Tagged Global Health Watch

To Curb Coronavirus, What’s Behind The Wearing Of A Mask?

The Centers for Disease Control and Prevention on Friday recommended wearing cloth face masks when going out, especially to places like grocery stores and pharmacies.

That’s because a “significant portion” of people with the virus lack symptoms or can transmit the disease through close contact before they show signs of illness, the CDC said. It is not recommending people try to purchase N95 or surgical masks, and the federal agency included online instructions on making masks out of materials at home.

The recommendation is optional. President Donald Trump, for instance, said he didn’t envision wearing one. But in recent days, the number of people sporting some type of protective face gear appears to have soared.

So what gives?

Many experts agree that wearing a mask probably won’t keep people from getting the coronavirus, but it might help prevent those with the disease — especially those without symptoms ― from spreading it.

The CDC’s announcement — which came after days of deliberation among White House officials, the coronavirus task force and other public health figures about the need for such a guideline — brings with it caution.

First, masks could give people a false sense of security.

“We don’t want people to feel like, ‘Oh, I’m wearing a mask. I’m protected and I’m protecting others,’” said Dr. Deborah Birx, during a White House briefing last week before the CDC issued its recommendation. Birx, a member of the president’s coronavirus task force, made clear that wearing a mask would not replace the need for frequent hand-washing and continued social distancing.

Another concern is that the recommendation could further strain the supply of medical-grade masks for health care workers, if consumers flooded the market to get their hands on one. Earlier statements from U.S. officials downplayed the use of face masks in public, in part for this reason.

But those messages ran counter to what other countries ― particularly in Asia — have recommended or required. Face masks have been ubiquitous in countries such as China, South Korea and Japan during the outbreak.

Before the CDC recommendation, residents in some hard-hit American cities, such as Los Angeles and New York, were encouraged to wear masks in public. Riverside County in Southern California mandated it.

Another issue: Homemade masks — and some store-bought ones ― don’t fit as tightly as medical masks.

“Virus can sneak around the edges,” said Melissa Perry, a professor of environmental and occupational health at George Washington University in Washington, D.C.

There’s also the matter of the fabric.

“What I see are people buying masks on the web that are fashionable, but the fabric is thin,” said John Lednicky, an aerovirologist at the University of Florida, who studies how viruses spread through the air. “If the weave is not tight enough, the virus will go right through them.”

Still, he said, a homemade mask “is better than nothing” if it could block some particles expelled by an infected person. But he cautioned that a mask protects only the nose and mouth areas. Another route of transmission is through the eyes. So, again, don’t touch your face or rub your eyes if possible.

Might eyeglasses add protection from particles?

“There’s some protection from eyeglasses, but there’s a lot of space around eyeglasses, so air currents can still hit your eyes,” he said.

And one more caution: “When putting it on and taking it off, you have to be careful. You might end up getting virus all over your hands,” said Marcus Plescia, chief medical officer with the Association of State and Territorial Health Officials. “Discard it carefully.”

If it’s made of fabric, wash it. If it’s paper or some other material, put it in a sealed plastic bag and throw it away. Wash your hands after.

Transmission Out Of Thin Air?

Researchers are debating whether simply talking or breathing can send tiny virus particles airborne ― and whether those bits would be in great enough quantity to allow for transmission to another person.

This critical question has no clear answer.

No doubt a cough or sneeze can shoot out droplets several feet, but those are relatively large and heavy and quickly fall to the ground, researchers say. Still, that’s a main route of transmission because the droplets can either land on a close contact — defined by the World Health Organization as within 1 meter ― or fall on surfaces, which other people then touch, possibly picking up the virus.

Staying 6 feet away from others and washing your hands a lot helps reduce the risk packed by droplets.

But what about smaller particles — those aerosols created simply by exhaling that can float in the air longer?

Evidence is not clear.

A special panel last week released a report reviewing studies from the U.S. and China, raising the possibility of airborne transmission. The studies’ findings suggest that normal breathing can release aerosolized virus, according to the letter from a special pandemic committee at the National Academy of Sciences to the head of the White House’s Office of Science and Technology Policy.

But, the committee added, “one must be cautious,” because what the studies found may not represent “viable virus in sufficient amounts to produce infection.”

The WHO, in a March 20 report, took a more cautious approach, saying there isn’t enough information to say such tiny particles are airborne outside of medical settings.

Aerosols containing the virus can occur during some medical procedures, such as ventilating a patient, the WHO said, which puts health care workers at risk. Further study is needed, the report concluded, to see if the virus shows up in air samples in patient rooms where no such procedures took place and “whether viable virus is found and what role it may play in transmission.”

Given the uncertainty, the bottom line, Lednicky and others said, is to avoid close contact and take other reasonable protective steps.

Masks are good to ensure that you are not transmitting the virus to others. But don’t forget about that 6-foot zone of personal space.

How Does This Translate To Everyday Life?

Experts agree that in the midst of this pandemic ― while people are encouraged to stay at home and isolate — it’s still important for physical and mental health to get exercise by walking or running. But what happens when you cross paths with another person, who may not be wearing a mask?

“More distance is better no matter what,” said Dr. Georges Benjamin, executive director of the American Public Health Association, who said there is only a small likelihood that you are running through a mist that might contain the virus.

“If you want to hold your breath [while passing near others], fine, but it’s probably not necessary,” he said.

And then there’s your neighbor’s friendly dog. Researchers don’t believe pets can transmit the disease. Still, to protect the pet, they suggest that those who are sick to avoid caring for or sharing their food with the animal, said Benjamin. Because keeping a proper distance from your neighbor is also key, it might be a good idea to skip the dog-petting.

“I would just say ‘Hi’ right now,” said Benjamin.

Overall, most health officials appear to consider masks a good idea. But they agree on three constants in this quickly changing matter: Keep your distance from others outside your household. Wash your hands ― often. And don’t touch your face.

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Global Health Watch Public Health

After COVID-19: Doctors Ponder Best Advice As Patients Recover From Coronavirus

When David Vega fell ill with the novel coronavirus in mid-March, fever, chills and nausea left the 27-year-old Indiana medical student curled up in bed for days.

After a test confirmed he had COVID-19, the disease caused by the coronavirus, his doctor advised Vega to isolate himself at home for an additional week. The week passed, and Vega improved. His doctor cleared him to get back to his regular routines without additional testing after he had gone three days without symptoms.

But getting an all-clear from his medical provider has not completely assuaged Vega’s fears. How can he be sure he no longer carries the virus? Is it safe for him to be with others? One of his roommates decided to move out, he said, and still acts cautiously around him.

“Even after the quarantine was over and I felt recovered,” he said in a message, “I felt paranoid and very [conscious] of the fact that I had COVID-19.”

As with so many other aspects of this novel coronavirus, determining when a patient has recovered is still fraught with uncertainties. Although federal officials have issued general guidelines, information about the disease is limited. Physicians said they can’t offer seemingly recovered patients who aren’t retested any guarantees about whether they will be able to transmit the virus.

“I feel that the public is kind of like my 91-year-old mom,” said Dr. Gary LeRoy, president of the American Academy of Family Physicians. The public is “asking these questions, and we as clinicians don’t have the answers like we’re used to.”

This predicament highlights how scientists still lack a complete picture of how COVID-19 is transmitted, doctors said. Generating more data on such mysteries as how much of the virus a person emits at different stages of infection could give doctors a clearer sense of a patient’s risk of sickening others.

The federal Centers for Disease Control and Prevention says doctors can verify whether a patient is healthy enough to leave home isolation in two ways. One method requires patients to test negative from samples taken at least 24 hours apart.

But the nationwide shortage of tests has made it difficult for doctors to vet patients in recovery with an exam, a fact the guidelines acknowledged. Several states including Minnesota have restricted testing to certain populations, such as hospitalized patients and health care workers.

“It’s still kind of an Easter egg hunt for the availability of testing materials and test kits to do COVID-19 tests,” said LeRoy.

The second method allows patients to come out of isolation at least seven days after symptoms begin or after being diagnosed and three days after they are symptom-free.

This option “will prevent most, but may not prevent all instances of secondary spread,” according to the CDC’s website. “The risk of transmission after recovery is likely very substantially less than that during illness.”

The agency declined a request for an interview.

Its recommendation gives state authorities and doctors the flexibility to amend their approach based on their circumstances.

“The guidelines are guidelines,” said Dr. Kathryn Edwards, a professor of pediatrics at Vanderbilt University who specializes in infectious diseases. “But they’re not the Ten Commandments.”

One vital piece of the recovery puzzle several doctors mentioned is figuring out when and how long people with COVID-19 are able to transmit the virus — particularly those who don’t develop symptoms at all.

David Vega, a medical student in Indianapolis who has recuperated from a COVID-19 infection, worries about how safe it is to be around others now, such as when he goes running or grocery shopping. “I think it’s still something in the back of my mind,” he says.(Courtesy of David Vega)

The number of asymptomatic patients could be sizable. CDC director Dr. Robert Redfield said in an interview with NPR that as many as 25% of those who test positive for the virus do not develop symptoms. And patients who eventually develop symptoms may be spreading the virus up to 48 hours before they start feeling ill, he added.

Early research has suggested that patients who have recovered from COVID-19 may also continue to spread the virus.

Even Vega, now symptom-free, said he hesitates to get close to others when he goes on a run or picks up groceries.

“I think it’s still something in the back of my mind,” he said. “I think that it’ll get better with time.”

The need to prevent transmission must be balanced against the benefit of the person returning to their daily life, said Edwards, especially if they are working in an essential industry like health care.

“We’re always between a rock and a hard place,” she said.

Other factors help determine when a patient is ready to leave isolation. A provider may choose to leave a person in home isolation longer if they work with a high-risk population, like the elderly, or if they have a spouse with preexisting conditions, said LeRoy.

Ultimately, medical providers will likely tailor their advice to the patient’s lifestyle, said Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials.

“These are difficult questions that would likely be dealt with on a case-by-case basis,” he said.

People worried about getting the virus from someone who has recovered or doesn’t have symptoms can reduce their risk by practicing social distancing and good hygiene, such as frequent hand-washing, said Plescia.

Despite the uncertainty, Plescia said, it is important not to ostracize those who have recovered. He is concerned they could become stigmatized.

“In the back of everyone’s mind, whether they want to acknowledge it or not, people are going to be fearful about something they don’t know,” said LeRoy.

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Global Health Watch Public Health

Global Health Watch: China Tries To Control Death Toll Narrative; Italy Starts Talking About How To Re-Open

Mysterious Heart Damage, Not Just Lung Troubles, Befalling COVID-19 Patients

While the focus of the COVID-19 pandemic has been on respiratory problems and securing enough ventilators, doctors on the front lines are grappling with a new medical mystery.

In addition to lung damage, many COVID-19 patients are also developing heart problems — and dying of cardiac arrest.

As more data comes in from China and Italy, as well as Washington state and New York, more cardiac experts are coming to believe the COVID-19 virus can infect the heart muscle. An initial study found cardiac damage in as many as 1 in 5 patients, leading to heart failure and death even among those who show no signs of respiratory distress.

That could change the way doctors and hospitals need to think about patients, particularly in the early stages of illness. It also could open up a second front in the battle against the COVID-19 pandemic, with a need for new precautions in people with preexisting heart problems, new demands for equipment and, ultimately, new treatment plans for damaged hearts among those who survive.

“It’s extremely important to answer the question: Is their heart being affected by the virus and can we do something about it?” said Dr. Ulrich Jorde, the head of heart failure, cardiac transplantation and mechanical circulatory support for the Montefiore Health System in New York City. “This may save many lives in the end.”

Virus Or Illness?

The question of whether the emerging heart problems are caused by the virus itself or are a byproduct of the body’s reaction to it has become one of the critical unknowns facing doctors as they race to understand the novel illness. Determining how the virus affects the heart is difficult, in part, because severe illness alone can influence heart health.

“Someone who’s dying from a bad pneumonia will ultimately die because the heart stops,” said Dr. Robert Bonow, a professor of cardiology at the Northwestern University Feinberg School of Medicine and editor of the medical journal JAMA Cardiology. “You can’t get enough oxygen into your system and things go haywire.”

But Bonow and many other cardiac specialists believe a COVID-19 infection could lead to damage to the heart in four or five ways. Some patients, they say, might be affected by more than one of those pathways at once.

