April 24am COVID-19 Update – Pennsylvania American College of Physicians

April 24 (morning) Pennsylvania COVID-19 Update

Explained inclusion of probable cases, but realized it can be confusing.  Today showed a decrease I probable cases, but further review showed more information was needed.  It does not affect the confirmed case count. 
The DoH has now included trend animations on its website as well, for reference.  We are bolstering our contact tracing efforts and looking at the best ways to utilize these resources and help us identify early if an outbreak begins to happen.  These were the tactics we used at the start of the pandemic and they helped to mitigate the spread. 
New confirmed cases per county (by region) for 14 days must be <50/100000 availability of testing, hospital beds, case management , contact tracing, modeling by CMU all together to make decisions. Confirmed case counts are what will count toward metrics in reopening decisions. 
On Thursday, the Department of Health reported that Pennsylvania had found another new 1,369 confirmed positive cases in the previous 24 hours, for a total of 37,053.  That represents 36,665 confirmed cases and 388 probable cases.  The increase includes 981 confirmed cases and 388 probable positives. The death total rose to 1,396 total confirmed COVID-19 deaths, an increase of 69 from Wednesday, all in adult patients.  That number includes 1,325 confirmed and 71 probable deaths.  The Health Department said the change was due to better data collection and confirmation of cases, and that probable deaths will be reported in the future. 
The state Health Department’s breakout of virus data for long-term care living facilities indicates 849 of the state’s deaths, about 61 percent, were nursing home residents.  There were 142,061  negative tests in PA as of midnight Wednesday night.
At least 1,950 are health care workers – accounting for about five percent of all positive cases; the total figure includes  673 in nursing homes. And from the department’s website, 5,679 cases – accounting for 14.5 percent of all cases- are in 408 of the state’s long-term care living facilities in 39 counties.
Two percent of hospitalizations were under 29 years of age, five percent were 30-49, 10% were 50-64, 20% were 65-79 and 21% were 80+.  The remainder were unclassified yet per age.
Of the total through Wednesday, 19,849 positive cases (54%) were female and 16,680 (45%) were male. Two percent (524) were unreported or neither.  Among the deaths, 758 (54%) were males and 658 (46%) were female with 5 unreported by sex.
By race, 7,051 were Caucasian (19%), 3,481 were African-American (9%) and 361 (1%) were Asian, with 145 listed as “Other.”  The vast majority, 26,015 (70% of all cases) remained unreported on the race of the patient.
On Thursday at noon,  2,746 positive patients were hospitalized, slightly less than eight percent of those testing positive.  At that time, 679 were using ventilators or ECMO.  The number of available intensive care unit (ICU) beds stood at 1,489, the number of available isolation rooms was 1,675 and the number of general medical beds was 7,909.  And 1476 of 5144 ventilators were in use (about 70% of ventilators were still available.) 
Of the patients who tested positive to date the age breakdown was: less than 1% are aged 0-4; less than 1% are aged 5-12; 1% are aged 13-18; 6% are aged 19-24; 39% are aged 25-49; 28% are aged 50-64; and 25% are aged 65 or older. 
See below for Thursday’s Questions and Answers with Governor Wolf and Secretary Levine.
Governor Clarifies Plans to Reopen PA
Governor Wolf on Thursday said that the 50 new cases/100,000 population for 14 days was a benchmark, but not the defining element in deciding to move a region to Yellow from the Red Phase. 
This is not the only barometer the Wolf Administration would use, and the yellow phase isn’t exactly a return to normal activity. The governor said that assessing medical capabilities, how consistent and widespread testing has been done, what’s happening in nearby counties and other factors would all be part of the decision making.
The published plan goes on to say:
“Additionally, to reopen a region, the commonwealth must ensure there is:
Enough testing available for individuals with symptoms and target populations such as those at high risk, health care personnel, and first responders.
Robust case investigation and contact tracing infrastructure is in place to facilitate early identification of cluster outbreaks and to issue proper isolation and quarantine orders.
Identification of area’s high-risk settings including correctional institutions, personal care homes, skilled nursing facilities, and other congregate care settings, and assurance that facilities have adequate safeguards in place such as staff training, employee screening, visitor procedures and screening, and adequate supplies of PPE to support continued operations
New cases per 100,000 by region, 14-day averages
The first metric that the Wolf Administration will be using to determine when counties begin the gradual process of reopening is a 14-day average of the total cases for each of the state’s six regional health districts, with the threshold of that average being 50 cases per 100,000 of population.
As of Thursday, only one of the six health districts has a 14-day average below 50: the Northwest (Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, Lawrence, McKean, Mercer, Venango and Warren counties), at 24.7.
As for the other districts, their current 14-day averages are:

