The question of testing has been central to the efforts by the U.S. and other countries to minimize the pandemic.

This article was first published on Thursday, April 16, 2020 in Kaiser Health News.

By Michelle Andrews

NEW YORK — This jampacked city, with its high-rises, brownstones and cheek-by-jowl single-family homes, is a ripe environment for the novel coronavirus that has killed more than 11,000 residents. That density also complicates a key strategy for alleviating the epidemic: testing.

In their initial response to the pandemic, city and state officials called for federal health officials to move more quickly on increasing testing capacity, seeking to identify those who had contracted the virus and isolate them to help stem the outbreak.

"Our single-greatest challenge is the lack of fast federal action to increase testing capacity and, without that, we cannot beat this epidemic back," said Mayor Bill de Blasio.

However, when it became clear that they lacked sufficient diagnostic tests and needed to preserve personal protective equipment for health care workers to treat hospitalized patients, city officials shifted to calling instead for testing only the sickest people — often just those needing hospitalization — and encouraging anyone else feeling ill to stay home. This approach is in line with guidelines from the federal Centers for Disease Control and Prevention.

But other officials say wider testing is needed now. That call is coming especially from representatives of people in neighborhoods that are home to many first responders and people who continue to work during the shutdown because their jobs are considered essential.

The question of testing has been central to the efforts by the U.S. and other countries to minimize the pandemic. South Korea's massive testing effort has been lauded as a powerful tool that helped reduce the spread of the virus. But the U.S. rollout of the initial tests was plagued with problems and delays, prompting frustrated calls for help from local officials and sharp criticism of President Donald Trump's management of the crisis.

In New York, Gov. Andrew Cuomo has consistently pressed hard for tests, saying early last month that "we want to identify people, because [we] want to put them in a position where they're not going to infect anybody else. … The more tests the better, the more positives you find the better because then you can isolate them and you slow the spread."

But the viral outbreak in New York City has outpaced officials' efforts to identify those who were infected. With the virus spreading through the city's densely populated neighborhoods, city officials refocused testing priorities on those who required hospitalization while most people were under orders to remain in their homes or practice social distancing if they had to go out.

Shelter-in-place directives that keep people apart make sense for every community fighting the spread of the virus when the option of testing widely doesn't exist. But keeping people off the streets is especially important in New York, whose 8.6 million residents are packed together more closely than those of any other major city, with more than 28,000 people per square mile, according to an analysis by Governing.com, an online platform for state and local government data.

For people with mild to moderate symptoms, or whose exposure to the virus is unknown, testing usually "won't change what we do, but it will potentially expose them or others [to the virus] if they leave their homes to get tested," said Dr. Theodore Long, vice president of ambulatory care at New York City Health + Hospitals, the public health care system that operates 11 hospitals and dozens of primary care clinics in the city's five boroughs.

Campaigns used by other cities don't work as well here. Drive-thru testing sites have limited utility, especially in Manhattan, where only about 1 in 5 people have a car. Testing at city parks or other outdoor venues could pose a significant risk of transmission because it would draw crowds, said Dr. Jeffrey Engel, former executive director of the Council of State and Territorial Epidemiologists, who is the organization's senior adviser on COVID-19.

"We should just assume everyone's infected," Engel said.

About 80% of people who become infected with the novel coronavirus recover on their own. For New Yorkers who are worried about their symptoms, Health + Hospitals has a hotline staffed by clinicians who can help determine whether someone should come in for testing. So far they've handled more than 50,000 calls. Ninety percent of the time they advise people to stay at home, said Long.

The sickest patients are advised to go to one of the hospital emergency departments or urgent care clinics for assessment and possible testing, said Dr. Andrew Wallach, NYC Health + Hospitals' chief medical officer of ambulatory care.

Meanwhile, tents outside the public hospitals have been set up to assess people with mild to moderate symptoms to spare emergency departments, said Long. The system isn't perfect, though. At times it has led to long, snaking lines of people outside hospital tents braving inclement weather and not maintaining the recommended 6-foot gaps for proper social distancing.

But the current testing rules have left out crucial groups of people, some officials charge. Earlier this month, New York City Councilman Justin Brannan, U.S. Rep. Jerrold Nadler and six state legislators wrote to de Blasio and Cuomo demanding a testing site in the Bay Ridge neighborhood of Brooklyn.