Doctors have long known that any serious medical event, even something as straightforward as hip surgery, can create enough stress to damage the heart. Moreover, a condition like pneumonia can cause widespread inflammation in the body. That, in turn, can lead to plaque in arteries becoming unstable, causing heart attacks. Inflammation can also cause a condition known as myocarditis, which can lead to the weakening of the heart muscle and, ultimately, heart failure.

But Bonow said the damage observed in COVID-19 patients could be from the virus directly infecting the heart muscle. Initial research suggests the coronavirus attaches to certain receptors in the lungs, and those same receptors are found in heart muscle as well.

Initial Data From China

In March, doctors from China published two studies that gave the first glimpse at how prevalent cardiac problems were among patients with COVID-19 illness. The larger of the two studies looked at 416 hospitalized patients. The researchers found that 19% showed signs of heart damage. And those who did were significantly more likely to die: 51% of those with heart damage died versus 4.5% who did not have it.

Patients who had heart disease before their coronavirus infections were much more likely to show heart damage afterward. But some patients with no previous heart disease also showed signs of cardiac damage. In fact, patients with no preexisting heart conditions who incurred heart damage during their infection were more likely to die than patients with previous heart disease but no COVID-19-induced cardiac damage.

It’s unclear why some patients experience more cardiac effects than others. Bonow said that could be due to a genetic predisposition or it could be because they’re exposed to higher viral loads.

Those uncertainties underscore the need for closer monitoring of cardiac markers in COVID-19 patients, Jorde said. If doctors in New York, Washington state and other hot spots can start to tease out how the virus is affecting the heart, they may be able to provide a risk score or other guidance to help clinicians manage COVID-19 patients in other parts of the country.

“We have to assume, maybe, that the virus affects the heart directly,” Jorde said. “But it’s essential to find out.”

Facing Obstacles

Gathering the data to do so amid the crisis, however, can be difficult. Ideally, doctors would take biopsies of the heart to determine whether the heart muscle is infected with the virus.

But COVID-19 patients are often so sick it’s difficult for them to undergo invasive procedures. And more testing could expose additional health care workers to the virus. Many hospitals aren’t using electrocardiograms on patients in isolation to avoid bringing additional staff into the room and using up limited masks or other protective equipment.

Still, Dr. Sahil Parikh, an interventional cardiologist at Columbia University Irving Medical Center in New York City, said hospitals are making a concerted effort to order the tests needed and to enter findings in medical records so they can sort out what’s going on with the heart.

“We all recognize that because we’re at the leading edge, for better or for worse, we need to try to compile information and use it to help advance the field,” he said.

Indeed, despite the surge in patients, doctors continue to gather data, compile trends and publish their findings in near real time. Parikh and several colleagues recently penned a compilation of what’s known about cardiac complications of COVID-19, making the article available online immediately and adding new findings before the article comes out in print.

Cardiologists in New York, New Jersey and Connecticut are sharing the latest COVID-19 information through a WhatsApp group that has at least 150 members. And even as New York hospitals are operating under crisis conditions, doctors are testing new drugs and treatments in clinical trials to ensure that what they have learned about the coronavirus can be shared elsewhere with scientific validity.

That work has already resulted in changes in the way hospitals deal with the cardiac implications of COVID-19. Doctors have found that the infection can mimic a heart attack. They have taken patients to the cardiac catheterization lab to clear a suspected blockage, only to find the patient wasn’t really experiencing a heart attack but had COVID-19.

For years, hospitals have rushed suspected heart attack patients directly to the catheterization lab, bypassing the emergency room, in an effort to shorten the time from when the patient enters the door to when doctors can clear the blockage with a balloon. Door-to-balloon time had become an important measure of how well hospitals treat heart attacks.

“We’re taking a step back from that now and thinking about having patients brought to the emergency department so they can get evaluated briefly, so that we could determine: Is this somebody who’s really at high risk for COVID-19?” Parikh said. “And is this manifestation that we’re calling a heart attack really a heart attack?”

New protocols now include bringing in a cardiologist and getting an EKG or an ultrasound to confirm a blockage.

“We’re doing that in large measure to protect the patient from what would be an otherwise unnecessary procedure,” Parikh said, “But also to help us decide which sort of level of personal protective equipment we would employ in the cath lab.”

Sorting out how the virus affects the heart should help doctors determine which therapies to pursue to keep patients alive.

Jorde said that after COVID-19 patients recover, they could have long-term effects from such heart damage. But, he said, treatments exist for various forms of heart damage that should be effective once the viral infection has cleared.

Still, that could require another wave of widespread health care demands after the pandemic has calmed.

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Global Health Watch Public Health States

Trump Administration Uses Wartime Powers To Be First In Line On Medical Supplies

The Trump administration quietly invoked the Defense Production Act to force medical suppliers in Texas and Colorado to sell to it first — ahead of states, hospitals or foreign countries.

It took this action more than a week before it announced Thursday that it would use the little-known aspect of the law to force 3M to fill its contract to the U.S. first. Firms face fines or jail time if they don’t comply.

The Cold War-era law gives federal officials the power to edge out the competition and force contractors to provide supplies to them before filling orders for other customers.

While it’s unclear how many times the power has been used during the coronavirus pandemic, federal contracting records examined by Kaiser Health News show that federal authorities staked first rights to $137 million in medical supplies. The orders in late March flew under the radar, even as dog-eat-dog bidding wars raged among states and nations for desperately needed medical protective gear.

“It’s like ‘Lord of the Flies’ out there for states and hospitals as they bid against each other for critical medical supplies and equipment,” Sen. Chris Murphy (D-Conn.) said in a statement to KHN. “Plus, there’s no transparency about what the federal government is doing with the equipment that they purchase when they outbid states and hospitals.”

Without public awareness of what was taken on a federal-first basis — and who it was given to — the states are left in the dark after being told repeatedly to procure their own goods. The federal government, President Donald Trump has said, is not the states’ “shipping clerk.”

“It’s putting people into the free market where the invisible hand doesn’t care who it strangles,” said Arthur Caplan, director of the division of medical ethics at New York University School of Medicine.

Trump enacted the first-in-line power of the DPA for the Health and Human Services Department in an executive order on March 18 — and nine days later extended the power to the Department of Homeland Security, which includes the Federal Emergency Management Agency.

On Thursday at his White House press briefing, Trump announced he had invoked the DPA “against” 3M. His executive order states that the government “shall use any and all authority available under the Act to acquire … the number of N-95 respirators that the Administrator determines to be appropriate.”

“We hit 3M hard today after seeing what they were doing with their Masks. ‘P Act’ all the way,” the president tweeted. “Big surprise to many in government as to what they were doing – will have a big price to pay!”

While the administration had asked the company to stop exporting respirators to the Latin American and Canadian markets, 3M stated in a press release Friday there would be humanitarian implications, since the company supplies a critical amount of those countries’ N95 masks. 3M also warned such a move could create a potential trade war where other countries then refuse to sell N95s to the U.S., potentially resulting in fewer N95s in the United States.

When federal authorities use the DPA to seek a so-called rated order, it relieves companies from having to decide which state or hospital or foreign government gets the goods first, said Eric Crusius, a partner at the Washington, D.C., firm Holland & Knight and a contract law specialist. It makes things simple — the federal government’s order is filled first.

The defense law was cited in contracts for an estimated $54 million in medical supplies from Colorado-based Marathon Medical Corp., a medical supply distributor, and an estimated $84 million from Texas-based Retractable Technologies Inc., which makes retractable needles.

A woman who answered the phone at Marathon Medical declined to give her name and said the company policy is not to talk to the media. Officials for RTI, contacted by phone and email, did not respond by press time.

Contracts show that federal HHS officials also invoked their right to be first in line for an estimated $13.5 million in goods produced by New Jersey-based health care products manufacturer and supplier Becton, Dickinson and Co.

A modification to that contract signed March 23 says it applies to “medical and surgical instruments, equipment and supplies” and cites “delegation of authority” under the Defense Production Act “ordered by President Donald J. Trump in response to” the threat of the coronavirus. It’s not clear what product officials ordered from the company.

Becton, Dickinson and Co. told KHN on Thursday that the contract had been modified — again — so that the Defense Production Act was not invoked. Because there is a lag in federal contract disclosures, it’s possible that the contracts for Retractable Technologies and Marathon Medical also have been modified.

All three records name the contract-awarding agency as the HHS Office of the Assistant Secretary for Preparedness and Response and note: “Only the agency awarding the contract may place orders.”

When federal officials made a similar move in Massachusetts, it took state leaders by surprise. Marylou Sudders, who leads the state coronavirus command center, said an order of 400 masks from MSC Industrial Supply was canceled abruptly due to federal intervention, according to a report in The Boston Globe.

MSC spokesperson Paul Mason told KHN that the Defense Production Act compelled his company to put federal orders first.

That cancellation and a similar seizure of goods sowed so much distrust in Massachusetts that the New England Patriots sent a team plane to ship personal protective gear from China, according to The Boston Globe.

Officials from the White House and FEMA declined to directly answer questions about the use of the 1950 law to put the feds first in line for goods. HHS provided a statement saying the Defense Production Act is “an important tool that may be used when necessary to ensure needed supplies are available and going where they are most urgently needed. HHS and FEMA are and will continue working with the private sector and States to increase supply and allocate needed PPE.”

Top Democratic leaders and even a Republican governor were clamoring for a change in how the market was run in recent weeks, as health care workers warned against being sent out to the coronavirus front lines without proper supplies.

In a letter to the president Thursday, Senate Minority Leader Chuck Schumer called for strong federal intervention and leadership on the issue, citing the need for a military logistician to run such a response.

“While you continue to dismiss the Defense Production Act as not being needed, it is clear that the capacity of American industry has not yet been fully harnessed,” Schumer’s letter says.

Trump fired back with his own letter that evening, stating that Navy Rear Adm. John Polowczyk, currently serving as the leader of FEMA’s supply chain task force, was in charge of “purchasing, distributing, etc.”

“The Defense Production Act (DPA) has been consistently used by my team and me for the purchase of billions of dollars’ worth of equipment, medical supplies, ventilators, and other related items,” he wrote. “It has been powerful leverage, so powerful that companies generally do whatever we are asking, without even a formal notice.”

But if the government is going to take more control — which many health and government leaders have urged it to do — it should be transparent about its actions, said Dr. Atul Grover, executive vice president of the Association of American Medical Colleges. He said medical leaders have been whiplashed by their orders for protective gear falling through and speculated that they lost out to federal agencies.

Some institutions “fully expected to be able to purchase [personal protective equipment] from contractors who then turned around and said, ‘No, we’re going with another buyer instead,’” he said.

When asked about this phenomenon during Thursday’s national briefing, Trump said the governments could work it out.

“If you think there is bidding between federal government and state, let us know and we’ll drop out immediately,” Trump said. “There are 151 countries that have this problem, and they’re ordering, too. It’s really a mess.”

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Global Health Watch Health Industry Public Health

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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Keeping Supply Chain Flowing: Truckers Across Globe Hit Roadblocks As Some Governments Step In To Help Them

Fox News’ Jesse Watters Said Travel Bans ‘More Critical In Saving Lives’ Than COVID Testing. He’s Wrong.

Defending President Donald Trump’s coronavirus response, Fox News commentator Jesse Watters highlighted federal efforts to restrict international travelers who may be infected — a ban he claimed mattered more than diagnostic testing.

“We were slow with the testing, but very quick with the travel ban. And that’s been much more critical in saving lives,” Watters said during a March 31 episode of “The Five.”

The administration has attracted stinging criticism from public health experts and state officials, who say the dearth of COVID-19 tests has made it impossible to get a handle on the disease’s spread. But the impact of the restrictions Trump imposed ― on people traveling from China and, by March, Europe — is another story.

So we decided to dig in. We contacted Fox News to find out the evidence on which Watters based his comment but did not hear back.

Early on, those restrictions won plaudits. After the March restrictions were announced, Dr. Anthony Fauci, who heads the National Institute of Allergy and Infectious Diseases and is a member of the White House coronavirus task force, said there was “compelling evidence” to justify restricting travel from those high-infection areas.

But the implementation is another story. Global health specialists told us there is little to no evidence that Trump’s restrictions have restrained COVID-19 ― they came too late and didn’t have the follow-up necessary to make a real dent. By contrast, they said, better and earlier testing could have saved countless lives.

The Wrong Approach At The Wrong Time

Targeted, quick travel restrictions can be part of the public health arsenal to control the spread of an illness such as COVID-19.

