POLICY BRIEFING – WEEK IN REVIEW
Antibody tests hold uncertain promise
Antibody testing as the key to reopening? Not so fast, experts say. Some have looked to tests that check for coronavirus antibodies, known as serology tests, as society's best hope, short of a vaccine, to reopen safely, potentially enabling individuals who are found to have the antibodies to go back to workplaces and resume normal life. But experts are now saying that is not realistic at this point. Dr. Jesse Ehrenfeld, immediate past chair of the Board of Trustees for the American Medical Association, argued that due the high rate of false-positive results and the unknown significance of antibody levels, serology tests should not be used as a determinant for decreased safety measures. The concerns raised by the American Medical Association were also incorporated into recent Centers for Disease Control and Prevention guidelines on serology testing. The CDC's website states that serology tests have only been designed and validated for surveillance and research and should not be used to determine past infection nor as an indication of immunity, as it is unknown how much immunity such markers indicate, or how long any immunity would last. Meanwhile, the CDC is working with federal agencies to validate commercially-produced serology tests, with results added to the FDA's Emergency Use Authorization page for serology tests as they become available. Various. 23 June 2020.
Travel restrictions put in reverse
Nearly three months ago, states and the federal government placed various travel restrictions and quarantine requirements on residents traveling in the tri-state area. At that time, New York City was a global epicenter of the pandemic. In a turn of tide, New York City seems to have gotten a grasp on the spread of the virus, while other areas in the country are now seeing record surges. If you had to guess what day of 2020 had the third highest new cases of covid-19 you might guess a day in late April, but you would be wrong. It was yesterday. It is just not new cases that are on the rise, but also covid-19-related hospitalizations. This means that the increasing numbers are not simply a result of increased testing and increased diagnoses of mild or asymptomatic cases. Intensive care units in Houston, which has one of the highest concentrations of medical systems in the country, are currently at 97% capacity. In response to these national trends, the Governors of New York, New Jersey, and Connecticut jointly announced that visitors from states meeting certain criteria would be required to self-quarantine for fourteen days upon arrival to the states. Arizona, Arkansas, Florida, South Carolina, and Texas are among states that had previously required quarantine of tri-state residents, but now themselves meet the quarantine criteria for visitors entering the northeast. Interestingly, re-opening has seemed to follow party lines, with Republican-led states were quicker to open than Democractic-led states. Of the ten states with infection rates high enough to trigger these travel advisories, eight of them are Republican-led. Previously, the fact that most cases were in states with Democratic leaders significantly affected relief legislation. It will be interesting to see if forthcoming proposals follow developing infection patterns. 25 June 2020.
Disease suppression is the next phase of recovery
. Published in the NEJM Catalyst series, physicians from the Kaiser Permanente health system in California argue for a new paradigm in combating the coronavirus. These authors present a concept that they refer to as "disease suppression." The goal of a "disease suppression" phase is to contain infections to a rate at which care provided in existing healthcare systems is sustainable and to prevent future waves, while also decreasing the need for "non-pharmacologic interventions" such as economic shutdowns. Their proposed solution is an eight-part plan, encompassing: robust testing programs; contact tracing, case finding, and isolation; community health care; care of patients in the home when possible; maintaining community-level surge capacity; targeted and safe health care reopening; ongoing research to combat covid-19; and effective communication. Until herd immunity is achieved, and if immunity is even possible, the focus must be on limiting future outbreaks. The New England Journal of Medicine Catalyst. Abbreviated from Brief19 for 25 June 2020.
Medicare and Medicaid data show covid-19's impact
On June 22, CMS renewed its call for a shift in the way hospitals are reimbursed for healthcare. The federal agency also released data that show the effects of the covid-19 pandemic on Medicare beneficiaries. The newly published data confirm that elderly and those with chronic health conditions are far more likely to suffer serious consequences from SARS-CoV-2 infection. These data also further expose glaring health outcome disparities that disproportionately affect racial and ethnic minorities and low-income populations. Nearly 175 Medicare beneficiaries per 100,000 were hospitalized due to covid-19 and an additional 343 per 100,000 were diagnosed but did not require hospitalization. Individuals dually enrolled in Medicare and Medicaid were also disproportionately likely to be infected. In fact, among dually covered patients on dialysis in the US, nearly 4% have been diagnosed with coronavirus already. Additionally, Black patients were found to have the highest rate of covid-19 infection at 1,107 cases per 100,000 people, followed by Hispanic and Asian people (692 and 455 per 100,000 respectively). White enrollees had the lowest rates, at 417 per 100,000 people. Centers for Medicare and Medicaid Services. Abbreviated from Brief19 for 24 June 2020.
Who is paying for coronavirus care?
Despite promises from the Trump administration that costs of covid-19 testing and care would be covered by insurers, some patients are finding that they are stuck holding the bill for costly services. Official guidance says that insurers must cover "medically necessary" tests. But as more people are being tested when they do not have symptoms, many insurers are beginning to balk at paying for these screening swabs. According to the America's Health Insurance Plans, a national association for health insurers, as more employers are requiring employees to test negative for the virus before returning to work, costs of covering all testing in the next year could reach nearly $45 billion. This could result in substantial costs passed on to the patients now, or in the future via insurance premium increases. Additionally, patients who have long-term complications related to coronavirus infection are finding that the care they have received may not be covered by their insurer, either. Insurers such as Cigna are including continuing care in covid-19 coverage only if complications are explicitly linked to the patient's infection. For many patients, ongoing complications may be multifactorial or may emerge several weeks or months after an initial infection, making the link hard to prove. Patients who were unable to receive coronavirus testing during the initial stages of the pandemic have an even more difficult time linking a subsequent diagnosis to an earlier covid-19 illness. The Trump administration has not issued guidance to health plans for continuing coverage following SARS-CoV-2 infection, but earlier this week did tell health insurance plans that they can drop benefits related to covid-19 with "reasonable" notice once the public health emergency expires. NPR, Politico. Abbreviated from Brief19 for 26 June 2020.