The area is home to many nurses, EMTs and other front-line personnel whose jobs are deemed essential, such as sanitation workers and bank tellers, Brannan said.

"These folks have no choice but to go out and go to work every day," Brannan said, where they risk spreading the virus or getting sick themselves. "It's dangerous. These folks need testing."

As of Tuesday, New York state had tested 526,012 people, nearly as many as California, Texas and Florida, the three most populous states, combined, according to the COVID Tracking Project, a crowdsourced compilation of the latest testing figures. That tally includes 118,302 people in New York City.

Hospitals recently expanded some of their testing protocols. NYC Health + Hospitals began opening up testing to all its workers, giving priority to employees who have symptoms of the virus or are in home isolation and those caring for COVID-19 patients.

Private hospital systems in the New York City area are also performing testing. NYU Langone Health, for example, has created several on-site testing areas by repurposing existing rooms that are large and well-ventilated, including a cafeteria, a library and an unused floor of a nursing home, said Dr. Andrew Brotman, executive vice president and vice dean for clinical affairs and strategy at Langone.

The health system is testing patients with COVID-19 symptoms who come to the emergency room as well as employees exhibiting symptoms, Brotman said.

Moving forward, "increasing testing will be a vital step to identify clusters of cases and stop the virus from spreading further — which will require isolating cases, tracing their contacts, and monitoring contacts under quarantine," said Dr. Thomas Frieden, former CDC director and health commissioner of New York City. "To begin to release restrictions and open society back up, we need to expand our testing volume massively, and have an army of contact tracers trained and ready."

Many experts agree. In his daily briefing last Thursday, Cuomo referred to large-scale rapid testing as "the bridge to the new economy and getting to work and restarting."

Michelle Andrews: andrews.khn@gmail.com, @mandrews110

Across the U.S., thousands of pediatric practices that provide front-line care for the nation's children are struggling to adjust to a dire new reality.

This article was first published on Tuesday, April 14, 2020 in Kaiser Health News.

By Jenny Gold

BERKELEY, Calif. — The silence was striking.

On a normal day, the well-child waiting room at Berkeley Pediatrics bustles with children playing, infants crying and teenagers furiously tapping on their smartphones.

On a recent Monday, the room was deserted, save for a bubbling tropical fish tank and a few empty chairs. Every book, puzzle and wooden block had been confiscated to prevent the spread of the coronavirus. There was not a young patient to be seen.

Since March 17, when San Francisco Bay Area officials issued the nation's first sweeping orders for residents to shelter in place, patient volume at the 78-year-old practice has dropped by nearly 60%. In accordance with guidance from the American Academy of Pediatrics, its seven doctors have canceled well-child visits for almost all children older than 18 months. And some parents balk at bringing in even babies for vaccines, opening the door to another potential crisis down the road.

In the days after the COVID-19 clampdown, the office scrambled to set up telehealth for sick visits. Still, this small, independent practice has gone from seeing more than 100 patients a day to about 40. It has laid off six staff members, and the physicians have taken a 40% pay cut.

"I've been practicing for a long time, and I've seen a lot of things. This is a very different beast," said Dr. Annemary Franks, who joined the practice in 1993. "I've never seen in a week the entire thing fall apart."

Across the U.S., thousands of pediatric practices that provide front-line care for the nation's children are struggling to adjust to a dire new reality: crashing revenue, terrified parents and a shortage of protective equipment, from gloves and goggles to thermometer covers. And all while they are being asked to care for young patients who could well be infected with COVID-19 — and prime vectors for transmission — without showing symptoms.

How well these practices adapt will be key as the nation looks to weather the pandemic: Pediatric offices provide a crucial release valve for the health care system by treating the broken bones, lacerations, colds, flus and chronic illnesses that might otherwise flood overburdened emergency departments.

"If it's a month or two of care this way, OK. But if this is months and months and months, we're going to see more practices go under," said Franks. "We don't have some pot of money that we have sitting around to get us through this. We're fee-for-service. You get paid for what you do."

Like many practices, Berkeley Pediatrics improvised overnight in the face of COVID-19. The brown-shingled Craftsman that houses the practice was quickly divided into two halves: upstairs for well patients, downstairs for those who are sick. They opened a back entrance up an unused set of stairs so well patients could bypass the sick.

