As Pennsylvania experiences a resurgence of COVID-19 cases with significantly higher daily case counts than in the spring and hospitalizations on the rise, the Pennsylvania Governor Wolf’s Administration has identified four new mitigation efforts, which Secretary of Health Dr. Rachel Levine announced on November 17, 2020.

“It is our collective responsibility to protect our communities and our most vulnerable Pennsylvanians from COVID-19 and to continue to work together to get through this pandemic. These targeted mitigation efforts, combined with existing ones, are paramount to saving lives and protecting our economy,” Gov. Wolf said. “The administration will continue to monitor the risks posed by COVID-19 across the commonwealth and will reinstate or institute new targeted mitigation tactics as necessary.”

The efforts announced include:

Protecting Our Health Care System

Dr. Levine issued a memorandum to acute care hospitals outlining expectations to care for Pennsylvanians who need care during the pandemic.

Hospitals are to work through the established health care coalitions and other partnerships to prepare for how they will support one another in the event that a hospital becomes overwhelmed during the pandemic. Hospitals should also be working to move up elective procedures necessary to protect a person’s health and prepare to suspend them if our health care system becomes strained.

Restrictions on elective surgeries put into effect in March and lifted in April were to help with both PPE and bed capacity and were considered successful.

Hospitalizations are increasing, as are ICU patients, and according to modeling from the Institute of Health Metrics and Evaluation, which does not take into account hospitalizations from influenza, Pennsylvania will run out of intensive care beds in December if ICU admissions continue at the current rate.

The same modeling indicates we will have sufficient medical-surgical beds with some uncertainty as to capacity from region to region.

Traveler Testing

Dr. Levine issued an order requiring anyone who visits from another state to have a negative COVID-19 test within 72 hours prior to entering the commonwealth.

If someone cannot get a test or chooses not to, they must quarantine for 14 days upon arrival in Pennsylvania.

Pennsylvanians visiting other states are required to have a negative COVID-19 test within 72 hours prior to their return to the commonwealth or to quarantine for 14 days upon return to Pennsylvania.

This order, which takes effect on Friday, November 20, does not apply to people who commute to and from another state for work or medical treatment.

Strengthened Masking Order

Dr. Levine first issued a masking order on April 15. The order signed today strengthens this initial order with these inclusions:

• Masks are required to be worn indoors and outdoors if you are away from your home.
• When outdoors, a mask must be worn if you are not able to remain physically distant (at least 6 feet away) from someone not in your household the entire time you are outdoors.
• When indoors, masks will now be required even if you are physically distant from members not in your household. This means that even if you are able to be 6 feet apart, you will need to wear a mask while inside if with people other than members of your household.
• This order applies to every indoor facility, including homes, retail establishments, gyms, doctors’ offices, public transportation, and anywhere food is prepared, packaged or served.

Colleges and Universities

The departments of Health and Education issued recommendations for colleges and universities to implement a testing plan for when students return to campus following the holidays.

These recommendations include establishing routine protocols for testing.

Colleges and universities should have adequate capacity for isolation and quarantine and should be prepared to enforce violations of established policies such as mask wearing and physical distancing.

Every college and university should test all students at the beginning of each term, when returning to campus after a break and to have regular screening testing throughout the semester/term.

“We must remain united in stopping COVID-19,” Dr. Levine said. “Wear a mask, wash your hands, stay apart and download the COVID Alert PA app. If you test positive, please answer the call of the case reviewer and provide information that can help protect others. It’s the selfless, right thing to do.”

From the American Hospital Association (AHA)

The U.S. Department of Health and Human Services (HHS) issued two important clarifications related to Provider Relief Fund (PRF) reporting.

First, HHS had previously stated that providers could claim only the value of depreciation for COVID-19-related capital purchases with useful lives of more than 12 months. However, at the AHA’s urging, the agency today stated that expenses for capital equipment, facilities projects and inventory may be fully expensed in cases where the purchase was directly related to the prevention, preparation for and response to the SARS-CoV-2 coronavirus. HHS provides several examples of such purchases, including:

• upgrading heating, ventilation and air conditioning systems to support negative pressure units;
• retrofitting COVID-19 units;
• enhancing or reconfiguring intensive care unit capabilities;
• leasing or purchasing temporary structures to screen and/or treat patients; and
• leasing permanent facilities to increase hospital capacity.

