May 1 (morning) Pennsylvania COVID-19 Update

CMS makes sweeping regulatory waivers and rule changes
The Centers for Medicare & Medicaid Services (CMS) today issued another round of sweeping regulatory waivers and rule changes to deliver expanded care to the nation’s seniors and provide flexibility to the healthcare system as America reopens. The announcement and changes can be found on the PA-ACP website here.

These changes include making it easier for Medicare and Medicaid beneficiaries to get tested for COVID-19 and continuing CMS’s efforts to further expand beneficiaries’ access to telehealth services.  Read the ACP's statement on this monumental decision to help preserve patient care:

Changes include paying for evaluation and management services via telephone calls between patients and physicians – at the same rates as in-office visits.  ACP has been advocating this change for some time.

Among the changes announced for the duration of the COVID-19 emergency:

  •  CMS previously announced that Medicare would pay for certain services conducted by audio-only telephone between beneficiaries and their doctors and other clinicians. Now, CMS is broadening that list to include many behavioral health and patient education services. CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020.
  • Since some Medicare beneficiaries don’t have access to interactive audio-video technology that is required for Medicare telehealth services, or choose not to use it even if offered by their practitioner, CMS is waiving the video requirement for certain telephone evaluation and management services, and adding them to the list of Medicare telehealth services. As a result, Medicare beneficiaries will be able to use an audio-only telephone to get these services.
  • As mandated by the CARES Act, CMS is paying for Medicare telehealth services provided by rural health clinics and federally qualified health clinics. Previously, these clinics could not be paid to provide telehealth expertise as “distant sites.” Now, Medicare beneficiaries located in rural and other medically underserved areas will have more options to access care from their home without having to travel
  • CMS is waiving limitations on the types of clinical practitioners that can furnish Medicare telehealth services.
  • Hospitals may bill for services furnished remotely by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is at home when the home is serving as a temporary provider based department of the hospital.
  • Hospitals may bill as the originating site for telehealth services furnished by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is located at home.
  • Until now, CMS only added new services to the list of Medicare services that may be furnished via telehealth using its rulemaking process. CMS is changing its process during the emergency, and will add new telehealth services on a sub-regulatory basis, considering requests by practitioners now learning to use telehealth as broadly as possible. This will speed up the process of adding services.

On Thursday, the Department of Health reported that Pennsylvania had found 1,397 new confirmed positive cases in the previous 24 hours, for a total of 45,763 confirmed cases.  The death total rose to 2,292  total confirmed COVID-19 deaths, an increase of 97 from Wednesday, all in adult patients.

The state Health Department’s breakout of virus data for long-term care living facilities indicates 1,505 of the state’s deaths, 66 percent, were nursing home residents.  There were 175,602 negative tests in PA as of midnight Wednesday night.

At least 2,753 are health care workers – accounting for about six percent of all positive cases; the total figure includes  1,032 workers in nursing homes. And from the department’s website, 8,112 cases – accounting for nearly 18 percent of all cases- are in 468 of the state’s long-term care living facilities in 42 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+.  The remainder were unclassified yet per age.

Of the total through Wednesday, 24,783 positive cases (54%) were female and  (45%) 20,384 were male. One percent (596) were unreported or neither.  Among the deaths, 1,191 (52%) were males and 1,089 (47%) were female with 12 unreported by sex.

By race, 9,774 positives were Caucasian (21%), 4,753 were African-American (10%) and 487 (1%) were Asian, with 213  listed as “Other.”  The vast majority, 30,536 (67% of all cases) remained unreported on the race of the patient.  A total of 836 deaths were among Caucasian victims, 226 were African American/Black, 26 were Asian and seven were listed as other.  1,197 deaths were not reported by race.

On Thursday at noon,  2,706 positive patients were hospitalized, slightly more than six percent of those testing positive.  At that time, 562 were using ventilators or breathing machines.  About 1,415(about 40%) of the 5,199  intensive care unit (ICU) beds were available, 7,031 general medical beds (46%) were available and 1,668 (53%) of the airborne isolation rooms are still available statewide.  And 1,443 of the state’s 5,199 ventilators were in use (72% 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.

Levine said the state has made 1,378 shipments of PPE to nursing and personal care homes since April 1, to each of 695 licensed SNFs and dozens of others.  Since April 1, the state has provided four million N95 masks, 241,000 hospital gowns, 1.3 million surgical masks, 1.3 million pairs of gloves and 80,000 face shields to hospitals, EMS personnel.

