Her Genetic Test Revealed A Microscopic Problem — And A Jumbo Price Tag

Michelle Kuppersmith, 32, feels great, works full time and exercises three to four times a week. So she was surprised when a routine blood test found that her body was making too many platelets, which help control bleeding. Kuppersmith’s doctor suspected she had a rare blood disorder called essential thrombocythemia, which can lead to blood clots, strokes and, in rare cases, leukemia.

Her doctor suggested a bone marrow biopsy, in which a large needle is used to suck out a sample of the spongy tissue at the center of the patient’s hip bone. Doctors examine the bone marrow under a microscope and analyze the DNA. The procedure allows doctors to judge a patient’s prognosis and select treatment, if needed. Kuppersmith had heard the procedure can be intensely painful, so she put it off for months.

The biopsy — performed by a provider in her insurance network, at a hospital in her network ― lasted only a few minutes, and Kuppersmith received relatively good news. While a genetic analysis of her bone marrow confirmed her doctor’s suspicions, it showed that the only treatment she needs, for now, is a daily, low-dose aspirin. She will check in with her doctor every three to four months to make sure the disease isn’t getting worse.

All in all, Kuppersmith felt relieved.

Then she got a notice saying her insurer refused to pay for the genetic analysis, leaving her responsible for a $2,400 payment.

The Patient: New York resident Michelle Kuppersmith, 32, who is insured by Maryland-based CareFirst Blue Cross Blue Shield. She works as director of special projects at a Washington-based, nonpartisan watchdog group. Because she was treated in New York, Empire Blue Cross Blue Shield — which covers that region ― handled part of her claim.

Total Amount Owed: $2,400 for out-of-network genetic profiling

The Providers: Kuppersmith had her bone marrow removed at the Mount Sinai Ruttenberg Treatment Center in New York City, which sent her biopsy sample to a California lab, Genoptix, for testing.

Medical Services: Bone marrow biopsy and molecular profiling, which involves looking for genetic mutations

What Gives: The field of “molecular diagnostics,” which includes a variety of gene-based testing, is undergoing explosive growth, said Gillian Hooker, president of the National Society of Genetic Counselors and vice president of clinical development for Concert Genetics, a health IT company in Nashville, Tennessee.

A Concert Genetics report found there are more than 140,000 molecular diagnostic products on the market, with 10 to 15 added each day.

The field is growing so quickly that even doctors are struggling to develop a common vocabulary, Hooker said.

Kuppersmith underwent a type of testing known as molecular profiling, which looks for DNA biomarkers to predict whether patients will benefit from new, targeted therapies. These mutations aren’t inherited; they develop over the course of a patient’s life, Hooker said.

Medicare spending on molecular diagnostics more than doubled from 2016 to 2018, increasing from $493 million to $1.1 billion, according to Laboratory Economics, a lab industry newsletter.

Charges range from hundreds to thousands of dollars, depending on how many genes are involved — and which billing codes laboratories use, Hooker said.

Based on Medicare data, at least 1,500 independent labs perform molecular testing, along with more than 500 hospital-based labs, said Jondavid Klipp, the newsletter’s publisher.

In a fast-evolving field with lots of money at stake, tests that a doctor or lab may regard as state-of-the-art an insurer might view as experimental.

Worse still, many of the commercial labs that perform the novel tests are out-of-network, as was Genoptix.

After lining up an in-network provider at an in-network hospital, Kuppersmith pushed back when she got a $2,400 charge for an out-of-network lab. She appealed and won but says, “There are a lot of people who don’t have the time or wherewithal to do this kind of fighting.”(Shelby Knowles for KHN)

Stephanie Bywater, chief compliance officer at NeoGenomics Laboratories, which owns Genoptix, said that insurance policies governing approval have not kept up with the rapid pace of scientific advances. Kuppersmith’s doctor ordered a test that has been available since 2014 and was updated in 2017, Bywater said.

Although experts agree that molecular diagnostics is an essential part of care for patients like Kuppersmith, doctors and insurance companies may not agree on which specific test is best, said Dr. Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.

Tests “can be performed a number of different ways by a number of different laboratories who charge different amounts,” Nichols said.

Insurance plans are much more likely to refuse to pay for molecular diagnostics than other lab tests. Laboratory Economics found Medicare contractors denied almost half of all molecular diagnostics claims over the past five years, compared with 5-10% of routine lab tests.

With so many insurance plans, so many new tests and so many new companies, it is difficult for a doctor to know which labs are in a patient’s network and which specific tests are covered, Nichols said.

“Different providers have contracts with different diagnostic companies,” which can affect a patient’s out-of-pocket costs, Nichols said. “It is incredibly complex and really difficult to determine the best, least expensive path.”

Kuppersmith said she has always been careful to check that her doctors accept her insurance. She made sure Mount Sinai was in her insurance network, too. But it never occurred to her that the biopsy would be sent to an outside lab ― or that it would undergo genetic analysis.

She added: “The looming threat of a $2,400 bill has caused me, in many ways, more anxiety than the illness ever has.”

Kuppersmith’s doctor recommended a bone marrow biopsy after suspecting she had a rare blood disorder. Though the biopsy was done by an in-network provider at an in-network hospital, Kuppersmith learned she was on the hook for $2,400 for out-of-network genetic profiling.(Shelby Knowles for KHN)

The Resolution: Despite making dozens of phone calls, Kuppersmith got nothing but confusing and contradictory answers when she tried to sort out the unexpected charge.

An agent for her insurer told her that her doctor hadn’t gotten preauthorization for the testing. But in an email to Kuppersmith, a Genoptix employee told her the insurance company had denied the claim because molecular profiling was viewed as experimental.

A spokesperson for New York-based Empire Blue Cross Blue Shield, which handled part of Kuppersmith’s claim, said her health plan “covers medically necessary genetic testing.”

New York, one of 28 states with laws against surprise billing, requires hospitals to inform patients in writing if their care may include out-of-network providers, said attorney Elisabeth Benjamin, vice president of health initiatives at the Community Service Society, which provides free help with insurance problems.

A spokesperson for Mount Sinai said the hospital complies with that law, noting that Kuppersmith was given such a document in 2018 — nearly one year before her bone marrow biopsy ― and signed it.

