Thousands of doctors, hospitals and other health providers are reaching out for a lifeline made available in the series of federal relief measures to counteract the effects of the viral outbreak.

This article was first published on Friday, April 10, 2020 in Kaiser Health News.

By Phil Galewitz

Darrin Menard, a family physician in Lafayette, Louisiana, has spent the past month easing patients" anxieties about the coronavirus that has killed 10 people in his parish so far.

But Menard has his own fears: How will his medical practice survive the pandemic?

His office typically sees 70 patients a day, but now it handles half that amount and many of those appointments are done over the phone or computer. He said revenue in the practice has dropped by 40% — which makes it challenging to pay a mortgage, staff salaries, malpractice insurance, utilities, electronic health records costs and other expenses.

To help stay afloat, Menard is one of thousands of doctors, hospitals and other health providers reaching out for a lifeline made available in the series of federal relief measures to counteract the effects of the viral outbreak.

He applied last week for a three-month advance on his Medicare billings, which he hopes will bring in about $120,000 or more to cushion the strain. He"s also applying for the Small Business Administration"s Paycheck Protection loans to help cover costs of meeting payroll.

"We are quite thankful for the help so I can keep the lights on in the office for us to be available for our patients," Menard said.

The Centers for Medicare & Medicaid Services announced in late March that it would implement for the first time a national accelerated Medicare payments program to help ease the financial strain for health providers. Thursday, officials said they had disbursed $51 billion to hospitals, doctors and other care providers.

"Healthcare providers are making massive financial sacrifices to care for the influx of coronavirus patients," CMS Administrator Seema Verma said in a statement.

"Many are rightly complying with federal recommendations to delay non-essential elective surgeries to preserve capacity and personal protective equipment. They shouldn"t be penalized for doing the right thing. Amid a public health storm of unprecedented fury, these payments are helping providers and suppliers ― so critical to defeating this terrible virus — stay afloat."

The federal help has inspired private insurers such as UnitedHealth Group and several Blue Cross Blue Shield plans to offer advanced payments and other financial support.

CMS in April has received more than 25,000 requests from providers and suppliers for expedited payments and has approved more than 17,000 requests. 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.

Most physicians can get an advance on three months of their Medicare reimbursements, and hospitals can get up to six months. Hospitals will generally have up to one year from the date the accelerated payment was made to repay the balance. Doctors will have up to seven months to complete repayments.

To put all this $51 billion in financial aid in perspective, traditional Medicare in 2019 paid $484 billion to health care providers.

Coronavirus patients are overwhelming hospitals in cities including New York, New Orleans and Detroit. But as other health systems brace for similar spikes, they are also seeing sharp drop-offs in regular doctor visits, emergency room arrivals, and the lucrative surgeries and medical procedures that are vital to their bottom lines.

The advanced Medicare payments are just part of the hundreds of billions of dollars the federal government is providing doctors, hospitals and other health providers.

Congress also set up a separate $100 billion program for hospitals and other health providers with coronavirus-related expenses.

The Trump administration Tuesday said it will begin distributing the first $30 billion from this fund to hospitals this week. The money will go to all hospitals based on their Medicare fee-for-service revenue.

Lobbying groups representing safety-net hospitals slammed the decision because they get a lower share of their revenue from Medicare than some other hospitals do. And safety-net hospitals have a higher percentage of patients who are uninsured or covered by Medicaid, the state-federal health insurance program for low-income people.

It also upset hospitals in New York, the epicenter of the U.S. epidemic, because they were getting no more funding than hospitals little affected by the outbreak.

Verma said the administration"s top priority was getting the funding to hospitals as quickly as possible. She said children"s hospitals, nursing homes, pediatricians and other health care providers that receive much of their revenue from Medicaid and other sources will be given priority when the second round of funding is distributed.

Other federal steps to help providers include Medicare for the first time paying for telemedicine treatments at the same rate as in-person visits. Previously, those fees paid less than half of what in-person visits paid.

Congress has also suspended a 2% Medicare reimbursement cut and bumped up Medicare fees by 20% for treating COVID-19 patients. The Trump administration said it is also paying hospitals Medicare rates for uninsured COVID-19 patients.

The billions in advanced Medicare payments are seen as one of the quickest ways to get funds to struggling hospitals and doctors.

