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Analysis: He Got Tested For Coronavirus. Then Came The Flood Of Medical Bills.

Kaiser Health News:Insurance - April 03, 2020

By March 5, Andrew Cencini, a computer science professor at Vermont’s Bennington College, had been having bouts of fever, malaise and a bit of difficulty breathing for a couple of weeks. Just before falling ill, he had traveled to New York City, helped with computers at a local prison and gone out on multiple calls as a volunteer firefighter.

So with COVID-19 cases rising across the country, he called his doctor for direction. He was advised to come to the doctor’s group practice, where staff took swabs for flu and other viruses as he sat in his truck. The results came back negative.

In an isolation room, the doctors put Andrew Cencini on an IV drip, did a chest X-ray and took the swabs.(Courtesy of Andrew Cencini)

By March 9, he reported to his doctor that he was feeling better but still had some cough and a low-grade fever. Within minutes, he got a call from the heads of a hospital emergency room and infectious-disease department where he lives in upstate New York: He should come right away to the ER for newly available coronavirus testing. Though they offered to send an ambulance, he felt fine and drove the hourlong trip.

In an isolation room, the doctors put him on an IV drip, did a chest X-ray and took the swabs.

Now back at work remotely, he faces a mounting array of bills. His patient responsibility, according to his insurer, is close to $2,000, and he fears there may be more bills to come.

“I was under the assumption that all that would be covered,” said Cencini, who makes $54,000 a year. “I could have chosen not to do all this, and put countless others at risk. But I was trying to do the right thing.”

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The new $2 trillion coronavirus aid package allocates well over $100 billion to what Senate Minority Leader Chuck Schumer of New York called “a Marshall Plan” for hospitals and medical needs.

But no one is doing much to similarly rescue patients from the related financial stress. And they desperately need protection from the kind of bills patients like Cencini are likely to incur in a system that freely charges for every bit of care it dispenses.

On March 18, President Donald Trump signed a law intended to ensure that Americans could be tested for the coronavirus free, whether they have insurance or not. (He had also announced that health insurers have agreed to waive patient copayments for treatment of COVID-19, the disease caused by the virus.) But their published policies vary widely and leave countless ways for patients to get stuck.

Although insurers had indeed agreed to cover the full cost of diagnostic coronavirus tests, that may well prove illusory: Cencini’s test was free, but his visit to the ER to get it was not.

As might be expected in a country where the price of a knee X-ray can vary by a factor of well over 10, labs so far are charging between about $51 (the Medicare reimbursement rate) and more than $100 for the test. How much will insurers cover?

Those testing laboratories want to be paid — and now. Last week, the American Clinical Laboratory Association, an industry group, complained that they were being overlooked in the coronavirus package.

“Collectively, these labs have completed over 234,000 tests to date, and nearly quadrupled our daily test capacity over the past week,” Julie Khani, president of the ACLA, said in a statement. “They are still waiting for reimbursement for tests performed. In many cases, labs are receiving specimens with incomplete or no insurance information, and are burdened with absorbing the cost.”

There are few provisions in the relief packages to ensure that patients will be protected from large medical bills related to testing, evaluation or treatment — especially since so much of it is taking place in a financial high-risk setting for patients: the emergency room.

In a study last year, about 1 in 6 visits to an emergency room or stays in a hospital had at least one out-of-network charge, increasing the risk of patients’ receiving surprise medical bills, many demanding payment from patients.

That is in large part because many in-network emergency rooms are staffed by doctors who work for private companies, which are not in the same networks. In a Texas study, more than 30% of ER physician services were out-of-network — and most of those services were delivered at in-network hospitals.

The doctor who saw Cencini works with Emergency Care Services of New York, which provides physicians on contract to hospitals and works with some but not all insurers. It is affiliated with TeamHealth, a medical staffing business owned by the private equity firm Blackstone that has come under fire for generating surprise bills.

Some senators had wanted to put a provision in legislation passed in response to the coronavirus to protect patients from surprise out-of-network billing — either a broad clause or one specifically related to coronavirus care. Lobbyists for hospitals, physician staffing firms and air ambulances apparently helped ensure it stayed out of the final version. They played what a person familiar with the negotiations, who spoke on the condition of anonymity, called “the COVID card”: “How could you possibly ask us to deal with surprise billing when we’re trying to battle this pandemic?”

Even without an ER visit, there are perilous billing risks. Not all hospitals and labs are capable of performing the test. And what if my in-network doctor sends my coronavirus test to an out-of-network lab? Before the pandemic, the Kaiser Health News-NPR “Bill of the Month” project produced a feature about Alexa Kasdan, a New Yorker with a head cold, whose throat swab was sent to an out-of-network lab that billed more than $28,000 for testing.

Even patients who do not contract the coronavirus are at a higher risk of incurring a surprise medical bill during the current crisis, when an unrelated health emergency could land you in an unfamiliar, out-of-network hospital because your hospital is too full of COVID-19 patients.

The coronavirus bills passed so far — and those on the table — offer inadequate protection from a system primed to bill patients for all kinds of costs. The Families First Coronavirus Response Act, passed last month, says the test and its related charges will be covered with no patient charge only to the extent that they are related to administering the test or evaluating whether a patient needs it.

That leaves hospital billers and coders wide berth. Cencini went to the ER to get a test, as he was instructed to do. When he called to protest his $1,622.52 bill for hospital charges (his insurer’s discounted rate from over $2,500 in the hospital’s billed charges), a patient representative confirmed that the ER visit and other services performed would be “eligible for cost-sharing” (in his case, all of it, since he had not met his deductible).

This weekend he was notified that the physician charge from Emergency Care Services of New York was $1,166. Though “covered” by his insurance, he owes another $321 for that, bringing his out-of-pocket costs to nearly $2,000.

By the way, his test came back negative.

When he got off the phone with his insurer, his blood was “at the boiling point,” he told us. “My retirement account is tanking and I’m expected to pay for this?”

The coronavirus aid package provides a stimulus payment of $1,200 per person for most adults. Thanks to the billing proclivities of the American health care system, that will not fully offset Cencini’s medical bills.

As The Country Disinfects, Diabetes Patients Can’t Find Rubbing Alcohol

While the masses hunt for toilet paper, Caroline Gregory and other people with diabetes are on a different mission: scouring stores for the rubbing alcohol or alcohol swabs needed to manage their disease.

Gregory stopped in Carlie C’s, Dollar General and then Harris Teeter in Fayetteville, North Carolina, in pursuit of this vital component of her medical routine.

“We’re all supposed to be staying at home, and I’m out going to 10 different stores,” said Gregory, 33, whose diabetes could heighten her risk for COVID-19 complications. “That’s also not safe.”

Rubbing alcohol and alcohol swabs or wipes are the latest products swept up by the nation’s demand for anything and everything seen as a disinfectant against the novel coronavirus — by hospitals and average consumers alike.

Andy Lerman, vice president of operations for Hydrox Laboratories, a manufacturer based outside Chicago, said the majority of the low-profit-margin medical product his company makes is headed to hospitals, which are going through it faster than they have in the past. He has seen distributors order more than five times the amount they typically do.

“Hospitals are wiping down everything all the time — with every type of virucide that they have at their disposal,” he said. “I’m making it as fast as I can, but I have more orders than I have capacity to manufacture.”

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Isopropyl alcohol — a primary ingredient in some types of rubbing alcohol — has been touted as a cleaner that neutralizes the coronavirus on everything from kitchen countertops to phones. And with the depletion of supplies of hand sanitizer, also seen as a defense against COVID-19, demand has exploded to make homemade versions. The Food and Drug Administration and the World Health Organization list isopropyl alcohol as a critical ingredient in their recommended recipes.

So, for those with diabetes or other chronic medical conditions, the general public’s resulting panic-buying spree has threatened their medical routines, such as when patients use an alcohol swab or a rubbing alcohol-soaked cotton ball to disinfect their skin before they inject insulin.

Alternatives like witch hazel may not have the same antiviral properties, and the proof of most brands of vodka isn’t high enough to be effective. Other compounds, like hydrogen peroxide and liquid iodine, can be unwieldy for diabetes patients to manage while changing insulin pump sites on the go, Gregory said.

Despite the inability to obtain their usual products, people with diabetes still need to maintain their blood sugar levels, said Kelly Mueller, vice president of community impact at the American Diabetes Association. She encouraged patients to wash their hands and pump sites carefully and let them air-dry.

But in the midst of the coronavirus panic, the problem is compounded by a dearth of antibacterial soap or hand sanitizer to replace the disinfecting swabs or rubbing alcohol needed to keep prick sites clean, said Alison Dvorchik. She lives in Orlando, Florida, with her 17-year-old son, Matthew, who has Type 1 diabetes.

“I’m worried for the entire Type 1 diabetic community,” she said. “That’s a cesspool of infection waiting to happen.”

Any potential infection is a strain on an already overburdened health care system, Dvorchik said. For now, she’s trying to ward off that fate for Matthew with a stash of 100 alcohol wipes from a friend — they use about three a day with Matthew’s insulin pump.

The madness began about three weeks ago, according to New Jersey-based AvaCare Medical CEO Steven Zeldes, who runs one of the nation’s larger online medical supply companies.

Overnight his site was swamped with “thousands and thousands” of orders around the country for rubbing alcohol and rubbing alcohol swabs — medical supply items that had not been a primary focus for the company.

At first, he suspected some sort of pricing mishap. Then, he realized rubbing alcohol was a primary ingredient in making homemade hand sanitizer.

The tsunami of orders cleared out the warehouses of AvaCare Medical’s distributors in under two days. Zeldes said the company was out of stock so fast that it received thousands of orders before being able to take down the listings.

“Our company was always a medical supply company for seniors or nursing homes or hospitals,” Zeldes said. “Now we’re a company for every single citizen of America.”

Cathi Carothers, an operations assistant at Lab Alley, a chemical supplier in Austin, Texas, said her company saw a similar explosion of interest in alcohol products from fire departments and post offices as well as Tesla, the Department of Homeland Security and Johns Hopkins University.

“No one could have anticipated this much demand in a month,” Carothers said.

When Lab Alley called Dow and ExxonMobil — two of the largest raw-component manufacturers of isopropyl alcohol in the U.S. — to procure more, she said, the companies told Lab Alley they’re prioritizing hospitals.

Dow confirmed to KHN it was working with the FDA and state officials to maximize production of all its high-demand products. ExxonMobil directed KHN to a news release stating it was actively working with hard-hit New York and Louisiana to send isopropyl alcohol from its Baton Rouge Chemical Plant, which it says is “home to the world’s largest” isopropyl alcohol production site.