Benjamin said that’s not OK, explaining: “I think a one-year-old, vague form like the one she signed would not comply with the state law — and certainly not the spirit of it.”

Instead of sending Kuppersmith a bill, Genoptix offered to help her appeal the denied coverage to CareFirst. At first, Genoptix asked Kuppersmith to designate the company as her personal health care representative. She was uncomfortable signing over what sounded like sweeping legal rights to strangers. Instead, she wrote an email granting the company permission to negotiate on her behalf. It was sufficient.

A few days after being contacted by KHN, Kuppersmith’s insurer said it would pay Genoptix at the in-network rate, covering $1,200 of the $2,400 charge. Genoptix said it has no plans to bill Kuppersmith for the other half of the charge.

The Takeaway: Kuppersmith is relieved her insurer changed its mind about her bill. But, she said: “I’m a relatively young, savvy person with a college degree. There are a lot of people who don’t have the time or wherewithal to do this kind of fighting.”

Patients should ask their health care providers if any outside contractors will be involved in their care, including pathologists, anesthesiologists, clinical labs or radiologists, experts said. And check if those involved are in-network.

“Try your best to ask in advance,” said Jack Hoadley, a research professor emeritus at Georgetown University. “Ask, ‘Do I have a choice about where [a blood or tissue sample] is sent?’”

Ask, too, if the sample will undergo molecular diagnostics. Since the testing is still relatively new — and expensive ― most insurers require patients to obtain “prior authorization,” or special permission, said Dr. Debra Regier, a medical geneticist at Children’s National Hospital in Washington and an associate with NORD, the National Organization of Rare Diseases. Getting this permission in advance can prevent many headaches.

Finally, be wary of signing blanket consent forms telling you that some components of your care may be out-of-network. Tell your provider that you want to be informed on a case-by-case basis when an out-of-network provider is involved and to consent to their participation.

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U.S. massively expanding hospitals as coronavirus death toll surpasses China’s

WASHINGTON/NEW YORK (Reuters) – The United States aims to build hundreds of temporary hospitals to ease pressure on a healthcare system under siege from the coronavirus pandemic, with the U.S. death toll now topping 3,600 to surpass the total in China, where the outbreak began.

A worker inspects part of a delivery of 64 hospital beds from Hillrom to The Mount Sinai Hospital during the outbreak of the coronavirus disease (COVID-19) in Manhattan, New York City, U.S., March 31, 2020. REUTERS/Andrew Kelly

In the face of such an onslaught, the U.S. Army Corps of Engineers is searching for hotels, dormitories, convention centers and large open spaces to build as many as 341 temporary hospitals, Lieutenant General Todd Semonite, the head of the corps, told the ABC News “Good Morning America” program.

U.S. officials have said the pandemic could lead to 100,000 to 200,000 deaths in the United States.

Besides straining infrastructure, the pandemic is taking a toll on doctors, nurses and other healthcare workers, who are overworked and lack the medical devices and protective gear needed.

“The duration itself is debilitating and exhausting and depressing,” New York Governor Andrew Cuomo told a news conference where he revealed that his brother, CNN news anchor Chris Cuomo, had tested positive for the virus.

“I’m speaking to healthcare professionals who say, ‘Look, more than physically tired, I’m just emotionally tired.’”

The corps, the engineering arm of the U.S. Army, already joined with New York state officials to convert New York City’s Jacob Javits Convention Center into a 1,000-bed hospital in the space of a week.

Like many temporary hospitals, the center will relieve the pressure by taking non-coronavirus patients. That will allow existing hospitals to focus on patients with COVID-19, the respiratory ailment caused by the coronavirus.

Confirmed U.S. cases surged to nearly 180,000 with 16,000 new positive tests reported on Tuesday. For a second day in a row, the United States recorded over 500 new deaths as the total climbed to nearly 3,600, according to a Reuters tally of officially reported data.

U.S. coronavirus-related deaths still trail those of Italy and Spain with more than 11,000 and 8,000 reported fatalities, respectively. China has 3,305. Worldwide, there are now more than 800,000 cases of the highly contagious illness caused by the virus and more than 39,000 deaths reported. (Graphic: tmsnrt.rs/2w7hX9T)

Besides the convention center, New York has a new field hospital in Central Park and another is being built at the USTA Billie Jean King National Tennis Center where the U.S. Open is played.

The convention center is blocks away from the Hudson River pier where the U.S. Navy hospital ship Comfort docked on Monday, ready to take up to 1,000 patients. It is similar to the USNS Mercy, which is already treating patients off Los Angeles.

New York remains the epicenter of the outbreak in the |United States. The state reported another 332 deaths on Tuesday, raising its total to 1,550, and another 9,298 new cases.

Authorities in New Orleans, Los Angeles and Chicago also were setting up field hospitals and convention centers.

‘GASPING FOR BREATH’

An intensive care nurse at a major hospital in Manhattan said he had been shocked by the deteriorating conditions of young patients with little or no underlying health issues.

“A 28-year-old, healthy fellow ICU nurse is currently so sick that he has difficulty walking up a single flight of stairs without gasping for breath,” said the nurse, requesting anonymity because he was not authorized to speak to the media.

“The apparent randomness of who gets hit and how hard is the most frightening part,” he said.

In the New York City suburbs, nurses are bracing for a surge of patients. The medical surgery unit at New York-Presbyterian Hospital’s Hudson Valley branch has 17 coronavirus patients, more than half its capacity, said nurse Emily Muzyka, 25.

“I had a meltdown and cried to my boyfriend,” Muzyka said after a relatively healthy, 44-year-old patient declined quickly and required ventilation.

No-visitor policies mean very ill patients may die alone.

“I’ve held patients’ hands through their final breaths in the past,” Muzyka said. “It’s a lonely death.”

In a Monday night tribute to first responders, New York’s landmark Empire State Building illuminated the top of its tower in red with a pulsating light on its antenna that simulated an ambulance beacon.

Meanwhile, Congress debated whether to consider another economic relief bill after passing a landmark $2.2 trillion package last week that will send checks to taxpayers, inject cash into businesses and fund hospitals.

