On January 9, 2020, the World Health Organization announced that an unknown coronavirus-related pneumonia had been discovered in Wuhan, China. The CDC reported the first U.S. case on January 21, 2020. As of March 27, 2021, approximately 30 million Americans have tested positive for the virus, resulting in 550,000 U.S. deaths. On a positive note, there have been more than 140 million vaccines administered in the U.S. (asamonitor.pub/3g3pECx). The last year has profoundly impacted the lives of individuals all over the world – particularly health care workers. The pandemic highlighted both strengths and weaknesses in the American health care system. There is no doubt that the emergency approval of both the Pzifer and Moderna vaccines in December 2020, as well as the Johnson & Johnson vaccine in March 2021, have and will continue to change the course of the pandemic. However, we still have a ways to go. Many of the health care issues that came to light during this time will continue to present problems in the future. Both federal and state governments have created temporary solutions for some issues and permanent legislation for others. A key aspect of shaping new legislation is advocacy. Below, we highlighted some of the main issues facing medicine and the legislation that has been created to address them. Both H.R. 748, the Coronavirus Aid, Relief and Economic Security (CARES) Act, and H.R. 1319, the American Rescue Plan Act of 2021, include provisions for health care.
Financial assistance for practices
The pandemic hit medical practices hard. Fear, along with stay-at-home orders, decreased office visits. Elective procedures were canceled or delayed. While practice costs increased due to PPE and other increased infection control needs, revenues dropped sharply. Even late into the summer, physicians' revenues were down compared with before the pandemic (asamonitor.pub/3dTqoHZ). Early financial assistance for small businesses helped, but financial issues still linger.
The CARES Act added $100 billion to the “Public Health and Social Services Fund,” which reimburses “eligible health care providers for health care related expenses or lost revenues” secondary to COVID 19. It also funds $349 billion into the Small Business Loan Program or the “Paycheck Protection Program” (PPP) (asamonitor.pub/3fXa4bM). The PPP helps small businesses suffering from the pandemic. The PPP has been helpful for many small medical and dental practices. The recently passed H.R. 1319 funds additional money to the PPP and the Provider Relief Fund.
In addition to small business financial assistance, the CARES act established a series of new policies that temporarily boost Medicare and Medicaid reimbursement (asamonitor.pub/3fXa4bM; asamonitor.pub/3tnhzwg). However, where H.R. 1319 helped physicians with small business assistance, unfortunately the bill also “triggered automatic federal budget reductions including a 4% decrease in Medicare payments. This cut is on top of the already 2% reductions in Medicare payments from a previous budget sequester.” Fortunately, the House recently passed a bill that delays both pay cuts through the end of the year. Unfortunately, the Senate only agreed to delay the 2% reduction, but not the 4% reduction at this time (asamonitor.pub/3gfCe1Z; asamonitor.pub/3fZdpqM). By the time that this article prints, hopefully we will have positive developments regarding this issue.
Increased awareness of need for PPE, ICU equipment and drug shortages
The pandemic quickly highlighted that the country did not have adequate stores of PPE. Masks that had always been a “one time use” prior to the pandemic were used for an entire day or even longer. In addition, there were critical drug shortages, particularly those used for sedation in ICUs, inhalers, and hydroxychloroquine and chloroquine.
The CARES Act increased the requirements for reporting drug shortages to the FDA, shortages of essential medical equipment and life-saving or life-sustaining devices to HHS, and enhanced and strengthened the strategic national stockpile (asamonitor.pub/3tnhzwg). H.R. 1319 directs an additional $10 billion to the Defense Production Act to boost production of PPE and rapid COVID-19 tests (asamonitor.pub/3fZdpqM).
“CMS greatly expanded coverage for Medicare telehealth services for 2021. Some of the expansion is permanent, and some of it will expire when the PHE expires.”
Coronavirus testing and vaccines
Early in the pandemic, there was a critical shortage of COVID-19 testing and turnaround time for results. Widespread and rapid testing has improved; however, there are many stories of people paying hundreds of dollars out of pocket to get a test. In short, the CARES Act required health insurances to provide all FDA-approved or authorized testing without cost sharing or prior authorization to the individual. The Biden Administration continued this policy in its bill. Despite both bills, however, this does not guarantee the patient will not get a charge. There are several caveats to this provision (asamonitor.pub/3tnhzwg).
