been reordering more tests through the office's International Reagent Resource ― a long-standing tool that public health labs have relied on. They have also revised testing protocols to use only one sample per person, which boosts the number of people screened.
Yet problems still abound with tests or other materials needed to be able to detect the virus. California Gov. Gavin Newsom said on March 12 that county public health labs can't use all of the 8,000 test kits the state has because they are missing key components.
In Pennsylvania, state officials weren't able to begin testing until March 2 because of problems with the CDC's initial kit, according to Nate Wardle, a spokesperson at its department of health. New York City received two newly manufactured CDC test kits on Feb. 29 and also began performing tests March 2, its health department told KHN.
"We are still limited on extraction kits," Mandy Cohen, the Health and Human Services secretary in North Carolina, said in an interview in mid-March. Officials earlier this month could test only 300 patients because of shortages in the extraction materials needed to register whether the novel coronavirus is present.
In North Dakota, Loralyn Hegland wrote her physician's practice an email on March 10 with the subject line "dry cough," wondering if she should come in for testing after learning that was one symptom of COVID-19. The recommendation she got echoes those of countless others across the U.S., saying her risk of being exposed was very low because she hadn't traveled outside the U.S. and had not come into contact with a person who had been "definitely" diagnosed with the virus.
Hegland, who lives in Fargo, didn't have a fever but decided to shelter herself, anyway, out of caution.
Would she push to get a test?
"What's the point?" she said. "You can't know what you don't know. It's just that simple. How else do you explain it to people when you're not testing?"
KHN Midwest correspondent Lauren Weber in St. Louis contributed to this article.