Category Archives: Physician

CMS rolls back more Medicare, telehealth regs for providers working through pandemic

Posted on by • Posted in American Medical Association (AMA), Coronavirus, Diagnostic Testing, Health Policy, Health System, Hospital, Hospital Industry, Hospital Outpatient Departments, Medicaid, Medicare, Medicare ACO, Nursing Home, Occupational Therapy, Office Visit, Pharmacist, Physical Therapy, Physician, Primary Care, Speech Language Pathologists, Telemedicine, Virtual Visit • Leave a comment

https://www.healthcaredive.com/news/CMS-second-round-COVID-rollbacks/577199/

 

How Telemedicine Is Changing Healthcare

Dive Brief:

  • CMS issued a another round of sweeping regulatory rollbacks Thursday that will temporarily change how some providers care for patients and get compensated during the ongoing pandemic.
  • Practitioners such as therapists previously restricted from providing telehealth services for reimbursement can now do so, and CMS is also upping payments for telephone-only telehealth visits. Accountable care organizations also scored a major win in the Thursday rule drop, with CMS pledging they wouldn’t be dinged financially for lower-than-expected health outcomes in their patient populations from COVID-19.​
  • Other major changes are related to COVID-19 testing for Medicare and Medicaid beneficiaries. A written practitioner’s order is no longer needed for diagnostic testing for Medicare payment purposes. The agency also said it will cover serology, or antibody testing, including certain FDA-authorized tests that patients self-collect at home.

Dive Insight:

The new rules come out of the recent public health emergency declaration, building on others announced in late March and early April. This round of changes, which take effect immediately, focuses on expanding testing capacity to help reopen the U.S. economy, according to CMS, along with delivering expanded care to seniors.

Major provider lobbies the American Hospital Association and American Medical Association praised the changes, noting that Medicare patients have been canceling needed medical appointments because of physical distancing and transportation challenges.

The Trump administration, which allowed traditional Medicare to temporarily cover telehealth in March, continues to expand virtual care access. CMS is expanding the types of specialists allowed to provide telehealth services for reimbursement to include physical therapists, occupational therapists, speech language pathologists and others. In the past, only doctors, nurse practitioners, physician assistants and certain others could do so.

Earlier changes included waiving the video requirement for telehealth patients without access to interactive audio-video technology – particularly those in rural areas. CMS is increasing payments for telephone visits from a range of about $14-$41 to about $46-$110, according to the release.

The rollbacks are a “major victory for medicine that will enable physicians to care for their patients, especially their elderly patients with chronic conditions who may not have access to audio-visual technology or high-speed Internet,” the AMA said.

Michael Abrams, managing partner of Numerof & Associates, a healthcare consulting firm, said the current, rapid adoption of telehealth is an experiment, and depending on the results, waivers could eventually become permanent.

“Once you increase pricing, you almost never roll it back,” Abrams said. “If this new pricing on telehealth visits makes it more attractive, attractive enough to substitute telehealth for in-office visits, that not only lowers the cost of care, but makes it very much more accessible, particularly for those whose ability to see a physician is limited.”

In a victory for ACOs, CMS said the value-based organizations wouldn’t incur any financial penalties because of COVID-19 testing and treatment for their patient populations. Roughly 60% of ACOs said previously they were likely to drop out of their risk-based model to avoid potential losses, according to the National Association of ACOs.

CMS is also allowing ACOs to remain at the same level of risk for another year, instead of bumping them up to the next risk level. NAACOs said it was “appreciative” of the changes in a statement, though they asked for additional relief for providers in two-sided risk arrangements.

Other loosened restrictions include those on who can administer COVID-19 diagnostic tests for payment to include any healthcare professional authorized to do so under state law, including pharmacists. Medicare and Medicaid recipients can now get tested at parking lot sites operated by pharmacies and other entities for reimbursement.

Outpatient hospital services such as wound care, drug administration, and behavioral health services can now be delivered in temporary expansion locations, including parking lot tents, converted hotels or patients’ homes for reimbursement, so long as they’re temporarily designated as part of a hospital.

Hospital outpatient departments that relocate off-campus are paid at lower rates under current law, but CMS is making a temporary exception to continue paying those physicians at their standard rates.

The agency will also pay for certain partial hospitalization services – that is, individual psychotherapy, patient education, and group psychotherapy – that are delivered in temporary expansion locations, including patient homes.

CMS is also now requiring nursing homes to inform residents, their families, and representatives of COVID-19 outbreaks in their facilities.

