with Paulina Firozi

Some doctors, hospitals and clinics serving the poorest Americans say they’re still being shut out of coronavirus pandemic aid, even though the Trump administration is trying to relieve providers like them after weeks of delays.

Behavioral health centers, pediatricians and children’s hospitals say rules around who can apply for the latest batch of funds from the Department of Health and Human Services are so strict that many are excluded from applying for it at all.

They also charge the whole process of applying for coronavirus relief funds was broadly confusing throughout April and May, as HHS announced how the money would be awarded — and days later switched it up. Some providers didn’t realize they needed to apply again after an initial round of funding, and that their payments could be based on their total patient revenue, not just their payments from Medicare.

And now HHS is disqualifying providers who previously received funds — even if it was a minuscule sum — from applying for a new pot of Medicaid-focused dollars.

The whole saga illustrates how complicated and challenging it has been for HHS to quickly allocate relief funds amid the pandemic.

Congress provided $175 billion as part of its sweeping coronavirus stimulus legislation to relieve health providers across the nation, who were forced to cancel income-generating visits and procedures during the state-imposed shutdowns in March, April and at least some of May. Spending on health services took a deep dive in April, down 38 percent compared to the same month last year.

Providers with more elderly patients on Medicare received payouts from HHS in April and May, using about $50 billion from the $175 billion allotment. Yet those with a younger, poorer mix of patients have mostly waited on the sidelines.

This latest batch of funds, totaling $25 billion, is now directed toward providers with large shares of patients on Medicaid or the Children’s Health Insurance Program. But previous widespread confusion about applying for the awards — and rules around who is now eligible — could still block some of them from collecting the funds, the providers say.

“I don’t think I really want to venture down that road of starting to assign blame, but I think what is clear [is] the process wasn’t understood by folks who needed to understand it,” Jack Rollins of the National Association of Medicaid Directors told me.

Several different opportunities to apply for funds resulted in a muddled process.

Seema Verma, director of the Centers for Medicare and Medicaid Services, told providers in early April they could apply for relief payments based on their Medicare revenue. Some providers with only a small population of Medicare payments did so and received a correspondingly small payment.

A few days later, HHS announced a redo of sorts. The agency said if providers reapplied through another portal, they could get payments based on their total patient revenue — a much larger sum for many providers. But providers say they didn't realize the opportunity to collect more dollars.

Then last week, HHS announced two more portals to provide payouts specifically for providers serving low-income patients. One is for providers with higher shares of Medicaid patients. The other is for so-called “safety net” hospitals with more uninsured patients and therefore more care that goes uncompensated.

But there was a catch: Providers who had previously received funds in April were disqualified from applying for funds via the new portals — even if their initial payments had been only a few hundred dollars. The situation is particularly affecting family physicians and behavioral health centers.

“Sadly, it means that they are disqualified,” said Shawn Martin, executive vice president of the American Academy of Family Physicians. “This is a mistake … in our opinion.”

Health providers, who employ hundreds of lobbyists in Washington, are always hovering whenever federal funding is within reach. 

Yet providers insist the relief funds are absolutely critical amid a pandemic that caused sweeping economic damage across industries.

AAFP said it anticipates as many as 20 percent of its members will close temporarily or permanently over the summer. Nearly half the members of the National Council for Behavioral Health said in an April survey they had laid off or furloughed employees or planned to do so as a result of the pandemic.

The group says it is seeing spikes in people seeking help for mental health and drug addiction, conditions that have tended to worsen because of stresses caused by the pandemic and isolation from the shutdowns. Yet its members have received little or no extra funding to date.

“The latest effort to distribute funds is deeply flawed,” the group's chief executive, Chuck Ingoglia, said in a statement. “Quite simply, behavioral health providers have been left behind.”

And the pandemic is far from over, even as the Trump administration downplays it.

Yesterday Vice President Pence called concerns about cases rising “overblown” in a Wall Street Journal op-ed. He wrote that about half of states have reported a decline or plateau in cases.

“But data indicate that the country has yet to quash the first wave of the virus — even though many states, especially in the South and Midwest, are moving forward with reopening plans,” my colleagues report. “Florida, Texas, Arizona and Oklahoma are among approximately a dozen states seeing a surge in cases and hospitalizations.”

Anthony Fauci, the nation's top infectious-disease expert who hasn't been put in front of the public lately, had some different takes than Pence.

He told NPR he last talked to Trump two weeks ago about “vaccine development efforts.” And he warned against the idea the United States is in the midst of a second wave, when the first wave isn't over yet.

