Home » Archive for April 2020

KHN’s ‘What The Health?’: SCOTUS Decides An ACA Case. No, Not THAT Case.

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The Supreme Court this week rejected the efforts of a Republican-controlled Congress in 2014 to cut off funding to insurance companies under a provision of the Affordable Care Act. In an 8-1 decision, the high court ruled that insurers must be paid the roughly $12 billion they are owed under the law’s “risk corridor” program.

Meanwhile, the efforts to address the COVID-19 health and economic impact are becoming more partisan, with Democrats pushing to provide more funding to states and localities and Republicans urging liability waivers for employers whose workers get sick after being summoned back to the workplace.

This week’s panelists are Julie Rovner of Kaiser Health News, Caitlin Owens of Axios and Mary Ellen McIntire of CQ Roll Call.

Among the takeaways from this week’s podcast:

The Supreme Court’s 8-1 ruling in the ACA “risk corridor” case may suggest that the court could overturn other actions taken by Republicans to weaken the ACA, such as President Donald Trump’s decision to deny payments to insurers to help cover out-of-pocket costs that the companies are forced to cover for very low-income customers. Still, it may not signal the end of perceived partisanship on the bench when it comes to the ACA. That will be tested in a case the court will take up this fall that could overturn the entire law.
States are beginning the long process of restarting their economies, but the diversity in efforts points to the politics that has pervaded the U.S. coronavirus response. Past public health crises have not been laden with such partisanship, which is fostered by the vast economic devastation from coronavirus.
Although the president has been hesitant to use his powers under the Defense Production Act to compel industries to help with the coronavirus fight, he quickly moved this week to implement it to force meatpacking plants to stay open or reopen, even after their work crews were hit hard by the outbreak. That was in large part because of fears of food shortages and the effects they could have on consumers.
The uplifting news that preliminary studies suggest an experimental drug — remdesivir — can help fight the coronavirus may have confused consumers. The drug still needs more testing, and even the promising results show only a small effect in helping patients recover.
The House will not return to Washington next week because of concerns about the spread of the coronavirus in the nation’s capital region — but the Senate will. Some Democrats are complaining that Senate Majority Leader Mitch McConnell is calling them back not to deal with the pandemic crisis but to push through more judicial nominees.
Rumors swirling about the potential ouster of Health and Human Services Secretary Alex Azar represent still more evidence that the Trump administration’s response to the pandemic is not well organized. Trump officials are caught between trying not to anger the boss and dealing with officials in other agencies who may not play well together.

Also this week, Rovner interviews KHN’s Carmen Heredia Rodriguez, who reported the latest KHN-NPR “Bill of the Month” installment about a patient who got what should have been a free COVID-19 test and ended up with a hefty bill. If you have an outrageous medical bill 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: NPR’s “What Would It Take to Bring More Pharmaceutical Manufacturing Back to the U.S.?” by Sydney Lupkin

Caitlin Owens: Axios’ “Why the Coronavirus Feels So Risky,” by Bryan Walsh

Mary Ellen McIntire: CQ Roll Call’s “Amazon Workers Tally Virus Cases, Voice Alarm About Risks,” by Emily Kopp

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunes, Stitcher, Google Play, Spotify, or Pocket Casts.

from Health Industry – Kaiser Health News

As Coronavirus Strikes, Crucial Data In Electronic Health Records Hard To Harvest

When President Donald Trump started touting hydroxychloroquine as “one of the biggest game changers” for treating COVID-19, researchers hoped electronic health records could quickly tell them if he was on the right track.

Yet pooling data from the digital records systems in thousands of hospitals has proved a technical nightmare thus far. That’s largely because software built by rival technology firms often cannot retrieve and share information to help doctors judge which coronavirus treatments are helping patients recover.

“I’m stunned at EHR vendors’ inability to consistently pull data from their systems,” said Dale Sanders, chief technology officer of Health Catalyst, a medical data analytics company. “It’s absolutely hampering our ability to understand and react to COVID.”

Over the past decade, federal officials have spent some $36 billion switching from paper to electronic health records, or EHRs, expecting, among other things, to harness volumes of medical data to reveal which treatments work best.