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House of Representatives Speaker Nancy Pelosi said Congress should focus next on state and local recovery efforts, but Senate Majority Leader Mitch McConnell urged a “wait-and-see” approach.

More than 30 states have ordered people to stay at home to contain the virus, but with the side effect of strangling the economy.

Goldman Sachs on Tuesday revised down its already pessimistic outlook for the U.S. economy, forecasting it would shrink 34% in the second quarter and projecting unemployment would rise to 15%.

Reporting by Susan Heavey, Doina Chiacu, Nick Brown, Gabriella Borter, Lisa Shumaker and Barbara Goldberg; Writing by Daniel Trotta; Editing by Frank McGurty and Howard Goller

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New York governor says brother, CNN anchor Chris Cuomo, has coronavirus

(Reuters) – The coronavirus pandemic took a personal turn for New York Governor Andrew Cuomo on Tuesday as he disclosed that his brother, CNN television anchor Chris Cuomo, had tested positive for the disease caused by the virus.

The disclosure came on the same day New York reported that cases in the state had increased by more than 9,000 from a day earlier, to 75,795, with deaths rising by 27 percent to 1,550, the most of any state.

“My brother Chris is positive for coronavirus, we found that this morning. He is going to be fine, he’s young, strong – not as strong as he thinks,” Cuomo told a daily briefing on the coronavirus. “I spoke to him this morning and he is going to be quarantined in his basement.”

Chris Cuomo, 49, confirmed the diagnosis on Twitter, saying he was worried about infecting his wife and children, but that he would continue to host his nightly show from his basement.

The governor was interviewed by his brother on CNN on Monday night and grilled about a potential presidential run given the praise he has garnered for his response to the virus. The elder Cuomo, 62, reiterated that he would not run for president.

States across the country, like New York, have been scrambling to purchases ventilators, one of the most pressing needs for hospitals treating patients.

The governor said he had ordered 17,000 ventilators from China at an average price of $25,000 each. But of that order, he said, he had firm commitment on only 2,500 units and complained about competing with the Federal Emergency Management Agency and other states in purchasing the equipment.

FILE PHOTO: CNN television news anchor Chris Cuomo poses as he arrives at the WarnerMedia Upfront event in New York City, New York, U.S., May 15, 2019. REUTERS/Mike Segar

“It’s like being on eBay with 50 other states bidding on a ventilator,” Cuomo said. “The federal government, FEMA, should have been the purchasing agent, buy everything, and then allocate by need to the states.”

Cuomo said various predictive models being used by New York indicate the apex of the surge for hospitals will come anywhere from 7 to 21 days from now.

“The virus is more powerful, more dangerous than we expected,” Cuomo said. “We’re still going up the mountain. The main battle is on top of the mountain.”

Reporting by Nathan Layne in Wilton, Connecticut, and Maria Caspani in New York; Editing by Chizu Nomiyama and Dan Grebler

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Why do men stop treatment for erectile dysfunction?

A new study published in the journal IJIR: Your Sexual Medicine Journal in March 2020 reports the most common reasons why men stop their treatment for erectile dysfunction. The most common reasons were that the treatment did not work, cost too much, or had unacceptable side effects. Loss of interest in sexual relationships was another primary reason.

Men’s beliefs about treatment for erectile dysfunction—what influences treatment use? A systematic review. Image Credit: Gorstevanovic / Shutterstock

In addition, the study also shows how important it is to educate men about the condition, how it can be treated, and the possibility of changing their beliefs to help them make use of the treatment. A good understanding of what factors modify treatment utilization decisions is necessary to help patients make better choices.

Researchers say, “erectile dysfunction can have a negative effect on men’s quality of life. However, this can potentially be improved with successful treatment for the condition. The findings from our research indicate that rates of discontinuation for treatment are high. Understanding the reasons for discontinuation of treatment is essential with regards to improving treatment use and, subsequently, quality of life in this patient population.”

What is erectile dysfunction?

Erectile dysfunction (ED) is the persistent inability to have or sustain an erection during sexual activity. It occurs in up to a tenth of men under 49 years, increasing to one in five between 60 and 69 years, but in over 70% of men past the age of 70.

ED can adversely affect self-confidence, cause depression, and reduce the quality of life.

Most men with ED are treated with oral phosphodiesterase type 5 inhibitors, but if this does not work, injectable drugs and urethral suppositories are sometimes used. As a last resort, penile implants are used.

The study

The researchers looked at the data from 50 studies, covering over 14,370 men. They asked about how they found the treatment, and what factors were linked to discontinuation of treatment.

The findings

The study found that the rates of discontinuation due to unsatisfactory response (in terms of hardness and duration of erection) varied with the type of treatment, but occurred in about a third of patients across all studies. For instance, with men on tablets, the rate was about 12%, but with injectables, about 15%. On the other hand, the use of suppositories was associated with inconsistent or poor efficacy resulting in discontinuation in about a third of patients.

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Discontinuation as a result of adverse effects such as headaches, Peyronie’s disease or priapism, and urethral pain was reported by less than 3% of men on tablets, 8% of men on injectables and 15% of men using suppositories.

A small percentage of men also reported that factors dealing with the quality of sexual relationship had to do with their discontinuation of the treatment. This factor was cited by about 7% of men on pills, 9% on injectables, 9% taking suppositories, and 7% of men with penile implants.

About 6% of men on pills said they stopped because they felt their partner was no longer interested in the sexual relationship, about 6% because they were not ready emotionally to invest in the relationship, and 4% because of conflict with their partners. Thus, there is a small but significant contribution by the quality of the sexual relationship on the continuation of treatment.

Said Williams, “Men’s perceptions of their sexual relationships and their emotional readiness for sexual activity are important when considering the most appropriate treatment for a man and his partner.”

Despite the safety and effectiveness of PDE5Is, many men stopped them because of not wanting to tie down sexual activity to their medication use, the lag time until response, and the cost of treatment.

Other misconceptions had to do with the fear of drug dependency, heart disease as a result of the medications. At the same time, embarrassment or inconvenience while buying the medication was also a factor for some people. If the medication was not on hand, such as if the patient forgot to buy it, the resulting embarrassment was also severe.