Both Medline, a major supplier in Chicago, and New Jersey-based Becton, Dickinson and Co., a health care product manufacturer and supplier, have felt the crush of demand. Medline spokesperson Stacy Rubenstein cited a 100% increase in March this year over last. Accordingly, both companies said they have ramped up production and enforced fair distribution measures.

Down the supply chain, Gregory, the Fayetteville woman with diabetes, said she lost it in line at Walgreens when she saw a sign saying the store was limiting customers to four bottles, which is more than she would go through in a year. (She uses it several times weekly to disinfect the sites of her insulin pump and every 10 days for her glucose monitor.)

“How much hand sanitizer are you making?” Gregory asked. “You certainly don’t need to be cleaning your kitchen with it — it’s not necessary. I think people are just panicking.”

Many forms of rubbing alcohol were sold out on Walgreens online site as of Sunday. Both Target and Rite Aid had also sold out of some rubbing alcohol and rubbing alcohol-related products online.

Finally, Gregory was able to snag one of the last orders for 100 wipes available through Healthcare Supply Pros, an online medical supply company. It should last her for about five months. She fears for older, poorer people with diabetes who may not have internet access or the money to do the same.

Plus, similar listings show the product is now sold out.

“Don’t hoard something that you don’t really need,” said Dvorchik, the mother of the teenager with diabetes. “Because the people who really need it can’t get it.”

Trump Touted Abbott’s Quick COVID-19 Test. HHS Document Shows Only 5,500 Are On Way For Entire U.S.

A coronavirus test made by Abbott Laboratories and introduced with considerable fanfare by President Donald Trump in a Rose Garden news conference this week is giving state and local health officials very little added capacity to perform speedy tests needed to control the COVID-19 pandemic.

“That’s a whole new ballgame,” Trump said. “I want to thank Abbott Labs for the incredible work they’ve done. They’ve been working around-the-clock.”

Yet a document circulated among officials at the Department of Health and Human Services and the Federal Emergency Management Agency this week shows that state and local public health labs were set to receive a total of only 5,500 coronavirus tests from the giant manufacturer of medical devices, diagnostics and drugs, according to emails obtained by Kaiser Health News.

That number falls well short of the “about 500,000 capacity of Abbott tests that” Dr. Deborah Birx, the White House coronavirus response coordinator, said were in the states and were “not being utilized.” Although it is unclear whether she was referring to just the quick test or combining it with another test — one with slower results — that Abbott previously received authorization to sell.

Millions of tests are urgently needed as the virus keeps communities across the country in lockdown and hospitals are overwhelmed with patients.

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Labs in all 50 states were set to receive roughly the same number of Abbott’s test cartridges and the devices on which they run ― 100 tests and 10 or 15 devices — the document shows, regardless of how many confirmed COVID-19 cases officials had reported in each state.

Abbott Labs spokesperson Darcy Ross on Thursday said the company had shipped tests to customers in 18 states but did not elaborate on how many were public clients or governments as opposed to private health care facilities. Ross also said the document circulated among federal officials showed an “intended purchase by HHS and FEMA” of tests and related instruments.

FEMA referred questions to HHS, whose spokesperson Mia Heck said, “We do not comment on any allegedly leaked documents.”

“We can confirm that the federal government is looking to make the initial purchase of a rapid point-of-care test to increase COVID-19 testing capacity in the United States,” she said. “Initially, each state will receive 15 point-of-care instruments, and then they will be able to resupply through the commercial market.”

Accuracy has been a broad problem in the testing for the novel coronavirus. Abbott Labs declined to address specifics on the clinical accuracy of its tests, which was fast-tracked through the Food and Drug Administration’s review process, saying that accuracy data and other performance characteristics will continue to be collected in the field.

State officials are scrambling to obtain Abbott’s highly touted machines after it said they could detect the novel coronavirus in as little as five minutes, or give a negative test result in about 13 minutes. That compares with at least 45 minutes to several days to get results from most of the other types of COVID-19 tests being used.

In announcing the test March 27, Abbott said it was “ramping up production to deliver 50,000 ID NOW COVID-19 tests per day” starting this week to the U.S. health care system.

The price of Abbott’s stock has jumped 26.5% since March 23.

The document circulated among HHS and FEMA officials March 30 and obtained by Kaiser Health News said 5,500 cartridges ― which translates to 5,500 tests — and 780 devices would be shipped to 55 state and local public health labs all over the U.S. An additional 1,200 tests would go to the Pacific territories. Smaller numbers would be sent to the CDC’s lab in Atlanta and the HHS’ Strategic National Stockpile.

Abbott has said the company is “working with the administration to deploy the tests to areas where they can have the greatest impact.”

But contrary to the document’s contents, distribution has been far from even. For example, within days of Abbott’s announcing it would ship its rapid test around the country, Detroit Mayor Mike Duggan said he had secured a commitment for five machines and 5,000 tests from the company, making it among the first cities to receive them. The city planned to immediately use them to test police officers and other first responders. A spokesperson for the city didn’t respond to questions Thursday about whether Detroit had the tests in hand.

“They tell me it’s extremely accurate,” Duggan said of the Abbott test Wednesday on CNN, adding it is supposed to be more accurate than the tests already available. “Right now, most of the tests we have are really not 90% accurate until the symptoms have shown themselves.”

Demand and hype for new tests developed by private companies surges with each new COVID-19 test that obtains emergency authorization from the FDA, but so far the results have been lackluster.

Since early February, the FDA has granted roughly two dozen emergency authorizations for clinical tests to detect the virus. The tests were developed by governments ― including the CDC and the New York state public health lab — and multiple private companies such as LabCorp, Quest Diagnostics, Roche Diagnostics and Thermo Fisher Scientific.

Yet providers have reported rampant problems with COVID-19 tests giving false negatives, in which the virus is not detected even in an infected person.

Few medical tests are 100% accurate. Any test can have false negatives or false positives. The problem isn’t unique to COVID-19 tests.

“False-negative test results — tests that indicate you are not infected, when you are — seem to be uncomfortably common,” Dr. Harlan Krumholz, director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation, wrote in a New York Times piece April 1. “Increasingly, and disturbingly, I hear a growing number of anecdotal stories from my fellow doctors of patients testing negative for coronavirus and then testing positive — or people who are almost certainly infected who are testing negative.”

Reasons for this can vary. The test itself might not be so good at picking out true cases from false ones. Or maybe it wasn’t the test at all, but how the sample was taken or how long it had been since the patient began showing symptoms. Doctors and patients should always consider that a result might not be accurate.

That may be especially true now because the COVID-19 test kits from manufacturers and clinical labs became available under emergency use rules.

Under those rules, manufacturers and labs have to submit documentation to the FDA but don’t have to provide as much information as they would under a regular approval process.

Part of the requirement is they show the FDA just how much ― or little — of the virus must exist in the samples before their test can detect it, said Joeffrey Chahine, technical director for the molecular pathology division at MedStar Georgetown University Hospital in Washington, D.C.

They also must show how well the tests specifically pick out the coronavirus, not confusing it with another virus, he said.

By relaxing some of the other information normally required, such as correlating results with the status of actual patients, the test kits could get onto the market sooner. And that’s the trade-off.

“This is the downside to loosening the FDA restrictions in that the tests weren’t required to go through the same level of quality assurance, the testing of the test, that we would normally see before they go on the market,” said Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials. “But I don’t think that was a bad decision. This is an emergency.”

Detroit, which was supposed to get thousands of Abbott tests this week, had more than 2,800 confirmed COVID-19 cases and 97 deaths as of Thursday evening, and is part of the next wave of emerging hot spots around the country, along with New Orleans and parts of Georgia.

Abbott said it would make tests available to health care providers in “urgent care settings” in the U.S. already using its testing platform, but would not elaborate on specifics.

Public health officials in New York City, Oklahoma and Louisiana said Thursday they had not received the Abbott tests.

“We’re aware we didn’t have an accurate picture,” Shelley Zumwalt, Oklahoma’s chief of innovation, said generally of Oklahoma’s slow testing start. That has begun to change due to increased testing at Oklahoma State University as well as drive-thru testing sites in over a dozen locations in the state.

Others said that even if they had the Abbott tests, they weren’t likely to make much of a dent.

“Each cartridge is one test, and the number of patients you can test depends on how many you use up for training and verification, and quality control, which needs to be run at least once a day,” said New York City Department of Health and Mental Hygiene spokesperson Stephanie Buhle. “So 100 cartridges will not go very far.”

KHN senior correspondent Julie Appleby contributed to this report.

Pandemic-Stricken Cities Have Empty Hospitals, But Reopening Them Is Difficult

Kaiser Health News:States - April 02, 2020

[UPDATED at 5:30 p.m. ET]

As city leaders across the country scramble to find space for the expected surge of COVID-19 patients, some are looking at a seemingly obvious choice: former hospital buildings, sitting empty, right downtown.

In Philadelphia, New Orleans, and Los Angeles, where hospitalizations from COVID-19 increase each day, shuttered hospitals that once served the city’s poor and uninsured sit at the center of a public health crisis that begs for exactly what they can offer: more space. But reopening closed hospitals, even in a public health emergency, is difficult.

Philadelphia, the largest city in America with no public hospital, is also the poorest. There, Hahnemann University Hospital shut its doors in September after its owner, Philadelphia Academic Health System, declared bankruptcy. While not public, the 496-bed safety-net hospital mainly treated patients on public insurance. Philadelphia Mayor Jim Kenney began talks with the building’s owner, California-based investment banker Joel Freedman, as soon as his administration saw projections that the demand for hospital beds during the pandemic would outpace the city’s capacity. Not long after negotiations started, city officials announced the talks were going badly.

“Mr. Freedman was difficult to work with at times when he was the owner of the hospital, and he is still difficult to work with as the owner of the shuttered hospital,” said Brian Abernathy, who is Philadelphia’s managing director and heading the city’s COVID-19 response.

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In New Orleans, where the soaring COVID-19 infection rate is disproportionately high compared with its population, Charity Hospital sits vacant in the middle of town. The former public hospital never reopened after Hurricane Katrina in 2005. The Louisiana State University System, which owns the building, incorporated Charity Hospital into the city’s new medical center, but the original building remains vacant. Instead of using it during the pandemic, the New Orleans Convention Center is being converted to a “step-down” facility with the capacity to treat up to 2,000 patients after they no longer need critical care.

Elsewhere, city governments have struck deals with the owners of empty hospital buildings to lease their space. At St. Vincent Medical Center in Los Angeles, the city is paying $236 per night per bed, for a total of $2.6 million each month.

