Tagged CMS

Must-Reads Of The Week From Brianna Labuskes

Hello! It is once again Friday, which means I’m going to attempt to do my very best to give you a snapshot of some (read: a fraction) of the best stories from the week amid a flood of them.

But first! Take yourself on this journey about how the most well-known coronavirus image (that gray blob with stone-like texture and red crowns and colored flecks) was made. Sometimes when the government is creating informational illustrations it focuses on the vector or the symptoms, but for this coronavirus the CDC’s Alissa Eckert and Dan Higgins went with what’s called a “beauty shot.” It’s a very cool read!

All right, here we go:

The confirmed number of confirmed cases globally ticked past a million this week in a grim milestone that experts still say represents only a percentage of the actual cases out there. The U.S. had recorded over 250,000 cases as of press time, with more than 6,500 deaths.

President Donald Trump invoked his wartime powers to help manufacturers secure supplies needed to make ventilators and protective face masks, but is it too little, too late? New York Gov. Andrew Cuomo, whose state has become the epicenter of the nation’s outbreak, said on Thursday it will use up all available ventilators in less than a week. Meanwhile, FEMA said that most of the ventilators Trump promised to obtain won’t be ready until June.

Governors are distraught over their inability to obtain the needed supplies, likening the process of requesting the equipment to eBay auctions. “You now literally will have a company call you up and say, ‘Well, California just outbid you,’” Cuomo said.

Another roadblock is that 2,000 of the ventilators in the national stockpile are unusable because of a lapse in a contract that left a monthslong gap, during which the machines weren’t being properly maintained.

In the meantime, General Motors has shrugged off Trump’s attacks on the company (he said GM and its chief executive were dragging their feet on the project) and are moving full-throttle ahead at producing the needed equipment. “Every ventilator is a life,” said one GM exec.

With so much focus on ventilators, doctors are being advised on how to ration care and being told that they’ll be supported in their decisions not to perform futile intubations.

One quick note on that front: New York lawmakers are moving on legislation that would grant sweeping civil- and criminal-liability protections to hospitals and health care workers dealing with coronavirus patients.

And even though there’s a ton of attention on ventilators, the survival rate of any patient who requires one is only 20% — meaning that even without a shortage, they can only help a fraction of patients.

In other important news on the preparedness front:


Trump warned Americans this week that “hard days” lie ahead and that people should be braced for a “bad two weeks,” with the White House projecting that the death toll could be somewhere between 100,000 to 240,000. For what it’s worth, disease forecasters were mystified over where the task force got those numbers, mostly because we don’t yet know enough about the virus.

(What helped change Trump’s mind, considering he’d previously mused that the country could return to normal in time to fill the pews on Easter? Polling numbers.)

To help states deal with the crisis, CMS relaxed safety rules for hospitals, giving them unprecedented flexibility. The changes include what counts as a hospital bed, how closely certain medical professionals need to be supervised and what kinds of health care can be delivered at home.

The administration decided not to follow suit after a handful of states reopened their exchanges, though Trump seemed to hint that the possibility was still on the table “as a matter of fairness.” Also, to note, if people have lost their insurance because of their jobs, that counts as a qualifying event and they have 60 days to enroll in the federal exchanges, regardless of what Trump does with a special session.

And although Drs. Anthony Fauci and Deborah Birx, along with Vice President Mike Pence, have emerged as the leading voices of the administration’s pandemic response, Trump’s son-in-law Jared Kushner has taken charge behind the scenes. Critics say its adding confusion to an already chaotic situation.

And reports continue to emerge that the Trump administration was cutting pandemic detection positions in China just months before the outbreak.

In other news on the administration:


House Speaker Nancy Pelosi will be creating a special committee to oversee the implementation of the $2.2 trillion stimulus package and any other coronavirus legislation coming down the pike. “Where there’s money there’s also frequently mischief,” Pelosi said, in perhaps one of my favorite quotes of the week. Meanwhile, House Democrats may be raring to get started on a fourth stimulus package, but Republicans are pumping the brakes. At the very least, they say, they want to see how the current stimulus package plays out.

The news came the same day as it was reported that 6.6 million Americans filed for unemployment benefits. That eye-popping number blows past all previous records. And experts say it represents only a sliver of the economic devastation the virus is wreaking on the country. There are many affected Americans who remain uncounted — some have lost jobs or income and did not initially qualify for benefits, and others, encountering state unemployment offices that were overwhelmed by the deluge of claimants, were unsuccessful in filing.