 

 

 

CMS suspends advance payments to providers, is reevaluating accelerated payments for hospitals

Posted on by • Posted in 2020 Election Issues, Cash, Cash Reserves, Cash-Flow Improvements, Center for Medicare and Medicaid Services (CMS), Coronavirus, Crisis, Crisis Management, Dept of Health and Human Services (HHS), Economic Crisis, Economic Stimulus, Health Policy, Health System, Hospital, Hospital Industry, Medicare, Paycheck Protection Program, Physician, Physician Practice Management, Supply Chain, The CARES Act • Leave a comment

https://www.fiercehealthcare.com/hospitals-health-systems/cms-suspends-accelerated-payment-program?mkt_tok=eyJpIjoiWXpNMlpXUTVaakpoTmpJMSIsInQiOiJzU3ViK3ZwV0oyMUxOS3N5T0tXY3h1anlUSW5ndTJ0MDlEMkE1S3BGRDg1Mlc1eDdpY3hGaHRCV0U1eUpFbWxhR3ZoSVlRdlU5M1NCek5FamxZZ0NLMEhxQ25teFwvNVwvSFEzYnlETEpuMnlZM0FJYThWeEhTcUFodElZUEcwS1RlIn0%3D&mrkid=959610

CMS suspends advance payments to providers, is reevaluating ...

The Trump administration is suspending a program that offered advanced payments to providers and reevaluating another program that offered accelerated payments to health systems after doling out about $100 billion. 

The Centers for Medicare & Medicaid Services (CMS) announced over the weekend it is immediately suspending its Advance Payment Program to Medicare Part B suppliers such as doctors, non-physician practitioners and durable medical equipment suppliers.

The agency is reevaluating the amounts that will be paid under its Accelerated Payment Program, which have been made available to fee-for-service Medicare providers such as hospitals in light of the $100 billion already sent to providers through the program.

CMS had expanded the loan programs to ensure providers and suppliers had resources needed to combat COVID-19 as many began furloughing or laying off workers due to sharp revenue drops from elective care amid the COVID-19 response.

CMS approved more than 24,000 applications under the program and advanced more than $40 billion to Part B suppliers in the last several weeks. It approved 21,000 applications for accelerated payments, totaling nearly $60 billion in payments to hospitals.

Prior to COVID-19, the agency had only approved just over 100 of such requests.

The advanced and accelerated payments are not grants, but instead payments that are required to be paid back within one year, officials said.  

In a release, CMS officials said the actions are also being taken “in light of the $175 billion recently appropriated for healthcare provider relief payments,” the agency said, referring to $100 billion allocated in the CARES Act as well as $75 billion allocated to providers through the Paycheck Protection Program and Health Care Enhancement Act.

The Department of Health and Human Services is distributing that money through the Provider Relief Fund. Those funds will be used to support healthcare-related expenses or lost revenue attributable to the COVID-19 pandemic and to ensure uninsured Americans can get treatment for COVID-19, officials said.

Among the recipients of the funding, HCA Healthcare said it benefited from about $4 billion in accelerated Medicare payments provided under the CARES Act, saying that money will be repaid over an eight-month period beginning in August. HCA also received about $700 million of funds from the first phase of the public health and social services emergency fund.

Those two pieces of economic assistance have had the greatest impact in stabilizing the health system’s financials amid challenges presented by COVID-19, HCA officials said during a recent conference call with analysts.

 

 

 

U.S. coronavirus updates

Posted on by • Posted in 2020 Election Issues, Clinical Testing, Coronavirus, Crisis, Crisis Management, Economic Crisis, Emergency Preparedness, Employee Benefits, Employee Furlough, Employee Layoffs, Employee Pay Cuts, Employer-Based Health Insurance, False Hope, Health Insurance Coverage Adequacy, Health Policy, Healthcare Providers, Intensive Care (ICU), Job Market, Job Search, Job Security, Leadership Decentralized, Mortality, Nurses, Out of Pocket Expenses, Pandemic, Personal Protective Equipment (PPE), Physician, Preexisting Conditions, Protest, Public Health, Public Safety, Social Distancing, Surprise Bills, Uncertainty, Underinsured, Unemployment, Unemployment Insurance, Uninsured, Unrealistic Expectations, Vaccination, Vaccine, Ventilators • Leave a comment

https://www.axios.com/coronavirus-west-virginia-first-case-ac32ce6d-5523-4310-a219-7d1d1dcb6b44.html

Coronavirus outbreak is level of public pain we haven't seen in ...

 

The pandemic is a long way from over, and its impact on our daily lives, information ecosystem, politics, cities and health care will last even longer.

The big picture: The novel coronavirus has infected more than 939,000 people and killed over 54,000 in the U.S., Johns Hopkins data shows. More than 105,000 Americans have recovered from the virus as of Sunday.

Lockdown measures: Demonstrators gathered in Florida, Texas and Louisiana Saturday to protest stay-at-home orders designed to protect against the spread of COVID-19, following a week of similar rallies across the U.S.

  • 16 states have released formal reopening plans, Vice President Mike Pence said at Thursday’s White House briefing. Several Southern states including South Carolina have already begun reopening their economies.
  • Alaska, Oklahoma and Georgia reopened some non-essential businesses Friday. President Trump said Wednesday he “strongly” disagrees with Georgia Gov. Brian Kemp on the move.
  • California’s stay-at-home orders and business restrictions will remain in place, Gov. Gavin Newsom made clear at a Wednesday news briefing. But some local authorities reopened beaches in Southern California Saturday.
  • New York recorded its third-straight day of fewer coronavirus deaths Friday. Still, Gov. Andrew Cuomo said he’s not willing to reopen the state, citing CDC guidance that states need two weeks of flat or declining numbers.

