News & Updates

CDC Source Article | Comments Courtesy of Matt Zavadsky

Sounds a lot like the EMS 9-1-1 response volume decrease?!

Interesting recommendations at the end.

Full report, with charts and graphs, attached.

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Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020

Early Release / June 3, 2020 / 69

 

https://www.cdc.gov/mmwr/volumes/69/wr/mm6923e1.htm?s_cid=mm6923e1_w

 

Summary

What is already known about this topic?

The National Syndromic Surveillance Program (NSSP) collects electronic health data in real time.

 

What is added by this report?

NSSP found that emergency department (ED) visits declined 42% during the early COVID-19 pandemic, from a mean of 2.1 million per week (March 31–April 27, 2019) to 1.2 million (March 29–April 25, 2020), with the steepest decreases in persons aged ≤14 years, females, and the Northeast. The proportion of infectious disease–related visits was four times higher during the early pandemic period.

 

What are the implications for public health practice?

To minimize SARS-CoV-2 transmission risk and address public concerns about visiting the ED during the pandemic, CDC recommends continued use of virtual visits and triage help lines and adherence to CDC infection control guidance.

 

On March 13, 2020, the United States declared a national emergency to combat coronavirus disease 2019 (COVID-19). As the number of persons hospitalized with COVID-19 increased, early reports from Austria (1), Hong Kong (2), Italy (3), and California (4) suggested sharp drops in the numbers of persons seeking emergency medical care for other reasons. To quantify the effect of COVID-19 on U.S. emergency department (ED) visits, CDC compared the volume of ED visits during four weeks early in the pandemic March 29–April 25, 2020 (weeks 14 to 17; the early pandemic period) to that during March 31–April 27, 2019 (the comparison period). During the early pandemic period, the total number of U.S. ED visits was 42% lower than during the same period a year earlier, with the largest declines in visits in persons aged ≤14 years, females, and the Northeast region. Health messages that reinforce the importance of immediately seeking care for symptoms of serious conditions, such as myocardial infarction, are needed. To minimize SARS-CoV-2, the virus that causes COVID-19, transmission risk and address public concerns about visiting the ED during the pandemic, CDC recommends continued use of virtual visits and triage help lines and adherence to CDC infection control guidance.

 

To assess trends in ED visits during the pandemic, CDC analyzed data from the National Syndromic Surveillance Program (NSSP), a collaborative network developed and maintained by CDC, state and local health departments, and academic and private sector health partners to collect electronic health data in real time. The national data in NSSP includes ED visits from a subset of hospitals in 47 states (all but Hawaii, South Dakota, and Wyoming), capturing approximately 73% of ED visits in the United States able to be analyzed at the national level. During the most recent week, 3,552 EDs reported data. Total ED visit volume, as well as patient age, sex, region, and reason for visit were analyzed.

 

Weekly number of ED visits were examined during January 1, 2019–May 30, 2020. In addition, ED visits during two 4-week periods were compared using mean differences and ratios. The change in mean visits per week during the early pandemic period and the comparison period was calculated as the mean difference in total visits in a diagnostic category between the two periods, divided by 4 weeks ([visits in diagnostic category {early pandemic period} – visits in diagnostic category {comparison period}]/4). The visit prevalence ratio (PR) was calculated for each diagnostic category as the proportion of ED visits during the early pandemic period divided by the proportion of visits during the comparison period ([visits in category {early pandemic period}/all visits {early pandemic period}]/[visits in category {comparison period}/all visits {comparison period}]). All analyses were conducted using R software (version 3.6.0; R Foundation).

 

Reason for visit was analyzed using a subset of records that had at least one specific, billable International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code. In addition to Hawaii, South Dakota, and Wyoming, four states (Florida, Louisiana, New York outside New York City, and Oklahoma), two California counties reporting to the NSSP (Santa Cruz and Solano), and the District of Columbia were also excluded from the diagnostic code analysis because they did not report diagnostic codes during both periods or had differences in completeness of codes between 2019 and 2020. Among eligible visits for the diagnostic code analysis, 20.3% without a valid ICD-10-CM code were excluded. ED visits were categorized using the Clinical Classifications Software Refined tool (version 2020.2; Healthcare Cost and Utilization Project), which combines ICD-10-CM codes into clinically meaningful groups (5). A visit with multiple ICD-10-CM codes could be included in multiple categories; for example, a visit by a patient with diabetes and hypertension would be included in the category for diabetes and the category for hypertension. Because COVID-19 is not yet classified in this tool, a custom category, defined as any visit with the ICD-10-CM code for confirmed COVID-19 diagnosis (U07.1), was created (6). The analysis was limited to the top 200 diagnostic categories during each period.