Second, HHS clarified that providers’ reporting of net patient revenue should NOT include any payments received from, or any payments made to, third parties that relate to care not provided in 2019 or 2020. The AHA had raised concerns with HHS about including in hospital reporting any Medicaid payments that have been made to settle years-old legal disputes over the program’s construction.

The AHA sent an alert to the field today on these, and other PRF advocacy issues. We will continue to encourage Congress to address our outstanding concerns.

Background
The Coronavirus Aid, Relief, and Economic Security (CARES) Act and Paycheck Protection Program and Health Care Enhancement Act included $175 billion in the Public Health and Social Services Emergency Fund to reimburse health care providers for health care-related expenses or lost revenues not otherwise reimbursed that are attributable to COVID-19. In order to accept these funds, recipients agreed to Terms & Conditions, which require compliance with reporting requirements as specified by HHS.

Further Questions
If you have questions, please contact AHA at 800-424-4301.

Pennsylvania Secretary of Health Dr. Rachel Levine urged Pennsylvanians to take COVID-19 and food safety precautions as they plan Thanksgiving celebrations during the holiday.

“The holidays are a time for togetherness, but this year, we must rethink what that looks like,” Secretary of Health Dr. Rachel Levine said. “This Thanksgiving, choose to celebrate with the people in your household and virtually connect with your loved ones. If you plan to leave your home to celebrate the holiday, please follow the travel mitigation order, wear a mask and stay six feet apart from others. Weather-permitting, sit outside and enjoy the day. Do whatever you can to limit the spread of COVID-19 at this critical point of the pandemic.”

The travel mitigation order goes into effect at 12:01 a.m. on November 20, 2020 and shall remain in effect until further notice.

The U.S. Centers for Disease Control and Prevention (CDC) recommends keeping anyone who is not preparing food out of the kitchen for COVID-19 and food safety reasons. Use single-use options like salad dressing and condiment packets. If you must attend a gathering, take your own food, drinks, cups, plates, and utensils.

As part of your celebration preparations, Pennsylvanians are encouraged to join the more than 528,000 residents who have already downloaded and use COVID Alert PA, the free mobile app offered by the Department of Health that is designed to help reduce the spread of COVID-19. The app uses Bluetooth Low Energy (BLE) technology and the exposure notification system developed by Apple and Google to help notify and give public health guidance to anyone who may have been in close contact with a person who has tested positive for COVID-19. Since the app only uses Bluetooth technology, it cannot and will not collect a user’s location data.

COVID Alert PA works in Pennsylvania, and several other locations in the United States including Delaware, Nevada, New Jersey, New York, North Carolina, North Dakota, Washington D.C., Wyoming, and some parts of California.

“We are seeing our highest case counts of the pandemic across Pennsylvania,” Dr. Levine said. “As I have said many times, the virus knows no boundaries, even between family members. It is imperative that everyone follows the safety measures laid out throughout the pandemic to protect themselves, loved ones, and all Pennsylvanians. In addition to COVID-19, practice food safety, especially when cooking the traditional Thanksgiving turkey.”

Further CDC cooking recommendations include thawing your turkey in the refrigerator in a container, leak-proof plastic bag in a sink of cold water, or in the microwave following the microwave oven manufacturer’s instructions. Never thaw your turkey by leaving it out on the counter. Remember that raw poultry can contaminate anything it touches with harmful bacteria. Bacteria can grow rapidly in the “danger zone” between 40°F and 140°F.

Cook your turkey thoroughly at an oven temperature of at least 325°F. It is not finished cooking until the food thermometer reaches a safe internal temperature of 165°F. Also, cook stuffing separately from the turkey and put the stuffing in the turkey just before placing the turkey in the oven to ensure the stuffing is thoroughly cooked.

For fire safety tips during Thanksgiving, click here.

