The High Price of Lowering Health Costs for 150 Million Americans

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The Problem

Employers — including companies, state governments and universities — purchase health care on behalf of roughly 150 million Americans. The cost of that care has continued to climb for both businesses and their workers.

For many years, employers saw wasteful care as the primary driver of their rising costs. They made benefits changes like adding wellness programs and raising deductibles to reduce unnecessary care, but costs continued to rise. Now, driven by a combination of new research and changing market forces — especially hospital consolidation — more employers see prices as their primary problem.

The Evidence

The prices employers pay hospitals have risen rapidly over the last decade. Those hospitals provide inpatient care and increasingly, as a result of consolidation, outpatient care too. Together, inpatient and outpatient care account for roughly two-thirds of employers’ total spending per employee.

By amassing and analyzing employers’ claims data in innovative ways, academics and researchers at organizations like the Health Care Cost Institute (HCCI) and RAND have helped illuminate for employers two key truths about the hospital-based health care they purchase:

1) PRICES VARY WIDELY FOR THE SAME SERVICES

Data show that providers charge private payers very different prices for the exact same services — even within the same geographic area.

For example, HCCI found the price of a C-section delivery in the San Francisco Bay Area varies between hospitals by as much as:$24,107

Research also shows that facilities with higher prices do not necessarily provide higher quality care. 

2) HOSPITALS CHARGE PRIVATE PAYERS MORE

Data show that hospitals charge employers and private insurers, on average, roughly twice what they charge Medicare for the exact same services. A recent RAND study analyzed more than 3,000 hospitals’ prices and found the most expensive facility in the country charged employers:4.1xMedicare

Hospitals claim this price difference is necessary because public payers like Medicare do not pay enough. However, there is a wide gap between the amount hospitals lose on Medicare (around -9% for inpatient care) and the amount more they charge employers compared to Medicare (200% or more).

Employer Efforts

A small but growing group of companies, public employers (like state governments and universities) and unions is using new data and tactics to tackle these high prices. (Learn more about who’s leading this work, how and why by listening to our full podcast episode in the player above.)

Note that the employers leading this charge tend to be large and self-funded, meaning they shoulder the risk for the insurance they provide employees, giving them extra flexibility and motivation to purchase health care differently. The approaches they are taking include:


Steering Employees

Some employers are implementing so-called tiered networks, where employees pay more if they want to continue seeing certain, more expensive providers. Others are trying to strongly steer employees to particular hospitals, sometimes know as centers of excellence, where employers have made special deals for particular services.

Purdue University, for example, covers travel and lodging and offers a $500 stipend to employees that get hip or knee replacements done at one Indiana hospital.

Negotiating New Deals

There is a movement among some employers to renegotiate hospital deals using Medicare rates as the baseline — since they are transparent and account for hospitals’ unique attributes like location and patient mix — as opposed to negotiating down from charges set by hospitals, which are seen by many as opaque and arbitrary. Other employers are pressuring their insurance carriers to renegotiate the contracts they have with hospitals.

In 2016, the Montana state employee health planled by Marilyn Bartlett, got all of the state’s hospitals to agree to a payment rate based on a multiple of Medicare. They saved more than $30 million in just three years. Bartlett is now advising other states trying to follow her playbook.

In 2020, several large Indiana employers urged insurance carrier Anthem to renegotiate their contract with Parkview Health, a hospital system RAND researchers identified as one of the most expensive in the country. After months of tense back-and-forth, the pair reached a five-year deal expected to save Anthem customers $700 million.

Legislating, Regulating, Litigating

Some employer coalitions are advocating for more intervention by policymakers to cap health care prices or at least make them more transparent. States like Colorado and Indiana have passed price transparency legislation, and new federal rules now require more hospital price transparency on a national level. Advocates expect strong industry opposition to stiffer measures, like price caps, which recently failed in the Montana legislature. 

Other advocates are calling for more scrutiny by state and federal officials of hospital mergers and other anticompetitive practices. Some employers and unions have even resorted to suing hospitals like Sutter Health in California.

Employer Challenges

Employers face a few key barriers to purchasing health care in different and more efficient ways:

Provider Power

Hospitals tend to have much more market power than individual employers, and that power has grown in recent years, enabling them to raise prices. Even very large employers have geographically dispersed workforces, making it hard to exert much leverage over any given hospital. Some employers have tried forming purchasing coalitions to pool their buying power, but they face tricky organizational dynamics and laws that prohibit collusion.

Sophistication

Employers can attempt to lower prices by renegotiating contracts with hospitals or tailoring provider networks, but the work is complicated and rife with tradeoffs. Few employers are sophisticated enough, for example, to assess a provider’s quality or to structure hospital payments in new ways. Employers looking for insurers to help them have limited options, as that industry has also become highly consolidated.

Employee Blowback

Employers say they primarily provide benefits to recruit and retain happy and healthy employees. Many are reluctant to risk upsetting employees by cutting out expensive providers or redesigning benefits in other ways.recent KFF survey found just 4% of employers had dropped a hospital in order to cut costs.

The Tradeoffs

Employers play a unique role in the United States health care system, and in the lives of the 150 million Americans who get insurance through work. For years, critics have questioned the wisdom of an employer-based health care system, and massive job losses created by the pandemic have reinforced those doubts for many.

Assuming employers do continue to purchase insurance on behalf of millions of Americans, though, focusing on lowering the prices they pay is one promising path to lowering total costs. However, as noted above, hospitals have expressed concern over the financial pressures they may face under these new deals. Complex benefit design strategies, like narrow or tiered networks, also run the risk of harming employees, who may make suboptimal choices or experience cost surprises. Finally, these strategies do not necessarily address other drivers of high costs including drug prices and wasteful care. 

One-third of US adults postponed care during pandemic: reports

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Dive Brief:

  • About 36% of nonelderly adults and 29% of children in the U.S. have delayed or foregone care because of concerns of being exposed to COVID-19 or providers limiting services due to the pandemic, according to new reports from the Urban Institute and Robert Wood Johnson Foundation.
  • Of those who put off care, more than three-quarters had one or more chronic health conditions and one in three said the result of not getting treatment was worsening health or limiting their ability to work and perform regular daily activities, the research based on polling in September showed.
  • However, the types of care being delayed are fairly routine. Among those surveyed, 25% put off dental care, while 21% put off checkups and 16% put off screenings or medical tests.