“When I look at the TV and I see pictures of people congregating at bars when the location they are indicates they shouldn’t be doing that, that’s very risky,” Fauci said in an interview with the Wall Street Journal's Stephanie Armour. “People keep talking about a second wave,” he added. “We’re still in a first wave.”

HHS says it's “prioritizing” getting funding to providers who haven't been paid any relief funds at all.

A spokesperson for the agency stressed that providers did get paid relief funds as long as they competed the full application process in April. Now HHS is focused on delivering funds to the providers who weren't eligible in that first round of funding, the spokesperson said.

“HHS has committed to making Provider Relief Funds to all Medicare and Medicaid-billing providers that are equal to at least 2 percent of their total 2018 revenue,” the spokesperson said.

But children’s hospitals say they’re also being shut out of the latest funding.

Often, more than half the patients at children’s hospitals are on Medicaid — a program that covers 1 in every 2 kids in the United States. These hospitals weren’t eligible for the previous, Medicare-based awards because they don’t have Medicare patients.

But many are still ineligible to apply via the portal for safety-net hospitals, according to Mark Wietecha, president of the Children’s Hospital Association. That’s because they don’t meet criteria for how much of their care goes uncompensated. Nearly every kid has insurance, as opposed to the adult population. But CHIP and Medicaid pay hospitals far less than Medicare or private plans, so children's hospitals operate on narrower margins.

The association is asking HHS for a special allotment, similar to pots of funding the agency has already provided for rural hospitals and hospitals in hot-spot areas of the country.

“This is an inadvertent oversight,” Wietecha said. “I don’t think anyone is against children … but I do think we are going to have to find some way to get support to the kids’ hospitals.”

Ahh, oof and ouch

AHH: An inexpensive steroid is the first drug shown to help some of the sickest patient with severe lung damage survive covid-19.

British scientists say the 60-year-old drug, dexamethasone, reduced the risk of death for patients on ventilators by a third, and reduced the risk for patients on oxygen by a fifth, Karla Adam, Lateshia Beachum and Carolyn Y. Johnson report.

The results of the British clinical trial were announced yesterday.

“British regulators speedily approved the drug for use in hospitalized patients requiring oxygen, and Prime Minister Boris Johnson trumpeted the results, declaring there was ‘genuine cause to celebrate a remarkable British scientific achievement and the benefits it will bring not just in this country but around the world,’” they write. 

“Dexamethasone is a workhorse steroid typically used to treat inflammation, including flare-ups of rheumatoid arthritis, and was given as a tablet, liquid or as an intravenous preparation in the trial. Some other steroids are also being tested against covid-19.”

But doctors expressed caution about the seemingly positive news, calling for details of the research so physicians could better understand the potential benefits and limitations of the steroid. 

OOF: Many nursing homes avoided sending covid-19 patients to hospitals.

Federal agencies, academic researchers and geriatric physicians pushed “treat in place” strategies because they said hospitals were risky places for the elderly. Keeping ill residents within nursing homes instead of sending them to hospitals was a practice occurring well before the coronavirus ever appeared.

“But what thousands of U.S. nursing homes neglected — including Absolut Care of Aurora Park — was the other side of the coin. To treat in place requires having effective means of treatment, staff who know how to deploy that treatment and procedures to stop the spread of infection,” Will Englund reports. “When the novel coronavirus pandemic struck, nursing homes did not swamp hospitals with patients. But neither did they prevent the deaths of more than 30,000 of their residents or, in many cases, even provide decent palliative care.” 

Many facilities were “more or less winging it” when the pandemic hit, he adds. 

Other homes took a different approach. One nursing home — the Terrace View Long-Term Care Facility in Buffalo — has 390 beds. Four of its residents were infected, and after all were transferred to an affiliated medical enter, one patient died. 

That's far fewer deaths than at Absolut Care of Aurora Park, a nursing home with 310 beds which treated patients in place. At the end of May, 153 of its residents were infected and 61 had died.

There have been more than 51,000 covid-19-related deaths linked to long-term care facilities across the country. 

That’s according to an analysis of state data by the Wall Street Journal’s Jon Kamp and Anna Wilde Mathews. 

Yet nursing homes and such facilities have started easing restrictions and allowing visitors again.

