Cartoon – Lack of Implementation Progress
‘Extremely erroneous’? Some health systems say hospital vaccination data is seriously flawed.
CMS is preparing to enforce its vaccine mandate for health care workers, but the agency may not have an accurate count of how many remain unvaccinated—and five health systems are pushing back on federal hospital vaccination data, calling it “extremely erroneous,” Cheryl Clark writes for MedPage Today.
Background
The Supreme Court earlier this month ruled that CMS could require most health care workers to be vaccinated against Covid-19—but U.S. officials currently do not know exactly how many workers remain unvaccinated, primarily due to a lack of reliable immunization data.
At the end of December, CDC reported that 77.6% of hospital workers were fully vaccinated. However, that figure was based on data from only about 40% of the nation’s hospitals. Hospitals currently send vaccination data to the agency on a voluntary basis, but beginning May 15, they will be required to send in weekly data, just like nursing homes have been.
According to Janis Orlowski, chief health care officer at the Association of American Medical Colleges (AAMC), CDC’s data is likely representative of providers nationwide, as an AAMC survey of 125 academic hospitals found similar results. More than 99% of doctors and close to 90% of nurses were vaccinated, she said, but vaccination rates dropped off to the 30% to 40% range for those in more operational roles, such as transportation and food service workers.
Is federal vaccination data for hospitals inaccurate?
Further adding to the confusion about health care workers’ vaccination rates are potential inaccuracies in a federal database that tracks Covid-19 vaccinations among workers in hospitals across the country. According to five health systems listed as having the highest numbers of unvaccinated workers, the database is “extremely erroneous,” Clark writes.
In the database, Adventist Health Orlando (AHO) is shown to have 18,576 unvaccinated workers, 637 partially vaccinated workers, and 25,253 fully vaccinated workers. However, Jeff Grainger, director of external communications for AdventHealth in Central Florida, said those numbers weren’t possible since the organization “[doesn’t] have 44,000 employees in one hospital.” He added that 96% of AHO’s team members have already complied with CMS’ mandate.
The University of Illinois Hospital (UI) was listed in the database as having 12,049 unvaccinated workers and 272 partially vaccinated workers. Jacqueline Carey, from health system’s public affairs department, disputed these numbers, saying UI had 6,530 workers as of Jan. 19, with 96% of them fully vaccinated. The remainder were either partially vaccinated or had approved exemptions.
The hospital with the third highest number of unvaccinated workers was Mount Sinai Hospital, Clark writes, but Lucia Lee, a hospital spokesperson, said the federal data was inaccurate. According to Lee, Mount Sinai Health System, of which the hospital is a part, has vaccinated 99% of its more than 43,000 employees.
A representative for Ochsner Medical Center, which is listed as having the fourth highest number of unvaccinated workers, also pushed back on the statistics in the database. Currently, 99.57% of Ochsner’s over 34,000 employees are compliant with its Covid-19 policy, with 95% of workers Ochsner Health and Ochsner LSU Health Shreveport fully vaccinated.
Finally, Kena Lewis, a spokesperson for Orlando Regional Medical Center, said that federal data showing the hospital has 44,154 workers is inaccurate. Instead, she said the hospital is one of 10 in the Orlando network, which has 23,709 total employees. Although Lewis did not give the health system’s vaccination rates, she said it “continues to review the guidelines regarding Covid-19 vaccination requirements for health care organizations and will take appropriate steps.”
Although it is not clear why there are discrepancies between the federal data and what these health systems are reporting regarding vaccination rates, there are some potential explanations, Clark writes.
According to Carey, the federal database only includes vaccination information provided by the UI health system and employee health services. This means that vaccinations workers received elsewhere, such as through a personal provider or pharmacy, are not included in the data, and they will show up as being unvaccinated.
Separately, a spokesperson for another of the five organizations told Clark on background that short-term nursing staff contracted through agencies may show up as unvaccinated in the federal database. Although the agencies assure employers the nurses are vaccinated, hospitals do not independently verify this information.
‘Stealth’ omicron: What you need to know about the subvariant
Scientists and health officials around the world are tracking the BA.2 subvariant of omicron, which has been referred to as “stealth omicron” because it cannot easily be identified via PCR tests.
What is the omicron BA.2 subvariant?
The BA. 2 omicron subvariant is a descendant of the original BA.1 omicron variant that has caused massive global Covid-19 surges. On Monday, the World Health Organization (WHO) urged researchers to prioritize the investigation of BA.2’s characteristics to determine whether it poses new challenges for areas already overwhelmed by the pandemic.
“The BA. 2 descendant lineage, which differs from BA. 1 in some of the mutations, including in the spike protein, is increasing in many countries,” WHO said. “Investigations into the characteristics of BA. 2, including immune escape properties and virulence, should be prioritized independently (and comparatively) to BA. 1.”
