May 12 COVID-19 Update – Pennsylvania American College of Physicians

Below:

• Governor threatens counties with loss of federal funds, license revocations, liability
• Daily COVID-19 data update
• DoH guidance update for permitted non-urgent and elective care
• Senator calls for Levine’s resignation
• Legislative reactions to Wolf’s announcement
• Senate takes Wolf to Court over business closure, waiver programs

 
Governor Wolf threatens PA counties with loss of federal funds, liability and license revocation
Monday morning, Governor Wolf held a public announcement and answered questions after a dozen Pennsylvania counties threatened to move themselves from the red phase to yellow this week.  Wolf said, “I cannot allow residents in a red county to get sick because their local officials can’t see the invisible risk of the virus in their community,”. “So, I must, and I will impose consequences if a county locally lifts restrictions when it has not yet been given the go-ahead by the state.”
 
He called those saying they’ll defy his decisions “morally wrong,” “selfish,” and “deserters,” saying they were willing to jeopardize the lives of all Pennsylvanians by their desire “to give up” in the face of what he portrayed as the ever-present threat of COVID-19.
 
Wolf highlighted four ramifications for those who “open illegally”:

• “Counties will not be eligible for federal stimulus discretionary funds the state receives and intends to provide to counties with populations of fewer than 500,000.”
• “Businesses in counties that do not abide by the law will no longer be eligible for business liability insurance and the protections it provides.” 
• “Restaurants that reopen for dine-in service in counties that have not been authorized to reopen will be at risk of losing their liquor license.”
• “County residents receiving unemployment compensation will be able to continue to receive benefits even if their employer reopens. Employees may choose not to return out of concern for personal safety and safety of co-workers.”

 
Originally, the statewide lockdown was intended to “flatten the curve,” to prevent a warned scenario that hospitals would be overrun and widespread death would ensue, and that once we accomplished that, we would be able to return to something akin to normal.
 
But according to UPMC, at the “peak” in mid-April, two percent of their system’s 5,500 hospital beds were occupied by COVID-19 patients, and Dr. Steven Shapiro, UPMC’s chief medical and scientific officer, last week said the predictive models used to inform our “flatten the curve” policies “have performed poorly, often neglecting critical variables,” such as who is most vulnerable and where they are located.
 
Just nine counties in the southeast and northeast have accounted for more than 72 percent of all new cases the last two weeks.  The other 58 counties have reported only 4,184 new cases, and a majority of those are in nursing homes, prisons and food processing plants.
 
Now the Governor is taking actions to keep people “safe” as a goal, which businesses and counties see as a moving of the goal posts.  They have become even more frustrated by the lack of transparency in decision making, refusal to share the process of determining qualifications to move from one phase to the other despite promises that the decisions will be science-driven, and a refusal to even consider the process of moving from yellow to green despite that being part of the Governor’s plan.
 
This afternoon, Sec. Levine said that in addition to meeting the benchmark of less than 50 new cases per 100,000 population, her staff consider modeling, capacity of hospital and health systems, contact tracing and ability to conduct testing, and added public health, social, economic and political impacts as qualifiers before making recommendations to the Governor, who makes the decisions.
 
Recent studies showed that the state currently has a staff of 160 public health nurses available for contact tracing, with projections of a need for more than 3,500 tracers, but the state has not taken steps to hire those individuals.  And as more testing is available at more locations, the state is insisting on testing only symptomatic individuals, but hospitals, health systems and even Rite Aid are testing asymptomatic individuals as well.  Counties with plans to do testing and hire tracers have not had the opportunity to meet with the Wolf Administration, while the southeastern Counties and Philadelphia have been having daily and weekly phone discussions. 
 
Immediately after the Governor’s statement, Attorney General Josh Shapiro took to Twitter to point out that the courts have repeatedly concluded that Wolf has been acting within his authority as governor.
 
The state Insurance Department also issued guidance, warning business owners that they could find themselves without insurance coverage for activities they take while reopening before the state allows it. 
 
By evening, at least one of the counties impacted by the threats had backed away from the edge a bit, but legislative reaction was fast and court cases have been threatened.  Additional legislation is being considered, including bills to mandate further transparency and inclusion of legislative and expert consultation for decision making. 
 
PA COVID-19 DATA UPDATE
On Monday, the Department of Health reported that Pennsylvania had found 543 new confirmed positive cases in the previous 24 hours, for a total of 57,154 confirmed cases.   
 