EHRs document every step doctors or other health care workers take in treating a COVID patient, from medicines prescribed to signs of progress or setbacks. Data collected from large numbers of patients could quickly yield answers about which treatments are succeeding.

But the pandemic is bringing into stark relief just how far the nation is from achieving the promised benefits, critics say.

Dr. Richard Cook, a research scientist and health care safety specialist, traces the data problems to missteps dating to the rollout of EHR, which began in earnest in 2009 and has been controversial ever since because commercial players produced ― and hospitals bought — systems that have proved more suited to billing than public health. “This was a boondoggle from the get-go, and the promoters knew it at the time,” Cook said.

Although some health systems are beginning to draw on EHR data to spot coronavirus trends and beneficial treatments, most health organizations around the country cannot readily do so.

“If we had a national database, we’d get a readout quickly about responses to [COVID-19] treatments,” said Dr. Eric Topol, director of the Scripps Research Translational Institute.

Medical researchers favor studies that test the efficacy of a drug in a formal clinical trial, and trials are underway for a variety of possible COVID-fighting medicines, including hydroxychloroquine. The results could take months or more, however, and doctors treating critically ill patients have few options in the meantime.

Topol said “real-world” evidence drawn from computerized records of COVID patients, while not as reliable as a clinical trial, is “still very useful” to help guide medical decisions.

Medical data has been hard to tease out because much of it resides in electronic “silos,” which government officials have not required technology companies to open up and eliminate.

“We’ll see piecemeal readouts of small numbers from individual health systems,” Topol said, but “don’t have the important data that we need.”

Sanders, whose firm is a member of the COVID-19 Healthcare Coalition, a business-sponsored group promoting coronavirus data-sharing and analysis, said federal health officials lost precious time by failing to address this need as early as mid-January.

He said the federal Centers for Disease Control and Prevention, or CDC, should have devised a COVID data-collection plan using standardized terminology so hospitals with incompatible EHRs could compare notes on the fast-paced pandemic.

The CDC did not respond to written requests seeking comment. A spokesman for the Health and Human Services office that coordinates health information technology policy said: “This is a novel disease so the health care system did not know what data we needed to collect ― we are learning that the system needs to build out reporting information on multiple clinical features.”

Still, several of the top EHR manufacturers have joined the data-sharing coalition, which is pledging to at least partially fill the information void. The group has access to COVID data from about two dozen health systems and is expecting to add more.

“This is the first attempt at this that I’m aware of where inherently competitive EHR vendors have come together to work together with clinical researchers,” said Dr. Brian Anderson, chief digital health physician with the MITRE Corp., a nonprofit technology group that formed the coalition in late March.

Anderson said the coalition is “getting close” to being able to share some results from reports of treating people with convalescent plasma recovered from patients who have survived COVID-19. The group is also examining treatment data on the drug remdesivir as it irons out some of the technical difficulties that complicated its analysis of hydroxychloroquine. Last week, the Food and Drug Administration warned that hydroxychloroquine could cause heart problems and should be used only in a hospital or clinical trial.

There are other signs the EHR industry is relaxing its grip on medical data in response to the emergency. Major EHR vendor Cerner Corp. has offered researchers access to some types of COVID-19 data, including “clinical complications and outcomes that could help drive important medical decisions.”

And some health systems have begun publishing data drawn from EHRs. One study released this month, for instance, tracked the outcome of 5,700 coronavirus patients treated at 12 hospitals in a New York City health system and found that 88% of patients placed on ventilators had died. All the hospitals shared the same records vendor.

“In crisis, people seek data and authorities demand it,” said Cook, the health care safety specialist. But, he said, “it is not possible to build such a system on demand.”

Ross Koppel, a professor at the University of Pennsylvania and longtime EHR safety expert, said that the COVID-19 pandemic illustrates both “strengths and disappointments” of the digital systems.

While health systems using a single vendor have been able to pool data, Koppel said, the industry has battled regulators seeking to adopt common standards, a practice known as interoperability.

“That failure to mine these oceans of invaluable data reflects the power of the vendors to prevent government requirements for data standards and interoperability,” he said.