Catch up quick: Deborah Birx said Sunday that it “bothers” her that the news cycle is still focused on Trump’s comments about disinfectants possibly treating coronavirus, arguing that “we’re missing the bigger pieces” about how Americans can defeat the virus.

  • Anthony Fauci said Saturday the U.S. is testing roughly 1.5 million to 2 million people a week. “We probably should get up to twice that as we get into the next several weeks, and I think we will,” he said.
  • The number of sailors aboard the USS Kidd to test positive for the coronavirus has risen from 18 Friday to 33, the U.S. Navy said Saturday. It’s the second major COVID-19 outbreak on a U.S. naval vessel, after the USS Theodore Roosevelt, where a total of 833 crew members tested positive, per the Navy’s latest statement.
  • The first person known to have the coronavirus when they died was killed by a heart attack “due to COVID-19 infection” on Feb. 6, autopsy results obtained by the San Francisco Chronicle on Saturday show.
  • Some young coronavirus patients are having severe strokes.
  • Trump tweeted Saturday that White House press conferences are “not worth the time & effort.” As first reported by Axios, Trump plans to pare back his coronavirus briefings.
  • The South is at risk of being devastated by the coronavirus, as states tend to have at-risk populations and weak health care systems.
  • New York Gov. Andrew Cuomo said Friday Trump was right to criticize the World Health Organization’s handling of the global outbreak.
  • Trump signed legislation Friday for $484 billion in more aid to small businesses and hospitals.
  • The House voted along party lines on Thursday to establish a select committee to oversee the federal government’s response to the crisis.
  • Unemployment: Another 4.4 million Americans filed last week. More than 26 million jobless filings have been made in five weeks due to the pandemic.

 

 

 

 

Envision Healthcare considering bankruptcy filing

Posted on by • Posted in Bankruptcy, Cash, Cash Reserves, Cash-Flow Improvements, Coronavirus, Credit Quality, Credit Ratings, Creditors, Crisis, Crisis Management, Emergency Care, Emergency Room Staffing, Financial Pressure, Financially Distressed, Pandemic, Physician, Physician Practice Management, Physician Staffing, Private Equity, Restructure, Turnaround, Turnaround Plan, Venture Capital • Leave a comment

https://mailchi.mp/0d4b1a52108c/the-weekly-gist-april-24-2020?e=d1e747d2d8

KKR-backed Envision Healthcare hires restructuring advisers ...

 

National physician staffing firm Envision Healthcare is considering filing for bankruptcy, according a report from Bloomberg. Sources say the company, backed by private equity (PE) firm KKR, which acquired Envision for $9.9B in June 2018, has hired restructuring advisors and is working with an investment bank. The abrupt halt to elective surgeries and reduction in emergency room volumes due to COVID-19 has caused Envision’s business to shrink by 65 to 75 percent in just two weeks at its 168 open ambulatory surgery centers (ASCs), compared to the same time period last year.

The Nashville-based company, which employs over 25,000 physicians and advanced practitioners, has already been reducing pay for providers and executives, in addition to implementing temporary furloughs. Envision is also struggling with a debt load of more than $7B, resulting from its 2018 leveraged buyout, and has been unable to convince its bondholders to approve a debt swap.

It remains to be seen whether Envision will be a bellwether for how other PE-backed physician groups will weather the ongoing COVID crisis. While Envision’s composition of mainly hospital- and ASC-based providers, coupled with its huge debt load, leave it on especially shaky financial footing, many PE-backed physician groups will struggle this year to achieve anything close to the 20 percent annual rate of return often promised to investors.

If high-profile PE-backed groups like Envision end up declaring bankruptcy, it will likely impact the calculus of the many independent practices which may have previously looked to PE firms for acquisition, and temper the enthusiasm of investors, who might see physician staffing and practice roll-ups as less attractive as volumes continue to fluctuate.

 

 

 

Interim Coronavirus Relief Bill

Posted on by • Posted in 2020 Election Issues, Bankruptcy, Clinical Testing, Coronavirus, Economic Crisis, Economic Stimulus, Economy, Emergency Preparedness, Employee Furlough, Employee Layoffs, Health Policy, Health System, Hospital, Hospital Industry, Job Market, Job Search, Job Security, Mortality, Pandemic, Partisanship, Physician, Unemployment, Unemployment Insurance • Leave a comment

https://heathercoxrichardson.substack.com/p/april-23-2020

Congress expected to announce deal on latest coronvirus relief bill

Today the House of Representatives passed a new $484 billion coronavirus relief bill by a vote of 388-5. The Senate passed it Tuesday. $381 billion is for small businesses left out in the cold when the money from the previous coronavirus relief package quickly ran dry. Republicans wanted to stop there, but Democrats demanded $75 billion for hospitals, and $25 billion for coronavirus testing, as well as a requirement that the administration figure out a strategy to get tests to states.