Dive Insight:

The early days of the pandemic saw widespread halts in non-emergency care, with big hits to provider finances. 

In recent months, health systems have emphasized the services can be provided in hospitals and doctors offices safely as long as certain protocols are followed, and at least some research has backed them up. Groups like the American Hospital Association have launched ad campaigns urging people to return for preventive and routine care as well as emergencies.

But patients are apparently still wary, according to the findings based on surveys of about 4,000 adults conducted in September.

The research shows another facet of the systemic inequities harshly spotlighted by the pandemic. People of color are more likely to put off care than other groups. While 34% of Whites said they put off care, that percentage rose to 40% among Blacks and 36% among Latinos.

Income also played a role, as 37% of those with household incomes at or below 250% of the poverty level put off care, compared to 25% of those with incomes above that threshold.

Putting off care has had an impact industrywide, as the normally robust healthcare sector lost 30,000 jobs in January. Molina Healthcare warned last week that utilization will remain depressed for the foreseeable future.

Younger Americans were also impacted, with nearly 30% of parents saying they delayed at least one type of care for their children, while 16% delayed multiple types of care. As with adults, dental care was the most common procedure that was put off, followed by checkups or other preventative healthcare screenings.

The researchers recommended improving communications among providers and patients.

“Patients must be reassured that providers’ safety precautions follow public health guidelines, and that these precautions effectively prevent transmission in offices, clinics, and hospitals,” they wrote. “More data showing healthcare settings are not common sources of transmission and better communication with the public to promote the importance of seeking needed and routine care are also needed.”

Hospital, insurer and employer groups band together in bid to achieve universal coverage

https://www.healthcarefinancenews.com/news/hospital-insurer-and-employer-groups-band-together-bid-achieve-universal-coverage

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The groups said that Americans “deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all.”

This week, a coalition of healthcare and employer groups called for achieving universal health coverage by expanding financial assistance to consumers, bolstering enrollment and outreach efforts, and taking additional steps to protect those who have lost or are at risk of losing employer-based coverage because of the economic downturn caused by the COVID-19 pandemic.

The Affordable Coverage Coalition encompasses groups representing the nation’s doctors, hospitals, employers and insurers. They include America’s Health Insurance PlansAmerican Hospital AssociationAmerican Medical AssociationAmerican Academy of Family Physicians, Blue Cross Blue Shield Association, Federation of American Hospitals and the American Benefits Council.

They have banded together to advocate for achieving universal coverage via expansion of the Affordable Care Act, which is supported by President Biden. Biden also intends to achieve universal coverage through a Medicare-like public option — a government-run health plan that would compete with private insurers.

WHAT’S THE IMPACT

Despite a lot of pre-election talk about universal healthcare coverage from elected officials and those vying for public office, achieving this has remained an elusive goal in the U.S. In a joint statement of principles, the groups said that Americans “deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all.”

“Achieving universal coverage is particularly critical as we strive to contain the COVID-19 pandemic and work to address long-standing inequities in healthcare access and outcomes,” the groups wrote.

The organizations support a number of steps to make health coverage more accessible and affordable, including protecting Americans who have lost or are at risk of losing employer-provided health coverage from becoming uninsured.

They also want to make Affordable Care Act premium tax credits and cost-sharing reductions more generous, and expand eligibility for them, as well as establish an insurance affordability fund to support any unexpected high costs for caring for those with serious health conditions, or to otherwise lower premiums or cost-sharing for ACA marketplace enrollees.

Also on the group’s to-do list: Restoring federal funding for outreach and enrollment programs; automatically enrolling and renewing those eligible for Medicaid and premium-free ACA marketplace plans; and providing incentives for additional states to expand Medicaid in order to close the low-income coverage gap.

THE LARGER TREND

The concept of universal coverage is gaining traction among patients thanks in large part to the COVID-19 pandemic. In fact, A Morning Consult poll taken in the pandemic’s early days showed about 41% of Americans say they’re more likely to support universal healthcare proposals. Twenty-six percent of U.S. adults say they’re “much more likely” to support such policy initiatives, while 15% say they’re somewhat more likely.

As expected, Democrats were the most favorable to the idea, with 59% saying they were either much more likely or somewhat more likely to support a universal healthcare proposal. Just 21% of Republicans said the same. Independents were somewhere in the middle, with 34% warming up to the idea of blanket coverage.

More than 21% of Republicans said they were less likely to support universal care in the wake of the COVID-19 crisis. Seven percent of independents reported the same, while for Democrats the number was statistically insignificant.

During his campaign, President Joe Biden said he supported a public option for healthcare coverage. He also pledged to strengthen the Affordable Care Act. By executive order, Biden opened a new ACA enrollment period for those left uninsured. It begins February 15 and goes through May 15.

Department of Justice tells Supreme Court it supports Affordable Care Act

https://www.healthcarefinancenews.com/news/department-justice-tells-supreme-court-it-supports-affordable-care-act

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Under the Biden Administration, the DOJ says the ACA can stand even though there is no longer a tax penalty for not having health insurance.

The Department of Justice, under the Biden Administration, has told the Supreme Court that it has changed its stance on the Affordable Care Act

The DOJ previously filed a brief contending that the ACA was unconstitutional because the individual mandate was inseverable from the rest of the law.

Following the change in Administration, the DOJ has reconsidered the government’s position and now takes the position that the ACA can stand, even though there is no longer a mandate for consumers to have health insurance or face a tax penalty, according to a February 10 filing.

WHY THIS MATTERS

Hospitals and health systems support the change in position.

“Without the ACA, millions of Americans will lose protections for pre-existing conditions and the health insurance coverage they have gained through the exchange marketplaces and Medicaid. We should be working to achieve universal coverage and preserve the progress we have made, not take coverage and consumer protections away,” said American Hospital Association CEO and president Rick Pollack. 

The Supreme Court is expected to return a decision before the end of the term in June.

THE LARGER TREND

The Supreme Court heard oral arguments on November 10, 2020 regarding whether the elimination of the tax penalty made the remainder of the ACA invalid under the law.

The DOJ sided with the Trump Administration and Republican states that brought the legal challenge, while 20 Democratic attorneys general supported the ACA and asked the court for quick resolution.

They were led by California Attorney General Xavier Becerra, who is Biden’s pick to head the Department of Health and Human Services.