In Philadelphia, Freedman offered the Hahnemann building to the city for $27 per bed per night, plus taxes, maintenance and insurance, which the city would pay directly. All told, that added up to just over $900,000 per month.

“I think he is looking at how to turn an asset that is earning no revenue into an asset that earns some revenue, and isn’t thinking through what the impacts are on public health,” Abernathy said of Freedman. “I think he’s looking at this as a business transaction rather than providing an imminent and important aid to the city and our residents.”

This isn’t the first time Freedman has come under fire by Philadelphians for his handling of the hospital. Its closure sparked protests from city officials, health care unions, and even presidential hopeful Bernie Sanders. Critics speculated that Freedman, whose private equity firm bought the struggling hospital in 2018, didn’t try in earnest to save it and planned to flip it for its valuable downtown real estate. Notably, Hahnemann’s real estate was parsed out into a separate company, Broad Street Healthcare Properties, also owned by Freedman, and not included in Philadelphia Academic Health System’s Chapter 11 bankruptcy petition.

A representative for Freedman said the building has an interested buyer, and that is one reason Broad Street Healthcare will not let the city use the building at cost.

“We’re offering this facility because of the public benefit in a health crisis, but it comes at a cost to the property owner,” said Broad Street representative Sam Singer.

As urban hospitals have struggled in recent years, it’s become increasingly common for private equity to get involved: Big firms buy struggling medical centers with the promise of financial support and to improve their operations and business strategy. When things go right, the business succeeds, and the private equity firm sells it in a public offering or to another bidder for more than it paid.

In other cases, though, the firms load companies up with debt, take dividends out for themselves, sell off valuable real estate and charge fees and high-interest loans, leaving a company in a much weaker position than it would have been otherwise, and often on the verge of bankruptcy.

“The house never loses,” said Eileen Appelbaum, co-director at the Center for Economic and Policy Research. “The private equity firm makes money whether the company succeeds or it doesn’t.”

For instance, Steward Health Care was able to expand from its base in Massachusetts to a 36-hospital network nationwide with backing from Cerberus Capital Management. Now, said Appelbaum, the chain of community hospitals is stuck paying rent to a separate real estate company, on all its properties, while also struggling to stay in the black. The network announced last week it would furlough non-clinical workers across nine states because the requirement to cancel elective surgeries caused too great a financial strain.

Freedman’s private equity firm is called Paladin Healthcare, and it has previously bought and managed hospitals in California and Washington, D.C., where it helped the struggling Howard University Hospital out of the red. Paladin then sold the hospital to Adventist HealthCare last summer.

Urban hospitals like Hahnemann have struggled to stay afloat in recent years, in part due to their lack of privately insured patients. Hospitals often finance the care of uninsured patients or those on Medicaid by treating those with private insurance, which reimburses the hospitals faster and at a higher rate. At Hahnemann, two-thirds of patients were on Medicaid or Medicare. While a financially struggling public or nonprofit hospital might continue serving a poorer community, a for-profit hospital has different incentives, said Vickie Williams, a former law professor for Gonzaga University.

“If your urban hospital is purchased by a for-profit company and it doesn’t perform sufficiently, they don’t have the same necessarily mission-driven directives to keep that hospital functioning for the good of the community at a loss,” said Williams, who is now senior counsel for CommonSpirit Health in Tacoma, Washington.

Freedman has said that he tried to sell the Hahnemann property to a nonprofit and requested money from the city and state to keep it open, but neither option worked.

Following news that Philadelphia had abandoned negotiations with Freedman, calls to seize the property in order to save lives came pouring in, including from elected officials.

“Eminent Domain was created for situations like #Hahnemann,” City Council member Helen Gym wrote on Twitter. “This is a public health emergency and Philly is the largest city in the nation WITHOUT a public hospital. We cannot allow unconscionable greed to get in the way of saving lives. Eminent domain this property.” Legal experts say the lengthy process of eminent domain and the requirement to pay the owner fair market value for the building make it an unlikely mechanism for an instance like this.

But in public health emergencies, local, state and federal governments do have broad authority to commandeer private property, such as hotels, convention centers, university dormitories or even defunct hospitals for disaster response. Williams, whose research has focused on preserving hospital infrastructure during a pandemic, said that so far in the United States, that hasn’t had to happen ― at least not in the traditional sense.

In Pennsylvania, the governor’s emergency declaration gives him the authority to “commandeer or utilize any private, public or quasi-public property if necessary to cope with the disaster emergency.” A health department representative said all options remain on the table in the event that the city’s hospital bed capacity is overrun.

In the interim, the mayor made a deal with Temple University to use its basketball arena, which would have the capacity to treat 250 non-critical patients, at no cost to the city.

This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.

KHN’s ‘What The Health?’: All Coronavirus All The Time

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Julie Rovner

Kaiser Health News

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Read Julie's Stories Joanne Kenen

Politico

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Read Joanne's Stories Alice Miranda Ollstein

Politico

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Read Alice's Stories Margot Sanger-Katz

The New York Times

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Read Margot's Stories

The medical and economic needs laid bare by the coronavirus pandemic are forcing some immediate changes to the U.S. health system. Congress, in its latest relief bill, provided $100 billion in funding for the hospital industry alone. Meanwhile, the federal government has quickly removed previous barriers to telehealth and other sometimes controversial practices.

But big fights are still brewing, including whether the federal government will reopen the Affordable Care Act marketplaces it runs and whether states can use emergency powers to ban abortions as “elective medical procedures.”

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • The ACA was passed on the heels of the Great Recession. The coronavirus outbreak has produced the first big economic downturn since then, and the law’s provisions to expand Medicaid and to provide an insurance option to those without jobs could provide a critical safety net during this crisis.
  • About a dozen states running their own ACA insurance marketplaces have opened up enrollment again to let people who did not enroll in the fall but are feeling the pinch from the coronavirus pandemic to reconsider. President Donald Trump said this week that he is mulling a similar move, but the messages from the administration on such action have been confusing.
  • People who had insurance through work and have lost their jobs don’t need a special enrollment period to sign up for an Obamacare plan. They are eligible because their job situation changed. However, the administration has not been publicizing that message.
  • Hospitals are eager to receive the $100 billion appropriated by Congress in response to the influx of patients with COVID-19, the disease caused by the coronavirus. But the administration has not yet said how that money will be apportioned.
  • A handful of states have prohibited abortions during the coronavirus emergency because, officials say, they are seeking to preserve protective gear for hospital staff treating COVID-19 patients. But it’s not clear that the abortion procedures ― especially medication abortions — are interfering with efforts to safeguard protective clothing or masks needed by hospitals. And women who do not get abortions will consume far more medical care by remaining pregnant and giving birth.

Also, this week, Rovner interviews KHN’s Liz Szabo, who reported the latest KHN-NPR “Bill of the Month” installment about a patient who underwent a very expensive genetic test. If you have an outrageous medical bill you would like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The New York Times’ “A Ventilator Stockpile With One Hitch: Thousands Do Not Work,” by David E. Sanger, Zolan Kanno-Youngs and Nicholas Kulish

Joanne Kenen: The New Yorker’s “The Life and Death of Juan Sanabria, One of New York City’s First Cornavirus Victims,” by Jonathan Blitzer

Margot Sanger-Katz: Bloomberg News’ “Hospitals Tell Doctors They’ll Be Fired If They Speak Out About Lack of Gear,” by Olivia Carville, Emma Court and Kristen V. Brown

Alice Miranda Ollstein: The Washington Post’s “Trump Ban on Fetal Tissue Research Blocks Coronavirus Treatment Effort,” by Amy Goldstein

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

DOJ and HHS Partner to Distribute More Than Half A Million Medical Supplies Confiscated From Price Gougers

HHS Gov News - April 02, 2020

The U.S. Department of Justice (DOJ) and U.S. Department of Health and Human Services (HHS) today announced the distribution of hoarded personal protective equipment (PPE), including approximately 192,000 N95 respirator masks, to those on the frontline of the novel coronavirus disease 2019 (COVID-19) response in New York and New Jersey.

The Federal Bureau of Investigation discovered the supplies during an enforcement operation by the Department of Justice's COVID-19 Hoarding and Price Gouging Task Force on March 30 and alerted HHS which used its authority under Defense Production Act to order that the supplies be immediately furnished to the United States. In addition to the N95 respirator masks, the supplies found included 598,000 medical grade gloves and 130,000 surgical masks, procedure masks, N100 masks, surgical gowns, disinfectant towels, particulate filters, bottles of hand sanitizer, and bottles of spray disinfectant.

"Cracking down on the hoarding of vital supplies allows us to distribute this material to the heroic healthcare workers on the frontlines who are most in need," said HHS Secretary Alex Azar. "Thanks to the quick work of the White House, the Department of Justice, and HHS, the seized resources were distributed in days to the doctors, nurses and first responders who need them. President Trump's all-of-America approach to combating the coronavirus involves an aggressive approach to stopping hoarding, and the American public can play a role by being on the lookout for this behavior."

HHS will pay the owner of the hoarded equipment pre-COVID-19 fair market value for the supplies and has begun distributing to meet the critical need for the supplies among healthcare workers in New York and New Jersey.

Specifically, after inspecting the supplies, HHS arranged for the delivery of the PPE to the New Jersey Department of Health, the New York State Department of Health and the New York City Department of Health and Mental Hygiene.

"This is the first of many such investigations that are underway," said Peter Navarro, DPA Policy Coordinator and Assistant to the President. "Our FBI agents and other law enforcement agencies are tracking down every tip and lead they get, and are devoting massive federal resources to this effort. All individuals and companies hoarding any of these critical supplies, or selling them at well above market prices, are hereby warned they should turn them over to local authorities or the federal government now or risk prompt seizure by the federal government."

"If you are amassing critical medical equipment for the purpose of selling it at exorbitant prices, you can expect a knock at your door," said Attorney General William P. Barr. "The Department of Justice's COVID-19 Hoarding and Price Gouging Task Force is working tirelessly around the clock with all our law enforcement partners to ensure that bad actors cannot illicitly profit from the COVID-19 pandemic facing our nation."

Vendors interested in selling PPE to the federal government should contact the Federal Emergency Management Agency at https://www.fema.gov/coronavirus/how-to-help. Anyone who learns of hoarding or price gouging of PPE should report it to the National Center for Disaster Fraud by dialing 1-866-720-5721 or emailing disaster@leo.gov.

HHS and the Federal Emergency Management Agency continue to collaborate with private industry to overcome the shortage of PPE across the country amid the COVID-19 pandemic.

