CMS: Revised Repayment Terms for Medicare Accelerated Payments

On October 8, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a Fact Sheet setting forth the repayment terms for advances made under the Medicare Accelerated and Advance Payments Program (AAPP).  These changes were mandated by the passage of the Continuing Appropriations Act, 2021 and Other Extensions Act, which was enacted on October 1, 2020.

Background

On March 28, 2020, CMS expanded the existing Accelerated and Advance Payments Program to provide relief to Medicare providers and suppliers that were experiencing cash flow disruptions as a result of the COVID-19 pandemic, and associated economic lockdowns.  Under the AAPP, Medicare providers and suppliers were eligible to receive an advance of up to three months of their historic Medicare payments.  These advances are structured as “loans,” and are required to be repaid through the offset of future Medicare payments.

CMS began accepting applications for Medicare advances in mid-March 2020, before ending the program in late April following the passage of the CARES Act.  CMS ultimately approved more than 45,000 applications for advances totaling approximately $100 billion, before it suspended the program in late April 2020.

Under the pre-existing terms of the AAPP, repayment through offset was required to commence on the 121st day following the provider or supplier’s receipt of the advance funds.  The program also called for a 100% offset until all advanced funds had been repaid.

Revised Payment Terms

Under the revised payment terms announced by CMS, providers and suppliers will not be subject to recoupment of their Medicare payments for a period of one year from the date they received their AAPP payment.  Starting on the date that is one year from their receipt of the AAPP payment, repayment will be made out of the provider’s or supplier’s future Medicare payments.  The schedule for such repayments will be as follows:

  • 25% of the provider’s or supplier’s Medicare payments will be offset against the outstanding AAPP balance for the next eleven (5) months; and
  • 50% of the provider’s or supplier’s Medicare payments will be offset against the outstanding AAPP balance for the next six (6) months

To the extent there remains an outstanding AAPP balance after that 17 month period (i.e., 29 months after the date the provider or supplier received its AAPP payment, the provider or supplier will receive a letter setting forth their remaining balance.  The provider or supplier will have 30 days from the date of that letter to repay the AAPP balance in full.  To the extent the AAPP balance is not repaid in full within that 30-day period, interest will begin to accrue on the unpaid balance at a rate of 4%, starting from the date of the letter.

Medicare providers and suppliers are also permitted to repay their accelerated or advance payments at any time by contacting their Medicare Administrative Contractor.

 

EMS.gov | Public Comment for EMS Controlled Substances Rule

From EMS.gov

Public Comment Period for Proposed Rule on EMS and Controlled Substances

As part of the Protecting Patient Access to Emergency Medications Act of 2017, which was passed 3 years ago, the DEA was required to establish regulations associated with the use of controlled substances by EMS agencies. The DEA has now published in the Federal Register proposed rules to implement the law. Comments on the proposed rules can be submitted electronically or by mail on or before December 4, 2020. Individuals, agencies and organizations may submit comments.

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CMS Updates Medicare COVID-19 Snapshot

From CMS on October 2, 2020

Today, the Centers for Medicare & Medicaid Services (CMS) released our monthly update of data that provides a snapshot of the impact of COVID-19 on the Medicare population. The updated data show over 1 million COVID-19 cases among the Medicare population and over 284,000 COVID-19 hospitalizations.

Other key findings:

  • The rate of COVID-19 cases among Medicare beneficiaries grew 30% since the August release to 1,562 cases per 100,000 beneficiaries.
  • Similarly, the rate of COVID-19 hospitalizations among Medicare beneficiaries grew 32% since the August release to 444 hospitalizations per 100,000 beneficiaries.
  • The rate of COVID-19 cases and hospitalizations grew the most among rural beneficiaries, Hispanic beneficiaries, and Medicare-only beneficiaries (those who are not dually eligible for Medicaid).
  • Medicare Fee-for-Service (Original Medicare) spending associated with COVID-19 hospitalizations grew to $4.4 billion or just under $25,000 per hospitalization.
  • Data on discharge status and length of stay for COVID-19 hospitalizations remained similar to previously reported figures in the August release. 31% of beneficiaries went home at the end of their hospital stay and 22% died. Nearly half of the hospitalizations lasted 7 days or less while 5% lasted more than 31 days.

The updated data on COVID-19 cases and hospitalizations among Medicare beneficiaries covers the period from January 1 to August 15, 2020. It is based on Medicare Fee-for-Service claims and Medicare Advantage encounter data CMS received by September 11, 2020.

JEMS | How Empress EMS (NY) Responded to COVID-19 in the Pandemic’s Epicenter

From JEMS on October 2, 2020 | By Hanan Cohen

The onset of the COVID-19 pandemic created extraordinary new challenges for the emergency medical services (EMS) industry. Frequently shifting state and federal guidance and emerging information about the novel virus has required EMS agencies to be even more nimble in delivering care.

This is true for Empress EMS, a PatientCare EMS Solutions company, which serves New Rochelle, New York – the first epicenter of America’s COVID-19 pandemic. Empress first began monitoring for COVID-19 on February 15, 2020, as it recognized the New York City area’s high risk for the virus.