 

The lowest number of visits reported to NSSP occurred during April 12–18, 2020 (week 16). Although visits have increased since the nadir, the most recent complete week (May 24–30, week 22) remained 26% below the corresponding week in 2019 (Figure 1). The number of ED visits decreased 42%, from a mean of 2,099,734 per week during March 31–April 27, 2019, to a mean of 1,220,211 per week during the early pandemic period of March 29–April 25, 2020. Visits declined for every age group (Figure 2), with the largest proportional declines in visits by children aged ≤10 years (72%) and 11–14 years (71%). Declines in ED visits varied by U.S. Department of Health and Human Services region,* with the largest declines in the Northeast (Region 1, 49%) and in the region that includes New Jersey and New York (Region 2, 48%) (Figure 2). Visits declined 37% among males and 45% among females across all NSSP EDs between the comparison and early pandemic periods.

 

Among all ages, an increase of >100 mean visits per week from the comparison period to the early pandemic period occurred in eight of the top 200 diagnostic categories (Table). These included 1) exposure, encounters, screening, or contact with infectious disease (mean increase 18,834 visits per week); 2) COVID-19 (17,774); 3) other general signs and symptoms (4,532); 4) pneumonia not caused by tuberculosis (3,911); 5) other specified and unspecified lower respiratory disease (1,506); 6) respiratory failure, insufficiency, or arrest (776); 7) cardiac arrest and ventricular fibrillation (472); and 8) socioeconomic or psychosocial factors (354). The largest declines were in visits for abdominal pain and other digestive or abdomen signs and symptoms (–66,456), musculoskeletal pain excluding low back pain (–52,150), essential hypertension (–45,184), nausea and vomiting (–38,536), other specified upper respiratory infections (–36,189), sprains and strains (–33,709), and superficial injuries (–30,918). Visits for nonspecific chest pain were also among the top 20 diagnostic categories for which visits decreased (–24,258). Although not in the top 20 declining diagnoses, visits for acute myocardial infarction also declined (–1,156).

 

During the early pandemic period, the proportion of ED visits for exposure, encounters, screening, or contact with infectious disease compared with total visits was nearly four times as large as during the comparison period (Table) (prevalence ratio [PR] = 3.79, 95% confidence interval [CI] = 3.76–3.83). The other diagnostic categories with the highest proportions of visits during the early pandemic compared with the comparison period were other specified and unspecified lower respiratory disease, which did not include influenza, pneumonia, asthma, or bronchitis (PR = 1.99; 95% CI = 1.96–2.02), cardiac arrest and ventricular fibrillation (PR = 1.98; 95% CI = 1.93–2.03), and pneumonia not caused by tuberculosis (PR = 1.91; 95% CI = 1.90–1.93). Diagnostic categories that were recorded less commonly during the early pandemic period included influenza (PR = 0.16; 95% CI = 0.15–0.16), no immunization or underimmunization (PR = 0.28; 95% CI = 0.27–0.30), otitis media (PR = 0.35; 95% CI = 0.34–0.36), and neoplasm-related encounters (PR = 0.40; 95% CI = 0.39–0.42).

 

In the 2019 comparison period, 12% of all ED visits were in children aged ≤10 years old, compared with 6% during the early pandemic period. Among children aged ≤10 years, the largest declines were in visits for influenza (97% decrease), otitis media (85%), other specified upper respiratory conditions (84%), nausea and vomiting (84%), asthma (84%), viral infection (79%), respiratory signs and symptoms (78%), abdominal pain and other digestive or abdomen symptoms (78%), and fever (72%). Mean weekly visits with confirmed COVID-19 diagnoses and screening for infectious disease during the early pandemic period were lower among children than among adults. Among all ages, the diagnostic categories with the largest changes (abdominal pain and other digestive or abdomen signs and symptoms, musculoskeletal pain, and essential hypertension) were the same in males and females, but declines in those categories were larger in females than males. Females also had large declines in visits for urinary tract infections (–19,833 mean weekly visits).

 

Discussion

During an early 4-week interval in the COVID-19 pandemic, ED visits were substantially lower than during the same 4-week period during the previous year; these decreases were especially pronounced for children and females and in the Northeast. In addition to diagnoses associated with lower respiratory disease, pneumonia, and difficulty breathing, the number and ratio of visits (early pandemic period versus comparison period) for cardiac arrest and ventricular fibrillation increased. The number of visits for conditions including nonspecific chest pain and acute myocardial infarction decreased, suggesting that some persons could be delaying care for conditions that might result in additional mortality if left untreated. Some declines were in categories including otitis media, superficial injuries, and sprains and strains that can often be managed through primary or urgent care. Future analyses will help clarify the proportion of the decline in ED visits that were not preventable or avoidable such as those for life-threatening conditions, those that were manageable through primary care, and those that represented actual reductions in injuries or illness attributable to changing activity patterns during the pandemic (such as lower risks for occupational and motor vehicle injuries or other infectious diseases).

 

The striking decline in ED visits nationwide, with the highest declines in regions where the pandemic was most severe in April 2020, suggests that the pandemic has altered the use of the ED by the public. Persons who use the ED as a safety net because they lack access to primary care and telemedicine might be disproportionately affected if they avoid seeking care because of concerns about the infection risk in the ED.