Limits in electronic data collection systems also are hindering COVID-19 public health and surveillance efforts.

Officials said they are sometimes required to manually fill out and fax some forms, wasting valuable time. Some information must be printed out from EHRs and reentered by public health authorities because it cannot be sent electronically.

Certain CDC forms, such as Person Under Investigation COVID case reports, can take up to 30 minutes to complete. Other forms exchanged between hospitals and laboratories often are missing critical information, leading to delays in contacting patients and identifying people they had close contact with. In some states, demographic information on race and ethnicity is missing 85% of the time, and patients’ addresses, half the time, according to Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.

“We’re using yesterday’s technology for the biggest public health emergency in our lifetimes,” Hamilton said. “COVID has demonstrated for people what we’ve known all along. You can’t leave public health at the end of the line.”

The government’s health IT chief says a new administrative rule to promote interoperability and bar EHR manufacturers from impeding the flow of information will take time to change behavior.

“If this were to have happened three or four years in the future when we have interoperability … we would be in a much better spot here. But unfortunately, that’s not quite the case, but we’re still keeping our work going,” Donald Rucker, national coordinator for health information technology, said during an April 15 virtual meeting.

from Health Industry – Kaiser Health News

Uso masivo de máscaras quirúrgicas pone en grave riesgo a los trabajadores de salud

Con los suministros médicos en alta demanda, autoridades federales dijeron que los trabajadores de salud pueden usar máscaras quirúrgicas para protegerse al tratar a pacientes con COVID-19. Pero la creciente evidencia sugiere que esta práctica los está poniendo en peligro.

Los Centros para el Control y Prevención de Enfermedades (CDC) dijeron recientemente que las máscaras quirúrgicas de grado inferior son “una alternativa aceptable” a las máscaras N95 a menos que los trabajadores realicen una intubación u otro procedimiento en un paciente con COVID-19 que pueda liberar un gran volumen de partículas de virus.

Pero académicos, líderes de organizaciones sin fines de lucro y ex reguladores en el campo de la seguridad laboral dicen que depender de máscaras quirúrgicas, que tienen un grado de protección mucho menor que los respiradores N95, seguramente ayude a diseminar la enfermedad entre los trabajadores de salud de primera línea, que estarían representando aproximadamente el 11% de todos los casos conocidos de COVID-19.

“No tengo dudas de que esa es una de las razones por las que muchos trabajadores de salud se enferman y muchos mueren”, dijo Jonathan Rosen, experto en salud y seguridad que asesora a sindicatos, estados y el gobierno federal.

Hasta el 23 de abril, más de 21,800 trabajadores de salud habían contraído el coronavirus, 71 de los cuales murieron, según un miembro del Comité de Educación y Trabajo de la Cámara, que recibió información de los CDC.

El consejo de los CDC se contradice con otra página de la misma entidad, que dice que una máscara quirúrgica “NO proporciona al usuario un nivel confiable de protección contra la inhalación de partículas más pequeñas en el aire y no se considera protección respiratoria”.

En pocas palabras, “una máscara quirúrgica no es EPP o equipo de protección personal”, dijo Amber Mitchell, presidenta y directora ejecutiva del International Safety Center.

La asignación de máscaras quirúrgicas tenía más sentido cuando los científicos inicialmente pensaron que el virus se había propagado por grandes gotas. Pero un creciente cuerpo de investigación muestra que se propaga por minúsculas partículas virales que pueden permanecer en el aire hasta 16 horas.

Una N95 bien ajustada impedirá que el 95% de las pequeñas partículas de aire, de hasta tres décimas de micrón de diámetro, que es lo más difícil de atrapar, lleguen a la cara del usuario. Pero las máscaras quirúrgicas, diseñadas para proteger a los pacientes de las gotas respiratorias de un cirujano, no son efectivas para bloquear partículas de menos de 100 micras, según el fabricante de máscaras 3M Corp.

Una partícula COVID-19 es de aproximadamente 1 a 4 micras, según una investigación reciente.