Before they get an appointment, all children are screened by phone for signs of the virus. When possible, sick children are treated via a video visit. If a child with respiratory symptoms needs to be seen in person, a doctor meets the child in the family's car in the parking lot, dressed in gown, gloves and face shield. Everyone who enters the office — whether child or caregiver — is checked for fever. The practice has only 75 plastic thermometer covers left, and supplies are on backorder. The doctors wear surgical masks even for well-child visits.

"Every day I think to myself, 'That's exactly the opposite of what I was taught in medical school and what I was trained to do,'" said Dr. Olivia Lang, another physician at Berkeley Pediatrics. "I'm not supposed to wear masks and scare my patients, but I'm doing it every day."

Telehealth makes eye contact challenging, she said. And in an effort to avoid in-person appointments, health care providers have resorted to prescribing antibiotics over the phone for symptoms suggesting ear infections and strep throat, without doing lab work. "We're supposed to be good stewards of antibiotics, and that's being dismantled," Lang said.

Another challenge is the availability of personal protective equipment, a struggle for all health care workers. Pediatric practices do not routinely keep stocks of the heavy-duty N95 masks, and they seldom use gowns or even simple surgical masks. Now, with hospitals facing critical shortages of PPE, pediatricians are often low on the list to get supplies.

Dr. Kristen Haddon, a pediatrician outside Boston, said the practice didn't jump to purchase supplies when cases of the novel coronavirus first emerged in Washington state in January. "It felt very far away and seemed very isolated," she said. By the time they realized the virus was widespread, "there was nothing to be had." They had no N95s, gowns or goggles, and only two boxes of surgical masks.

Pediatricians are considered at particular risk of infection, given preliminary research that suggests children infected with COVID-19 are more likely than adults to have mild cases and may be contagious while showing no symptoms at all. "We have absolutely no idea who is infected and who isn't," said Haddon. "Kids cough and sneeze in our face all the time. And one cough could be really bad for me."

Dr. Niki Saxena, a pediatrician in Redwood City, California, said her practice is carefully guarding the handful of N95s they have left from the SARS epidemic and have had to make "some very scary decisions" about how to protect staff. Their options, she said, are to shut down the office — in which case they would go out of business — or to be very precise about when they use protective equipment.

"When you're in battle, you have to keep your powder dry until you have to use it," she said. "When I see someone walking through the grocery store with an N95, it takes all my willpower not to rip it off their face."

At Berkeley Pediatrics, staff members are wiping down gowns after seeing a patient and simply reusing them. When she gets home, said Dr. Katrina Michel, she stops in the garage, strips off her clothing and leaves it on the floor. She tells her two young children not to touch her until she's had a chance to shower. "I've never been afraid to go to work for my personal safety before," she said.

She worries, too, for the well-being of her patients, as the efforts to contain the novel coronavirus increasingly interrupt basic care. Across the country, pediatricians report that some parents are canceling routine checkups and vaccination appointments — including first-time vaccinations for infants — because they worry about getting infected at the office.

"We don't want to create a pertussis outbreak because we didn't vaccinate all of our babies on time," said Michel.

Many practices are delaying booster shots for older kids. Dr. Tina Carrol-Scott, a Miami pediatrician, said she's concerned that the mixed messaging could backfire with parents who are vaccine-hesitant. "If we start taking the stance that because of coronavirus it's OK for you to be delayed a month or two, it kind of takes away our credibility as physicians," she said. "Parents are going to say, 'Well, it was OK to delay during coronavirus, why not now?'"

And it's not just missed vaccinations that are a concern. Pediatricians are tracking growth and development at well-child visits. For newborns, that includes checks for weight loss, jaundice and congenital diseases.

"We've had parents of infants who are 1 week old say, 'Oh I don't want to come in; I don't think it's safe,'" said Dr. Scott Needle, a pediatrician in Sacramento, California. "We've had to tell them, 'Look, for a 1-week-old baby just out of the hospital, there are a lot of things you need to check that could be much more dangerous than coronavirus at this point.'"

Saxena said the caseload at her Redwood City practice is less than 25% of what's typical, and warned of even broader ramifications on child health care as the pandemic wears on.