Implications

The limitations of the study were lack of data on the duration of ED, its severity, and the quality of the relationship, in many studies. The outcome was difficulty in evaluating how these factors contributed to treatment duration.

Surprisingly only 12/50 studies looked at psychological or cognitive factors leading to the cessation of treatment, despite the psychogenic origin of ED in almost all cases. The treatment cost was not explored thoroughly.

The researchers suggest that future work should explore the role of beliefs about ED and its treatment because this could play a pivotal role in the decision to continue or stop therapy.

For instance, patient expectations about treatment effectiveness play a part in awakening perceptions of treatment failure. Men who got back to their doctors about the side effects of treatment were more likely to continue the treatment, the study found. This suggests that finding out what thoughts the patient has about his treatment, and trying to correct any misconceptions therein, may help to promote the use of this treatment. This is a crucial way to help doctors avoid treatment failure.

Psychological theory could be a valuable tool, suggest the authors, to look at what hinders men with ED from coming forward to exploit current treatment modalities. It could also spot the factors which promote or enhance treatment utilization. Thirdly, it could help assess how this treatment is being viewed and used by the end-users. Such evaluation procedures could help this group of patients to use available ED treatments more effectively.

Journal reference:

Williams, P. et al. (2020). Men’s beliefs about treatment for erectile dysfunction—what influences treatment use? A systematic review. IJIR: Your Sexual Medicine Journal, https://doi.org/10.1038/s41443-020-0249-1.

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Coronavirus Patients Caught In Conflict Between Hospital And Nursing Homes

A wrenching conflict is emerging as the COVID-19 virus storms through U.S. communities: Some patients are falling into a no man’s land between hospitals and nursing homes.

Hospitals need to clear out patients who no longer need acute care. But nursing homes don’t want to take patients discharged from hospitals for fear they’ll bring the coronavirus with them.

“It’s a huge and very difficult issue,” said Cassie Sauer, president of the Washington State Hospital Association, whose members were hit early by the coronavirus.

Each side has legitimate concerns. Hospitals in coronavirus hot spots need to free up beds for the next wave of critically ill patients. They are canceling elective and nonessential procedures. They are also trying to move coronavirus patients out of the hospital as quickly as possible.

The goal is to “allow hospitals to reserve beds for the most severely ill patients by discharging those who are less severely ill to skilled nursing facilities,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said a few weeks ago as the federal agency relaxed rules restricting which Medicare patients can receive nursing home care.

Nursing homes are alarmed at the prospect of taking patients who may have coronavirus infections. The consequences could be dire. The first nursing home known to have COVID-19, the Life Care Center in Kirkland, Washington, saw the virus spread like wildfire. It killed 37 people.

“We’re looking at case fatality rates of 30, 40, 50% in nursing homes when coronavirus gets introduced,” said Christopher Laxton, executive director of AMDA — the Society for Post-Acute and Long-Term Care Medicine, which represents nursing home medical directors.

Fears extend to patients with other conditions, such as strokes or heart attacks, who’ve been in the hospital and do not have COVID-19 symptoms but could harbor the virus.

In its most recent guidance, the American Health Care Association, an industry trade group, said nursing homes can accept patients “who are COVID negative or do not have symptoms.” If someone has symptoms such as a dry cough or fever, they “should be tested for COVID-19 before being admitted to the facility.” If someone is COVID positive, they should be kept only “with other COVID positive residents.”

But nursing home doctors worry this doesn’t go far enough. According to a resolution by the California Association of Long Term Care Medicine, nursing homes should not have to take patients known to have the coronavirus unless “they have two negative tests that are 24 hours apart, OR 10 days after admission AND no fever for 72 hours.” A new AMDA resolution echoes this caution.

“We have an obligation to our patients to draw the line,” said Dr. Michael Wasserman, president of the California association. “Increasing the number of COVID-19 positive residents in facilities — whether these facilities have patients with the virus or not — raises the risk of infecting the uninfected and dramatically increasing the number of deaths.”

For their part, hospital leaders say an emphasis on testing before discharging patients is impractical, given the shortage of tests and delays in receiving results.

“Many nursing homes are requiring a negative COVID-19 test even for patients who were in the hospital for nothing to do with COVID,” said Sauer in Washington state. “We don’t agree with this. It’s using up very limited testing resources.”

Nowhere are tensions higher than in New York, where Gov. Andrew Cuomo has said 73,000 extra hospital beds will be needed within weeks to treat a surge of COVID-19 patients. Hospitals in the state have 53,000 beds.

On Wednesday, the New York State Department of Health issued an advisory noting: “No resident shall be denied re-admission or admission to the NH [nursing home] solely based on a confirmed or suspected diagnosis of COVID-19.”

Speaking on behalf of nursing home physicians, AMDA voiced strong opposition, calling the policy “over-reaching, not consistent with science, unenforceable, and beyond all, not in the least consistent with patient safety principles” in a statement.

Some nursing homes are sending residents with suspected coronavirus to hospitals for evaluation and then refusing to take them back until tests confirm their negative status.

“Essentially, they’re dumping patients on hospitals and saying, ‘Too bad — you’re stuck with them now,’” said a consultant who works closely with hospitals and spoke on the condition of anonymity.

Others want to do their part to serve COVID-19 patients. “It is our obligation to keep the health care system flowing,” said Scott LaRue, president of ArchCare, the health care system of the Archdiocese of New York.

LaRue has no illusions about keeping the coronavirus out of ArchCare’s five nursing homes, which, combined, have 1,700 beds.

“In New York City the virus is everywhere,” he said. That means it has to be managed, not avoided. “Our intention is to take COVID-19 stable patients” and move them to a single floor at each nursing home, he said.

That will happen under two conditions, LaRue said. First, ArchCare will need sufficient personal protective equipment — gowns, masks and face shields — for its staff. Currently, the system can’t get face shields. It was due to run out of gowns by Wednesday.

Second, ArchCare will need to test whether its protocols for managing COVID-positive patients are working. Those include putting patients in isolation, monitoring them more closely, limiting the number of people who can go in, and ensuring that staff use personal protective equipment and are trained properly.

So far, only one of its nursing home patients is known to have COVID-19.