La investigación de principios de abril, en dos hospitales de Corea del Sur, halló que las máscaras quirúrgicas “parecen ser ineficaces para prevenir la diseminación” de partículas de coronavirus. Un estudio chino de 2013 descubrió que el doble de trabajadores de la salud, el 17%, contraía una enfermedad respiratoria si usaban una máscara quirúrgica para tratar a pacientes enfermos, en comparación con el 7% de los que usaban en forma continua las N95, según el American Journal of Respiratory and Critical Care Medicine.

“Mi opinión personal sería, ya que hay evidencia de transmisión de aerosoles, [al menos] un N95 debe usarse para la atención directa de pacientes sospechosos o confirmados por COVID”, dijo el Dr. Robert Harrison, médico y profesor de la Universidad de California. -Escuela de medicina de San Francisco que fundó UCSF Occupational Health Services.

En una declaración enviada por correo electrónico, los CDC sugirieron que su orientación está destinada a conservar los recursos escasos y se aplica principalmente a situaciones de escasez.

Las máscaras quirúrgicas deben usarse cuando los N95 “son tan limitados que los estándares de atención practicados rutinariamente… ya no son posibles”, dijo Martha Sharan, vocera de la agencia. “Los respiradores N95 más allá de su vida útil designada por el fabricante, cuando estén disponibles, son preferibles al uso de máscaras faciales”.

Sin embargo, muchos centros de salud, citando las pautas de los CDC y el escaso suministro, están proporcionando N95 en entornos médicos limitados.

A principios de este mes, el sindicato nacional Teamsters informó que el 64% de su membresía de trabajadores de la salud, que incluye a personas que trabajan en hogares de ancianos, hospitales y otras instalaciones médicas, no pudo obtener máscaras N95.

En Michigan Medicine, el centro médico de la Universidad de Michigan, los empleados no reciben N95 excepto por realizar procedimientos específicos en pacientes con COVID positivo, como intubación o una broncoscopía, o tratarlos en la unidad de cuidados intensivos, dijo Katie Scott, una registrada enfermera en el hospital y vicepresidenta de la Asociación de Enfermeras de Michigan. Los empleados que de otra manera tratan a pacientes con COVID-19 reciben máscaras quirúrgicas.

Eso coincide con el protocolo de los CDC, pero deja a las enfermeras como Scott, que ha leído la investigación sobre máscaras quirúrgicas versus N95, que se sienten expuestas.

“Estamos en riesgo de contraer este virus y corremos el riesgo de llevarlo a nuestras familias”, dijo Scott. “Está claro que estas pautas de mascarillas quirúrgicas no están funcionando”.

Según informes de noticias recientes, casi 3,000 trabajadores de la salud en el área de Detroit, que incluye a Ann Arbor, el hogar de Michigan Medicine, sospechan o confirman infecciones con COVID-19.

En Michigan Medicine, los empleados no pueden traer su propio equipo de protección, de acuerdo con una queja que el sindicato de enfermeras presentó ante la Administración de Seguridad y Salud Ocupacional de Michigan. Scott tiene PPE que sus amigos y familiares le han enviado por correo, incluidas las máscaras N95. Se sienta en casa mientras ella cuida a los pacientes.

“Pensar que voy a trabajar y dejaré esta máscara en mi casa en la mesa de la cocina porque el empleador no me deja usarla”, dijo Scott. “Te sientes sacrificado de alguna manera”.

Los informes noticiosos desde Kentucky hasta Florida y California han documentado que las enfermeras enfrentan represalias o presión para renunciar cuando traen sus propios respiradores N95.

Un vocero de Michigan Medicine se negó a responder preguntas sobre los protocolos del equipo de protección del hospital. La Asociación Americana de Hospitales no tiene una postura sobre permitir que los empleados traigan sus propios N95 al trabajo, dijo Robyn Begley, vicepresidenta senior y directora de enfermería del grupo comercial.

En Nueva York, el epicentro del brote de coronavirus de la nación, las enfermeras de todo el estado informan que reciben máscaras quirúrgicas, no N95, para usar al tratar a pacientes con COVID-19, según una declaración jurada presentada por Lisa Baum, la principal representante de seguridad y salud ocupacional. para la Asociación de Enfermeras del Estado de Nueva York.