The Defense Production Act and Presidential Executive Order March 25 are intended to prevent accumulation in excess of reasonable demands of business, personal, or home consumption, or for the purpose of resale at prices in excess of prevailing market prices, also known as hoarding and price gouging, of medical supplies critical to the COVID-19 response.

OCR Announces Notification of Enforcement Discretion to Allow Uses and Disclosures of Protected Health Information by Business Associates for Public Health and Health Oversight Activities During The COVID-19 Nationwide Public Health Emergency

HHS Gov News - April 02, 2020

Today, the Office for Civil Rights (OCR) at the U.S Department of Health and Human Services (HHS) announced, effective immediately, that it will exercise its enforcement discretion and will not impose penalties for violations of certain provisions of the HIPAA Privacy Rule against health care providers or their business associates for the good faith uses and disclosures of protected health information (PHI) by business associates for public health and health oversight activities during the COVID-19 nationwide public health emergency.

This Notification was issued to support Federal public health authorities and health oversight agencies, like the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS), state and local health departments, and state emergency operations centers who need access to COVID-19 related data, including PHI. The HIPAA Privacy Rule already permits covered entities to provide this data, and today's announcement now permits business associates to also share this data without risk of a HIPAA penalty.

"The CDC, CMS, and state and local health departments need quick access to COVID-19 related health data to fight this pandemic," said Roger Severino, OCR Director. "Granting HIPAA business associates greater freedom to cooperate and exchange information with public health and oversight agencies can help flatten the curve and potentially save lives," Severino added.

This Notification of Enforcement Discretion may be found at: https://www.hhs.govhttps://www.hhs.gov/sites/default/files/notification-enforcement-discretion-hipaa.pdf

OCR has a new webpage with all COVID-19 related materials issued by OCR at: https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-covid19/index.html.

California Hospitals Face Surge With Proven Fixes And Some Hail Marys

Kaiser Health News:States - April 01, 2020

California’s hospitals thought they were ready for the next big disaster.

They’ve retrofitted their buildings to withstand a major earthquake and  whisked patients out of danger during deadly wildfires. They’ve kept patients alive with backup generators amid sweeping power shutoffs and trained their staff to thwart would-be shooters.

But nothing has prepared them for a crisis of the magnitude facing hospitals today.

“We’re in a battle with an unseen enemy, and we have to be fully mobilized in a way that’s never been seen in our careers,” said Dr. Stephen Parodi, an infectious disease expert for Kaiser Permanente in California. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

As California enters the most critical period in the state’s battle against COVID-19, the state’s 416 hospitals — big and small, public and private — are scrambling to build the capacity needed for an onslaught of critically ill patients.

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Hospitals from Los Angeles to San Jose are already seeing a steady increase in patients infected by the virus, and so far, hospital officials say they have enough space to treat them. But they also issued a dire warning: What happens over the next four to six weeks will determine whether the experience of California overall looks more like that of New York, which has seen an explosion of hospitalizations and deaths, or like that of the San Francisco Bay Area, which has so far managed to prevent a major spike in new infections, hospitalizations and death.

Some of their preparations share common themes: Postpone elective surgeries. Make greater use of telemedicine to limit face-to-face contact. Erect tents outside to care for less critical patients. Add beds — hospital by hospital, a few dozen at a time — to spaces like cafeterias, operating rooms and decommissioned wings.

But by necessity — because of shortages of testing, ventilators, personal protective equipment and even doctors and nurses — they’re also trying creative and sometimes untried strategies to bolster their readiness and increase their capacity.

In San Diego, hospitals may use college dormitories as alternative care sites. A large public hospital in Los Angeles is turning to 3D printing to manufacture ventilator parts. And in hard-hit Santa Clara County, with a population of nearly 2 million, public and private hospitals have joined forces to alleviate pressure on local hospitals by caring for patients at the Santa Clara Convention Center.

Yet some hospitals acknowledge that, despite their efforts, they may end up having to park patients in hallways.

“The need in this pandemic is so different and so extraordinary and so big that a hospital’s typical surge plan will be insufficient for what we’re dealing with in this state and across the nation,” said Carmela Coyle, president and CEO of the California Hospital Association.

Across the U.S., more than 213,000 cases of COVID-19 have been confirmed, and at least 4,750 people have died. California accounts for more than 9,400 cases and at least 199 deaths.

Health officials and hospital administrators are singling out April as the most consequential month in California’s effort to combat a steep increase in new infections. State Health and Human Services Secretary Mark Ghaly said Wednesday that the number of hospitalizations is expected to peak in mid-May.

Gov. Gavin Newsom said there were 1,855 COVID-19 cases in hospitals Wednesday, a number that had tripled in six days, and 774 patients in critical care. By mid-May, the number of critical care patients is expected to climb to 27,000, he said.

Newsom said the state needs nearly 70,000 more hospital beds, bringing its overall capacity to more than 140,000 — both inside hospitals and also at alternative care sites like convention centers. The state also needs 10,000 more ventilators than it normally has to aid the crush of patients needing help to breathe, he said, and so far has acquired fewer than half.

Newsom and state health officials worked with the Trump administration to bring a naval hospital ship to the Port of Los Angeles, where it is already treating patients not infected with the novel coronavirus. The state is working with the Army Corps of Engineers to deploy eight mobile field hospitals, including one in Santa Clara County. And it is bringing hospitals back online that were shuttered or slated to close, including one each in Daly City, Los Angeles, Long Beach and Costa Mesa.

The governor is also drafting a plan to make greater use of hotels and motels and nursing homes to house patients, if needed.

But the size of the surge that hits hospitals depends on how well the public follows social distancing and stay-at-home orders, said Newsom and hospital administrators. “This is not just about health care providers caring for the sick,” said Dr. Steve Lockhart, the chief medical officer of Sutter Health, which has 22 hospitals across Northern California.

While hospitals welcomed the state assistance, they’re also undertaking dramatic measures to prepare on their own.

“I’m genuinely very worried, and it scares me that so many people are still out there doing business as usual,” said Chris Van Gorder, CEO of Scripps Health, a system with five major hospitals in San Diego County. “It wouldn’t take a lot to overwhelm us.”

Internal projections show the hospital system could need 8,000 beds by June, he said. It has 1,200.

In addition to taking precautions to protect its health care workers — such as using baby monitors to observe patients without risking infection — it is working with area colleges to use dorm rooms as hospital rooms for patients with mild cases of COVID-19, among other efforts, he said.

“Honestly, I think we should have been better prepared than we are,” Van Gorder said. “But hospitals cannot take on this burden themselves.”

Van Gorder and other hospital administrators say a continued shortage of COVID-19 tests has hampered their response — because they still don’t know exactly which patients have the virus — as has the chronic underfunding of public health infrastructure.

Kaiser Permanente wants to double the capacity of its 36 California hospitals, Parodi said. It is also working with the garment industry to manufacture face masks, and eyeing hotel rooms for less critical patients.

Harbor-UCLA Medical Center, a 425-bed safety-net hospital in Los Angeles, is working to increase its capacity by 200%, said Dr. Anish Mahajan, the hospital’s chief medical officer.

Harbor-UCLA is using 3D printers to produce ventilator piping equipped to serve two patients per machine. And in March it transformed a new emergency wing into an intensive care unit for COVID-19 patients.

“This was a shocking thing to do,” Mahajan said of the unprecedented move to create extra space.

He said some measures are untested, but hospitals across the state are facing extreme pressure to do whatever they can to meet their greatest needs.

In March, Stanford Hospital in the San Francisco Bay Area launched a massive telemedicine overhaul of its emergency department to reduce the number of employees who interact with patients in person. This is the first time the hospital has used telemedicine like this, said Dr. Ryan Ribeira, an emergency physician who spearheaded the project.

Stanford also did some soul-searching, thinking about which of its staff might be at highest risk if they catch COVID-19, and has assigned them to parts of the hospital with no coronavirus patients or areas dedicated to telemedicine. “These are people that we might have otherwise had to drop off the schedule,” Ribeira said.

Nearby, several San Francisco hospitals that were previously competitors have joined forces to create a dedicated COVID-19 floor at Saint Francis Memorial Hospital with four dozen critical care beds.

The city currently has 1,300 beds, including 200 ICU beds. If the number of patients surges as it has in New York, officials anticipate needing 5,000 additional beds.

But the San Francisco Bay Area hasn’t yet seen the expected surge. UCSF Health had 15 inpatients with COVID-19 Tuesday. Zuckerberg San Francisco General Hospital and Trauma Center had 18 inpatients with the disease Wednesday.

While hospital officials are cautiously optimistic that local and state stay-at-home orders have worked to slow the spread of the virus, they are still preparing for what could be a major increase in admissions.

“The next two weeks is when we’re really going to see the surge,” said San Francisco General CEO Susan Ehrlich. “We’re preparing for the worst but hoping for the best.”

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

Listen: COVID-19 Stresses Rural Hospitals Even Before They Have A Single Case

Kaiser Health News:States - April 01, 2020

KHN Midwest correspondent Lauren Weber appeared on WOSU’s “All Sides with Ann Fisher” out of Columbus, Ohio, to talk about the coronavirus pandemic’s impact on rural hospitals. Weber recently reported on the financial implications for such hospitals even before they handle any COVID-19 cases.

Almost half of the nation’s rural hospitals already operated in the red on a good day. Rural hospital CEOs now warn that some soon may be unable to pay their workers because they’ve had to cancel elective procedures, therapy, tests and other visits that bring in most of their revenue. Despite the recent federal bailout, their doors may close when the community most needs them.

Click here to listen on WOSU’s website.

Under Pressure, Florida Governor Finally Orders Residents To Stay Home

Kaiser Health News:States - April 01, 2020

With pressure mounting from public health officials and political leaders nationwide, Florida Gov. Ron DeSantis on Wednesday reversed course and ordered residents across the state to stay at home to help reduce the toll of the coronavirus pandemic.

The order takes effect at 12:01 a.m. Friday, April 3.

Florida joins more than 30 other states and the District of Columbia in moves that have similarly restricted residents and businesses. DeSantis’ decision came as Texas and Pennsylvania took similar action.

For more than a week, DeSantis said a statewide order was unnecessary because many parts of the state ― particularly large swaths of central and northern Florida — had few if any cases. When asked about the issue Tuesday, the governor said he wasn’t issuing an order because he had not been told by the White House coronavirus task force that an order was necessary.

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DeSantis spoke to President Donald Trump about the outbreak before his announcement.

DeSantis said what changed his mind was Trump’s call on Sunday for the national social-distancing guidelines to be extended through April because of mathematical models showing how death tolls would soar if the population did not observe the recommended public health guidelines for staying at home. Trump has not issued a national stay-at-home order.