 

Syndromic surveillance has important strengths, including automated electronic reporting and the ability to track outbreaks in real time (7). Among all visits, 74% are reported within 24 hours, with 75% of discharge diagnoses typically added to the record within 1 week.

 

The findings in this report are subject to at least four limitations. First, hospitals reporting to NSSP change over time as facilities are added, and more rarely, as they close (8). An average of 3,173 hospitals reported to NSSP nationally in April 2019, representing an estimated 66% of U.S. ED visits, and an average of 3,467 reported in April 2020, representing 73% of ED visits. Second, diagnostic categories rely on the use of specific codes, which were missing in 20% of visits and might be used inconsistently across hospitals and providers, which could result in misclassification. The COVID-19 diagnosis code was introduced recently (April 1, 2020) and timing of uptake might have differed across hospitals (6). Third, NSSP coverage is not uniform across or within all states; in some states nearly all hospitals report, whereas in others, a lower proportion statewide or only those in certain counties report. Finally, because this analysis is limited to ED visit data, the proportion of persons who did not visit EDs but received treatment elsewhere is not captured.

 

Health care systems should continue to address public concern about exposure to SARS-CoV-2 in the ED through adherence to CDC infection control recommendations, such as immediately screening every person for fever and symptoms of COVID-19, and maintaining separate, well-ventilated triage areas for patients with and without signs and symptoms of COVID-19 (9). Wider access is needed to health messages that reinforce the importance of immediately seeking care for serious conditions for which ED visits cannot be avoided, such as symptoms of myocardial infarction. Expanded access to triage telephone lines that help persons rapidly decide whether they need to go to an ED for symptoms of possible COVID-19 infection and other urgent conditions is also needed. For conditions that do not require immediate care or in-person treatment, health care systems should continue to expand the use of virtual visits during the pandemic (10).

 

Time Magazine Source Article | Comments Courtesy of Matt Zavadsky

Nice article in this weeks’ Time Magazine, coinciding with National EMS Week! No highlights – it’s ALL important!

Emergency Medical Workers Are Integral to the Fight Against Coronavirus. Just a Few Decades Ago, America’s EMS System Didn’t Even Exist

Sunday marks the beginning of EMS Week,  an annual time to recognize the life-saving efforts of emergency medical services personnel. While celebratory events won’t take place in person this year, EMS personnel are getting more recognition than usual: even before EMS week, virtually and during daily cheers for healthcare workers, they are widely hailed as heroes on the front lines of the COVID-19 pandemic.

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Modern Healthcare Source Article 

Feds to overhaul national stockpile of medical supplies

President Donald Trump on Thursday said his administration will improve the Strategic National Stockpile of drugs and medical supplies to ensure the U.S. is prepared to respond to viruses like COVID-19 in the future.

Officials will use lessons learned from the current pandemic and supply-chain management strategies from the Department of Defense to refill and preserve the stockpile going forward. The federal government now has a "well-defined understanding" of which critical supplies it needs and in what amounts, a senior administration official said.

When the COVID-19 outbreak began in the U.S., the federal government had one to three weeks of supply for most items in the national stockpile. According to a senior administration official, the Trump administration aims to create a 90-day supply for those items to create "a buffer" until the U.S. can increase domestic manufacturing surge capacity.

The administration is fundamentally rethinking how HHS, Defense and the Federal Emergency Management Agency coordinate their activities so they can respond more effectively.

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Summary Courtesy of Matt Zavadsky

• Breaking News: In its latest round of waivers, CMS is announcing the delay of the implementation of the Ambulance Cost Data Collection process for the suppliers and providers who were selected for Round 1 of the reporting process.

  Salient provision on page 29, copied below…

  Wonder if they’d allow us to change reporting years to report the additional costs and decreased revenue related to the COVID-19 pandemic? We’re asking!

  
  

  Ambulance Services: Medicare Ground Ambulance Data Collection System (New since May 11 Release)

• • CMS is modifying the data collection period and data reporting period, as defined at 42 CFR § 414.626(a), for ground ambulance organizations (as defined at 42 CFR § 414.605) that were selected by CMS under 42 CFR § 414.626(c) to collect data beginning between January 1, 2020 and December 31, 2020 (year 1) for purposes of complying with the data reporting requirements described at 42 CFR § 414.626.
  • Under this modification, these ground ambulance organizations can select a new continuous 12-month data collection period that begins between January 1, 2021 and December 31, 2021, collect data necessary to complete the Medicare Ground Ambulance Data Collection Instrument during their selected data collection period, and submit a completed Medicare Ground Ambulance Data Collection Instrument during the data reporting period that corresponds to their selected data collection period.
  • CMS is modifying this data collection and reporting period to increase flexibilities for ground ambulance organizations that would otherwise be required to collect data in 2020- 2021 so that they can focus on their operations and patient care. As a result of this modification, ground ambulance organizations selected for year 1 data collection and reporting will collect and report data during the same period of time that will apply to ground ambulance organizations selected by CMS under 42 CFR § 414.626(c) to collect data beginning between January 1, 2021 and December 31, 2021 (year 2) for purposes of complying with the data reporting requirements described at 42 CFR § 414.626.