Hospitals ask Supreme Court to reverse payment cuts

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The American Hospital Association, other trade groups and individual hospitals filed petitions Feb. 10 asking the U.S. Supreme Court to reverse appeals court decisions in two cases involving outpatient payment cuts to hospitals. 

One lawsuit hospitals are asking the Supreme Court to hear challenges HHS’ payment reductions in 2019 for certain outpatient off-campus provider-based departments. 

Under the 2019 Medicare Outpatient Prospective Payment System final rule, CMS made payments for clinic visits site-neutral by reducing the payment rate for evaluation and management services provided at off-campus provider-based departments by 60 percent.

In an attempt to overturn the rule, the AHA, the Association of American Medical Colleges and dozens of hospitals across the nation sued HHS. They argued CMS exceeded its authority when it finalized the payment cut in the OPPS rule. They further claimed the site-neutral payment policy violates the Medicare statute’s mandate of budget neutrality. 

HHS argued that under the Bipartisan Budget Act of 2015 it has authority to develop a method for controlling unnecessary increases in outpatient department services. Since “method” is not defined in the statute, the government argued its approach satisfies generic definitions of the term. U.S. District Judge Rosemary M. Collyer rejected that argument and set aside the regulation implementing the rate reduction in September 2019.

HHS filed an appeal in the case, and the appellate court reversed the lower court’s decision July 17.

The second lawsuit hospitals are asking the Supreme Court to hear challenges HHS’ nearly 30 percent cut to 2018 and 2019 outpatient drug payments for certain hospitals participating in the 340B Drug Pricing Program. 

A district court sided with hospitals and found the payment reductions were unlawful. Two members of a three-judge panel of the U.S. Court of Appeals overturned that ruling in July. 

The hospitals argue in both petitions that the Supreme Court should review the cases because of the “excessive deference” the appeals court gave to HHS’ interpretation of the respective governing statutes. 

Drugmakers sue HHS over 340B advisory opinion in feud over contract pharmacy access

Hospital associations sue HHS over 340B enforcement

Drug companies AstraZeneca, Eli Lilly and Sanofi filed separate lawsuits seeking to preserve their ability to restrict offering 340B-discounted drugs to contract pharmacies.

The lawsuits, filed Tuesday in different federal courts, seek to get rid of an advisory opinion filed by the Department of Health and Human Services’ (HHS’) general counsel that says drug companies must offer 340B drugs to contract pharmacies, which are third-party entities that dispense drugs on behalf of hospitals participating in the program.

The drug companies argue that the advisory opinion contracts the statute for the 340B program, which requires manufacturers to offer discounted products to safety net hospitals and other providers in exchange for participation in Medicare and Medicaid.

“The statute, on its face, does not require manufacturers to recognize any contract pharmacies, much less unlimited contract pharmacies,” the legal filing from AstraZeneca said.

AstraZeneca wants a federal court to declare the advisory opinion didn’t follow proper procedure and exceeded HHS’ statutory authority. The manufacturer also wants a court to declare that companies are not required to offer 340B discounts to contract pharmacies.

The lawsuits come less than a week after the American Hospital Association (AHA) and five other groups and three individual systems sent letters to the drug companies that have halted or restricted sales to contract pharmacies. They wanted the drugmakers to reinstate sending the discounted products to their pharmacies and reimburse facilities for any damages.

AHA and several groups sued HHS to get the agency to clamp down on the drug manufacturers’ moves.

AstraZeneca, Eli Lilly, Novartis, Novo Nordisk, Sanofi and United Therapeutics have taken a range of actions to clamp down on sales to contract pharmacies, which a majority of 340B-covered entities use.

The companies have argued that the discounts do not filter down to patients, but hospital and advocacy groups charge that the discounts are vital, especially as safety net providers operate on thin margins.

“Make no mistake: the boom in contract pharmacies has been fueled by the prospect of outsized profit margins on 340B discounted drugs,” AstraZeneca argued in its court filing.

Could coronavirus derail the decades-long shift to value-based care?

As the coronavirus sickens tens of thousands of Americans while pressuring the bottom lines of medical providers, analysts worry the pandemic could also hit pause on the decades-long march toward value-based care, as hospitals and doctors look to recoup revenue in the short-term instead of putting more dollars at risk.

Massive health systems and independent physician offices alike are diverting funds to shore up resources like personal protective equipment, ventilators and staff to prepare for an expected influx of COVID-19 patients or to cope with those already there. Expenses are skyrocketing as providers halt non-essential visits including lucrative elective procedures like joint replacements, winnowing down a major source of revenue.​

Clinicians in value-based payment arrangements face higher levels of financial risk than their fee-for-service counterparts. Money spent preparing for the coronavirus and treating COVID-19 patients will be a sunk cost and they could be dinged financially again at the end of the year when their spending and performance is evaluated.

Already, the coronavirus is leading providers to think about exiting the models.

survey published this week of more than 220 accountable care organizations nationwide found almost 60% are likely to drop out of their risk-based model to avoid financial losses. Some 77% are “very concerned” about the coronavirus’ impact on their 2020 performance.

“The value-based movement is at a critical juncture,” wrote National Association of ACOs CEO Clif Gaus in a letter to CMS Administrator Seema Verma last month.

Fee-for-service still dominates — roughly 40% of healthcare payments made in 2018 were under fee-for-service, according to the Health Care Payment Learning & Action Network (LAN) — but it’s been on the downswing. One in three healthcare payments currently flows through some sort of alternative payment model, and that has been projected to grow.

Among the four main types of value-based arrangements — shared risk, global capitation, bundled care and shared savings —​ most require an upfront financial commitment. And providers are unlikely to put more capital at risk given the current economic situation, analysts told Healthcare Dive, instead focusing on making up the losses they sustained during the outbreak by ramping up capacity.

Doctor’s offices and hospitals will reschedule delayed procedures and even operate on weekends to recapture as much revenue as possible before they’re likely to consider taking on more risk.

“Even if you’re not in the hotspots, you are preparing right now. This puts on hold a lot of the initiatives that have been on the value-based side of things,” Jefferies senior healthcare analyst Brian Tanquilut told Healthcare Dive. “I don’t think the value-based discussion goes away, but I think it will take a recovery of the hospital system before it can go there.”

Pleas for loss waivers

The National Association of ACOs told CMS in mid-March that ACOs in Medicare’s flagship ACO program the Shared Savings Program, along with other shared risk models like the Next Generation ACO model and the upcoming Direct Contracting initiative, could face losses beyond their control because of the pandemic.