"It"s money we will desperately need," said Patrick McCabe, senior vice president of finance at Yale New Haven Health, the largest health system in Connecticut. It is counting on more than $450 million in advanced Medicare payments to get through the pandemic — at least for the next couple of months.

The health system, which runs a $5 billion annual budget, could lose more than $600 million as a result of the added expenses of preparing and dealing with COVID-19 and the drop-off in other revenue, he said. Such a loss — without any federal assistance — would more than wipe out the health system"s ability to upgrade equipment and keep up with rising expenses, he added.

McCabe said determining whether the federal relief will be enough depends on how long the pandemic lasts.

Shelly Schlenker, senior vice president of public policy and advocacy for CommonSpirit Health, a Chicago-based Catholic health system with 137 hospitals, said she expects all these facilities will apply for advanced Medicare payments.

"Hospitals are in urgent need of assistance to meet the demands of the pandemic," she said. "It"s an unprecedented time."

Even with all the government help, industry analysts say, the economic fallout from COVID-19, the disease caused by the coronavirus, will rock the health industry, which communities often count on to fuel their economies.

The average large hospital will see about a 51% decline in revenue as a result of the pandemic, said Christopher Kerns, vice president at the Advisory Board Co., a consulting firm.

While some patients who postpone procedures will return, Kern said, hospital systems shouldn"t expect a quick recovery. "Health systems are going to try to capture as much pent-up demand as possible, but there are big challenges with that," he said.

Before the crisis, a quarter of U.S. rural hospitals were at high risk of closing, according to a report this month from consulting firm Guidehouse. These 354 hospitals span 40 states, though most are in the Southeast and central states.

"It was already troubling that the economic outlook for rural hospitals deteriorated during the longest period of uninterrupted economic growth our country has ever experienced," said Dave Mosley, a Guidehouse partner. "A major crisis like the COVID-19 pandemic or any significant economic downturn is likely to make the situation even more dire."

Update: This story was updated on April 10 at 9:40 a.m. ET to add the new figure from federal officials on the Medicare fee-for-service spending in 2019. 

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

CMS says the decision will allow insurers and the agency to "focus on patient care," and will last "until after the public health emergency has ended."

This article was first published on Wednesday, April 8, 2020 in Kaiser Health News.

By Fred Schulte

Federal health officials, citing a need to focus on the COVID-19 pandemic, have temporarily halted some efforts to recover hundreds of millions of dollars in overpayments made to Medicare Advantage health plans.

The Centers for Medicare & Medicaid Services says the decision will allow insurers and the agency to "focus on patient care," and will last "until after the public health emergency has ended."

Critics aren't convinced that's a wise idea.

"Some loosening of regulations during a crisis is necessary. But is this an abdication of oversight?" asked David Lipschutz, associate director and a senior policy attorney with the Center for Medicare Advocacy. "This is a serious concern we will have to grapple with at some point."

Medicare Advantage plans are offered by private health insurers under contracts with Medicare. They treat more than 24 million Americans, most of them seniors at a relatively high risk of serious health complications from the pandemic.

The added costs these health plans will shoulder as a result remains unclear. Several plans have announced they will waive copayments for COVID-19 testing and care. In an April 3 letter to CMS Administrator Seema Verma, the industry advocacy group Better Medicare Alliance asked the agency to "monitor the unanticipated costs incurred as a result of the COVID-19 crisis, and work with Congress to put in place appropriate financial protections, such as excess loss protection for Medicare Advantage."

CMS on Monday announced a 1.66% rate increase for the plans in 2021.

The trade group applauded CMS' decision to relax auditing and other paperwork requirements. The CMS audits are designed to curb overcharging by Medicare Advantage plans, to which the government pays more than $200 billion a year. The audits are years behind schedule, largely because of industry opposition.

In July 2019, Kaiser Health News reported that the government had overpaid Medicare Advantage plans by nearly $30 billion in the past three years alone. In addition, as many as 20 whistleblower lawsuits ― the most recent filed late last month by the Justice Department against industry giant Anthem — have accused health plans of ripping off Medicare by exaggerating how sick their patients were.

The coronavirus emergency puts a unique strain on Medicare Advantage plans. Unlike standard Medicare, which pays medical providers for each service they render, Medicare Advantage plans are paid based on the health of members. That means they receive higher rates for sicker patients and less for those in robust health.