NYT Source Article | Comments Courtesy of Matt Zavadsky

Outstanding article in Sunday’s New York Times.  Our new normal? 

Crisis Standards of Care? 

We will have a treasure trove of data to analyze…  Did withholding CPR on cases with low probably of survival change the overall picture of OOHCA survival?  Do patients treated and transported with 1 provider and a driver (as is allowed in some states now) make any difference in patient outcomes?  Did no transport protocols put in place to preserve hospital capacity result in any adverse patient outcomes?

Shout out to NAEMT’s Medical Director, Craig Manifold for contributing to this story, and tip of the hat to Bill Bullard for sharing it…

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Paramedics, Strained in the Hot Zone, Pull Back From CPR

Their mission is to save lives at any cost. But in New Jersey, the coronavirus has sickened so many emergency workers that some units are holding off on risky procedures like CPR.

May 10, 2020

By Rukmini Callimachi, Photographs by Ryan Christopher Jones

https://www.nytimes.com/2020/05/10/nyregion/paramedics-cpr-coronavirus.html

NEWARK — The calls for patients in cardiac arrest came in one after another.

A 39-year-old man, followed by a 65-year-old, whose neighbor called 911 after getting no response when he rang the doorbell. Then a 52-year-old woman’s heart stopped, as did that of a 90-year-old, who had collapsed on her bedroom floor.

The ambulances turned on their sirens and screamed through red lights. But what the paramedics did after rushing to the victims — or more precisely, what they did not do — is a window into how a deadly virus has reshaped emergency medicine. After confirming that the patients’ hearts had flatlined, they declared each of them dead at the scene, without attempting CPR.

Before coronavirus cases hit hard a few weeks ago, John McAleer, a paramedic who responded to the call for the 90-year-old woman, would have begun chest compressions. His partner would have started an IV to administer epinephrine, which acts as a stimulant. They might have used the defibrillator to try to shock her heart back to life.

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D Magazine source article 

Is DFW Scared to Death?

April data show North Texas residents are less likely to call 911, and those who do are often waiting until it's too late.

BY WILL MADDOX

MAY 8, 2020

 

https://www.dmagazine.com/healthcare-business/2020/05/is-dfw-scared-to-death/

North Texas residents are still calling 911 infrequently and visiting the doctor less, and it is resulting in a higher rate of patients who are pronounced dead when EMS crews arrive after an emergency call, according to data from North Texas emergency response service MedStar.

Compared to April 2019, the number of patients who were in cardiac arrest was up 113 percent in April this year. Of those patients, the number who were pronounced dead on the scene by MedStar crews rose 164 percent relative to last April. This data is similar to results from March, which reflected similar if less drastic changes in behavior around calling 911 and cardiac arrest.

The increases in cardiac arrest and deaths was even more striking considering total volume is down 19 percent compared to January, and total ambulance transports to the hospital are down 28 percent in that same time period.

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CPSM Source Article | Author Matt Zavadsky

The COVID-19 pandemic has changed our world forever.  These are unprecedented times, and virtually every aspect of local governance and service delivery has been impacted.  Perhaps one of the service delivery models most impacted by the coronavirus is your local emergency medical services (EMS) system.

Whether your EMS service is provided by the fire department, a separate department of the city or county government, contracted to a private provider, a hospital-based agency, or a combination of these, the impact of COVID-19 on the workforce, operations, protocols, and even the role of your local EMS system is dramatically different than it was only a few months ago.

Workforce

Protecting the Front Line – EMS is healthcare, and healthcare workers are on the front line of this pandemic.  The highly contagious nature of the coronavirus places EMS workers, who often provide their services in dynamically diverse settings, at significant risk.  A tracking system implemented by the International Association of Fire Chiefs reports that since the COVID-19 outbreak, over 10,500 EMS and fire workers have been exposed to COVID-19, 4,800 have had to be quarantined, and 575 have been diagnosed with the disease.  Sadly, more than 20 of them have succumbed to the virus.

• Best Practice – Assure your EMS agency leadership is reporting personnel exposures, quarantines and COVID-19 diagnoses into this tracking system. It provides a basis for federal funding to help mitigate these impacts.

Mitigation of this risk requires EMS providers to take extreme measures to protect themselves, and the patients entrusted to their care, from airborne virus transmission.  The use of personal protective equipment (PPE) such as N95 masks, face shields and gowns has never been greater.  For example, at MedStar, the regional governmental EMS authority in Fort Worth, Texas, the daily ‘burn rate’ for N95 masks increased from an average of four per day in January 2020, to 160 per day in April.  The dramatic increase in use of PPE has strained supply chains, and although recently there has been some improvement, local governments will need to pay particular attention to the availability of PPE for their EMS agencies.