"If people stop going to the doctor altogether," she said, "then primary care practices will shutter just like movie theaters and restaurants."

Jenny Gold: jgold@kff.org, @JennyAGold

Probably few hospital systems need the emergency federal grants announced this week to handle the coronavirus crisis as badly as Florida’s Jackson Health does.

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

Probably few hospital systems need the emergency federal grants announced this week to handle the coronavirus crisis as badly as Florida’s Jackson Health does.

Miami, its base of operations, is the worst COVID-19 hot spot in one of the most severely hit states. Even in normal years, the system sometimes barely makes money. At least two of its staff members have died of the virus.

But in a scathing letter to policymakers, system CEO Carlos Migoya said the way Washington has handled the bailout “could jeopardize the very existence” of Jackson, one of the nation’s largest public health systems, and similar hospital groups.

“We are here for you right now,” Migoya, who has tested positive for COVID-19 himself, said in a Thursday letter to Alex Azar, secretary of Health and Human Services. “Please, be here for us right now.”

Migoya and executives at other beleaguered systems are blasting the government’s decision to take a one-size-fits-all approach to distributing the first $30 billion in emergency grants. HHS confirmed Friday it would give hospitals and doctors money according to their historical share of revenue from the Medicare program for seniors — not according to their coronavirus burden.

That method is “woefully insufficient to address the financial challenges facing hospitals at this time, especially those located in ‘hot spot’ areas such as the New York City region,” Kenneth Raske, CEO of the Greater New York Hospital Association, said in a memo to association members.

States such as Minnesota, Nebraska and Montana, which the pandemic has touched relatively lightly, are getting more than $300,000 per reported COVID-19 case in the $30 billion, according to a Kaiser Health News analysis.

On the other hand, New York, the worst-hit state, would receive only $12,000 per case. Florida is getting $132,000 per case. KHN relied on an analysis by staff on the House Ways and Means Committee along with COVID-19 cases tabulated by The New York Times.

The CARES Act, the emergency law passed last month to address the pandemic, gives HHS wide latitude to administer $100 billion in grants to hospitals and doctors.

But the decision to allocate the first $30 billion according to past Medicare business surprised many observers.

The law says the $100 billion is intended “to prevent, prepare for and respond to coronavirus,” including paying for protective equipment, testing supplies, extra employees and temporary shelters and other measures ahead of an expected surge of cases. It says hospitals must apply for the money.

“It seems weird that they wouldn’t just target areas geographically based on where the surge has been,” said Chas Roades, CEO of Gist Healthcare, a consulting firm.

Issuing the funds based on Medicare revenue “allowed us to make initial payments to providers as quickly as possible,” an HHS spokesperson said Friday. Some of the money was expected to go out as soon as Friday in electronic deposits.

HHS “has failed to consider congressional intent” in distributing the $30 billion by not accounting for “the number of COVID-19 cases hospitals are treating,” New Jersey Sens. Bob Menendez and Cory Booker and Rep. Bill Pascrell said in a Friday letter to Azar.

All three are Democrats. Behind New York, New Jersey has the second-highest number of recorded coronavirus cases, as of Friday afternoon.

The administration is struggling to balance the need to help systems slammed by the coronavirus with the need to provide immediate relief, said Bill Horton, a health care lawyer with Jones Walker in Birmingham, Alabama.

“Providers have to appreciate that there is a focus on trying to respond to their cries of pain and coming up with ways to get some money out there,” he said. On the other hand, he said, HHS sets itself up for criticism by paying “a chunk of money without particular regard for who has been hardest hit.”

Medicare revenue can vary sharply by hospital, depending on who their patients are and what part of the country they are in.

HHS’ method “could tilt the playing field” against hospitals whose patients are largely uninsured or covered by the Medicaid program for low-income patients, said Bruce Siegel, CEO of America’s Essential Hospitals, a group of systems serving the poor and vulnerable.

HHS said the next slice of the $100 billion to go out “will focus on providers in areas particularly impacted by the COVID-19 outbreak” as well as rural hospitals and those with lower shares of Medicare revenue.

Jackson Health’s budget depends heavily on reimbursement for the kind of elective procedures that it has canceled to ensure it has the capacity to handle COVID-19 patients, Migoya said. Lost revenue is $25 million per month, it estimates.