The idea is to stop people in hot spots from carrying the virus to uninfected areas. The restrictions also tamp down the risk that an infected traveler will expose others in the closed quarters of an airport, airplane or other mode of transportation.

But the experts we spoke to made clear that these restrictions can work only as one (smaller) part of a comprehensive strategy. Without other aggressive public health measures, they would have little value. The timing of American restrictions — and how they interacted with other domestic efforts ― rendered them ineffective.

The administration’s first coronavirus-related travel restrictions took effect Feb. 2, targeting noncitizens who had recently traveled to or from China. On Feb. 29, it took similar steps with people who had traveled to or from Iran.

For context, the incidence of a severe respiratory illness began to emerge in China late last year. These cases were confirmed to be a novel coronavirus by Jan. 7, and the first American case was reported Jan. 20 — almost two weeks before any travel restrictions were in effect.

Expanded travel restrictions took effect March 13 and 16 to include people in Europe, including the United Kingdom and Ireland.

Experts told us those measures represented the wrong approach at the wrong time.

“When the travel ban was put in place, the risk of importation from China was quite small,” said William Hanage, an associate professor of epidemiology at the Harvard T.H. Chan School of Public Health.

For one thing, China had also put in place its own limitations on travel ― limiting travel to and from Wuhan starting Jan. 23. And, by then, there were already several cases of COVID-19 across the United States and in other countries that had not been targeted by restrictions.

And while European cases shot up in early March — particularly in Italy ― even those travel restrictions were misplaced, Hanage said. At that point, Americans already faced a domestic threat from the virus.

So was the administration “very quick” with a travel ban? Not really.

If anything, the travel limitations gave people “a false sense that something with a big impact was being done,” said Jennifer Kates, a vice president and global health expert at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

That false security, others said, distracted from the reality that more essential precautions weren’t in place.

Limited Effectiveness Without Widespread Testing

Well-implemented travel restrictions can buy time on the margins, research suggests. But that time has to be used effectively — to ramp up emergency preparedness and bolster activities like testing and isolating people who may have been exposed.

And there is no way to know if the administration’s initial travel restriction ― barring people who had been to China — reduced the spread of the coronavirus.

That’s because the administration limited testing for the virus to people who were sick enough to be hospitalized or who had been to Wuhan recently. Those are people with a heightened risk of exposure and not representative of the broader swath of people affected by the travel limitations, said Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security.

“Had we expanded testing during this time and still found few cases, I would be more convinced that the travel ban had an impact. But we didn’t.”

Available research on travel bans isn’t promising, either.

A March 20 analysis run by Think Global Health, a project of the Council on Foreign Relations, compared countries that did and didn’t restrict travel with China. The researchers found no correlation between travel restrictions and preventing a pandemic outbreak.

“The combination of the travel restrictions within China and international travel restrictions against China may have delayed the spread of COVID-19, but more so in nations that used that time to reduce community spread of the virus,” the researchers wrote.

That last part is crucial ― travel restrictions may have bought time, but that mattered only if countries actively fought domestic spread.

Other research backs that up. A paper published in Science last month found that when China imposed its own travel restrictions, it made only a modest difference in curbing the spread of the coronavirus, both domestically and to other countries — at most, buying a few days’ time. And, this paper also notes, travel restrictions were effective only when coupled with other efforts to halt transmission.

By contrast, researchers were unanimous in noting the effectiveness of robust testing of people who may have been exposed — and then isolating those who test positive for the virus. This test-and-quarantine approach has been proven effective in South Korea, which experienced its first case on the same day as in the U.S. but where the number of new COVID-19 cases is now on a dramatic decline.

If you could pick only one strategy ― travel bans or testing — the choice is clear, Nuzzo argued.

“We don’t have any evidence that travel bans did much to stop or slow the spread,” she said. “Conversely, testing is essential. Had we been better able to find and isolate cases and traced their contacts, we could have kept case numbers down.”

The World Health Organization makes a similar point: It says temporary restrictions are justified only in narrow circumstances and as a way to buy time. But that time, the organization says, must be used to “rapidly implement effective preparedness measures” ― like testing.

Another point that supports this position: the real-world experience unfolding in the United States.

The “travel ban didn’t work,” said Lawrence Gostin, a university professor at Georgetown Law who specializes in global health law. “This is self-evident, because the U.S. is now the global epicenter.”

Our Ruling

Arguing in support of the White House coronavirus response, Watters said the United States was “very quick with the travel ban” and that was “much more critical in saving lives.”

This is incorrect. Travel restrictions could have bought a bit of time. But they were instituted after the coronavirus had already entered the United States.

And the evidence at hand suggests travel restrictions are most effective in combating viral spread if they are accompanied by targeted, robust testing and quarantining, which are the areas in which the administration stumbled. If you were to pick only one area to excel in — testing people for the coronavirus, or travel restrictions ― experts told us the research clearly supports testing, even without travel bans.

Watters’ claim has no factual basis and misrepresents real-world evidence on multiple levels. We rate it False.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Task Force Freezes Aid To Foreign Countries After American States’ Requests For PPE Were Severely Underestimated

Online Coronavirus Tests Are Just The Latest Iffy Products Marketed To Anxious Consumers

Companies with experience in the “at-home” testing market began announcing in mid-March that they would be offering direct-to-consumer test kits for COVID-19.

With panic running high and tests at hospitals and doctors’ offices hard to come by, the appeal was obvious.

The kits were touted as a way for consumers to manage this difficult situation themselves. No struggle to see the doctor. No calls to the health department. No waiting in line at a drive-thru test site. Instead, consumers could collect their own samples, by either swabbing the throat or cheek or spitting into a cup. The samples would then be mailed back to the companies’ partner laboratories, which would test for the coronavirus. Prices ranged from $135 to $181.

But criticism was swift. At-home tests could be skimming the resources needed for lab-based tests. There is also the possibility of people collecting their samples incorrectly and questions about follow-up care.

Not to mention the risk of inaccurate results.

The Food and Drug Administration responded with a March 20 press release, which stated that the FDA had not authorized any test “that is available to purchase for testing yourself at home for COVID-19.”

At least four companies, Nurx, EverlyWell, Forward and Carbon Health, have since said they halted sales — though two of the companies still have information about the tests on their websites as of Monday afternoon.

While these companies are legitimate and have a track record for at-home testing and providing medical care, there may be others out there hawking products that do not.

“Some are coming from reputable places and some are not, and that’s hard for the average consumer to tell,” said Eric Topol, director and founder of the Scripps Research Translational Institute.

‘A Lot Of Bunk, Junk And Crank Stuff’

For example, a number of questionable internet reports related to coronavirus tests, vaccines and “miracle” cures already are circulating on social media.

And for scared consumers, it may be difficult to tell the difference. “There’s a lot of bunk, junk and crank stuff out there,” said Arthur Caplan, founding head of the Division of Medical Ethics at NYU School of Medicine in New York City.

The FDA said, for instance, in its March 20 release that it “is beginning to see unauthorized fraudulent test kits that are being marketed to test for COVID-19 in the home.”

One key sign that an at-home kit is a sham is that it will offer consumers an almost immediate test result. “That would not be possible,” said Topol.

Websites touting miracle cures and preventatives ― herbs, teas, essential oils, tinctures and colloidal silver — are prevalent.

QAnon conspiracy theorists on YouTube and Twitter have irresponsibly told viewers to buy and drink “Miracle Mineral Solution,” an industrial bleach product, to ward off the coronavirus. Facebook and Instagram posts claim that marijuana, cocaine or vitamin C can kill or prevent the coronavirus. Salespeople are offering fake N95 masks.

To be clear, the FDA said in 1999 that any products containing colloidal silver are not “safe or effective,” and the National Institutes of Health has said that there are no known benefits to ingesting silver supplements and that it can cause serious side effects. The FDA also warned consumers in 2019 not to buy or ingest “Miracle Mineral Solution” because it can cause severe health effects.

The FDA and the Federal Trade Commission jointly issued warning letters on March 9 to seven companies for selling “products that fraudulently claim to prevent, treat or cure COVID-19.”

One of the warning letters was issued to Jim Bakker, a prominent televangelist, who allowed a guest to promote colloidal silver as a cure for COVID-19, and then sold it during a Feb. 12 broadcast of “The Jim Bakker Show.” The state of Missouri has since filed a lawsuit against Bakker for “falsely promising to consumers that Silver Solution can cure, eliminate, kill or deactivate coronavirus.”

Conservative radio host Alex Jones received a cease-and-desist letter March 12 from the New York attorney general’s office for selling products on his website that contain colloidal silver and claim to treat or cure coronavirus infections.

“There is nothing homeopathic or nutritional that can help you with the virus,” said Caplan. “The idea that people are floating some kind of diagnostic solution or magic or therapy on the internet, it’s all total crap.”

There have also been reports of consumers buying up a fish tank cleaner on eBay that has the same active ingredient as the antimalarial drug chloroquine, which President Donald Trump touted as a possible treatment for COVID-19. An Arizona man recently died after ingesting the fish tank additive, thinking it would prevent the coronavirus.

In an update issued March 24, the FDA said it was aware of people buying the fish tank cleaning product and advised consumers: “Don’t take any form of chloroquine unless it has been prescribed for you by your health care provider and obtained from legitimate sources.”

On March 20, the Department of Justice announced that Attorney General William Barr had asked all U.S. attorneys “to prioritize the investigation and prosecution of Coronavirus-related fraud schemes.”

The DOJ detailed its first enforcement action on March 22 for a COVID-19 fraud against a website called “coronavirusmedicalkit.com,” which claimed to sell coronavirus vaccine kits from the World Health Organization.

Despite all the false promises from these products, it’s important for consumers to remember that there is no FDA-approved treatment or vaccine for the novel coronavirus.

And the best way to prevent the spread of the virus is to practice social distancing and wash your hands, public health experts say.

Regaining A Sense Of Control Is A Motivator

Consumers may be motivated to buy these types of items because they are trying to regain control in an uncertain situation, explained April Thames, an associate professor of psychology at the University of Southern California’s Dornsife College of Letters, Arts and Sciences.

“People have this heightened anxiety, and they are willing to try anything out there that’s a possible treatment or cure,” said Thames. It creates an opening for scam artists “to market products that sound like they are effective.”

Caplan’s ultimate advice to consumers who see coronavirus-related products on the internet?

“Anything online, ignore it.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Coronavirus Patients Caught In Conflict Between Hospital And Nursing Homes

A wrenching conflict is emerging as the COVID-19 virus storms through U.S. communities: Some patients are falling into a no man’s land between hospitals and nursing homes.

Hospitals need to clear out patients who no longer need acute care. But nursing homes don’t want to take patients discharged from hospitals for fear they’ll bring the coronavirus with them.

“It’s a huge and very difficult issue,” said Cassie Sauer, president of the Washington State Hospital Association, whose members were hit early by the coronavirus.

Each side has legitimate concerns. Hospitals in coronavirus hot spots need to free up beds for the next wave of critically ill patients. They are canceling elective and nonessential procedures. They are also trying to move coronavirus patients out of the hospital as quickly as possible.

The goal is to “allow hospitals to reserve beds for the most severely ill patients by discharging those who are less severely ill to skilled nursing facilities,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said a few weeks ago as the federal agency relaxed rules restricting which Medicare patients can receive nursing home care.

Nursing homes are alarmed at the prospect of taking patients who may have coronavirus infections. The consequences could be dire. The first nursing home known to have COVID-19, the Life Care Center in Kirkland, Washington, saw the virus spread like wildfire. It killed 37 people.

“We’re looking at case fatality rates of 30, 40, 50% in nursing homes when coronavirus gets introduced,” said Christopher Laxton, executive director of AMDA — the Society for Post-Acute and Long-Term Care Medicine, which represents nursing home medical directors.

Fears extend to patients with other conditions, such as strokes or heart attacks, who’ve been in the hospital and do not have COVID-19 symptoms but could harbor the virus.

In its most recent guidance, the American Health Care Association, an industry trade group, said nursing homes can accept patients “who are COVID negative or do not have symptoms.” If someone has symptoms such as a dry cough or fever, they “should be tested for COVID-19 before being admitted to the facility.” If someone is COVID positive, they should be kept only “with other COVID positive residents.”

But nursing home doctors worry this doesn’t go far enough. According to a resolution by the California Association of Long Term Care Medicine, nursing homes should not have to take patients known to have the coronavirus unless “they have two negative tests that are 24 hours apart, OR 10 days after admission AND no fever for 72 hours.” A new AMDA resolution echoes this caution.

