On Call: The Newsletter of the Alliance of Specialty Medicine – COVID-19 Edition

Spring 2020

Specialty Docs Advocate for COVID-19 Relief Bills

On March 27, 2020 President Trump signed into law the largest stimulus package in U.S. history in response to the coronavirus disease (COVID-19) pandemic. The $2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136) was passed by the Senate by a vote of 96-0 and followed two days later with a voice vote by the full House of Representatives.

While the rescue package was largely aimed at curtailing the economic impact of the crisis, several medical societies, including the Alliance of Specialty Medicine advocated for specific healthcare provisions aimed at assisting doctors, nurses and other frontline healthcare workers who are scrambling to provide patient care in the midst of a global pandemic.

In its letter to Congressional leadership, the Alliance highlighted the fact that, similar to many other small businesses across the country, independent physician practices were also doing their part in following CMS guidelines to limit or even cancel all non-essential surgeries and procedures. While certainly the smart and responsible action to take to help stop community spread, it also meant a sudden drop in revenue and risking the financial obligations of physician practices.  The Alliance noted that critical changes would need to be made to existing federal small business loan programs to help independent physician practices keep their doors open.  Moreover, greater flexibility was needed for providers to offer telemedicine and for those who treat Medicare patients.

The vast details of the CARES Act addressed the COVID-19 healthcare crisis and the Alliance’s concerns on several fronts.  First and foremost, hospitals and health care providers will receive $100 billion in support, though a Provider Relief Fund. The new law temporarily lifts the Medicare sequester, which reduces payments to providers by two percent, from May 1 through December 31, 2020 and also extends funding for several public health programs, including community health centers, through November.

The CARES Act includes several measures to expand the provision of telehealth, including providing additional flexibility for telehealth services and allowing hospice providers to certify and re-certify patients through telehealth (rather than requiring face-to-face visits). It allows for patients with health savings accounts (HSAs) and high-deductible health plans to use telehealth before they meet their deductibles and expands Medicare payments for certain health centers and clinics using telehealth.

On the small business side, the CARES Act established the Paycheck Protection Program, a program to enable employers with up to 500 employees to carry their payroll and other operating costs through this crisis. This program, which is administered by the Small Business Administration (SBA), establishes a cap of $10 million per loan or 250% of the average monthly payroll, whichever is less. For example, assuming no previous SBA loans for the same period or for the same purposes, if a business has a $300K monthly payroll, the loan amount would be $750K given the current covered statutory time frame of February 15, 2020 to June 30, 2020, though subsequent legislation extended that timeframe and other conditions of the program.

In addition to these vital healthcare provisions, the CARES Act also funded The National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) with an additional $945 million to combat the virus. There is also $16 billion to replenish the Strategic National Stockpile (SNS), $1 billion for additional medical supplies through the authority of the Defense Production Act (DPA), and $3.5 billion to expand production and development of COVID-19 related vaccines and tests. It also allocates $500 million for public health modernization. The bill will require the U.S. Department of Health and Human Services (HHS) to report on the nation’s dependence on foreign countries for certain drugs and medical supplies, and mandates that providers of coronavirus diagnostic testing publish their cash price for the tests.

As Congress works to assemble its next legislative response to the COVID-19 pandemic, the Alliance is urging lawmakers to address several issues that are a priority for specialty medicine. These priorities include ensuring that initial disbursements from the $100 billion fund can be retained by providers who have delayed elective procedures, revising the terms of the Medicare Accelerated and Advance Payment Program, providing additional medical liability protections for physicians during COVID-19 response, waiving Medicare Physician Fee Schedule budget neutrality requirements and providing positive physician payment updates, further clarifying eligibility for the Paycheck Protection Program, and addressing physician workforce shortages.

COVID Response Includes Several Changes to Telehealth Access

In addition to the massive federal funding response to the COVID-19 pandemic, both Congress and the Administration have gone to great lengths to expand the availability of telehealth services.

Since early March, Congress has passed three COVID-19 related laws.  Each of them contained provisions dealing with telehealth expansion and access.  The first package, The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Public Law No: 116-123) allowed the HHS Secretary to waive certain Medicare telehealth restrictions during the coronavirus public health emergency, including “originating site” restrictions that limited where Medicare beneficiaries had to be located in order to receive services via telehealth.  The second legislative package, the Family First Coronavirus First Response Act (P.L. 116-127) made a technical change to the Medicare telehealth provision of the first relief package to ensure that new Medicare beneficiaries are able to access telehealth services under the emergency authority granted to the Secretary. Finally, the Coronavirus Aid, Relief, and Economic Security Act (CARES) (P.L. 116-136) includes additional changes to further expand the Secretary’s authority to waive requirements on the use of telehealth services.

