KFF Health News

KFF Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Amid Coronavirus Distress, Wealthy Hospitals Hoard Millions

KFF Health News, April 28, 2020

Wealthy hospitals sitting on millions or even billions of dollars are in a competitive stampede against near-insolvent hospitals for the same limited pots of financial relief.

This article was first published on Tuesday, April 28, 2020 in Kaiser Health News.

By Jordan Rau

Inova Health System, with campuses in some of the wealthiest suburbs of Washington, D.C., and Truman Medical Centers, a safety-net hospital in downtown Kansas City, Missouri, have little in common. But, today, they are confronting the same financial plague: mass cancellations of nonessential surgeries that are their biggest moneymakers while bracing for an expensive onslaught of coronavirus patients.

Yet Truman has less than a month's worth of cash reserves to keep it afloat while Inova entered the outbreak with enough money to operate for at least 21 months, according to Inova's financial disclosure for 2019, before the stock market decline. At that time, Inova told its bondholders it had $3.1 billion in investments it could liquidate within three days. Tapping any of that may never be necessary because Inova also drew down its entire $238 million line of credit earlier this year to prepare for the pandemic.

"At the end of the day, not all hospitals are created equal," said Charlie Shields, Truman's president and CEO. "If you were sitting on a year of … cash on hand, that would not be as challenging, but most safety-net hospitals are south of 25 days, and we're probably around 10. How do you manage through that?"

But Dr. J. Stephen Jones, Inova's president and CEO, said, "Our finances are a mess at this point," with the system postponing non-urgent treatments and eliminating 427 administration and management positions.

"This is an existential threat to every health care organization, no matter how strong they come into it," said Jones, who cut his own salary by 25%.

As the coronavirus wreaks havoc with hospital finances, wealthy hospitals sitting on millions or even billions of dollars are in a competitive stampede against near-insolvent hospitals for the same limited pots of financial relief. Those include the $175 billion bailout fund Congress allotted for health care providers as part of two recent coronavirus packages and loans from private banks.

Certainly, even the richest hospitals are having their balance sheets despoiled by a triple punch: the stock market slump, the cost of preparation for coronavirus patients and the cessation of profitable surgeries, which is costing many hospitals half or more of their revenues. Inova, for instance, has spent $32 million to buy personal protective equipment and install negative air pressure systems in 200 hospital rooms, Jones said. (As of Monday morning, the system had 323 coronavirus patients.)

But unlike safety-net and smaller hospitals, many big health systems have the resources to stay afloat without financial assistance through the summer and beyond. Half of the 284 hospitals whose bonds Moody's Investors Service rated in 2018 had enough cash on hand to cover six months or more.

They also don't have to rely for survival on revenue from only treating patients. Before the stock market drop, 365 hospitals — about one of every 13 — reported an investment portfolio exceeding $100 million, according to a Kaiser Health News analysis of hospital cost reports from 2018 filed with Medicare. Together, those investments pumped $2.8 billion into those hospitals that year.

"A lot of the big hospitals have developed fortress balance sheets since the financial crisis" of 2008, said Chas Roades, co-founder and CEO of Gist Healthcare, a consulting firm. "The reflex is to protect the operation." But, he said, "if that's a rainy day fund, it's raining pretty hard right now."

The wealthier hospitals face sacrifices that other hospitals might envy, such as having to postpone ambitious building projects or adding to their already large investment portfolios. They are less concerned with running out of money than with depleting their cash reservoirs so much that their credit ratings would be downgraded, which could lead to higher borrowing costs.

"Most would prefer to have a line of credit than liquidate a stock holding," said Lisa Goldstein, an associate managing director at Moody's.

UCHealth, a 12-hospital nonprofit system in Colorado, has temporarily stopped contributing to its investments, which as of the end of last year totaled more than $544 million in cash and liquid investments and $4 billion in long-term investments, according to its financial disclosure report. Even before the pandemic, it had been stockpiling extra cash to build an 11-story tower at the University of Colorado Hospital in Denver that will cost $388 million, said Dan Rieber, UCHealth's chief financial officer. The system has enough liquidity to operate for more than 300 days without any new income and has obtained new lines of credit.

But when large health systems draw down those lines of credit, it makes it harder for smaller hospitals to get private aid because lenders may be tapped out, said Christopher Kerns, a vice president at Advisory Board, a health care consulting firm. "In our own discussions with lenders, there's only so much cash that's available, and that is putting the squeeze on the small or midsize organizations, and they are finding themselves very crushed," Kerns said.

The federal Health and Human Services Department has not made financial leeway assets a factor in deciding how it will distribute the $100 billion bailout fund passed in March. The department is doling out the first $30 billion based on how much each health care provider was paid by Medicare last year. The department plans to distribute the remaining money with an eye toward the prevalence of coronavirus infections in a hospital or region, and in the number of low-income and uninsured patients. The latest federal stimulus package — signed by President Donald Trump on Friday — added $75 billion to the relief fund.

"There isn't a mechanism right now to distinguish between the exceedingly well-endowed hospitals and those that are struggling," said Dan Mendelson, founder of the consulting company Avalere Health and a private equity investor.

The association representing safety-net hospitals, America's Essential Hospitals, has urged that cash reserves be a factor in divvying up the money, which is widely viewed as insufficient to cover all hospitals' costs. Some member hospitals have fewer than 10 days of cash reserves and run on average margins of 1.6%, a fifth of the industry average, according to the group.

"Our hospitals are struggling now to manage surging patient volume, staff and supply shortages, and other severe challenges as their limited cash reserves dwindle," Dr. Bruce Siegel, the association's president, said in a statement.

Certainly, even the wealthiest hospitals are seeing their robust balance sheets being turned upside down. Following the guidance of the federal government, UCHealth has postponed elective surgeries, leading to a drop in business of 50% to 60%. Elizabeth Concordia, UCHealth's CEO, said the system expects that it will not completely rebound even when the pandemic has diminished because many older people will be reluctant to return for elective surgeries for fear they might become infected with the coronavirus.

She said UCHealth is also on the front lines of fighting the pandemic. It currently has admitted 240 COVID-19 patients, more than any other Colorado hospital, and has been analyzing tests for rural hospitals without yet setting a contract for how much it will be reimbursed. It has also maintained its 25,000-person workforce without imposing pay reductions or furloughs.

"COVID is having a devastating impact on all of our finances," Concordia said.

But for those hospitals with their own wealth, investment earnings can provide a buffer that most hospitals don't have. In a forthcoming paper in the Journal of General Internal Medicine, researchers at the Johns Hopkins Bloomberg School of Public Health led by Ge Bai found that nearly all investment earnings for nonprofit hospitals were earned by just a quarter of the hospitals. Without that amount, their aggregate net income would have been 31% lower.

Investment income made up 5% of the total revenue for Trinity Health, a 92-hospital Catholic system based in Michigan and operating in 22 states, according to its financial disclosures to bondholders covering the last six months of 2019. Those investment earnings of $468 million accounted for 58% of Trinity's surplus.

As of December, Trinity had $9.6 billion in cash and investments, enough to operate for six months. It also reported credit lines totaling $1.2 billion. Trinity did not respond to requests for comment.

The wealthier hospital systems are strongly positioned to take full advantage of whatever method the government sets for distributing the remainder of the bailout funds. They employ more reimbursement staff and have in place sophisticated methods to document every expense that they can attribute to the coronavirus response, said Simone Rauscher Singh, an assistant professor at the University of Michigan School of Public Health.

"The big hospitals are ramping up their capacity to document all this so they can go back later and say, 'This is what we spent,'" she said. "The small hospitals are going to be in an even worse position to do that."

Jordan Rau: jrau@kff.org, @JordanRau

Telehealth Will be Free, No Copays, They Said. But Angry Patients Are Getting Billed.

KFF Health News, April 27, 2020

In a fragmented health system the shift to cost-free telemedicine for patients is going far less smoothly than the speeches and press releases suggest.

