In New York City, emergency hospital beds are multiplying — inside tents set up in Central Park, on a hospital ship docked on Manhattan's West Side and in the Javits Convention Center, which now houses about 1,000 beds.
To give the rest of the country similar flexibility in addressing the wave of COVID-19 patients expected to need hospital care soon, the federal government is relaxing a lot of what are usually thought of as safety requirements, says Seema Verma, administrator of the Centers for Medicare and Medicaid Services, and a senior member of the White House Coronavirus Task Force. Hospitals can now operate inside dorms, for example, as well as gyms, schools, and parking lots.
Right now, Verma tells All Things Considered Host Mary Louise Kelly, thousands of civil servants at CMS are moving heaven and earth to make it easier for hospitals to care for patients during the coronavirus crisis. The agency has a huge reach — it runs Medicare, with 60 million enrollees, overseeing provider payments and plans. It also works in partnership with states to administer Medicaid, with 74 million enrollees, and oversees many nursing homes, managing inspections and quality ratings of the facilities.
On Tuesday, Verma spoke with Kelly about how the Trump administration thinks "relaxing safety rules" and easing licensing restrictions might help patients, and why widespread testing continues to be such a problem. The interview has been edited for length and clarity.
These tents we've all watched being pitched in Central Park. Can you give us a concrete example or two of what you envision this actually looking like in other American cities?
Sure. FEMA is doing an incredible job setting up these temporary hospitals in New York and other parts of the country. But we want to empower local communities to also be able to take action and to tap into their local resources. So, for example, hospitals don't need to be thinking about only providing services within their four walls. You know, right now there are surgery centers that are out there — about 5,000 of them across the country. And those surgery centers are not performing elective surgeries. So they have some capacity there, they have medical equipment.
And that could be a place where hospitals say, 'We're going to direct all of our cancer patients there. We're going to perform infusion therapy there.' And so they're allowed to go beyond their four walls. That allows us to also treat patients that may not have just [coronavirus] — there are people out there that need medical care, whether it's cancer treatment or some other type of care. It allows facilities to create separation, so you can put infected patients in one place and coronavirus in another — it allows them that flexibility to triage patients. They could even do that outside of the emergency room — in the parking lot — and figure out where people need to go.
This is still up to states — they can decide what they want to do — but your goal is to kick the door open and make this easier for them?
That's exactly it. We are getting rid of lots of different regulations. One is this concept of hospital without walls. So a hospital that may be located close to a college university — a lot of the universities have gone virtual, so the dorms are empty. And they could say, 'We're going to provide services in these dorms' and they can already start working on that to prepare for the surge. And that way, the hospital can focus on the most complex patients. The other thing that we're doing for hospitals is giving them more flexibility to boost their workforce. There are a lot of rules and regulations in terms of credentialing, and we're relaxing those a little bit. They still have to defer to their state law, but the federal government's not getting in the way of that.
This is things like relaxing supervision of residents and nurse practitioners and others?
Exactly. And then letting some of those paraprofessionals — whether it's physician assistants or nurse anesthetists — to allow them to operate at the top of their license. So, for example, a nurse anesthetist. They can perform or assist in a surgery — putting somebody under — and they don't necessarily need to be supervised by an anesthesiologist. They can do that and their license would allow them, but there [are] sometimes federal barriers that don't allow them to do that. And that becomes really important, because you can imagine when you're worried about the workforce, you may want to have your anesthesiologist in the ICU and have the nurse anesthetist in a different location, maybe performing a lower-level surgery. So it just allows us to really maximize the entire workforce, to make sure that they can deal with the surge in patients.
This is all on an emergency basis — temporary basis? These rule changes will be rolled back once the coronavirus crisis becomes less acute?
That's exactly it. This is under the president's emergency declaration, an emergency rulemaking, so we will be bringing some of these flexibilities back. One of the other things that we're doing is that we have something called the STARK law. It's a very weedy policy issue, but that law essentially doesn't allow hospitals to give incentives to their workforce. Now, we're going to waive that so that they can help their workforce — they can provide meals and childcare and laundry services to basically support their health care workers on the front lines. So we're waiving those rules as well.
Those rules were in place to deter health care fraud. The safety standards were all in place for a reason, primarily to ensure patient care and quality care. How do you navigate that fine line when presumably quality care and deterring fraud remain priorities, too?
Quality is top of mind, but this is an unprecedented crisis for the health care system, and we've got to make sure that we provide enough flexibility so that they can give quality care, that they can give care. If they're in a surge capacity where they don't have beds available, that's a worse situation. So we want to empower our hospitals and our health care workers that are on the frontlines and give them the flexibility to deal with the crisis at hand.
One other change to ask you about, which is for emergency rooms. They have also been granted greater flexibility — being allowed to use telehealth services. Walk me through what that would look like if I were sick or injured and walked into my E.R.
It allows them to screen patients through telehealth, and they can also provide those services outside of the emergency room. And that's really important because we know that protective equipment is something that we're trying to be very conservative with. If you have everybody coming into the emergency room, they have to use more protective equipment. By allowing telehealth and more flexibility, they can screen people before they even come into the facility. That's safer for the patient, and it's also safer for the health care workers.
Relaxing these rules — this comes as we are now three months into what's become a global pandemic. Is the administration — and your agency included — are you playing catch up right now?