Governor announces $324 million in hospital funding
Governor Wolf announced that nearly $324 million in funding has been awarded to 31 hospitals across the commonwealth through the Hospital Emergency Loan Program, or HELP, which provides short-term financial relief as hospitals combat the surge of COVID-19 cases in their area.

“This funding will allow our hospitals to hold steady in that fight with the peace of mind that they have access to the resources they need to provide critical care to their communities, ” he said.

The federal Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law on March 27, 2020, with the goal of easing the financial strain of the pandemic and smoothing the transition back into regular health care operation. The loan package was made available to the commonwealth’s hospitals to provide immediate financial support for working capital to ensure that these facilities have sufficient personnel, equipment, and personal protective equipment.

Pennsylvania licensed hospitals that are eligible to receive federal grant funding through the CARES Act are eligible for HELP.

UPMC: COVID-19 death rate lower than expected, UPMC opens for non-emergency surgeries , testing all patients for antibodies
A UPMC doctor on Thursday made a case the death rate for people infected with the new coronavirus may be as low as 0.25% — far lower than the mortality rates of 2-4% or even higher cited in the early days of the pandemic.

Yealy went on to offer a hypothetical scenario of 3% of Allegheny County residents being exposed — a conservative number compared to the findings of New York and California studies.

That would mean about 36,000 people in Allegheny have been exposed to the coronavirus. With 94 COVID-19 deaths in the county as of Thursday, it would mean 0.25 percent of people exposed to the coronavirus had died, he said. “There is a big difference between 0.25% mortality and 7%,” Yealy said.

Yealy said about 1,300 people in Allegheny have tested positive for COVID-19. In his hypothetical scenario, another 34,700 would have been exposed but with no symptoms. Those who were positive but not tested may also have antibodies to protect them from future infection.  Yealy further said the majority of the deaths among UPMC patients were people over 80, with many being nursing home residents.

Dr. Rachel Sackrowitz, the chief medical officer for UPMC’s intensive care units, said 234 COVID-19 patients have recovered and been discharged. “This is very good news. It means people are getting better and we’re all on the right track together.”  Only 2% percent of UPMC’s 5,500 beds are occupied by COVID-19 patients and the number of new COVID-19 patients is declining.

He cited that figure in explaining that UPMC plans to quickly scale up its level of the non-emergency surgeries that were largely banned to conserve beds and supplies for COVID-19 patients. The ban is now being eased as the volume of COVID-19 patients falls short of worst-case predictions.

The officials said UPMC remains ready to deal with any upturn in COVID-19 cases and on Thursday also announced that all patients treated within the health system will start receiving a COVID-19 antibody test.

Auditor General DePasquale to audit business waiver program
Auditor General Eugene DePasquale says he will audit the Gov. Tom Wolf's business waiver program. "Could more business have remained open, in light of social distancing?" He said his audit began this morning.

He said he was considering a post-facto audit of the process, but that the Senate Republicans’ letter helped him decide to dive into the audit in the middle of the Governor’s response.  He noted that he has not pre-judged whether the Governor should have been more transparent about the waivers.  “We’ll certainly be asking them that question during the audit,” he said.

DePasquale will not name businesses in his audit.  He said his aim is to look for systemic issues.

House passes bill to require Wolf present a plan for COVID-19 testing
The state House of Representatives, on a bipartisan 132-70 vote, added an amendment to legislation on virus testing that would require the Governor present a statewide plan for COVID-19 testing to ensure appropriate funding is provided for the effort. House Democrats has blocked consideration of the amendment on Wednesday, but 23 Democrats voted with Republicans son Thursday.

“At nearly every daily briefing Gov. Wolf and Secretary of Health Rachel Levine express the need for increased testing; however, no one in Pennsylvania, including those at leading laboratories developing tests, are aware of any plans to do so,” said House Majority Leader Bryan Cutler, R-Lancaster. “We hope today’s vote will urge the Governor to take the steps necessary to ease the fear of Pennsylvanians and test everyone we should.”

Wolf has said that expanded testing and contract tracing are necessary to moving counties from red to yellow to green, but he said earlier this week the Administration is still working on a plan that Secretary Levine called “aspirational” and this morning he acknowledged that he doesn’t have an estimate of how much such a program would cost to adequately expand.

The amendment also seeks “a description of how the plan supports the efforts to limit the spread of COVID-19 at life-sustaining businesses which have been permitted to continue to operate under” the Governor’s disaster emergency orders, as well as businesses not currently operating due to the Governor’s orders, but which will be able to resume operations as the Governor gradually lifts those orders. And the amendment indicates the submitted plan will be deemed approved once an appropriation of federally-provided funds has been made for the procurement of testing kits or equipment.