Currently, there is no evidence that BA. 2 is more transmissible or evades immunity better than BA. 1, the Washington Post reports.
In fact, experts still know very little about the transmissibility of BA.2 compared with BA.1, said Jeremy Luban, a professor of molecular medicine, biochemistry, and molecular pharmacology at UMass Medical School. And according to Luban, it is too early to determine whether vaccines and existing medications will provide adequate protection against BA.2.
Like the original omicron variant, BA.2 has many mutations, including roughly 20 found in the area targeted by most vaccines. BA.2 also has unique mutations that are not found in BA.1, which could limit the effectiveness of monoclonal antibodies, Luban said.
Further, scientists have found that BA.2 is harder to detect with PCR tests than BA.1. Although researchers were able to quickly differentiate BA.1 from the delta variant using a PCR test, the BA.2 subvariant does not possess the same “S gene target failure” seen in BA.1. As a result, BA.2 looks like the delta variant on the test, according to Wesley Long, a pathologist at Houston Methodist Hospital.
“It’s not that the test doesn’t detect it; it’s just that it doesn’t look like omicron,” Long said. “Don’t get the impression that ‘stealth omicron’ means we can’t detect it. All of our PCR tests can still detect it.”
Where is BA.2 circulating?
So far, BA.2 has been identified in 40 countries, including the United States. Although there are few reported cases of BA.2 in the United States, the subvariant is widely circulating in Asia and Europe.
Throughout Europe, BA.2 seems to be the most widespread in Denmark—but experts said that could be because of the country’s robust program of sequencing the virus’s genome, the Post reports. On Jan. 20, health officials said that the BA.2 cases made up more than 50% of the country’s omicron cases.
In the United States, at least three cases have been found at Houston Methodist Hospital in Texas, which is currently studying the genetic makeup of virus samples from its patients, the Post reports.
“The good news is we have only three,” said James Musser, director of the Center for Molecular and Translational Human Infectious Diseases Research at Houston Methodist. “We certainly do not see the 5% and more that is being reported in the U.K. now and certainly not the 40% that is being reported in Denmark.”
In addition, a spokesperson for the Washington Department of Health on Monday told Fox News, “Two cases of BA.2 … were detected earlier this month in Washington.”
BA.2 remains ‘an open question’
Although BA.2 is now on at least four continents, experts say this new subvariant shouldn’t be a cause for panic, as it is expected to be relatively mild, USA Today reports.
“I don’t think it’s going to cause the degree of chaos and disruption, morbidity and mortality that BA.1 did,” said Jacob Lemieux, an infectious disease specialist at Massachusetts General Hospital. “I’m cautiously optimistic that we’re going to continue to move to a better place and, hopefully, one where each new variant on the horizon isn’t news.”
Similarly, Robert Garry, a virologist at Tulane University School of Medicine, said, “Variants have come, variants have gone.” He added, “I don’t think there’s any reason to think this one is a whole lot worse than the current version of omicron.”
Still, Musser argued that BA.2 deserves close attention until scientists can learn more about it.
“We know that omicron … can clearly evade preexisting immunity” from both vaccines and exposure to other variants of the virus, he said. “What we don’t know yet is whether son-of-omicron does that better or worse than omicron. So that’s an open question.”
Mass General Brigham required to implement a cost-savings plan
https://www.healthcarefinancenews.com/news/mass-general-brigham-required-implement-cost-savings-plan
The Massachusetts Health Policy Commission has unanimously voted to hold Mass General Brigham accountable for its spending and is requiring the health system to develop and implement a performance improvement plan that will result in cost-saving reforms.
The proposed performance improvement plan must contain specific cost-reducing action steps, savings goals, process and outcome metrics, timetables, and supporting evidence, among other requirements.
MGB has 45 days to file the proposed performance improvement plan with the HPC, request a waiver from the requirement, or request an extension of the filing deadline.
From 2014 to 2019, MGB had a larger, cumulative commercial spending in excess of the benchmark than any other provider, totaling $293 million, the HPC said. MGB’s ongoing cost-control strategies have not reduced its commercial spending growth to below-benchmark rates, the HPC Board said.
MGB is seeking to spend nearly $2.3 billion in Massachusetts on expansions and improvements at two of its hospitals and on the creation of three new ambulatory sites in the communities of Westborough, Westwood, and Woburn, Massachusetts.
“Mass General Brigham has a spending problem,” HPC Chair Dr. Stuart Altman said by statement. “Its spending performance and plan for new expansions at their flagship hospitals and into the Boston suburbs raise significant concerns, as documented by the HPC today.”
The HPC’s analyses found that these expansions would increase commercial healthcare spending by at least $46 million to $90.1 million and translate into higher commercial insurance premiums for Massachusetts residents, families and businesses.