“Una máscara quirúrgica no es una forma de EPP. … [Si] tose o estornuda, atrapa parte del virus. No protege al usuario”, dijo Baum en una entrevista con Kaiser Health News.

Hasta ahora, al menos 16 miembros de la NYSNA han muerto por el coronavirus, al menos 94 han sido hospitalizados y más de 1,000 han dado positivo, según estimaciones de sindicatos.

National Nurses United ha presionado a los legisladores de Washington para que promulguen leyes que aumenten la producción de N95 al obligar a la Casa Blanca a invocar la Ley de Producción de Defensa, una ley de la era de la Guerra de Corea que permite al gobierno federal, en una emergencia, dirigir negocios privados en la producción y distribución de bienes.

También está pidiendo al Congreso que exija que la Administración de Seguridad y Salud Ocupacional establezca un estándar temporal de emergencia para exigir que los empleadores brinden a los trabajadores de la salud equipos de protección, incluidas máscaras N95, cuando interactúan con pacientes sospechosos de tener COVID-19.

“El empleador tiene la responsabilidad de proteger a sus empleados”, dijo Amirah Sequeira, principal defensora legislativa del sindicato. “Al mismo tiempo, cuando tiene una crisis a esta escala, el gobierno federal también tiene la responsabilidad de garantizar el aumento de las compras y, si no de las compras, de la producción”.

La AHA ha cabildeado en contra de un mandato que ampliaría el uso de N95. Begley reconoció que “los suministros son inadecuados” y dijo que la mayor demanda global hace que conseguir N95 sea mucho más difícil.

“Si no conservamos los suministros ya limitados, no habrá N95 restantes para el personal de atención médica que realiza procedimientos que involucren aerolización”, dijo Begley.

Pero la falta de más y mejor equipo de protección para los trabajadores de la salud podría costar más vidas, advirtieron líderes sindicales en una teleconferencia reciente sobre las condiciones peligrosas que enfrentan los trabajadores.

“Las enfermeras no tienen miedo de cuidar a los pacientes si tenemos la protección adecuada”, dijo Bonnie Castillo, directora ejecutiva de National Nurses United. “Pero no somos mártires sacrificando nuestras vidas porque nuestro gobierno y nuestros empleadores no hicieron su trabajo”.

from Health Industry – Kaiser Health News

COVID Tests Are Free, Except When They’re Not

Even before a novel virus swept around the world, Anna Davis Abel wore a mask to protect herself from getting sick.

The 25-year-old writer lives with lupus, a chronic autoimmune disease that makes her more susceptible to catching a virus or an infection. Davis Abel’s doctor cleared her to travel to a literary conference in San Antonio in early March. Then she developed a sore throat and low-grade fever several days after arriving home in Morgantown, West Virginia.

Consulting a nurse on the phone, Davis Abel was told to manage her symptoms at home. But her symptoms only worsened, so she secured an appointment with her primary care doctor.

“At that point, I was, like, taking shot glasses of Sudafed,” she said.

Given the spread of the coronavirus and a chronic condition that left her vulnerable to a more serious case of COVID-19, she was concerned she’d been infected. To find out, her doctor first ordered tests to evaluate whether Davis Abel’s symptoms were caused by some other respiratory disease. According to the doctor’s notes in her medical record, “we needed to rule out all other viral possibilities before being eligible for the COVID-19 test.”

“Unfortunately at this time, COVID-19 testing is very limited and is not widely available to most patients,” the record noted.

Davis Abel tested positive for influenza Type B.

Then the bill came.

The tests that Anna Davis Abel’s doctor ordered to rule out respiratory diseases other than COVID-19, along with the doctor visit, amounted to $2,121 in charges, according to records. Davis Abel was responsible for $536.46 before her insurer retroactively covered it.(Rebecca Kiger for KHN)

The Patient: Anna Davis Abel is a 25-year-old graduate student studying creative writing at West Virginia University in Morgantown. She is insured through an Aetna plan the university offers.

Total Amount Billed: WVU Medicine charged Davis Abel $2,121 for the visit and testing, according to records. Aetna initially paid $1,584.54 for these services. Abel was responsible for the copay, the remaining amount of her deductible and a coinsurance cost of 20%. In total, she owed $536.46.