“We won’t know for 14 days if the steps we’re taking are working,” LaRue said.

But it’s unrealistic to expect other nursing homes to follow suit.

“I would be surprised if 10% to 15% of skilled nursing facilities in the U.S. could take a COVID-positive patient and treat that patient safely while ensuring that other residents in the home are safe,” said David Grabowski, a professor of Health Care Policy at Harvard Medical School.

In a new commentary in the Journal of the American Medical Association, Grabowski calls for establishing “centers of excellence” to care for patients recovering from COVID-19 and building “temporary capacity” in hot spots where the need for post-hospital services is likely to surge.

That’s beginning to happen. On Tuesday, Cuomo announced that a field hospital being built by the U.S. Army Corps of Engineers to house overflow coronavirus patients at the Jacob K. Javits Convention Center in New York City would include 1,000 beds for patients who don’t need acute care services.

On Wednesday, a unit of Partners HealthCare, a large Massachusetts health care system, announced a new center for patients recovering from COVID-19 on the fourth floor of Spaulding Hospital for Continuing Care, a long-term care hospital in Cambridge. The center, set to open soon, will have 60 beds and accept patients from Massachusetts General Hospital and Brigham and Women’s Hospital.

In the Twin Cities area of Minnesota, Allina Health, which operates 11 hospitals, is partnering with Presbyterian Homes & Services to convert a 50-bed skilled nursing home to a “step-down site,” said Dr. Emily Downing, a vice president of Allina Health. The goal is to help COVID-19 patients recover so they can return to nursing homes or senior living communities.

Katie Smith Sloan, president of LeadingAge, which represents not-for-profit nursing homes, home care agencies and assisted living centers, said she was hearing about nascent plans to reopen closed nursing homes for COVID-19 patients. Government agencies need to make financing available to build extra capacity to care for these patients, she said.

As for patients who need less intensive care or who need to be quarantined after the hospital to ensure they aren’t infectious, other options exist.

“King County has bought a hotel and is leasing another and is looking at what are now empty ambulatory surgery centers or a Christian summer camp in the area,” said Sauer of the Washington State Hospital Association.

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Spread of coronavirus accelerates in U.S. jails and prisons

NEW YORK (Reuters) – Sean Hernandez says he covers his mouth and nose with a t-shirt or towel when he leaves his cell, the only defense he can improvise against the coronavirus outbreak now sweeping through New York’s Rikers Island jail system.

FILE PHOTO: Signage is seen outside of Rikers Island, a prison facility, where multiple cases of the coronavirus disease (COVID-19) have been confirmed in Queens, New York City, U.S., March 22, 2020. REUTERS/Andrew Kelly

Inmates have no access to gloves or proper masks and have only cold water to wash their hands, said Hernandez, who was convicted of attempted murder and has served eight years. He said inmates watched on Thursday as a guard coughed, her cheeks turned red and she collapsed to the ground.

“We are pleading with officers” for better defenses, he said. “They just shrug. In the end, we are just inmates, second-class citizens. We are like livestock.”

As of Saturday, at least 132 inmates and 104 staff at jails across New York City had tested positive for COVID-19, the disease caused by the coronavirus. The virus appears to be spreading quickly through a jail system famous for its overcrowded cell blocks. The city’s Department of Correction said it is taking many measures to protect detainees, and declined to comment on Hernandez’s account of an infected guard collapsing.

Across the United States, jails and prisons are reporting an accelerating spread of the new disease, and they are taking a varied approach to protecting the inmates in their charge. Thousands of inmates are being released from detention, in some cases with little or no medical screening to determine if they may be infected by the coronavirus and at risk of spreading it into the community, Reuters found.

Since March 22, jails have reported 226 inmates and 131 staff with confirmed cases of COVID-19, according to a Reuters survey of cities and counties that run America’s 20 largest jails. The numbers are almost certainly an undercount given the fast spread of the virus. Hot spots include Cook County jail in Chicago, Illinois. Since the first case was confirmed there on Sunday, the virus has infected 89 inmates and nine staff. Test results are pending for 92 other detainees.

Inmate advocates, local officials and public defenders are urging jails and prisons to speed up the release of inmates. Jails typically hold people for relatively short periods as they await trial. They have more flexibility to reduce populations than state or federal prisons, whose inmates have been convicted and sentenced.

“We are nowhere close to the rate of release we need to see to stop the spread of COVID-19,” said Udi Ofer, director of the justice division at the American Civil Liberties Union. “Every day that government officials do not act is another day that lives are put at risk.”

Some groups are pushing back. Victims’ rights group Marsy’s Law, named after the murdered sister of billionaire Henry Nicholas, has criticized the releases, saying victims of crimes should be notified before the people who committed them are let out — a process that could delay releases of some inmates by weeks or months. However, officials supervising releases in New York, Los Angeles, Houston and other major cities say they are releasing only low-level, non-violent offenders.

New York City has freed about 450 inmates from its jails since last weekend as it scrambles to contain the virus, which has killed more than 28,300 people, including more than 2,050 in the United States.

The city’s independent oversight body for the jails, the Board of Correction, has identified around 2,000 people who could be released — including inmates aged 50 and above, the infirm, nonviolent, low-level offenders or people jailed for parole violations. The city has declined to disclose the number of inmates it has tested for the virus.

On Friday, the New York state government identified 1,100 low-level parole violators for immediate release, including 400 in New York City jails. “Hundreds more will be released soon,” said Colby Hamilton, a spokesman for the mayor.

‘THERE IS NO PROTECTION’

The United States has more people behind bars than any other nation, a total incarcerated population of nearly 2.3 million as of 2017, including nearly 1.5 million in state and federal prisons and another 745,000 in local jails, according to the U.S. Bureau of Justice Statistics.

An inmate released on Monday from Rikers Island said sick and healthy people often mingled freely inside the jail. After a prisoner and a guard in his area of the jail were diagnosed with COVID-19, the inmate said he started spending more time in his two-man cell. But he still had to line up with other inmates at the medicine window to get his daily dose of methadone, a drug-addiction treatment.

“There is no protection,” said the 32-year-old inmate, who spoke on condition of anonymity. “You want to get away from people but you can’t.”