To go from sequencing a novel virus to developing a vaccine to treat it within one year is nothing short of a medical miracle. The CARES Act required health insurance plans to pay for vaccines. H.R. 1319 broadens the undertaking and invests heavily in state and local health departments to manage all aspects of COVID (vaccines, testing, and tracing), in addition to investments in the CDC and the FDA (asamonitor.pub/3fZdpqM).
Immunity from frivolous lawsuits during pandemic
The CARES Act granted liability protection from medical malpractice lawsuits to volunteer health care workers who provide care within their scope of practice for COVID-19 treatment during the public health emergency (PHE) (asamonitor.pub/3mF1lwj). But these provisions only extend through the PHE and only include volunteers. Unfortunately, provider protections were not included in H.R. 1319. There is bipartisan support for provider protections under the Coronavirus Provider Protection Act, but the bill remains in committee (asamonitor.pub/3fZdpqM).
Some states are looking at provider protections. For instance, Texas has introduced a bill in the current session, H.B. 3747, that creates liability protections for all health care providers or institutions (asamonitor.pub/3mFDnAX).
Telemedicine and broadband internet expansion
Reliable, high-speed internet has been critically important during the pandemic. The expansion of telemedicine during the pandemic has been a lifeline for many physician practices and patients. CMS greatly expanded coverage for Medicare telehealth services for 2021. Some of the expansion is permanent, and some of it will expire when the PHE expires.
The pandemic highlighted the need for basic internet access for all. Many states are looking at options to expand broadband access to rural areas. In Texas, the house and senate have filed identical legislation this session (H.B. 1146 and S.B. 506) that would establish a comprehensive state plan for internet coverage.
Investment in the public health force
President Biden's plan invests heavily in the public health workforce, the National Health Service Corps, GME teaching centers, Medical Reserve Corps, Indian Health Service, and the VA. It also provides money for community mental health and substance use disorder treatment (asamonitor.pub/3fZdpqM).
Disparities in health care for minorities and challenged socioeconomic groups
COVID has disproportionately affected minorities. Multiple studies have shown higher rates of infection, hospitalization and death among Black, Hispanic, Asian and American Indian minorities. The causes are multifactorial; however, it highlights the longstanding problem of disparities in our health care system.
H.R. 1319 addresses health care disparities by increasing funding to the nation's public health system, the ACA, unemployment benefits, sick and paid family leave, extending SNAP benefits, mental health and substance use disorders, and expanding Medicaid. Increasing funding to the public health infrastructure was one of the primary goals of this legislation (asamonitor.pub/2Qhu3ap).
The quest for mid-level provider independent practice has been an issue for years. The pandemic's unprecedented health care crisis left some areas of the country with provider shortages. This became a platform for advanced practitioner registered nurses (APRN) to push independent practice. Pre-pandemic there were approximately 24 states that allowed APRNs full practice authority and approximately 16 states that allowed limited independent practice. During the pandemic, CMS issued waivers to allow NPs to practice at their fullest extent. In addition, approximately 23 states passed executive orders suspending supervision requirements during the PHE (asamonitor.pub/3mEPBcZ). Supporters argued that the broadened scope of practice should remain intact after the pandemic to allow more access to care, particularly in underserved areas. Independent practice resolutions have passed in Florida and California since the start of the pandemic. Oftentimes these independent practice bills include CRNAs. On April 21, 2020, the VA granted CRNAs independent practice authority (asamonitor.pub/3tdrcxx).
In 2018, the American Association of Nurse Anesthetists (AANA) approved the descriptor “nurse anesthesiologist.” Since then, there have been battles in several states by the nursing associations to authorize the term. Health care organizations worldwide, including the Council on Accreditation of Nurse Anesthesia Educational Programs, define anesthesiology as the practice of medicine by a physician who has completed a medical residency in anesthesiology (asamonitor.pub/3tfyz7O). ASA is working to strengthen state laws that limit the use of the title “anesthesiologist” to individuals who are licensed to practice medicine (MD, DO). This battle was recently won in New Hampshire (asamonitor.pub/3mEWRWm).
2020 and 2021 have had a profound impact on medicine. A year ago, most of us would have never imagined that wearing a mask would become a political statement. As discussed above, there are many issues that physician anesthesiologists will need to advocate both for and against to protect our patients and speciality. As physicians, we owe it to ourselves and the patients we serve to advocate for continued patient safety, as well as affordable and accessible health care. ASA, state societies, and your advocacy remain paramount in preventing ambiguity in care and promoting our profession. Become involved! Find your state component at asahq.org/about-asa/component-societies
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