In follow-up to the new authorities provided by Congress, the Trump Administration took several regulatory steps to expand access to telehealth for patients and remove some bureaucratic hurdles for providers who need to rely more on telehealth to ensure patients receive medically necessary care, while also keeping their practices open. These steps include:

  • The Centers for Medicare and Medicaid Services (CMS) implementing a first round of Medicare telehealth waivers specifying that, effective March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings, including in any healthcare facility and in the patient’s home.
  • The Department of Health and Human Services publishing a policy statement specifying that it generally would not impose administrative sanctions on physicians and other practitioners for reducing or waiving any cost-sharing obligations that beneficiaries may owe for covered telehealth services.
  • The Office of Civil Rights issuing a further statement “effective immediately, that it will exercise its enforcement discretion and will waive potential penalties for HIPPA violations against health care providers that serve patients through everyday communications technologies during the COVID-19 public health emergency. This exercise of discretion applies to widely available communications apps such as FaceTime or Skype, when used in good faith for any telehealth treatment or diagnostic purpose, regardless of whether the telehealth service is directly related to COVID-19.”

CMS took additional steps by issuing two Interim Final Rules with Comment that further expanded the availability of Medicare telehealth services (see here and here), including by establishing coverage and payment for evaluation and management services furnished via audio-only telephone; allowing for payment of telehealth services as if they had been furnished in person; expanding the list of services eligible to be furnished via telehealth; and much more.  Separately, CMS also further exercised its waiver authority to expand the list of clinicians eligible to furnish telehealth, and to specify that certain additional Medicare services could be furnished via audio-only communications technology, as identified on the Medicare Telehealth Services List.

When President Trump declared an emergency under the Stafford Act, CMS was also given additional waiver authority under section 1812(f) and section 1135 through which states can gain new authority to use their Medicaid programs to respond to the coronavirus pandemic. For instance, States may be able to expand the use of telehealth services in their Medicaid programs to combat the coronavirus outbreak. CMS issued additional Medicaid telehealth guidance while also highlighting their main website for telehealth in Medicaid.  CMS also issued a Telehealth Toolkit to Accelerate State Use of Telehealth in Medicaid and CHIP, which includes policy considerations, state checklists, frequently asked questions, and more.

Additionally, CMS and its federal partners have issued guidance promoting the use of telehealth by private plans and encouraging states to support issuers’ efforts (see here and here).  The guidance addresses the use of non-enforcement policies to facilitate changes in plan benefits to add telehealth benefits or reduce or eliminate cost-sharing for telehealth and other remote care services.

Specialists and their patients have significantly benefitted from these added flexibilities and regulatory revisions.   In fact, most specialists and their patients have come to realize the value of delivering and receiving health care in a virtual environment. To ensure physicians and patients can continue to deliver and receive care beyond the current public health emergency and in the event of future community-wide outbreaks, the Alliance is calling on CMS to work with the Congress and its federal agency partners to ensure ongoing access to telehealth services beyond the COVID-19 public health emergency and to permanently enable practitioners and patients to continue to use an array of non-public-facing audio and video technologies to deliver and receive virtual care and telehealth services.

Plastic Surgeons Combat PPE Shortage

Throughout the COVID-19 pandemic, the American Society of Plastic Surgeons (ASPS) has been working with its local, state and regional plastic surgery partners and the federal government to increase access to personal protective equipment (PPE) and ventilators, coordinate small business relief information and remove governmental barriers to allow plastic surgeons to assist in the fight against COVID-19.

ASPS has developed a suite of resources to help plastic surgeons and patients manage the crisis, including a website that houses ASPS webinars focused on telemedicine, employment law and managing plastic surgery practices through the crisis; guidance for plastic surgeons regarding the resumption of elective procedures; and financial recovery resources. Specifically, the specialty has made a concerted effort to address the nation’s severe PPE shortage to protect its colleagues at the frontlines and to reduce the spread of this disease.

In March, ASPS leadership worked with the U.S. Surgeon General and White House officials to establish a PPE and ventilator clearinghouse that would help the Federal Emergency Management Agency (FEMA) collect and distribute much-needed supplies to first responders during the pandemic. The Society shared the PPE Clearinghouse with congressional offices as a resource to help local hospitals, nursing homes, and health systems request access to ventilators, N-95 masks, and other medical supplies. ASPS also collaborated with state plastic surgery and medical societies in Illinois, Michigan, New Jersey and New York, at the request of those states’ governors, to help direct supplies to localized needs. ASPS urged its members and industry to partners to provide ventilators to address the ventilator shortage due to the nation’s limited ventilator manufacturing supply chain.

In addition, to assisting state and federal authorities with the procurement process, the Society has urged Congress and the Administration to take additional action to bolster the nation’s PPE supply chain in the various COVID-19 relief packages. ASPS recognizes that the nation’s current supply chain is already in dire jeopardy and there needs to be immediate investments to ensure that medical professionals and patients have access to PPE supplies as more states lift stay-at-home orders. Without increased investments, the specialty has warned lawmakers about the consequences of reduced access to care not only for COVID-19 patients, but the health care industry in general.

ASPS is committed to partnering with local, state, and federal stakeholders throughout this pandemic to help saves lives and ensure continued access to care for patients across the nation. To learn more about ASPS’s Clearinghouse, we encourage you to visit their website here.

