US House Passes Families First Coronavirus Act

The House of Representatives passed H.R. 6201, the Families First Coronavirus Act, in the early hours of Saturday morning. The large-scale economic relief plan aims to support Americans in combatting the spread of the coronavirus through the expansion of paid leave, food assistance, and unemployment assistance and increased federal Medicaid funding.  The Senate is expected to pass the bill early this week, and the President is expected to sign it.

Additional packages are expected to come together in the coming weeks. Today, Senator Schumer proposed at least $750 billion to combat the coronavirus as lawmakers discuss a third legislative package.  See more detail below from Schumer’s office. Those in need of federal regulatory relief or financial support should communicate needs to Congress.  We stand ready to assist if this work is not already underway.  

Additionally, on Friday, March 13, the President issued a national emergency declaration. This declaration led to a 1135 waiver, which gives the CMS the broad authority to waive many rules and regulations, including conditions of participation, program regulations, Emergency Medical Treatment and Labor Act (EMTALA) rules, and Stark regulations.

Accordingly, CMS released a fact sheet, clarified that it would issue several blanket 1135 waivers under the declaration. For instance, CMS said it has made blanket waivers available for items including but not limited to the 3-day inpatient hospital stay requirements for Medicare skilled nursing facility (SNF) coverage and regulations that limit critical access hospitals to 25-bed capacities and lengths of stay to no more than 96 hours.

CMS also will establish a toll-free hotline for non-certified Medicare Part B suppliers and providers to enroll and get temporary Medicare billing privileges.  In addition, CMS said states and U.S. territories can request 1135 waivers for certain Medicaid and CHIP requirements, including:

  • Prior authorization requirements in fee-for-service programs;
  • Provider licensing location requirements; and
  • Provider enrollment and revalidation requirements.

CMS Approves First State Request for 1135 Medicaid Waiver in Florida

On March 13, 2020, President Trump declared the rapidly evolving COVID-19 situation a national emergency.   This bold action enables the Centers for Medicare and Medicaid Services (CMS) to waive certain requirements in Medicare, Medicaid, and CHIP under Section 1135 authority. This includes the ability to grant state and territorial Medicaid agencies a wider range of flexibilities, and states may now submit Section 1135 waiver requests for CMS approval that will remove administrative burdens and expand access to needed services.

Shortly after the President’s declaration, Florida became the first state to submit a Section 1135 waiver request in response to the COVID-19 national emergency.  In keeping with CMS’s commitment to ensure our state partners have the tools they need to combat COVID-19, the agency acted within days to approve a wide variety of appropriate Medicaid flexibilities.

“I want to thank Governor DeSantis for his leadership in Medicaid and for taking full advantage of federal flexibilities,” said CMS Administrator Seema Verma. “CMS is committed to removing all unnecessary administrative and bureaucratic barriers that may hinder an effective response to this public health emergency, and I have directed my team to expeditiously process these requests.”

The state’s approval letter can be found here, and includes flexibilities that enable the state to waive prior authorization requirements to remove barriers to needed services, streamline provider enrollment processes to ensure access to care for beneficiaries, allow care to be provided in alternative settings in the event a facility is evacuated to an unlicensed facility, suspend certain nursing home screening requirements to provide necessary administrative relief, and extend deadlines for appeals and state fair hearing requests. These flexibilities will enable the state to focus its resources on combatting this outbreak and provide the best possible care to Medicaid beneficiaries in their state. 

“Florida is acutely focused on eliminating unnecessary barriers on our health care providers who are on the front lines serving our communities most impacted by COVID-19,” said Florida Governor Ron DeSantis.  “President Trump recognizes this need and Administrator Seema Verma is providing Florida the critical flexibility for our state’s Medicaid program by waiving prior authorization requirements for essential health care services and expedited provider enrollment.”

CMS provides guidance to states on how to apply for Section 1135 waivers through the Medicaid Disaster Response Tool Kit, which can be found here.  CMS will continue to expeditiously review and approve as appropriate all Section 1135 waivers and other requests that the agency receives to ensure that we are providing our state partners with the maximum flexibility they need to care for their Medicaid beneficiaries during the public health emergency. To support these efforts, CMS is developing checklists and tools to expedite requests and approvals for waivers and other commonly requested flexibilities.

While Florida is the first state to apply for this waiver authority, CMS expects more states will also submit similar requests.  Additional Section 1135 approval letters will be posted here as they are issued.

This action, and earlier CMS actions in response to the COVID-19 virus, are part of the ongoing White House Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19 click here www.coronavirus.gov.  For information specific to CMS, please visit the Current Emergencies Website.

First Case of 2019 Novel Coronavirus in the United States

he New England Journal of Medicine has rapidly published a peer-reviewed paper on the Snohomish County WA ‘Patient 1’. This was the first reported case of COVID 19 in the US. This seminal document, which given the magnitude of the case and its initial findings is released in full here

The work by Michelle L. Holshue, M.P.H., Chas DeBolt, M.P.H., Scott Lindquist, M.D., Kathy H. Lofy, et al for the Washington State 2019-nCoV Case Investigation Team was turned round in just over 5 weeks and below is an ‘Executive summary’ ( as extracted from the paper) but the full paper and range of results should be read in full.

Patient Presentation

On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever. On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after traveling to visit family in Wuhan, China. The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronavirus outbreak in China and, because of his symptoms and recent travel, decided to see a health care provider.

On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to have dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.

Viral Presence

Both upper respiratory specimens obtained on illness day 7 remained positive for 2019-nCoV, including persistent high levels in a nasopharyngeal swab specimen (Ct values, 23 to 24).