CMS did pause some reporting requirements for value-based initiatives late last month. The agency pushed back the deadline for groups participating in the Medicare ACO program, Merit-based Incentive Payment System and the Hospital Readmissions Reduction Program to report quality data, or waived reporting entirely for the fourth quarter of 2019. The relaxation was framed as a way to help value-based organizations free up time and resources amid the pandemic.

But provider groups including NAACOS and the American Hospital Association have lobbied aggressively for the Trump administration to forgive all ACO losses for 2020. CMS is reviewing their request.

But all normal rules have gone out the window, experts say, and it’s almost impossible to move the needle toward value in the future when providers are facing a tsunami of patients now.

“This is not about managing a population. This is about doing everything you can to keep these people alive,” Dean Ungar, vice president of Moody’s Investors Service, told Healthcare Dive. “Coronavirus is really a five-alarm fire. But if your building’s on fire, that doesn’t really tell you how to maintain your business in normal circumstances.”

Silver lining?

Some, however, are more optimistic that the unique financial challenges brought on by the pandemic highlight the problems with the traditional fee-for-service model and could even nudge providers toward value-based arrangements down the line.

“If all of your revenue is based on patients walking in the door, when they can’t walk in the door anymore, you’re kind of up the creek without a paddle,” Dan Bowles, SVP of growth and network operations at accountable care organization Aledade told Healthcare Dive. “You need to find a way to create non-visit-based revenue.”

Some hope the pandemic could help the value-based movement in the long term as practices look for ways to uncouple revenue from patient volume. And, as medical costs continue to rise, accounting for 19% of the country’s GDP, any pause in the shift to value-based care due to the coronavirus is likely to be a short detour, not a complete derailment.

“Maybe some providers are going to see it in a different light when their business kind of dries up — see that there’s a benefit to it,” Ungar said. “Ultimately, it’s a trend of where things are going, but it’s a big ship and it’s moving slowly.”

And value-based care arrangements were built predominantly for the populations being hit hardest by the coronavirus: those with serious underlying medical conditions like chronic lung disease or severe obesity.

If those vulnerable patients were being treated in value-based arrangements, it’s possible more COVID-19 cases could have been caught earlier before they became life-threatening, Moody’s analyst Stefan Kahandaliyanage told Healthcare Dive. That could renew industry’s focus on managing the health of those most at-risk from novel infectious diseases in the future.

“Costs are very high and there’s been a pandemic,” Kahandaliyanage said. “Let’s get more healthy before the next pandemic comes.”

Hospitals that don’t submit daily COVID-19 data could lose participation in Medicare, Medicaid

US Department of Health and Human Services moves to Microsoft Office 365

Hospitals currently not reporting daily COVID-19 data have a few months to get in compliance or risk being thrown out of Medicare and Medicaid.

The Department of Health and Human Services (HHS) announced Tuesday it will send notices to all hospitals over their requirements for reporting COVID-19 data to the Trump administration.

Any hospital not in compliance with the daily reporting requirements will have 14 weeks to get in line or risk their participation in Medicare and Medicaid, officials said.

The agency gave an enforcement timeline that gives “hospitals ample opportunity to come into compliance,” said Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma on a call with reporters Tuesday.

The Trump administration wants hospitals to submit daily data that includes COVID-19 deaths and hospitalizations as well as patients currently in the intensive care unit with the virus. Hospitals must submit data on the ages of patients admitted with suspected COVID-19 infections. Facilities need to also report their inventory of the COVID-19 therapy Remdesivir, any staffing shortages and the number of ventilators. Every week hospitals also report data on their personal protective equipment on hand and supply of critical medications.

Facilities now must also report on new data for influenza cases. “The new requirements will allow us to gather critical information on influenza at hospitals across the U.S.,” said Centers for Disease Controls and Prevention Director Robert Redfield, M.D.

Verma said that the large majority of hospitals in CMS’ system are already reporting this data to the agency. CMS will also give hospitals that are not in compliance a wide berth to get them into compliance.

Hospitals will be sent multiple notices over the 14-week timeline to get their data reporting in line.

“This work of getting hospitals into compliance around reporting has been an ongoing effort,” Verma said.

CMS proposed the mandatory daily reporting requirements back in August, much to the chagrin of hospital advocates. 

The American Hospital Association (AHA) said that CMS tying Medicare and Medicaid participation to compliance “remains an overly heavy-handed approach that could jeopardize access to hospital care for all Americans,” according to a statement released Tuesday. 

“Today’s interpretive guidance on COVID data reporting does answer some of the questions hospitals and health systems have been asking about compliance since the interim final rule was released six weeks ago,” the group said. “In particular, the Administration will provide hospitals with information on whether their data are making it into HHS Protect and they will give hospitals the necessary time to adjust their data collection to come into compliance if need be.”

The Federation of American Hospitals called the new rules “sledgehammer enforcement.”

“It is both inappropriate and frankly overkill for CMS to tie compliance with reporting to Medicare conditions of participation,” said FAH President and CEO Chip Kahn in a statement.

Providers win Medicare loan extension, DSH relief but lose other asks in stop-gap spending law

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Dive Brief:

  • A stop-gap funding bill the president signed into law Thursday will keep the government open until mid-December and includes some provisions that could help providers’ bottom lines. The bill includes relief on advanced and accelerated Medicare loans and a delay of Medicaid payment cuts for disproportionate share hospitals.
  • The legislation extending government funding at current levels was passed by the House earlier this month and approved by the Senate on Wednesday. But more sweeping aid many providers wanted, including more grants for hospitals and a higher federal match rate for Medicaid, were left out of the legislation.
  • Provider groups like the American Hospital Association thanked Congress and the Trump administration for the relief, but AHA noted it would continue lobbying for Medicare loan forgiveness and an extended deadline for the Medicaid DSH cuts.

Dive Insight:

The continuing resolution, and its healthcare provisions within, are pretty much the only direct aid providers can expect from Washington before the looming November presidential election. Congress has largely punted on a fifth round of COVID-19 relief legislation amid partisan deadlock, with Republicans backing a much skinnier package than Democrats.

The CR delays the repayment date for $100 billion in advanced Medicare loans to providers by a year. CMS originally planned to start recouping the loans from providers’ fee-for-service Medicare payments in late July, but unilaterally decided to hold off as lawmakers negotiated the bill.