The death total rose to 3,731 confirmed COVID-19 deaths, an increase of 24 from Sunday’s report, all in adult patients.  2,552 of the state’s deaths, more than 68 percent, were nursing home residents.  There were 231,704 negative tests in PA as of midnight Sunday night.
 
At least 3,790  health care workers – accounted for about four percent of all positive cases.  The total figure includes 1,655 workers in nursing homes. And 11,801 cases – accounting for 20 percent of all cases- are in 540 of the state’s long-term care living facilities in 44 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 19% were 80+.  Forty-four percent were unclassified yet per age.
 
Of the total through Sunday, 31,264 positive cases (55%) were female and 25,254 (44%) were male. One percent (636)  were unreported or neither.  Among the deaths, 1,861 (50%) were males 1,854 (50%) were female with 16 unreported by sex.
 
By race, 13,692 positives were Caucasian (24%), 6,458 were African-American (11%) and 682 (1%) were Asian, with 289  listed as “Other.”  The vast majority, 36,021 (63% of all cases) remained unreported on the race of the patient.  A total of 1,367 deaths were among Caucasian victims, 391were African American/Black, 40 were Asian and 11 were listed as other.  1,922 deaths (53%) weren’t reported by race.
 
On Monday, 2,176 positive patients were hospitalized.  At that time, 477 were using ventilators and 20 were on ECMO machines.  About 1,344 (38%) of the 5,199  intensive care unit (ICU) beds were available, 6,554 general medical beds (45%) were available and 1,553 (53%) of the airborne isolation rooms are still available statewide.  And 1,351 of the state’s 5,346 ventilators were in use (nearly 73% 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; 37% are aged 25-49; 26% are aged 50-64; and 28% are aged 65 or older. 
 
Questions for Secretary Levine
Is the state stepping up license inspections at nursing homes in the wake of the deaths?  LEVINE: DHS and DoH have that responsibility, and, at the order of CMS,  we’re not doing the routine inspections required every year but we’re certainly talking with them.
 
What is the role of the national guard at Brighton House?  Will it be evacuated?  LEVINE: We placed today a temporary administrator, Alair health Systems of NJ, with the agreement of all the parties. The National Guard will be there till May 18, when staff contracted by the facility will be on site. 
 
Will it be evacuated and will the management during the pandemic be investigated?  LEVINE: No it is not being evacuated.  We are looking forward and making sure the patients are being taken care of.
 
The National Guard says it’s the ninth nursing facility it has done this for, why wasn’t it the first since it was the first and largest?  LEVINE: Looking at the responses in other states, this has been the most challenging situation for all of us.  There are homes that had significant issues in staffing in other parts of the state, so the decision was to have the National Guard go to those other sites to keep them open and functioning.
 
The state statute that gives the state power to impose a manager, wither when health care provider failed to bring into compliance or when demonstrated it is unwilling or unable to achieve compliance.  Which of these two options is the reason for the state imposing a temporary manager at Brighton? LEVINE: According to our legal experts, that is if the administration refuses to work with us.  This action was taken at the joint agreement of all parties.
 
Given that NJ and NY are releasing data on infections and deaths, why has PA refused, since it doesn’t impact privacy?  LEVINE: We were waiting for CMS approval, and that data will be released later this week.
 
What did Bucks Co. officials say to you during your skype meeting over the weekend and did it change your mind?  LEVINE: We had a good discussion and we are going to be working with them and will be working with them and other counties in the Southeast on a plan for metrics we are using and how we look at those counties going from red to yell
ow.
 
What advice do you have for childcare facilities going from red to yellow this Friday?  LEVINE: We have guidance on the website and it’s the DHS that determines those guidelines.
 
Please provide more details of your talks with Philadelphia and southeastern PA counties and development of a plan related to their specific challenges.  LEVINE: We had discussions with Philadelphia, Montgomery and Bucks Counties and will continue them. On the metrics and data we would use and all the other considerations we will use, and those discussions will continue this week.
 
What message do you have for counties defying the governor’s orders and moving to yellow?  How could their reopening affect neighboring counties?  LEVINE: The Governor had addressed that.  We are concerned about counties going red to yellow before they are ready from a public health standpoint and we are looking at all the data and we don’t want to precipitate outbreaks of COVID 19.
 
Do you have a response for Sen. Mastriano who was at the Capitol today calling for your resignation?  LEVINE: I have no response to that – I serve at the discretion of the Governor and he addressed that earlier.
 