• Best Practice – Assure availability of PPE for your EMS workers.

Modification of Medical Protocols – There are medical procedures that place EMS workers at a higher risk for airborne viruses.  These include many advanced airway maneuvers and breathing treatments.  Agency medical directors should carefully review patient care protocols and modify protocols to minimize the use of these procedures, or at the very least, provide very specific guidance on how to safely administer these treatments when they are absolutely needed.  Similarly, the overall approach to resource dispatch and on-scene processes should be modified to minimize the number of personnel entering potentially infectious environments.

• Best Practice: EMS Medical Directors should modify medical protocols to minimize potential transmission of airborne pathogens.

Personnel Screening and Testing – The heightened risk of EMS workers contracting, and potentially spreading, COVID-19 requires the implementation of workplace controls.  At a minimum, EMS workers should undergo a health screening and temperature check at the start of every shift.  If their shifts are longer than twelve hours, the test should be administered every twelve hours.  Employees who are symptomatic for COVID-19 should not be allowed to work, or even enter EMS facilities.  Similarly, any EMS worker who has an exposure to a patient suspected of having COVID-19, should be placed on administrative leave and isolated while testing is completed.  To minimize the impact on staffing, priority testing should be provided to any EMS worker with a possible COVID-19 exposure.  You should also arrange for a safe and comfortable environment for them to be isolated such as a local hotel, or recreational vehicle.

• Best Practice – EMS workers should be health screened prior to on-duty shifts and given priority for testing after an exposure, or if they are symptomatic.

Information Exchange in the FOG of War – Dynamically changing information and guidance from sources like the CDC, NIH, federal administrative agencies and local health authorities, has created a FOG of War.  This adds to the concern of your local EMS providers.  Communication is key and you should assure that the lines of communication from your agency’s leaders to the field providers is timely, accurate and relevant to both the clinical impact of the virus and responsive to their fears and concerns.  This will not only help assure that clinical best practices are conveyed in a timely manner, but that you are continually aware of the ‘ground truth’ of what’s happening in the field and address any issues faced by your crucial field staff.

• Best Practice – EMS agency leadership should facilitate frequent information exchanges with EMS workers.

Operations

Response Procedures – Responses to potential COVID-19 patients should be modified to minimize the number of EMS personnel who enter potentially hazardous environments.  9-1-1 EMS calls should be screened for the presence of high-risk clinical presentations and any calls with a high index of suspicion should be handled differently.  For example, low-acuity calls (calls in which no significant life threat is present), may not require a response from first responders who may typically respond.  When multiple responders do arrive, the responders should meet on scene PRIOR to making patient contact and decide which essential personnel need to enter the scene.  This will reduce the number of EMS workers entering the potentially hazardous scene.  MedStar modified dispatch processes to screen 9-1-1 callers for the risk of potential of COVID-19 related illnesses and advise all responding personnel of calls with a high index of suspicion.  On-scene processes have been revised to limit the number of responders entering potentially hazardous environments.  Similarly, for CPR calls, whenever possible, mechanical CPR devices are used to minimize the need for EMS workers to actually provide external chest compressions.  Further, the local health authority should provide the EMS agency with a list of people under investigation (PUIs) in their response area.  These addresses can be ‘flagged’ so that calls to those addresses can be managed in the appropriate way.

• Best Practice – Dispatch, response and on-scene procedures should be revised to minimize the number of EMS responders in hazardous environments.

Inter-Agency Communications – When EMS does treat a potential COVID-19 patient, processes should be in place to rapidly test the patient for the presence of the coronavirus and report the test outcomes to the EMS agency(s) who were involved in patient care.  The federal government has loosened patient privacy requirements to facilitate this information exchange.

Ambulance Riders – During most transports to the hospital, it is standard practice for the EMS agency to allow a family member to ride in the ambulance with the patient.  Due to the close quarters in most ambulances, and the fact that many hospitals are restricting visitors, the practice of allowing family members to ride with the patient should be discouraged.  This may need to be allowed in rare cases such as a parent riding with a child, or if translation services are required.  The same restrictions should be applied to student observers or other third-party riders who may typically be allowed to ride on ambulances for clinical or educational purposes.

• Best Practice – Operational policies should be revised to allow the exchange of information for suspected COVID-19 patients between agencies and to limit riders on ambulances.

New Roles for EMS Agencies

Treat and Referral Protocols – To preserve healthcare system capacity, as well as minimize patient exposures, EMS systems should work with their medical control authority to implement protocols that facilitate EMS personnel referring low-acuity 9-1-1 patients to follow-up care other than transport to a hospital emergency department.  When implementing these protocols, instructions and leave-behind materials on how to access medical resources for follow-up should be provided to patients who are not transported.  These protocols and supplemental information can either be provided on-scene when EMS providers arrive, or over the telephone on 9-1-1 calls without EMS resources being sent to the scene.