  • Southeast (Berks, Bucks, Chester, Delaware, Lancaster, Montgomery, Philadelphia and Schuylkill counties) = 337.2;
  • Southcentral (Adams, Bedford, Blair, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lebanon, Mifflin, Perry and York counties) = 91.2;
  • Southwest (Allegheny, Armstrong, Beaver, Butler, Cambria, Fayette, Greene, Indiana, Somerset, Washington and Westmoreland counties) = 69.8;
  • Northeast (Carbon, Lackawanna, Lehigh, Luzerne, Monroe, Northampton, Pike, Susquehanna, Wayne and Wyoming counties) = 430.2; and
  • Northcentral (Bradford, Centre, Clinton, Columbia, Lycoming, Montour, Northumberland, Potter, Snyder, Sullivan, Tioga and Union counties) = 66.4.

We expect those numbers to change regularly going forward, with some increasing and others decreasing, depending on many local issues.
HHS Announces Additional Allocations of CARES Act Provider Relief Fund
The CARES Act provides relief to healthcare providers on the frontline of the COVID-19 outbreak. $100 billion is being distributed by the Administration to healthcare providers including hospitals battling this disease.
$50 billion of the Provider Relief Fund is allocated for general distribution to Medicare facilities and providers impacted by COVID-19, based on eligible providers’ 2018 net patient revenue.  

$30 billion was distributed immediately, proportionate to providers’ share of Medicare fee-for-service reimbursements in 2019. On Friday, April 10, $26 billion was delivered to bank accounts. The remaining $4 billion of the expedited $30 billion distribution was sent on April 17.  
This simple formula, working with the data we had, was used to get the money out the door as quickly as possible. We were very clear that additional funds would be going out quickly to help providers with a relatively small share of their revenue coming from Medicare fee-for-service, such as children’s hospitals.  
Those funds are beginning to be delivered this week. HHS will begin distribution of the remaining $20 billion of the general distribution to these providers to augment their allocation so that the whole $50 billion general distribution is allocated proportional to providers’ share of 2018 net patient revenue.  
On April 24, a portion of providers will automatically be sent an advance payment based off the revenue data they submit in CMS cost reports. Providers without adequate cost report data on file will need to submit their revenue information to a portal opening this week at https://www.hhs.gov/providerrelief for additional general distribution funds.  

  • Payments will go out weekly, on a rolling basis, as information is validated, with the first wave being delivered at the end of this week (April 24, 2020).  
  • Providers who receive funds from the general distribution have to sign an attestation confirming receipt of funds and agree to the terms and conditions of payment and confirm the CMS cost report.  The portal for providers to sign the attestation confirming receipt of these funds launched the week of April 13, 2020. Recipients have 30 days to complete the required filing. You can find that information HERE.
  • The terms and conditions also include other measures to help prevent fraud and misuse of the funds. All recipients will be required to submit documents sufficient to ensure that these funds were used for healthcare-related expenses or lost revenue attributable to coronavirus. There will be significant anti-fraud and auditing work done by HHS, including the work of the Office of the Inspector General.  
  • As part of this commitment, as a condition to receiving these funds, providers must agree not to seek collection of out-of-pocket payments from a presumptive or actual COVID-19 patient that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.


  • $10 billion will be allocated for a targeted distribution to hospitals in areas that have been particularly impacted by the COVID-19 outbreak. As an example, hospitals serving COVID-19 patients in New York, which has a high percentage of total confirmed COVID-19 cases, are expected to receive a large share of the funds.  


  • As announced in early April, a portion of the $100 billion Provider Relief Fund will be used to reimburse healthcare providers, at Medicare rates, for COVID-related treatment of the uninsured.  