The insurers assess the health status of each member through face-to-face medical visits, which have been sharply curtailed by the crisis. The industry also argues that during the COVID-19 emergency, health plans and their doctors have little time to process paperwork.

"There's a recognition that providers need to be focused on treating the epidemic," said Thomas Kornfield, a senior consultant with the health care consulting firm Avalere Health and a former CMS official. Asking doctors and insurers to prepare medical records for review "when they face an unprecedented situation is not a good idea," he said.

Still, concerns that some plans overcharge Medicare have been raised for years. In December, the Health and Human Services inspector general linked alleged schemes to $6.7 billion in questionable payments during 2017.

The March 26 Justice Department civil case accuses Anthem, whose holdings include several large Blue Cross Blue Shield plans, of illegally billing Medicare for diseases that were not supported by medical records. Anthem received more than $112 million in improper payments for 2015, according to the government.

Anthem denied wrongdoing. "We are confident that our health plans and associates have complied with Medicare Advantage regulations," the company said in a statement.

The whistleblower cases have emerged as a primary tool for holding health plans accountable largely because the CMS audit program has foundered amid fierce protests from the industry. The industry argues the audits, called risk adjustment data validation, or RADV, are flawed and the results unreliable.

The controversy has resulted in long delays in conducting audits and recouping overpayments. CMS officials say they have yet to complete audits for 2011, 2012 and 2013.

That's years behind schedule. CMS officials had expected to finish the 2011 audits by the end of 2016, for instance. (KHN is suing CMS under the Freedom of Information Act to compel public release of the audit findings. The case is pending in federal court in San Francisco.)

CMS said it would continue reviewing some audit materials but suspend the collection of records for reviews of 2015 payments and beyond until "the public health emergency has ended."

The CMS action also temporarily waives the collection of some data the government uses to rate the quality of health plans and patient satisfaction with them. Medicare uses this information to rate the health plans from one to five stars.

"CMS is committed to allowing health plans, providers, and physician offices to focus on caring for Medicare beneficiaries during this public health emergency and not put staff at health plans at risk by requiring travel or collection of data in offices that are overwhelmed by patients needing care," the agency said.

CMS said it is "reprioritizing" its enforcement of regulations to focus on problems that could pose a danger to patients, such as "lack of access to critically needed health services or prescription drugs" and "complaints alleging infection control concerns, including COVID-19 or other respiratory illnesses."

Fred Schulte: fschulte@kff.org, @fredschulte

People with cancer are among those at high risk of complications if infected with the new coronavirus.

By Will Stone

This article was first published on Tuesday, April 7, 2020 in Kaiser Health News.

The federal government has encouraged health centers to delay nonessential surgeries while weighing the severity of patients' conditions and the availability of personal protective equipment, beds and staffing at hospitals.

People with cancer are among those at high risk of complications if infected with the new coronavirus. It's estimated 1.8 million people will be diagnosed with cancer in the U.S. this year. More than 600,000 people are receiving chemotherapy.

That means millions of Americans may be navigating unforeseen challenges to getting care.

Christine Rayburn in Olympia, Washington, was diagnosed with breast cancer in mid-February. The new coronavirus was in the news, but the 48-year-old did not imagine the outbreak would affect her. Her doctor said Rayburn needed to start treatment immediately. The cancer had already spread to her lymph nodes.

"The cancer tumor seemed to have attached itself to a nerve," said Rayburn, who was a schoolteacher for many years. "I feel pain from it on a regular basis."

After getting her diagnosis and the treatment plan from her medical team, Rayburn was focused on getting surgery as fast as possible.

Meanwhile, the coronavirus outbreak was getting worse, and Seattle, just an hour north of where Rayburn lives, had become a national focal point.

Rayburn's husband, David Forsberg, began to get a little nervous about whether his wife's procedure would go forward as planned.

"It did cross my mind," he said. "But I did not want to bother with that possibility on top of everything else."

Two days before Rayburn's lumpectomy to remove the tumor, Forsberg said, the surgeon phoned, "pretty livid" with bad news. "She said, 'Look, they've canceled it indefinitely,'" Forsberg remembered.

The procedure had been scheduled at Providence St. Peter Hospital in Olympia, a facility run by Providence Health & Services. Across Washington, hospitals were calling off elective surgeries, in order to conserve the limited supply of personal protective equipment, or PPE, and to prevent patients and staffers from unnecessary exposure to the new coronavirus.

