April 29 COVID-19 Update – Pennsylvania American College of Physicians

April 29 Pennsylvania COVID-19 Update

On Tuesday, the Department of Health reported that Pennsylvania had found 1,214 new confirmed positive cases in the previous 24 hours, for a total of 43,264 confirmed cases.  The death total rose to 1,716 total confirmed COVID-19 deaths, an increase of 119 from Monday, all in adult patients. 
The state Health Department’s breakout of virus data for long-term care living facilities indicates 1089 of the state’s deaths, almost 62 percent, were nursing home residents.  There were 165,824 negative tests in PA as of midnight Friday night.
At least 2,519 are health care workers, a daily increase of 125  – accounting for about five percent of all positive cases; the total figure includes  920 in nursing homes. And from the department’s website, 7,360 cases – accounting for 17 percent of all cases- are in 452 of the state’s long-term care living facilities in 41 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 20% were 80+.  The remainder were unclassified yet per age.
Of the total through Monday, 23,375 positive cases (54%) were female and 19,311 (45%) were male. One percent (578) were unreported or neither.  Among the deaths, 914 (53%) were males and 793 (46%) were female with nine were unreported by sex.
By race, 8,935 positives were Caucasian (21%), 4,342 were African-American (10%) and 451 (1%) were Asian, with 195  listed as “Other.”  The vast majority, 29,341 (68% of all cases) remained unreported on the race of the patient.  A total of 645 deaths were among Caucasian victims, 186 were African American/Black, 21 were Asian and 5 were listed as other.  859 deaths were not reported by race.
On Tuesday at noon,  2,783 positive patients were hospitalized, slightly more than six percent of those testing positive.  At that time, 611  were using ventilators or breathing machines.  About 1,403 (about 40%) of  intensive care unit (ICU) beds were available, and 7909 general medical beds (47%) were available and 1,704 (53%) of the airborne isolation rooms are still available statewide.  And 1,449 of the state’s 5,197 ventilators were in use (nearly 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; 38% are aged 25-49; 27% are aged 50-64; and 26% are aged 65 or older. 
CMS Halts Advance Medicare Payment Program
The Centers for Medicare & Medicaid Services has paused its program to give providers advance Medicare payments to help them keep their practices open in the wake of COVID-19, suggesting that the program is no longer necessary, although some physician groups disagree.
CMS is “reevaluating the amounts that will be paid under its Accelerated Payment Program and suspending its Advance Payment Program to Part B suppliers effective immediately.” The CMS has paid over $100 billion to healthcare providers and suppliers through these programs.
In a fact sheet update accompanying the announcement, CMS explained that “beginning on April 26, 2020, CMS will not be accepting any new applications for the Advance Payment Program, and CMS will be reevaluating all pending and new applications for Accelerated Payments in light of historical direct payments made available through HHS’s Provider Relief Fund. Significant additional funding will continue to be available to hospitals and other healthcare providers through other programs.” The agency noted that the Department of Health and Human Services has already given $30 billion to providers through the CARES Act Provider Relief Fund.
The ACP had previously taken issue with some of the terms of the Advance Payment program. “We urge CMS to continue to work towards further decreasing processing time for applications and to extend the amount of time by which physicians would have to pay back Medicare for advance payments,” Robert McLean, MD, president of the American College of Physicians (ACP), said in an April 15 letter to the agency.
“Specifically, the College strongly recommends that this loan payment timeframe be extended to at least a year from the date that the load payment is received. Given the economic uncertainty surrounding this pandemic, extending the payback timeline would give physicians additional flexibility to weather an ever-changing economic forecast.”
The American Academy of Family Physicians (AAFP) also expressed concern. “Family medicine practices facing financial issues likely have already pursued relief through the Advance Payments Program,” Shawn Martin, the AAFP’s senior vice president of advocacy, said in an email. “However, the situation remains fluid for most practices and the administration has now taken away one option to secure financial support during this crucial time.”