This story was first published on Monday, April 27, 2020 in Kaiser Health News.

By Jay Hancock April 27, 2020

Karen Taylor had been coughing for weeks when she decided to see a doctor in early April. COVID-19 cases had just exceeded 5,000 in Texas, where she lives.

Cigna, her health insurer, said it would waive out-of-pocket costs for "telehealth" patients seeking coronavirus screening through video conferences. So Taylor, a sales manager, talked with her physician on an internet video call.

The doctor's office charged her $70. She protested. But "they said, 'No, it goes toward your deductible and you've got to pay the whole $70,'" she said.

Policymakers and insurers across the country say they are eliminating copayments, deductibles and other barriers to telemedicine for patients confined at home who need a doctor for any reason.

"We are encouraging people to use telemedicine," New York Gov. Andrew Cuomo said last month after ordering insurers to eliminate copays, typically collected at the time of a doctor visit, for telehealth visits.

But in a fragmented health system — which encompasses dozens of insurers, 50 state regulators and thousands of independent doctor practices ― the shift to cost-free telemedicine for patients is going far less smoothly than the speeches and press releases suggest. In some cases, doctors are billing for telephone calls that used to be free.

Patients say doctors and insurers are charging them upfront for video appointments and phone calls, not just copays but sometimes the entire cost of the visit, even if it's covered by insurance.

Despite what politicians have promised, insurers said they were not able to immediately eliminate telehealth copays for millions of members who carry their cards but receive coverage through self-insured employers. Executives at telehealth organizations say insurers have been slow to update their software and policies.

"A lot of the insurers who said that they're not going to charge copayments for telemedicine ― they haven't implemented that," said George Favvas, CEO of Circle Medical, a San Francisco company that delivers family medicine and other primary care via livestream. "That's starting to hit us right now."

One problem is that insurers have waived copays and other telehealth cost sharing for in-network doctors only. Another is that Blue Cross Blue Shield, Aetna, Cigna, UnitedHealthcare and other carriers promoting telehealth have little power to change telemedicine benefits for self-insured employers whose claims they process.

Such plans cover more than 100 million Americans — more than the number of beneficiaries covered by the Medicare program for seniors or by Medicaid for low-income families. All four insurance giants say improved telehealth benefits don't necessarily apply to such coverage. Nor can governors or state insurance regulators force those plans, which are regulated federally, to upgrade telehealth coverage.

"Many employer plans are eliminating cost sharing" now that federal regulators have eased the rules for certain kinds of plans to improve telehealth benefits, said Brian Marcotte, CEO of the Business Group on Health, a coalition of very large, mostly self-insured employers.

For many doctors, business and billings have plunged because of the coronavirus shutdown. New rules notwithstanding, many practices may be eager to collect telehealth revenue immediately from patients rather than wait for insurance companies to pay, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

"A lot of providers may not have agreements in place with the plans that they work with to deliver services via telemedicine," she said. "So these providers are protecting themselves upfront by either asking for full payment or by getting the copayment."

David DeKeyser, a marketing strategist in Brooklyn, New York, sought a physician's advice via video after coming in contact with someone who attended an event where coronavirus was detected. The office charged the whole visit — $280, not just the copay ― to his debit card without notifying him.

"It happened to be payday for me," he said. A week earlier and the charge could have caused a bank overdraft, he said. An email exchange got the bill reversed, he said.

With wider acceptance, telehealth calls have suddenly become an important and lucrative potential source of physician revenue. Medicare and some commercial insurers have said they will pay the same rate for video calls as for office visits.

Some doctors are charging for phone calls once considered an incidental and non-billable part of a previous office visit. Blue Cross plans in Massachusetts, Wyoming, Alabama and North Carolina are paying for phoned-in patient visits, according to America's Health Insurance Plans, a lobbying group.

"A lot of carriers wouldn't reimburse telephonic encounters" in the past, Corlette said.

Catherine Parisian, a professor in North Carolina, said what seemed like a routine follow-up call with her specialist last month became a telehealth consultation with an $80 copay.

"What would have been treated as a phone call, they now bill as telemedicine," she said. "The physician would not call me without billing me." She protested the charge and said she has not been billed yet.

By many accounts, the number of doctor encounters via video has soared since the Department of Health and Human Services said in mid-March that it would take "unprecedented steps to expand Americans' access to telehealth services."

Medicare expanded benefits to pay for most telemedicine nationwide instead of just for patients in rural areas and other limited circumstances, HHS said. The program has also temporarily dropped a ban on doctors waiving copays and other patient cost sharing. Such waivers might have been considered violations of federal anti-kickback laws.

At the same time, the CARES Act, passed by Congress last month to address the COVID-19 emergency, allows private, high-deductible health insurance to make an exception for telehealth in patient cost sharing. Such plans can now pay for video doctor visits even if patients haven't met the deductible.

Dozens of private health insurers listed by AHIP say they have eliminated copays and other cost sharing for telemedicine. Cigna, however, has waived out-of-pocket costs only for telehealth associated with COVID-19 screening. Cigna did not respond to requests for comment.

Teladoc Health, a large, publicly traded telemedicine company, said its volume has doubled to 20,000 medical visits a day since early March. Its stock price has nearly doubled, too, since Jan. 1.

With such a sharp increase, it's not surprising that insurers and physicians are struggling to keep up, said Circle Medical CEO Favvas.

"It's going to be an imperfect process for a while," he said. "It's understandable given that things are moving so quickly."

Abbie VanSickle, a California journalist, wanted her baby's scheduled wellness visit done remotely because she worried about visiting a medical office during a pandemic. Her insurer, UnitedHealthcare, would not pay for it, the pediatrician told her. Mom and baby had to come in.

"It seems like such an unnecessary risk to take," VanSickle said. "If we can't do wellness visits, we're surely not alone."

A UnitedHealthcare spokesperson said that there was a misunderstanding and that the baby's remote visit would be covered without a copay.

Jacklyn Grace Lacey, a New York City medical anthropologist, had a similar problem. She had to renew a prescription a few weeks after Cuomo ordered insurers to waive patient cost sharing for telehealth appointments.

The doctor's office told her she needed to come in for a visit or book a telemedicine appointment. The video visit came with an "administrative fee" of $50 that she would have had to pay upfront, she said — five times what the copay would have been for an in-person session.

"I was not going to go into a doctor's office and potentially expose people just to get a refill on my monthly medication," she said.

Jay Hancock: jhancock@kff.org, @JayHancock1

Vaping, Opioid Addiction Accelerate Coronavirus Risks, Says NIDA Director

KFF Health News, April 26, 2020

Dr. Nora Volkow, who heads the National Institute on Drug Abuse, explains how emerging science points to added challenges for these patient populations and the public health system.

This article was first published on Friday, April 24, 2020 in Kaiser Health News.

By Shefali Luthr

In 2018, opioid overdoses claimed about 47,000 American lives. Last year, federal authorities reported that 5.4 million middle and high school students vaped. And just two months ago, about 2,800 cases of vaping-associated lung injuries resulted in hospitalizations; 68 people died.

Until mid-March, these numbers commanded attention. But as the coronavirus death toll climbs and the economic costs of attempting to control its spread wreak havoc, the public health focus is now dramatically different.

In the background, though, these other issues — the opioid epidemic and vaping crisis — persist in heaping complications on an overwhelmed public health system.

It is creating a distinctly American problem, said Dr. Nora Volkow, who heads the National Institute on Drug Abuse.

Volkow spoke with Kaiser Health News about the emerging science around COVID-19’s relationship to vaping and to opioid use disorder, as well as how these underlying epidemics could increase people’s risks. Her remarks have been edited for length and clarity.

Q: We’ve already been experiencing two epidemics at once — vaping and the opioid crisis — and now we’re in the midst of a third. Does that change the nature of addressing the coronavirus in the United States?

It makes a different kind of situation than we see abroad. It forces us as a country to be urgently multitasking, to focus on the urgent needs of COVID while not ignoring the other epidemics devastating America. That’s certainly challenging.

