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

N.Y. Leads the Nation in COVID-19 Tests, But the Effort Still Lags Behind Demand

KFF Health News, April 16, 2020

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

True Toll Of COVID-19 On U.S. Healthcare Workers Unknown

KFF Health News, April 15, 2020

The CDC says 27 health worker deaths have been recorded, based on a small number of test-result reports.

This story was first published on Wednesday, April 15, 2020 in Kaiser Health News.

By Christina Jewett and Liz Szabo

The number of health care workers who have tested positive for the coronavirus is likely far higher than the reported tally of 9,200, and U.S. officials say they have no comprehensive way to count those who lose their lives trying to save others.

The Centers for Disease Control and Prevention released the infection tally Tuesday and said 27 health worker deaths have been recorded, based on a small number of test-result reports.

Officials stressed that the count was drawn from just 16% of the nation's COVID-19 cases, so the true numbers of health care infections and deaths are certainly far higher.

CDC officials said data provided by the states most closely tracking the occupations of people with the virus suggests that health care workers account for about 11% of COVID-19 infections.

"We wanted to spotlight health care providers because they are the national heroes now caring for others with this disease at a time of great uncertainty," said Dr. Anne Schuchat, principal deputy director of the CDC. "We know their institutions are trying to provide material to help them work safely, but already thousands have been infected."

Media reports and Twitter posts have shown case after case of workers saying they do not have adequate protective gear to keep from getting sick. In a recent "60 Minutes" report, a front-line nurse from New York City said she was given a Yankees rain poncho in lieu of official attire.

The data on worker deaths so far has come from "case report" forms that labs send to the CDC, which may be forwarded before a patient's course of care is completed. Of more than 310,000 forms the CDC analyzed for the report, only about 4,400 included an answer to the questions of whether a health care worker was treated and whether the person survived.

Among those reports, 27 were listed as deceased. Schuchat said the CDC is conducting a 14-state hospital study and tapping into other infection surveillance methods and reviewing media reports to document additional deaths. She said challenges remain, such as tallying cases of people in New York City who die at home and relying on overburdened health staff to relay data.

"In some facilities, the person who is supposed to do the reporting is caring for patients and is overwhelmed," Schuchat said.

Kaiser Health News and The Guardian have launched a project called "Lost on the Frontline" to document the lives of health care workers who die during the pandemic. They include hospital janitors, substance abuse counselors, doctors and nurses.

Some states, including Ohio, have reported rates of health care worker illness as high as 20% but have not revealed data at the county, city or hospital levels. One health system, Henry Ford in the Detroit area, reported that more than 700 employees tested positive for COVID-19. Yet they have declined to say how many workers died, as in Ohio, to protect patient privacy.

The CDC data released Tuesday showed that 73% of the health workers falling ill are female and their median age is 42.

That so many are getting sick is alarming to Christopher Friese, a nurse who continues to see patients and is director of the University of Michigan's Center for Improving Patient and Population Health. He said it's also concerning that the names of those who die are so hard to come by.

"It's an insult that we can't even honor or respect these colleagues in a respectful way," he said. "We have nurses in Manhattan in garbage bags and goggles, and we have no way to track our fallen clinicians. We cannot even grieve properly: We can't even honor them because we may not even know who we've lost."

Christina Jewett: ChristinaJ@kff.org, @by_cjewett

Liz Szabo: lszabo@kff.org, @LizSzabo

Pediatric Practices Struggle to Adapt and Survive Amid COVID-19

KFF Health News, April 14, 2020

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

How Do We Exit The Shutdown? Hire An Army Of Public Health Workers

KFF Health News, April 13, 2020

There's broad agreement that core public health work — the ability to find people with the virus and prevent them from passing it to others — will be essential to reopening schools and businesses.

This article was first published on Monday, April 13, 2020 in Kaiser Health News.

By Anna Maria Barry-Jester

Last month, facing the prospect of overwhelmed hospitals and unchecked spread of the novel coronavirus, seven Bay Area county and city health departments joined forces to become the first region in the nation to pass sweeping regulations ordering millions of people indoors and shuttering the local economy.

It shocked people, but health experts around the country applauded the bold step, which since has been broadly replicated.