The relief bill comes as more than 26 million Americans are out of work and almost 50,000 Americans have died of Covid-19. The representatives had to drive to Washington, D.C., or fly unusual routes because regular flights are canceled. They arrived for the vote in the Capitol building in alphabetical groups of 50 to 60 so they could keep their distance from each other. A number of Republicans refused to wear masks during the vote, while all but one Democrat wore one.

Democrats inserted into the bill a new committee to oversee the administration’s “preparedness for and response to the coronavirus crisis,” chaired by Jim Clyburn (D-SC). The committee has the power to subpoena witnesses and documents. Republicans and Trump objected.

But the Democrats did not get any more aid to states, crippled by the crisis, than the $150 billion previously provided. The bipartisan National Governors Association, headed by Maryland Governor Larry Hogan, a Republican, has asked for $500 billion to help the states replace lost tax revenues. Democrats wanted such aid, but Republicans refused.

Senate Majority Leader Mitch McConnell (R-KY) went on talk radio host Hugh Hewitt’s show on Wednesday and tried to make the question of state aid partisan. He said that he opposed granting money to states whose problems, he said, stemmed from their underfunded state pension plans. Instead, the states should consider bankruptcy. A document put out by McConnell’s office called aid to the states a “blue state bailout.”

In fact, Michael Leachman, the senior director of state fiscal research at the Center on Budget and Policy Priorities, said that McConnell has it wrong. States have not been overspending; their expenses for education and infrastructure are actually significantly below what they were in 2008, despite more inhabitants, and they have put about 7.6% of their budgets into rainy day funds, a historic high, up from the previous high of 5% they held in reserve in 2006 before the Great Recession.

The problem is that states have to balance their budgets annually, and they depend on sales and income taxes for 70% of their revenue. The shutdowns have decimated tax revenues as shopping ends and people lose their jobs. At the same time, unemployment claims are climbing dramatically. States are looking at a $500 billion loss between now and 2022.

States need money to avoid massive layoffs and deep spending cuts, actions that would make the economic crisis continue much longer than it would if they do not have to make them. They would not use bailout money on pensions, Leachman writes, but put it in state general funds, which are collapsing. Pensions come out of a separate trust fund (although the general fund does put money toward future pensions, that’s less than 5% spending from the general fund). Federal bankruptcy law currently does not allow states to declare bankruptcy, but in any case, Leachman writes, there is no need for it. Bankruptcy relieves high debt levels, but state debt is not high, and once the pandemic passes, the states should be financially sound again.

If Leachman’s explanation was scholarly, New York Governor Andrew Cuomo was blunt. “New York puts into that federal pot $116B more than we take out. Kentucky takes out $148B more than they put in,” he said at a press conference. “Senator McConnell, who’s getting bailed out here? It’s your state that’s living on the money that we generate.” A recent study by the Rockefeller Institute of Government shows that New Yorkers as a group pay in to the federal government $1,792 per capita more than they take out, while for every dollar Kentucky puts in, it gets $2.61 back.

Cuomo called McConnell out for trying to turn the crisis into a political fight: “That’s not what this country is all about,” Cuomo said. “It’s not red and blue, it’s red, white and blue.”

Today’s other big news was Trump’s suggestion at his coronavirus briefing that it would be worth studying whether injecting disinfectant into patients would kill the novel coronavirus. “And then I see the disinfectant where it knocks it out in a minute. One minute. And is there a way we can do something like that, by injection inside or almost a cleaning?” he said. “Because, you see, it gets on the lungs, and it does a tremendous number on the lungs. So it’d be interesting to check that. So that you’re going to have to use medical doctors, but it sounds — it sounds interesting to me.” He also suggested using heat and light to kill the virus.

Doctors were horrified at his comment, calling it irresponsible and dangerous. Disinfectants are poisonous and are deadly if they are used inappropriately. “To be clear:” emergency medicine physician Dara Kass tweeted, “Intracavitary UV light and swallowing bleach or isopropyl alcohol can kill you. Don’t do it.”

Trump’s emphasis on dramatic cures for Covid-19 reinforces his disagreement with health experts that we must dramatically increase our testing for the disease so we can identify hot spots and isolate them before they spread. At today’s briefing, Trump disagreed with Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases and one of the administration’s top medical advisors about the pandemic, who recently said “We absolutely need to significantly ramp up, not only the number of tests but the capacity to actually perform them.” Today, Trump said: “I don’t agree with him on that, no, I think we’re doing a great job on testing.”

In fact, the U.S. lags behind other nations in per capita tests, and Trump’s continuing reluctance to support getting them seems to me mystifying. It is this odd gap Congress is trying to address with its requirement in the new coronavirus package that the administration must figure out a strategy to get tests to states. The bill now heads to the Oval Office for Trump’s signature.

For all the dark nitty-gritty of politics today, it is also a day that begins a joyous month, and that seems to me a far better way to leave you all tonight than with the day’s troubles. For those who celebrate, Ramadan Mubarak.