Q: What is the evidence around the relationship between vaping and the coronavirus?

Because of the recency, there’s no data to show if there are differences in outcomes between people who vape and people who do not vape. There’s no reported scientific evidence. We will start seeing it.

We know from all the cases of acute lung injury that vaping, particularly certain combinations of chemicals that were related to vaping of THC, actually led to death. The cause of death was pulmonary dysfunction. We know from animal experiments that vaping itself — not even giving any drugs with it — can produce inflammatory changes in the lung.

We already know for COVID that, with comorbid conditions — particularly those that affect the lungs, the heart, the immune system — [patients] are more likely to have negative outcomes.

One can predict an association. In the meantime, because of the data that already exist, we should be very cautious. The prudent thing is to strongly advise individuals who are vaping to stop.

Q: Young people so far appear to have lower risks of COVID complications. Does vaping change that?

We know there have been fatalities among young people. One very important area of research is to try to understand the specific vulnerabilities among young people.

Why would you want to risk it when you already know vaping produces inflammatory changes in the lungs? We know in medicine, a tissue that has suffered harm is more vulnerable.

The big centers where you are observing the rise in COVID-19 cases, that’s where you are more likely to see the comorbidity of vaping.

It’s young people that are mostly vaping, but also older people, many of whom otherwise would be smoking tobacco. [Smoking] also raises the risk. Even though the samples have not been large enough, overall, smokers have done worse than nonsmokers when they have COVID.

Q: Let’s talk about opioid use disorder. What kind of comorbidities are we starting to see between opioid use disorder and COVID-19?

People who have opioid use disorder are also likely to be smokers. Smoking itself increases harm to your lungs.

We do know that opioids actually are immunosuppressants. This has been extensively studied. Nicotine also can disrupt immunity and actually impair the capacity of the cell to respond to viral infections.

One of the things opioids do is they depress your respiration. If it’s severe enough, they stop breathing. That’s what leads to death.

Whether you overdose or not, when you are taking opioids, the frequency of your breathing is down, and the oxygen in your blood tends to be lower.

The [COVID] infection targets the respiratory tissues in the lungs. It interferes with the capacity to transfer oxygen into the blood.

If you get COVID and you are taking opioids, the physiological consequences are going to be much worse. You’re not only going to have the effects of the virus itself, but you’ll have the depressive effects of opioids in the respiratory system [and] in the brain that lead to much less circulation in the lungs.

Q: What about other supports for people in recovery?

Community support systems like syringe exchange programs are closing. Methadone clinics are closing. If they’re not closing, they’re unable to process the same number of patients — because the staff is getting sick or the place where the methadone clinic was does not allow for so many people. Public transportation is not available for people to attend their methadone clinics.

We’re also hearing from our investigators they have observed a significant reduction in the capacity of the health care system to initiate people on medication for opioid use disorder — especially buprenorphine. Many of the buprenorphine initiations were done in health care facilities that are saturated with COVID.

Q: What’s happening to address those problems?

If in the past, if you were a physician or a nurse practitioner and you wanted to initiate someone on buprenorphine, the laws were that you needed to see that person physically. That’s changed. It’s now possible you can initiate someone on buprenorphine through telehealth. That’s incredibly valuable.

There’s extended reimbursement for telehealth, which expands access to treatment. There are also apps that have been created that provide individuals who have addiction [access] to mentors or coaches, as well as access to therapies and group therapies.

That is one of the aspects that has actually been accelerated by the COVID crisis. These may facilitate treatment into the future, even when COVID’s no longer there.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Seniors With COVID-19 Show Unusual Symptoms, Doctors Say

KFF Health News, April 24, 2020

If early signs of COVID-19 are missed, seniors may deteriorate before getting needed care.

This article was first published on Friday, April 24, 2020 in Kaiser Health News.

By Judith Graham

Older adults with COVID-19, the illness caused by the coronavirus, have several "atypical" symptoms, complicating efforts to ensure they get timely and appropriate treatment, according to physicians.

COVID-19 is typically signaled by three symptoms: a fever, an insistent cough and shortness of breath. But older adults — the age group most at risk of severe complications or death from this condition ― may have none of these characteristics.

Instead, seniors may seem "off" — not acting like themselves ― early on after being infected by the coronavirus. They may sleep more than usual or stop eating. They may seem unusually apathetic or confused, losing orientation to their surroundings. They may become dizzy and fall. Sometimes, seniors stop speaking or simply collapse.

"With a lot of conditions, older adults don't present in a typical way, and we"re seeing that with COVID-19 as well," said Dr. Camille Vaughan, section chief of geriatrics and gerontology at Emory University.

The reason has to do with how older bodies respond to illness and infection.

At advanced ages, "someone"s immune response may be blunted and their ability to regulate temperature may be altered," said Dr. Joseph Ouslander, a professor of geriatric medicine at Florida Atlantic University's Schmidt College of Medicine.

"Underlying chronic illnesses can mask or interfere with signs of infection," he said. "Some older people, whether from age-related changes or previous neurologic issues such as a stroke, may have altered cough reflexes. Others with cognitive impairment may not be able to communicate their symptoms."

Recognizing danger signs is important: If early signs of COVID-19 are missed, seniors may deteriorate before getting needed care. And people may go in and out of their homes without adequate protective measures, risking the spread of infection.

Dr. Quratulain Syed, an Atlanta geriatrician, describes a man in his 80s whom she treated in mid-March. Over a period of days, this patient, who had heart disease, diabetes and moderate cognitive impairment, stopped walking and became incontinent and profoundly lethargic. But he didn't have a fever or a cough. His only respiratory symptom: sneezing off and on.

The man's elderly spouse called 911 twice. Both times, paramedics checked his vital signs and declared he was OK. After another worried call from the overwhelmed spouse, Syed insisted the patient be taken to the hospital, where he tested positive for COVID-19.

"I was quite concerned about the paramedics and health aides who'd been in the house and who hadn't used PPE [personal protective equipment]," Syed said.

Dr. Sam Torbati, medical director of the Ruth and Harry Roman Emergency Department at Cedars-Sinai Medical Center, describes treating seniors who initially appear to be trauma patients but are found to have COVID-19.

"They get weak and dehydrated," he said, "and when they stand to walk, they collapse and injure themselves badly."

Torbati has seen older adults who are profoundly disoriented and unable to speak and who appear at first to have suffered strokes.

"When we test them, we discover that what's producing these changes is a central nervous system effect of coronavirus," he said.

Dr. Laura Perry, an assistant professor of medicine at the University of California-San Francisco, saw a patient like this several weeks ago. The woman, in her 80s, had what seemed to be a cold before becoming very confused. In the hospital, she couldn't identify where she was or stay awake during an examination. Perry diagnosed hypoactive delirium, an altered mental state in which people become inactive and drowsy. The patient tested positive for coronavirus and is still in the ICU.

Dr. Anthony Perry, an associate professor of geriatric medicine at Rush University Medical Center in Chicago, tells of an 81-year-old woman with nausea, vomiting and diarrhea who tested positive for COVID-19 in the emergency room. After receiving IV fluids, oxygen and medication for her intestinal upset, she returned home after two days and is doing well.

Another 80-year-old Rush patient with similar symptoms — nausea and vomiting, but no cough, fever or shortness of breath ― is in intensive care after getting a positive COVID-19 test and due to be put on a ventilator. The difference? This patient is frail with "a lot of cardiovascular disease," Perry said. Other than that, it's not yet clear why some older patients do well while others do not.

So far, reports of cases like these have been anecdotal. But a few physicians are trying to gather more systematic information.

In Switzerland, Dr, Sylvain Nguyen, a geriatrician at the University of Lausanne Hospital Center, put together a list of typical and atypical symptoms in older COVID-19 patients for a paper to be published in the Revue Médicale Suisse. Included on the atypical list are changes in a patient's usual status, delirium, falls, fatigue, lethargy, low blood pressure, painful swallowing, fainting, diarrhea, nausea, vomiting, abdominal pain and the loss of smell and taste.