The ACP also panned the move. “ACP is concerned that CMS has not provided sufficient information or justification on why they are suspending the program, and we think it is a step in the wrong direction,” Bob Doherty, the ACP’s senior vice president of governmental affairs and public policy, said in an email.
“The funds being provided for physicians and other health care professionals as part of the Provider Relief Fund are not nearly enough to make up for all of the lost revenue that medical practices are experiencing. It is also unknown how much of the additional money that Congress approved last week for emergency funding for the health care system will be sent to physicians, as opposed to other parts of the health care system.”
Governor takes media questions
The governor spoke with reporters about the coronavirus in Pennsylvania Tuesday afternoon.
Wolf was asked about the process of opening counties. He has said he’ll begin gradually reopening some counties in early May, starting with counties in the northern tier with a handful of cases.
“We’re looking at making common-sense decisions here as to when to open,” Wolf said. “We’re certainly try to be as rational and logical as we can.”  Wolf said there would be “some subjectivity” in the decisions.
The governor was asked about a possibility of an influx of visitors from other regions, as areas that draw tourists are reopened. He said the state is developing a contact tracing system that will track people who have been exposed to someone infected with the virus. But Wolf said he didn’t foresee measures to block traffic from other areas that may be traveling to northern Pennsylvania.
Wolf said he isn’t concerned where people are coming from, but state officials are concerned if people have been exposed to those who have contracted the virus.
The governor also said as regions are opened, if state officials start seeing an uptick in new cases, restrictions could be imposed again. If necessary, Wolf said, “We’ll walk it back.”
Wolf has said he plans to gradually reopen some regions in Pennsylvania beginning May 8. He has said he plans to reopen some counties in northcentral and northwestern regions, where there haven’t been many cases.
Even as restrictions are eased, the governor has said he has concerns about customers and workers being willing to come back. “I think that’s a real worry,” Wolf said.
“If people don’t feel safe, they’re not going to come back to work,” Wolf said, “If people don’t feel safe, they’re not going to be customers.” Wolf said the state needs better testing capacity and robust contact traci
ng to help build confidence so people do return to work, and stores and the economy can bounce back.
Wolf was asked about getting about COVID-19 cases in nursing homes. The state has released cases and fatalities by county but has not identified the facilities where cases have been found. More than 60% of all deaths from COVID-19 in Pennsylvania were in long-term care facilities, including nursing homes and personal care homes.  Wolf has said the state will do everything possible to protect residents and staff at long-term care facilities. Visitors have been barred from those facilities.
Wolf was asked about including Lancaster County in the southeastern region in making decisions on easing restrictions. Some Lancaster County officials have said they don’t want to be lumped into the southeastern region in the state when it comes to reopening. The governor said Lancaster County isn’t necessarily being included in the Philadelphia region on reopening decisions. “The decision has not been made about how we’re going to reopen,” Wolf said.
The governor was asked about expanding testing in state prisons. One inmate has died at the state prison in Montgomery County. Wolf said the state corrections department is testing those who are at risk but would be getting more information about conditions in the prison. Visitors have been prohibited from visiting state prisons during the pandemic.
Wolf has said the reopening of regions will occur in three phases: red, yellow and green. While all the state remains in the red zone, Wolf has said some rural areas should move into the yellow phase in early May.
Even those in the yellow phase will still have some restrictions. While some businesses would be allowed to reopen, no large gatherings (defined as more than 25 people) would be allowed. Even in the yellow zone, casinos, theaters and gyms would still be closed and restaurants and bars would still be limited to carry out or delivery services.
Tuesday Questions for Sec Levine
Sen. Yaw is saying this is no worse than the flu and healthy shouldn’t be quarantined. What do you say?  LEVINE: On this I must disagree  This is a global pandemic with over 3 million cases, approaching a million cases in the US and over 50,000 deaths.  It is much more contagious and more lethal than the flu.  It’s dangerous.  The standard of care is to isolate then quarantine.
Can libraries, pet groomers and hairdressers reopen under yellow?  LEVINE: Yes, we will, but we want people to follow social isolations, want people to wear masks.