Stool obtained on illness day 7 was also positive for 2019-nCoV (Ct values, 36 to 38).

Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus

Day 8: Condition Improves

On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.

History Taking

This case report highlights the importance of clinicians eliciting a recent history of travel or exposure to sick contacts in any patient presenting for medical care with acute illness symptoms, in order to ensure appropriate identification and prompt isolation of patients who may be at risk for 2019-nCoV infection and to help reduce further transmission. Finally, this report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis, and duration of viral shedding associated with 2019-nCoV infection to inform clinical management and public health decision making.

Conclusion

There is little doubt that this paper is about to become a globally sited document as we continue to deal with COVID 19. As far as EMS and our first response to it goes, the paper reinforces the key actions currently being taken

Governor Whitmer Signs Executive Order Temporarily Closing Bars, Theaters, Casinos, and Other Public Spaces; Limiting Restaurants to Delivery and Carry-Out Orders

Today, Governor Gretchen Whitmer signed Executive Order 2020-9, which temporarily closes theaters, bars, and casinos, and limits restaurants to carry-out and delivery orders.   

Under Executive Order 2020-9, effective Monday, March 16 at 3:00pm, the following places of public accommodation will be closed; restaurants, cafes, coffee houses, bars, taverns, brewpubs, distilleries, clubs, movie theaters, indoor and outdoor performance venues, gymnasiums, fitness centers, recreation centers, indoor sports facilities, indoor exercise facilities, exercise studios, spas, and casinos.    

This order does not restrict a place of business from offering food and beverage using delivery service, window service, walk-up service, drive-through service, or drive-up service. Places of public accommodation are encouraged to do so and use precautions to mitigate potential transmission of COVID-19, including social distancing. Restaurants may allow five people inside at a time to pick up orders, so long as they stay six feet apart from each other.  

These restrictions do not apply to the following locations: office buildings, grocery stores, markets, food pantries, pharmacies, drug stores, and providers of medical equipment and supplies, health care facilities, residential care facilities, congregate care facilities, and juvenile justice facilities, warehouse and distribution centers, and industrial and manufacturing facilities.    

Order restrictions will remain in place until Monday, March 30 at 11:59 pm.     

“This disease is a challenge unlike any we’ve experienced in our lifetimes,” said Governor Whitmer. “Fighting it will cause significant but temporary changes to our daily lives. By practicing social distancing and taking aggressive action now, the state is working to mitigate the spread of coronavirus so we reduce the risk that our health care system becomes overwhelmed. This is about saving lives. Michiganders are tough and we are going to get through this, but it will require everyone doing their part. That means making smart choices and not putting yourself or others at risk by going out in public unless it is absolutely necessary.”  

“We need to move quickly to slow the spread of the virus and protect public health,” said Dr. Joneigh Khaldun. “I realize these actions will present temporary changes to the way we live, but they are critical to help ensure our health care system is prepared to treat those who need the most urgent medical care.”  

“This crisis will require business and labor working together to ensure that we are putting the best interests of Michiganders first in order to protect public health,” said Jeff Donofrio, Director of the Department of Labor and Economic Opportunity. “We understand that these decisions will impact the way we do business, but the decisions we make now will allow us to get our economy back on track sooner rather than later. We are putting measures in place to help protect the employers, employees, and individuals that will be impacted.”  

To mitigate the spread of COVID-19, Governors across the United States have begun implementing similar measures in their states, including Jay Inslee (D-WA), Charlie Baker (R-MA), and Tom Wolf (D-PA).  

Patients with confirmed infection have reportedly had mild to severe respiratory illness with symptoms of:  

  • Fever   
  • Cough   
  • Shortness of breath     

The best prevention for viruses, such as influenza, the common cold or COVID-19 is to:  

  • If you think you have been exposed to COVID-19, call your health care provider. If you do not have a health care provider, call the nearest hospital.   
  • Wash your hands often with soap and warm water for 20 seconds. If not available, use hand sanitizer.     
  • Avoid touching your eyes, nose, or mouth with unwashed hands.     
  • Cover your mouth and nose with a tissue or upper sleeve when coughing or sneezing.     
  • Avoid contact with people who are sick.     
  • If you are sick, stay home, and avoid contact with others.   
  • Replace handshakes with elbow bumps.   
  • Stay at least 6 feet away from others when in a public setting.     

Information around this outbreak is changing rapidly. The latest information is available at Michigan.gov/Coronavirus and CDC.gov/Coronavirus.   

President Signs Law Providing Funds to Combat COVID-19

President Donald Trump signed H.R. H.R. 6074 into law, approving $8.3 billion in supplemental appropriations to fund programs in response to the COVID-19 illness. The bill would bolster vaccine development, research, equipment stockpiles, and state and local health budgets as government officials and health workers fight to contain the outbreak, which has claimed 11 lives in the U.S. and sickened more than 160 people across more than a dozen states.

The American Ambulance Associatoin advocated to negotiators of the bill that first responders needed to be included in the funding package and that all communities be eligible for the funding. Due in part to our outreach, the emergency funding provides a transfer of no less than $10 million to the National Institute of Environmental Health Sciences for worker-based training aimed at preventing exposure of the virus to emergency first responders, and others at risk of exposure (i.e., hospital employees).

The supplemental also appropriates $1 billion for state and local preparedness, which will allow state and local governments to carry out preparedness and response activities, with each State receiving a minimum of $4 million. Of the $1 billion, $300 million is allocated for global disease detection and emergency response, and FY 2019 Public Health Emergency Preparedness grantees.