Masks must be worn outdoors when park visitors are unable to adequately social distance

Pennsylvania Department of Conservation and Natural Resources (DCNR) Secretary Cindy Adams Dunn announced changes to operating procedures for state park and forest facilities that will require out-of-state visitors to comply with orders intended to prevent the spread and mitigate the impacts of COVID-19.

“Since the beginning of efforts to address the pandemic we have kept our state park and forest lands open to all so that people can safely enjoy outdoor recreation as a way to maintain positive physical and mental health, and that will continue to be the case,” Dunn said. “We are making some changes to our overnight stays for out-of-state-visitors and our programming to help decrease the spread of COVID-19.”

For the safety of visitors and staff, DCNR will be requiring guests to cancel and refunds will be issued if they are unable to honor mitigation efforts:

• Anyone who visits from another state must have a negative COVID-19 test within 72 prior to entering the commonwealth;
• If someone cannot get a test or chooses not to, they must quarantine for 14 days upon arrival in Pennsylvania before visiting a state park or forest; and
• Pennsylvanians visiting other states are required to have a negative COVID-19 test within 72 hours prior to their return to the commonwealth or to quarantine for 14 days upon return.

Out-of-state visitors cannot use state park overnight facilities to meet the 14-day quarantine requirement. Out-of-state residents visiting for the day also must comply with the mitigation efforts.  Visitors who don’t comply may be fined between $25 and $300.

Visitor center exhibit halls and interpretive areas will be closed, and all indoor programs will be canceled. Restrooms will continue to be available.

Masks are required to be worn:

• In park and forest offices;
• In any other indoor public space including restrooms;
• During both indoor and outdoor special events and gatherings; and
• Outdoors when visitors are unable to adequately social distance.

All outdoor environmental education and recreation programs will be limited to 20 people, to include staff and volunteer leaders. Masks must be work by all participants, and services will be denied if visitors cannot comply.

These will remain in effect until at least January 15, 2021.

Dunn noted that visits to Pennsylvania state parks have increased by more than a million visitors a month since the start of mitigation efforts, and that interest is expected to hold strong through the winter and spring.

“We encourage people to embrace being active outdoors, even in the winter, because there are so many benefits associated with enjoying nature,” Dunn said. “With the appropriate clothing and preparedness, winter is among the most beautiful and peaceful times in our parks and forests.”

To help avoid exposure to COVID-19 and still enjoy the outdoors:

• Don’t hike or recreate in groups – go with those under the same roof, and adhere to social distancing (stay 6 feet apart)
• Take hand sanitizer with you and use it regularly
• Avoid touching your face, eyes, and nose
• Cover your nose and mouth when coughing and sneezing with a tissue or flexed elbow
• If you are sick, stay home

Visitors can help keep state parks and forest lands safe by following these practices:

• Avoid crowded parking lots and trailheads
• Bring a bag and either carry out your trash or dispose of it properly
• Clean up after pets
• Avoid activities that put you at greater risk of injury, so you don’t require a trip to the emergency room

Pennsylvania has 121 state parks and 20 forest districts, and they are all open year round.

Information about state parks and forests is available on the DCNR website. Updates also are being provided on DCNR’s Facebook and Twitter accounts.

(As prepared for delivery – November 19, 2020)

Thank you. It’s a pleasure to speak to you on this tenth annual Rural Health Day. Let me start by thanking all of you on the frontlines for your hard work and dedication at this difficult time in history. It’s not lost on me how much rural providers have sacrificed. You are heroes in this war. Coronavirus has not spared any part of the world, and it has been particularly challenging for rural providers, which already faced considerable difficulties going into this pandemic.

The good news is that there is light at the end of the tunnel. Recent news about impending vaccines and new treatments is heartening. Life will eventually return to normal. As we face many difficult days ahead and all the challenges of immunizing a nation, I am also encouraged by the progress CMS has made in addressing some of the most critical rural health issues.

During my first year at CMS, I traveled to a rural health center and even visited the rural health association headquarters in Kansas. Coming from Indiana I had some familiarity with rural health care, but I am indebted to those who have continued to educate me about the issues rural communities face.