Data comes from hospitals and nursing homes in Switzerland, Italy and France, Nguyen said in an email.

On the front lines, physicians need to make sure they carefully assess an older patient's symptoms.

"While we have to have a high suspicion of COVID-19 because it's so dangerous in the older population, there are many other things to consider," said Dr. Kathleen Unroe, a geriatrician at Indiana University's School of Medicine.

Seniors may also do poorly because their routines have changed. In nursing homes and most assisted living centers, activities have stopped and "residents are going to get weaker and more deconditioned because they're not walking to and from the dining hall," she said.

At home, isolated seniors may not be getting as much help with medication management or other essential needs from family members who are keeping their distance, other experts suggested. Or they may have become apathetic or depressed.

"I'd want to know "What's the potential this person has had an exposure [to the coronavirus], especially in the last two weeks?"" said Vaughan of Emory. "Do they have home health personnel coming in? Have they gotten together with other family members? Are chronic conditions being controlled? Is there another diagnosis that seems more likely?"

"Someone may be just having a bad day. But if they're not themselves for a couple of days, absolutely reach out to a primary care doctor or a local health system hotline to see if they meet the threshold for [coronavirus] testing," Vaughan advised. "Be persistent. If you get a 'no' the first time and things aren't improving, call back and ask again."

Judith Graham: khn.navigatingaging@gmail.com, @judith_graham

Born Into a Pandemic: Virus Complicates Births for Moms and Babies

KFF Health News, April 24, 2020

Across the U.S., COVID-19 is radically altering medical care, not only for vulnerable elders but also for pregnant women and their babies entering the world.

This article was first published on Friday, April 24, 2020 in Kaiser Health News.

By JoNel Aleccia and Laura Ungar

Mallory Pease's contractions grew stronger as her husband, Mitchell, drove her to Oaklawn Hospital in Marshall, Michigan, to give birth to their second child. It had been a routine pregnancy, but she told her doctor she'd recently developed a sore throat, aches, coughing and shortness of breath — symptoms her provider knew could indicate COVID-19.

So, when she arrived at the hospital, she was taken to an isolation area, tested for the coronavirus and given oxygen. She took shallow, panting breaths as she delivered her daughter on March 23 in about five hours.

But she could hold little Alivia for only five minutes before the newborn was whisked off to a nursery. Pease, 27, was transferred to a COVID-19 floor, where she was told her test came back positive. By the next morning, she was so ill that her doctors discussed putting her on a ventilator.

As she struggled to breathe and worried for her life, her heart ached to hold her newborn. Instead, she held tight to the memory of that brief glimpse.

When she finally got to cradle Alivia in her arms four days later, she said, "it was kind of like meeting her all over again."

Across the U.S., COVID-19 is radically altering medical care, not only for vulnerable elders but also for pregnant women and their babies entering the world. "In the last six weeks, our entire world that was known as being normal has completely turned around," said Dr. Edith Cheng, division chief for maternal fetal medicine at the University of Washington.

Hospitals from Seattle to St. Louis are recommending separating infected mothers from their newborns for days, and asking the women to forgo the intimacy of skin-to-skin contact, and sometimes breastfeeding, to help prevent their infants from contracting the disease.

The actions are based on guidance from medical associations. Officials with the Centers for Disease Control and Prevention had advised separation across the board until updating their guidance on April 4 to consider it case by case.

Separation runs counter to most any parent's birth plan — and to the best research on family-centered care. But experts say it's important to put protections in place, given the still-evolving understanding of the effects of COVID-19 during pregnancy and childbirth.

"Can babies be infected if the mother is infected at birth? The answer is yes, not commonly, but yes," said Dr. Karen Puopolo, an associate professor of pediatrics at the University of Pennsylvania School of Medicine and co-author of the American Academy of Pediatrics guidelines on COVID-19 and newborns.

It's not clear how many pregnant afternoon, that's still many thousands of expectant women potentially affected women have been infected with COVID-19 across the U.S. They accounted for just 2% of cases tallied in one early report. With more than 830,000 confirmed infections in the U.S. as of Wednesday by the deadly respiratory virus.

Many pregnant women may be infected and not know it. Of 215 women admitted for delivery at New York-Presbyterian Allen Hospital and Columbia University Irving Medical Center in New York City from March 22 to April 4, about 15% tested positive for the coronavirus, but the vast majority showed no symptoms upon admission.

Scattered reports of infants possibly being sickened by the coronavirus are surfacing nationwide. A 9-month-old baby in Chicago who tested positive for COVID-19 died in March, though further investigation has raised questions about whether the virus was to blame. This month, a 6-week-old girl who tested positive for the virus died in Connecticut; investigation also continues into her cause of death. Kentucky's governor recently announced that the state's new cases included a 10-day-old boy.

Very young babies may be at higher risk for serious complications from COVID-19 than other children. Although those 18 and younger make up fewer than 2% of all COVID-19 cases in the U.S., infants accounted for most of the hospitalizations in pediatric cases, according to the CDC. Of 95 children younger than 1 hospitalized between Feb. 12 and April 2, at least 59 were hospitalized, and five were admitted to the ICU.

That information — plus limited data on infections in babies in China — has shifted the thinking of many obstetrics specialists, said Cheng.

In recent weeks, several pregnant women infected with COVID-19 have delivered babies at Cheng's hospital, the UW Medical Center in Seattle. Their newborns were sent to a special section in the neonatal intensive care unit. At other facilities, separation might involve taking the newborn to another room, or letting the mother and baby stay in the same room, but 6 feet apart and often separated by a curtain.

They're kept apart from moms — and sometimes dads, who also may be sick — until the parents have had no symptoms for three days or for a week after their first symptoms, whichever is greater.

Given the still-scant data about the effects of COVID-19, some experts question whether separating mothers and newborns is wise or warranted. Disrupting the bonding that occurs in the first days of life could have far-reaching consequences, said Dr. Yalda Afshar, an OB-GYN at UCLA Health in Los Angeles.

"Being completely data-blind but counseling women on their outcomes and their babies' outcomes is just wrong," she said.

To fill the data void, Afshar and colleagues at the University of California-San Francisco have created a nationwide pregnancy registry to track the effects of COVID-19 on pregnant women and their newborns. Already, more than 1,000 people have signed up for the study.

Silvana Vergara Tobin, 33, who runs an online art gallery in New York City, is among them. Tobin fell ill with COVID-19 in mid-March and is worried about the potential effects on the baby boy she expects to deliver in August.

"What really scares me is that I might get it again," said Tobin, whose symptoms included sinus headaches, body aches and a persistent cough. "Or that the baby didn't get immunity and he might get it once he's born."

The registry will track women and their babies from early pregnancy through a year postpartum, trying to answer basic questions. "Do pregnant women with COVID have more severe, less severe or different disease?" Afshar said. "Does it transmit in utero? Does it cause birth defects?"

Doctors and patients said it's frustrating that so much remains unknown.

Alaine Gilpin, who lives near Louisville, Kentucky, tested positive for COVID-19 in early April after coughing for a month but showing no other symptoms. She gave birth at Norton Women's & Children's Hospital on April 11 at 5½ months' gestation. The baby boy weighed just 1 pound, 9 ounces and needed the aid of a ventilation machine. She now wonders: "Could this be a result of COVID?"

To protect moms and babies, many hospitals with enough test kits are starting to test all women who show up to give birth. Dr. Chemen Neal, an OB-GYN with Indiana University Health, said her colleagues bathe the babies of COVID-positive moms just after birth. And like medical professionals elsewhere, they talk to each mom about pumping breast milk for her baby or breastfeeding only after washing her torso and hands and wearing a surgical mask.

At some hospitals, COVID-19 births can be especially challenging. At Barnes-Jewish Hospital in St. Louis, for example, women with symptoms can't give birth in the normal labor and delivery area because it's in a building that also houses severely immunocompromised patients. A triage tent has been set up outside, and moms with known or suspected COVID-19 are routed through the emergency room into a special delivery area.