 

 

 

Mayo Clinic furloughs, cuts hours of 30,000 employees to help offset $3B in pandemic losses

Posted on by • Posted in Cash, Cash Reserves, Coronavirus, Crisis, Crisis Management, Employee Benefits, Employee Furlough, Employee Layoffs, Employee Pay Cuts, Employee Protections, Employer-Based Health Insurance, Health Insurance Coverage Adequacy, Health System, Hospital, Hospital Industry, Out of Pocket Expenses, Pandemic, Physician, Underinsured, Unemployment, Unemployment Insurance, Uninsured • Leave a comment

https://www.beckershospitalreview.com/finance/mayo-clinic-furloughs-cuts-hours-of-30-000-employees-to-help-offset-3b-in-pandemic-losses.html?utm_medium=email

Information for Orlando Residents - Orlando - Mayo Clinic

Rochester, Minn.-based Mayo Clinic said it will furlough or cut the hours of about 30,000 staff members to help offset about $3 billion in losses incurred by the COVID-19 pandemic, according to The Post Bulletin.

Mayo Clinic announced that it would need to take several cost cutting measures, including furloughs, earlier in April. However, the system didn’t disclose the number of employees that would be affected.

The temporary reduction in workforce is one of the ways the system is working to offset a $3 billion loss from the pandemic. Even with the cost-cutting measures, Mayo anticipates a $900 million shortfall this year.

The furloughs or reduced hours affect about 42 percent of Mayo Clinic’s 70,000 employees across its campuses in Arizona, Florida and Minnesota. 

Affected employees will still receive healthcare benefits.

The furloughs will begin in May and be spread throughout the rest of the year, Mayo Clinic spokesperson Ginger Plumbo told the publication. The duration of the furlough will vary depending on the hospital unit, she added.

The furloughs will not affect physicians at the system, but physicians will receive a 10 percent wage reduction. In addition, senior managers will receive pay cuts of 15 percent and top executives will take a 20 percent reduction.

The furloughs, cut hours and wage reductions are expected to save $1.4 billion.

Mayo Clinic also has been taking other cost-cutting measures, including a hiring freeze and halting major construction projects.

Mayo Clinic is also tapping into its reserves to bring $900 million in cash to the system.

 

 

 

 

A mysterious blood-clotting complication is killing coronavirus patients

Posted on by • Posted in Blood Clots, Centers for Disease Control & Prevention (CDC), Coronavirus, Health System, Infection Control, Infectious Virus, Intensive Care (ICU), Mortality, Pandemic, Physician, Preexisting Conditions, Social Distancing, Uncertainty • Leave a comment

https://www.washingtonpost.com/health/2020/04/22/coronavirus-blood-clots/?utm_campaign=wp_news_alert_revere_trending_now&utm_medium=email&utm_source=alert&wpisrc=al_trending_now__alert-hse–alert-national&wpmk=1

Blood-clotting complication is killing coronavirus patients ...

Once thought a relatively straightforward respiratory virus, covid-19 is proving to be much more frightening.

Craig Coopersmith was up early that morning as usual and typed his daily inquiry into his phone. “Good morning, Team Covid,” he wrote, asking for updates from the ICU team leaders working across 10 hospitals in the Emory University health system in Atlanta.

One doctor replied that one of his patients had a strange blood problem. Despite receiving anticoagulants, the patient was still developing clots in various parts of his body. A second said she’d seen something similar. And a third. Soon, every person on the text chat had reported the same thing.

“That’s when we knew we had a huge problem,” said Coopersmith, a critical-care surgeon. As he checked with his counterparts at other medical centers, he became increasingly alarmed: “It was in as many as 20, 30 or 40 percent of their patients.”

One month ago, as the country went into lockdown to prepare for the first wave of coronavirus cases, many doctors felt confident that they knew what they were dealing with. Based on early reports, covid-19 appeared to be a standard variety respiratory virus, albeit a very contagious and lethal one with no vaccine and no treatment. But they’ve since become increasingly convinced that covid-19 attacks not only the lungs, but also the kidneys, heart, intestines, liver and brain.

And many are also reporting bizarre, unsettling cases that don’t seem to follow the textbooks they’ve trained on. They describe patients with startlingly low oxygen levels — so low that they would normally be unconscious or near death — talking and swiping on their phones. Asymptomatic pregnant women suddenly in cardiac arrest. Patients who by all conventional measures seem to have mild disease deteriorating within minutes and dying at home.

With no clear patterns in terms of age or chronic conditions, some scientists now hypothesize that at least some of these abnormalities may be explained by severe changes in patients’ blood.

The concern is so acute that some doctors groups have raised the controversial possibility of giving preventive blood thinners to everyone with covid-19 — even those well enough to endure their illness at home.

Blood clots, in which the red liquid turns gel-like, appear to be the opposite of what occurs in Ebola, Dengue, Lassa and other hemorrhagic fevers that lead to uncontrolled bleeding. But they are actually part of the same phenomenon — and can have similarly devastating consequences.

Autopsies have shown that some people’s lungs are filled with hundreds of microclots. Errant blood clots of a larger size can break off and travel to the brain or heart, causing a stroke or a heart attack. On Saturday, Broadway actor Nick Cordero, 41, had his right leg amputated after being infected with the novel coronavirus and suffering from clots that blocked blood from getting to his toes.