I learned about the many burdensome CMS regulations that may make sense in an urban community but don’t take into account the unique challenges in rural communities.  Rural Americans might live a long distance from the closest healthcare providers. These providers in turn often have limited resources and tight profit margins due to low patient volume, making it difficult to maintain robust workforces. These problems result in a systemically fragmented rural healthcare system, limited access to important specialty services, and disproportionately poor health outcomes for 60 million of our fellow Americans.

And that’s why I made rural health one of CMS’ top strategic initiatives. Over the past 4 years, we worked across the entire agency in every department to address rural health challenges. This represented a departure from established practice, as rural America’s pressing healthcare problems have been largely ignored for too long. I am proud of what the CMS team has accomplished. Their efforts have laid the foundation for rethinking rural health across the country.

During my time in office, CMS has constantly sought to bring the principles of the free market and competition to bear on the many areas of the healthcare system we oversee. We have had many successes in that effort, including some that affect rural areas directly. For example, when we came into office, insurers were fleeing the Exchanges. By 2018, 50 percent of counties in America – the majority of which are rural – had the non-choice of just one health insurer in their exchange; today, that number has plummeted to 9 percent.  And our changes to Medicare Advantage have increased plan options  for our beneficiaries, many of whom who have historically enjoyed limited choice due to anemic market competition. In 2021, Medicare beneficiaries in rural areas will have more than double the plan options they had in 2017.

That’s because we have given plans in Medicare Advantage – the privately administered branch of the Medicare program – flexibility and incentives to design supplemental benefits, including transportation and meal delivery that can help keep rural patients healthy.  We recently allowed Medicare Advantage plans to count telehealth providers in certain specialty areas – such as Dermatology, Psychiatry, Cardiology, and more – toward our network adequacy requirements. This increased flexibility has allowed them to assemble more robust health care provider networks in rural areas using telehealth.

But the fact remains: compared to their urban and suburban counterparts, rural areas present a special challenge for a market-based approach to healthcare policy. Infusing competitive forces is more complicated – sometimes downright impossible – given the unique obstacles rural areas face.

From the beginning, we have sought to address these problems by leveraging innovation and the transformative power of technology. Our historic work to promote the seamless and secure flow of medical records is a game changer for virtually every American, but it represents a particularly important breakthrough for rural Americans. Access to electronic medical information removes geographic barriers that prevent them from accessing the most up to date medical providers, research studies, and other services that typically cluster around dense urban areas.

We expanded telehealth because of its potential for rural areas where transportation over long distances can be difficult and providers are often in short supply. Starting in 2017, we allowed for short virtual check-ins with patients in their home and expanded the number of services that could be provided via telehealth, benefits that predate and will outlast the pandemic.

During the pandemic itself, we dramatically accelerated the telehealth expansion to help patients under stay-at-home orders receive care. At President Trump’s direction, we got rid of various restrictive regulations, including those that prevented telehealth from being furnished in people’s homes, including nursing homes.

We also expanded the types of providers that can provide telehealth and removed face-to-face requirements for certain types of care. Finally, we added over 135 telehealth services, such as emergency department visits, mental healthcare, and eye exams.

Just a few months ago, thanks to a groundbreaking Executive Order from President Trump, we proposed to make many of these flexibilities permanent, including prolonged office visits, mental health services, and more. We’ve proposed extending still others, such as lower level emergency department visits, psychological testing services, and more, beyond the end of the public health emergency. The result is a veritable revolution in healthcare delivery that will be a boon for rural patients.

Before moving on from this subject, it’s important to understand that our regulatory authority is largely limited specifically to telehealth services. We cannot make telehealth available permanently outside of rural areas, permanently expand the list of providers authorized to provide it, nor allow patients to receive telehealth services from their homes. Congress, then, has an essential role to play in following through on this historic opportunity. Without a change to the statute, telehealth will eventually revert to a more limited benefit that cannot be utilized from a patient’s home. In an earlier age, doctors commonly made house calls. Congress has the opportunity bring the reinvigoration of that tradition across the finish line.