The Providers: Davis Abel visited the WVU Healthcare University Town Centre clinic for her primary care appointment. A laboratory within the WVU health system processed her testing for respiratory disease. Both sites were in-network for her plan.

Medical Services: A BioFire Respiratory Panel was used to test a specimen collected from the back of Davis Abel’s nose and throat for more than a dozen respiratory diseases.

What Gives: Congress has taken action to make COVID-19 testing more affordable for consumers with health insurance.

The Families First Coronavirus Response Act requires private insurers to pay for certain services and items related to testing at no cost to the patient. A second piece of legislation, known as the CARES Act, expanded the number of tests and services insurers must cover at no cost. The latter law also requires health plans to reimburse out-of-network providers for their services. However, experts said, there are gaps in these federal protections that may expose patients to unexpected medical bills.

The guidelines state that insurers are required to cover the cost of an appointment without cost sharing only if the doctor orders or administers a COVID-19 test. Even if the patient shows symptoms and receives other care related to the novel virus, without a test the patient may be on the hook for the cost of the visit, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

“They’re getting a battery of other tests,” said Corlette. “But because there’s not enough [COVID-19] tests, they can’t get this protection.”

A national shortage of COVID-19 tests complicates a patient’s ability to qualify for the federal safeguard. Despite efforts by the federal government and the private sector, some resources needed to increase testing remain scarce, said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.

This reality means some medical providers, like Davis Abel’s doctor, must rule out other respiratory diseases before ordering a COVID-19 test, leaving some patients with a difficult choice. Do they seek medical attention and risk a high medical bill? Or do they forgo care altogether?

A second hole in these federal protections may leave patients holding the bill for their COVID-19 test, experts said. The law prohibits insurers from charging patients for testing, but it does not block medical providers from doing so. If an insurer does not cover the total amount charged by a provider, the patient may get balance-billed, or slapped with a surprise charge.

Guidance from the federal Department of Health and Human Services says that that should not happen because almost any patient can be considered at risk for COVID-19 right now, but it’s unclear if or how that will be enforced.

If any of you are interested in the whole #COVID19 video @NBCNews used, here you go. I can guess why they edited it 🤪 pic.twitter.com/cawpAMfOkS

— Anna Davis Abel (@AnnaDavisAbel) April 15, 2020

Davis Abel’s appointment was on March 11, making her ineligible for the protections offered by the federal laws. By then, however, Aetna had pledged to cover COVID-19 testing without cost sharing. The hospital system then sent Davis Abel a bill for the remaining amount.

WVU Medicine declined to comment on the case.

It’s unlikely Davis Abel is the only patient getting charged for care, according to Karen Pollitz, a senior fellow at the Kaiser Family Foundation. Pollitz said insured consumers may get dinged with a bill if they get care from an out-of-network provider even though the federal protections also require insurers to cover that cost.

Consumers may find protection from these bills through a requirement attached to federal relief funding for medical providers. Health care facilities that receive any of the $100 billion from the CARES Act Provider Relief Fund are not allowed to balance-bill patients for COVID-19 treatment. (Kaiser Health News is an editorially independent program of the foundation.)

Resolution: Aetna retroactively covered Davis Abel’s bill from the hospital after reporters made inquiries. In a statement, the insurer said it is waiving claims after receiving information from her provider that the services were related to COVID-19 testing.

It also said Davis Abel represents a “unique” case and is not aware of whether other members have submitted claims for services they needed to obtain a COVID-19 test. The insurer said it would waive additional testing related to the novel virus if the provider deemed those services necessary.

Before Aetna took action, two strangers read Davis Abel’s story on Twitter and sent her the full amount for the bill. She used the donations to help pay for a medical bill from a previous procedure.

Nearly 10 days after her appointment, Davis Abel received a drive-thru COVID-19 test offered by the same clinic. Her primary care doctor, who ordered the test, said in an email to Davis Abel that new data suggested patients could fall ill with the coronavirus and the flu at the same time.