It also lowers the rate of recoupment to 25% for the first 11 months of repayment, down from the current 100% rate, and 50% for the next six months. Providers have 29 months to pay back the funds in full before interest kicks in, and the interest rate is decreased from 9.6% to 4%.

The original repayment terms and timeline would have been difficult for some cash-strapped doctor’s offices and hospitals to meet, as the burden imposed by COVID-19 hasn’t lifted and is worsening in many areas of the country. Many providers took out the loans earlier this year as a lifeline to stave off insolvency — still a very real threat for many practices.

About 35% of primary care physicians say revenue and income are still significantly lower than pre-pandemic levels, losses that could force them to close, according to a September survey by the Larry A. Green Center and the Primary Care Collaborative.

AHA CEO Rick Pollack said in a Wednesday statement the massive hospital association appreciated the provisions, but would keep pushing for full loan forgiveness, along with extending the delay of DSH cuts for all of the 2021 fiscal year. The CR pushed back the original payment cut start date from Dec. 1 to Dec. 12.

The Association of American Medical Colleges was more worried about the impact on the system.

“We are concerned that health care providers, researchers, students, and public health professionals — who have been our country’s first line of defense against COVID-19 — will remain in limbo despite ongoing challenges that the pandemic presents,” CEO David Skorton said in a statement. “We strongly believe that a larger COVID-19 legislative relief package is essential to our nation’s health.”

However, drastic estimates from providers on financial losses largely haven’t panned out, though public health experts do warn COVID-19 could worsen going into the winter months. AHA estimated U.S. hospitals would see operating profits fall by almost $51 billion in April, the month with the sharpest volume decline because of the pandemic. It’s likelier hospitals lost about half that, according to research from a congressional advisory board, with federal grants covering the worst of short-term losses.

The CR also includes a provision stopping Medicare beneficiaries from seeing a monthly $50 Part B premium hike next year. It will keep the government open until Dec. 11, setting up another funding fight to avoid a shutdown after the election.

 

 

 

 

The N95 shortage America can’t seem to fix

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Nurses and doctors depend on respirator masks to protect them from covid-19. So why are we still running low on an item that once cost around $1?

The patient exhaled. She lifted her tongue for a thermometer. She raised her finger for a blood sugar test, and that’s when she started coughing. One cough can send 3,000 droplets into the air, one droplet can contain millions of coronavirus particles, and now some of those particles were heading for the face of emergency department nurse Kelly Williams.

The nurse inhaled. Strapped over her mouth and nose was an N95 respirator, the disposable filtering mask that has become the world’s most reliable and coveted defense against the virus.

N95s were designed to be thrown away after every patient. By this July afternoon, Williams had been wearing the same one for more than two months.

To get to her, the N95 had traveled from a British factory to a Baltimore warehouse, in a supply chain as tangled and layered as the web of microscopic fibers inside the mask’s filter.

It was purchased by Johns Hopkins Hospital, the famed medical institution that has tracked cases of the novel coronavirus around the world since the pandemic’s start. When its map of dots marking clusters of infections began to show pools of red across the United States, Hopkins was quietly unpacking a stock of personal protective equipment it had been building for over a year — a literal lifesaver when the onslaught of covid-19 cases led to a massive shortage of N95s.

Six months later, that shortage persists, leaving health-care workers exposed, patients at risk and public health experts flummoxed over a seemingly simple question: Why is the world’s richest country still struggling to meet the demand for an item that once cost around $1 a piece?

At Hopkins, nurses are asked to keep wearing their N95s until the masks are broken or visibly dirty. Williams, a 30-year-old from Georgia with a marathoner’s endurance and a nurse’s practicality, went into health care after working for three years in the corporate offices of retailers Abercrombie & Fitch and Under Armour. She understood supply chains. She believed that the makers of N95s, anticipating the pandemic’s eventual end, would invest only so much in expanding production. She believed it was her duty, on top of risking her life for her patients, to make her disposable respirator mask last through as many 12-hour shifts as she could.

When the country was short of ventilators, the companies that made them shared their trade secrets with other manufacturers. Through the powers of the Defense Production Act, President Trump ordered General Motors to make ventilators. Other companies followed, many supported by the government, until the terrifying problem of not enough ventilators wasn’t a problem at all.

But for N95s and other respirators, Trump has used this authority far less, allowing major manufacturers to scale up as they see fit and potential new manufacturers to go untapped and underfunded. The organizations that represent millions of nurses, doctors, hospitals and clinics are pleading for more federal intervention, while the administration maintains that the government has already done enough and that the PPE industry has stepped up on its own.

As the weather cools and the death toll climbs, America’s health-care workers fear that when winter comes, they still won’t have enough respirators. And the longer the shortage lasts, the longer N95s will remain largely out of reach for millions of others who could be protected by them — teachers and day-care workers, factory employees and flight attendants, restaurant servers and grocery store clerks.

While the pandemic that has killed almost 200,000 Americans drags on, Williams will keep trying to conserve her respirator, wearing it as she rushes in and out of virus-filled rooms, touches virus-shedding patients, and now, comforts a covid-positive woman who is having a coughing fit.

“How can I help you feel a little more comfortable?” Williams asked her patient, who was in her 80s. The woman was about to be admitted to the hospital. Her oxygen level was too low, so they had to run tubes of air into her nostrils. If her situation didn’t improve, a ventilator could come next.

This was the routine in the part of the emergency department Williams called “Covidland.” She’d just risked exposure to care for this woman, but she would never get to find out what happened to her.

She could only take a deep breath through her N95, roll her patients upstairs and hope that she would never become one of them.

‘The gauntlet’

Before the N95 was on her face, it was in a plastic wrapper, in a box, on a shelf inside an East Baltimore warehouse four miles from the hospital. The 165,000-square-foot building had concrete floors, rolling doors, overhead lighting — unremarkable, except to a man named Burton Fuller.

Fuller, a 38-year-old father of three, had once planned on becoming a doctor. Instead, he went into hospital supply chains. It was the kind of job that didn’t earn many follow-up questions at dinner parties. But six months after Fuller was hired at Hopkins, the pandemic made him the person that everyone relied on and no one envied. It was up to him to keep 40,000 employees in six hospitals safe.

Even before covid-19, masks were key to that equation. There are surgical masks, which protect a patient from a nurse’s germs, and respirator masks, which protect a nurse from the patient. Humans have recognized the need for protective masks since at least A.D. 77, when Pliny the Elder wrote about wearing animal bladders as face coverings to make breathing easier in lead-filled mines.