Another challenge is keeping babies safe after they are discharged from the hospital. Ideally, experts recommend infected moms stay 6 feet from their babies while another caretaker provides daily care, but often this is difficult, particularly for women who lack family support.

Pease worried about passing the virus to her baby after getting home. Before embracing Alivia at her aunt's house, and for the next few days, she said, she wore a mask and "washed my hands like crazy."

But over time, Pease's symptoms have eased and she's gotten stronger. Though she still gets tired in the evenings, she's now able to feed, change and care for her newborn. And she said her bond with the baby is strong.

"Alivia is good. She's happy," Pease said. "She never skipped a beat."

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

Laura Ungar: lungar@kff.org, @laura_ungar

OSHA Probing Health Worker Deaths But Urges Inspectors To Spare The Penalties

KFF Health News, April 23, 2020

The nation's top worker safety agency is not viewed as an advocate likely to rush to workers' aid.

This article was first published on Wednesday, April 22, 2020 in Kaiser Health News.

By Christina Jewett and Shefali Luthra

The Occupational Safety and Health Administration has in recent weeks launched investigations into deaths of workers at 34 health care employers across the U.S., federal records show, but former agency officials warn that the agency has already signaled it will only cite and fine the most flagrant violators.

The investigations come as health care workers have aired complaints on social media and to lawmakers about a lack of personal protective equipment, pressure to work while sick, and retaliation for voicing safety concerns as they have cared for more than 826,000 patients stricken by the coronavirus.

Despite those concerns, the nation's top worker safety agency is not viewed as an advocate likely to rush to workers' aid. President Donald Trump tapped a Labor Department leader who has represented corporations railing against the very agency he leads.

"It's a worker safety crisis of monstrous proportions and OSHA is nowhere to be found," said David Michaels, an epidemiologist and George Washington University professor who was assistant secretary of Labor and ran OSHA from 2009 to 2017.

Employers are required to report a work-related death to OSHA or face fines for failing to do so. Yet former OSHA leaders say the agency has not openly reminded hospitals and nursing homes to file such reports in recent weeks.

Last week, the Centers for Disease Control and Prevention reported that more than 9,200 health workers had been infected with the coronavirus, a number the agency concedes is a vast undercount. The estimate was based on a set of lab-generated reports in which only 16% included the patient's profession. The agency said the true number is probably closer to 11% of all known cases.

Federal records show the OSHA fatality investigations ― searchable here — involve hospitals, an emergency medical service agency, a jail health department and nursing homes. Its investigations can be prompted by the complaint of a worker, a former worker or even an OSHA official who sees a news report about a workplace death. They can be conducted by phone and fax or involve an on-site inspection.

One fatality investigation launched April 7 focuses on Marion Regional Nursing home in Hamilton, Alabama, where nurse Rose Harrison, 60, worked before she died of COVID-19, her daughter Amanda Williams said.

Williams said her mother was not given a mask when caring for a patient on March 25 ― 10 days after the county's first coronavirus case — who later tested positive for the virus. Williams said her mother felt pressured to keep going to work even as she was coughing, fatigued and running a low-grade fever.

"She kept telling me 'Amanda, I have to work, I have to get my house paid off,'" Williams said, noting her mother said she was urged to work unless her temperature reached 100.4.

Williams said that she drove her mother to the hospital on April 3 and that Harrison was unhappy she'd spent the week working. Harrison went on a ventilator the following day, fully expecting to recover. She died April 6.

"When your mother dies mad, you're pretty much mad," Williams, one of Harrison's three daughters, said. "I think if proper steps were taken from the beginning, this would have been different."

North Mississippi Health Services, which owns the nursing home, and the home's administrator did not reply to calls or emails.

An April 13 OSHA memo said the agency would prioritize death investigations involving health care workers and first responders. It said "formal complaints alleging unprotected exposures to COVID-19 … may warrant an on-site inspection."

Michaels, the former Labor Department official, said a subsequent OSHA memo suggested that officials are unlikely to penalize all but the most careless employers.

The memo about employers' "good faith" efforts said a citation may be issued "where the employer cannot demonstrate any efforts to comply."

Michaels said that "any efforts" to comply with work safety rules could amount to making even one phone call to try to buy masks for workers.

Federal OSHA officials did not respond to a request for comment.

Democrats criticized Trump last year when he tapped Eugene Scalia, who spent years of his legal career defending major corporations, to head the Labor Department.

Scalia fought OSHA on behalf of SeaWorld after it was cited over the death of a woman training killer whales, The New York Times reported. Scalia's team argued the work-safety agency was not meant to regulate the training of killer whales. He also argued that SeaWorld had adequate safety measures in place, but ultimately lost the case.

Sen. Bernie Sanders, alluding to Scalia's record of defending firms like Chevron and Goldman Sachs, called the appointment "obscene."

Since March 27, the ongoing fatality investigations have been mostly categorized as "partial" investigations, which initially focus on one area of noncompliance. Four are labeled "complete," meaning they cover a wide range of hospital operations.

One of the "complete" investigations is listed at Coral Gables Hospital in South Florida, where respiratory therapist Jorge Mateo, 82, worked before he died of coronavirus complications, his daughter said.

The hospital reported the death, according to a statement from Shelly Weiss Friedberg of Tenet Healthcare, which owns the hospital. She said Mateo was with the hospital for four decades and "the loss of Jorge Mateo is felt throughout our entire community."

A subsequent investigation — also labeled as "complete" ― was opened April 10 at Palmetto General Hospital, in South Florida.

There, 33-year-old Danielle Dicenso worked for a staffing agency as an ICU nurse, treating coronavirus patients. Dicenso died after developing COVID-19 symptoms, including fever and a cough, according to reports in the Miami Herald. The Palm Beach County medical examiner has not yet determined a cause of death, a spokesperson told Kaiser Health News.

Her husband, David Dicenso, told local news station WSVN she had not been given a protective mask and was "very scared of going to work."

Weiss Friedberg, of Tenet, which also owns Palmetto, said in an email that "nurses are provided appropriate personal protective equipment (PPE) in compliance with Centers for Disease Control (CDC) guidelines."

The latest guidelines say staff can wear a face mask if no N95 respirator is available when performing routine care with COVID-19 patients. For higher-risk procedures, such as intubation, workers must receive N95 masks.

OSHA opened an inspection at St. Catherine of Siena Medical Center, a Long Island hospital, on April 11. Federal officials had learned from a local news story about a patient care assistant dying of COVID-19, hospital leadership confirmed.

The hospital has no record of that employee having any interaction with COVID patients, said James O'Connor, its executive vice president. The hospital tests employees for COVID-19 only if they have had confirmed exposure to someone who tested positive and if they develop symptoms.

O'Connor said all employees who are in contact with suspected COVID-19 patients get the full suite of PPE; they are told to clean their N95 masks after each shift, he said, and to change masks entirely every three shifts.

That can mean workers wear the same equipment for multiple days.

Early research suggests that N95s can be sanitized and reused up to three times. But that paper has not yet undergone peer review. In an affidavit the New York State Nurses Association filed regarding another state hospital, the union argued that it has "yet to be adequately proven that disposable respirators can be effectively decontaminated" without putting the wearer at risk.

As recently as April 16, the local nurses union told Newsday that St. Catherine workers on Long Island are being told to share PPE.

While OSHA does have a "general duty" clause urging employers to keep workers safe and a standard for respiratory protection, it has no written rule on protecting workers from airborne disease, said Debbie Berkowitz, a former OSHA chief of staff and director of the National Employment Law Project's worker safety and health program.

As OSHA and the Centers for Disease Control and Prevention downgrade their requirements week by week, workers are left with the choice in some places to wear a bandana in situations that had called for a properly fitted N95 mask, which can filter out particles as small as 0.1 microns.

"OSHA has really completely abandoned their mandate to protect workers," Berkowitz said, "and every worker is on their own."

