Testing Nursing Home Workers Can Help Stop Coronavirus. But Who Should Pay?

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Like all nursing home workers in New York State, Shikilia Davis is required to get a test for coronavirus twice a week, part of a state order aimed at containing the startling death toll of residents in nursing homes.

But late last month, Ms. Davis said her employer, Apex Rehabilitation & Healthcare on Long Island, sent her home after she refused to provide her insurance card before getting tested. She said the nursing home wanted to bill her health insurer rather than paying for the test itself, even though Ms. Davis’s insurer has declined to cover the tests.

“This is a bill I do not want to get stuck with,” said Ms. Davis, who works as a dietary aide at Apex, where, according to state data, 33 people died or were believed to have died from the virus. She feared that the lab company could hold her responsible for paying the bill once her insurance claim was denied. “I don’t have money lying around.”

The dispute over who should pay for worker testing is at the messy heart of a national effort to reduce the virus’s spread in nursing homes by screening workers and residents. It has become a hot-button labor issue for some of the nation’s most poorly paid health care workers.

A report released on June 4 by the Centers for Medicare and Medicaid Services, which oversees most nursing homes in the United States, estimated that almost 32,000 residents have died of the virus, more than one-fourth of all Covid-19 deaths in the country.

Regular testing of nursing home staff — who come and go each day from their workplaces, potentially introducing the virus to the facilities and spreading it to residents — is seen as one of the most important ways to contain outbreaks. The first significant outbreak in the United States was in a nursing home in the Seattle area, and the virus has killed residents in many facilities in New York and New Jersey.

Like so many aspects of the U.S. response to the pandemic, the effort has been stymied by a lack of federal coordination and a patchwork of state policies. In California, nursing homes have been given conflicting instructions from local and state governments. Some states, like Ohio, are sending in the National Guard to help administer tests. Others, like New Jersey, require testing but have pushed the logistics and costs onto the nursing homes. Still other states, like Alabama, have not issued any requirements for testing.

Even at the federal level, different agencies are offering conflicting advice. C.M.S., the oversight agency, wants nursing homes to test workers weekly, but has not made it a requirement. The Centers for Disease Control and Prevention, however, has said that facilities can adjust how often they test workers based on the local prevalence of coronavirus.

Adm. Brett P. Giroir, the assistant secretary of health who has been overseeing the government’s testing response, said last Wednesday that the federal government had done a good job of communicating with nursing homes and states. “C.M.S. expects all nursing home residents to get a baseline test, and that everybody who works in that nursing home should be tested weekly until we get further knowledge,” he said. “I think we’ve been pretty clear about that.”

Testing every nursing home resident and worker would be a significant undertaking. Dr. Ashish Jha, the director of the Harvard Global Health Institute, has estimated that screening all residents and staff once every two weeks would add up to 150,000 tests a day. The American Health Care Association, which represents for-profit nursing homes and assisted living centers, has said that testing all 3 million workers and residents just once will cost $672 million.

One of the most contentious details has been the question of who should pay for it.

Tests of nursing home residents can be billed to insurers like Medicare and Medicaid, but the question of who pays for workers’ testing is less clear. Nursing home employees are some of the lowest paid workers in the health care industry and often work by the hour, and for multiple facilities. Many do not have health insurance, and about 42 percent of workers who care for older people receive some kind of public assistance.

Nursing homes, which have received nearly $5 billion in federal stimulus funding to cover coronavirus expenses — including testing — have pushed back against paying for the tests, and asked for more government help. Insurers have also said they should not be required to pay.

Nowhere is this playing out more dramatically than in New York, where Gov. Cuomo has faced criticism in April over his now-rescinded policy of requiring nursing homes to accept infected patients from hospitals.

In early May, he issued an executive order that all workers — whether full or part time, contract workers or on staff — must be tested twice a week. The state identified labs that nursing homes could hire to do the testing, and has provided supplies to facilities that said they did not have enough.

New York also issued an opinion that the workers’ tests were “medically necessary,” and should be covered by insurance. If insurance did not cover, the state said, the nursing homes would be responsible to pay for the tests, which cost about $100.