The evolution of early masks brought leather beaks stuffed with straw and herbs to ward off the bubonic plague, and long beards that firefighters would wet and clamp between their teeth. Once the far more effective gas mask became standard for coal miners breathing in silica and soldiers facing chemical weapons, engineers at the Minnesota Mining and Manufacturing Company, better known as 3M, started trying to make a protective respirator that wasn’t so bulky. They realized in the 1960s that the technology used to make pre-made gift bows could also make a mask that was a lightweight, molded cup. And so began the single-use respirator as it exists today.

Inside that cup, and more recently, inside the flat-fold versions, is the key component: fibers 1/50th the width of a human hair, blown together in an intricate web that creates an obstacle course for dangerous particles. An electrostatic charge works like a magnet to trap the floating menaces and attach them to the fibers. If an N95 is fitted properly — a metal nose piece folded snugly, no beard in the way — less than 5 percent of even the most difficult-to-catch particles will make it into the lungs.

At Hopkins, Fuller’s job was to get manufacturers to deliver N95s and other equipment directly to the warehouse, rather than through a distributor. In 2019, the shelves started to fill up, and on one of them was the N95 that would make its way to nurse Kelly Williams. The respirator had been made by 3M at a plant in Aycliffe, a town of 7,000 in northern England.

But this Hopkins stockpile was rare in the world of hospitals, where costs were cut by using medical supply companies to provide equipment when it was needed, rather than letting PPE pile up.

Hospital administrators knew that in cases of natural disaster, chemical warfare or what global health officials used to call “Disease X,” the federal government had its own warehouses in secret locations, filled with PPE.

Except that in 2009, while Fuller was in his first job out of college, the H1N1 flu epidemic depleted 85 million N95s from the national stockpile — and the supply was never replenished. In 2013, 2014, 2016 and 2017, public health officials published alarming reports warning of a “massive gap” in what remained. Even more concerning, they said, the vast majority of N95s and the materials needed to manufacture them were now being made in Asia.

The Department of Health and Human Services did fund the invention of a “one-of-a-kind, high-speed machine” that could make 1.5 million N95s per day. But when the design was completed in 2018, the Trump administration did not purchase it.

This year, as the virus spread from Wuhan to Washington state, HHS turned down a January offer from a manufacturer who could make millions of N95s. The agency didn’t start ordering N95s from multiple companies until March 21. Paul Mango, deputy chief of staff for policy at HHS, would later call that timeline “friggin’ light speed … the fastest this has ever been done.”

By then, the United States had 8,000 reported coronavirus cases and 85 deaths, and health-care workers were panicking over PPE shortages.

Fuller’s orders began being canceled. As the Hopkins emergency department was being readied for covid-19 patients, and Williams was being told she would need to start wearing an N95, the hospital’s administration decided not to reveal how many N95s were in the warehouse.

“Only a half a dozen people know,” Fuller said. “Behavioral economics say that if we communicate a number someone perceives as high, they will use the supply more gratuitously. If we communicate a number they perceive as low, they may hoard to ensure there is enough.”

As the boxes of N95s were loaded into trucks headed for Hopkins hospitals, Fuller and a dozen staff members entered what he would come to call “the gauntlet.” Every hospital and health department in the country was competing for N95s and other PPE, a mess of bidding wars, price gouging and worthless knockoff masks. Fuller uncovered one scam when a company CEO, claiming to be based in Indianapolis, didn’t recognize the name of the city’s most famous steakhouse.

“For every mask shipment we have been able to bring in,” Fuller said, “there are 10 or 15 transactions we have had to terminate.”

He worked so much that his wife, home with their children, received flowers from Hopkins executives. He joked about the other crucial stockpile in his life, his wine collection.

Fuller was desperate to make the stockpiled N95s last as long as possible. He wanted every employee wearing one to also wear a face shield, but those, too, were impossible to find.

So at the end of March, the warehouse filled with folding tables spaced six feet apart. Volunteers were given foam strips, elastic straps and sheets of plastic to make homemade shields. At one of the most prestigious medical institutions in the country, they were trying to fix the problem for themselves, with scissors, staplers and hot glue guns.

‘Bracing yourself’

A face shield was clipped to Williams’s belt in the middle of May, when for only the fourth time during the pandemic, she unwrapped a new N95.

After nine weeks in and out of Covidland, she had come to trust in her disposable respirator. It hurt her nose, gave her acne and made breathing hard. But the power of its protection was starting to give her back the feeling of safety she’d lost in March when she and the dozens of colleagues who worked alongside her each shift watched the areas where they’d cared for gunshot victims and heart attack patients turn into isolation rooms. They were tested to make sure the N95s fit their faces and taught to use other respirators that looked like gas masks or blew clean air into a hood.

And then, they were slammed. The first covid patient to go on a ventilator at Hopkins was a 40-year-old who worked out every day. The ambulance bay became a testing center. Williams’s co-workers were crying in the break room. Her patients couldn’t breathe, and then tubes were going down their throats, and then it felt like she couldn’t breathe, like everything she knew about nursing would never be enough.

“Our lives changed overnight,” she said. “You’re bracing yourself for people to die.”

She started silently saying a prayer she knew, every morning, every few hours, then sometimes 20 times a day in Covidland.

God, grant me the serenity to accept the things I cannot change, it began. She said it before her patient started violently shaking and flailing, seizing in his bed. She couldn’t run out the door to ask for help, because to leave the room without potentially taking the virus out, she had to sanitize her gloves, trash them, take her gown off, trash it, exit into an antechamber, take off her first layer of gloves, sanitize her hands and wipe down her face shield. So she ran to the window and banged on it, then ran back to her patient, trying to hold him down, her face inches from his.

Courage, to change the things I can, the prayer continued. Williams said it in the car that she drove to work and wouldn’t let any member of her family touch. Its speakers blared Lizzo-filled playlists she used to pump herself up for what she told her friends was an “awesome learning experience.” She had been a nurse for only two years. Her job in merchandising at Under Armour had brought her to Baltimore, where she met her husband, Sean, and his two children. They were the ones to make her realize that she wanted a job where she could actually see the impact of all those hours she worked. Now, every day might be the day she took the virus home to them.