Any update in criteria specific criteria in moving a county from yellow into the green phase? LEVINE: We have not determined what criteria will be for counties to go from yellow to green, and of course the first counties only went to yellow on Friday and 13 more this Friday. We’re working on other criteria for counties to go from red to yellow, and as we’re working on that, we’ll start to think about what would be necessary to go from yellow to green.
 
Do all PA counties have to be in yellow before any can go into green?  LEVINE: We haven’t made any of those determinations at the present time.
 
Are residents expected to help enforce the rules in the yellow phase?  If so, to whom should they direct their reporting, police, 911 or the DoH?  LEVINE: I would not call 911 unless it’s an emergency.  If there are concerns about businesses, they could contact local authorities, or the number on our website.
 
Your daily numbers include that 2% of those hospitalized are under 29 years old.  What are the youngest patients, and the youngest patients hospitalized?  LEVINE: I do not have that granular data and I will have to check and get back to you.
 
Gov Wolf said counties defying the orders would not receive discretionary funding from Pennsylvania.  A short time ago he tweeted that he would announce consequences for counties defying state orders.  Will there be additional  consequences, and can you elaborate? LEVINE: No I’m going to leave that to the Governor.
 
What are some of the consequences for counties that move into yellow before you and the Governor say its ok? LEVINE: Well, it’s more than just the Governor and I saying okay.  We have an expert team looking at all the date and trajectory, models and we go over the public health impacts, social impacts, political impacts and economic impacts, that all goes into our recommendations and then the Governor makes his decisions.
 
Johns Hopkins started a training course online for people to become contact tracers. Since there’s a push for needing contact tracers, would you recommend people take this training course?  LEVINE: There are a number of different training courses that are available, and I think they are great.  I don’t have a specific preference for one or another. JHU is obviously a fantastic university, but I wouldn’t recommend one course over any other course.
 
Will DoH release hospitalization rates and discharges by county?  How about revised daily death counts?
LEVINE: We are working on all of our death data. I’ll talk with our team about how granular we can get.
 
Some people who have taken an antibody test were told if positive, they would be given to the DoH and they would be considered a presumed COVID case.  Is that true, and has the Department included that in the daily counts, or will it begin to do that soon in another category? LEVINE: We haven’t been getting that data and we’re not reporting it in a separate or different count.
 
If moving to yellow causes infections, how long will that take to know and how will you monitor that? LEVINE: By expanding testing in those areas as well as our ability to do case investigations and then responding to any outbreak with the patient being isolated and the contacts being quarantined.  The incubation period has to be taken into consideration and that can be 2-14 days, with an average of 5.   So it would be at least 5-7 days till we knew of this, and possibly two weeks or more.
 
The Northeast region saw the fewest cases today than it has seen in at least two weeks. Does that suggest community spread is slowing down in NE PA? And does it open up the potential for the region to move into the yellow phase? LEVINE: It’s a very positive sign, but again one day’s data is not as important as a trend in data so we’ll be watching that very carefully and a trend in decreasing cases would be very positive and we would taking that into consideration as we consider ALL the variables that result in counties moving from red to yellow.
 
Rite Aid said it would test asymptomatic people in line with Federal guidelines from DHHS.  What role do federal guidelines play in determining which Pennsylvanians get tests?  LEVINE: We are prioritizing testing of symptomatic individuals, but I have no problem if Rite Aid tests asymptomatic individuals as well, but our priority remains symptomatic individuals. As they announced today, they will be expanding their tests and we want to expand testing throughout Pennsylvania.
 
If Rite Aid can do that, what’s to stop other health care providers from rushing ahead to test asymptomatic patients? LEVINE: I don’t have an objection if providers want to do that.  We will continue to prioritize testing of symptomatic patients, but we know there will be a role for population based surveillance type testing and we look forward to getting to that.
 
Could the Department work with Rite Aid to direct their tests go to nursing homes etc. that would benefit from universal testing? LEVINE: We will work with all testing suppliers to help with testing of our priorities which includes nursing homes and personal care homes.
 
New York has plans to test all nursing home staff twice a week.  Does Pennsylvania have a similar plan? LEVINE: We are working on those plans and we plan to announce more on that later this week.
 
If a person is given several negative tests because they are tested every time they go to a medical facility, are those considered separate negative tests, or is each test counted as negative?  LEVINE: Each test would be counted as negative.
 