Christina Jewett: ChristinaJ@kff.org, @by_cjewett

Shefali Luthra: ShefaliL@kff.org, @Shefalil

How Climate Change is Putting Doctors in the Hot Seat

KFF Health News, April 20, 2020

Patients' health issues represent the subtler ways that climate change is showing up in the exam room, according to the physicians who treated them.

This article was first published on Monday, April 20, 2020 in Kaiser Health News.

By Melissa Bailey

BOSTON — A 4-year-old girl was rushed to the emergency room three times in one week for asthma attacks.

An elderly man, who'd been holed up in a top-floor apartment with no air conditioning during a heat wave, showed up at a hospital with a temperature of 106 degrees.

A 27-year-old man arrived in the ER with trouble breathing ― and learned he had end-stage kidney disease, linked to his time as a sugar cane farmer in the sweltering fields of El Salvador.

These patients, whose cases were recounted by doctors, all arrived at Boston-area hospitals in recent years. While the coronavirus pandemic is at the forefront of doctor-patient conversations these days, there's another factor continuing to shape patients' health: climate change.

Global warming is often associated with dramatic effects such as hurricanes, fires and floods, but patients' health issues represent the subtler ways that climate change is showing up in the exam room, according to the physicians who treated them.

Dr. Renee Salas, an emergency physician at Massachusetts General Hospital, said she was working a night shift when the 4-year-old arrived the third time, struggling to breathe. The girl's mother felt helpless that she couldn't protect her daughter, whose condition was so severe that she had to be admitted to the hospital, Salas recalled.

She found time to talk with the patient's mother about the larger factors at play: The girl's asthma appeared to be triggered by a high pollen count that week. And pollen levels are rising in general because of higher levels of carbon dioxide, which she explained is linked to human-caused climate change.

Salas, a national expert on climate change and health, is a driving force behind an initiative to spur clinicians and hospitals to take a more active role in responding to climate change. The effort launched in Boston in February, and organizers aim to spread it to seven U.S. cities and Australia over the next year and a half.

Although there is scientific consensus on a mounting climate crisis, some people reject the idea that rising temperatures are linked to human activity. The controversy can make doctors hesitant to bring it up.

Even at the climate change discussion in Boston, one panelist suggested the topic may be too political for the exam room. Dr. Nicholas Hill, head of the Pulmonary, Critical Care and Sleep Division at Tufts Medical Center of Medicine, recalled treating a "cute little old lady" in her 80s who likes Fox News, a favorite of climate change doubters. With someone like her, talking about climate change may hurt the doctor-patient relationship, he suggested. "How far do you go in advocating with patients?"

Doctors and nurses are well suited to influence public opinion because the public considers them "trusted messengers," said Dr. Aaron Bernstein, who co-organized the Boston event and co-directs the Center for Climate, Health, and the Global Environment at Harvard's school of public health. People have confidence they will provide reliable information when they make highly personal and even life-or-death decisions.

Bernstein and others are urging clinicians to exert their influence by contacting elected officials, serving as expert witnesses, attending public protests and reducing their hospital's carbon emissions. They're also encouraging them to raise the topic with patients.

Dr. Mary Rice, a pulmonologist who researches air quality at Beth-Israel Deaconess Medical Center here, recognized that in a 20-minute clinic visit, doctors don't have much time to spare.

But "I think we should be talking to our patients about this," she said. "Just inserting that sentence, that one of the reasons your allergies are getting worse is that the allergy season is worse than it used to be, and that's because of climate change."

Salas, who has been a doctor for seven years, said she had little awareness of the topic until she heard climate change described as the "greatest public health emergency of our time" during a 2013 conference.

"I was dumbfounded about why I hadn't heard of this, climate change harming health," she said. "I clearly saw this is going to make my job harder" in emergency medicine.

Now, Salas said, she sees ample evidence of climate change in the exam room. After Hurricane Maria devastated Puerto Rico, for instance, a woman seeking refuge in Boston showed up with a bag of empty pill bottles and thrust it at Salas, asking for refills, she recalled. The patient hadn't had her medications replenished for weeks because of the storm, whose destructive power was likely intensified by climate change, according to scientists.

Climate change presents many threats across the country, Salas noted: Heat stress can exacerbate mental illness, prompt more aggression and violence, and hurt pregnancy outcomes. Air pollution worsens respiratory problems. High temperatures can weaken the effectiveness of medications such as albuterol inhalers and EpiPens.

The delivery of health care is also being disrupted. Disasters like Hurricane Maria have caused shortages in basic medical supplies. Last November, nearly 250 California hospitals lost power in planned outages to prevent wildfires. Natural disasters can interrupt the treatment of cancer, leading to earlier death.

Even a short heat wave can upend routine care: On a hot day last summer, for instance, power failed at Mount Auburn Hospital in Cambridge, Massachusetts, and firefighters had to move patients down from the top floor because it was too hot, Salas said.

Other effects of climate change vary by region. Salas and others urged clinicians to look out for unexpected conditions, such as Lyme disease and West Nile virus, that are spreading to new territory as temperatures rise.

In California, where wildfires have become a fact of life, researchers are scrambling to document the ways smoke inhalation is affecting patients' health, including higher rates of acute bronchitis, pneumonia, heart attacks, strokes, irregular heartbeats and premature births.

Researchers have shown that heavy exposure to wildfire smoke can change the DNA of immune cells, but they're uncertain whether that will have a long-term impact, said Dr. Mary Prunicki, director of air pollution and health research at Stanford University's center for allergy and asthma research.

"It causes a lot of anxiety," Prunicki said. "Everyone feels helpless because we simply don't know — we're not able to give concrete facts back to the patient."

In Denver, Dr. Jay Lemery, a professor of emergency medicine at the University of Colorado School of Medicine, said he's seeing how people with chronic illnesses like diabetes and chronic obstructive pulmonary disease suffer more with extreme heat.

There's no medical code for "hottest day of the year," Lemery said, "but we see it; it's real. Those people are struggling in a way that they wouldn't" because of climbing temperatures, he said. "Climate change right now is a threat multiplier — it makes bad things worse."

Lemery and Prunicki are among the doctors planning to organize events in their respective regions to educate peers about climate-related threats to patients' health, through the Climate Crisis and Clinical Practice Initiative, the effort launched in Boston in February.

"There are so many really brilliant, smart clinicians who have no clue" about the link between climate change and human health, said Lemery, who has also written a textbook and started a fellowship on the topic.

Salas said she sometimes hears pushback that climate change is too political for the exam room. But despite misleading information from the fossil fuel industry, she said, the science is clear. Based on the evidence, 97% of climate scientists agree that humans are causing global warming.

Salas said that, as she sat with the distraught mother of the 4-year-old girl with asthma in Boston, her decision to broach the topic was easy.

"Of course I have to talk to her about climate change," Salas said, "because it's impairing her ability to care for her daughter."

Melissa Bailey: @mmbaily

In Fine Print, HHS Appears To Ban All Surprise Billing During The Pandemic

KFF Health News, April 18, 2020

Federal officials offering emergency funding to hospitals, clinics and doctors’ practices have included this stipulation: They cannot foist surprise medical bills on COVID-19 patients.

This article was first published on Friday, April 17, 2020 in Kaiser Health News.

By Emmarie Huetteman

Federal officials offering emergency funding to hospitals, clinics and doctors’ practices have included this stipulation: They cannot foist surprise medical bills on COVID-19 patients.

But buried in the Department of Health and Human Services’ terms and conditions for eligibility is language that could carry much broader implications. It says “HHS broadly views every patient as a possible case of COVID-19,” the guidance states.

Some say that line could disrupt a longtime health care industry practice of balance billing, in which a patient is billed for the difference between what a provider charges and what the insurer pays, a major source of surprise bills ― which can be financially devastating ― for patients. It is banned in several states, though not federally.

For those immersed in the ongoing fight over surprise medical billing, the possibility that HHS might have done with fine print what Congress and the White House could not do with bipartisan support and ample public outrage caught some off-guard and raised questions about what exactly HHS meant.