“Deaths among senior-care center staff and residents appear to represent at least 40% of the overall count of more than 116,000 U.S. fatalities related to Covid-19 as compiled by Johns Hopkins University,” they report. “The pace of reopening elder-care facilities is uneven around the U.S., with a patchwork of rules that is frustrating some of their operators.”

OUCH: The House coronavirus task force announced it will investigate the five biggest for-profit nursing home companies. 

The panel’s chairman, House Majority Whip James Clyburn (D-S.C.), sent letters to CMS and the five companies, looking for information related to the management of the pandemic in the facilities, Politico’s Kyle Cheney and Rachel Roubein report.

“The panel is probing a wide range of issues, from the scale of the outbreak in the facilities to potential shortages of protective equipment for patients and staff,” they report. “The five companies Clyburn is contacting — Genesis HealthCare, Life Care Centers of America, Ensign Group, SavaSeniorCare and Consulate Health Care — operate more than 850 facilities for 80,000 residents in 40 states. Each has seen outbreaks at multiple facilities, including more than 1,500 across 187 facilities at Genesis HealthCare, according to the committee.” 

In the letter to the homes, Clyburn wrote: “Family members also report that nursing homes have failed to provide timely information about outbreaks and symptoms experienced by their loved ones—sometimes only notifying them of a problem after their loved ones passed away … Such practices unquestionably fall short of the care Americans expect for the most vulnerable amongst us.”

The Trump administration's move

Officials in Tulsa are begging Trump to cancel his scheduled rally as virus cases surge. 

They’re warning the campaign event set for Saturday in a nearly 20,000-person indoor arena will become a “super spreader,” the New York Times’s Noah Weiland reports. 

Bruce Dart, the executive director of the Tulsa health department, called it a “perfect storm that we can’t afford to have.” 

“Tulsa County, which includes the city of Tulsa, tallied 89 new coronavirus cases on Monday, its one-day high since the virus’s outbreak, according to the Tulsa Area Emergency Management Agency. The number of active coronavirus cases climbed to 532 from 188 in a one-week period, a 182 percent increase; hospitalizations with Covid-19 almost doubled,” Noah reports.

The event is particularly risky because the longer people are in a contaminated space, the more virus particles they can inhale. 

William Schaffner, an infectious-disease expert at Vanderbilt University Medical Center, put it bluntly: “That virus, I guarantee you, will be present at the event — someone will bring it.”

Many academics have recently expressed support for people gathering in large crowds to protest police violence, prompting accusations from conservative corners that their guidance can be politically biased.

A Tulsa judge denied a push by some residents and business owners to block Trump’s rally. 

“The lawsuit in the district court of Tulsa County sought a temporary injunction against the company that manages the 19,000-seat venue, the BOK Center, ‘to protect against a substantial, imminent, and deadly risk to the community,’ according to a copy of the complaint. Judge Rebecca Nightingale denied the request,” DeNeen L. Brown, Annie Gowen and Joshua Partlow report. 

Meanwhile, Tulsa’s Republican mayor, G.T. Bynum, said he doesn’t plan to use his emergency powers to block the visit, but he has expressed unease about the event. 

“Do I share anxiety about having a full house at the BOK Center? Of course. As someone who is cautious by nature, I don’t like to be the first to try anything. I would have loved some other city to have proven the safety of such an event already,” Bynum wrote in a statement. 

Fauci told The Daily Beast's Erin Banco and Olivia Messer that he personally wouldn't attend Trump's upcoming rallies in Tulsa and Phoenix, Ariz.

“I'm in a high risk category. Personally, I would not. Of course not,” Fauci said. “Outside is better than inside, no crowd is better than crowd,” he added of the rallies.

There’s more to learn about the coronavirus

New research found coronavirus-containing aerosol droplets could spread through the air when you flush the toilet. 

Scientists simulated toilet water and air flows and found the droplets “appear to spread wide enough and linger long enough to be inhaled,” Karin Brulliard and William Wan report. “The novel coronavirus has been found in the feces of covid-19 patients, but it remains unknown whether such clouds could contain enough virus to infect a person.” 

The main takeaway: Close your toilet lid when possible. 

“For all our paranoia about the surface of toilet seats — the tissue paper we oh-so-carefully lay down, the thin covers often offered in public stalls — germ transmission from skin contact is a relatively small health risk compared with what happens after you flush,” Karin and William add. “That’s when bits of fecal matter swish around so violently that they can be propelled into the air, become aerosolized and then settle on the surroundings.”

A new study found children and teenagers are only half as likely to get infected with the coronavirus as adults 20 and older. 