Every health care provider who has provided treatment for uninsured COVID-19 patients on or after February 4, 2020, can request claims reimbursement through the program and will be reimbursed at Medicare rates, subject to available funding.  
Steps will involve enrolling as a provider participant, checking patient eligibility and benefits, submitting patient information, submitting claims, and receiving payment via direct deposit.  
Providers can register for the program on April 27, 2020, and begin submitting claims in early May 2020. For more information, visit coviduninsuredclaim.hrsa.gov.  

  • $10 billion will be allocated for rural health clinics and hospitals, most of which operate on especially thin margins and are far less likely to be profitable than their urban counterparts.  

This money will be distributed as early as next week on the basis of operating expenses, using a methodology that distributes payments proportionately to each facility and clinic.  
This method recognizes the precarious financial position of many rural hospitals, a significant number of which are unprofitable.  
Rural hospitals are more financially exposed to significant declines in revenue or increases in expenses related to COVID-19 than their urban counterparts.  
Providers can find more information on this additional relief HERE. 
Congressional Relief Bill Passes – to President for signature
After two weeks of stalemate and days of negotiations, the US Senate approved a nearly $500 billion coronavirus aid bill on Wednesday afternoon with the House passing the bill on Thursday evening.
The agreement centers around providing $380 billion for small businesses and also includes $75 billion for hospitals and $25 billion more for disease testing.
Turzai and Governor now in accord on Construction Opening
House Speaker Mike Turzai today put out a statement after talking with Governor Wolf about plans to reopen the state’s construction businesses next Friday May 1.  Turzai said, “The more than 260,000 hard-working men and women in Pennsylvania’s construction trades got good news as Gov. Wolf announced the opening of all construction projects next week on May 1. This announcement follows House action, including the bipartisan passage of House Bill 2400, which I authored. This bill would safely open construction projects.
Turzai said, “Gov. Wolf and I had a positive discussion today; he was open to the suggestion that construction activities could be done safely, allowing tradespersons to resume their important work – much of it seasonal. Working with him on this issue showed we can move forward together on fighting COVID-19, while rebuilding the economy.
“The people who work in the construction trades can see light now at the end this COVID-19 tunnel. This is about employees and self-employed persons in construction who want to put food on the table and provide shelter for their families. People across Pennsylvania want the dignity of work, an opportunity to care for their families, and to be safe.”
State Senate Holds Joint Hearing on COVID-19 Response
The State Senate Community, Economic & Recreational Development and Senate Veterans Affairs & Emergency Preparedness Committees held a hearing Thursday morning at 10 am on Governor Wolf’s COVID-19 response  and its impacts.  During the hearing, liability reforms were discussed.  Sen. Tom Killion (R, Delaware) said there are concerns about companies which produced PPE being sued if equipment is not «up to par. He asked if legislative action is necessary to protect businesses, similar to good Samaritan» laws. The State Chamber of Business and Industry noted they are tremendously concerned about liability issues, with PPE, noting protective action was not an excuse for gross negligence.  Sen. Michele Brooks (R, Mercer) said her office requested other members to support legislation to address liability concerns previously stated. Sen. Bob Mensch  (R, Montgomery) said an attorney believed the administration created a liability situation by mandating masks. He said these created concerns with various industries, such as sanitation, on finding masks for employees. He said there are “great concerns” regarding liability because of that mandate.
When questioned if DOH’s Right-to-Know operations are open. Sec. Levine indicated that under the governor’s disaster declaration no state agency’s Right-to-Know operations are open. It was pointed out that other agencies are still processing Right-to-Know requests and urged DOH to reopen that function. Sec. Levine said that the department’s attorneys are working fulltime on COVID-19 related issues but that she will bring the issue up to the governor’s Office of General Counsel.
House to consider several health insurance bills Monday
The House Insurance Committee scheduled a voting meeting for Monday on several bills, including  
HBs 469, HB 470, HB 471, HB 1439 and HB 1696.  We fully expect significant amendments to be offered to these bills in Committee or later in the legislative process, as most are aimed at forcing changes by health care insurers.