As the first wave of $30 billion in payouts began to hit bank accounts last week, providers were asked to sign an online form agreeing to the government’s terms. Among those terms is that, “for all care for a possible or actual case of COVID-19,” the provider will not charge patients any more in out-of-pocket costs than they would have if the provider were in-network, or contracted with their insurance company.

The agreement is posted on the HHS.gov page.

“The intent of the terms and conditions was to bar balance billing for actual or presumptive COVID-19,” an HHS spokesperson said late Friday. “We are clarifying this in the terms and conditions.”

Lobbyists, advocates and other experts say the ambiguity could be enough to mandate that providers who accept federal funds have agreed not to send surprise medical bills to patients — whether or not they test positive for COVID-19.

“If you took the broadest interpretation, any of us could be a potential patient,” said Jack Hoadley, a professor emeritus of health policy at Georgetown University and former commissioner of the Medicare Payment Advisory Commission.

Last week, as HHS released an initial draft of its terms and conditions for the emergency funds allocated by Congress in the CARES Act, the Trump administration startled many in health care by declaring that providers would have to agree not to send surprise bills to COVID-19 patients for treatment. A White House spokesperson declined to comment.

But the blanket assertion by health officials that “every patient” is considered a COVID-19 patient, offered without further clarification, seems to go beyond the administration’s announcement and open the door to lawsuits over whether HHS intended to ban balance billing entirely.

“Because the terms and conditions do not appear to be sufficiently clarified, there is a concern that there will be legal challenges around the balance-billing provision,” said Rodney Whitlock, a health policy consultant and former Senate staffer.

Some providers and others in the health care industry have fought tooth and nail to safeguard their control over what they can bill patients for care. Dark-money groups, later revealed to be connected to physician staffing firms owned by profit-driven private equity firms, spent millions last summer to buy political ads targeting members of Congress who were working on legislation to end surprise billing.

Congress has yet to pass any legislation on the matter, but the debate is ongoing behind the scenes. Lawmakers included modest protections against being billed for COVID-19 testing in relief legislation but declined to go further.

Hoadley of Georgetown said HHS’ guidance should address some of the problems that Congress did not account for explicitly in its relief legislation, such as cases of patients being billed for testing for COVID-19 when the test results were negative.

“The providers, the insurers, everybody else is going to need clarification, as well as, of course, all of us as potential patients,” Hoadley said. “That’s going to affect our willingness to” seek testing or treatment, he said.

Frederick Isasi, executive director of Families USA, a nonprofit that advocates for health care consumers, said the group supports the administration’s guidance “wholeheartedly” but urged lawmakers to enshrine broad protections against surprise billing into law.

“It’s time to just ban them permanently, not just related to COVID,” Isasi said, adding: “Families should avail themselves of this as broadly as possible.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

'It's Not Over Until It's Over': 5 Things To Know About Hitting The COVID-19 Peak

KFF Health News, April 17, 2020

Health experts say not to expect a single peak day — when new cases reach their highest level — to determine when the tide has turned.

This article was first published on Friday, April 17, 2020 in Kaiser Health News.

By Phil Galewitz

As New York, California and other states begin to see their numbers of new COVID-19 cases level off or even slip, it might appear as if we're nearing the end of the pandemic.

President Donald Trump and some governors have pointed to the slowdown as an indication that the day has come for reopening the country. "Our experts say the curve has flattened and the peak in new cases is behind us," Trump said Thursday in announcing the administration's guidance to states about how to begin easing social distancing measures and stay-at home orders.

But with the national toll of coronavirus deaths climbing each day and an ongoing scarcity of testing, health experts warn that the country is nowhere near "that day." Indeed, a study released this week by Harvard scientists suggests that without an effective treatment or vaccine, social distancing measures may have to stay in place into 2022.

Kaiser Health News spoke to several disease detectives about what reaching the peak level of cases means and under what conditions people can go back to work and school without fear of getting infected. Here's what they said.

It's Hard To See The Peak

Health experts say not to expect a single peak day — when new cases reach their highest level — to determine when the tide has turned. As with any disease, the numbers need to decline for at least a week to discern any real trend. Some health experts say two weeks because that would give a better view of how widely the disease is still spreading. It typically takes people that long to show signs of infection after being exposed to the virus.

But getting a true reading of the number of cases of COVID-19, the disease caused by the coronavirus, is tricky because of the lack of testing in many places, particularly among people under age 65 and those without symptoms.

Another factor is that states and counties will hit peaks at different times based on how quickly they instituted stay-at-home orders or other social distancing rules.

"We are a story of multiple epidemics, and the experience in the Northeast is quite different than on the West Coast," said Esther Chernak, director of the Center for Public Health Readiness and Communication at Drexel University in Philadelphia.

Also making it hard to determine the peak is the success in some areas of "flattening the curve" of new cases. The widespread efforts at social distancing were designed to help avoid a dramatic spike in the number of people contracting the virus. But that can result instead in a flat rate that may remain high for weeks.

"The flatter the curve, the harder to identify the peak," said William Miller, a professor of epidemiology at Ohio State University.

The Peak Does Not Mean The Pandemic Is Nearly Over

Lowering the number of new cases is important, but it doesn't mean the virus is disappearing. It suggests instead that social distancing has slowed the spread of the disease and elongated the course of the pandemic, said Pia MacDonald, an infectious disease expert at RTI International, a nonprofit research institute in North Carolina. The "flatten the curve" strategy was designed to help lessen the surge of patients so the health care system would have more time to build capacity, discover better treatments and eventually come up with a vaccine.

Getting past peak is important, Chernak said, but only if it leads to a relatively low number of new cases.

"This absolutely does not mean the pandemic is nearing an end," MacDonald said. "Once you get past the peak, it's not over until it's over. It's just the starting time for the rest of the response."

What Comes Next Depends On Readiness

Although Trump said the nation has passed the peak of new cases, health experts cautioned that from a scientific perspective that won't be clear until until there is a consistent decline in the number of new cases — which is not true now nationally or in many large states.

"We are at the plateau of the curve in many states," said Dr. Ricardo Izurieta, an infectious disease specialist at the University of South Florida. "We have to make sure we see a decline in cases before we can see a light at the end of the tunnel."

Even after the peak, many people are susceptible.

"The only way to stop the spread of the disease is to reduce human contact," Chernak said. "The good news is having people stay home is working, but it's been brutal on people and on society and on the economy."

Before allowing people to gather in groups, more testing needs to be done, people who are infected need to be quarantined, and their contacts must be tracked down and isolated for two weeks, she said, but added: "We don't seem to have a national strategy to achieve this."

"Before any public health interventions are relaxed, we better be ready to test every single person for COVID," MacDonald said.

In addition, she said, city and county health departments lack staffing to contact people who have been near those who are infected to get them to isolate. The tools "needed to lift up the social distancing we do not have ready to go," MacDonald said.

You're Going To Need Masks A Long Time

Whether people can go back out to resume daily activities will depend on their individual risk of infection.

While some states say they will work together to determine how and when to ease social distancing standards to restart the economy, Chernak said a more national plan will be needed, especially given Americans' desire to travel within the country.

"Without aggressive testing and contact tracing, people will still be at risk when going out," she said. Social gatherings will be limited to a few people, and wearing masks in public will likely remain necessary.

She said major changes will be necessary in nursing home operations to reduce the spread of disease because the elderly are at the highest risk of complications from COVID-19.

Miller said it's likely another surge of COVID-19 cases could occur after social distancing measures are loosened.

"How big that will be depends on how long you wait from a public health perspective [to relax preventative measures]. The longer you wait is better, but the economy is worse off."

The experts pointed to the 1918 pandemic of flu, which infected a quarter of the world's population and killed 50 million people. Months after the first surge, there were several spikes in cases, with the second surge being the deadliest.