“We cut off our own funding sources in order to sustain our mission,” he wrote in the letter to Azar.

Hospitals in relatively COVID-19-free areas, on the other hand, could continue elective procedures but still receive a big chunk of the $30 billion, said Gerard Anderson, a health economist at Johns Hopkins University.

“If I’m in rural Kansas and I don’t have any COVID patients in my area, I’m not going to ― I should not — stop doing elective surgeries,” he said.

Even the type of Medicare payments hospitals typically receive will give some systems a much bigger share of the $30 billion than others of the same size.

HHS is basing the payments on traditional “fee for service” Medicare revenue. But hospitals with a big chunk of managed care Medicare business, called Medicare Advantage, won’t be credited for that.

In Florida, more than four Medicare members out of every 10 are in Medicare Advantage plans, one of the highest portions in the country, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

In New York, 39% of beneficiaries are in Medicare Advantage. In Montana, by contrast, the figure is 17%. In Wyoming, it’s 3%.

Jackson’s South Florida location and patient mix “both skew heavily away from the fee-for-service model,” Migoya wrote. “No one wants to talk about money in the middle of a health crisis, but hope alone will not cash checks to employees or suppliers.”

KHN correspondent Rachana Pradhan contributed to this report.

Advanced age is associated with significantly worse outcomes for older patients, and even those who survive are unlikely to return to their previous level of functioning.

This article was first published on Thursday, April 9, 2020 in Kaiser Health News.

By Judith Graham

Reports of recovery from serious illness caused by the coronavirus have been trickling in from around the world.

Physicians are swapping anecdotes on social media: a 38-year-old man who went home after three weeks at the Cleveland Clinic, including 10 days in intensive care. A 93-year-old woman in New Orleans whose breathing tube was removed, successfully, after three days. A patient at Massachusetts General Hospital who was taken off a ventilator after five days and was doing well.

"Patients are definitely recovering from Covid-19 ARDS [acute respiratory distress syndrome] and coming off vents," Dr. Theodore "Jack" Iwashyna, a professor of pulmonary and critical care medicine at the University of Michigan, wrote on Twitter recently.

But the outlook for older adults, who account for a disproportionate share of critically ill COVID-19 patients, is not encouraging. Advanced age is associated with significantly worse outcomes for older patients, and even those who survive are unlikely to return to their previous level of functioning.

According to a new study in The Lancet based on data from China, the overall death rate for people diagnosed with coronavirus is 1.4%. But that rises to 4% for those in their 60s, 8.6% for people in their 70s and 13.4% for those age 80 and older.

How often do people who are critically ill recover? According to a report from Britain out last week, of 775 patients with COVID-19 admitted to critical care, 79 died, 86 survived and were discharged to another location, and 609 were still being treated in critical care, with uncertain futures. Experts note this is preliminary data, before a surge of patients expected over the next several weeks.

According to a just-published small study of 24 critically ill COVID-19 patients treated in Seattle hospitals, 50% died within 18 days. (Four of the 12 who died had a do-not-resuscitate order in place.) Of those who survived, three remained on ventilators in intensive care units, four left the ICU but stayed in the hospital, and five were discharged home. The study appeared in the New England Journal of Medicine.Bottom of Form

What does recovery from COVID-19 look like? I asked Dr. Kenneth Lyn-Kew, an associate professor of pulmonology and critical care medicine at National Jewish Health in Denver, named the No.1 respiratory hospital in the nation last year by U.S. News & World Report. Our conversation has been edited for length and clarity.

Q: What's known about recovery?

It's helpful to think about mild, moderate and severe disease. Most people, upwards of 80%, will have mild symptoms. Their recovery typically takes a couple of weeks. They might feel horrible, profoundly fatigued, with muscle aches, a bad cough, a fever and chest discomfort. Then, that goes away. Also, there are some people who never have symptoms, who never even know they had it.

Q: What about people with moderate illness?

Because we're so early into this, we have less information about these patients. Often, they spend a few days in the hospital. People feel more short of breath: Sometimes, an underlying condition like asthma is exacerbated. Typically, they need a bit of oxygen for a few days.

Also, there are patients who have high fevers or severe diarrheal illness with COVID-19. Those patients can get dehydrated and need IV fluids.