Lewis Kaplan, a University of Pennsylvania physician and head of the American Society of Critical Care Medicine, said that every year, doctors treat a large variety of people with clotting complications, from those with cancer to victims of severe trauma, “and they don’t clot like this.”

“The problem we are having is that while we understand that there is a clot, we don’t yet understand why there is a clot,” Kaplan said. “We don’t know. And therefore, we are scared.”

‘It crept up on us’

The first sign that something was going haywire was in legs, which were turning blue and swelling. Even patients on blood thinners in the ICU were developing clots in them — which is not unusual in one or two patients in one unit, but is for so many at the same time. Next came the clogging of the dialysis machines, which filter impurities in blood when kidneys are failing, and were getting jammed up several times a day.

“There was a universal understanding that this was different,” Coopersmith said.

Then came the autopsies. When they opened up some deceased patients’ lungs, they expected to find evidence of pneumonia and damage to the tiny air sacs that exchange oxygen and carbon dioxide between the lungs and the bloodstream. Instead, they found tiny clots all over.

Zoom meetings were convened in some of the largest medical centers nationwide. Tufts. Yale-New Haven. The University of Pennsylvania. Brigham and Women’s. Columbia-Presbyterian. Theories were shared. Treatments debated.

And although there was no consensus on the biology of why this was happening and what could be done about it, many came to believe the clots might be responsible for a significant share of U.S. coronavirus deaths — possibly helping to explain why so many people are dying at home.

In hindsight, there were hints that blood problems had been an issue in China and Italy as well, but it was more of a footnote in studies and on information-sharing calls that focused on the disease’s effects on lungs.

“It crept up on us. We weren’t hearing a tremendous amount about this internationally,” said Greg Piazza, a cardiovascular specialist at Brigham and Women’s who has begun a study of bleeding complications of covid-19.

Helen W. Boucher, an infectious-disease specialist at Tufts Medical Center, said there’s no reason to think anything is different about the virus in the United States. More likely, she said, the problem was more obvious to American doctors because of the unique demographics of U.S. patients, including large percentages with heart disease and obesity that make them more vulnerable to the ravages of blood clots. She also noted small but important differences in the monitoring and treatment of patients in ICUs in this country that would make clots easier to detect.

“Part of this is by virtue of the fact that we have such incredible intensive care facilities,” she said.

A leading cause of death

The body’s circulatory or cardiovascular system is often described as a network of one-way streets that connect the heart to other organs. Blood is the transport system, responsible for moving nutrients to the cells and waste away from them. A common cold or a cut on the finger can lead to changes that help repair the damage, but when the body undergoes a more significant trauma, the blood can overreact, leading to an imbalance that can cause excessive clots or bleeding — and sometimes both.

Scientists call this “hemostatic derangement.” In math, a derangement is a permutation in which no element is in its original position.

Harlan Krumholz, a cardiac specialist at the Yale-New Haven Hospital Center, said no one knows whether blood complications are a result of a direct assault on blood vessels, or a hyperactive inflammatory response to the virus by the patient’s immune system.

“One of the theories is that once the body is so engaged in a fight against an invader, the body starts consuming the clotting factors, which can result in either blood clots or bleeding. In Ebola, the balance was more toward bleeding. In covid-19, it’s more blood clots,” he said.

A Dutch study published April 10 in the journal Thrombosis Research provided more evidence that the issue is widespread, finding that among 184 covid-19 patients in an intensive care unit, 38 percent had blood that clotted abnormally. The researchers called it “a conservative estimation” because many of the patients were still hospitalized and at risk of further complications.

Early data from China on a sample of 183 patients showed that more than 70 percent of patients who died of covid-19 had small clots develop throughout their bloodstream.

Although acute respiratory distress syndrome (ARDS) still appears to be the leading cause of death in covid-19 patients, blood complications are not far behind, said Behnood Bikdeli, a fourth-year fellow at Columbia University Irving Medical Center, who helped anchor a paper about the blood clots in the Journal of The American College of Cardiology.

“My guess is it’s one of the top three causes of demise and deterioration in covid-19 patients,” he said.

That recognition is prompting many hospitals to change the way they think about the disease and manage it. When the novel coronavirus first hit, the Centers for Disease Control and Prevention and others put people with asthma at the top of their lists of those who might be the most vulnerable. But recently, European researchers writing in the journal Lancet noted that it was “striking” how underrepresented asthma patients had been. Earlier this month, when New York state released data about the top chronic health problems of those who died of covid-19, asthma was not among them. Instead, they were almost all cardiovascular conditions.

Some medical centers recently have begun giving all hospitalized covid-19 patients small doses of blood thinners as preventive measures, and many are adjusting doses upward for the most seriously ill. The challenge is that the more you give, the greater the danger of upsetting the balance in the other direction and having the patient bleed out.

Another big mystery the doctors hope the blood issue will shed light on is why some maternity patients are collapsing during or after giving birth.