In addition, just last year, to address disparities in Medicare payment among rural and urban hospitals, we boosted Medicare payments for many rural hospitals, to bring payments on par with those in urban areas. This is helping hospitals improve their financial sustainability and attract talent, improving access in rural America.

Reducing regulatory burden has also been a key focus. We have given hospitals greater flexibility on physician supervision requirements for certain types of hospital services and eased Medicare requirements so practitioners like physician assistants and nurse practitioners can independently provide more services so long as it’s within their scope of practice. The telehealth executive order I mentioned a moment ago also directed CMS to propose extending a pandemic flexibility that allowed physicians to virtually supervise their staff as they provide care to patients. Thanks to these reforms, rural hospitals can make the most of often limited workforces while maintaining patient safety.

To further ease the burden on physicians of all stripes, we have reformed their quality program and empowered them to pick the metrics most relevant to their specialty or the types of patients they see, rather than overloading them with largely irrelevant measures. Rural providers, often stretched thin, have benefitted tremendously from these reforms with more than 98 percent of eligible clinicians in rural practices participating as of 2018. Yet more simplifications lie in store.

These reforms are significant and tangible, but our most significant move is aimed at a more comprehensive reboot strategy for rural health.  Because without it, the longstanding, fundamental issues remain.

Most recently, we announced a new avenue for local and rural communities to take an active role in the transformation of their care. Called the Community Health Access and Rural Transformation model, or CHART, it represents a more flexible, grassroots approach to rural healthcare delivery than the top-down, one-size-fits-all approach that has failed rural Americans for so long.

Specifically, CHART would provide upfront funding to up to fifteen lead organizations that would bring together local parties – state Medicaid agencies and commercial payers, local hospitals, clinics, and other providers. These organizations would be eligible to receive upfront infrastructure investments, in grants of up to $5 million each for a total rural investment of $75 million, with which to organize the healthcare delivery system that works best for them. That may include explore transitioning to a “hub and spoke” model, in which one relatively large hospital serves as a kind of command and control center for smaller, more limited provider types.  It may involve reducing services for some hospitals and adding more for others, like maternity and home health.  It allows communities to think about what might work best for them.

It also requires rural hospitals to move to a stable, predictable, value-based payment and away from the current erratic, volume-based system that often doesn’t work for rural providers with low patient volume. It represents the first steps in a radical rethinking of how we pay for care in rural communities.  Contrary to the stale approach that has prevailed for so long, simply throwing more money at the problem is not enough. In some cases, funding increases may indeed be necessary, but how we pay is just as important as how much we pay.  All reimbursement systems should be structured to create incentives to produce better outcomes for patients.

Finally, we have paired these payment reforms with unprecedented regulatory flexibilities and program waivers for which rural providers have been asking for years. Specifically, the model waives certain conditions of participation in our programs, allowing hospitals to reduce unnecessary overhead costs while maintaining their status as hospitals or critical-access hospitals. Organizations can also employ value-based incentives such as reducing or waiving Part B co-insurance amounts to promote high-value preventive care.

In sum, the model’s seed funding, combined with the regulatory flexibilities and technical support will give rural providers what they have never had enough of before: breathing room to provide high-quality care to rural patients. In the months and years to come, CHART promises finally to deliver the wholesale transformation rural healthcare has needed for so long. If these local ventures fulfill their potential, they may serve as models for rural areas throughout the country.

Too often, policymakers have placated rural Americans with token solutions that fail to advance the systemic, fundamental transformation necessary to tackle these pervasive problems. Under our watch, that wildly insufficient approach has gone by the wayside. I am incredibly grateful to and proud of the CMS team that has spearheaded these reforms.

We have gone beyond merely tinkering around the edges of policy in favor of lasting, transformative change.  We have disrupted the status quo for sake of the American patient and thought big and acted boldly on issue after issue. Rural Americans are already experiencing the improvements brought by our reforms, but their beneficial effects will be felt in rural areas for years to come. Thank you.

By Liz Carey
Most rural hospitals did not have large numbers of Covid-19 patients this spring and summer. The current record-breaking surge in rural areas will likely be different.
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