The New York City Department of Correction said it has taken measures to address the outbreak, including distributing masks to inmates in areas where someone tested positive for COVID-19, promoting distancing between inmates, cleaning cells and providing soap.

“The Department of Correction is doing everything we can to safely and humanely house people in our custody amid the broader COVID-19 crisis,” said Peter Thorne, the deputy commissioner of public information.

Some jails are releasing inmates who may be ill. In Marietta, Georgia, Aubrey Hardyway, 21, developed a cough, headache, sore throat and a 103-degree fever while held at the Cobb County Adult Detention Center on theft charges. “I just couldn’t take it, I was feeling terrible,” he said.

Four days after falling ill, Hardyway says he was tested for flu and strep throat. When both came back negative, he was taken to a nearby hospital for blood work and other tests. Hardyway says he was never told if he was tested for the coronavirus. A doctor urged deputies to quarantine Hardyway, he says, but he was released hours later after he returned to jail and his friends paid his bond.

Hardyway says he believes he might have exposed cellmates and guards who were in contact with him. At least one deputy has tested positive for the virus and a second has been quarantined after showing symptoms, according to two sources familiar with the jail’s operations.

The Cobb County Sheriff’s Office did not respond to requests for comment.

Jails report they are adopting different tactics to keep the virus out. Some screen new inmates before they’re even booked, taking their temperatures inside police cruisers or garages. Some are quarantining new arrivals until they are medically cleared to join the general population. Some are doing nothing.

Federal prison guards have asked for permission to wear masks on duty, though the Bureau of Prisons had so far declined, said Sandy Parr, a vice president of the union that represents federal prison workers. The Bureau of Prisons did not respond to a request for comment. Fourteen federal inmates and 13 staff have tested positive for the virus, the bureau said on its website.

A pandemic could be “very dangerous for our inmate population,” Parr said.

Some courts are beginning to agree: A federal judge late on Thursday ordered federal authorities to immediately release 10 people who were being held in county jails in New Jersey while their immigration cases were being heard. U.S. District Judge Analisa Torres ruled that each detainee “faces an imminent risk of death or serious injury in immigration detention” because of the outbreak.

THOUSANDS BEING RELEASED

Inmate releases are being driven by judges, public defenders, prosecutors and occasional orders by political leaders. New Jersey’s chief justice ordered the release of 1,000 jail inmates statewide at the start of the week, seeking to prevent deaths behind bars.

Los Angeles County has released at least 1,700 inmates who had sentences with less than 30 days left. In California’s Santa Clara County, authorities cut the inmate population by at least 400 by releasing some people, delaying sentences and other steps. Harris County, Texas, which includes Houston, has cut its jail population by at least 500.

In some counties, police are issuing citations for low-level crimes instead of arresting people. Furloughing work-release prisoners is another strategy to try to limit spread of the virus in crowded and often-unsanitary facilities, where the quality of medical care varies dramatically. Some worry the churn of detainees — coupled with the constant shuffle of officers coming from outside — will spread the illness across jails and communities.

Among a dozen large U.S. jails surveyed by Reuters, there was no uniform approach to preventing an infected inmate from spreading the coronavirus into a community.

Some jurisdictions screened inmates before letting them out. Others, such as King County Correctional Facility in Washington, did not.

“At this time, there is no enhanced screening of inmates occurring at release unless there is some type of pre-existing medical or psychiatric issue,” said Captain David Weirich of the King County Department of Adult and Juvenile Detention, where at least one correctional officer has tested positive for the coronavirus according to the county.

In Ohio, the Hamilton County Justice Center is checking the temperature of all released inmates before they leave. At the John E. Polk Correctional Facility in Seminole, Florida, if an inmate shows any signs of illness, they’re referred to an outside medical provider. Other jails are offering literature on COVID-19 to exiting inmates.

Inmates in federal prisons said some religious services have been cancelled, along with education programs and most visits.

“If the virus gets in here, and we are all expecting it to, we are doomed,” said Steven Jones, a 55-year-old inmate at a federal prison in Littleton, Colorado.

Ned Parker and Grant Smith reported from New York. Linda So and Brad Heath reported from Washington. Additional reporting by Peter Eisler, Beatrix Lockwood and Karen Freifeld. Editing by Jason Szep

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Partisan divide returns in U.S. Congress on coronavirus next steps

WASHINGTON (Reuters) – Fresh partisan divisions flared on Sunday on the next steps for the U.S. Congress in dealing with the coronavirus crisis, with the top House of Representatives Republican casting doubt on the need for more economic stimulus legislation while House Speaker Nancy Pelosi signaled she plans to move forward with it.

U.S. House Minority Leader Kevin McCarthy (R-CA) speaks to the media after a meeting in the office of House U.S. Senate Majority Leader Mitch McConnell (R-KY) to wrap up work on coronavirus economic aid legislation, during the coronavirus disease (COVID-19) outbreak, in Washington, U.S., March 22, 2020. REUTERS/Mary F. Calvert

President Donald Trump on Friday signed into law a $2.2 trillion aid package – the largest on record – to address the economic downturn inflicted by the coronavirus pandemic after the Democratic-led House and Republican-led Senate put aside partisan differences to pass it nearly unanimously.

It was the third legislative package approved by lawmakers to address the mounting crisis.

Trump on Sunday left open the possibility that he would support a fourth relief bill, telling reporters he was prepared to do “whatever’s necessary” to save lives and bring back the economy.

But House Minority Leader Kevin McCarthy was more cautious in comments that aired earlier in the day.

“I’m not sure we need a fourth package,” McCarthy told the Fox News program “Sunday Morning Futures,” noting he wants to see the first three packages take effect first.

Pelosi, the top Democrat in Congress, told CNN’s “State of the Union” program that the three bills already signed into law were merely a “down payment.”

“We have to do more,” Pelosi said, adding that the existing bills do not provide enough because “every single day, the need grows.”

“We have to pass another bill that goes to meeting the need more substantially than we have. We have other issues that we have to deal with in the bill in terms of personal protective equipment and OSHA (Occupational Safety and Health Administration) rules that protect workers,” Pelosi said.