In other news about Congress and the economic damage from the outbreak:


The Democratic National Convention, expected to draw as many as 50,000 visitors, was postponed from July to August in one of the largest disruptions to the 2020 elections so far. On the other hand, Wisconsin is going ahead with its primary on Tuesday, which is causing mixed reactions … including apoplectic rage.

More stories on elections:


Much focus this week was on serology tests that serve the dual purpose of finding Americans who can safely return to some normalcy and helping researchers find treatments for COVID-19. Experts are fairly unified on the fact that to get the country back into operation, we need a way to identify those who are now immune to the disease. And using plasma collected from recovered patients is a century-old practice (which, to be clear, has had mixed results in past diseases).

Beyond studies on actually treating the coronavirus illness (a small study out this week showed a much-touted malaria drug combo had positive results), doctors are also trying to figure out how to treat the phenomenon known as “cytokine storm,” in which the body’s own immune system attacks its organs. This is thought to be the cause of some of the severe cases seen in younger patients.

On a side note, the Food and Drug Administration on Sunday issued an emergency-use authorization for hydroxychloroquine and chloroquine, despite scant evidence that they work against COVID-19.


With Florida (and three other states who had been hesitating) finally caving into pressure to issue the stay-at-home order, the vast majority of Americans are now huddled at home. The good news is that the extreme measures seem to be working in California, which was an earlier disciple of flattening the curve.

Google, meanwhile, is offering the government a report on “mobility data” to help states recognize where social-distancing measures are failing, with a specific focus on how foot traffic has increased or declined to six categories of destinations: homes; workplaces; retail and recreation establishments; parks; grocery stores and pharmacies; and transit stations.

Although things might seem a bit grim right now because of these measures, a look at data from the 1918 flu pandemic shows cities that locked down emerged from the crisis stronger economically than those that didn’t. One caveat, though: Because working-age people were harder hit by the 1918 flu (and the coronavirus strikes worse among older generations), any comparisons might not hold.


So, onto some of the stories I find most fascinating … aka the science behind all of this.


I’m going to cut this off here, or else this will no longer be able to be called the Breeze. If you want a more comprehensive roundup, please check out the Morning Briefings from the week, which are chock-full of more stories than you could ever finish reading. Including ones on workers’ protests and the supply chain; the gun store debate; how jails are “ticking time bombs;” autocrats’ power grab; snapshots from a New York in crisis; health disparities; and a call to arms for medical workers that doesn’t guarantee coverage of potential hospital bills.

Please have a safe and restful weekend, if possible!

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Global Health Watch

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Among other sweeping changes:

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

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

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Health Industry Public Health States

The Nation’s 5,000 Outpatient Surgery Centers Could Help With The COVID-19 Overflow

As the number of COVID-19 cases continues to rise, a group of anesthesiologists wants to convert America’s surgery centers into critical care units for infected patients.

Many of the country’s more than 5,000 outpatient surgery centers have closed or sharply cut back on the number of elective procedures they perform, to comply with requests from government agencies and professional societies. But those surgery centers have space and staff, as well as anesthesia machines that could be repurposed into ventilators — all of which could be especially crucial in hard-hit areas like New York.

“Half of the surgery centers in New York are not doing anything,” said Adam Schlifke, an anesthesiologist and clinical assistant professor at Stanford University in California, who is leading the push for the centers to help. “All these anesthesiologists and nurses who are sitting on the sidelines, they want to help. They don’t know how to help. There’s nowhere for them to help. What if they could work in the surgery centers?”

Opening such outpatient centers nationwide to coronavirus patients would nearly double the number of facilities nationwide, up from the country’s fewer than 6,200 hospitals. But turning day facilities into places for 24/7 care worries some anesthesiologists. There are questions about staffing, regulations and payment. They also fear that using surgery centers as critical care units would do more harm than good if the centers aren’t properly equipped to handle severe cases of COVID-19.

“Even if we lifted the regulatory restrictions, surgery centers are licensed to do a certain thing,” said Dr. Steven Dalbec, a private practice anesthesiologist in Columbia, Missouri, who once ran a surgery center in Arizona. “If we could say, ‘OK, we’re going to lift all those restrictions and let you take care of critically ill patients,’ it’s not something that could happen overnight.”

Still, that’s exactly why Schlifke argues that it’s important to start now, especially in parts of the country with fewer cases. His group has created a blueprint that outlines the steps needed for surgery centers to convert.