You warned against overemphasizing 50/1000.  Can you see an instance where a county would fail to get that benchmark and still move from red to yellow? LEVINE: I think I t would be unlikely that any county that doesn’t meet the threshold would be allowed to move.
IF you live in a county that’s red, and you work in yellow, can you move to work?  LEVINE: Yes, there’s no limitation on travel in that instance.
Coroners want to know how they can be sure number of fatalities are accurate.  LEVINE: Any time something moves this quickly, there will have to be reconciliation of numbers coming from different sources.  We respect the coroners so much and have a conf call with them scheduled Friday.
What can you say to assure people the state’s death toll is comprehensive and accurate?  LEVINE: We are getting from the NEDDS system, and collect data from hospitals, nursing homes, coroners and reconciling all that info
A lawsuit has been filed that accuses the DoH of failing to inspect nursing homes. Do you have any comment?  LEVINE: I cannot comment on any lawsuit.  We are following CMS guidelines and put out our own.
On 4-16 your guidance was that life sustaining businesses still have to wear masks.  Is it true that doesn’t apply to retail concessions and city employees at airports?  LEVINE: Airports are under FAA guidance and oversight.  Our recommendation is to wear masks.  That’s sort of more a recommendation not a requirement.
DoH said that the Easton  hospital promised to remain open through June 30.  Given rates, is it important that Easton hospital remain open that long? LEVINE: I think it is and we need all available hospital beds.
How did you reach the agreement about  June 30?  LEVINE: I’m not at liberty to talk about those the negotiations.
Why does my county have to wait to reopen for a county I don’t live in never have been in and will never visit?  LEVINE: We’re going to be looking at quantitative factors and a lot of qualitative factors.
The death count in Philadelphia hasn’t changed in five days but the county data being released is soaring. How do you account for that? LEVINE: We’re working on reconciling that every day.
There’s a spike in Northampton county of positives – it’s spiked more than seven percent but none of the other NE counties did. Why? LEVINE: We’ll take a look at that.
Mohegan sun testing continues to be down.  How do we get to the 200 a day we hope for? LEVINE:  I suggested anyone with symptoms come for testing, but we have plenty of capacity at that site and are asking people to go get tested and get the results, which we’ll usually have in 24 hours.
The governor suggested other regions than DoH that could be used in the reopening decision making.  Will Pennsylvanians be given those benchmarks and what reasons and factors led to a county NOT being opened?  LEVINE: The Governor has said we won’t necessarily be held to the schema of DoH.  Quantitative and qualitative and will be pleased to discuss why afterwards.
There is another Tuesday spike in the numbers.  Is this a pattern?  LEVINE: Yes, it’s been lower on Monday and higher on Tuesday, so there may be a lag it’s hard to predict for the future and yes, it’s a pattern.
How can seniors and the disabled to get tested if they are not in Montgomery County or the Northeast, and not in a hospital network.  LEVINE: They can call their physician who can recommend where it can be done.  We have asked hospitals to test people even if they are outside the network. Rite Aid and CVS are also doing testing and you could get it done there.
Is there some fundamental difference between your reporting with coroners’ reports?  They reported 75 deaths and five from elsewhere, today you reported 55.  LEVINE: that person lives in another county, the death attributes to the person’s home county.  We have to follow CDC reporting guidelines.
The governor talked about mental health being a reason for opening marinas, gold and other outdoor activities.  Is there any even anecdotal evidence for how PA is doing on the mental health side?  LEVINE: DHS, and DDAP work with them and continually every day I remind people of using the text line and hotline support and referral hotline.  This has been extremely stressful for individuals and families.  Anxiety provoking and could be causing depression. We urge people to use those resources.
What guidance do you have for life sustaining operations or those going yellow who are working outside of an office?  LEVINE: Whenever possible we would like business to continue to telework if you can – that would be great.  If businesses want or need people to come back in to work, they should wear masks, maintain six feet of distancing, and handwashing to prevent the spread.