ImageDr. David Nace, the chief medical officer at the University of Pittsburgh Medical Center’s senior communities, had blood drawn for an antibody test.
Dr. David Nace, the chief medical officer at the University of Pittsburgh Medical Center’s senior communities, had blood drawn for an antibody test.Credit…University of Pittsburgh Medical Center

But despite the state’s position, some insurers have said they will not cover the screening tests, including a large benefit fund that is jointly run by employers like hospitals and nursing homes and the union that represents their workers, 1199SEIU United Healthcare Workers East. The benefit fund’s lawyers ruled that under federal law, union health funds must be used only for the benefit of the workers’ health and not for other reasons. These tests were similar to health screenings that many employers routinely pay for, such as drug tests or physicals. “It’s their responsibility to pay,” Lorraine Brown-Zanders, the union vice president for Long Island, where Apex is located, said of the nursing homes. “But now you’re going to punish the workers?”

Nursing homes say they cannot afford to be saddled with the full cost of a test. “We need to work in partnership with the state to ensure the cost — the extensive cost — of these tests are covered,” said Stephen B. Hanse, the president and chief executive of the New York State Health Facilities Association, which represents nursing homes in the state.

Meanwhile, workers say they are caught in the middle. Ms. Davis is a member of the 1199SEIU union. Ms. Brown Zanders said the benefit fund sent Apex and other nursing homes a letter in early May saying they would not cover the tests.

Ms. Davis said she ended up getting tested at free sites around Long Island and submitting the results to the nursing home so she could return to work. The administrator of Apex did not return emails and calls requesting comment.

A state trade group for health insurers, the New York Health Plan Association, said it did not know whether its members were refusing to cover the workers’ tests, but that they had received no clear guidance from the federal government over what was required.

“This confusion is compounded by rapidly changing and sometimes conflicting guidelines as well as uncertainties about the reliability and value of certain tests,” Eric Linzer, the group’s president and chief executive, said in a statement. “We await more guidance as well as answers to these ever-evolving concerns.”

  • Frequently Asked Questions and Advice

    Updated June 5, 2020

    • How does blood type influence coronavirus?

      A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.

    • How many people have lost their jobs due to coronavirus in the U.S.?

      The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.

    • Will protests set off a second viral wave of coronavirus?

      Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.

    • How do we start exercising again without hurting ourselves after months of lockdown?

      Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

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      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

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      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

Nationally, a similar standoff is also playing out. The National Association of Insurance Commissioners has asked the federal government for better guidance about how screening tests should be covered, but an association spokeswoman said the group has not yet received a response. A spokeswoman for America’s Health Insurance Plans, an industry trade group, said it was also waiting for federal advice on employee testing.

“It is essential that strategies that addresses workplace testing be part of an overarching public and occupational health strategy, and that federal guidance clearly articulate the roles of insurance providers, employers and public health officials,” the spokeswoman, Kristine Grow, said in a statement.

Adm. Giroir said last Wednesday that insurers, who are required to cover medically necessary coronavirus tests under the federal CARES act, should not be asked to cover worker screenings. “We would expect that to be borne either by the employer directly or under the state plan,” he said in a call with reporters.

Meanwhile, nursing home operators say that even though they want to test residents and staff, a poorly coordinated plan has made their job difficult.

Dr. David A. Nace, the chief medical officer of UPMC Senior Communities in Pittsburgh, which operates nursing homes and assisted-living facilities, said when he talks to colleagues around the country, many say they still struggle to find enough supplies to do the testing. “It still remains limited, despite what anybody’s going to tell you,” he said.

Carol Silver Elliott, the president and chief executive of Jewish Home Family, a consortium of senior care services that includes a nursing home in northern New Jersey, said she had to scramble to find a lab that could process hundreds of tests. Under an executive order, nursing home workers should be regularly tested, but the lab she had been using could only do a few at a time, and had a turnaround of several days.

“As we were wringing our hands over this, one of my colleagues” — someone who worked at another nursing home — “sent me an email and she said they had heard of a lab out of Colorado that had testing available,” she said. Ms. Silver Elliott said she grabbed the phone and called immediately, and the lab had enough capacity to receive her tests by overnight mail.

Jewish Home Family, a nonprofit, is self-insured, meaning it directly pays for workers’ health costs. She said they are spending about $50,000 on testing, although some of that is reimbursed by insurance.

Ms. Silver Elliott said there were 22 deaths in the nursing home because of the virus, and 6 deaths in the assisted living facility. She noted that New Jersey homes must pay for the tests themselves, while other states have covered the cost. “We got no guidance, no assistance, no support — nothing,” she said.

“The biggest lesson, to be honest with you, is that we can only depend on ourselves,” she said. “And I feel sort of sad when I say that, but that’s the reality.”