HB 469 would require most health insurance policies cover the ten Essential Health Benefits, and would virtually eliminate Short Term Limited Duration health care polities as a result.
HB 470 
prohibits lifetime and annual limits on Essential Health Benefits for individuals.
HB 471 prohibits insurers from discriminating against a qualified individual or group based on a pre-existing medical condition.
HB 913 modifies state law re children’s coverage on parents’ health care insurance, allowing children on parents’ policies even if that policy is owned by an employer.  The bill also would put Pennsylvania in line with federal age coverage provisions, reducing the maximum age from 29 to under 26 years of age.
HB 1439 – requires insurers issuing or administering a health insurance policy or plan to file a written annual certification that they have completed a comprehensive review of all health insurance policies and health plans with mental health or substance use disorder benefits and meet the standards of  the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act.
HB 1696 requires insurers to file information with the Department, to determine whether the insurer is in compliance with the Mental Health Parity and Addiction Equity Act.
National and PA Polls – Public Support for Social Distancing
A national Politico/Morning Consult Poll shows wide support for continued social distancing measures, and majorities still say they are more concerned with the public health implications of the coronavirus. 
The poll, conducted Saturday and Sunday does show an uptick in the percentage of voters worried about the U.S. economy. Just over a third in the new poll, 35%, say they are more concerned about the economic impact of the coronavirus, up 6 points from last week. The majority, 58%, say they are more worried about the public health impacts, down 6 points from 64% last week.
Ending social distancing now is still a fringe position. Only 14% say Americans should stop social distancing to stimulate the economy even if it means increasing the spread of the virus, though that’s up 4 points from last week. More than three in four, 76%, say Americans should continue to social distance for as long as necessary, even if it means continued economic damage.
A Pennsylvania poll by Fox43/Susquehanna Polling and Research showed of 693 registered or likely voters taken April 14-20, showed 68% of people say the governor is doing a good job managing the novel coronavirus issue. In the poll, 18% disapprove and 13% of people say they weren’t sure. 
Governor Wolf has bipartisan support, according to Susquehanna P&R President Jim Lee, who says along with 83% of Democrats approving of the governor’s handling of the issue, 57% of Republicans statewide are also on board. 
Lee says, nearly all Pennsylvanians are listening to his orders when it comes to social distancing. According to the poll, 98% of Pennsylvanians have either fully complied (84%) or partially complied (14%) with the commonwealth’s social distancing guidelines. One percent of people admit they are practicing no social distancing.
“That 1% may not seem like a big deal but 1% of the state’s population is 120,000 people who have decided to ignore these guidelines,” Lee said. “That means a number of those people could be going around spreading the virus. Even that 1% saying no means we’re not out of the woods yet.”
However, the governor lacks the same wide-ranging support on one of his key issues, the decision to indefinitely close all non-life-sustaining businesses. The poll indicates almost 44% of Pennsylvanians either want to go back to work immediately (11%) or at the start of May (33%), while 38% say their businesses should stay closed indefinitely. 
Thursday Q/As with Sec. Levine
Thousands of infections were throughout NYC before first confirmed case , and in other cities according to NE University study. What does that mean for the course of the pandemic? – LEVINE: I haven’t had an opportunity to look at that modeling and that’s an interesting hypothesis – we’ll analyze it.
Will reopening be county by county or region by region?  Will all counties have to meet the metrics to open a region?  LEVINE: It will be region by region, but we’ll be looking at many metrics and other variables possibly as well.
You are saying there must be enough testing for reopening to occur.   How is that defined? LEVINE: We won’t be able to test asymptomatic individuals.  We have been prioritizing health care workers, nursing home workers and we will start to look at anyone who has symptoms.  We will not be able to do widespread testing of individuals at this time.  We’ll be looking at HAP members, RITE AID, mass testing sites, mobile testing as suggested by Sen. Baker to accomplish this.
CDC Director Redfield’s reminder to get a flu shot – is it too early to plan or make additional preparations for the fall? LEVINE: Not early but we always have robust plans for the flu season.  We will have a robust pushout of the flu vaccine, so they are strong enough to deal with COVID-19