In Montgomery County, officials discovered 200 people in a correctional facility tested positive without symptoms.  Is it time to do more comprehensive testing in those facilities and nursing homes?  LEVINE: We do know that an individual can have COVID-19 and not have any symptoms.  It would be extremely difficult to test every resident and staff
at institutions and nursing homes.  We are now seeking as wide a range of symptomatic people, but hope to be able to do that in the future.  However, just because you are negative doesn’t mean you won’t be tomorrow.  We’ll need a regular pattern of testing.
Philadelphia’s health commissioner said it looks like the city is past the peak of the pandemic. Do you agree?  LEVINE: I agree  with that, but the trends and data are more important, and looking at those trends, it does appear we are, but we have to be very very careful that we don’t see additional outbreaks.
As you try to purchase masks and PPE have you encountered issues with price gouging, and have you paid those premium prices? LEVINE:  I don’t do that, but PEMA has been working on it. They have been careful to avoid price gouging.
What supplies and parts manufacturers have committed to helping expand these resources  in PA?  LEVINE: I heard from Secretary Dennis Davin that there is robust participation on the manufacturing portal, but I don’t have the info on that.
Penn Highlands reported they have 2,500 tests for a five hospital system and no nasal or antibody tests.  What are you doing to help these rural systems?  LEVINE: We are focused on viral testing and testing those who have symptoms.  With antibody tests, we need to know the efficacy and aren’t sure of the clinical value, but we are interested from the public health value.
What time will you give areas for reopening?  If they are moving to yellow on May 8, will you give them a timeline in advance?  LEVINE: We plan to give the info out May 1 for May 8.
The governor said he isn’t wedded to the DoH regional map.  If so,  then what will regions look like?  Will patterns of travel and neighboring counties be considered? LEVINE: A lot of factors will go into that. We use our DoH regions, but as the Governor said, we won’t be wedded to that scheme.
We are So focused on at-risk populations, is testing inadequate for measuring number of cases per 100,000?  What will clarify that benchmark?  LEVINE: We have a number of tests, and other statistical and public health measures.  We will have an aspirational testing target number.
What needs to happen before we can test widely enough to go back to normal?  LEVINE: When we go from red to yellow, counties and regions should have confidence that we are moving forward with contact tracing, laboratories  and good judgment.  The commonwealth and resident do have confidence in the Governor and his plans.
With the positives in nursing homes in one county – one home could jeopardize an entire region being able to move from red to yellow.  LEVINE:  Those Long Term Care facilities will be included in the counts for counties and regions.  They will be included.
If state health officials have a county moving from  red to yellow should the courts remain closed?  LEVINE: We don’t control the court system, but we know the Office of General Counsel has regular discussions with them. We hope the court stays as remote as possible.
Residents in northern Pennsylvania want to know, where they can go for antibody testing? LEVINE: We have a statewide list of testing sites, but don’t have that information on antibody testing. The antibody test in my opinion does not provide useful clinical data.  It means you had it and have antibodies.  We don’t know how protective those antibodies are or for how long they will be.
If health concerns were the only consideration, should the state have in-person voting on June 2?  LEVINE: I’ll defer that question to the Governor who’s discussed that with Sec. Boockvar at the Department of State.
Senate Democrats Policy Committee hears from frontline COVID-19 workers
The State Senate Democratic Policy Committee held a hearing Tuesday to hear from some frontline workers during the pandemic, and celebrating Workers Memorial Day to “remember workers killed or injured on the job and to renew the fight for strong safety and health protections.”
Last week, the Republican Policy Committee had held a similar hearing with representatives of business and health systems. 
The committee had invited representatives of fire and EMS services, nurses, home health workers, Postal Workers and Carpenters Unions, and representatives of the Transit Workers’ and Food and Commercial Workers Unions, and the Service Employees International Union.  Sen. Pam Iovino of Pittsburgh said that frontline workers need to “inform us on how to correct current conditions for the best path ahead.”