"It just felt like one of those really bad movies, and I was being sacrificed," Rayburn said.

"It was like we just got cut off from the experts we were relying on," her husband said.

The hospital said it would review the decision in a few weeks. But Rayburn's surgeon said that was too long to wait, and they needed to move to Plan B, which was to begin chemotherapy.

Originally, chemotherapy was supposed to happen after Rayburn's tumor surgery. And rearranging the treatment plan wasn't ideal because chemotherapy isn't shown to significantly shrink tumors in Rayburn's type of breast cancer.

Still, chemotherapy could help stop the cancer from spreading further. But as the couple figured out the new treatment plan, they ran into more obstacles.

"She needed an echocardiogram, except they had canceled all echocardiograms," said Forsberg.

They spent days on the phone trying to get all the pieces in place so she could start chemotherapy. Rayburn also started writing to her local lawmakers about her predicament.

Hospitals Prioritize Urgent Cases

In mid-March, Washington Gov. Jay Inslee banned most elective procedures, but he did carve out exceptions for certain urgent, life-threatening situations.

"It actually said that it [the ban] excluded removing cancerous tumors," Rayburn said.

Providence hospitals use algorithms and a team of physicians to figure out which surgeries can be delayed, said Elaine Couture, chief executive of Providence Health in the Washington-Montana region.

"There are no perfect decisions at all in any of this," said Couture. "None."

Couture would not talk about specific patients but said she assumes other cases were more urgent than Rayburn's.

"Were there other patients that even had more aggressive types of cancer that were [surgically] completed?" Couture said. "As sick as you are, there can be other people that are needing something even sooner than you do."

Couture said hospitals are burning through supplies of masks, gowns and gloves and need to make tough calls about elective procedures.

"I don't like that, either, and it's not the way that we want our health care system to work," Couture said.

Across the Providence hospital system, personal protective equipment is being used much faster than it can be replenished, she said.

No Single Standard

At the American Cancer Society, Deputy Chief Medical Officer Dr. Len Lichtenfeld is hearing from patients across the country who are having their chemotherapy delayed or surgery canceled.

"There was someone who had a brain tumor who was told they would not be able to have surgery, which was, basically, and appears to be a death sentence for that patient," said Lichtenfeld.

This is uncharted territory for cancer care, he said. Hospitals are making these "decisions on the fly" in response to how the pandemic looks in a particular community. "There is no single national standard that can be applied. I am afraid this is going to become much more common in the coming weeks."

The cancer society recommends that people postpone their routine cancer screenings — for now.

The American College of Surgeons has published guidance on how to triage surgical care for cancer patients. But Lichtenfeld said every decision ultimately depends on the availability of resources at the hospital and the pressures of COVID-19. In Washington state, which has been hit hard, hospitals are shifting surgical space and beds away from other kinds of treatment.

"We need to forecast two to three weeks down the line when there are more patients that are ill," said Dr. Steven Pergam, medical director of infection prevention at the Seattle Cancer Care Alliance. "We need to make sure there's adequate bed capacity."

Pergam said the care alliance is adjusting treatment plans and, at times, avoiding procedures that would keep cancer patients in the hospital for a prolonged period.

"It really depends on the cancer and the aggressive nature of it," he said. "We have looked at giving chemotherapy in the outpatient department and changing the particular regimens people get to make them less toxic."

But Pergam said they expect to keep doing urgent surgeries for cancer patients, even as the pandemic grows worse.

Christine Rayburn in Olympia was steeling herself for the months of chemotherapy to come: staying inside her home and even avoiding contact with her adult daughters, to avoid any possible exposure to the coronavirus.

Then, two weeks ago, the surgeon called again. She had persuaded the hospital to allow the surgery after all, 10 days later than initially planned.

Rayburn and her husband wonder what would have happened if they hadn't spoken up or pushed to get her lumpectomy back on the hospital's surgical schedule. Forsberg said it's possible they could have ended up without the care Rayburn needed.

"If we didn't say anything, in my mind that may be where we would be at," he said. "But in our minds, that was not an option."

This story is part of a partnership between NPR and Kaiser Health News.

Will Stone: @WStonereports

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 in Kaiser Health News.

By Markian Hawryluk

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 compilation of 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.

Markian Hawryluk: MarkianH@kff.org, @MarkianHawryluk