“We have to do more on family medical leave. We have to be able to make people who get tested also have their visit to the doctor covered,” Pelosi added.

‘MORE SUPPORT’

U.S. Treasury Secretary Steve Mnuchin said on Sunday he expects the stimulus package signed by Trump on Friday will provide economic relief overall for about 10 weeks. Mnuchin said his main focus now is on carrying out its provisions to get money to Americans as soon as possible.

“We also have the (coronavirus) task force and the medical professionals making recommendations to the president about when they think the economy will be re-opened, and if for whatever reason this takes longer than we think, we will go back to Congress and get more support for the American economy,” Mnuchin said on the CBS program “Face the Nation.”

“But I hope that’s not needed,” Mnuchin added.

McCarthy’s comments illustrated the continuing tensions between the two parties in Congress, raising questions about just how quickly they could come together to pass a fourth legislative package.

“What concerns me is when I listen to Nancy Pelosi talk about a fourth package now. It’s because she did not get in the things she really wanted,” McCarthy said, mentioning election law and environmental policy changes and funding for women’s healthcare and abortion provider Planned Parenthood as initiatives he accused Pelosi of wanting to pursue.

The latest rescue package included a $500 billion fund to help hard-hit industries and a comparable amount for direct payments of up to $3,000 apiece to millions of U.S. families. It also provided $350 billion for small-business loans, $250 billion for expanded unemployment aid and at least $100 billion for hospitals and related health systems.

Republican Senator Rick Scott criticized the latest round of stimulus legislation even though he voted for it, saying it will hurt economic recovery because “we’ve created incentive for somebody to stay home rather than go to work because they make more money being at home.”

Governors in numerous states have closed non-essential businesses and taken other steps to try to slow the spread of the pathogen.

Reporting by Sarah N. Lynch, Chris Sanders, Doina Chiacu and Phil Stewart in Washington; Editing by Will Dunham and Diane Craft

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The Nation’s 5,000 Outpatient Surgery Centers Could Help With The COVID-19 Overflow

As the number of COVID-19 cases continues to rise, a group of anesthesiologists wants to convert America’s surgery centers into critical care units for infected patients.

Many of the country’s more than 5,000 outpatient surgery centers have closed or sharply cut back on the number of elective procedures they perform, to comply with requests from government agencies and professional societies. But those surgery centers have space and staff, as well as anesthesia machines that could be repurposed into ventilators — all of which could be especially crucial in hard-hit areas like New York.

“Half of the surgery centers in New York are not doing anything,” said Adam Schlifke, an anesthesiologist and clinical assistant professor at Stanford University in California, who is leading the push for the centers to help. “All these anesthesiologists and nurses who are sitting on the sidelines, they want to help. They don’t know how to help. There’s nowhere for them to help. What if they could work in the surgery centers?”

Opening such outpatient centers nationwide to coronavirus patients would nearly double the number of facilities nationwide, up from the country’s fewer than 6,200 hospitals. But turning day facilities into places for 24/7 care worries some anesthesiologists. There are questions about staffing, regulations and payment. They also fear that using surgery centers as critical care units would do more harm than good if the centers aren’t properly equipped to handle severe cases of COVID-19.

“Even if we lifted the regulatory restrictions, surgery centers are licensed to do a certain thing,” said Dr. Steven Dalbec, a private practice anesthesiologist in Columbia, Missouri, who once ran a surgery center in Arizona. “If we could say, ‘OK, we’re going to lift all those restrictions and let you take care of critically ill patients,’ it’s not something that could happen overnight.”

Still, that’s exactly why Schlifke argues that it’s important to start now, especially in parts of the country with fewer cases. His group has created a blueprint that outlines the steps needed for surgery centers to convert.

In the coming days, Schlifke said, he and the approximately 75 members of the CovidVent coalition of anesthesiologists he’s helping organize will call for a federal executive order to enable the conversion of surgery centers and hospital operating rooms into COVID-19 care sites to help save lives.

The order is needed, he said, because he recognizes that providers want to get paid. The idea is so new, he said, there’s no reimbursement plan in place for surgery centers that agree to treat COVID-19 patients.

What’s most troubling, Schlifke said, is the number of anesthesiologists who cannot help with the pandemic because their center is either closed or they are busy with elective surgeries that aren’t necessary. It’s a frustrating dilemma.

“They want to work,” Schlifke said.

The CovidVent group also wants to make sure surgery centers follow Centers for Medicare & Medicaid Services recommendations that call for them to end nonessential elective surgeries to keep front-line medical providers safe amid shortages of protective supplies such as masks. Many of those surgery centers are in states like New York, California and Washington where hospitals can’t keep up with the demand.

“An important question for hospitals and health systems that continue to perform elective and nonessential surgeries is, ‘Why?’” said Dr. Greg Martin, president-elect of the Society of Critical Care Medicine, which represents intensive care doctors. “How do they justify the risk to the otherwise healthy individuals, justify the risk to the health care provider workforce who may be imminently needed elsewhere, and justify the unnecessary consumption of health care resources such as masks, gloves and gowns?”

But William Prentice, CEO of the Ambulatory Surgery Center Association, an industry group, argued that some surgeries remain necessary. “We’re pushing things off that can be pushed off,” he said.

Meanwhile, in Washington, D.C., Vice President Mike Pence has already come out in support of the use of anesthesiology equipment as ventilators.

Anesthesia machines used in the operating room can be repurposed as mechanical ventilators, Martin said. “But they function differently and do not have all the same settings as ICU ventilators, so employing them in COVID-19 care requires education or oversight from those who are expert in using them.”

Dalbec also supports converting anesthesia machines into ventilators. He now works at Boone Hospital Center in Columbia, Missouri, which he said is prepared to do that if needed. As of Friday, he said, the 230-bed hospital hasn’t treated a confirmed COVID-19 patient.

But creating new intensive care units is challenging, according to both Dalbec and Martin.

Dalbec, who ran a surgery center in Tucson, Arizona, for 10 years, worries a lot of surgery centers don’t have the training, skills or supplies to care for critically ill patients.

“Time is of the essence,” Dalbec said. “And so that would make the care for these patients considerably challenging.”