The HPC also said this would impact healthcare access and equity as care shifts to MGB providers from other providers in Massachusetts. Other providers are anticipated to lose $153 million to $261 million in commercial revenue each year. These other providers have fewer financial resources and lower average prices for commercially insured patients and they generally serve larger proportions of MassHealth patients and communities with higher social needs than MGB, HPC said.
Based on these findings, the HPC concluded these expansions are inconsistent with the Commonwealth’s healthcare cost containment goals.
The HPC’s Board took separate action, voting unanimously to issue a public comment detailing its analyses of the three expansion proposals currently under review by the Massachusetts Department of Public Health Determination of Need Program.
WHY THIS MATTERS
MGB includes two academic medical centers and is the largest and generally highest-priced system in the Commonwealth, HPC said.
The HPC’s findings and conclusions stand in contrast to those of Independent Cost Analyses that were conducted by a third-party vendor and released on December 28, 2021, which conclude that all three projects are consistent with the Commonwealth’s cost containment goals.
The December cost analysis, part of the determination of need process, projected those three sites would result in a “small overall decrease” in healthcare spending, MGB said, according to WGBH. Its proposed suburban locations would give its existing patients a lower-cost option than hospital care and save them a drive into Boston, the report said.
“Today’s comments by the Health Policy Commission ignore this state’s crippling healthcare capacity crisis — which preceded the pandemic, as well as the fact that patients deserve the choice to access high quality care, closer to their homes, at a lower cost,” MGB said, according to the report.
THE LARGER TREND
Massachusetts established the Health Policy Commission in 2012 as an independent government agency to lead collective efforts to make healthcare more affordable for residents.
This is the first performance improvement plan to be required from a provider or health plan by the HPC.
Program of All-Inclusive Care for the Elderly(“PACE”)
While the ongoing pandemic has impacted all Americans, Covid has been most detrimental to the elderly and people with disabilities, many of whom depend on long-term services and supports (LTSS). This has
placed greater emphasis on alternative care models that allow elderly Americans with
LTSS needs to live at home, where a vast majority of this population prefers to receive
care. Today, more than 800,000 people are on waitlists to receive home and community-based services. This transition of care to the home is a theme that has become prevalent during Covid and warrants attention going forward.
Additionally, value-based care has emerged as a fixture of the healthcare landscape.
More than a trend, this secular theme has brought with it a proliferation of new
companies. While value-based care has different meanings depending on application,
the core concept is that all stakeholders win. Members receive better care, payers see
cost savings and providers are less encumbered with administrative work, allowing them
to be more engaged with members. Value-based care underscores the concept that the
best outcomes are achieved when all stakeholders are aligned.
One of these models that inherently encompasses value-based care AND offers an
alternative LTSS model that is home and community-based is the Program of All-Inclusive Care for the Elderly (“PACE”). PACE is a fully integrated, highly coordinated
care model that provides comprehensive medical and social services to frail, medically
complex, elderly individuals, most of whom are dually eligible for Medicare and Medicaid
benefits. PACE addresses the social determinants of health – transportation, meals, and
social isolation, to name a few. 95% of PACE participants live safely in the community.
PACE is a fully capitated model, which allows providers to deliver all services
participants need, rather than limit them to those reimbursable under Medicare and
Medicaid fee-for-service plans.
PACE produces tangible outcomes for all stakeholders:
Members experience reduced hospital admissions, decreased rehospitalizations,
reduced ER visits, fewer nursing home admissions and better preventive care;
States pay PACE programs 13% less than the cost of other Medicaid services;
Seniors receive better quality outcomes and can remain living in their communities; and importantly
97.5% of family caregivers would recommend PACE to someone in a similar situation.
The PACE model is roughly 50 years old, and in recent years enrollment has grown at a healthy 9% CAGR. Yet, while there are approximately 58,000 PACE participants, there are ~2 million Americans that could qualify, representing a penetration rate of just 3%. This is low. There are many reasons for this: regulation and policy challenges, limited access to the program, lack of awareness of the program by seniors, and capital-intensity to develop.
In Cain Brothers’ view, as we look to emerge from this pandemic, PACE is well positioned for an acceleration. There are a number of factors we have been watching that support this:
The current administration is pushing to expand home and community-based services. In April 2021, Senator Bob Casey (D-PA), Chairman of the Special Committee on Aging, introduced the PACE Plus Act that would strengthen and expand access to the PACE program;
The existing PACE landscape remains very fragmented and many players would benefit from scale and
innovation;
Over the last few years, more private investment has come into the sector, which should help to fuel growth and expansion; and
More state Medicaid programs are planning for or are in the process of (most recently, DC and Illinois) developing and expanding PACE programs creating an opportunity for new entrants.
How might the PACE landscape change over the next few years? We could see consolidation of current players, new entrants, or partnerships between not-for-profits and for-profits. Whatever the form, PACE clearly benefits all stakeholders. The pandemic has cast a light on this value proposition and carved a path for adoption to meaningfully accelerate.