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CMS: COVID Testing and Screening Guidance for SNF and Long-Term Care Facilities

On August 25, 2020, the Centers for Medicare and Medicaid Services (CMS) published an interim final rule with a comment period titled “Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments of 1988 (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.”  The interim final rule sets forth a number of new requirements designed to limit the COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes.

Specifically, the interim final rule requires skilled nursing and other long-term care facilities to test residents and staff for COVID-19.  The frequency of such testing is based on the positivity rate in which the facility is located, and can require COVID-19 testing as frequently as twice per week.  Regardless of the frequency of required COVID-19 tests, facilities must also screen all staff, residents, and persons entering the facility for the signs and symptoms of COVID-19.

These requirements extend to individuals that provide services to nursing homes under arrangements, including health care personnel rendering care to residents within the facility.  In subsequent guidance, CMS clarified that these testing and screening requirements apply to EMS personnel and other health care providers that render care to residents within the facility.  However, in that same guidance, CMS indicated that EMS personnel must be permitted to enter the facility provided that: (1) they are not subject to a work exclusion as a result of to an exposure to COVID-19 or (2) showing signs or symptoms of COVID-19 after being screened.”  CMS further indicated that “EMS personnel do not need to be screened so they can attend to an emergency without delay.”

In plain terms, CMS has created an affirmative obligation on nursing homes to ensure that any individual that provides services under a contractual arrangement with the nursing home comply with these testing and screening requirements.  CMS has expressly waived the screening requirements for EMS personnel responding to medical emergencies at a nursing home.  However, CMS has not specifically addressed the testing and screening requirements applicable to EMS personnel responding to nursing homes in non-emergency situations. 

The A.A.A. is aware that a handful of State Health Agencies have issued their own guidance on this issue.  The A.A.A. is also aware that individual nursing homes have started to require proof that EMS personnel have been tested for COVID-19 prior to allowing these individuals to enter the nursing home in a non-emergency situation.

EMS agencies may already be subject to state and local testing mandates.  EMS agencies may also have their own internal policies that require employees to be periodically tested for COVID-19.  As a result, there exists the potential for conflict where these existing testing policies conflict with the testing requirements of your local nursing homes.

The A.A.A. has been engaged in an ongoing conversation with CMS on these issues since the issuance of the interim final rule in August.  As part of that conversation, the A.A.A. pushed for the exclusion of EMS personnel from the screening requirement when responding to medical emergencies, which was included in the recent CMS guidance document.  The A.A.A. also continues to push for additional funding for COVID-19 testing for EMS agencies.  CMS has recognized that the frequent testing of health care workers is essential to reducing the spread of the novel coronavirus.  CMS has allocated funding for these purposes to other industries, including hospitals and nursing homes.  As front-line health care workers, EMS agencies should have similar access to testing funds.  The A.A.A. will continue to push for funding equity for the EMS industry.

In the interim, we strongly encourage our members to work with their state associations and other stakeholders to advocate for reasonable rules related to testing on the state and local levels.  To the extent the applicable state or local agency has determined the appropriate frequency for the testing of EMS personnel responding to medical emergencies, those rules should also apply to EMS personnel responding to scheduled transports and other non-emergencies that start or end at a nursing home.  Requiring more frequent testing in these situations would impose an undue burden on EMS agencies that provide these services.  More frequent testing may also prove counterproductive, as it may discourage EMS agencies that cannot meet these higher requirements from responding in these situations.  We also encourage our members to continue to push for state and local funding for the testing of their employees.

 

Update – SNF COVID-19 Testing Does Not Apply to EMS

CMS Clarify in Guidance that EMS Personnel Are Not Required To Be Tested under Skilled Nursing Facility Testing Interim Final Rule

The Centers for Medicare & Medicaid Services (CMS) have issued guidance clarifying the types of personnel who are subject to the testing requirements when entering a Skilled Nursing Facility (SNF) in the Interim Final Rule with Comment (IFC) on Additional Policy and Regulatory Revisions in Response to the COVID– 19 Public Health Emergency.  The new guidance memo states:

 

Entry of Health Care Workers and Other Providers of Services

Health care workers who are not employees of the facility but provide direct care to the facility’s residents, such as hospice workers, Emergency Medical Services (EMS) personnel, dialysis technicians, laboratory technicians, radiology technicians, social workers, clergy etc., must be permitted to come into the facility as long as they are not subject to a work exclusion due to an exposure to COVID-19 or show signs or symptoms of COVID-19 after being screened. We note that EMS personnel do not need to be screened so they can attend to an emergency without delay. We remind facilities that all staff, including individuals providing services under arrangement as well as volunteers, should adhere to the core principles of COVID-19 infection prevention and must comply with COVID-19 testing requirements.

 

CMS issued this guidance at the request of the American Ambulance Association (AAA) to address concerns our members had raised about some SNFs misinterpreting the requirements.  The guidance is also consistent with AAA’s interpretation of the IFC.   As we indicated in an earlier Member Advisory, the IFC requires SNFs to test certain individuals for COVID-19 before they enter the facility.  Specifically, it applies to employees, consultants, and contractors of a skilled nursing facility (SNF).  It does not apply to vendors, suppliers, attending physicians, family, or visitors. Providers, such as medical directors and hospice, that are under a contract or consultants to a SNF are subject to the rule.  EMS personnel do not come within the scope of the IFC.