I think that we've been responsive to the health care community. Some of these waivers that we put out yesterday — we have been having conversations with different states and localities and they had actually received these waivers already. This is a rapidly changing situation, and we are trying to be as responsive as the needs arise. I think if we had done this a month ago, I think the issues around fraud and abuse would have been more paramount. I think people have a better understanding of the surge that the health care system may face, and I think these flexibilities are coming exactly at the right time.
You're saying you think hospitals and states might've pushed back more had you done this a month ago?
I think they would have been less understood. I think people would have said, 'Why are you doing this?' And now I think people understand why. And there's a lot of support. Just this morning we've received a lot of support from the ambulance community, from the cancer community, from hospitals that really appreciate the flexibility because they're understanding that they're going to need that to be able to deal with the surge. We've had daily calls with providers across the health care system — whether it's nursing homes, home health agencies, hospices — and we're having a dialogue with them, and they're telling us this is the flexibility that we're going to need to deal with this unprecedented health care crisis.
NPR is interviewing governors in state after state who are telling us they do not have the tests they need, even as the president insists the testing problems are over. Does the president not have accurate information?
I think from a high level, we are seeing testing ramping up every single day. We have completed over a million tests — I think that was announced yesterday. I think we're also seeing incredible examples of innovation from the private sector, [like] the Abbott test that [the task force] talked about yesterday, which is a point-of-care test that can go to doctors offices and people can get results in a matter of minutes.
I do have to push back, though. We had Maryland Gov. Larry Hogan on NPR this morning saying no state has enough testing. And he speaks for all of them — he's also chairman of the National Governors Association.
Fair to say, we need to do more testing, and this is changing. I think there is a lot of innovation that's going on that's going to help address those concerns that governors and other folks have raised.
Why are they still so hard to come by? Why are they not getting to states that need them?
I think there's been progress from where we started, and it continues to get better every day. That being said, we certainly recognize that there's more that needs to get done and that we need to be able to test more. I can tell you from my perspective, we have oversight of the nursing homes. Those nursing homes being impacted need to be able to test their residents, so they can isolate those patients that are sick. One of the things that we did just yesterday with our regulations is we said to labs, we will pay you to go into a person's home that's homebound — so they can't leave — or to go into a nursing home and to test all those patients. I think that those types of policies are also going to encourage and increase the amount of testing.
The president yesterday on a conference call with governors said he hasn't heard about testing in weeks, suggesting this problem is behind us. I mean, what is your understanding of what is the disconnect there, where you're hearing such different things from the White House and from the people leading states, from governors?
I think the president is acknowledging all of the private sector innovation that we've seen. You've seen that the private sector come up with different types of tests and it's happened very quickly. You're seeing the FDA removing regulatory barriers to allow for rapid approval. So I think from his perspective, testing is getting better. That being said, obviously there's more work to be done. I can tell you there's a very active force — that Dr. Giroir from HHS is leading — to increase the number of tests.
A question about testing that's specific to your agency, which is now asking hospitals around the country to report back, COVID-19 test results. But [it's only] asking hospitals — why not require them to report their test results back? And why not have done that weeks ago?
We've had great collaboration with the hospitals. What we're asking them to do is something that they haven't done before, so we put out this letter. We haven't gotten any pushback. I personally talked to all of the hospital associations and they understood the need to do this and they were supportive.
Can you put any rough number on a percentage of hospitals around the country that are reporting the results back?
You know, we have about 4,500 hospitals nationwide — that letter just went out on Saturday. Within that, there's about 9,000 labs, so a lot of the hospitals may have multiple labs.
I think we're getting a great response on that, and that's important because as we are considering the next 30 days, we need this information to understand how the virus is spreading. We also need to understand the acuity of the patients that these hospitals are serving, so how many people are in the ICU? We also want to understand the supplies that they have at hand: Where are the ventilators? How many ventilators do they have? Part of that is also getting better information on supplies — so we can target those high-need areas and make sure we can support hospitals.
Do you have any tools to help enforce that — to help ensure that hospitals comply and report the numbers back?
So far, we haven't seen a problem. If there is an issue, obviously, the administration could take steps. But I've got to tell you, our hospitals have been terrific and they've been great partners in this.
What is your sense of how much worse this [coronavirus epidemic] might get before it gets better?
It's hard to tell. What I will say is we're seeing the same type of pattern in different communities — it's not different in terms of how it spreads. That's why I think that all of the recommendations that the White House has made in terms of staying at home, hand-washing and social distancing is so important. What's hard to know is: What type of an impact are those recommendations going to have? But I think it's necessary that each and every American take those recommendations seriously.
It must be as chilling to you, as a White House Task Force member, as to any of us, to hear your colleagues on it — Dr. Birx, Dr. Fauci — give numbers like 100,000 Americans, 200,000 Americans might die.
We're trying to do everything that we can to make sure that it doesn't get to those numbers. All of the efforts that CMS is making to give more flexibility to the health care system [are being done] to make sure that they're better prepared to deal with this surge. If we know that people can get good medical care, that's also going to help us keep down those numbers. Another thing that's going to help us keep down those numbers is just preventing these infections from happening in the first place. If people take those precautions, that's going to make a big difference.
Will you be creating a special enrollment period [for HealthCare.gov] for people who need health coverage to get it, as coronavirus rips through the country?
We continue to look at that. Also, we are now looking at the CARES Act that passed and there was the $100 billion for the health care system. And so we're looking at that funding stream and looking at how that might support the needs of the uninsured.
Noah Caldwell and Christopher Intagliata produced and edited this story for radio. Selena Simmons-Duffin and Ina Jaffe contributed reporting.