Slow Rolling End to the P-H-E
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Politico Pulse reports (here, and credit image) on “The end of the Covid-19 public health emergency — and the return to some semblance of pre-pandemic health care . . . The PHE began during the Trump administration and came to affect nearly all parts of American health care . . . with the government appropriating $4.6 trillion to fight the virus. Though some policies originally from the emergency declaration are here to stay, many patients, providers and health companies are preparing to readjust to the old ways of doing things.”
Different and very important aspects of the end of the Public Health Emergency continue to unfold. In the headlines, the Centers for Disease Control and Prevention's (CDC) August 2021 order prolonging the Title 42 pandemic policy, which mandated that migrants be expelled from the U.S.-Mexico border regardless of asylum needs, states that the Title 42 pandemic policy ends when the public health emergency ends.
Title 42 of the Public Health Services Act authorizes the Director of the Centers for Disease Control and Prevention (CDC) to suspend entry of individuals into the U.S. to protect public health. When the Centers for Disease Control and Prevention (CDC) invoked Title 42 at the start of the COVID pandemic in 2020, it gave border patrol agents the authority to expel migrants to their home country or the country they were last in, which was often Mexico.
Also ending: CMS reported in a May 1 guidance to state survey agency directors that the PHE’s end brings with it the end of numerous policies and waivers, including the end of the COVID-19 vaccination requirements for Medicare and Medicaid certified providers and suppliers. For patients requiring renal dialysis, CMS temporarily let dialysis facilities provide services to patients in nursing homes, long-term care facilities, assisted living facilities, and similar types of facilities, rather than restricting care to dialysis facilities. In training programs, academic and teaching physicians could be at any location when supervising telehealth visits conducted by a resident. Also in telehealth, outpatient physical therapists will no longer be able to bill Medicare for telehealth services.
A potentially confusing mix of “permissions” from CMS will persist, in the absence of further Congressional action, since Congress extended some telehealth policies through the end of 2024, but not others. InsideHealthPolicy (IHP) reports that some Members are urging the administration to facilitate interstate licensing, change direct supervision provisions, allow mid-year changes for insurance plans, include telehealth as an excepted benefit and cement the 40 Medicare telehealth billing codes.
IHP (here) summarizes other recent and pending PHE-related changes in programs and services.
The New York Times (here) summarizes what the end of the PHE means for various health insurance plan beneficiaries.
Medicaid Re-enrollment
The most significant financial and human consequences of the end of the PHE, however, may be in the growth of the Medicaid program during the pandemic, secondary to suspension of what would otherwise be regular requirements for beneficiaries to periodically re-enroll. Now the periodic re-enrollment requirements are to be resumed, in a process of previously untried and potentially startling complexity which may leave 15 million Medicaid beneficiaries out of the program.
Growth in the nation’s largest Medicaid program, that of New York State, is chronicled (here) by that state’s conservative-leaning Empire Center: “Albany’s newly enacted budget appears to increase the state share of Medicaid spending by $4.2 billion or 13 percent, continuing a trend of explosive growth for the safety-net health plan in the aftermath of the pandemic . . . Overall spending on Medicaid, including federal aid and funding from New York City and the 57 counties, is expected to break $100 billion for the first time in the year ahead.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Physician Participation in Medicare Program Down
Medscape’s survey of more than 10,000 physicians (here) concludes that 65% of physicians said they would continue treating current Medicare or Medicaid patients and take on new ones. Medscape reported that “It is the lowest percentage it has seen in its annual compensation reports. Five years ago, 71 percent of physicians said they would continue treating current Medicare or Medicaid patients and take on new ones.” Eight percent of physicians said they would not take on new Medicare patients, five percent said they would not take on new Medicaid patients, and twenty-two percent said they had not decided what to do about new or current Medicare or Medicaid patients.
LPNs in Hospitals: Back to the Future
Becker’s reports (here) that “Baton Rouge, La.-based Franciscan Missionaries of Our Lady Health System is working to boost its licensed practical nurse pipeline and welcome more of these clinicians to the hospital setting. FMOL Health System has always employed LPNs but switched to staffing predominantly registered nurses in its hospitals within the last decade or two, mirroring industrywide trends. As RNs became the most common type of nurses working in hospital settings, LPNs shifted to outpatient clinics, nursing homes and other ambulatory care settings. Now, more hospitals and health systems are seeking to reintroduce LPNs to hospital settings amid ongoing nursing shortages.”
The CNO reports “LPNs had not been trained in a hospital in a while, so when they graduated they were not comfortable coming to work in a hospital . . . we have to reintegrate those students into clinical rotations in acute care settings so that they gain that comfort."
HOSPITALS, NURSING HOMES AND OTHER HEALTH FACILITIES
Doctor, Discharge That Patient!
The Journal of Hospital Medicine, official journal of the hospitalists and the Society of Hospital Medicine, reports (here) that instructions for early discharge of a patient make no difference in the actual time of discharge, or in the length of stay, and are therefore likely to be unproductive as tools for accelerating “patient throughput.”
“It is common practice for organizations to try to improve throughput by asking clinicians to round on discharging patients first or to discharge a set number of patients by a specific time (e.g., ‘discharge before 10 a.m.’). Hospital capacity strain occurs when there is a higher demand for hospital beds than the available supply. Hospital discharges frequently occur in the afternoon or evening hours, resulting in an imbalance between supply and demand for hospital beds. Delayed discharges can adversely affect patient flow throughout the hospital which, in turn, can result in delays in care, increased mortality, increased length of stay (LOS), and higher costs.”
The study reports “Prioritizing discharges by a specific time, such as 10 a.m. or noon, is a common tactic to improve hospital throughput. However, this practice has had mixed results, with some studies showing earlier discharge times, while others show no impact on LOS or even longer LOS.”
Business concepts—throughput: “Hospital LOS has been suggested as a system measure for hospital-wide flow, and when applying business concepts of throughput to a hospital setting, throughput is defined as when a product is processed to a finished good (i.e., when the patient leaves the hospital). These concepts paired with the study's results indicate that prioritizing discharges first does not necessarily improve throughput . . . Our findings suggest that it may be more effective to support clinicians to use their clinical judgment to determine priorities, rather than focusing solely on discharging patients or trying to hit a specific time target. (Italics added.)
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Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org
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