Grant me the serenity to accept the things I cannot change, courage, to change the things I can, and wisdom to know the difference. Another day in Covidland, and Williams was wearing her new N95, pumping her palms into an unconscious man’s chest, not thinking of all the particles flying out of his airways. Another, and her face shield popped off and clattered to the floor. Another, and a young Latina mother told Williams she couldn’t self-quarantine because she could not afford to stay home from work.

Another, and Williams was watching the chest of a middle-aged man rise and fall by the force of a ventilator. Outside the walls of the hospital on this day in July, America seemed to have moved on from the conversation about the shortage of N95s. Instead, people were fighting over simple cloth masks.

Maybe this patient had worn one. Maybe he’d said he didn’t believe in them. Either way, it was her job to take care of him. Williams suctioned virus-filled fluid from his airways, and breathed in again.

‘Not profitable’

The radio advertisements could be heard across South Dakota, playing inside cars passing billboards plastered with the same message: 3M is hiring in Aberdeen. In a state that hosted 460,000 people at an August motorcycle rally and requires no one to wear a mask sits the largest respirator plant in the United States.

Its N95 manufacturing lines have been running 24 hours a day, 7 days a week since Jan. 21, the same day public health officials announced the arrival of the coronavirus in Washington state.

Plant manager Andy Rehder hired 200 new employees this year and was still looking for more this summer so he could staff another N95 line being built. Rehder, whose wife wears an N95 as a hospital social worker, had a Bloomberg Magazine article from March displayed in his office. The headline asked, “How do you make more masks yesterday?”

The question still hangs over the plant, and the entire country, nearly six months after that article was published.

Ask the Trump administration, and the N95 shortage is nearly solved. Rear Adm. John Polowczyk, whom Trump put in charge of securing PPE, said that by December, 160 million N95s will be made in the United States per month. By his calculations, that will be enough to handle a “peak surge” from hospitals, clinics, independent physicians, nursing homes, dentists and first responders. The Strategic National Stockpile has 60 million N95s on hand, and states are rebuilding their stockpiles.

“I’ve got production up to what we think is the limits of what we need,” Polowczyk said. “I believe now that hospital systems are making management decisions that might lead to an appearance that we still don’t have masks, which is the farthest from the truth.”

But ask the people inside hospitals, and the shortage is far from over. An August survey of 21,500 nurses showed 68 percent of them are required to reuse respirators, many for more than the five times recommended by the CDC, and some even more than Kelly Williams. One Texas nurse reported she’s still wearing the same five N95s she was given in March.

Many health-care facilities that ordered KN95s, Chinese-made masks meant to have a similar filtering efficiency, gave up on them after realizing that the looser fit left workers in danger. The N95 shortage is more acute for primary care physicians, home health aides and hospice workers. But even for many hospital systems, the situation remains “fragile and challenging,” the American Hospital Association said this month.

“Maddening, frustrating, mind-blowing, aggravating, that’s the polite language for it,” said American Medical Association President Susan Bailey, who still hears from doctors who do not have respirators. “There has been such an outpouring for support for ‘health-care heroes.’ Everybody knows now how important it is for our front-line health-care workers to be able to work in a safe environment. … And yet, that desire doesn’t seem to be turning into a reality.”

The AMA, AHA, American Nurses Association and the AFL-CIO all point to the same solution: broader use of the Defense Production Act, which gives the president power over funding for the production and distribution of critical supplies during crises.

In August, Trump stood before a group of socially distanced reporters, praising himself for using the DPA “more comprehensively than any president in history.”

“There was a time,” he said, “when the media would say, ‘Why aren’t you using it? Why aren’t you using it?’ Well, we have used it a lot, where necessary. Only where necessary.”

That’s not what it looks like to the man who used to run Trump’s DPA program within the Federal Emergency Management Agency. Larry Hall, who retired last year, said the authority has been executed in an “ad hoc, haphazard fashion.”

Along with ordering 3M to import 166.5 million masks from China, the administration has used the DPA to invest $296.9 million in bolstering the N95 and filter-making supply chains. The Department of Defense, which oversees that funding, spends more per year on instruments, uniforms and travel for military bands.

“By not having a national strategy,” Hall said, “we have fewer masks.”

Ask the PPE industry and the refrain is that without long-term guarantees that the government will keep buying respirators, N95 manufacturers are wary of investing too much, and other companies that could start making respirators or the filters for them are hesitant to do so.

Peter Tsai, the scientist who invented a method to charge the fibers inside the respirator filter, knows why: “It is not profitable to make respirators in the United States,” he said. It can take six months just to create one manufacturing line that makes the N95′s filter.

But there is a workaround, Tsai said. Companies that already make similar filters — for vehicle emissions, air pollution and water systems — can modify their equipment to make N95 filters.

While Tsai, 68, has been fielding hundreds of calls from hospitals and researchers trying to sanitize N95s with heat and ultraviolet light, he has been working with Oak Ridge National Laboratory in Tennessee to woo the 15 to 20 American companies that have the potential to produce respirator filters more quickly.

The government has funded just three of these companies through the DPA.

Others have gradually joined in on their own. But then those filters have to be made into respirators, and those respirators have to be approved by NIOSH, the National Institute for Occupational Safety and Health.

The entire process has moved at a glacial pace in comparison with the flurry of activity that rid the country of its ventilator shortage. Ventec, a company known for its efficient, toaster-size ventilators, handed its plans over to General Motors so that the auto company, under the DPA, could mass produce a product that was known to work. Other ventilator companies followed, handing over their trade secrets to Ford, Foxconn and other major manufacturers.

But when GM started making N95s, engineers with expertise in car interiors and air bags were charged with figuring out the process from scratch, the company said. Although they received advice from major mask makers, there were no groundbreaking corporate partnerships this time. The first N95s GM made were rejected by NIOSH. The second design didn’t correctly fit most people.

Other potential manufacturers went through the same challenges as GM, failing tests and making flat-fold N95s that experts worry do not offer a tight enough seal.

“If there was some kind of intellectual sharing, they wouldn’t be doing that,” said Christopher Coffey, who was the associate director for science in the NIOSH approvals program before retiring in January.

The DPA does have a provision that would allow manufacturers to work together without being subject to antitrust laws. But it has yet to be used for N95s.

Instead, established U.S. makers of N95s, whose products have been successfully protecting miners, construction workers and health-care professionals for decades, have continued to protect their processes as intellectual property.