Specialty Spotlight ASRS: A Specialists View of the COVID-19 Pandemic

               

 

 

Earlier this spring, Dr. Lisa Olmos of the University of Washington sat down to discuss her experience with the COVID-19 pandemic in Seattle.

Her message to her fellow medical professionals is:

“Do not underestimate this disease. Be meticulous about protecting yourself, your patients, staff, and family. Try to think several steps ahead. If you wait for official guidelines, it may be too late.”

At the time of the interview, Lisa’s department had just moved to a surge planning triage system. To minimize time in the clinic and reduce exposure, retina specialists at the eye institute are each assigned 1 OR day and 1 clinic day. During their assigned days, they see their own urgently scheduled patients and any emergency triage patients, as well as perform emergency surgeries needed by the retina service.

UW Medicine had also just instituted a policy to require all surgery patients to have routine perioperative COVID-19 testing. UW Medicine is fortunate to have an excellent virology lab, and as a result access to testing with relatively rapid turnover is possible.  These new policies had been added in addition to previously enacted policies described below and, in the timeline, to protect patients and staff.

COVID-19 Sentinel Events

Lisa shared a series of sentinel events (see timeline) that shaped her views and UW Medicine’s policy and procedures. Seattle and its suburbs had some unfortunate firsts:

  • First US diagnosed US case on January 20th
  • First known US person to die from COVID-19 on February 29
  • First reported US cluster of cases on March 1 (Life Care Center of Kirkland)

While Washington State did not enact a shelter-in-place order until March 25, major employers (such as Microsoft and Amazon) had already instituted work at home policies and public and private schools had closed. These measures likely slowed the pandemic.

UW Medicine COVID-19 Policies

Being the epicenter of the US outbreak, UW Medicine was one of the first institutions to create a COVID-19 Command Center, which developed a series of policies (e.g., postponing all non-essential patient visits and surgeries, triaging high-risk patients).  Further the Department of Ophthalmology at UW swiftly assembled a COVID-19 Task Force, which created ophthalmology-specific guidelines for clinical care, such as mandating the use of surgical masks and slit lamp shields, and establishing policies to limit patient exposure in waiting and exam rooms to protect patients and staff.

In addition, the whole department was rapidly certified in telehealth through a UW online course. Telehealth will be used to screen patients at high risk and may be used for some post op care, at provider and patient’s discretion.  Retina clinic volume at UW Eye Institute, at the time of the interview, was down to approximately 20%, decreasing from approximately 300 scheduled patient visits per week to approximately 60. Some of this drop can be attributed to self-selection. Surgical cases have fallen about 50% from approximately 10 per week to about 5. One reason retinal surgery volume has not dropped as much as clinic volume is that, as an academic medical center, UW Medicine is a safety net for the community and does urgent retinal surgeries. It is also the only medical school and Level 1 trauma center in the 5-state region.

No ophthalmology faculty or staff have thus far tested positive for COVID-19.

Fellows

The department is trying to minimize retina fellows’ exposure, just as they are for faculty, with a new consolidated clinical schedule. The department’s 2 retina fellows are alternating call weeks. They assist in the OR, which helps cases go more efficiently with reduced operative time. Fellows are running some of the triage clinics and supervising some of the resident clinics with telephonic support from the entire retina faculty, and remote learning opportunities are being provided. Work on clinical research projects and case reports that can be performed remotely is encouraged.

Tips for Protecting Yourself and Your Family

To protect herself in clinic, Lisa wears hospital scrubs, puts her hair up in a bun and covers it with a disposable surgical cap, wears her glasses instead of her usual contact lenses in lieu of an eye shield, and wears a standard surgical mask.

Since the hospital is working to conserve personal protective equipment, Lisa switches her surgical mask half way through the day. At the end of the day, she disposes of her cap and mask, changes into street clothes and goes home. As soon as she gets home, she showers, then she sees her family.

In addition to recommending efficiency in the operating room to reduce operative time and avoiding general anesthesia wherever possible due to its aerosol generating properties, Lisa suggests using a draping pattern (long drape that directs everything to the end of the bed and floor) to reduce risk of exposure.

 

Covid-19 and Neurosurgery: Response, Adaptation and Action on Behalf of Our Patients

The COVID-19 pandemic is a generational event. It has disrupted every aspect of modern life. Businesses are shuttered. Schools and universities are closed. Social distancing has altered our normal mores for connecting with our neighbors, friends and colleagues. Although many in medicine are dramatically affected by the pandemic as they are on the ‘front lines’ of the crisis, the pandemic has had a ripple effect through the entire health care system.

Neurosurgery is no exception. The pandemic has been a significant disruption to the way neurosurgeons interact with and care for their patients. It has been remarkable how the medical community has come together and has been able to pivot on the spot to adjust the way we deliver care to our patients.

 

To explore and highlight the impact of the COVID-19 pandemic on the practice of neurosurgery, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) is releasing a series of articles in Neurosurgery Blog: More than Just Brain Surgery. A sample from this series includes:

We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.