“We have an obligation to our patients to draw the line,” said Dr. Michael Wasserman, president of the California association. “Increasing the number of COVID-19 positive residents in facilities — whether these facilities have patients with the virus or not — raises the risk of infecting the uninfected and dramatically increasing the number of deaths.”

For their part, hospital leaders say an emphasis on testing before discharging patients is impractical, given the shortage of tests and delays in receiving results.

“Many nursing homes are requiring a negative COVID-19 test even for patients who were in the hospital for nothing to do with COVID,” said Sauer in Washington state. “We don’t agree with this. It’s using up very limited testing resources.”

Nowhere are tensions higher than in New York, where Gov. Andrew Cuomo has said 73,000 extra hospital beds will be needed within weeks to treat a surge of COVID-19 patients. Hospitals in the state have 53,000 beds.

On Wednesday, the New York State Department of Health issued an advisory noting: “No resident shall be denied re-admission or admission to the NH [nursing home] solely based on a confirmed or suspected diagnosis of COVID-19.”

Speaking on behalf of nursing home physicians, AMDA voiced strong opposition, calling the policy “over-reaching, not consistent with science, unenforceable, and beyond all, not in the least consistent with patient safety principles” in a statement.

Some nursing homes are sending residents with suspected coronavirus to hospitals for evaluation and then refusing to take them back until tests confirm their negative status.

“Essentially, they’re dumping patients on hospitals and saying, ‘Too bad — you’re stuck with them now,’” said a consultant who works closely with hospitals and spoke on the condition of anonymity.

Others want to do their part to serve COVID-19 patients. “It is our obligation to keep the health care system flowing,” said Scott LaRue, president of ArchCare, the health care system of the Archdiocese of New York.

LaRue has no illusions about keeping the coronavirus out of ArchCare’s five nursing homes, which, combined, have 1,700 beds.

“In New York City the virus is everywhere,” he said. That means it has to be managed, not avoided. “Our intention is to take COVID-19 stable patients” and move them to a single floor at each nursing home, he said.

That will happen under two conditions, LaRue said. First, ArchCare will need sufficient personal protective equipment — gowns, masks and face shields — for its staff. Currently, the system can’t get face shields. It was due to run out of gowns by Wednesday.

Second, ArchCare will need to test whether its protocols for managing COVID-positive patients are working. Those include putting patients in isolation, monitoring them more closely, limiting the number of people who can go in, and ensuring that staff use personal protective equipment and are trained properly.

So far, only one of its nursing home patients is known to have COVID-19.

“We won’t know for 14 days if the steps we’re taking are working,” LaRue said.

But it’s unrealistic to expect other nursing homes to follow suit.

“I would be surprised if 10% to 15% of skilled nursing facilities in the U.S. could take a COVID-positive patient and treat that patient safely while ensuring that other residents in the home are safe,” said David Grabowski, a professor of Health Care Policy at Harvard Medical School.

In a new commentary in the Journal of the American Medical Association, Grabowski calls for establishing “centers of excellence” to care for patients recovering from COVID-19 and building “temporary capacity” in hot spots where the need for post-hospital services is likely to surge.

That’s beginning to happen. On Tuesday, Cuomo announced that a field hospital being built by the U.S. Army Corps of Engineers to house overflow coronavirus patients at the Jacob K. Javits Convention Center in New York City would include 1,000 beds for patients who don’t need acute care services.

On Wednesday, a unit of Partners HealthCare, a large Massachusetts health care system, announced a new center for patients recovering from COVID-19 on the fourth floor of Spaulding Hospital for Continuing Care, a long-term care hospital in Cambridge. The center, set to open soon, will have 60 beds and accept patients from Massachusetts General Hospital and Brigham and Women’s Hospital.

In the Twin Cities area of Minnesota, Allina Health, which operates 11 hospitals, is partnering with Presbyterian Homes & Services to convert a 50-bed skilled nursing home to a “step-down site,” said Dr. Emily Downing, a vice president of Allina Health. The goal is to help COVID-19 patients recover so they can return to nursing homes or senior living communities.

Katie Smith Sloan, president of LeadingAge, which represents not-for-profit nursing homes, home care agencies and assisted living centers, said she was hearing about nascent plans to reopen closed nursing homes for COVID-19 patients. Government agencies need to make financing available to build extra capacity to care for these patients, she said.

As for patients who need less intensive care or who need to be quarantined after the hospital to ensure they aren’t infectious, other options exist.

“King County has bought a hotel and is leasing another and is looking at what are now empty ambulatory surgery centers or a Christian summer camp in the area,” said Sauer of the Washington State Hospital Association.

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‘Red Dawn Breaking Bad’: Officials Warned About Safety Gear Shortfall Early On, Emails Show

A high-ranking federal official in late February warned that the United States needed to plan for not having enough personal protective equipment for medical workers as they began to battle the novel coronavirus, according to internal emails obtained by Kaiser Health News.

The messages provide a sharp contrast to President Donald Trump’s statements at the time that the threat the coronavirus posed to the American public remained “very low.” In fact, concerns were already mounting, the emails show, that medical workers and first responders would not have enough masks, gloves, face shields and other supplies, known as PPE, to protect themselves against infection when treating COVID-19 patients.

The emails, part of a lengthy chain titled “Red Dawn Breaking Bad,” includes senior officials across the Department of Veterans Affairs, the State Department, the Department of Homeland Security and the Department of Health and Human Services, as well as outside academics and some state health officials. KHN obtained the correspondence through a public records request in King County, Washington, where officials struggled as the virus set upon a nursing home in the Seattle area, eventually killing 37 people. It was the scene of the first major outbreak in the nation.

“We should plan assuming we won’t have enough PPE — so need to change the battlefield and how we envision or even define the front lines,” Dr. Carter Mecher, a physician and senior medical adviser at the Department of Veterans Affairs, wrote on Feb. 25. It would be weeks before front-line health workers would take to social media with the hashtag #GetMePPE and before health systems would appeal to the public to donate protective gear.

In the email, Mecher said confirmed-positive patients should be categorized under two groups with different care models for each: those with mild symptoms should be encouraged to stay home under self-isolation, while more serious patients should go to hospital emergency rooms.

“The demand is rising and there is no guarantee that we can continue with the supply since the supply-chain has been disrupted,” Eva Lee, director of the Center for Operations Research in Medicine and HealthCare at Georgia Tech and a former health scientist at the Atlanta VA Medical Center, wrote that same day citing shortages of personal protective equipment and medical supplies. “I do not know if we have enough resources to protect all frontline providers.”

Reached on Saturday, Lee said she isn’t sure who saw the message trail but “what I want is that we take action because at the end of the day we need to save patients and health care workers.”

Mecher, also reached Saturday, said the emails were an “an informal group of us who have known each other for years exchanging information.” He said concerns aired at the time on medical protective gear were top of mind for most people in health care. More than 35 people were on the email chain, many of them high-ranking government officials.

The same day Mecher and others raised the concern in the messages, Trump made remarks to a business roundtable group in New Delhi, India.

“We think we’re in very good shape in the United States,” he said, noting that the U.S. closed the borders to some areas. “Let’s just say we’re fortunate so far.  And we think it’s going to remain that way.”

The White House declined to comment. In a statement, VA press secretary Christina Mandreucci said, “All VA facilities are equipped with essential items and supplies to handle additional coronavirus cases, and the department is continually monitoring the status of those items to ensure a robust supply chain.”

Doctors and other front-line medical workers in the weeks since have escalated concerns about shortages of medical gear, voicing alarm about the need to protect themselves, their families and patients against COVID-19, which as of Saturday evening had sickened more than 121,000 in the United States and killed at least 2,000.

As Mecher and others sent emails about growing PPE concerns, HHS Secretary Alex Azar testified to lawmakers that the U.S. had 30 million N95 respirator masks stockpiled but needed 300 million to combat the outbreak. Some senior U.S. government officials were also warning the public to not buy masks for themselves to conserve the supply for health care providers.

U.S. Surgeon General Jerome Adams tweeted on Feb. 29: “Seriously people – STOP BUYING MASKS!  They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!”

Still, on Feb. 27, the FDA in a statement said that officials were not aware of widespread shortages of equipment.

“We are aware of reports from CDC and other U.S. partners of increased ordering of a range of human medical products through distributors as some healthcare facilities in the U.S. are preparing for potential needs if the outbreak becomes severe,” the agency said.

Simultaneously, Trump downplayed the risk of the novel coronavirus to the American public even though the Centers for Disease Control and Prevention was warning it was only a matter of time before it would spread across the country. On Feb. 29, the CDC also updated its strategies for health workers to optimize supplies of N95 masks.

An HHS spokesperson said Saturday the department has been in “an all-out effort to mobilize America’s capacity” for personal protective equipment and other supplies, including allowing the use of industrial N95 respirators in health care settings and awarding contracts to several private manufacturers to buy roughly 600 million masks over the next 18 months.

“Health care supply chains are private-sector-driven,” the spokesperson said. “The federal role is to support that work, coordinate information across the industry and with state or local agencies if needed during emergencies, and drive manufacturing demand as best we can.”

The emails from King County officials and others in Washington state also show growing concern about the exposure of health care workers to the virus, as well as a view into local officials’ attempts to get help from the CDC.

In one instance, local medical leaders were alarmed that paramedics and other emergency personnel were possibly exposed after encountering confirmed-positive patients at the Life Care Center of Kirkland, the Seattle-area nursing home where roughly three dozen people have died because of the virus.

“We are having a very serious challenge related to hospital exposures and impact on the health care system,” Dr. Jeff Duchin, the public health officer for Seattle and King County, wrote in a different email to CDC officials March 1. Duchin pleaded for a field team to test exposed health care workers and additional support.

Duchin’s email came hours after a physician at UW Medicine wrote about being “very concerned” about exposed workers at multiple hospitals and their attempts to isolate infected workers.

“I suspect that we will not be able to follow current CDC [recommendations] for exposed HCWs [health care workers] either,” wrote Dr. John Lynch, medical director of employee health for Harborview Medical Center and associate professor of Medicine and Allergy and Infectious Diseases at the University of Washington. “As you migh [sic] imagine, I am very concerned about the hospitals at this point.”

Those concerns have been underscored with an unusual weekend statement from Dr. Patrice Harris, president of the American Medical Association, which represents doctors, calling on Saturday for more coordination of needed medical supplies.

“At this critical moment, a unified effort is urgently needed to identify gaps in the supply of and lack of access to PPE necessary to fight COVID-19,” the statement says. “Physicians stand ready to provide urgent medical care on the front lines in a pandemic crisis. But their need for protective gear is equally urgent and necessary.”

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Centros de salud comunitarios enfrentan al coronavirus, bajo presión financiera

La administración Trump acaba de anunciar $100 millones en fondos suplementarios para centros de salud comunitarios, para apoyar la respuesta a la pandemia de coronavirus.

“Los centros de salud están desempeñando un papel fundamental”, dijo James Macrae, administrador asociado de la Oficina de Atención Primaria de Salud del gobierno federal.

Alrededor de 29 millones de personas en el país dependen de estos centros, que ofrecen atención médica a pacientes de bajos ingresos y sin seguro. Millones de latinos reciben atención en estas clínicas.

A medida que los hospitales reciben más pacientes con COVID-19, los centros están revisando la forma en que atienden a los pacientes y han puesto en marcha nuevos protocolos para el manejo de enfermedades infecciosas.

Los fondos extra del gobierno se repartirán entre 1,381 centros de salud comunitarios (muchos de los cuales operan múltiples clínicas), principalmente para respaldar más pruebas para COVID-19, telemedicina y adquisición de equipos de protección personal.

“No está cerca de lo que se necesita, pero estamos agradecidos”, dijo Bob Marsalli, CEO de la Washington Association for Community Health, un grupo que representa a los centros de salud comunitarios en el estado de Washington.

Marsalli dijo que los centros en el estado están bajo una creciente presión financiera a medida que recrudece la batalla contra el coronavirus, al tiempo que pierden algunas fuentes clave de financiación.

“[Nuestras clínicas] están reasignando su fuerza laboral de manera inteligente, pero frenética, para mantenerse al día con la demanda”, dijo Marsalli.

Nuevas reglas de juego

En circunstancias normales, HealthPoint, un centro de salud comunitario en Auburn, Washington, alentaría a los pacientes a ir a la clínica para todas sus necesidades médicas, tanto para surtir una receta como para aprender sobre nutrición.