An RN from Hershey Medical Center expressed concern that nurses have now been given the order to wear their N95 masks six times, even when they are used between multiple patients. She remarked that hospitals without unions are in even worse situations. She said management refuses to meet with staff to discuss concerns and that in some nursing homes workers are being forced to clean up after patients without any PPE.
She asserted that adequate PPE has to be provided now and stockpiled for any potential surges, and that rapid testing and contact tracing has to occur to prevent local outbreaks from becoming surges. She added that paid sick leave needs to be offered to health care workers, so they do not become vectors.
A home health care worker testified about her issues taking care of her brother, while herself immunocompromised.  She expressed concern for the lack of testing, saying that she is scared that workers could have the virus without showing any symptoms. Additionally, Rothrock said PPE that would lessen the risk of exposure has been unavailable to home health care workers, and that home health care workers lacked quality training, adequate wages, medical coverage, and paid sick leave. She added that home health care workers have always been forgotten and now they have to rely on volunteers or private sellers to source any PPE or disinfectants.
During questions, lack of adequate PPE and disinfectants repeatedly came up in the discussions of hospitals and home health. The Senators asked the testifiers what recommendations they would have for guidelines. 
Sen. Daylin Leach asked why hospitals are saying different things than workers and if there is pressure on workers to not talk about supply shortages. He was told that some union workers were told by administrators to not ask questions about masks and that some workers have walked off the job because of that. Sen. Leach said those stories are “troubling” and that embarrassment cannot govern how things are done. The home health worker commented that the 48,000 home health care workers in the state have no access to PPE. She stressed that they would have to purchase supplies on the open market but that they have not been able to crowdsource any supplies and that it is not unique to Pennsylvania.
Senators threaten Wolf with subpoena over business waivers
Sens. Mike Regan, R-Cumberland/York counties, and Tom Killion, R-Delaware County, sent letters to the governor and his Community and Economic Development Secretary Dennis Davin saying the administration’s failure to commit to a timeline at a Senate committee hearing last week for producing records about the waiver program is unacceptable and threatened a subpoena unless the materials are delivered by Wednesday April 29.
“…there are serious and significant questions outstanding regarding the waiver process generally, and particularly as to the perceived inconsistencies in the department’s granting and/or denial of these requests.  Answers to these questions are essential to
a legislative understanding of the governor’s response to the COVID-19 pandemic, which is in turn essential to our consideration of current and future legislative proposals,” the letters stated.
A Community & Economic Development spokeswoman confirmed receipt of the letter, but said that “The needs of Pennsylvania’s business community while protecting public health and safety has been a priority. The administration is reviewing the letter and will determine how best to respond in light of the extensive resources that have been devoted to addressing this disaster.”
The letters request a series of records documenting which businesses received waivers and which ones didn’t and the rationale behind those determinations be delivered to Regan’s Capitol office by Wednesday.
After the governor released a list of life-sustaining businesses that were allowed to remain open as part of his COVID-19 response. Many businesses were barred from opening. The waiver program gave those businesses deemed not life sustaining a chance to make a case to be allowed to reopen.
State Senator Questions Commonwealth Response
Tuesday morning, State Sen. Gene Yaw of Williamsport questioned the state’s response to COVID-19.  He said, “The average number of deaths from the flu in Pennsylvania annually is almost 3,000, and so we are only half-way there when it comes to COVID-19 data.  So, the numbers are starting to indicate this is not a whole lot worse than the average flu season.”
Yaw said a statewide shutdown was the wrong move based on history in the United States. In a radio interview, Yaw said, “We isolated healthy people.  When I started in grade school, if you got measles, mumps or chicken pox, there was a county health officer that came around and put a sign on your door on the side of your house that your house was quarantined.  We didn’t do that this time.  We quarantined all the healthy people.  I don’t understand that.  I really don’t.”
The five states with direct mass transit connections to New York City (NY, NJ, MA, PA, CT) have suffered 36,874 deaths out of a population of 51.6 million, while the rest of the USA has lost 22,372 out of a population of 275.9 million.  These five states, with 16% of the US population account for 62% of COVID-19 deaths.