“That was a signal,” DeSantis said. “It’s a very serious situation.”

Scott Gottlieb, a former Food and Drug Administration commissioner under Trump who has been outspoken on the need for officials to act to quell the outbreak, said in a tweet:

“New actions just announced by Florida’s Governor to implement tougher mitigation will hopefully reduce spread of #COVID19 in state. Florida is also testing much less than other states and needs more screening capacity to keep up with its expanding epidemic.”

Before DeSantis reversed course, Gottlieb said in an interview with CNBC earlier Wednesday that Florida and Texas are “wild card” states that could leave the United States with more deaths from the coronavirus if they don’t take tougher actions.

Many public health experts had strongly criticized Florida officials for allowing large spring-break beach gatherings in mid-March, raising concerns that the parties could be spreading COVID-19, the disease caused by the coronavirus. Even more recently, large beach and sandbar parties in late March have brought condemnation.

DeSantis resisted closing all beaches via a state decree, but most counties in Florida have now done so on their own.

The Florida order is less restrictive than that of some other states. In addition to common exceptions for errands deemed essential, such as grocery shopping and picking up prescriptions, it allows people to still attend religious services at churches and synagogues and take care of relatives and their pets.

The Florida governor had already ordered nightclubs and restaurant dining rooms across the state to close and restricted gatherings of 10 or more people on beaches. The state had already closed all schools.

Several of Florida’s largest cities and counties — including all of South Florida, which on Wednesday afternoon had about 3,900 COVID-19 cases — had earlier ordered residents to stay at home.

Public health and political leaders praised DeSantis’ order Wednesday, although some said he should have acted earlier.

“Thank you, Governor, for making the right call,” said Florida Agriculture Commissioner Nikki Fried, a statewide elected member of the Florida Cabinet. She noted she asked DeSantis to issue the order on March 20 to save lives.

As of Tuesday morning, Florida had about 7,000 confirmed cases of COVID-19, nearly 900 hospitalizations and at least 87 deaths. More than 60% of the cases were in South Florida.

Listen: Why It Takes So Long To Get COVID-19 Test Results

In this episode of “The Daily Dive,” a news podcast, KHN senior correspondent Julie Appleby and iHeart Radio’s Oscar Ramirez discuss the steps involved in processing coronavirus tests and how these circumstances can lead to lags and variations in the turnaround time the patients face as they wait for results.

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For more on this topic, check out Julie’s story.

 

‘Essential’ Or Not, These Workers Report For Duty

Kaiser Health News:States - April 01, 2020

Pauline Lawrence is a home health aide for a 97-year-old man who depends on her.(Heidi de Marco/KHN)

Use Our Content This story can be republished for free (details). WEST HOLLYWOOD, Calif. — Pauline Lawrence is 63, an age that puts her at increased risk if she contracts COVID-19.

Yet, three days a week, she spends 16 hours with someone at even greater risk: a 97-year-old man who depends on her and two other home health aides to survive.

“Somebody has to take care of him,” said Lawrence, an immigrant from Jamaica who lives with her 30-year-old son in a South Los Angeles apartment. “I will stand up to do what I have to do to help.”

Under California’s statewide stay-at-home order that is intended to stem the spread of the novel coronavirus — as well as similar orders issued by cities and counties — many businesses must shut down completely. More than 30 governors have issued similar orders for their states.

But the orders allow “essential” businesses to remain open and “essential” workers to stay on the job.

Who’s considered “essential”? For starters, health care workers, law enforcement personnel, plumbers and grocery store clerks. But many workers dubbed essential are not as obvious, including cannabis dispensary and entertainment industry employees under California’s statewide order, and gardeners and landscapers under the Los Angeles County order.

Among the people who continue to work without the luxury of working from home are a high percentage of low-wage earners, those who earn median hourly wages of $10.22, according to a recent national analysis by the Brookings Institution. And among low-wage earners, black and Latino workers are overrepresented compared with their share of the total workforce.

Lawrence cares for Charles Smurr, 97, a retired office manager. Smurr lives alone and depends on three home health aides to help him with his needs, from 7:30 a.m. to 11:30 p.m. every day. “I’m not afraid to keep working,” Lawrence says. “I’m a woman of God.”(Heidi de Marco/KHN)

Lawrence, who wears protective gear during her entire shift, disinfects everything when she enters the two-bedroom apartment and as she works. After she leaves, she says, she does her best to prevent any germs from entering her home. “I take my clothes off and put them in a plastic bag before I enter my house.”(Heidi de Marco/KHN)

Jose Solorio, 56, Ismael Garcia, 33, and Oscar Bravo, 41, are landscapers in Pasadena, California. “We are worried like everyone else, but our risk is lower than if we worked in an office,” Garcia says.(Heidi de Marco/KHN)

 (Heidi de Marco/KHN)

Jose Solorio says he will continue to work as long as he can. Like his co-workers, he is the main provider for his family. “It’s in God’s hands,” he says about the threat of getting sick.(Heidi de Marco/KHN)

Tony Serrato, 34, is a cook at Pie ‘n Burger in Pasadena, where takeout orders keep him busy. His hours were cut when the stay-at-home order went into effect, and he now works 20 hours a week, down from 40. “It’s not enough, but it’s something,” he says.(Heidi de Marco/KHN)

Serrato prepares a burger Thursday. Pie ‘n Burger employs just two workers per shift under the new coronavirus rules: one cook and one person answering the phones. Owner Michael Osborn says the restaurant is doing only about one-third of its regular business and is producing about 120 burgers a day. Osborn had to cut 25 employees when restaurants were ordered closed except for takeout or pickup service. He describes it as the hardest thing he’s ever had to do.(Heidi de Marco/KHN)

Gustavo Rojas, 33, works as an auto mechanic at Homer’s Auto Services in Monrovia, California. Rojas says work is consistent but slower than before. “Everyone needs their car,” he says. Rojas is part of a three-man crew. The mechanics don’t wear masks and only sometimes wear gloves, but Rojas says they wipe down high-touch parts of each car when it arrives at the shop, with a focus on the steering wheel.(Heidi de Marco/KHN)

 (Heidi de Marco/KHN)

 (Heidi de Marco/KHN)

Victoria Garrido, 23, is a sales associate at Get Yok’d Sports Nutrition, a supplement and health food store in Pasadena. Sales have fallen 70% since the stay-at-home orders went into effect, says owner Sarb Derzakarian. With only about 25 customers a day, he says, he doesn’t know how long he can keep the store open.(Heidi de Marco/KHN)

Garrido and other employees disinfect after each customer leaves. Garrido cleans the door handles, credit card machines and anything else the customer has touched. “I want to wear a mask,” says Garrido, “but it’s hard to work like that.”(Heidi de Marco/KHN)

Tommie Ramirez, 29, is a “budtender” at The Pottery, a cannabis dispensary in the Mid-City neighborhood in central Los Angeles. Ramirez wears gloves at work and practices social distancing but worries about bringing the virus home to her elderly parents.(Heidi de Marco/KHN)

Ramirez grabs a cannabis tincture for a customer. The dispensary has taken precautions to keep employees and customers safe, including placing signs around the shop.(Heidi de Marco/KHN)

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

With Coronavirus Rare In Rural Florida, Experts Dispute Way Forward

Kaiser Health News:States - April 01, 2020

JUPITER, Fla. ― Florida Gov. Ron DeSantis has refused to issue a statewide “stay-at-home” order to stem the spread of the novel coronavirus because the disease has not hit many areas of the state, he said.

At least 30 states have issued statewide stay-at-home orders so far. Florida, among eight states with the most COVID-19 cases, is the only one without such an order.

DeSantis’ approach in trying to manage the disease without doing undue harm to the economy mirrors comments from President Donald Trump, who Monday reiterated his belief that a nationwide stay-at-home order is not needed. “There are some parts of the country that are in far deeper trouble than others,” he told reporters. “There are other parts that, frankly, are not in trouble at all.”

But as the outbreak marches across the country, public health officials stress that the lack of testing is masking the true picture of the epidemic, a situation that they argue is playing out in Florida.

As of Tuesday night, 29 of Florida’s 67 counties had 10 or fewer cases of COVID-19, the disease caused by the coronavirus. In 13 largely rural and poor counties — mostly in the northern part of the state between Gainesville and Tallahassee — no cases had been reported to the state health department.

Yet many rural counties have tested fewer than 75 patients in the past two weeks, according to health department data.

Public health experts and emergency management officials disagree on whether a statewide stay-at-home order would make a difference in these rural counties.

Several of Florida’s largest cities and counties — including all of South Florida, which has about 3,900 COVID-19 cases — have ordered people to stay at home. These orders generally make exceptions only for travel to grocery stores, pharmacies, gas stations or other essential errands. People are allowed outside their homes to walk or run but are not allowed to congregate in groups. They also exempt essential workers, including those in health care.

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“I would be doing a stay-at-home order” across the state, said Dr. Leslie Beitsch, chairman of the behavioral sciences and social medicine department at Florida State University’s College of Medicine. “It tells people this is serious, and we are doing something unprecedented.”

But in Okeechobee County, an agricultural community with about 40,000 people in the south-central part of the state, Emergency Management Director Mitch Smeykal said, an order would have little benefit.

“The cows still have to be milked twice a day or they are not going to be able to produce any milk,” he said.

He said residents already understand the seriousness of the outbreak, having seen the run on food in area grocery stores and the early departure of thousands of part-time residents to return to their permanent homes.

As of Tuesday night, just 55 people have been tested in the county and no COVID-19 cases had been confirmed.

Smeykal said rural counties are likely not seeing anyone with the virus yet because people already live and work far from neighbors and crowds. But it’s only a matter of time until a positive test emerges, he said.

“We probably do have a case in the county, but it hasn’t presented itself yet,” he said. “We are not going to be spared from this.”

Florida has more than 6,700 cases of COVID-19 and has done about 65,000 tests — far fewer than the tallies in New York and other states. As of Tuesday night, more than 85 people had died and 850 had been hospitalized because of COVID-19 in Florida.

According to the Florida health department, only people who have had close contact with a laboratory-confirmed case of COVID-19 and have a fever, cough and/or shortness of breath can be tested.

On Monday, DeSantis issued a stay-at-home order for residents of South Florida until April 14, saying the action makes sense for the region because of the number of cases concentrated there.

DeSantis has ordered restaurant dining rooms and bars to close and restricted gatherings of more than 10 people across the state. The state has also closed all public schools. DeSantis directed travelers arriving in the state from the New York metro area or Louisiana to self-isolate for 14 days.