A county can make the list for opening with 50 or less/100,000, do you calculate the new cases over that TIME?  LEVINE: Not counties that are isolated.  A county could meet the criteria  but if other counties in the region are higher, that county could not reopen?
Are Union Snyder, Northumberland counties qualified. now?  LEVINE: I’m not going to look at that today.  We’re talking about almost two weeks from now and will make those calculations now.
Why are daycare centers allowed to open, but not gyms or schools? LEVINE: People will NEED daycare if they are going back to work.  We’re not going to open up restaurants because of social distancing. 
The Exponential epidemic explanation -people don’t understand that. Can you shed light on it? LEVINE:  Previously every 2-3 days the number of cases were doubling.  If it went from 8 -16- 64, etc. going up at a straight line rate 1000, 2000, 4000.  FEMA was using the University of Washington model and we could have had 100,000 cases by now if that continued.  But because of everyone’s efforts, we’ve been able to bend that curve and its still going up, but not at that rate.  Still we have many cases, particularly in the SE, hospitals which are challenged, but we’ve been able to keep up, but we’re not out of the woods yet.
How many and which counties are revising the numbers downward because of duplicates? LEVINE: I don’t have that information.
Would the governor consider removing long term care facilities from the numbers given the closeness of those individuals?  LEVINE: No we won’t – and we need to do everything we can to protect them.
Due to shortage of tests, only testing those with symptoms and over 65.  What steps need taken to get to the 50/100000 threshold? LEVINE: Having reagents and chemicals for those tests will help.  The patients at Mohegan Sun are having tests performed in Exton. 
What percent of total population should be tested before reopening the state?  LEVINE: We will expand that testing, but we’re not at a point where we can do that, even with symptomatic patients.
Antibody tests – what’s the status?  LEVINE: We’re continuing to look at it.  There are challenges with the antibody tests.  They must be good, accurate and have
solid sensitivity.  One of the common viruses that cause common cold is a coronavirus.  How effective are those antibodies?  Partially effective and how long-lived is it?  We need to conduct further investigations on it.
When a region goes into yellow what is aggressive containment? LEVINE: Watching for symptomatic individuals, aggressive testing, isolating and contact tracing of professional contacts, goes back to where we were seven weeks ago as we try to turn a region to yellow.
Under the governor’s plan, when can we project Phila and other counties to phase to Yellow?  are LEVINE: We are not there.  The highest rate of new cases – I can’t predict when that will be.  We will get there, but don’t know when.
Will kids camps and summer sports camps open under yellow?  LEVINE: We haven’t made that determination yet.
If 100,000 are in a county and it reported 49 new cases, would that meet the benchmark?  LEVINE: Hard for me to respond on that, the decision will be by REGION, not county. 
Beaver County has a problem at the  Brighton rehab facility. Will that factor into the county?  LEVINE: Yes, if there’s a Long Term Care facility with a large number of cases, they would be included.
When statewide order ends May 8, are we permitted to visit family?  LEVINE: In regions that are yellow, yes.  Be we still recommend wearing of masks as much as possible, and part of the effort to prevent recurrence of virus.
How will contact tracing be done and funded?  LEVINE: Public health nurses in county and state health centers and county/municipal volunteers will help.  We’re working on that strategy.
Allegheny Co. officials removed 5 today that were duplicates, and Westmoreland numbers are still off, and they keep shifting.  Why is that? LEVINE: We’re trying to be transparent, which is why we included probables.  It is really difficult to explain. Case numbers have ebbed and flowed – sometimes just a resident of a different county. 
Has it been decided which regions there are?  LEVINE: We’re working on it but won’t be finalized until the 8th.
Ventilator supplies seem to be okay, but not dialysis machines. Is that accurate? LEVINE: We have heard that some hospitals are scrambling for them. We have no granular data at this point, but we’ll get it.
Why are you waiting till next week to meet with Coroners if they are such a critical part of the effort?  LEVINE: We want to wait until we have more information.
The number of tests has fallen – does that reflect less need or less supply?  LEVINE: We will have to look at the numbers – fell over Easter and Passover, but it’s one of the reasons we are lowering requirements for testing.
Are suicides related to COVID-19 issues being reported as COVID deaths?  LEVINE: No, they would not be considered COVID-19 deaths.