“Por lo general, nuestro lobby está colmado”, dijo la doctora Esther Johnston. “Es un espacio abierto y todos están juntos”.

Pero en estos días solo hay unos pocos pacientes con máscaras quirúrgicas esperando que los atiendan. Y Johnston les dice a los pacientes que no vayan a menos que realmente necesiten atención médica.

“Es un poco frustrante y desmoralizante, pero es la realidad de la situación”, dijo.

HealthPoint dirige más de una docena de clínicas en todo el oeste de Washington. Ahora, en la entrada de sus centros, el personal hace preguntas a los pacientes para identificar los síntomas de COVID-19 y controlar los mantiene a distancia uno del otro una vez dentro.

Johnston dijo que la clínica no se abrió para albergar una afluencia de pacientes con enfermedades infecciosas. Tienen un limitado número de cuartos, y cada uno debe cerrarse y limpiarse después que entra un paciente sospechoso de tener COVID-19.

“Simplemente no tenemos suficiente espacio para poder hacer eso de forma rutinaria”, dijo.

Al igual que muchos centros de salud comunitarios, el modelo de HealthPoint es atender a más personas para que no vayan a las salas de emergencia. Pero ahora la organización está tomando nuevas precauciones para prevenir la propagación del coronavirus y mantener al personal seguro. (Will Stone for KHN)

Johnston se preocupa por lo que vendrá a medida que aumenten los casos de COVID-19 en su área.

“Nos enorgullecemos de ser un espacio de atención primaria”, dijo Johnston. “No tenemos suficientes máscaras N95, ni, para ser sinceros, estábamos preparados para una situación en la que todos debían estar bien equipados”.

La doctora Judy Featherstone, directora médica de HealthPoint, dijo que ahora la mayoría de las citas se hacen por teléfono. Su personal está atendiendo llamadas de personas preocupadas por los síntomas, así como de nuevos pacientes que quieren tener un médico en caso que contraigan el coronavirus.

“Es un poco como tomar 20 años de trabajo y rediseñarlo en una semana”, dijo Featherstone. “Creo que estamos anticipando posibles problemas de la fuerza laboral”.

Al igual que muchas clínicas en Washington, HealthPoint ha establecido sitios de pruebas al aire libre, pero el suministro de kits y equipos de protección personal, limita el número de pacientes que pueden hacérselas.

Crece la tensión financiera

A medida que van menos pacientes para recibir atención, autoridades se preocupan por el futuro financiero de los centros. Las clínicas han cambiado a citas telefónicas, pero el programa de Medicaid de Washington tardó varias semanas en ajustar la forma en que paga esas visitas. Mientras tanto, los centros de salud comunitarios están eliminando las visitas dentales de rutina, un flujo de financiación clave.

“Toma esos tres factores… y ya has comenzado a perder ingresos antes de prepararte para nuevas formas de brindar atención”, dijo Michael Erikson, CEO de Neighborcare Health, que atiende a más de 70,000 residentes de Washington, más de la mitad de ellos bajo Medicaid. “Estamos en camino de perder $3 millones al mes”.

La Washington Association for Community Health proyecta que el recorte en la atención dental podría llevar a un déficit de $250 millones para el sistema de centros de salud comunitarios del estado durante los próximos nueve meses.

Rol vital en el sistema de salud

Las clínicas comunitarias juegan un papel importante en el servicio a pacientes que de otro modo terminarían en una sala de emergencias. Erikson dijo que su organización está tratando de aliviar la presión sobre el sistema hospitalario al ver pacientes con problemas de atención médica urgentes no relacionados con COVID-19.

“Por ejemplo, a un paciente para el cuidado de heridas que tiene diabetes subyacente no quieres exponerlo a un posible entorno con COVID-19”, dijo Erikson.

Algunos líderes de clínicas comunitarias también se preocupan por perder personal debido a una infección real o sospechada por coronavirus.

“Es muy crítico que las clínicas permanezcan con todo el personal, de modo que solo aquellos que están gravemente enfermos vayan al hospital”, dijo Sheila Berschauer, directora ejecutiva de Moses Lake Community Health Center, un proveedor de atención médica rural en Washington que atiende a un tercio de la población de su condado, de aproximadamente 100,000 residentes.

Si incluso cinco a 10 trabajadores de salud se enferman, dijo Berschauer, eso podría afectar su organización y, como resultado, posiblemente abrumar al hospital local.

Berschauer agregó que algunos pacientes aún no se dan cuenta de la gravedad de la pandemia y se enojan cuando se los deriva al sitio de prueba al aire libre en lugar de a la clínica.

Un trabajador de alud en un centro en las afueras de Seattle dijo que varios pacientes han tergiversado sus riesgos de COVID-19 para pasar el examen.

“Recibimos una paciente que logró pasar todos los controles y llegó ante un médico para recién entonces revelarnos que su pareja está expuesta a COVID y que se siente enferma”, dijo un empleado (le preocupa perder su trabajo por hablar, por lo que NPR y KHN no están usando su nombre).

Los trabajadores de salud que vieron al paciente no usaron equipo protector porque esos suministros limitados están reservados para pacientes con riesgo conocido de COVID-19.

“Ahora todos los proveedores y el personal de esa instalación deben comenzar a autocontrolarse para detectar signos de infección”, dijo el empleado. “Si se infectan, entonces toda la clínica cierra. Es un problema muy grande”.

Esta historia es parte de una asociación entre NPR y Kaiser Health News

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Resurge la telemedicina, por miedo al coronavirus y cambios en los pagos

Lukas Kopacki, quien regresó a casa después que el campus de su universidad cerrara por la pandemia de coronavirus, se había estado sintiendo mal durante días, con dolores de cabeza y garganta, y dificultad para respirar. Pero le preocupaba que ir al consultorio médico pudiera enfermarlo más.

“No tenía ganas de entrar en ese agujero negro de bacterias y virus”, dijo Kopacki, de 19 años, de Ringwood, Nueva Jersey.

Entonces, la semana del 16 de marzo, el estudiante de la Universidad de Vermont decidió llamar a Teladoc, una compañía que conecta a pacientes con médicos por teléfono en todo el país. El médico le diagnosticó una infección sinusal y le envió una receta para un antibiótico a su farmacia local.

Con su cobertura de salud de Aetna, que a principios de marzo renunció temporalmente a su copago de $45 por atención virtual, Kopacki pagó de su bolsillo $1.44, que cubrió los costos del medicamento.

“Fue fácil y rápido”, dijo.

Recibir atención médica por teléfono o videoconferencia ha existido durante varias décadas, pero el brote de coronavirus ha llevado a un aumento en el uso de la telemedicina como nunca antes se había visto, según los sistemas de salud y los grupos de proveedores en todo el país.

Millones de estadounidenses buscan atención conectándose electrónicamente con un médico, muchos por primera vez. Los sistemas de salud, las aseguradoras y los grupos de médicos dijeron que esta práctica permite a las personas practicar el distanciamiento social a la vez que reduce la propagación de la enfermedad, y protege a los trabajadores de salud.

Las empresas privadas de tecnología como Teladoc, Doctor On Demand y Amwell, y los grandes sistemas de atención médica, pueden proporcionar un médico directamente a alguien que se contacte con ellos.

Otros pacientes pueden pedir una cita de telemedicina con su médico habitual, que puede utilizar aplicaciones informáticas a través de celulares y computadoras. Todos los tipos de atención primaria y especializada, y los servicios de salud mental se pueden proporcionar a través de la telemedicina.

Muchos hospitales han agregado recientemente servicios de telemedicina para evitar que los pacientes preocupados por el coronavirus colmen sus salas de emergencia.

También estimulados por el objetivo de mantener a los pacientes alejados de las instalaciones médicas abarrotadas, las aseguradoras, del gobierno y privadas han aumentado el pago de las visitas de telemedicina para que estén a la par de las citas en persona.

Antes del brote, las aseguradoras pagaban menos de la mitad de esa cantidad, lo que disuadía a muchos médicos de ofrecer este servicio.

La semana del 16, Medicare habilitó a todos los afiliados usar la telemedicina, una opción que anteriormente solo estaba disponible para personas que viven en áreas remotas, y para chequeos específicos y breves. El gobierno federal también dijo que los médicos podrían ofrecer servicio fuera de sus estados durante la pandemia para tratar a los pacientes de Medicare virtualmente, incluso si no tienen licencia en el estado del paciente.

California, Florida y otros estados también han renunciado a sus requisitos de que un médico tenga licencia en el estado para brindar atención.

La Clínica Cleveland está en camino de registrar más de 60,000 visitas de telemedicina en marzo, según sus autoridades. Antes de marzo, ese sistema de salud, que tiene hospitales en Ohio y Florida, promediaba unas 3,400 visitas virtuales al mes.

Su sistema Express Care Online atiende a pacientes de todo el país las 24 horas del día. Alrededor del 75% de las llamadas ahora provienen de personas preocupadas de haber contraído COVID-19, dijo el doctor Matthew Faiman, director médico del servicio. Al igual que muchos otros sistemas de salud, la atención de urgencia virtual de Cleveland Clinic está renunciando a los copagos de los pacientes durante la pandemia.

“Estamos viendo un aumento significativo en la demanda de pacientes que buscan atención, tanto las personas preocupadas por el virus como los pacientes que están enfermos y que necesitan saber cómo manejar sus síntomas”, explicó Faiman.

La clínica ha contratado más médicos para telesalud desde que se cancelaron las cirugías electivas y menos pacientes van al consultorio.

“La telemedicina ha estado en los bordes del sistema por un tiempo”, dijo el doctor Manish Naik, director de tecnología de información médica de la Clínica Regional de Austin, en Texas. “Y, cuando todo esto termine, muchos médicos y pacientes querrán que la opción de telemedicina permanezca”.

Por supuesto, tales visitas tienen limitaciones, como cuando los médicos necesitan auscultar los pulmones o el corazón de un paciente u ordenar una radiografía para verificar si hay neumonía. Pero Naik dijo que la telemedicina también brinda a los médicos una visión más completa de los pacientes a través de “observación en el hogar” e interacciones que muestran “cosas que nunca antes pudimos ver”.

Antes de marzo, NYU Langone Health en Nueva York tenía alrededor de 50 visitas virtuales por día a través de su plataforma de telemedicina de atención de urgencia. Durante la semana del 23 de marzo, el sistema hospitalario ha promediado alrededor de 900 por día.

Para el 80% de las visitas de telemedicina, la tos es la principal preocupación, seguida por la fiebre, dijo el doctor Paul Testa, jefe de información médica. NYU Langone tiene 170 médicos que atienden a pacientes a través de la telemedicina, en comparación con 35 antes, dijo.

“No estamos recomendando pruebas para todos, pero estamos aconsejando el cuidado personal, la hidratación y el autoaislamiento”, agregó Testa. “El objetivo es crear una opción para estos pacientes en lugar que se apresuren a una urgencia o a una sala de emergencias”.

Si un paciente tiene problemas para respirar, un proveedor de telemedicina de la NYU le indicará que llame a una ambulancia si es necesario o que vaya a la sala de emergencias.

Teladoc tiene un promedio de 15,000 visitas de pacientes por día en los Estados Unidos, 50% más que en febrero. Los tiempos de espera han aumentado de minutos a horas en algunos casos, dijo un vocero.

En la Clínica Regional de Austin, que cuenta con 340 médicos en 28 consultorios, casi la mitad de las visitas de pacientes ahora son virtuales en comparación con una fracción antes del brote.

“Con la situación de COVID-19, tenemos pacientes que están nerviosos por venir, y no queremos pacientes con síntomas que expongan a otros”, dijo Naik.

La administración Trump estuvo actuando para ampliar las opciones de telemedicina incluso antes de la pandemia. En 2019, le permitió a Medicare pagar por primera vez a los médicos un promedio de $14 por una llamada telefónica de cinco minutos para comunicarse con sus pacientes.

Ken Prussner, de 74 años, de Herndon, Virginia, usó la computadora de su casa el lunes 23 para conectarse con su médico de toda la vida.

Prussner tenía una enfermedad gastrointestinal y un poco de fiebre, y su familia quería asegurarse que no tuviera COVID-19. Habló con su médico como si estuviera en el consultorio. Prussner tenía una infección típica del intestino delgado que desaparecería por sí sola en tres o cinco días.

“Fue bastante sencillo”, dijo Prussner, oficial retirado del Servicio Exterior de los Estados Unidos.