An ICU has sophisticated equipment, such as bedside machines to monitor a patient’s heart rate and mechanical ventilators to help them breathe, Martin said. Ventilators need to be hooked up to oxygen and gas lines, which supply patients with the appropriate mix of air.

Only a few areas of the hospital have the equipment and gas hookups to provide ventilator care to critically ill patients, Martin said. These include the operating room, emergency department and units used for post-anesthesia care. To convert an ordinary hospital unit to an ICU, Martin said, “You would literally need to tear down the wall and run the piping in.”

Hospitals are already looking to use operating rooms for intensive care, Martin said.

“Using OR space, equipment and staff to care for sick COVID-19 patients is the right thing to do,” Martin said. “This is one approach that most health systems are already considering and using.”

Many outpatient operating rooms at surgery centers already have the required gas and oxygen hookups, Martin said. “Some will have fully configured operating rooms with ventilators,” he said. “It would be one way to expand ICU-level patient care space.”

But they are unlikely to stock all the medications used in an ICU.

Another challenge, he said, would be that staff from most surgery centers may be pulled into hospitals — anesthesiologists, nurses and nurse anesthetists — and surgery centers would not have all the pharmacists, respiratory therapists and other staff.

Intensive care units are staffed by specially trained doctors, nurses and respiratory therapists, who set up ventilators and closely monitor patients’ breathing, Martin said. “The hardest thing to change is the staffing,” he said. “We only have a certain number of doctors, nurses and respiratory therapists.”

CovidVent is working with several telemedicine groups that could help treat patients in areas where the staff lacks the expertise, Schlifke said.

Outpatient surgery centers would need to receive a waiver from federal regulators to keep patients overnight or perform medical care they don’t currently perform, Prentice said.

Prentice said he’s optimistic that the Centers for Medicare & Medicaid Services will make an announcement about such waivers in coming days.

“Once we get that flexibility, we can find the best way to help,” Prentice said. “Decisions about how to best to use ambulatory surgery centers need to be made in conjunction with hospitals at the local level.”

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Britons warned some coronavirus lockdown measures could last months

LONDON (Reuters) – Some lockdown measures to combat coronavirus in Britain could last months and only be gradually lifted, a senior medical official said on Sunday as Prime Minister Boris Johnson warned the situation will get worse before it gets better.

FILE PHOTO: Britain’s Prime Minister Boris Johnson leaves Downing Street, as the spread of coronavirus disease (COVID-19) continues. London, Britain, March 25, 2020. REUTERS/Hannah Mckay/File Photo

Britain has reported 19,522 confirmed cases of the disease and 1,228 deaths, after an increase of 209 fatalities as of 5 p.m. local time on Saturday compared with the previous day, the health ministry said.

“The important thing is this is a moving target,” Deputy Chief Medical Officer Jenny Harries said.

“If we do well it moves forward and comes down and we manage all our care through our health and care systems sensibly in a controlled way and that is what we are aiming for,” she told a news conference.

“This is not to say we would be in complete lockdown for six months but it means that as a nation we have to be really, really responsible and keep doing what we are all doing until we are sure that we can gradually start lifting various interventions.”

Her warning came as Johnson wrote to 30 million households in Britain urging them to stick to strict rules to prevent the publicly funded National Health Service (NHS) from being overwhelmed by a surge in cases.

“We know things will get worse before they get better,” Johnson said. “At this moment of national emergency, I urge you, please, to stay at home, protect the NHS and save lives.”

The number of tests being carried out has hit 10,000 a day, senior minister Michael Gove said and authorities are trying to acquire more ventilators.

Britain has placed an order for thousands of the devices to be made by a consortium of companies including Ford (F.N), Airbus (AIR.PA) and Rolls-Royce (RR.L).

The repurposing of industry echoes Britain’s Second World War effort, with housing minister Robert Jenrick saying that all parts of the country are now on an “emergency footing” as strategic coordination centers are established.

“This is an unprecedented step in peacetime,” he said.

Writing by Costas Pitas; Editing by Louise Heavens, Frances Kerry and Giles Elgood

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Coronavirus deaths fall again in Italy but lockdown extension looms

ROME (Reuters) – The number of deaths from coronavirus in Italy fell for the second consecutive day on Sunday but the country still looked almost certain to see an extension of stringent containment measures.

The Civil Protection department said 756 people had died in the last day, bringing the total to 10,779 – more than a third of all deaths from the virus worldwide.

There were 133 fewer deaths than the 889 deaths reported on Saturday, when the numbers fell from a record high of 919 on Friday.

While the total number of confirmed cases rose to 97,689 on Sunday from a previous 92,472, it was the lowest daily rise in new cases since Wednesday.

But despite hopes by Italian officials that the downward trend would continue, it appeared increasingly likely that restrictions on all but essential activities that were due to expire on Friday would be soon officially extended.

“The measures that were due to expire on April 3 inevitably will be extended,” Regional Affairs Minister Francesco Boccia told Sky TG24 television.

He said the timing would be decided by Prime Minister Giuseppe Conte and the government based on data from the medical and scientific community.

“I think that it would be inappropriate and irresponsible to talk of re-opening (schools and production sites),” Boccia said.

Italian media have reported that the extension could last for a further two weeks until about April 18.

Italy’s sports minister said on Sunday he would propose banning all sports events, including soccer matches, for the whole of April.

Health Minister Roberto Speranza asked Italians not to let the guard down.

“We would erase all the efforts made so far to rein in contagion. The sacrifices of the last weeks are serious,” he told Corriere della Sera newspaper in an interview published on Sunday.

The daily deaths in the northern region of Lombardy, the area that has borne the brunt of the emergency, were down sharply from Saturday’s tally.

Slideshow (2 Images)

“There isn’t an exponential rise in the data anymore, showing that what has been done is giving results,” said Danilo Cereda, an official from the Lombardy regional government.

But Giulio Gallera, the top health official in the northern region of Lombardy, said Italians had to acknowledge that they would have to live “in a different way in the coming months”.

More than 662,700 people have been infected by the novel coronavirus across the world and 30,751 have died, according to a Reuters tally.

Additional reporting by Gavin Jones; editing by Philip Pullella and Jane Merriman

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