Davis Abel’s fever and coughing had not subsided. Eight days after the test, she received her result. Negative for COVID-19. She did not pay for the test.

The Takeaway: Experts recommend that insured patients educate themselves about their health care plan. Seek care at an in-network provider whenever possible. Call the insurer to find out exactly what COVID-19 care it covers. Several insurance companies have pledged to waive cost sharing for treatment.

Uninsured consumers may be able to get a free COVID-19 test several ways, Pollitz said. One way is to visit an outpatient testing area at a facility that received relief funding — the law bars the provider from balance-billing patients for care related to the coronavirus.

Another option is through Medicaid. States may now use the government health insurance program for the poor and disabled to cover the cost of testing uninsured residents who qualify.

A third way consumers could receive a free COVID-19 test is through the National Disaster Medical System. That network of health care providers — generally activated in response to an emergency — treats patients and then charges the federal government for their services, said Pollitz. However, she acknowledged, it may be difficult to find a provider who participates in the program.

“The problem right now is the supply of them,” Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, said about COVID-19 tests. “But once that changes, people need to be confident that they’re not going to be stuck with a big bill.”

Dan Weissmann, host of the podcast “An Arm and a Leg,” reported the audio version of this story. You can hear more about Davis Abel’s story on this week’s episode of the podcast.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

from Health Industry – Kaiser Health News

Widely Used Surgical Masks Are Putting Health Care Workers At Serious Risk

With medical supplies in high demand, federal authorities say health workers can wear surgical masks for protection while treating COVID-19 patients — but growing evidence suggests the practice is putting workers in jeopardy.

The Centers for Disease Control and Prevention recently said lower-grade surgical masks are “an acceptable alternative” to N95 masks unless workers are performing an intubation or another procedure on a COVID patient that could unleash a high volume of virus particles.

But scholars, nonprofit leaders and former regulators in the specialized field of occupational safety say relying on surgical masks — which are considerably less protective than N95 respirators — is almost certainly fueling illness among front-line health workers, who likely make up about 11% of all known COVID-19 cases.

“There’s no doubt in my mind that that’s one of the reasons that so many health care workers are getting sick and many are dying,” said Jonathan Rosen, a health and safety expert who advises unions, states and the federal government.

As of April 23, more than 21,800 health care workers had gotten the coronavirus and 71 had died, according to a House Education and Labor Committee staffer briefed by the CDC.

The CDC’s advice contrasts with another CDC webpage that says a surgical mask does “NOT provide the wearer with a reliable level of protection from inhaling smaller airborne particles and is not considered respiratory protection.”

Put simply, in worker safety, “a surgical mask is not PPE,” or personal protective equipment, said Amber Mitchell, president and executive director of the International Safety Center and immediate past chair of the occupational health and safety section of the American Public Health Association.

The allowance for surgical masks made more sense when scientists initially thought the virus was spread by large droplets. But a growing body of research shows it’s spread by minuscule viral particles that can linger in the air as long as 16 hours.

A properly fitted N95 will block 95% of tiny air particles — down to three-tenths of a micron in diameter, which is the hardest to catch — from reaching the wearer’s face. But surgical masks, designed to protect patients from a surgeon’s respiratory droplets, aren’t effective at blocking particles smaller than 100 microns, according to mask maker 3M Corp.

A COVID-19 particle is about 1 to 4 microns, according to recent research.

Research from early April, examining two hospitals in South Korea, found surgical masks “seem to be ineffective in preventing the dissemination” of coronavirus particles. A 2013 Chinese study found that twice as many health workers, 17%, got a respiratory illness if they wore a surgical mask treating sick patients, compared with 7% of those who continuously used an N95, per the American Journal of Respiratory and Critical Care Medicine.

“My personal opinion would be, since there’s evidence of aerosol transmission, [at least] an N95 should be used for direct care of suspect or COVID-confirmed patients,” said Dr. Robert Harrison, a physician and professor at the University of California-San Francisco medical school who founded UCSF Occupational Health Services.

In an emailed statement, the CDC suggested that its guidance is meant to conserve scarce resources and applies primarily to shortage situations.