They also say it can't go on forever. And so Bay Area leaders, along with others around the nation, are trying to figure out how we can resume something akin to normal life without triggering a catastrophic wave of illness and death.

The shelter-in-place orders were a sledgehammer response to two colliding realities: a little-understood virus that is proving ferociously deadly in vulnerable populations and a withered public health infrastructure that has made it impossible to track and contain the spread of the virus that causes COVID-19.

For all the light the new virus has shone on vulnerabilities of the U.S. hospital system — shortfalls in hospital capacity, ventilators and protective gear — what many officials see are the cracks in the foundations of public health.

"Nothing should come as a surprise," said Laura Biesiadecki, senior director for preparedness, recovery and response with the National Association of County and City Health Officials, which represents more than 3,000 local health departments. "What you're seeing in COVID-19 is an exacerbation of existing fault lines that everyone in the public health community has recognized over the years."

Still, there's broad agreement that core public health work — the ability to find people with the virus and prevent them from passing it to others — will be essential to reopening schools and businesses. That strategy is endorsed by the director of the Centers for Disease Control and Prevention, who recently told NPR the agency was working on a plan to deploy more disease investigators.

We spoke with more than two dozen health experts to get their thoughts on what public health resources will be needed to reopen the economy.

1. What works?

It may be rare that the World Health Organization and experts on the right and left in the U.S. see the same solutions to a problem, but that's the case when it comes to reopening the economy in the face of COVID-19. The principles are simple: Stabilize the number of people who have the virus (through the strict social distancing already in place), and ensure hospitals can handle the cases they have. Then, put tools in place to stop new infections in their tracks so there isn't a renewed outbreak.

It all starts with testing, and several countries that revamped their public health programs in the wake of the deadly 2003 SARS epidemic seem to be reaping the benefits now. That includes Singapore, which quickly ramped up testing for both active infections of COVID-19 and an antibody test to show previous infection, and South Korea, which tested tens of thousands of people in the weeks after it detected its first cases.

South Korea, like many other Asian countries, is also relying on hundreds of workers armed with phone location data, credit card information and security footage to try to reach everyone who has come into contact with an infected person. Authorities release detailed information to the public whenever someone infected has been in their area. Though South Korea and Singapore report a recent surge in cases imported from abroad, both countries have seen far more moderate economic and health fallouts than has the U.S.

Politically and culturally, European nations make for an easier comparison with the U.S. Germany not only deployed widespread testing early on, but it also has sent health teams to people's homes to check for symptoms and initiate aggressive interventions if symptoms arise.

Italy, which has had more than double the deaths of China despite having less than 5% of its population, has lessons for the U.S. as well — and not all grim.

The scenes from Lombardy, where doctors have rationed care for weeks, making decisions about who lives and who dies, are bleak. But neighboring Veneto, which found its first case of the virus on the same day as Lombardy, is faring much better, said Dr. Nancy Binkin, a professor at the University of California-San Diego who spent 12 of her 20 years at the CDC embedded in Italy's public health system.

Binkin and colleagues suspect the difference lies in the extensive use of public health tools to contain the initial outbreak in Veneto. That included testing nearly everyone in the town of Vò where the first cases were found, quarantining that city, and making heavy use of assistenti sanitari, or health assistants, to track down people with the virus and make sure they stay isolated.

There have been far fewer infected health workers in Veneto, and deaths overall, than in Lombardy, which is renowned for the quality of its hospitals and health care.

What the places with fewer cases have in common is not just social distancing, said Binkin, but also aggressive tactics to identify and isolate people with the virus.

2. How does the U.S. compare?

U.S. public health budgets and staff have hemorrhaged over the years, accompanied by a steady stream of warning calls that the U.S. was not ready to face a pandemic.

When COVID-19 arrived, identifying and tracking everyone with the virus was all but impossible for local health departments because of flawed tests and narrow guidelines for who should get tested. Compounding the problem was a beleaguered public health infrastructure.

The stay-at-home orders are largely about slowing the spread of the virus — to keep hospitals from being overwhelmed — not necessarily about preventing cases, said Adia Benton, an anthropologist at Northwestern University who studies inequalities in global health. Mobilizing a massive workforce to isolate everyone with the virus could prevent infections, Benton said. "The interventions we see reflect what we value," she said.