COVID-19 deaths pass peak from delta surge
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Welcome to Wednesday’s Overnight Health Care, where we’re following the latest moves on policy and news affecting your health. Subscribe here: thehill.com/newsletter-signup.
Masks come to the Super Bowl: Fans attending the big game next month will be given KN95 masks.
Despite omicron being less severe on average, the sheer number of cases has driven deaths past the peak from last year’s delta surge.
The average number of U.S. COVID-19 deaths this week surpassed the height of the delta surge earlier this fall and is at its highest point since last winter, when the nation was coming out of the peak winter surge.
The seven-day average of deaths hit 2,166 on Monday, according to the latest data from the Centers for Disease Control and Prevention (CDC). Average daily deaths in mid-September before the omicron variant was discovered peaked at around 1,900.
While increasing evidence shows omicron may be less likely to cause death or serious illness than delta, the sheer infectiousness and the speed at which it spreads has overwhelmed hospitals, primarily with people who have not been vaccinated.
The U.S. saw the highest numbers of deaths in the pandemic just over a year ago, before vaccines were widely available, when the daily average reached 3,400. The last time the U.S. topped 2,000 deaths was last February, as the country was slowly coming down from the January peak.
Caution urged: Infections are falling in states that were hardest hit earlier, as well as broadly across the nation. Hospitalizations are also falling, but deaths are a lagging indicator and are still increasing. CDC Director Rochelle Walsenky said deaths have increased about 21 percent over the past week.
The fact that the omicron variant tends to cause less severe disease on average also helped avoid an even greater crisis that would have occurred if it was as severe as the delta variant.
Long COVID-19: Study author explains four factors that can predict how you get it
Long COVID-19 has had an air of mystery around it for months. Doctors have struggled to explain or understand why some people who contract COVID-19 end up having lingering symptoms like fatigue, difficulty thinking clearly, or shortness of breath weeks or even months later.
A new study published in the journal Cell helps shed some light on the condition, for the first time identifying four factors that can help predict whether someone will develop long COVID-19.
“Being able to identify the factors that can cause the disease, cause the chronic condition, is the first step towards defining that it actually is a condition that can be treatable,” Jim Heath, president of the Institute for Systems Biology in Seattle, and an author of the study, said in an interview. “And then some of these factors also are in fact the kind of things one can imagine developing treatments for.”
The most important factor the study identified in predicting long COVID-19 is the presence of certain kinds of antibodies called autoantibodies, which mistakenly attack healthy parts of the body. Autoantibodies are associated with autoimmune diseases, like lupus, where your immune system attacks your own body.
But someone does not have to have an autoimmune disease to have autoantibodies present and be at higher risk for long COVID-19, Heath said.
“Most people that have autoantibodies don’t really know it,” he said. “They’re what you call subclinical … maybe you have a risk of some autoimmune disease but it hasn’t developed.”
Still, he said one practical application of the study is that lupus treatments could be “worth exploring” as treatments for long COVID-19.
The second factor that can lead to long COVID-19 is the reactivation of a different virus called Epstein-Barr Virus (EBV), which is extremely common, infecting up to 90 percent of people at some point, and often causes only mild symptoms.
The virus usually becomes inactive in the body following the initial infection, but it can be reactivated when someone gets COVID-19, helping lead to long COVID-19 symptoms.
Heath said EBV could become reactivated when the immune system is distracted by fighting COVID-19.
“It could be that the large distraction that’s COVID-19 infection is taking that attention away,” he said.
The third factor identified is how much of the virus that causes COVID-19, officially called SARS-Cov-2, is present in the blood, known as the “viral load.”
This factor along with the role of EBV suggests that new antiviral drugs that fight the immediate effects of COVID-19 infection, like the Pfizer pill Paxlovid, might also be useful in treating long COVID-19.
“Two of these predictive factors are virus levels that are in the blood,” Heath said. “So that suggests that these antivirals that are being used to treat acute disease probably have a role for long COVID as well.”
The final of the four factors that can predict long COVID-19 is more easily identifiable: if a patient has Type 2 diabetes.
While these four factors are a step forward in understanding what causes long COVID-19 and helping develop treatments, the mechanism for why they are associated with long COVID-19 is still not fully clear.
“They have a flavor of mechanistic factors,” Heath said. “The actual mechanism is not clear.”
The study followed 309 COVID-19 patients, taking blood and swab samples at different points in time.
In addition, one way to likely cut the risk of long COVID-19 is vaccination. A separate study from the United Kingdom found that vaccinated people were 41 percent less likely to develop long COVID-19.
Thought of the Day: On Meaningful Work
Cartoon – Destroying the Company
Cartoon – Doctors without borders, meet…
HENRY KOTULA 