Dr. Marissa Levine, a professor of public health and family medicine at the University of South Florida in Tampa, said the paucity of positive test results in many Florida counties gives a false sense of security.

“Until we do more widespread community testing, we won’t really know who has been exposed,” Levine said. From her standpoint, she said, the governor should set restrictions across the state. “From a public health standpoint, there is no question that the earlier you do it the better.”

Florida’s large senior population, the age group hit hardest by COVID-19, is another reason to go to a statewide lockdown, Levine added. A stay-at-home order would signal to people, even in counties with few or no cases, that people need to change their normal behavior.

“When you don’t have such an order in place, I worry people may not be as cautious or [not] go about their hand-washing and social distancing,” Levine said.

In Hendry County, which has four positive COVID-19 cases after administering 63 tests, residents are practicing the same precautions as in urban areas on lockdown, said R.D. Williams, CEO of Hendry Regional Medical Center. The rural community halfway between West Palm Beach and Fort Myers reported its first positive test Sunday.

Williams said he favors DeSantis’ approach because projections on the spread of the outbreak in the region don’t support the need for a shelter-in-place approach statewide.

March and April mark the peak of the harvest season for sugar cane, so hundreds of migrant workers in Hendry County are still going to work.

“Those operations are going full speed,” Williams said. Because those workers are outside, he added, it’s easier for them to practice social distancing than in a production facility.

While rural Florida has not struggled with the coronavirus, if cases escalate, these areas could be hard-pressed to handle an outbreak because of a lack of doctors and hospitals, said Jerne Shapiro, a lecturer in the department of epidemiology at the University of Florida. Many rural residents also lack insurance and may not have a strong understanding of the health system or how to seek help, she said.

“This is going to exacerbate the problems we have in these rural counties where people now are struggling to get seen by a provider,” she noted. “The gap for this underserved population is only going to be magnified.”

Optimizing Ventilator Use during the COVID-19 Pandemic

HHS Gov News - March 31, 2020

Because of the unprecedented demand on hospital and ICU resources during the COVID-19 (SARS CoV-2) pandemic, many hospitals may be challenged with providing mechanical ventilation to all those in need of this therapy. The U.S. Department of Health and Human Services (HHS) and the Federal Emergency Management Agency (FEMA) are working with multiple partners that include healthcare systems, academic institutions, professional medical societies, and the National Academies of Science, Engineering and Medicine to develop crisis standards of care strategies for ventilator support when resources are limited.

To meet the growing demand for mechanical ventilators, the HHS Assistant Secretary for Health and U.S. Surgeon General issued an open letter to the healthcare community stressing the need to aggressively implement the following four measures:

  1. Rigorous adherence to all social distancing measures, including limitations on gatherings and travel. This is the best way to reduce infections and thus demand for ventilators.
  2. Following guidelines to optimize the use of mechanical ventilators. This includes canceling elective surgeries, using equipment from state regions not experiencing outbreaks, as well as transition of anesthesia machines and other respiratory devices for use as mechanical support for those in respiratory failure from COVID-19 and other diseases.
  3. Judicious, data driven requests and usage of the Strategic National Stockpile (SNS) of ventilators and equipment. To be able to allocate ventilators where they are most needed, all states must be data-driven in their requests based on the actual capacity for mechanical ventilation, including anesthesia machine conversions.
  4. Increasing the capacity of the SNS through federal procurement. The SNS will receive at least an additional 20,000 mechanical ventilators by mid-May 2020.

In addition, a possible crisis standard-of-care strategy, currently contemplated by several centers, is using one ventilator for two patients. Co-venting should only be considered as an absolute last resort and for a limited amount of time.

“According to our best projections, combined with information on the ground, the availability of precious medical resources will be limited in some places because of the numbers of patients and their severity of illness,” said Assistant Secretary for Health, ADM Brett P. Giroir. We want our healthcare heroes on the frontlines to be armed with the broadest possible range of ventilator support strategies to aid in the decisions that must be made at the individual institution, care-provider, and patient levels during the current time of limited resources and evolving standards of care.”

You may find the open letter and other resources: https://www.hhs.gov/about/news/coronavirus/optimizing-ventilator-use-during-covid19-pandemic.html.

Her Genetic Test Revealed A Microscopic Problem — And A Jumbo Price Tag

Kaiser Health News:Insurance - March 31, 2020

Michelle Kuppersmith, 32, feels great, works full time and exercises three to four times a week. So she was surprised when a routine blood test found that her body was making too many platelets, which help control bleeding. Kuppersmith’s doctor suspected she had a rare blood disorder called essential thrombocythemia, which can lead to blood clots, strokes and, in rare cases, leukemia.

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Her doctor suggested a bone marrow biopsy, in which a large needle is used to suck out a sample of the spongy tissue at the center of the patient’s hip bone. Doctors examine the bone marrow under a microscope and analyze the DNA. The procedure allows doctors to judge a patient’s prognosis and select treatment, if needed. Kuppersmith had heard the procedure can be intensely painful, so she put it off for months.

The biopsy — performed by a provider in her insurance network, at a hospital in her network ― lasted only a few minutes, and Kuppersmith received relatively good news. While a genetic analysis of her bone marrow confirmed her doctor’s suspicions, it showed that the only treatment she needs, for now, is a daily, low-dose aspirin. She will check in with her doctor every three to four months to make sure the disease isn’t getting worse.

All in all, Kuppersmith felt relieved.

Then she got a notice saying her insurer refused to pay for the genetic analysis, leaving her responsible for a $2,400 payment.

The Patient: New York resident Michelle Kuppersmith, 32, who is insured by Maryland-based CareFirst Blue Cross Blue Shield. She works as director of special projects at a Washington-based, nonpartisan watchdog group. Because she was treated in New York, Empire Blue Cross Blue Shield — which covers that region ― handled part of her claim.

Total Amount Owed: $2,400 for out-of-network genetic profiling

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The Providers: Kuppersmith had her bone marrow removed at the Mount Sinai Ruttenberg Treatment Center in New York City, which sent her biopsy sample to a California lab, Genoptix, for testing.

Medical Services: Bone marrow biopsy and molecular profiling, which involves looking for genetic mutations

What Gives: The field of “molecular diagnostics,” which includes a variety of gene-based testing, is undergoing explosive growth, said Gillian Hooker, president of the National Society of Genetic Counselors and vice president of clinical development for Concert Genetics, a health IT company in Nashville, Tennessee.

A Concert Genetics report found there are more than 140,000 molecular diagnostic products on the market, with 10 to 15 added each day.

The field is growing so quickly that even doctors are struggling to develop a common vocabulary, Hooker said.

Kuppersmith underwent a type of testing known as molecular profiling, which looks for DNA biomarkers to predict whether patients will benefit from new, targeted therapies. These mutations aren’t inherited; they develop over the course of a patient’s life, Hooker said.

Medicare spending on molecular diagnostics more than doubled from 2016 to 2018, increasing from $493 million to $1.1 billion, according to Laboratory Economics, a lab industry newsletter.

Charges range from hundreds to thousands of dollars, depending on how many genes are involved — and which billing codes laboratories use, Hooker said.

Based on Medicare data, at least 1,500 independent labs perform molecular testing, along with more than 500 hospital-based labs, said Jondavid Klipp, the newsletter’s publisher.

In a fast-evolving field with lots of money at stake, tests that a doctor or lab may regard as state-of-the-art an insurer might view as experimental.

Worse still, many of the commercial labs that perform the novel tests are out-of-network, as was Genoptix.

After lining up an in-network provider at an in-network hospital, Kuppersmith pushed back when she got a $2,400 charge for an out-of-network lab. She appealed and won but says, “There are a lot of people who don’t have the time or wherewithal to do this kind of fighting.”(Shelby Knowles for KHN)

Stephanie Bywater, chief compliance officer at NeoGenomics Laboratories, which owns Genoptix, said that insurance policies governing approval have not kept up with the rapid pace of scientific advances. Kuppersmith’s doctor ordered a test that has been available since 2014 and was updated in 2017, Bywater said.

Although experts agree that molecular diagnostics is an essential part of care for patients like Kuppersmith, doctors and insurance companies may not agree on which specific test is best, said Dr. Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.

Tests “can be performed a number of different ways by a number of different laboratories who charge different amounts,” Nichols said.

Insurance plans are much more likely to refuse to pay for molecular diagnostics than other lab tests. Laboratory Economics found Medicare contractors denied almost half of all molecular diagnostics claims over the past five years, compared with 5-10% of routine lab tests.

With so many insurance plans, so many new tests and so many new companies, it is difficult for a doctor to know which labs are in a patient’s network and which specific tests are covered, Nichols said.

“Different providers have contracts with different diagnostic companies,” which can affect a patient’s out-of-pocket costs, Nichols said. “It is incredibly complex and really difficult to determine the best, least expensive path.”

Kuppersmith said she has always been careful to check that her doctors accept her insurance. She made sure Mount Sinai was in her insurance network, too. But it never occurred to her that the biopsy would be sent to an outside lab ― or that it would undergo genetic analysis.

She added: “The looming threat of a $2,400 bill has caused me, in many ways, more anxiety than the illness ever has.”

Kuppersmith’s doctor recommended a bone marrow biopsy after suspecting she had a rare blood disorder. Though the biopsy was done by an in-network provider at an in-network hospital, Kuppersmith learned she was on the hook for $2,400 for out-of-network genetic profiling.(Shelby Knowles for KHN)

The Resolution: Despite making dozens of phone calls, Kuppersmith got nothing but confusing and contradictory answers when she tried to sort out the unexpected charge.

An agent for her insurer told her that her doctor hadn’t gotten preauthorization for the testing. But in an email to Kuppersmith, a Genoptix employee told her the insurance company had denied the claim because molecular profiling was viewed as experimental.

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A spokesperson for New York-based Empire Blue Cross Blue Shield, which handled part of Kuppersmith’s claim, said her health plan “covers medically necessary genetic testing.”

New York, one of 28 states with laws against surprise billing, requires hospitals to inform patients in writing if their care may include out-of-network providers, said attorney Elisabeth Benjamin, vice president of health initiatives at the Community Service Society, which provides free help with insurance problems.

A spokesperson for Mount Sinai said the hospital complies with that law, noting that Kuppersmith was given such a document in 2018 — nearly one year before her bone marrow biopsy ― and signed it.

Benjamin said that’s not OK, explaining: “I think a one-year-old, vague form like the one she signed would not comply with the state law — and certainly not the spirit of it.”