Can you please describe in as much detail as possible what contact tracing looks like in yellow counties, including how many DoH personnel are conducting contact tracing, the capacity to test known contacts and the ability to increase contact tracing capacity? LEVINE: We are absolutely working on plans to increase our capacity; we are doing really well.  I don’t have granular detail about specific numbers – we’ll have to get back to you on that. But we have a whole program that’s working on contact tracing and I think we’re doing really well.
 
The Governor gave his reaction to counties moving from red to yellow, what is your reaction to those counties defying the order?  LEVINE: I have no further comments beyond what the governor said.
 
This is the fewest number of new positive cases since March 28.  Is this a positive thing or is it just a function of lower over the weekend reporting? LEVINE: Well, we’ll see.  We have noticed for weeks now that there tends to be a lower
ing of reports on weekends, especially if there’s a Holiday.
 
Why is the state paying for the Brighton Manager? Shouldn’t the facility pay that fee? LEVINE: Usually when we put in a temporary manager that reports to us, we pay the fee. That’s pretty routine.
 
Why did the Lycoming County positives increase by one today while the nursing home count in the county increased by 3? Is that a statistical reconciliation issue? LEVINE: I’m not exactly sure in terms of that granularity of that data.
 
Has the CMU model been completed, and will it be made public?  LEVINE: The CMU model is public and it’s available on our website.  And it’s not one completion – actually they update it every week.
 
Can you list some of the variables factored into the red yellow green phases? For example, have you factored in the fact that there will be some people who are not compliant and that there will be some risky behaviors?  LEVINE: Yes, the models we look at do factor in behavior with the stay at home orders in red counties, and masking, etc.  That behavior is factored in.
 
With 65% of deaths in nursing and PC homes, what measures are you taking to ensure the health of those patients and workers? LEVINE: The wellbeing and the safety and the health of persons in LTCs are our top priority.  We have a collaboration between PEMA DoH and the facilities, themselves, infection control, 100% of facilities that have cases, contracted with ECRI to do further infection control, had national guard go in, have pushed out well over 1500 specific pushes for N95 masks, and PPE, and the last few weeks now that hospitals are doing better, we have been pushing out the PPE.  We will continue to do absolutely everything we can to protect the staff and the residents of LTC facilities.
 
Can you elaborate on why you are NOT reporting antibody test results? LEVINE: We are reporting antibody test results.  We’re not reporting it separately than any other test results.
 
Health Department guidance issued for non-urgent and elective care
The PA Department of Health today released new guidance for physicians along with approval to resume non-urgent and elective care, if the appropriate PPE is available and telemedicine is not clinically sufficient. The Guidance document is available online.
 
Senator calls for Levine’s resignation
Sen. Doug Mastriano of Franklin County today called for the immediate resignation of Pennsylvania Health Secretary Dr. Rachel Levine, saying her actions were a major factor in the large number of covid-19 cases and deaths in the state’s nursing homes.  He said Levine has committed the equivalent of policy malpractice in her handling of the coronavirus pandemic, specifically in her handling of the virus’s spread through nursing homes and other long-term care facilities.  The Department’s guidance had nursing home patients who were transferred to hospitals because of complications from COVID-19 discharged back to their homes, which are nursing homes to ensure enough beds were available in hospitals.  A plan that was developed for these homes in March was never implemented.
 
The Senator also blasted Levine for what he called the department’s poor response to the outbreaks in homes once it had become apparent they were one of the epicenters of the problem in Pennsylvania.

Legislative Leaders’ Comments re Developments
Democratic Sen. Andy Dinniman called for coming together to solve problems, noting that when he realized the crisis in the nursing home sector, he was one of the first to demand action and hold the Governor to a better standard of action and care.
 
Senate Minority Leader Jay Costa Jr. compared county decision making on COVID-19 phasing to local efforts at gun control.  “When we say at the county level that we know what’s best for our people. It’s amazing to me at this point. Where was the compassion last June when we cut 12,000 people off cash assistance? We didn’t care about them.”  We want to continue to be able to meet this enemy.  The Governor is not the problem.  Secretary Levine is not the problem.  Look at Washington DC and ask why he has not done things he should have done.
 
House Majority Leader Frank Dermody, D-Allegheny County, said the governor is being prudent in trying to relax the social-distancing restrictions carefully to limit the likelihood that there will be a resurgence of coronavirus.
 
“The governor is doing everything he must to lead us in this war against a deadly enemy. Pennsylvanians have made untold sacrifices and ending the fight now would betray all those efforts and weaken our defenses,” Dermody said. “Rash decisions made against the weight of medical advice will open the door for even more tragedy.”
 