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Must-Reads Of The Week From Brianna Labuskes

Hello! We have once again reached Friday, and I’ll do my best to give you a snapshot of the biggest health news from the week. But, first, I must dispel some bad advice that I’ve seen: Everyone wants to see your pet on those video conferences! Don’t hide them away in this time of need! Show us the doggos, the cats, and the … whatever this is. (A porcupine, I think?) Also make sure you’re following DogsOfKFF on Twitter for some of the best content on that social media platform.

All right, onto the news.

As predicted, the United States has surpassed China in the number of confirmed coronavirus cases, with nearly 93,000 to China’s nearly 82,000, as of 1 p.m. ET Friday. According to Johns Hopkins’ tracker, we also have surpassed 1,300 recorded deaths. (Worldwide, we’re at more than 566,000 and over 25,000 deaths.) Meanwhile, all that data comes with an asterisk in that most experts believe there are far more cases going unrecorded either because of testing flaws or overwhelmed state health departments that can’t keep up. Either way, not exactly something we want to be first in.

Meanwhile, the House came back to Washington to approve the $2.2 trillion stimulus package the Senate managed to send through this week (more on that in a second), despite concerns over lawmakers’ safety. There had been (dim but existent) hope earlier in the week that the House might be able to pass the legislation by unanimous consent. But that seemed too easy to be true, and it was. Concerns that a voice vote would be derailed by objections from a libertarian Kentucky lawmaker went unrealized, and the House passed the legislation Friday afternoon. The bill now goes to President Donald Trump, who is expected to sign it.

So what exactly is in that legislation?

— Direct payments of $1,200 to millions of Americans, including those earning up to $75,000, and an additional $500 per child

— $100 billion for grants to hospitals, public and nonprofit health organizations and Medicare and Medicaid suppliers, including a 20% bump in Medicare payments for treating patients with the virus

— $221 billion in a variety of tax benefits for businesses, including allowing businesses to defer payroll taxes, which finance Medicare and Social Security, for the rest of the year

— More than $25 billion in new money for food assistance programs, like SNAP

— Expanded jobless aid, providing an additional 13 weeks and a four-month enhancement of benefits, and extending the payments for the first time to freelancers and gig workers

— $377 billion in federally guaranteed loans to small businesses and the establishment of a $500 billion government lending program for distressed companies

— Millions in aid for states to begin offering early voting or voting by mail

— A rule that blocks foreclosures and evictions during the crisis on properties where the federal government backs the mortgage

— The suspension of federal student loan payments for six months and waives the interest

Predictably, some sectors (like cruise ships) were unhappy with being left out, but for once some people were pleased — for example, the hospital industry, which got the $100 billion it asked for.

For those of you, like me, who love a good tick-tock, here are a few inside looks at how Senate leaders and White House advisers struck a quick, expansive deal in a Washington that typically seems incapable of compromise.

The New York Times: As Coronavirus Spread, Largest Stimulus in History United a Polarized Senate

Politico: Inside the 10 Days to Rescue the Economy

The Washington Post: The Dealmaker’s Dealmaker: Mnuchin Steps In as Trump’s Negotiator, but President’s Doubts Linger With Economy in Crisis

The urgency of the legislation was underscored by an astronomical jump in jobless claims this week. Nearly 3.3. million Americans applied for benefits, up from 200,000 during pre-outbreak days. The “widespread carnage,” as one economist put it, is expected to get worse. While the stimulus package is expected to help mitigate some of the devastation, many have said it should be looked at as just the beginning.

It seemed strangely appropriate this week that the health law turned 10 amid a pandemic — the legislation’s journey to here has been anything but smooth, why should this anniversary be? But one ripple effect of the pandemic and economic fallout might actually be a boost to the health law, which is likely to serve as a crucial safety net for many Americans who possibly lost their employer-sponsored coverage in the past few weeks. States have already started reopening their marketplaces, and the federal government is being urged to follow suit.

Trump chafed this week at the drastic measures states are putting in place to try to curb the outbreak, raising eyebrows when he said he’d like to see church pews full by Easter. Public health experts have warned that lifting the social-distancing measures would result in a surge of cases that slam an already stretched-thin hospital system. But for Trump, who has tied his reputation to the well-being of the stock market, the economic toll seems too much. (The rhetoric also started a truly bizarre push from conservatives for older Americans to sacrifice themselves for the good of the country.)

The president’s most recent proposal to kick-start parts of the country is identifying places by risk level and applying strategies to match. But experts, like Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, warn that even “cool spots” that aren’t seeing many cases might be in for a surge coming down the pike.

Meanwhile, Gov. Andrew Cuomo has said that New York’s experience presages America’s future. But some say that’s not necessarily accurate. Leading specialists say that while it is likely that devastation similar to New York’s will emerge in other places, there’s hope that in lower-density areas, where there are fewer factors like mass transit to exacerbate the spread, the outcome might be different.

Realistically, though, Americans will need to eventually think about returning to normalcy. Are there exit strategies from this complete lockdown that would work effectively? Here’s the problem: All the experts say success relies on extreme, aggressive and widespread testing to isolate the sick before they can give it to anyone. This has not exactly been America’s strong suit in recent weeks.

There are two storylines that have taken hold to demonstrate how much this pandemic will strain the hospital system, the first being the lack of ventilators available. States and hospitals have been pleading with the federal government to invoke war powers to jump-start the manufacturing process on the equipment. This comes as doctors are being forced to split ventilators between patients (a risky practice), planning to make the tough ethical decisions to ration care, creating policies to not resuscitate, searching for alternative treatments despite the dangers they might pose, and being warned that morgues are reaching capacity.

But Trump, who had been set to announce a partnership with GM to produce up to 80,000 ventilators, balked this week at the $1 billion price tag that came with it. “I don’t believe you need 40,000 or 30,000 ventilators,” he said, in a reference to New York, where Gov. Andrew Cuomo has appealed for federal help in obtaining them. “You go into major hospitals sometimes, and they’ll have two ventilators. And now all of a sudden they’re saying, ‘Can we order 30,000 ventilators?’”

The second notable thread throughout the country is a lack of personal protective equipment for health care workers on the front lines of the epidemic. There might be a long medical tradition of accepting elevated risk in the middle of a crisis, but many health care workers are frustrated that they’re being put in that position. Some are resorting to using hand-sewn masks, which do little to protect them and trash bags for surgical gowns. But others are drawing a line in the sand.

Meanwhile, something that might get missed with everyone’s attention directed at the coasts: Atlanta’s mayor is warning that its hospitals are at capacity.

Gilead, whose antiviral drug is getting a lot of buzz, was granted orphan drug status for the treatment because there are fewer than 200,000 cases of COVID-19 in the States right now. The designation would have granted Gilead lucrative perks, like the ability to keep generic competitors from the marketplace. But the news was meant with rage-filled incredulity from, uh, pretty much everyone, and so the company rescinded the request. As one expert said: “I think it’s embarrassing to take something that’s potentially the most widespread disease in the history of the pharmaceutical industry and claim it’s a rare disease.”

Meanwhile, an antimalarial drug is getting tons of attention after Trump touted it as a possible game changer. But a new, more carefully constructed study that finds it did little to help patients in China shows why people shouldn’t be looking for a quick, miracle cure. Researchers say this doesn’t disprove that the drug works but is a good check on expectations, especially when people are trying to self-medicate with the drug — resulting in shortages for those who need it for other illnesses and fatal consequences for others.

On the good-news front (there is some!), Moderna said there could be a vaccine ready for the fall for health care workers under emergency use authorization, ahead of the wider release that’s not expected to come for about a year.

And another treatment that some scientists are hopeful about is the practice of injecting recovered patients’ blood into new patients. The strategy is at least a century old but has scattershot results. “It’s not exactly a shot in the dark, but it’s not tried and true,” says one scientist. Still, in this era, people are willing to try what they can.

And here are some other interesting stories to get you through the weekend.

Federal Response:

Politico: Trump Team Failed to Follow NSC’s Pandemic Playbook

Politico: Those Who Intentionally Spread Coronavirus Could Be Charged As Terrorists

The New York Times: As Coronavirus Surveillance Escalates, Personal Privacy Plummets

2020 Elections:

The New York Times: Joe Biden, Struggling for Visibility, Faults Trump’s Response to Coronavirus

The New York Times: Is All of 2020 Postponed?

From The States:

Stateline: One Governor’s Actions Highlight the Strengths — and Shortcomings — of State-Led Interventions

The New York Times: Governors Tell Outsiders From ‘Hot Zone’ to Stay Away as Virus Divides States

NBC News: Entire Senior Home in New Jersey, 94 People, Presumed to Have Coronavirus

Science And Innovation:

The New York Times: The Virus Can Be Stopped, But Only With Harsh Steps, Experts Say

The New York Times: Warmer Weather May Slow, But Not Halt Coronavirus

The Washington Post: What Research on Coronavirus Structure Can Tell Us About How to Kill It

The Washington Post: The Science of Why Coronavirus Is So Hard to Stop

Reuters: Smokers Likely to Be More at Risk From Coronavirus: EU Agency

Public Health:

ProPublica: Domestic Violence and Child Abuse Will Rise During Quarantines. So Will Neglect of At-Risk People, Social Workers Say.

NBC News: Anti-Abortion Groups Seek Halt to Abortions During Coronavirus Pandemic

Politico: New York’s Health Care Workforce Braces for Influx of Retirees, Inexperienced Staffers

That’s it from me! Have a safe and healthy weekend!

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Global Health Watch

Physicians Fear For Their Families As They Battle Coronavirus With Too Little Armor

Dr. Jessica Kiss’ twin girls cry most mornings when she goes to work. They’re 9, old enough to know she could catch the coronavirus from her patients and get so sick she could die.

Kiss shares that fear, and worries at least as much about bringing the virus home to her family — especially since she depends on a mask more than a week old to protect her.

“I have four small children. I’m always thinking of them,” said the 37-year-old California family physician, who has one daughter with asthma. “But there really is no choice. I took an oath as a doctor to do the right thing.”

Kiss’ concerns are mirrored by dozens of physician parents from around the nation in an impassioned letter to Congress begging that the remainder of the relevant personal protective equipment be released from the Strategic National Stockpile, a federal cache of medical supplies, for those on the front lines. They join a growing chorus of American health care workers who say they’re battling the virus with far too little armor as shortages force them to reuse personal protective equipment, known as PPE, or rely on homemade substitutes. Sometimes they must even go without protection altogether.

“We are physically bringing home bacteria and viruses,” said Dr. Hala Sabry, an emergency medicine physician outside Los Angeles who founded the Physician Moms Group on Facebook, which has more than 70,000 members. “We need PPE, and we need it now. We actually needed it yesterday.”

The danger is clear. A March 21 editorial in The Lancet said 3,300 health care workers were infected with the COVID-19 virus in China as of early March. At least 22 died by the end of February.

The virus has also stricken health care workers in the United States. On March 14, the American College of Emergency Physicians announced that two members — one in Washington state and another in New Jersey — were in critical condition with COVID-19.

At the private practice outside Los Angeles where Kiss works, three patients have had confirmed cases of COVID-19 since the pandemic began. Tests are pending on 10 others, she said, and they suspect at least 50 more potential cases based on symptoms.

Ideally, Kiss said, she’d use a fresh, tight-fitting N95 respirator mask each time she examined a patient. But she has had just one mask since March 16, when she got a box of five for her practice from a physician friend. Someone left a box of them on the friend’s porch, she said.

When she encounters a patient with symptoms resembling COVID-19, Kiss said, she wears a face shield over her mask, wiping it down with medical-grade wipes between treating patients.

As soon as she gets home from work, she said, she jumps straight into the shower and then launders her scrubs. She knows it could be devastating if she infects her family, even though children generally experience milder symptoms than adults. According to the Centers for Disease Control and Prevention, her daughter’s asthma may put the girl at greater risk of a severe form of the disease.

Dr. Niran Al-Agba of Bremerton, Washington, said she worries “every single day” about bringing the COVID-19 virus home to her family.

“I’ve been hugging them a lot,” the 45-year-old pediatrician said in a phone interview, as she cuddled one of her four children on her lap. “It’s the hardest part of what we’re doing. I could lose my husband. I could lose myself. I could lose my children.”

Al-Agba said she first realized she’d need N95 masks and gowns after hearing about a COVID-19 death about 30 miles away in Kirkland last month. She asked her distributor to order them, but they were sold out. In early March, she found one N95 mask among painting gear in a storage facility. She figured she could reuse the mask if she sprayed it down with a little isopropyl alcohol and also protected herself with gloves, goggles and a jacket instead of a gown. So that’s what she did, visiting symptomatic patients in their cars to reduce the risk of spreading the virus in her office and the need for more protective equipment for other staffers.