Instead of sending Kuppersmith a bill, Genoptix offered to help her appeal the denied coverage to CareFirst. At first, Genoptix asked Kuppersmith to designate the company as her personal health care representative. She was uncomfortable signing over what sounded like sweeping legal rights to strangers. Instead, she wrote an email granting the company permission to negotiate on her behalf. It was sufficient.

A few days after being contacted by KHN, Kuppersmith’s insurer said it would pay Genoptix at the in-network rate, covering $1,200 of the $2,400 charge. Genoptix said it has no plans to bill Kuppersmith for the other half of the charge.

The Takeaway: Kuppersmith is relieved her insurer changed its mind about her bill. But, she said: “I’m a relatively young, savvy person with a college degree. There are a lot of people who don’t have the time or wherewithal to do this kind of fighting.”

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Patients should ask their health care providers if any outside contractors will be involved in their care, including pathologists, anesthesiologists, clinical labs or radiologists, experts said. And check if those involved are in-network.

“Try your best to ask in advance,” said Jack Hoadley, a research professor emeritus at Georgetown University. “Ask, ‘Do I have a choice about where [a blood or tissue sample] is sent?’”

Ask, too, if the sample will undergo molecular diagnostics. Since the testing is still relatively new — and expensive ― most insurers require patients to obtain “prior authorization,” or special permission, said Dr. Debra Regier, a medical geneticist at Children’s National Hospital in Washington and an associate with NORD, the National Organization of Rare Diseases. Getting this permission in advance can prevent many headaches.

Finally, be wary of signing blanket consent forms telling you that some components of your care may be out-of-network. Tell your provider that you want to be informed on a case-by-case basis when an out-of-network provider is involved and to consent to their participation.

More Than 5,000 Surgery Centers Can Now Serve As Makeshift Hospitals During COVID-19 Crisis

The Trump administration cleared the way Monday to immediately use outpatient surgery centers, inpatient rehabilitation hospitals, hotels and even dormitories as makeshift hospitals, health care centers or quarantine sites during the coronavirus crisis.

The Centers for Medicare & Medicaid Services announced it is temporarily waiving a range of rules, thereby allowing doctors to care for more patients.

Hospitals and health systems overwhelmed with COVID-19 patients will be able to transfer people with other medical needs to the nation’s 5,000 outpatient surgery centers, about half of which are affiliated with hospitals. This will give the country thousands of additional hospital beds and operating rooms, some of which have ventilators or anesthesia gas machines that could be repurposed as ventilators.

Outpatient surgery centers will be allowed to treat patients with other critical needs — such as serious injuries, cancer or heart attacks — unrelated to COVID-19, allowing hospitals to conserve scarce resources and reduce the risk of infection to these patients.

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Until now, federal regulations allowed outpatient surgery centers to care for patients for a maximum of 24 hours.

“Transferring uninfected patients will help hospital staffs to focus on the most critical COVID-19 patients, maintain infection control protocols, and conserve personal protective equipment,” the agency said in a statement.

Many outpatient surgery centers had closed after being told to halt elective procedures. A coalition of anesthesiologists in recent weeks called for them to stop performing nonessential surgery and assist hospitals.

The waivers “will allow hospitals to save more lives” by performing “surgeries and procedures that can’t wait until the pandemic is over,” said Bill Prentice, CEO the Ambulatory Surgery Center Association, an industry group.

Before the CMS announcement, the California Ambulatory Surgery Association had expressed its willingness to help.

The outpatient centers “want to be part of the solution as the entire healthcare industry must rise to meet this enormous challenge,” said Michelle George, president of the California Ambulatory Surgery Association, in a statement issued Monday morning. “We have valuable resources to lend to this crisis — whether it is staff, space, equipment, supplies or other capabilities. ASCs are coordinating with the public health teams on local and regional levels to identify how their facilities can be utilized most effectively on a case by case basis.”

Advocates who have pushed for surgery centers to assist hospitals praised the move.

“This is a great step in fighting this pandemic,” said Dr. Adam Schlifke, an anesthesiologist and clinical assistant professor at Stanford University in California.

“We recognize that it’s going to be hard,” Schlifke said. “It’s extremely complicated, but we are here to support all the surgery centers that will need to convert as a result of this order.”

The waivers will allow hospitals to hire local physicians and health care providers to address potential surges; transfer critical equipment, including telemedicine equipment, to doctors’ offices; and provide meals and child care for their health care workers.

Hospitals will be able to triage sick patients at community locations, then send them to the most appropriate facility, according to CMS.

“Front-line health care providers need to be able to focus on patient care in the most flexible and innovative ways possible,” said CMS Administrator Seema Verma. “This unprecedented temporary relaxation in regulation will help the health care system deal with patient surges by giving it tools and support to create nontraditional care sites and staff them quickly.”

Even with additional facilities, hospitals and health care systems could run out of staff, especially as health providers become sick with COVID-19. Although surgery centers typically employ their own nurses, they tend to share surgeons with local hospitals.

More than a dozen states and health care associations had requested waivers. The CMS move means that other states will no longer need to apply for waivers.

Texas had taken the lead in recent days, even before the new announcement, by permitting hospitals to use off-site facilities. Texas Gov. Greg Abbott last week signaled his interest in using outpatient surgery centers to expand care by ordering them to tell the state how many ventilators they possess.

Among other sweeping changes:

  • Ambulances will be allowed to transport patients to outpatient surgery centers, community mental health centers, federally qualified health centers, physician’s offices, urgent care facilities and any locations furnishing dialysis services when a dedicated kidney failure treatment center isn’t available. Hospitals will be able to charge for services provided outside their four walls and emergency departments can use telehealth services to evaluate sick people.
  • Physician-owned hospitals can temporarily increase their number of licensed beds, operating rooms and procedure rooms, according to CMS.
  • Instead of going to crowded emergency rooms, patients could go to off-site locations to be evaluated by emergency health care providers using telemedicine. That change will help preserve space in the emergency room for those who need it most. CMS will allow health providers to treat more patients via apps or telephone and bill at the same rate as in-person visits.
  • Physician assistants and nurse practitioners will be allowed to order tests and medications that may have previously required a physician’s order, as long as state law allows it. Also, certified registered nurse anesthetists will no longer have to work under the supervision of a doctor, freeing up physicians to focus more on patients and less on supervising.
  • To reduce the need for patients with health problems unrelated to COVID-19 to go to a doctor’s office or hospital, doctors will be allowed to monitor patients remotely with devices that can measure a patient’s oxygen saturation levels using pulse oximetry.

Health care experts have been suggesting the administration offer such waivers for weeks. The country has “got to muster all reasonable facilities and personnel,” said Arthur Caplan, a bioethics professor at NYU Langone Medical Center. “The best way to ration is to avoid it by stretching resources and sharing.”

COVID-19 Bonanza: Stimulus Hands Health Industry Billions Not Directly Related To Pandemic

Kaiser Health News:Medicaid - March 30, 2020

The coronavirus stimulus package Congress rushed out last week to help the nation’s hospitals and health care networks hands the industry billions of dollars in windfall subsidies and other spending that has little to do with defeating the COVID-19 pandemic.

The $2 trillion legislation, which President Donald Trump signed Friday, includes more than $100 billion in emergency funds to compensate hospitals and other health care providers for lost revenue and other costs associated with COVID-19. The measure also calls for spending up to $16 billion to replenish the nation’s depleted stockpile of medical gear, such as ventilators, medicines and personal protective equipment, or PPE.

But health care businesses will get billions of dollars in additional funding not directly related to the pandemic, in some cases because Congress agreed to reverse scheduled cuts in the rates paid by Medicaid and Medicare, which the federal government had tried for years to impose.

“Anything that could tangentially be related to the crisis lobbyists tried to get stuffed in this bill ― particularly health-care-related items,” said Steve Ellis, vice president of Taxpayers for Common Sense, a nonpartisan watchdog group. While the stimulus package is “not as big” a “Christmas tree” as some other bills, Ellis said, “I’m sure we’ll find a few baubles and gifts along the way.”

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Hospitals have won widespread praise as their doctors and other medical staffs labor under perilous conditions, including shortages of protective gear. And, perhaps not surprisingly, the industry emerged as a big winner in the stimulus negotiations. Not only can hospitals draw on the $100 billion fund to stem their losses and cover other costs, but they will also see a boost in one stream of revenue as Congress overturned some planned rate cuts.

More than 3,000 hospitals that treat outsize numbers of Medicaid or uninsured patients, for instance, will share in an $8 billion windfall through the stimulus provision that reverses cuts in their Medicaid payments for 2020 and 2021.

Separately, hospitals will rake in at least $3 billion more because of a temporary suspension of a 2% cut in Medicare fees, according to the Federation of American Hospitals, which represents more than 1,000 for-profit hospitals and health systems. The infusion of cash also benefits doctors, nursing homes, home health companies and others.

“That’s welcome news during this time of crisis,” said Joanne Cunningham, executive director of the Partnership for Quality Home Healthcare.

Also tucked into the stimulus: a rollback of planned rate cuts to clinical laboratories and some medical equipment suppliers.

At this stage, it is unclear how much these measures will add to the COVID-19 tab ― or if far more stimulus would be required for the health care industry to rebound.

Take the 2% rate cut known as “the sequester.” The Office of Management and Budget expected it would save Medicare $16.2 billion in fiscal 2021. But the stimulus bill rescinds that rate cut from May 1 through the end of this year. As part of the legislation, Congress said it would, in effect, recoup the payments later by adding another year to the sequester. Whether lawmakers will follow through on that is anyone’s guess.

Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA), expects the sequester relief to translate to a “huge” financial boost for more than 15,000 medical practices his group represents.

“This would never have been done under any other circumstances,” Gilberg said. “The situation was recognized as dire.”

Dr. Patrice Harris, president of the American Medical Association, said the stimulus offers “needed financial relief to hard-hit workers, health systems and physician practices. At this critical moment, physician practices need significant financial support to sustain themselves and continue to meet the health care needs of all Americans during this time.”

Similarly, American Hospital Association CEO Rick Pollack called the legislation “an important first step forward. But, he added, “more will need to be done to deal with the unprecedented challenge of this virus.”

In a nod to clinical laboratories, which have helped bail out the federal government’s early failure to supply enough COVID-19 tests, the stimulus delayed planned rate cuts in 2021 likely to amount to tens of millions of dollars in revenue. Medicare officials have been at odds with the lab industry for years over rates for lab tests.

While other health care interests praised the bill, the laboratory trade association said it comes up short.

Just before the Senate passed the stimulus bill Wednesday, American Clinical Laboratory Association President Julie Khani slammed Congress for not designating funding to support labs. She said labs were in “an untenable situation, absorbing growing, uncompensated costs for testing specimens with no assurance that they will be appropriately or fairly reimbursed for all the tests they are performing.”