In a joint statement, Senate President Pro Tempore Joe Scarnati and Majority Leader Jake Corman said “You can only govern to the willingness of the people to be governed. Governor Wolf has lost that.”
 
“Pennsylvania residents have done an outstanding job of rising to the cause of reducing community spread and flattening the curve. Instead of threatening local officials and communities, the Governor should listen to the outcry in response to his dogma.”
 
Scarnati and Corman said Wolf should talk with elected officials because they are the “best measure when it comes to knowing if their communities can return to their livelihoods in a safe way.”
 
Corman said, “I believe the Governor and Secretary are doing their level best, to keep the Commonwealth safe.  But we as the legislature are an equal branch of government and our job is to fix things. 
 
“We must look to people to self-determine their future.  We can look at the life sustaining business waiver program, and see what a failure it was.  Unemployment Compensation?  I had a neighbor today stop me who filed in early April.  He got his rejection in May, and the rejection said he had till April 21 to appeal.  It was mailed a week after his time for appeal ended!
 
As for our nursing homes – what a real disastrous event that has been. Tomorrow we will take action.  The PLCB still hasn’t figured out who ordered state stores closed, but beer distributors were considered life sustaining – and no one made the decision!  Our job is to try to improve things.
 
Not by pointing fingers but allowing people the respect to say, “you know what? We can do this! We’re Americans.  We take on challenges.”  Following guidelines by the CDC and the DoH.  But to threaten a bunch of “politicians?” That term was used 18 times.  They are local elected officials who are responsible for the health of their local communities.
 
I believe every decision they made they believed was in the best interest of the Commonwealth.  We believe that empowering people is the best way to move forward.  We trust them and their ability.
 
House Speaker Mike Turzai this afternoon said that Wolf’s process to move certain counties into the yellow zone is a “crayon box” approach.  Different regions are affected differently, but the one thing we know is that in each of the counties, the hot box is in personal nursing homes.  Staying at home and unemployed does not equal being safe.  We can work safely. 
 
“On May 1, the Governor opened up construction.  After the House passed legislation to do that.  It’s voluntary, not mandatory.  But for 350,000 Pennsylvanians, it is now an opportunity to put food and shelter over your head for your
family.  What can we do that’s voluntary across the state under CDC guidelines?  We should be able to move about our daily lives using safe distancing protocols. But we don’t have a plan in PA for people living in these nursing, personal care and assisted living facilities. 
 
In the federal CARES Act funding, Pennsylvania received $4.9 billion.  $1 billion already went to seven counties with 500,000 or more in their county lines (Philadelphia, Montgomery, Allegheny, Bucks, Delaware, Lancaster, and Chester Counties.) We are sitting on $3.9 billion designed to be spent on COVID related prevention and treatment.
 
We want to start off with at least $500 million to go to these academic health systems to support our long term care homes and skilled nursing facilities.  I am introducing legislation to do that, and I also ask you all to urge Health Secretary Levine to publish all data the department has.  It has to be published and it has to be daily. 
 
Rank and file legislators were less measured in their responses to the Wolf declarations.
 
Senate going to court over Wolf’s refusal to honor subpoena, claim of executive privilege
The Senate today asked the state’s Commonwealth Court to force Governor Wolf to release documents associated with mandated business closures related to COVID-19 public health emergency.
 
In the court filing, the Senate asked the court to enforce the Senate’s subpoena that sought access to the records in order to examine if legislative action would be necessary to correct inequities, both as part of the ongoing pandemic, as well as for any future emergencies, according to Senate President Pro Tempore Joe Scarnati (R-25), Majority Leader Jake Corman (R-34) and Senator Mike Regan (R-31), chairman of the Senate Veterans Affairs and Emergency Preparedness Committee that voted April 30 to subpoena the records.
 
The Senate is “clearly within its authority, the records demanded are sufficiently specific, and the records sought are reasonably relevant to its investigation of the waiver process overseen by DCED to exempt businesses from Governor Wolf’s March 19th closure order in response to the COVID-19 pandemic,” according to the filing.
 
The Senate Veterans Affairs and Emergency Preparedness Committee voted on April 30 to subpoena the documents following the March 19 closures and after the Governor denied an April 24 request to Wolf and DCED.  In a letter responding to the subpoena, the Governor said he cannot release the information to the Senate due to executive privilege and an audit being conducted by the state’s Auditor General at the request of the Senate.