The amended legislation could come up for a final floor vote in the House as early as Monday when the chamber returns to session.

Senate moves to subpoena business  waiver records
The State Senate Veterans Affairs and Emergency Preparedness Committee on a party-line vote, initiated a subpoena of documents related to the Wolf Administration’s business waiver program.

“I don’t think in my time anything [else] generated more phone calls to my office, to my district offices,” said Senate Majority Leader Jake Corman.  After Thursday’s committee meeting, he said callers questioned how to apply, how to get their applications approved and why their applications were rejected but other applications were approved.

“We have requested these documents repeatedly and given the administration ample opportunities to provide clarity about their methods behind granting waivers to some employers and not others,” Corman said. “Since they have chosen not to provide the information, this is the next logical step in the process of providing the oversight the founding fathers had in mind when they created three co-equal branches of government.”

Corman added that Wolf suggested if the Legislature want the information, it should go the subpoena route.  He said he and his caucus expect the administration to comply with the subpoena, which gives the administration until May 8 to turn over the requested information. Republican legal staff explained if the administration should fail to comply, it’s unclear how quickly – given the current impact COVID-19 has had on the state’s legal system – the courts could adjudicate the matter.

Unlike the Auditor General’s rules about providing identifying information in their audits, Corman said the Senate will make as much information available as legally possible. He said that will include all the businesses, by name, that received or applied for waivers.

Unemployment Claims top 1.6 million – nearly 25% of state workforce
More than 131,000 Pennsylvanians filed jobless claims in the week ending April 25 after losing their jobs or getting hours reduced due to COVID-19.  This brings the state’s total in six weeks to more than 1.6 million, 24.8% of the workforce.

Questions for Dr. Levine
How did the department develop the 50/100,000 metric?  LEVINE:  We were looking for a metric that provides info on change over time.  So we decided we would use that.  And we’ll be looking at other data and modeling, so some of that will be quantitative, some will be qualitative.

When a county is ready to move to green phase will bars and restaurants have special restrictions?  LEVINE:  We’re focused on red to yellow, so we haven’t made any plans for that.

Since the president eliminated social distancing guidelines, What will PA use going forward? LEVINE:  Our stance doesn’t change. We will continue to use the social distancing and guidelines we’ve adopted.

When an area moves to yellow, is that a signal of all types of businesses to resume, or will some remain closed?  LEVINE:  Those where a large number can congregate, for example, movie theatres, restaurants, concerts and large gatherings will not. We will discuss life in the yellow zone tomorrow.

Do you plan to test asymptomatic staff at nursing homes?  LEVINE:  We are testing individuals who are symptomatic. We’re also working with these facilities extensively, with guidance, CMS guidance with staff and our contractor.  Where there are severe outbreaks, the National Guard has gone in.  If there is someone symptomatic in a nursing home that hasn’t had cases, we’ll test them.

There was an enormous leap in deaths yesterday – any still to come with your reconciliations, another spike?  LEVINE:  We are collecting data from lots of sources and work to validate that data.  It is possible we will see another large increase in cases.

Manor Care in Sinking Spring and Manor Care west have similar situations to Butler and Beaver County.  Are you doing anything different there?  LEVINE:  We have several situations and we are aware of all of those and working with them

Hospital systems have the ability to do more tests and you are still only testing symptomatic patients. Any plan to change that?  LEVINE:  We have limited those tests, but have recently made significant changes – we no longer test only health care workers, EMS workers and senior citizens. We have more capacity and that’s great – we want to expand to any person with symptoms.  The one place where hospitals will be testing asymptomatic individuals is before elective surgeries.  That will be useful in terms of our surveillance.

Are masks effective when people are outside, working out and sweaty.  LEVINE:  We recommend you wear a mask if you’re going to encounter any people.  If you’re going to be encountering people, wear a mask.

PA continues to include probable cases in its count.  Is the state still only counting deaths that are confirmed? LEVINE:  They have not been added back in and we don’t see that happening.

Sen. John Yudichak has helped get PPE for nursing home staff in Luzerne County after the state didn’t help them get additional funds to purchase that equipment. Was there a problem?  LEVINE:  We have  pushed out many many shipments of PPE to nursing homes.  We had a large pushout of N95 masks just this week.  The staff at skilled nursing facilities need to take care of patients – they are not paying for this equipment that we’re pushing out.  That said, we are always pleased with Public private partnerships.