She added a not-so-veiled threat, saying: “If Congress fails to designate essential emergency funding for clinical laboratories to support our efforts, labs will be soon be forced to make difficult decisions about whether they can keep building the [testing] capacity our nation needs.”

The lab association, in a statement to Kaiser Health News, said labs have absorbed “stunning” Medicare reimbursement cuts of as much as 30% for many common tests in recent years.

In public securities filings this year, lab giants Quest Diagnostics Inc. and Laboratory Corp of America Holdings, known as LabCorp, reported they expected rate cuts in 2020 totaling more than $150 million. LabCorp said it supported the views of the lab association. Quest did not respond to a request for comment.

While labs processing COVID-19 tests missed out on direct funding, they could be eligible for some of the $100 billion allocated for hospitals and other providers to cover their losses, congressional aides said.

And the stimulus measure states that even in the event a lab is out-of-network, health plans are expected to pay the price it sets — as long as the lab publishes that price online — or negotiate with the lab.

Given that laws in some states ban surprise billing in particular, this provision seems to favor the labs, said Katie Keith, a Georgetown University law professor and health policy expert. “No one just lets the provider set the price,” she said.

The lab association disputes that, saying that many health plans are expected to pay them less than the $51.50 government recommended for a COVID-19 test.

Just how the $100 billion in health care funding will be distributed and how much oversight will occur is another unknown.

Health and Human Services Secretary Alex Azar has the authority to decide how long the emergency provisions remain in effect. Tracking all that money will be a challenge as well.

Ellis, the taxpayer advocate, noted that no government agency “is ready to handle the rush of extra funding.” He said that the stimulus grants extra resources to inspector general offices to monitor spending.

“There will be waste, there will be abuse,” he said. “It’s about exposing and rooting it out.”

The HHS Office of Inspector General expects to receive $4 million to support this oversight, according to spokesman Donald White.

Some groups aren’t waiting to compete over the $100 billion. The MGMA sent a letter March 27 to Azar and the Centers for Medicare & Medicaid Services chief Seema Verma asking for more direct help. Gilberg noted that some medical practices, such as doctors who perform colonoscopies, have not been able to continue their work.

“Doctors and physician practices are having a lot of trouble right now,” Gilberg said. “They are literally shut down, and they are having financial troubles. Their operations have come to a full halt.”

KHN correspondents Rachana Pradhan and Emmarie Huetteman contributed to this report.

Already Taxed Health Care Workers Not ‘Immune’ From Layoffs And Less Pay

Kaiser Health News:States - March 30, 2020

Just three weeks ago, Dr. Kathryn Davis worried about the coronavirus, but not about how it might affect her group of five OB-GYNs who practice at a suburban hospital outside Boston.

“In medicine we think we’re relatively immune from the economy,” Davis said. “People are always going to get sick; people are always going to need doctors.”

Then, two weeks ago, she watched her practice revenue drop 50% almost overnight after Massachusetts officials told doctors and hospitals to stop performing elective tests and procedures. For Davis, that meant no more non-urgent gynecological visits and screenings.

Late last week, as Davis and her partners absorbed the stunning turn of events, they devised a stopgap plan. The 35 nurses, medical assistants and secretaries they employ would have two options: move from full-time to part-time status or start collecting unemployment. Doctors in the practice would take a substantial pay cut. Davis said she’s hearing from colleagues who may have to permanently close their offices if the focus on crisis-level care continues for months.

“It’s shocking,” she said. “Everyone has been blindsided.”

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Atrius Health, the largest independent physician group in Massachusetts, said patient volume is down 75% since mid-March. It is temporarily closing offices, placing many nonclinical employees on furlough and withholding pay for those who remain. The average withholding is 20%, and the company pledges that pay withheld will be returned. The lowest-paid workers, those earning up to $55,000, are exempt.

“What we’re trying to do is piece together a solution to get through the crisis and keep employed as many people as we can,” said Dr. Steven Strongwater, Atrius Health’s CEO.

Atrius cares for 745,000 patients in clinics that often include primary care, specialists, radiology and a pharmacy under one roof.

Strongwater said physician groups must be included when the federal government distributes $100 billion to hospitals from the $2 trillion stimulus package.

It’s not clear if that money will stop the tide of layoffs and lost pay at hospitals as well as in doctor’s offices. A Harvard Medical School physician group will suspend retirement contributions starting April 1.

Beth Israel Lahey Health, the second-largest hospital network in Massachusetts, announced executive pay cuts Monday.

“The suspension of elective procedures and decline in visits to our primary care practices and urgent care centers have resulted in financial challenges,” wrote CEO Dr. Kevin Tabb in an email to employees. Tabb said he would take a 50% salary cut. Other executives and hospital presidents in the system will forgo 20% of their salaries for the next three months.

“Although executive leadership compensation is being reduced, we will never compromise on doing the things that are essential to protect your safety and the safety of our patients,” Tabb told staff.

Dallas-based Steward Health Care has told hospital employees in Massachusetts and eight other states where it operates to expect furloughs focused on nonclinical staff. In a statement, Steward Health Care said it prepared for the pandemic but is experiencing a “seismic financial shock.”

“Elective surgeries are the cornerstone of our hospital system’s operating model — and the negative impact due to the cancellations of these procedures cannot be overstated. In addition, patients are understandably cautious and choosing to defer any nonemergency treatments or routine visits until this crisis has passed.”

Dr. Kaarkuzhali Babu Krishnamurthy, an assistant professor of neurology at Harvard Medical School who studies medical ethics, said employers need to think more carefully about the ethics of asking doctors and nurses to live on less when many are working longer hours and putting the health of their families at risk.

“At a time when health care systems are calling on doctors and nurses to do more, this is not the time to be making it more difficult to do that,” said Krishnamurthy.

There’s talk of redeploying laid-off health care workers to new COVID-19 units opening in shuttered hospitals or to patient overflow sites. Tim Foley, executive vice president for the largest health care union in Massachusetts, 1199SEIU, is promoting the development of a staff registry.

“It is more important, now more than ever, to explore all options to maintain the level of urgent care needed across the state and we look forward to working with all stakeholders to do just that,” Foley said in an email.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

Secretary Azar Statement on FDA Authorization of Mask Sterilization Procedure

HHS Gov News - March 30, 2020

On Sunday, the Food and Drug Administration issued a revised Emergency Use Authorization to allow the large-scale use of a system created by Battelle Memorial Institute to decontaminate used N95 respirators during the COVID-19 pandemic. HHS Secretary Alex Azar issued the following statement:

"Getting personal protective equipment to the heroic healthcare workers on the frontlines of the pandemic is one of President Trump's top priorities. FDA's quick action in authorizing Battelle's technology will help hospitals get the maximum use out of their N95 respirators, while we work on multiple fronts to expand supplies available to them. FDA worked closely with the company and responded rapidly to each of their requests, as the agency has done with all emergency use authorizations during this crisis. If you're a company who wants to help get our healthcare workers what they need to stay safe—or help fight the pandemic in any other way—our door is open to you."

HHS Accelerates Clinical Trials, Prepares for Manufacturing of COVID-19 Vaccines

HHS Gov News - March 30, 2020

The U.S. Department of Health and Human Services took steps today to speed the development and manufacturing of vaccines to prevent COVID-19, working with New Jersey-based Janssen Research & Development, part of Johnson & Johnson, and Moderna of Cambridge, Massachusetts.

The Biomedical Advanced Research and Development Authority (BARDA), part of the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR), will support non-clinical studies and a Phase 1 clinical trial of Janssen’s COVID-19 investigational vaccine, Ad26 SARS-CoV-2. This clinical trial will examine the vaccine’s safety in healthy adult volunteers and its ability to induce an immune response in the recipients.

The Phase 1 clinical trial is set to begin no later than fall of 2020 with the goal of making COVID-19 vaccine available for emergency use in the United States in early 2021. Janssen began developing its vaccine in February with BARDA support using the same vaccine platform used to develop an investigational vaccine rapidly for Ebola.

In parallel to initial clinical evaluation, BARDA also will work with Janssen to accelerate advanced clinical trials, regulatory support, and large-scale manufacturing to produce up to 300 million doses of vaccine in the United States each year.

At the same time, BARDA will collaborate with Moderna to prepare now for Phase 2 and 3 clinical trials of a vaccine known as SARS-CoV-2 mRNA-1273, being developed by Moderna and the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.

These later clinical trials require enrolling hundreds, and potentially thousands of people to determine the investigational vaccine’s safety and effectiveness. BARDA support includes expertise and funding to expand manufacturing in order to produce thousands of doses of the investigational vaccine for these studies.

Collaborating on clinical trial preparation now means the later clinical trial phases can begin immediately upon successful completion of the Phase 1 clinical trial currently underway. Working in parallel instead of taking the traditional sequential approach to vaccine development potentially shaves months off the timeline for vaccine development.

The Moderna vaccine becomes the latest emergency medical product to transition from the NIAID to BARDA for late-stage development with the ultimate goal of U.S. Food and Drug Administration (FDA) licensure.

“Vaccines are essential to saving lives,” said BARDA Director Rick Bright, Ph.D. “Delivering a safe and effective vaccine for a rapidly spreading disease like COVID-19 requires accelerated action with parallel development streams. The rapid progress we are making with industry partners clearly demonstrates a commitment to protecting people at home and abroad.”

BARDA and the companies will work with the FDA to streamline the development and regulatory processes in order to make a safe and effective vaccine available as quickly as possible.

There are currently no FDA-approved vaccines or treatments for COVID-19. FDA has provided emergency use authorization for 20 diagnotic tests. However, in addition to taking steps to speed vaccine development, last week BARDA also awarded contracts to New York University for obtaining specimens to support medical countermeasure development and to Cue Inc., Luminex, and Vela Diagnostics USA, Inc. to support development of additional COVID-19 diagnostic tests. HHS continues to seek partners for COVID-19 medical countermeasures, and offers multiple ways to submit proposals for potential new products or technologies.

About HHS, ASPR, and BARDA

HHS works to enhance and protect the health and well-being of all Americans, providing for effective health and human services and fostering advances in medicine, public health, and social services. The mission of ASPR is to save lives and protect Americans from 21st century health security threats. Within ASPR, BARDA invests in the innovation, advanced research and development, acquisition, and manufacturing of medical countermeasures – vaccines, drugs, therapeutics, diagnostic tools, and non-pharmaceutical products needed to combat health security threats. To date, 54 BARDA-supported products have achieved regulatory approval, licensure or clearance.

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