Surgical masks should be used when N95s “are so limited that routinely practiced standards of care … are no longer possible,” said Martha Sharan, an agency spokesperson. “N95 respirators beyond their manufacture-designated shelf life, when available, are preferable to use of facemasks.”

Yet many health facilities — citing the CDC guidelines and scarce supply — are providing N95s in only limited medical settings.

Earlier this month, the national Teamsters union reported that 64% of its health care worker membership — which includes people working in nursing homes, hospitals and other medical facilities — could not get N95 masks.

At Michigan Medicine, the University of Michigan’s medical center, employees don’t get N95s except for performing specific procedures on COVID-positive patients — such as intubation or a bronchoscopy — or treating them in the intensive care unit, said Katie Scott, a registered nurse at the hospital and vice president of the Michigan Nurses Association. Employees who otherwise treat COVID-19 patients receive surgical masks.

That matches CDC protocol but leaves nurses like Scott — who has read the research on surgical masks versus N95s — feeling exposed.

“We are at a risk of getting this virus, and we are at a risk of bringing it home to our families,” Scott said. “It’s clear these surgical mask guidelines aren’t working.”

Nearly 3,000 health workers in the Detroit area — which includes Ann Arbor, the home of Michigan Medicine — have suspected or confirmed COVID-19 infections, according to recent news reports.

At Michigan Medicine, employees cannot bring in their own protective equipment, according to a complaint the nurses union filed with the Michigan Occupational Safety and Health Administration. Scott has PPE that her friends and family have mailed her, including N95 masks. It sits at home while she cares for patients.

“To think I’m going to work and am leaving this mask at home on my kitchen table because the employer won’t let me wear it,” Scott said. “You feel sacrificial in a way.”

News reports from Kentucky to Florida to California have documented nurses facing retaliation or pressure to step down when they’ve brought their own N95 respirators.

A spokesperson for Michigan Medicine declined to answer questions about the hospital’s protective equipment protocols. The American Hospital Association does not have a stance on letting employees bring their own N95s to work, said Robyn Begley, the trade group’s senior vice president and chief nursing officer.

In New York, the epicenter of the nation’s coronavirus outbreak, nurses across the state report receiving surgical masks, not N95s, to wear when treating COVID-19 patients, according to a court affidavit submitted by Lisa Baum, the lead occupational health and safety representative for the New York State Nurses Association.

“A surgical mask is not a form of PPE. … [If you] cough or sneeze, it catches some of the virus. It does not protect the wearer,” Baum said in an interview with Kaiser Health News.

So far, at least 16 NYSNA members have died from the coronavirus, at least 94 have been hospitalized and more than 1,000 have tested positive, according to union estimates.

National Nurses United has pushed Washington lawmakers to pass legislation that would ramp up production of N95s by compelling the White House to invoke the Defense Production Act, a Korean War-era law that allows the federal government, in an emergency, to direct private business in the production and distribution of goods.

It is also calling on Congress to require that the Occupational Safety and Health Administration put forth an emergency temporary standard to mandate that employers provide health care workers with protective equipment, including N95 masks, when they interact with patients suspected to have COVID-19.

“The employer has a responsibility to protect their employees,” said Amirah Sequeira, the union’s lead legislative advocate. “At the same time, when you have a crisis at this scale, the federal government also has a responsibility to ensure the very increase in purchasing, and, if not purchasing, production.”

The AHA has lobbied against a mandate that would expand use of N95s. Begley acknowledged that “supplies are inadequate” and said heightened global demand makes getting N95s much more difficult.

“If we fail to conserve already limited supplies, there will be no N95s remaining for health care staff performing aerosolizing procedures,” Begley said.

But the failure to get more and better protective gear to health workers could cost more lives, union leaders warned in a recent teleconference about the dangerous conditions workers are facing.

“Nurses are not afraid to care for our patients if we have the right protections,” said Bonnie Castillo, the executive director of National Nurses United, “but we’re not martyrs sacrificing our lives because our government and our employers didn’t do their job.”

from Health Industry – Kaiser Health News

Amid Coronavirus Distress, Wealthy Hospitals Hoard Millions

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

from Health Industry – Kaiser Health News

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