Public health is run locally, and health departments have different resources and organization. They are also confronting different degrees of outbreak.

In Tennessee, front-line health workers still are contact tracing everyone who gets the virus. To do so, many employees are working seven days a week, 12 hours a day, said Dr. Mary-Margaret Fill, a physician and epidemiologist with the state who is helping coordinate its emergency response. "They are the internal cog in this response; without them we fall apart," she said.

In California, public health is the responsibility of counties, and resources vary wildly. Many, including Sacramento and Orange counties, moved away from contact tracing weeks ago, citing minimal access to testing and a surge in cases. (A lack of testing is one thing nearly all health departments have in common.)

Even San Francisco, with its abundant wealth and renowned expertise in HIV, was relying on a skeleton staff to track routine communicable diseases like measles, tuberculosis and sexually transmitted diseases, according to the city's health officer, Dr. Tomás Aragón.

Los Angeles County, with its 4,000 public health employees, is still doing some contact tracing for every person who tests positive, said Dr. Barbara Ferrer, director of the Los Angeles County Department of Public Health. Rural Tulare County is trying to do the same, but has pinpointed the need for more people to trace cases as its greatest hurdle.

Those techniques matter everywhere. "Social distancing, contact tracing, identification, quarantine and isolation. We need all of those tools," said Ferrer.

3. How do we ramp up?

Experts say the situation necessitates, at least temporarily, adding thousands of people to the ranks of public health. Three former Obama administration officials called for a "public health firefighting force" via a program like AmeriCorps or the Peace Corps.

Others suggest we make use of programs already in place. The Medical Reserve Corps program, a national network of volunteer medical and public health professionals, has 175,000 volunteers, some of whom have already been deployed to state health departments, said Biesiadecki. That program could be expanded.

"We need a Marshall Plan. We need a New Deal. We need a WPA for public health," said Gregg Gonsalves, a Yale epidemiologist who won a MacArthur Fellowship for his work on global health and justice.

And it doesn't necessarily require M.D.s, Ph.D.s or even public health degrees. In many countries, governments have trained community health workers in situations like these.

But in the absence of a federal program, some local departments in the U.S. are already taking up the cause. San Francisco, for example, is planning to recruit around 160 people to keep tabs on people diagnosed with the virus. Aragón said he hopes to repurpose staff from within the county where possible, and hire where necessary.

"We started off with a scarcity mentality," Aragón said. "We have to have an abundance mentality. The amount of money that's being lost economically, if we put just a fraction of that into our public health workforce, we could get the economy back up and running."

Massachusetts asked the global health nonprofit Partners in Health to help it hire 1,000 people to carry out mass contact tracing.

In Connecticut, Yale University faculty said they realized the state had the capacity to contact trace only in Fairfield County, a wealthy bedroom community of New York, leaving few resources for much poorer New Haven, where the university is located. So they recruited more than 100 public health, nursing and medical students, said Dr. Sten Vermund, dean of Yale School of Medicine. The volunteers were trained online by the state and, working alongside university staff, have been doing contact tracing for the local hospital.

But he doesn't think these volunteer efforts are the solution. Vermund called it "the definition of insanity" if the U.S. didn't take this moment to reinvest in public health. "There is no greater threat to the economic well-being of planet Earth," he said, "than pandemic respiratory viral illness."

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

Anna Maria Barry-Jester: annab@kff.org, @annabarryjester

Furor Erupts: Billions Going To Hospitals Based On Medicare Billings, Not COVID-19

KFF Health News, April 11, 2020

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.

To 'Keep The Lights On,' Doctors And Hospitals Ask For Advance Medicare Payments

KFF Health News, April 10, 2020

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

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

By Phil Galewitz

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

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

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

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

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

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

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

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

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

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

CMS in April has received more than 25,000 requests from providers and suppliers for expedited payments and has approved more than 17,000 requests. Before the pandemic, CMS had approved about 100 requests for advanced payments in the past five years, mostly for natural disasters such as hurricanes and tornadoes.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

What Does Recovery From COVID-19 Look Like? It Depends. A Pulmonologist Explains.

KFF Health News, April 9, 2020

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

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