COVID-19 Testing – One of the greatest needs in many communities is testing for coronavirus.  EMS agencies can be a valuable resource for this testing by staffing public access testing sites, or going to the homes of individuals who are quarantined to do specimen collection.  Skilled Nursing Facilities (SNFs) and jails often have unique environments that make residents of those facilities especially vulnerable to the spread of COVID-19.  In Texas, Emergency Medical Task Forces (EMTFs) comprised of EMS, public health and regulatory officials are deployed to SNFs identified by the state as “hot spots” for the coronavirus.  These EMTFs arrive at the facility to not only test all residents and staff, but provide education to the staff on PPE use and recommendation for isolating COVID positive residents.

• Best Practice – EMS agencies should partner with public health and the healthcare system to fill gaps created by the COVID-19 pandemic.

Economics

Financial Perfect Storm – Many cities and counties are experiencing significant financial impacts from the COVID-19 pandemic.  Stay in place orders reduce commerce in the jurisdiction, resulting in the loss of jobs and tax revenue.  Simultaneously, expenses for mitigating the impact of COVID-19 are skyrocketing.  EMS agencies are experiencing the same economic imbalance.  Backfill and other personnel expenses for quarantined personnel is dramatically increasing.  The use and price for PPE has exponentially increased.  In January, MedStar in Fort Worth paid $0.67 for an N95 mask; in April, that same mask was $3.65.  From a revenue perspective, due to stay in place orders, and orders to limit medical care to preserve hospital capacity, 9-1-1 response and transport volumes have dropped substantially in most communities.  EMS agencies are most often only reimbursed by 3rd party insurers when they transport patients to the hospital.  Decreases in both response and transport volume have dramatically reduced EMS revenue.  In a recent study conducted by the National Association of Emergency Medical Technicians, 69% of survey respondents indicated their response volumes have decreased since the declaration of the Public Health Emergency (PHE) and 35% of EMS agencies indicated they will only be able to sustain operations for 2 months without significant financial relief.

• Best Practice – Cities and counties should include EMS agencies in their plans for economic relief from sources such as CARES Act funding and FEMA grants.

Summary

Cities, counties and their respective departments have learned a lot from the COVID-19 pandemic, but the education is not over.  The full impact of the virus on local communities may not be known for months or years to come.

CPSM has numerous experts and resources available to assist governmental leaders navigate these uncharted waters.

References and Resources:

CDC EMS guidelines

NHTSA EMS Resources

MedStar EMS Protocols and Guidelines for COVID-19

National Association of Emergency Medical Technicians COVID Resources

International Association of Fire Chiefs COVID-19 Exposure Tracking

Global Medical Response Emerging Infectious Disease Resources

Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

Ambulance services generally do not file cost reports.  As such, it will be important for ambulance providers to assure they are accounting their 2018 ‘net revenue’ appropriately be prepared to submit this data to HHS next week.  Ambulance agencies should check with their national associations, many of whom have resources available to assist with this calculation.

Asbel Montes and Brian Choate from the Solutions Group provided an informative 10 minute video that provides insight into calculating net revenue here.

Since concern has been raised about the adequacy of the allocated funds, it will also be crucial to file this information as soon as the HRSA web link is opened on Monday.  Plan NOW!  If you outsource your billing, it is important to reach out to them TODAY to start getting this data ready for submission.  Note that the calculation of your net revenue will likely be impacted by the rates you charge.  Net revenue calculations, and therefore the amount of eligible relief funding, will be less for agencies that charge below market rates.

Also, this process will include relief funding for the cost of providing care to uninsured COVD-19 patients, actual or presumed.  This will include ambulance services.  It’s important that you begin accounting your costs and revenues for treating and transporting these patients.

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HHS formula for $20 billion in CARES Act provider grants prompts questions

RACHEL COHRS

April 23, 2010

 

https://www.modernhealthcare.com/finance/hhs-formula-20-billion-cares-act-provider-grants-prompts-questions

The formula HHS will use to distribute $20 billion in COVID-19 relief grants is unclear about how much money providers will get and if enough money will be left after the first direct deposits go out Friday.

HHS Secretary Alex Azar said Wednesday that the department will soon pay out an additional $20 billion from the Coronavirus Aid, Relief, and Economic Security Act's provider relief fund to top up providers that were disadvantaged in the department's first $30 billion round of grant funds based on Medicare fee-for-service reimbursement. The department will now use 2018 net patient revenue to decide providers' total share of the total $50 billion, and send out the second round of grants accordingly.

But cost report data is incomplete, and Azar said some of the funds will be distributed on Friday before the department begins collecting data from providers who don't already have information on file. Some are worried that they could be left out, or that funds could be delayed.

The second round of funds should benefit some providers who were largely excluded from the earlier tranche, such as children's hospitals. The first round's formula emphasized Medicare revenue. According to Azar, one large children's hospital that got $233,000 from the first round of funds will get an additional $32 million on Friday.