Though 3M helped Ford make the far more expensive powered respirators, which blow clean air into a hood, the company has not entered into any major partnerships with outside manufacturers to make N95s. Asked why, 3M declined to explain, instead pointing to its other pandemic partnerships.

Ford gained its own approval to manufacture disposable respirators but has made just 16,000 of them while focusing instead on face shields and surgical masks. Other major U.S. manufacturers of N95s, including Honeywell and Moldex, have kept their manufacturing in-house, too.

“Folks aren’t likely to share that information outside of their own company,” said Jeff Peterson, who now oversees NIOSH approvals. NIOSH employees may know how 3M makes its respirators and the filters inside them. But by contract, they can’t tell other manufacturers how to do the same.

Meanwhile, 3M continues to dominate the American N95 market. While other parts of its business, such as office supplies and industrial adhesives, have struggled during the pandemic, 3M has invested $100 million to expand domestic production of respirators from 22 million to 50 million per month. Once the new production line is up and running in South Dakota in October, that number is expected to reach 95 million per month in the United States.

It still won’t be enough.

“Even though we are making more respirators than ever before and have dramatically increased production,” 3M spokeswoman Jennifer Ehrlich said, “the demand is more than we, and the entire industry, can supply for the foreseeable future.”

‘I just don’t get it’

Her N95 was already on, but Williams’s hands were slipping as she tried to force on a pair of gloves. She could hear the alarms going off. One of her patients was crashing, and she had to get into the room.

She should be able to just go, her runner’s legs carrying her to the bedside. But in Covidland, there were two closed doors standing in her way. She had started wearing her N95 all day so she could be ready for this moment. She pulled on her gown and another set of gloves and her face shield, reached for the door — and realized the patient inside was her 13-year-old stepson Kellen.

She jolted awake. She was in her bed. Her husband was asleep beside her. She slid out from her sheets and went downstairs to check on her stepchildren. Kellen and 19-year-old Alle were sleeping, too.

The nurse inhaled. She could still hear the alarms.

This is what it meant now, to be a health-care worker: across the country, nurses and doctors were reporting increased sleeplessness, anxiety, depression and post-traumatic stress.

Williams reminded herself that she’d always had an N95, and the heavier, more protective respirators she sometimes wore instead.

But she knew, too, that covid-19 had taken the lives of more than 1,000 health-care workers, including a New Jersey primary care doctor who, determined to keep his practice open, doubled up on surgical masks when his N95 orders didn’t come. And a California nurse who rushed into a covid patient’s room to perform chest compressions. She saved his life, then doused her hair in hand sanitizer. She hadn’t been given an N95 at the beginning of her shift.

And then there was the news that shook every health-care worker Williams knew: Less than two miles from Hopkins, the head of the ICU at Mercy Hospital died after contracting the virus in July.

Joseph Costa was one of the people who’d guided the hospital through its PPE shortage early in the pandemic. His husband, David Hart, remembered him coming home and saying, “This is my mask for the week.” Neighbors pushed N95s through their mailbox slot.

“This is the United States of America, and we can’t seem to get factories built to deliver this stuff? I just don’t get it,” Hart said.

He will never know exactly how his husband, who insisted on caring for covid patients alongside his staff, became infected. Costa died in the ICU, the gloved hands of his colleagues on him as he went. Minutes later, they returned to caring for other patients.

At Mercy, at Hopkins, at every hospital that had found a way to get N95s, health-care workers wore their PPE to try to save the lives of people who contracted the virus because they had none.

Williams and her colleagues didn’t need to see the statistics to know that the pandemic was disproportionately affecting Black and Brown people, especially those deemed essential workers. They saw it in their patients and heard it from their families and friends.

Williams worked side by side with Shanika Young, a nurse whose brother seemed to have every known covid-19 symptom before he started to recover.

Afraid of infecting anyone in her community, Young went weeks without seeing her parents and newborn niece. She adopted a hound-mix puppy to have a friend when she couldn’t see her own. In the weeks that followed the killing of George Floyd, she agonized over her decision to stay away from the protests. She knew there wouldn’t be N95s there.

On a sweltering August morning, she left her dog in her apartment and packed her respirator in her car. She, too, re-wore her mask, but usually for four or five 12-hours shifts.

Now Young was taking it across Baltimore, not toward the hospital, but to a predominantly Hispanic neighborhood with one of the worst infection rates in the city.

During the pandemic, Baltimore has seen outbreaks in its homeless shelters, its trash-collecting facility and its jail. Now every place Young drove by fell on one side or the other of a new dividing line in America: those who have PPE and those who don’t. Bodegas, restaurants, nail salons and funeral homes. Downtown, a nonprofit’s dental clinic remained shuttered. She passed a mental health counseling center where sessions were still conducted only by video, and a physical therapist who wore KN95s to see clients. She parked near a school that, without N95s, had no way of ensuring its teachers were protected. It serves primarily Latino children, all of whom would be forced to learn online.

In the parking lot of the church, a booth that used to sell $1 snow cones had been transformed into a coronavirus testing center run by a team of Hopkins doctors and nurses.

On her day off, Young volunteered to work with them, spending hours sweating in her scrubs, sending swabs deep into nose after nose. She wore a surgical mask on top of her N95.

“I don’t think there’s any science that says this is actually safer,” she said. “But it’s just a mental thing.”

The line of people sweating on the asphalt was so long, Young couldn’t see the people at the end: a man in painter’s clothes, a mother pushing a stroller and a woman who, like Young, was wearing scrubs. Stitched onto the chest was the name of a retirement home.

‘Hazard’

The coughing patient was starting to fall asleep when Williams left her in the covid unit. Her shift had been over for more than 30 minutes. She checked in to make sure there was no one else who needed her help and headed for the locker room. She washed her hands twice. She used alcohol wipes to sanitize her phone, glasses, ID badges and pens.

She took off her N95, and she inhaled.

For the first time in two months, she decided that this respirator was done. Its straps were starting to feel too stretched. The shape of it looked just a little too warped.

Instead of hanging the N95 from a hook in her locker to air dry, she stuffed it in a bag marked “hazard.”

A new mask, still in its plastic packaging, was waiting for her next shift. She would wear it as long as possible, especially after learning that the Hopkins stockpile had run out of the British-made mask she wore and couldn’t get any more. She needed to change to a different type of N95, one that felt unfamiliar once again. She told herself that she was grateful just to have it. She told herself that it would protect her just the same.