When they do get sick, they usually remain asymptomatic, or have mild, “subclinical” symptoms of covid-19, Joel Achenbach and Laura Meckler report. For children and teens between the ages of 10 and 19 infected with the virus, 21 percent show symptoms, compared with 69 percent among people older than 70, the study found.  

That information can help officials making decisions about regarding reopening schools and day cares. 

“These results have implications for the likely effectiveness of school closures in mitigating SARS-CoV-2 transmission, in that these might be less effective than for other respiratory infections,” authors from the London School of Hygiene & Tropical Medicine write.

“From the start of the pandemic, it has been known that children are typically spared the worst effects of the disease. They rarely die of it. But they can still get sick and can spread the virus, including to older family members who are more likely to have a severe illness,” Joel and Laura add. 

Insurers paid a medical laboratory in suburban Dallas as much as $2,315 for coronavirus tests, even as major diagnostic labs charge $100. 

Gibson Diagnostic Labs even charged $6,946 when it said it erroneously charged patients three times the base rate, the New York Times’s Sarah Kliff reports

“It is one of a small number of medical labs, hospitals and emergency rooms taking advantage of the way Congress has designed compensation for coronavirus tests and treatment,” Sarah writes. “… How can a simple coronavirus test cost $100 in one lab and 2,200 percent more in another? It comes back to a fundamental fact about the American health care system: The government does not regulate health care prices.” 

Angie Meoli, a senior vice president at Aetna, said there’s been a “small number of laboratories that are charging egregious prices for Covid-19 tests.”

Unregulated prices mean high prices in general and major price variation, Sarah reports. 

She adds: “Many health care providers have settled on test prices of $50 to $200. Medicare initially paid heath providers $51.31 for coronavirus tests but bumped reimbursements up to $100 in mid-April. LabCorp, one of the country’s largest diagnostic testing firms, bills insurers $100 for its tests. A few health providers have set their prices significantly higher.” 

China's role

More than 50 scientists have resigned or been fired for not disclosing financial ties to foreign governments, most often China.

The National Institutes of Health has been investigating the failure of NIH grantees to disclose such ties. In 93 percent of the cases, the hidden funding came from a Chinese institution, Science Magazine reports.

The figures were presented last week by NIH head of extramural research Michael Laurer. His presentation “offered by far the most detailed breakout of an effort NIH launched in August 2018 that has roiled the U.S. biomedical community, and resulted in criminal charges against some prominent researchers, including Charles Lieber, chair of Harvard University’s department of chemistry and chemical biology,” Jeffrey Mervis writes.

“It’s not what we had hoped, and it’s not a fun task,” NIH Director Francis Collins said in response to the findings, calling the data “sobering.”

China actively tried to cover up the spread of the coronavirus by obfuscating data and suppressing warnings by doctors and journalists.

That's according to an interim report from House Foreign Affairs Committee Republicans, who looked at how China responded in the early phases of the pandemic. The 50-page report, which the minority staff members plan to update, says China deliberately and repeatedly violated its obligations under international health regulations to provide accurate and timely information about the virus and its rapid spread.

“Senior [Chinese Communist Party] leaders, including CCP General Secretary Xi Jinping, knew a pandemic was ongoing weeks before it was announced,” the report says. 

“Reflecting on what we have uncovered so far, the failures of the CCP to protect their citizens and fulfill their obligations under international law have resulted in disappeared journalists, a world seized by a public health emergency, and hundreds of thousands of dead,” it adds.

The report also slams the World Health Organization, saying the organization has “repeatedly parroted CCP talking points while ignoring conflicting information.”

And here are a few more stories to catch up on this morning: 

The economic fallout: 
  • Americans who lost their job during the pandemic or who have otherwise taken a hit to their income are avoiding going to the doctor or seeking health care they may need because of the costs, the New York Times’s Reed Abelson reports.
More on the administration’s efforts: 
  • HHS is shifting into an oversight role over the federal coronavirus response, the Wall Street Journal’s Armour reports, “an abrupt shift from April when the agency was under fire for its handling of the initial stages of the crisis.”
In the region: 
  • D.C. officials said more than 400 samples collected at testing sites can’t be processed because they were exposed to heat, Dana Hedgpeth and Fenit Nirappil report.
In the states: 
  • Florida, Texas and Arizona all set records for the most reported coronavirus cases in one day, the New York Times reports: “Florida reported 2,783 new cases, Texas 2,622, and Arizona 2,392.”

 

 

Sugar rush