But a Modern Healthcare analysis found that nearly a quarter of the 82 children's hospitals that filed full-year 2018 CMS cost reports failed to fill out the net patient revenue field that will be used to distribute the funds.

Children's Hospital Association chief operating officer Amy Knight said the new distribution formula is an improvement for children's hospitals, but a lack of centralized data will complicate the effort.

"That data is hard to come by, which is a challenge for children's hospitals," Knight said.

Independent physician groups are also worried about their share of the funds, as they don't file CMS cost reports. American Academy of Family Physicians Senior Vice President Shawn Martin said he was concerned that some physician practices have additional reporting and data analysis obstacles to obtaining the funds.

With data missing, McDermott+Consulting vice president Mara McDermott said it's difficult to tell what total proportion HHS is using to send out the first wave of direct deposit payments, and how much will be left over.

"It feels like a total black box to me. How do you rebalance the funds with less than you started with?" McDermott said.

With funds going to smooth uneven grants from the first round, some providers will likely get less than they would have if the $20 billion had just been determined proportionally on cost report data. Federation of American Hospitals President and CEO Chip Kahn said he is disappointed the formula isn't focused on COVID-19 related losses, and is unsure his member hospitals will get enough support in the second round.

"I can't say until we see all of the money, but I have my doubts and I sincerely hope they find other ways to give out what's left and the new $75 billion," Kahn said, referring to Congress' passage of a bill replenishing grant funds on Thursday.

While HHS chose to distribute funds to rural hospitals and Indian Health Service providers based on operating expenses, they are allocating general funds by net patient revenue.

Health policy experts including Guidehouse healthcare partner Dave Moseley said the net patient revenue metric favors providers with more commercially insured patients, which are largely better off anyway. But Moseley also noted HHS had to make hard choices to get the grants out fast.

"When there is an expediency requirement, equitability is not as high on the priority list," Moseley said.

Many variables such as different organizational structures, market pricing, and payer mix are difficult to account for using any one metric, Knight said.

"It's messy, and people are working hard to create some sense of relief. No number is perfect," Knight said.

Modern Healthcare source article | Comments courtesy of Matt Zavadsky

Good information for providers as they evaluate the risks/benefits of accepting the initial CMS funds distribution. 

Also, in case you missed it, Kaiser Health News and NPR reported over the weekend about an ambiguous phrase in the HHS post regarding the distribution. 

Providers accepting the funds agree to not balance bill COVID-19 patients, and:

• “If you ceased operation as a result of the COVID-19 pandemic, you are still eligible to receive funds so long as you provided diagnoses, testing, or care for individuals with possible or actual cases of COVID-19. Care does not have to be specific to treating COVID-19. HHS broadly views every patient as a possible case of COVID-19.”

And this provision…

“HHS' payment of this initial tranche of funds is conditioned on the healthcare provider's acceptance of the Terms and Conditions, which acceptance must occur within 30 days of receipt of payment. Not returning the payment within 30 days of receipt will be viewed as acceptance of the Terms and Conditions”

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CARES Act grants could spark False Claims Act issues

RACHEL COHRS

April 18, 2020

https://www.modernhealthcare.com/legal/cares-act-grants-could-spark-false-claims-act-issues 

 

While CMS Administrator Seema Verma touted that Congress' COVID-19 provider grant funds would have "no strings attached," agreeing to the assistance could open providers up to False Claims Act liability risks.

 

Many providers on April 10 received part of a $30 billion fund created in the Coronavirus Aid, Relief, and Economic Security Act, as well as a list of terms and conditions from HHS for keeping the money.

 

Several of the terms and conditions have prompted providers to seek counsel from their attorneys. Even if providers aren't technically filing a claim and didn't apply for the grants, they are not allowed to keep any money they aren't legally eligible for and could be penalized for "reverse false claims."

 

"There was a very long string attached to it," said William Jordan, a former Department of Justice official and partner at Alston & Bird.

 

Under the HHS provisions, providers can only use the funds "to prevent, prepare for, and respond to coronavirus," and for "healthcare related expenses or lost revenues that are attributable to coronavirus."

 

Documenting lost revenues may be easier for providers if they can compare patient volumes from 2019 or 2020 budget projections, according to James Segroves, a partner at Reed Smith.

 

"That may be the cleanest way to try to demonstrate compliance and not have to deal with years of investigation," Segroves said.

 

If providers don't document how they are complying with any one of the terms and conditions, it could provide an opening for FCA litigation.

 

The grant conditions require providers to track how the money is spent for quarterly reporting requirements and future audits, which may be easiest if the funds are kept in a separate account. Jordan said it's still possible to use the funds without a separate account, but it's important to maintain stringent accounting practices.

 

The added requirement may force some health systems and practices to reprioritize their expenses and bulk up their compliance practices, especially if they don't have a sophisticated system in place.

 

"What your compliance plan is on January 1, 2020 is not the same plan that should be in place on May 1," King & Spalding partner Michael Paulhus said.