In the coming days, Schlifke said, he and the approximately 75 members of the CovidVent coalition of anesthesiologists he’s helping organize will call for a federal executive order to enable the conversion of surgery centers and hospital operating rooms into COVID-19 care sites to help save lives.

The order is needed, he said, because he recognizes that providers want to get paid. The idea is so new, he said, there’s no reimbursement plan in place for surgery centers that agree to treat COVID-19 patients.

What’s most troubling, Schlifke said, is the number of anesthesiologists who cannot help with the pandemic because their center is either closed or they are busy with elective surgeries that aren’t necessary. It’s a frustrating dilemma.

“They want to work,” Schlifke said.

The CovidVent group also wants to make sure surgery centers follow Centers for Medicare & Medicaid Services recommendations that call for them to end nonessential elective surgeries to keep front-line medical providers safe amid shortages of protective supplies such as masks. Many of those surgery centers are in states like New York, California and Washington where hospitals can’t keep up with the demand.

“An important question for hospitals and health systems that continue to perform elective and nonessential surgeries is, ‘Why?’” said Dr. Greg Martin, president-elect of the Society of Critical Care Medicine, which represents intensive care doctors. “How do they justify the risk to the otherwise healthy individuals, justify the risk to the health care provider workforce who may be imminently needed elsewhere, and justify the unnecessary consumption of health care resources such as masks, gloves and gowns?”

But William Prentice, CEO of the Ambulatory Surgery Center Association, an industry group, argued that some surgeries remain necessary. “We’re pushing things off that can be pushed off,” he said.

Meanwhile, in Washington, D.C., Vice President Mike Pence has already come out in support of the use of anesthesiology equipment as ventilators.

Anesthesia machines used in the operating room can be repurposed as mechanical ventilators, Martin said. “But they function differently and do not have all the same settings as ICU ventilators, so employing them in COVID-19 care requires education or oversight from those who are expert in using them.”

Dalbec also supports converting anesthesia machines into ventilators. He now works at Boone Hospital Center in Columbia, Missouri, which he said is prepared to do that if needed. As of Friday, he said, the 230-bed hospital hasn’t treated a confirmed COVID-19 patient.

But creating new intensive care units is challenging, according to both Dalbec and Martin.

Dalbec, who ran a surgery center in Tucson, Arizona, for 10 years, worries a lot of surgery centers don’t have the training, skills or supplies to care for critically ill patients.

“Time is of the essence,” Dalbec said. “And so that would make the care for these patients considerably challenging.”

An ICU has sophisticated equipment, such as bedside machines to monitor a patient’s heart rate and mechanical ventilators to help them breathe, Martin said. Ventilators need to be hooked up to oxygen and gas lines, which supply patients with the appropriate mix of air.

Only a few areas of the hospital have the equipment and gas hookups to provide ventilator care to critically ill patients, Martin said. These include the operating room, emergency department and units used for post-anesthesia care. To convert an ordinary hospital unit to an ICU, Martin said, “You would literally need to tear down the wall and run the piping in.”

Hospitals are already looking to use operating rooms for intensive care, Martin said.

“Using OR space, equipment and staff to care for sick COVID-19 patients is the right thing to do,” Martin said. “This is one approach that most health systems are already considering and using.”

Many outpatient operating rooms at surgery centers already have the required gas and oxygen hookups, Martin said. “Some will have fully configured operating rooms with ventilators,” he said. “It would be one way to expand ICU-level patient care space.”

But they are unlikely to stock all the medications used in an ICU.

Another challenge, he said, would be that staff from most surgery centers may be pulled into hospitals — anesthesiologists, nurses and nurse anesthetists — and surgery centers would not have all the pharmacists, respiratory therapists and other staff.

Intensive care units are staffed by specially trained doctors, nurses and respiratory therapists, who set up ventilators and closely monitor patients’ breathing, Martin said. “The hardest thing to change is the staffing,” he said. “We only have a certain number of doctors, nurses and respiratory therapists.”

CovidVent is working with several telemedicine groups that could help treat patients in areas where the staff lacks the expertise, Schlifke said.

Outpatient surgery centers would need to receive a waiver from federal regulators to keep patients overnight or perform medical care they don’t currently perform, Prentice said.

Prentice said he’s optimistic that the Centers for Medicare & Medicaid Services will make an announcement about such waivers in coming days.

“Once we get that flexibility, we can find the best way to help,” Prentice said. “Decisions about how to best to use ambulatory surgery centers need to be made in conjunction with hospitals at the local level.”

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California Health Industry Public Health States