A paper published in the American Journal of Obstetrics & Gynecology MFM in late March detailed how two women with no prior symptoms of covid-19 ended up in intensive care. The first was a 38-year-old patient of New York-Presbyterian/Columbia University Irving Medical Center in Manhattan who spiked a fever of 101.3 while undergoing a C-section delivery and began bleeding profusely. The second woman, 33, also underwent a C-section. But the next day, she developed a cough that progressed to respiratory distress. Her heart started beating irregularly and her blood pressure jumped to as high as 200/90.

Several physician-researchers said that the relationship between covid-19, clotting and pregnant women is “an area of interest.” Women in childbirth have always experienced clotting and bleeding complications because of the involvement of the blood-rich placenta, but it’s possible that covid-19 may be triggering additional cases by making some women’s bodies “lose balance.”

“There’s lots of speculation,” Krumholz said. “That’s one of the frustrating things about this virus. We’re in a lot of darkness still.”

 

 

 

 

Envision hires restructuring advisers, considers bankruptcy filing

Posted on by • Posted in Bankruptcy, Chapter 11, Coronavirus, Crisis, Crisis Management, Economic Crisis, Economic Stimulus, Employee Benefits, Employee Furlough, Employee Layoffs, Employee Pay Cuts, Employee Protections, Employee Retirement Contributions, Operating Expenses, Operating Income, Operating Margin, Operating Performance, Operating Revenue, Physician, Physician Staffing, Private Equity, Restructure • Leave a comment

https://www.beckershospitalreview.com/finance/envision-hires-restructuring-advisers-considers-bankruptcy-filing.html?utm_medium=email

Envision Healthcare Said to Be Considering Bankruptcy, 2 Years ...

Envision Healthcare, a Nashville, Tenn.-based physician staffing company owned by private equity firm KKR, is struggling to manage its $7 billion debt load and recently hired lawyers and an investment bank to advise on its restructuring options, sources told Bloomberg.

The company is looking at restructuring options, including a potential Chapter 11 bankruptcy filing, as it faces financial pressure from the COVID-19 pandemic, according to Bloomberg. Envision has seen a significant decline in patient volume across its practices and specialties during the pandemic.  

No decision has been made on a course of action for Envision, and the company is still seeking to ease its debt burden by swapping $1.2 billion of unsecured notes for a new term loan. Creditors have until the end of the month to decide whether to participate in the deal.

The company is exploring its restructuring options after taking several steps to improve its financial position, including holding back pay for physicians, reducing salaries of senior leadership and furloughing nonclinical staff. The company said clinical pay will be reduced in services with low patient volumes, and performance-based bonuses and clinician profit-sharing will be delayed until the fall. Additionally, Envision temporarily suspended retirement contributions, merit increases and promotions for all employees.

About a week after Envision implemented many of the changes, U.S. Sen. Elizabeth Warren of Massachusetts and U.S. Rep. Katie Porter of California sent a letter to Envision and other healthcare staffing companies backed by private equity regarding pay and benefits.

The letter, which Ms. Porter posted on Twitter, said Envision is cutting its physicians’ pay and benefits, “all while our doctors face new financial strains of their own” amid the COVID-19 pandemic.

In response, Envision cited challenges healthcare organizations are facing.

“The nation’s healthcare system has experienced a drastic drop in patient volume since the beginning of the COVID-19 crisis,” wrote Envision, which has more than 40,000 team members, 27,000 of whom are physicians and clinicians. “Even as COVID-19 fills emergency departments in hot spots around the country, Envision’s overall emergency volume is actually down 45 percent.”

Hospital and physician groups are trying to secure funds from the Coronavirus Aid, Relief and Economic Security Act and get additional aid. Though the private equity industry is lobbying Washington to gain access to the funds, it remains unclear whether private equity-backed companies like Envision will receive the emergency government funds. 

 

 

 

 

New England Journal of Medicine publishes letter from doctor explaining how FBI and DHS almost grabbed the medical masks his hospital was buying

Posted on by • Posted in 2020 Election Issues, Coronavirus, Pandemic, Personal Protective Equipment (PPE), Physician, Physician Leadership, Supply Chain • Leave a comment

https://www.alternet.org/2020/04/new-england-journal-of-medicine-publishes-letter-from-doctor-explaining-how-fbi-and-dhs-almost-grabbed-the-medical-masks-his-hospital-was-buying/

New England Journal of Medicine publishes letter from doctor ...

The New England Journal of Medicine has begun a new series called “Covid-19 Notes,” which is focusing on the innovative responses to the dealing with the coronavirus. On Friday, the journal published a letter about acquiring N95 masks written by Dr. Andrew W. Artenstein, M.D., of Baystate Health in Springfield, Massachusetts. Here’s an excerpt from the letter:

As a chief physician executive, I rarely get involved in my health system’s supply-chain activities. The Covid-19 pandemic has changed that. Protecting our caregivers is essential so that these talented professionals can safely provide compassionate care to our patients. Yet we continue to be stymied by a lack of personal protective equipment (PPE), and the cavalry does not appear to be coming.