 

Providers could run afoul of false claims law if they use the grants to double-dip for expenses that another assistance program covers. Some of the money can be used for payroll expenses, but with limits— employees can only be paid using grant funds up to an annual rate of up to $197,300, so salaries for more highly paid workers would need to be paid at least partly using separate funds.

 

Grant recipients are also banned from billing out-of-network patients more for COVID-19 treatments than they would have otherwise paid in-network. But if contracts didn't exist previously, it could throw a wrench in calculating in-network rates, according to Hooper, Lundy & Bookman founding partner Lloyd Bookman. Insurers use a wide variety of benefit designs to determine those rates.

 

"I don't understand how providers do that in the real world," Bookman said.

 

Providers have 30 days to either agree to HHS' terms and conditions or return the grant money. Since some of the regulatory terms are ambiguous, some lawyers suggested their clients should keep a paper trail of how they interpreted HHS' requirements or reach out to the agency for clarification.

 

If any FCA issues arise in the future, having record of interpretations can help establish whether a provider intentionally tried to defraud the government.

 

"The regulations may change and the interpretations may change, and you have to be willing to repay the funds if that happens. But with the benefit of hindsight, this will be an important step," said Crowell & Moring partner David Robbins.

 

The regulatory system is moving at warp speed, and it's possible that more clarity on providers' obligations could come later. Bookman said he is currently advising clients to hold off on agreeing to the grant terms until later in the 30-day window to make sure they have as much information as possible. If providers don't agree to or reject the terms by the HHS deadline, they are automatically considered as agreeing to them.

 

The coronavirus pandemic has caused providers to scramble as they brace for a surge of sick patients or try to pay bills as their revenue shrinks without elective procedures. The federal government may consider those extenuating circumstances as they're considering bringing a false claims case.

 

"Everybody is human. They have compassion. But they will bring cases," Robbins said.

NPR Source Article | Comments Courtesy of Matt Zavadsky

Very interesting article from Kaiser Health News and replicated by NPR - the implications could be very significant, and depending on the pending HHS clarification, may give those who received round 1 stimulus payments reasons to re-consider accepting those payments.  Providers may generate more revenue by balance billing, than they receive in stimulus payments.

 

It’s not referenced in the article, but here is the actual language in the HHS guidance regarding the stimulus payments:

 

• “If you ceased operation as a result of the COVID-19 pandemic, you are still eligible to receive funds so long as you provided diagnoses, testing, or care for individuals with possible or actual cases of COVID-19. Care does not have to be specific to treating COVID-19. HHS broadly views every patient as a possible case of COVID-19.”

 

Also, we have talked with many ambulance providers who are/were unaware they received this payment.  Typically, those have been providers who outsource their billing, and funds go into a general revenue or other account they do not monitor closely.  The CARES Act public notice contains language states that if you keep the payment, it is presumed you agree with all the provisions of accepting the fund – including the balanced billing provision.

 

“HHS' payment of this initial tranche of funds is conditioned on the healthcare provider's acceptance of the Terms and Conditions, which acceptance must occur within 30 days of receipt of payment. Not returning the payment within 30 days of receipt will be viewed as acceptance of the Terms and Conditions”

• 2020.04 CARES Act Provider Relief Fund.pdf
  
• 2020.04.13 Highlights - HHS Relief Fund Payment Terms and Conditions.pdf
  

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In Fine Print, HHS Seems To Have Banned Surprise Medical Bills During The Pandemic

April 17, 20208:25 PM

EMMARIE HUETTEMAN

 

https://www.npr.org/sections/health-shots/2020/04/17/837749925/in-fine-print-hhs-seems-to-have-banned-surprise-medical-bills-during-the-pandemi

 

U.S. officials offering emergency funding to hospitals, clinics and doctors' practices during the coronavirus pandemic have included this stipulation: They are not permitted to foist surprise medical bills on COVID-19 patients.

 

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

 

Some health care analysts say that line could disrupt a longtime health care industry practice of balance billing, in which a patient is billed for the difference between what a provider charges and what the insurer pays.

 

Such charges are a major source of surprise bills, and can be financially devastating for patients. The practice of balance billing is banned in several states, though not federally.

 

The possibility that HHS might have done with fine print what Congress and the White House could not do — despite bipartisan support and public outrage — caught some who have been immersed in the issue off guard, and raised questions about what exactly HHS meant.

 

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

 

The agreement is posted on the HHS.gov page.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Congress has yet to pass any legislation on surprise billing, but debate over the practice continues behind the scenes. Lawmakers did include modest provisions in relief legislation that prevent people from having to pay out of pocket for COVID-19 tests.

 

Hoadley of Georgetown says HHS' guidance should have addressed some of the problems that Congress did not explicitly account for in its relief legislation.

 

"The providers, the insurers, everybody else is going to need clarification, as well as, of course, all of us as potential patients," Hoadley says. "That's going to affect our willingness to" seek testing or treatment.

 

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

 

"It's time to just ban them permanently, not just related to COVID," Isasi says.

 

Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.