There also appears to be a small population of people who can develop myocarditis ― inflammation of the heart. They come in with symptoms that mimic heart attacks.

Q: How long do these patients stay hospitalized?

It can vary. Some people get a little oxygen and IV fluid and leave the hospital after two to three days. Some of these moderate patients start to look a little better, then all of a sudden get a lot worse and decompensate.

Q: What about patients with serious illness?

Many of the sickest patients have acute respiratory distress syndrome [ARDS, a disease that floods the lungs with fluid and deprives people of oxygen]. These are the patients who end up on mechanical ventilators.

Those least likely to recover seem to be frail older patients with other preexisting illnesses such as COPD [chronic obstructive pulmonary disease] or heart disease. But there's no guarantee that a young person who gets ARDS will recover.

ARDS mortality is usually between 30% and 40%. But if you break that down, people who have ARDS due to trauma — for instance, car accidents ― tend to have lower death rates than people who have ARDS due to infection. For older people, who tend to have more infections, mortality rates are much higher — up to 60%. But this isn't COVID-specific data. We still have a lot to learn about that.

Q: If someone is sick enough to need ventilation, what's involved?

People usually need a couple of weeks of mechanical ventilation.

Ventilation is very uncomfortable for many people and they end up on medication to make them more comfortable. For some people, just a bit of medication is enough.

Other people require heavier doses of medications such as narcotics, propofol, benzodiazepines or Precedex [a sedative]. Because they act on your brain, these medications can induce delirium [a sudden, serious alteration in thinking and awareness]. We really try to minimize that because delirium has a significant impact on a person's recovery.

Being on more medication affects other things also: a patient's sleep-wake cycle. Their mobility, which can make them weaker. It can slow down their gastrointestinal tract so they don't tolerate nutrition as well and get suboptimal nutrition. Many of these patients end up having PTSD [post-traumatic stress disorder] and impaired concentration afterwards.

Q: When can someone go off a respirator?

There are three criteria. They have to be awake enough to protect their swallowing mechanism and their airway. They have to have a low enough need for oxygen that I can support that with something else, such as nasal prongs. And they have to be able to clear enough carbon dioxide.

Q: What will a patient look like at the end of those two weeks?

That depends. If we're able to do everything right, these people are up and walking around with the ventilator. Those patients come out on the other end looking pretty good. Maybe they'll have some weakness, some weight loss, a little PTSD.

The patients who are sicker and more intolerant of the technology, they tend to come out weak, forgetful, confused, deconditioned, maybe not even able to get out of bed. Sometimes, in spite of our best efforts, they'll have skin wounds.

Some of these patients have significant lung fibrosis ― scarring of the lungs and reduced lung function. This might be a short-term part of their recovery or it could be long-term.

Q: Are there special considerations for older adults?

Older adults tend to have more preexisting illnesses that put them at more risk for complications. Their immune system is less robust. They're more prone to secondary infections such as pneumonia in spite of everything we do to prevent that.

Frailty is an important factor as well. If you come in frail and weak, you have less reserve to fight this through.

Q: When are people ready to be discharged?

You can go home on supplemental oxygen if you still need that kind of assistance. But you need to be able to feed yourself and move around or, if you have more disability, have someone to provide that for you.

Some people spend a couple of weeks in the ICU, then two to three days on a medical/surgical ward. Other people take another week or two to regain some strength. Some will go to an acute rehabilitation facility to get rehab three times a day. Others can go to a skilled nursing facility, where they'll get rehab over a couple of months and then go home.

Q: Who's unlikely to recover?

That we just don't know yet. When we sit down after all this and look at everything afterwards, we can pull up those patterns.

In the ideal world, I wish I could predict who would do well and who wouldn't, so I could talk to them and their family and have an honest conversation.

Q: Are other factors complicating recovery?

With such a high number of sick people, it's harder to do things to maximize recovery, such as bringing in physical therapy and occupational therapy. People aren't able to get as much therapy because there are only so many therapists and some hospitals are limiting who can come in.

COVID-19 is really a nasty disease because of its infectiousness. It isolates people from a lot of things they need to get better — perhaps, most importantly, their family, whose support is really critical along with all the other things I've talked about here.

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