Our supply-chain group has worked around the clock to secure gowns, gloves, face masks, goggles, face shields, and N95 respirators. These employees have adapted to a new normal, exploring every lead, no matter how unusual. Deals, some bizarre and convoluted, and many involving large sums of money, have dissolved at the last minute when we were outbid or outmuscled, sometimes by the federal government. Then we got lucky, but getting the supplies was not easy. […]

Hours before our planned departure, we were told to expect only a quarter of our original order. We went anyway, since we desperately needed any supplies we could get. Upon arrival, we were jubilant to see pallets of KN95 respirators and face masks being unloaded. We opened several boxes, examined their contents, and hoped that this random sample would be representative of the entire shipment. Before we could send the funds by wire transfer, two Federal Bureau of Investigation agents arrived, showed their badges, and started questioning me. No, this shipment was not headed for resale or the black market. The agents checked my credentials, and I tried to convince them that the shipment of PPE was bound for hospitals. After receiving my assurances and hearing about our health system’s urgent needs, the agents let the boxes of equipment be released and loaded into the trucks. But I was soon shocked to learn that the Department of Homeland Security was still considering redirecting our PPE. Only some quick calls leading to intervention by our congressional representative prevented its seizure. I remained nervous and worried on the long drive back, feelings that did not abate until midnight, when I received the call that the PPE shipment was secured at our warehouse.

It would be nice to have federal leadership that doesn’t make acquiring essential medical equipment seem more like buying a heroin shipment.

https://www.nejm.org/doi/full/10.1056/NEJMc2010025?query=featured_coronavirus

 

 

 

 

In front of White House, nurses read names of colleagues killed by coronavirus

Posted on by • Posted in 2020 Election Issues, Centers for Disease Control & Prevention (CDC), Clinical Testing, Core Values, Coronavirus, Crisis, Crisis Management, Front Lines, Health Policy, Healthcare Providers, Infection Control, Infectious Virus, Labor Union, Nurses, Nurses Union, Occupational Safety and Health Administration (OSHA), Pandemic, Personal Protective Equipment (PPE), Physician, Public Health, Public Safety, Quarantine, Social Distancing • Leave a comment

https://www.washingtonpost.com/local/nurses-read-names-of-colleagues-who-died-of-the-coronavirus-in-front-of-the-white-house/2020/04/21/fc93184c-83e6-11ea-878a-86477a724bdb_story.html?fbclid=IwAR3uHwtfPR-JqZaeFCfIrwmVEzDRSN574QocAt932Pa2pyUt6oL9KC3Kka8&fbclid=IwAR2VQF-oNTrPWkrGFODp9d_WMPOzIUW-imvhPWPGZlU2SN32I6W7trHrjEA&fbclid=IwAR2vXZ6AGvzXd9kZp1naBhLYA8Z2MzWVpYi2zbfXUNM9ybmRZ6FhW1hASEU&utm_campaign=wp_main&utm_medium=social&utm_source=facebook

Coronavirus deaths: Nurses read names at White House of colleagues ...

Registered nurses gathered Tuesday in front of the White House to read the names of health-care workers who have died fighting the coronavirus pandemic.

Wearing masks and standing six feet apart, the nurses held up photographs of the deceased as Melody Jones, a member of the National Nurses United union, addressed the news media in an otherwise empty Lafayette Square.

The names came from all over the country — New York and Alabama, Puerto Rico and Nevada, California and Michigan, Florida and Maryland, New Jersey and the District.

A man in blue scrubs stood behind Jones as she read, holding a metallic gold sign painted with the message: “20 seconds won’t scrub ‘hero’ blood off your hands.”

“Let us remember and honor the ultimate sacrifice these nurses paid,” Jones said. “We commit ourselves to fight like hell for the living.”

The protest stood in stark contrast to demonstrations in recent days in some parts of the country in which protesters have demanded the reopening of nonessential businesses. Nurses have been spotted at those gatherings, too, standing arms crossed, in opposition to demonstrators, many of whom are unmasked and milling in crowds.

More than 9,000 health-care workers in the United States have tested positive for the novel coronavirus, according to figures from the Centers for Disease Control and Prevention. Those numbers are believed to be an undercount of infections due to a lack of tests in many areas.

The nurses said Tuesday that they wanted to bring their demands for more personal protective equipment directly to President Trump’s doorstep.

Health-care providers in hospitals, clinics, nursing homes, assisted-living facilities and rehabilitation centers have for weeks asked lawmakers and government agencies for more protective equipment to shield themselves and their vulnerable patients from the spread of covid-19.

National Nurses United last month petitioned the Occupational Safety and Health Administration to institute an emergency safety standard that would provide nurses with more protective gear, including N95 respirator masks, face shields, gowns, gloves and shoe coverings.

Health-care workers, governors and other officials have for weeks demanded that Trump enforce the Defense Production Act to order mass production of those materials. Many have also petitioned Congress to mandate Trump use his authority to help boost the production of such gear.

Last week, a protest in the shadow of the Capitol displayed the faces of health-care workers demanding better protection on 1,000 signs. The sign represented protesters that organizers said would not have been safe if gathered together on the Capitol lawn.