Lycoming county may move to yellow, but  only 1,200 people have been tested in the county.  How do you know it’s safe if so few have been tested?  LEVINE:  We understand, but that means less people have shown symptoms which is good.  We are working to expand testing now and the hospitals there have more ability to test at the hospitals or Rite Aid or other .  We will be watching for outbreaks and clusters of cases, and if they occur, we will use appropriate isolation and quarantine to snuff those out.

As testing increases, so with the number of positives.  Will there be any “float” on the numbers so this increase doesn’t impact movement to yellow?  LEVINE:  I don’t think that will happen.  Remember that we’re looking at other qualitative factors as well.

Are the 50 cases per 100,000 inhabitants mandatory as a benchmark?  LEVINE:  I would say it is necessary, but if we see a county with significantly more than 50, its more unlikely to move to yellow.

Remdesivir may be a successful treatment for COVID-19.  What does it do?  LEVINE:  Remdesivir was developed to combat Ebola, its an antiviral and a study now shows it can be effective.  Is it a gamechanger? I wouldn’t say that, but it appears to be very promising.  In science and medicine,  more studies need to be done – as far as the dosage, length of treatment, the number of patients its successful with, etc.

If there’s a resurgence in the fall, what ways might you prepare differently?  LEVINE:  The great difficulty was getting testing done in February and into early March.  We have more capacity now; and had a great call with the feds about testing, swabs, test media, and information on how to access other materials yesterday.  We’re very pleased that testing will be available in the schema we roll out.  From an aspirational point of view, how can we use testing to control or prevent an outbreak in the fall is the key.

One post on social media from a state Representative  shows 40 counties opening May 4.  Others believe this, and that their lives will suddenly go back to normal. How do you deal with this kind of misinformation on social media? LEVINE:  It’s challenging, but I suggest anyone can go to our websites and get accurate information.

There is an outbreak of cases in two Lycoming county nursing homes.  What’s the plan for that? LEVINE:  We treat patients either In place or in the hospital.  It depends on the individual patient who can be kept in isolation, cohort the patients and staff with enough PPE, resources, infection control consultations.  If a patient is severely ill, the recommendation is to transport them to a hospital for care.

Will the state post statistics for recovered patients?  LEVINE:  We talked about this.  We have 45,000 who contracted COVID – you can do the math.  With cases testing positive, about 14 days and they should be better.  We want to give you validated information so we’re not able to provide that information.

Why did the state appoint a manager at Brighton? LEVINE:  We didn’t go in; this was a collaborative decision to enlist a temporary manager.

Stepping in temp manager – what more is being done?  LEVINE:  ECRI is consulting, and we are doing  everything that is possible to protect residents and staff.  I don’t have that granular detail.

How are providers doing with including race and ethnicity in reports?  LEVINE:  We called upon all reporters to include it and report those results to us.  We’re doing better but we’re not there yet.

Have you enforced that?  LEVINE:  It’s difficult to enforce it.  We feel they will comply, and it takes a while.

What is the goal of the temporary manager  Is the temporary manager there to bring the home into compliance or transition to closing it?  LEVINE:  The temporary manager was hired to prevent further spread and take care of patients.

Illinois said hospice patients who contract COVID are being listed as deaths to the virus. Is that the case in Pennsylvania?  LEVINE:  I’ll have to look into that.

Will you be hiring lay people to help with contract tracing?  LEVINE:  We’ll be doing that and will have more information on that soon.

What will be the impact of the money announced today on hospitals?  LEVINE:  The federal money and loan programs  will help keep them afloat,  and procedures and operations are a very large part of their revenue.  We want them to stay open and take care of patients.

Are there enough test kits for all SNFs?  LEVINE:  We provide testing for them now.

Has DoH traced any cases back to the March 17 special elections in Bucks, Westmoreland and Mercer County?   LEVINE: We don’t have that granular detail

Rep. Frank Burns is calling for all businesses to be allowed to do curbside pickup – if state stores can do it, why can’t all retailers?  LEVINE:  We’re going with the Governor’s schema where some can do that and then more when we move a county or region to green.  That’s the schema we’re following.

How often will the state make announcements about counties moving – daily or weekly?  LEVINE:  We’ll make that announcement when we do.

What time tomorrow to release the info?  LEVINE:  I honestly don’t know. We normally do a press release at noon and an availability at 2, but I don’t know.

What steps are you taking to make those openings as safe as possible? LEVINE:  We will still be insisting on social distancing, no more than 25 people in a business, and other guidelines to be followed.

A week away – widespread testing and contact tracing?  LEVINE:  We are confident that we have the systems in place to make that happen.