Recently, she began getting donations of such equipment. Someone left two boxes of N95s on her doorstep. Three retired dentists dropped off supplies. Patients brought her dozens of homemade masks. Al-Agba plans to make these supplies last, so she’s continuing to examine patients in cars.

In the March 19 letter to Congress, about 50 other physicians described similar experiences and fears for their families, with their names excluded to protect them from possible retaliation from employers. Several described having few or no masks or gowns. Two said their health centers stopped testing for COVID-19 because there is not enough protective gear to keep workers safe. One described buying N95 masks from the Home Depot to distribute to colleagues; another spoke of buying safety glasses from a local construction site.

“Healthcare workers around the country continue to risk exposure — some requiring quarantine and others falling ill,” said the letter. “With emergency rooms and hospitals running at and even over capacity, and as the crisis expands, so does the risk to our healthcare workers. And with a shortage of PPE, that risk is even greater.”

Besides asking the government to release the entire stockpile of masks and other protective equipment — some of which has already been sent to states — the doctors requested it be replenished with newly manufactured equipment that is steered to health care workers before retail stores.

They called on the U.S. Government Accountability Office to investigate the distribution of stockpile supplies and recommended ways to ensure they are distributed as efficiently as possible. They said the current system, which requires requests from local, state and territorial authorities, “may create delays that could cause significant harm to the health and welfare of the general public.”

At this point, Sabry said, the federal government should not be keeping any part of the stockpile for a rainy day.

“It’s pouring in the United States right now,” she said. “What are they waiting for? How bad does it have to get?”

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Telemedicine Surges, Fueled By Coronavirus Fears And Shift In Payment Rules

Lukas Kopacki, home from college after the coronavirus pandemic closed his campus, was feeling lousy for days with headaches, sore throat and difficulty breathing through his nose. But he worried that a trip to a doctor’s office might make him sicker.

“I had no desire to go into that cesspool of bacteria and viruses,” said Kopacki, 19, of Ringwood, New Jersey.

So, last week the University of Vermont student called Teladoc, a company that connects patients to doctors by phone nationwide. Its physician diagnosed his sinus infection and sent a prescription for an antibiotic to his local pharmacy. With his Aetna health coverage, which earlier this month temporarily waived its $45 patient copayment for virtual care, Kopacki paid out-of-pocket $1.44, which covered his costs for the drug.

“It was quick and easy,” he said.

Getting heath care by phone or video conferencing has been around for several decades, but the outbreak of coronavirus has led to an increase in telemedicine use as never seen before, according to health systems and provider groups across the country.

Millions of Americans are seeking care by connecting with a doctor electronically, many for the first time. Health systems, insurers and physician groups said it allows people to practice social distancing while reducing the spread of the disease and protecting health workers.

Private technology companies such as Teladoc, Doctor On Demand and Amwell and large health care systems can provide a doctor directly to someone who contacts them. Other patients may seek a telemedicine appointment with their regular physician, who can use computer applications through smartphones and computers. All types of primary and specialty care and mental health services can be provided via telemedicine.

Many hospitals have recently added telemedicine services to keep patients concerned about the coronavirus from clogging their emergency rooms.

Also spurred by the goal to keep patients away from crowded medical facilities, government and private insurers have increased the payment for telemedicine visits so they are on par with in-person visits. Before the outbreak, insurers paid less than half that amount, which dissuaded many doctors from offering the services.

Medicare last week allowed all enrollees to use telemedicine — an option that previously was available only to people living in remote areas and for a specific, short checkup. The federal government also said doctors could practice across state lines during the pandemic to treat Medicare patients virtually, even if not licensed in the patient’s state. California, Florida and other states have also waived their requirements that a physician be licensed in the state to provide care.

The Cleveland Clinic is on track to log more than 60,000 telemedicine visits in March, according to officials there. Before March, that health system ― which has hospitals in Ohio and Florida — averaged about 3,400 virtual visits a month.

Its Express Care Online system serves patients across the country 24 hours a day. About 75% of the calls now come from people worried they have COVID-19, said Dr. Matthew Faiman, medical director of the service. Like many other health systems, Cleveland Clinic’s virtual urgent care is waiving patient copays during the pandemic.

“We are seeing a significant upsurge in demand from patients seeking care ― both the worried well and patients who are sick and wanting to know how to manage their symptoms,” Faiman said. The clinic has pulled more doctors into the telehealth work since elective surgeries were canceled and fewer patients are making in-person visits.

He applauded the Medicare changes and predicted such changes will likely stay after the national emergency ends.

Dr. Manish Naik, chief medical information technology officer at the Austin Regional Clinic in Texas, also predicted it will be hard to go back.

“Telemedicine has been on the brink for a while now,” Naik said. “And doctors and patients are going to find that when this is all over and the dust settles there are a lot of people who are going to want the telemedicine option to stay.”

Of course, such visits have limitations, such as when doctors need to listen to a patient’s lungs or order an X-ray to check for pneumonia. But Naik said telemedicine also gives doctors a more complete view of the patients through “observation around the home” and interactions there that shows “things we never could see before.”

Before March, NYU Langone Health in New York had about 50 virtual visits a day through its urgent care telemedicine platform. During the week of March 23, the hospital system is averaging about 900 a day.

For 80% of telemedicine visits, cough is the chief complaint followed by fever, said Dr. Paul Testa, its chief medical information officer. NYU Langone has 170 doctors who attend to telemedicine patients, up from 35 two weeks ago, he said.

“We are not recommending testing for everyone, but we are recommending self-care, hydration and self-isolation,” Testa added. “The goal is to create a new front line for these patients rather than have them rush into an urgent care or ER.”

If a patient is having trouble breathing or otherwise is in distress, an NYU telemedicine provider will direct them to call an ambulance if necessary or go to the ER and alert the hospital the patient is coming.

Teladoc is averaging 15,000 patient visits a day in the United States, 50% higher than in February. Wait times have increased from minutes to hours in some cases, a spokesperson said.

At the Austin Regional Clinic, which has 340 doctors in 28 offices, nearly half of patient visits are now virtual compared with a fraction before the outbreak.

“With the COVID-19 situation, we have patients who are nervous about coming in, and we don’t want patients with symptoms coming in and exposing others,” Naik said.

He said that for years the clinic made the telemedicine option available, but it did not make sense financially to promote it because insurers paid less than half the rate they would for an in-person visit.

The Medicare payment change can’t be understated, he said, because it covers such a large number of patients and because private insurers usually follow Medicare policies. “That’s really allowed us to open things up,” Naik said.

Advocates for decades have called on Medicare to expand telemedicine coverage, but federal officials held back because of concerns about increased costs. Critics worried telemedicine would not replace in-person doctor visits but lead to more total visits because of the ease with which people could connect to their doctors via telemedicine.

The Trump administration had been moving to widen telemedicine options even before the pandemic. In 2019, it allowed Medicare for the first time to pay doctors on average about $14 for a five-minute “check-in” phone call with their patients.

Ken Prussner, 74, of Herndon, Virginia, used his home computer Monday to connect with his longtime physician.

Prussner had a gastrointestinal illness and a low-grade fever and his family wanted to make sure he didn’t have COVID-19. His doctor’s office sent him a website link and his physician spoke to him as if he was in the office. He allayed Prussner’s fear, telling him he had a typical lower-bowel infection that would clear up on its own within three to five days.

“It was pretty seamless,” said Prussner, a retired U.S. Foreign Service officer.

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Under Financial Strain, Community Health Centers Ramp Up Coronavirus Response

On Tuesday, the Trump administration announced $100 million in supplemental funding for community health centers to support the response to the coronavirus pandemic.

“Health centers are playing a critical role,” said James Macrae, associate administrator at the federal Bureau of Primary Health Care.

About 29 million people in the U.S. rely on community health centers, which provide care to low-income and uninsured patients. As hospitals take on more COVID-19 patients, community health centers are reworking how they care for patients. Some safety-net clinics have instituted new infectious disease protocols and temporarily shifted resources away from routine primary care.

The new funding goes to 1,381 community health centers (many of which operate multiple clinics), primarily to support more COVID-19 testing, telehealth and the acquisition of personal protective equipment.

“It’s nowhere near what is needed, but we are thankful,” said Bob Marsalli, CEO of the Washington Association for Community Health, a group representing community health clinics in Washington state.

Marsalli said community health centers in the state are under increasing financial strain as they ramp up for the coronavirus battle, while also losing some key sources of funding.

“[Our clinics] are reallocating their workforce intelligently, but frantically, to keep up with the demand,” said Marsalli.

Rapidly Redesigning Systems

Under normal circumstances, HealthPoint, a community health center in Auburn, Washington, would encourage patients to walk into the clinic for all their medical needs, whether refilling a prescription or learning about nutrition.

“Usually our lobby is slammed,” said Dr. Esther Johnston. “It’s open space and everyone is together.”

But recently only a few patients in surgical masks were waiting for appointments. And Johnston is telling patients to stay away unless they absolutely need care.

“It is a bit frustrating and demoralizing, but it’s the reality of the situation,” she said.

HealthPoint runs more than a dozen clinics throughout western Washington. Now, at the entryway of its clinics, staff query everyone to identify COVID-19 symptoms and monitor patients to make sure they remain at a distance from one another once inside.

Johnston said the clinic was not set up to house an influx of patients with infectious diseases. There are limited exam rooms and each one needs to be shut down and cleaned after a patient suspected of having COVID-19 comes in.

“We just don’t have enough space to be able to do that on a routine basis,” she said.

Like many community health centers, HealthPoint’s model is built around bringing people into clinics for primary care. Now the organization is taking new precautions to prevent the spread of coronavirus and keep staff safe.(Will Stone for KHN)

Johnston worries about what’s coming as COVID-19 cases rise in her area.

“We pride ourselves on being a primary care home,” Johnston said. “We don’t have enough N95 masks, nor, to be honest, were we prepared for a situation where everyone had to be properly fitted.”

HealthPoint’s chief medical officer, Dr. Judy Featherstone, said most appointments are now done over the phone. Her staff is fielding calls from people concerned about symptoms, as well as new patients who want to have a doctor in case they contract the COVID-19 virus.

“It is a bit like taking 20 years of work and redesigning it in a week,” said Featherstone. “I think we are anticipating potential workforce problems.”

Like many clinics in Washington, HealthPoint has set up outdoor testing sites, but the supply of kits and personal protective gear, or PPE, limits the number of patients who can be tested for COVID-19.

New Financial Strain On Clinics

As fewer patients come in for care, the leadership worries about the center’s financial future. Clinics have switched to telephone-based appointments, but it took several weeks for Washington’s Medicaid program to adjust how it pays for those visits. Meanwhile, community health centers are eliminating routine dental visits, a key funding stream.

“You take those three factors … and you have already started to lose revenue before you’re gearing up for new ways of providing care,” said Michael Erikson, CEO of Neighborcare Health, which serves more than 70,000 Washington residents, over half of them on Medicaid. “We are on a pathway to losing $3 million a month.”

The Washington Association for Community Health projects that the cutback in dental care could lead to a $250 million shortfall for the state’s community health center system over the next nine months.

Vital Role In The Health System

Community clinics play an important role in serving patients who otherwise might have no place to go besides the ER. Erikson said his organization is trying to relieve some pressure on the hospital system by seeing patients with urgent health care issues not related to COVID-19.

“For instance, a wound care patient who has underlying diabetes, you do not want to expose that patient to a potential COVID environment,” said Erikson.

Some community clinic leaders now worry about losing staff to suspected or actual coronavirus infection.

“It is very critical that the clinics stay at full staff so only those who are critically sick are cared for at the hospital,” said Sheila Berschauer, CEO of Moses Lake Community Health Center, a rural health care provider in Washington that serves about a third of its county’s population of about 100,000.

If even five to 10 health care workers fall ill, Berschauer said, that could strain her organization and, as a result, possibly overwhelm the local hospital.

She said some patients still don’t appreciate the severity of the pandemic and become upset when they are sent to the outdoor testing site rather than into the clinic.

A health care worker at a health center outside Seattle said several patients have misrepresented their COVID-19 risks in order to get past screening.

“We had a patient make it all the way into the exam room before she revealed that her partner is COVID exposed, and she is feeling ill,” the employee said. The worker is worried about losing their job for speaking out, so NPR and KHN are not using the person’s name.