"If we pull off the public health measures too early, the virus is still circulating and can infect more people," said Dr. Howard Markel, professor of the history of medicine at the University of Michigan. "We want that circulation to be among as few people as possible. So when new cases do erupt, the public health departments can test and isolate people."

The Harvard researchers, in their article this week in the journal Science, said their model suggested that a resurgence of the virus "could occur as late as 2025 even after a prolonged period of apparent elimination."

Will School Bells Ring In The Fall?

Experts say there is no one-size-fits-all approach to when office buildings can reopen, schools can restart and large public gatherings can resume.

The decision on whether to send youngsters back to school is key. While children have been hospitalized or killed by the virus much less frequently than adults, they are not immune. They may be carriers who can infect their parents. There are also questions of whether older teachers will be at increased risk being around dozens of students each day, MacDonald said.

Another factor: The virus is likely to re-erupt next winter, similar to what happens with the flu, said Jerne Shapiro, a lecturer in the University of Florida Department of Epidemiology.

Without a vaccine, people's risk doesn't change, she said.

"Someone who is susceptible now is susceptible in the future," Shapiro said.

Experts doubt large festivals, concerts and baseball games will happen in the months ahead. California Gov. Gavin Newsom endorsed that view Tuesday, telling reporters that large-scale events are "not in the cards."

"It's safe to say it will be a long time until we see mass gatherings," MacDonald said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

California Shies Away From Calls To Eliminate Restrictions On Nurse Practitioners

KFF Health News, April 17, 2020

California allows nurse practitioners to work only under the supervision of a doctor, and most limitations on their practice are likely to hold.

This article was first published on Friday, April 17, 2020 in Kaiser Health News.

By Rachel Bluth

As the demand for health care workers surges with the coronavirus case count, many states are rushing to lift restrictions on nurse practitioners, who provide much of the same care as doctors do.

But California allows nurse practitioners to work only under the supervision of a doctor, and most limitations on their practice are likely to hold.

Although easing restrictions is a simple regulatory matter elsewhere, such proposals in California are dragged down by decades of contentious political fighting — and the state's powerful doctors' lobby argues that California already has enough providers.

These "are often some of the definitive health care battles that happen in Sacramento," said Mike Madrid, a Republican political consultant who has been analyzing California politics for more than 25 years. "They're evergreen fights, they never go away."

Nurse practitioners are highly trained nurses with at least a master's degree. By comparison, registered nurses have at least an associate's degree.

There are more than 290,000 nurse practitioners in the country, and about 27,000 of them practice in California.

In 28 states plus the District of Columbia, nurse practitioners can practice much like a physician: They can provide primary care, write prescriptions and see patients. Some of those states require physician supervision when nurse practitioners are just starting out, but most allow them to operate without oversight right away.

But 22 states always require physician oversight, including California. Nurse practitioners in the Golden State must have a formal "collaboration" or supervision agreement with a physician who reviews their charts a few times each year.

In March, Alex Azar, secretary of the U.S. Department of Health and Human Services, encouraged governors to lift supervision requirements on some medical professionals to provide more flexibility for the health care system to respond to COVID-19.

Five states have suspended these requirements and an additional 12 have modified them to give providers with extra training more independence, according to the American Association of Nurse Practitioners.

The Mississippi Board of Nursing rushed to give nurse practitioners more authority to prescribe drugs on March 16. Wisconsin Gov. Tony Evers suspended supervision requirements on March 27, as did Kentucky Gov. Andy Beshear on March 31. New Jersey Gov. Philip Murphy lifted all supervision requirements for physician assistants and advanced practice nurses April 1.

Yet California has been cautious.

In a March 30 executive order, Gov. Gavin Newsom directed the state Department of Consumer Affairs, which controls professional licensing, the power to change or temporarily waive regulations to let the health care workforce respond to the crisis.

That opened the door for nurse practitioners to ask the department to kill the supervision requirements without actually lifting them.

"In some ways, it created a bit of a buffer between him and these decisions," said Garrett Chan, president and CEO of HealthImpact, a group that studies the nursing workforce in California.

On Tuesday, the department acted. It temporarily lifted the cap on how many nurse practitioners each physician could supervise. Instead of one physician supervising four nurse practitioners, physicians can supervise an unlimited number of nurse practitioners.

"It's unclear how this is helping anybody," Chan said.

Veronica Harms, the department's deputy director of communications, said via email that the department didn't eliminate the supervision requirements altogether because it wants to keep patients safe while responding to the needs of the health care system.

"The Department approved what was needed to meet the immediate demand for health care," Harms wrote.

Nurse practitioners have tried for years to get the authority to practice independently in California, and have been repeatedly thwarted by the powerful California Medical Association, which represents more than 48,000 doctors.

Doctors have a financial incentive to keep overseeing nurse practitioners. In exchange for reviewing charts and prescriptions every few months, physicians bill nurse practitioners between $5,000 and $15,000 per year, according to a report by the California Health Care Foundation and the University of California-San Francisco. (California Healthline is an editorially independent service of the California Health Care Foundation.)

The association has one of the strongest lobbies in Sacramento and contributed almost $11 million, primarily to state legislative candidates, since mid-January 2019. It has fought for years against lifting the supervision requirements on nurse practitioners, defeating at least three such "scope of practice" bills in the legislature.

Most recently, the association opposed AB-890, which died in committee last year and was reintroduced in January. The bill, introduced by Assembly member Jim Wood (D-Santa Rosa), created two ways for nurse practitioners to operate without physician supervision.

The California Medical Association wrote in an opposition letter that the measure would lead to "diminishing the quality of care for and lowering the standards for licensed individuals practicing medicine in the state."

"It's politics," said Susanne Phillips, the associate dean of clinical affairs at the University of California-Irvine School of Nursing. "We have a very, very strong medical lobby in the state of California. They do not want to see California go to full-practice authority."

Now, the association is arguing that the state already has enough providers to address the pandemic because many doctors have been laying off staff and closing their offices.

"In a world where you have primary care physicians and literally thousands of other physicians out of work, I'm not sure what eliminating supervision of nurse practitioners gets you," said Anthony York, spokesperson for the California Medical Association.

The association argues that California has slowed the virus's spread enough to avoid the severe health care provider shortages seen in harder-hit places like New York, Spain and Italy. Many California emergency rooms are operating under capacity, not inundated, York added.

But nurse practitioners counter that emergency room statistics alone offer an incomplete view of the crisis.

If nurse practitioners had the ability to practice independently, said Phillips of UC-Irvine, they would have the flexibility to treat patients in different settings, which would relieve pressure on hospitals and prove healthier for patients. For instance, a nurse practitioner could treat a new mother and her baby at an outpatient facility instead of in the hospital, where both patients and providers could be exposed to the virus.

"California's current statutory scheme does not allow NPs to provide care in settings and communities that are in desperate need," wrote the California Association for Nurse Practitioners, along with more than a dozen other groups, in a letter to the Department of Consumer Affairs on April 1. "California NPs are more prepared than ever to help address this public health crisis and to provide critically-needed care across the state."

For nurse practitioner Sonia Luckey, who practices at Providence ExpressCare, a primary care clinic in Newport Beach, California, waiving supervision requirements would let her serve her patients more holistically, she said.

Luckey, 54, is certified in both family medicine and psychiatric medicine and has been practicing for 26 years. The physician who oversees her is an internist, not a psychiatrist, so that limits how she can use her psychiatry training.

Though Luckey knows how to treat patients with severe mental illness, she has to refer them to someone else.

"That whole mental health side of me is unable to respond to this crisis because of the way the laws are structured," she said. "I could be seeing a whole other cohort of patients right now."

The stress of the pandemic is worsening some of her patients' mental health issues, she said. Shortness of breath, one hallmark of COVID-19, is also the hallmark of a panic or anxiety attack. Luckey said her extra years of schooling trained her to distinguish between the two in ways other providers can't.

"I was able to prevent a hospital visit and prevent that exposure," she said. "Not everybody can do that."

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Rachel Bluth: rbluth@kff.org, @RachelHBluth

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