Health care workers who saw the patient were not wearing PPE because those limited supplies are reserved for patients known to be at risk of COVID-19.

“Now all of the providers and staff in that facility need to start self-monitoring for signs of infection,” the employee said. “If they get infected, then the entire clinic closes. It’s a big deal.”

This story is part of a partnership between NPR and Kaiser Health News.

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Scientists Are Learning Hard And Valuable Lessons About COVID-19, But Many Questions Are Still Unanswered

Shortfall Of Comfort Care Signals Undue Suffering For Coronavirus Patients

For Jill Hofstede, whose 90-year-old mother has Alzheimer’s disease, news about the coronavirus becomes more terrifying every day.

Although the potential shortages of mechanical ventilators and intensive care beds have made headlines, Hofstede fears a surge of COVID-19 patients could deprive her mother of something far more basic should she contract the disease: relief from pain and suffering.

“I do not want her to die of the virus,” said Hofstede, 57, a mother of five who lives in Brush Prairie, Washington. Even more crucially, Hofstede said, “I would not want her to suffer.”

“There should be some right to dying with dignity, even in the midst of a pandemic,” she said.

Some experts worry that a long-standing shortage of palliative care professionals ― who focus on the physical pain and mental and spiritual distress caused by serious illness — could leave many COVID-19 patients in distress.

“There is already a shortage, which will only worsen as demand goes up because of current events,” said Dr. Arif Kamal, a palliative care researcher at the Duke University School of Medicine.

The supply of palliative care teams could be further diminished if many health care providers become ill themselves.

Palliative care staffing could not meet the country’s needs even before the coronavirus appeared.

Among all U.S. hospitals with at least 50 beds, 72% provide palliative care, according to a report from the Center to Advance Palliative Care. That number is dramatically lower in certain states. Fewer than 40% of hospitals provide palliative care in Alabama, Mississippi, New Mexico, Oklahoma and Wyoming.

Yet palliative care is vital when patients are suffering, especially for those near death, said Dr. Diane Meier, director of the Center to Advance Palliative Care, a nonprofit organization.

Specialist palliative care teams are “a scarce resource, just like ventilators,” Meier said.

Patients in acute respiratory distress can survive only if they are put on a mechanical ventilator, which breathes for them until their bodies recover, said Dr. Greg Martin, president-elect of the Society of Critical Care Medicine, which represents intensive care doctors. Ventilators require specially trained staff, including critical care nurses and respiratory therapists, to set them up, monitor them and adjust the mix of air patients need.

A new report from the society concluded there is only enough hospital staff to operate 130,000 ventilators, although the country may need many more. That could lead to rationing and difficult decisions about which patients to save.

Kristen Goode said she fears that her 86-year-old grandfather, who has leukemia, will go without the comfort care or pain relief provided by palliative care teams

“There are a lot of things they can do to make sure patients aren’t suffering, but that takes time and personnel,” said Goode, 27, of Huntsville, Alabama.

Many hospitals recognize the valuable role palliative care teams play, Meier said.

“We are part of the command and control center at virtually every hospital we’re talking to,” Meier said.

Hofstede isn’t optimistic. “There is no way this small group of professionals will be able to meet the need,” she said.

She worries that because of the coronavirus pandemic frail patients like her mother “won’t even get into the hospital, that they will be turned away from  testing and not even get in the door.”

Hofstede, who cares for her mother at home, feels unequipped to treat a desperately sick patient. “I would hate for my loved one to be home and not get the medical assistance they need,” she said.

A new report from Imperial College London estimates that more than 1 million Americans could die from COVID-19. Studies show that older people are at greatest risk, according to the Centers for Disease Control and Prevention.

Dr. Rachelle Bernacki, a palliative care physician at Boston’s Dana Farber Cancer Institute, said she is already trying to make sure the hospital has key medications on hand.

“Palliative care is right on the front line” of the coronavirus outbreak, Bernacki said. “We are going to be playing a very important role. People will be leaning on us.”

Some COVID-19 patients with pneumonia develop a life-threatening complication called acute respiratory distress syndrome, in which fluid leaks into the lungs and makes breathing difficult or impossible. Patients who can’t breathe often become anxious and panicked, which can make it even harder to breathe, said Christopher Friese, a professor at the University of Michigan School of Nursing.

Doctors have many ways to relieve the suffering caused by COVID-19, said Dr. Christian Sinclair, associate professor of internal medicine at the University of Kansas Medical Center. These include oxygen masks or nasal tubes; drugs called bronchodilators that relax muscles in the airways and increase airflow to the lungs; low-dose morphine and anti-anxiety medications, such as Valium or Xanax, he said.

Simple measures can help COVID-19 patients being treated at home, as well, Sinclair said. He recommends helping patients sit up, which can ease breathing problems.

Studies show that patients who use handheld electric fans to blow air into their faces have less anxiety and breathe more comfortably, said Dr. Rab Razzak, clinical director of palliative care at University Hospitals Cleveland Medical Center. Razzak, who treats many patients with breathing problems unrelated to COVID-19, also teaches his patients breathing exercises often used in meditation.

Although a wide range of health professionals can prescribe medication, health providers who don’t specialize in palliative care may be unfamiliar with these therapies, said Arthur Caplan, a bioethics professor at NYU Langone Medical Center.

Caplan noted that palliative care professionals also excel in talking to patients and their loved ones about the end of life ― a topic many doctors avoid.

Razzak said his institution is training other health staff to deliver palliative care. And Vital Talk, a nonprofit that teaches communication skills to doctors, has created a “playbook” for talking to patients about coronavirus, including sample scripts doctors can follow.

More than 1,000 people registered for a March 18 webinar from the Center to Advance Palliative Care about preparing for COVID-19, Meier said. She had to turn others away because the computer system couldn’t handle any more.

During the webinar, Dr. R. Sean Morrison of the Icahn School of Medicine at Mount Sinai said, “Palliative care is everyone’s job. Everyone who comes in with severe COVID-19 is going to have breathlessness and respiratory symptoms,” two symptoms that palliative care doctors are accustomed to treating.

Even under normal working conditions, 22% of patients with serious illness say hospital staff was not attentive to their needs, while 18% reported getting conflicting information from hospital staff, according to a 2018 Commonwealth Fund report.

Goode said her past experience taking care of an elderly grandparent doesn’t inspire confidence that hospitals will be able to meet everyone’s needs.

Two years ago, Goode’s grandmother had a serious fall. An emergency room doctor told Goode that her grandmother — who had Alzheimer’s disease ― was bleeding internally, but was too frail to undergo surgery or other invasive medical interventions. Her grandmother waited 2½ hours to receive pain relievers. She died three days after the fall.

“This was the normal operations on a Thursday afternoon at a Level 2 trauma center,” Goode said. “If the health care system is so overwhelmed that they need to pick and choose who gets care, then they won’t have the bandwidth to administer a lot of the palliative care treatments, either.”

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Trump’s Boast About U.S., South Korea Coronavirus Testing Misses The Mark

Boasting about his administration’s response to the coronavirus crisis — and arguing the outbreak would soon be under control — President Donald Trump claimed that recent American efforts to test widely for COVID-19 surpass those of other countries.

“We’ve done more tests in eight days than South Korea has done in eight weeks,” Trump said during a March 24 virtual town hall hosted by Fox News, reiterating a statement made just moments before by Dr. Deborah Birx, the head of the White House coronavirus response. The statement was repeated during the White House briefing that evening.

Trump doubled down the next day, tweeting that “over an eight day span, the United States now does more testing than what South Korea (which has been a very successful tester) does over an eight week span.”

Why the comparison with South Korea? South Korea has been heralded globally for its swift response to the pandemic, which appears to have slowed its rate of new infections. Meanwhile, a national shortage of tests has hamstrung American efforts, resulting in many people at risk being forced to delay testing until they are seriously ill.

With that context, we were curious. Is the president’s claim accurate? Has American testing been as robust as his statement indicates?

We contacted the White House and Centers for Disease Control and Prevention but never heard back. But the numbers suggest his picture is inaccurate and, more important, missing crucial context to understanding the battle against COVID-19.

The Raw Numbers

South Korea publishes a daily report of how many tests it has performed. As of Tuesday, 348,582 people had been tested, and testing began in early February. About 9,000 of those people were confirmed to have the virus. (The 345,582 figure includes tests that were run but hadn’t yet yielded results.)

In the United States, it’s harder to tell. The CDC doesn’t put out updated, aggregated counts of tests performed in public and private labs — which is important to note. Since the start of March, a large chunk of American-done tests have been conducted in commercial — not government-run — labs.

Experts pointed us to a credible tally that suggests that, on the raw numbers, the president’s stat is flawed.

The COVID Tracking Project, a dataset managed and updated by volunteer journalists and scientists, estimates that, as of Tuesday, American labs had performed a total of about 359,000 tests for COVID-19. That tally comes from state and local health departments around the country, including testing done in both public and commercial labs.

From March 15 through Tuesday, the United States conducted about 331,000 of those tests, per the tracker.

The raw comparison, then, suggests that the United States’ eight-day tally falls short of South Korea’s eight-week tally. Out of curiosity, we looked at the March 23 data for South Korea as well. At that point, it had run 338,036 tests. So even if Trump was off by a day, the American figure falls short.

And, experts reminded us, this raw-data comparison isn’t that meaningful. If you want to compare data between the two countries, you need to look at the bigger picture.

More Effective Comparisons

Put simply, “raw numbers are not the best metric, given population size differences,” said Jennifer Kates, a global health researcher at the nonprofit Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

That’s because the United States is simply a much larger country than South Korea — about 327 million people, compared with about 51.5 million.

To account for that, researchers serious about comparing the nations’ responses would adjust to per capita rates of testing. That shows the extent to which the number of tests performed gauges how many people are at risk of infection.

“If a country has five people in it, of course they could only have five tests,” said Dr. Robert Gallo, director of the Institute of Human Virology at the University of Maryland School of Medicine and a co-discoverer of HIV.

When you control for population, the American response compares poorly. Its tally of 359,000 tests per 327 million people works out to about 1,084 tests per million. South Korea has run closer to 6,768 tests per million.

Put another way, South Korea’s testing rate for coronavirus is more than six times that of the American rate. To catch up, Kates noted, American labs would need to perform 2.24 million more tests — not an insurmountable task, but definitely a lift.

It’s not just the number of tests performed, either. Researchers have stressed repeatedly that the timing of when the tests were run is also a big part of the equation. Both nations reported their first cases on the same day, Jan. 20.

In the entire month of February, American labs ran fewer than 1,000 coronavirus tests, per the volunteer COVID tracker. (Government health officials had begun sounding the alarm in January.)

By Feb. 29, South Korea had completed more than 55,000 tests, with almost 30,000 awaiting confirmation, for a total of more than 80,000 tests performed.

“For the assertion … the U.S. has done more #COVID19 testing in the last 8 days than South Korea cumulatively, that doesn’t mean anything,” tweeted Dr. Eric Topol, a physician and researcher. “Nearly 0 tests were done for 2 months when they were desperately needed.”

What’s Needed Now

Many public health researchers say the U.S. is still not running enough diagnostics daily to meet demand — arguing that, though there has been significant improvement, labs need to be doing about 150,000 tests per day.

Right now, the COVID tracker suggests about 65,000 tests are being run per day. While that is a substantial increase from even a week ago, it’s still well below the target number.

Beyond testing, there’s the question of what happened after results were confirmed. Patients infected, epidemiologists argue, should be targeted, caught early and quickly separated from other people. That’s key to stopping the spread of the virus — and something that still hasn’t happened on a large scale.

“South Korea followed up tests vigorously to support isolation and quarantine — the steps needed to reduce spread,” said Dr. Joshua Sharfstein, vice dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health in Baltimore. “The U.S. has a long ways to go to develop this critical capacity.”

Our Ruling

Trump claimed that the United States has “done more tests in eight days than South Korea has done in eight weeks.”

The CDC has not put out comprehensive data on this. But independent work on the subject suggests the comparison is flawed. In eight days, the United States performed almost as many tests as South Korea did in eight weeks, but not necessarily more.

In addition, that statistic is relatively less important. The American rate of testing per capita is more than six times lower than South Korea’s. It’s certainly possible to catch up, but that hasn’t happened yet.

The president’s statement frames the data in a way that is misleading and doesn’t accurately represent the status of the American response to COVID-19. We rate it False.

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