 

Even though the testing requirements of the IFC do not extend to ground ambulance services that do not have a contractual relationship with a SNF, the AAA supports the efforts of all of our members to follow the World Health Organization and Centers for Disease Control and Prevention Guidelines to have EMT and paramedics use full Personal Protective Equipment (PPE) when they are engaging with any patient, not only those in SNFs.  We also want to recognize the best practices of many members who have worked with SNFs to establish outdoor locations where the SNF personnel, when possible, can bring a patient out of the building to transfer the patient to the ambulance.  These and other examples of safe practices can help control the spread of COVID-19, which is the paramount concern.

CMS | Independent Nursing Home COVID-19 Commission Findings Validate Unprecedented Federal Response

From the Centers for Medicare and Medicaid Services

Today, the Centers for Medicare & Medicaid Services (CMS) received the final report from the independent Coronavirus Commission for Safety and Quality in Nursing Homes (Commission), which was facilitated by MITRE.  CMS also released an overview of the robust public health actions the agency has taken to date to combat the spread of the coronavirus disease 2019 (COVID-19) in nursing homes. The Commission’s findings align with the actions the Trump Administration and CMS have taken to contain the spread of the virus and to safeguard nursing home residents from the ongoing threat of the COVID-19 pandemic. Today’s announcement delivers on the Administration’s commitments to keeping nursing home residents safe and to transparency for the American people in the face of this unprecedented pandemic.

The Trump Administration’s effort to protect the uniquely vulnerable residents of nursing homes from COVID-19 is nothing short of unprecedented,” said CMS Administrator Seema Verma. “In tasking a contractor to convene this independent Commission comprised of a broad range of experts and stakeholders, President Trump sought to refine our approach still further as we continue to battle the virus in the months to come. Its findings represent both an invaluable action plan for the future and a resounding vindication of our overall approach to date. We are grateful for the Commission’s important contribution.”

As the capstone to the Commission’s extensive report, tomorrow, Administrator Verma will join Vice President Mike Pence and the Centers for Disease Control and Prevention (CDC) Director Dr. Robert R. Redfield, some members of the Commission, and other public health and elder care experts at the White House. The Vice President, Dr. Redfield and Administrator Verma will lead the group in a discussion regarding the Commission’s findings and general issues facing the nation’s elder care system.

Nursing homes and other shared or congregate living facilities have been severely affected by COVID-19, as these facilities often house older individuals who suffer from multiple medical conditions, making them particularly susceptible to complications from the virus. To help CMS inform immediate and future actions as well as identify opportunities for improvement, the   Commission was created to conduct an independent review and comprehensive assessments of confronting COVID-19. The Commission’s report contains best practices that emphasize and reinforce CMS strategies and initiatives to ensure nursing home residents are protected from COVID-19.

As outlined in the overview released today, the Trump Administration has already taken significant steps to implement many of the Commission’s findings. The Administration has worked to support nursing homes financially during this challenging time, distributing over $21 billion to America’s nursing homes – more than $1.5 million each on average. To ensure nursing homes had access to supplies, the Trump Administration shipped a 14-day supply of personal protective equipment (PPE) to more than 15,000 nursing homes across the Nation in May.

The Administration has also required facilities to report data about COVID-19 cases, deaths, and supply levels, with 99.3 percent of facilities currently reporting. CMS took action to keep COVID-19 out of nursing homes by requiring them to test staff, a requirement that was paired with the Administration’s distribution of 13,850 point-of-care testing devices to America’s nursing homes. The Administration has also deployed federal Task Force Strike Teams in six waves, in 18 states so far, to 61 facilities particularly affected by COVID-19 to share best practices and gain a deeper understanding of how the virus spreads. CMS also required states to conduct focused infection control inspections at their nursing homes; between June and July, states completed these inspections at 99.8 percent of Medicare and Medicaid certified nursing homes.

Additionally, since March, CMS has conducted weekly calls with nursing homes, issued over 22 guidance documents and established a National Nursing Home COVID-19 Training program focused on infection control and best practices.  CMS is also using COVID-19 data to target support to the highest risk nursing homes. In May, CMS released a new toolkit developed to aid nursing homes, Governors, states, departments of health, and other agencies who provide oversight and assistance to nursing homes.  The toolkit is a catalogue of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19. CMS updates the toolkit on a biweekly basis.

To view the full independent Coronavirus Commission for Safety and Quality in Nursing Homes report, visit here:  cms.gov/files/document/covid-final-nh-commission-report.pdf

To view the Trump Administration Response to Commission findings, visit here: cms.gov/files/document/covid-independent-nursing-home-covid-19-federal-response.pdf

To view the COVID-19 Guidance and Updates for Nursing Homes during COVID-19, visit here: cms.gov/files/document/covid-guidance-and-updates-nursing-homes-during-covid-19.pdf

The full list of CMS Public Health Actions for Nursing Homes on COVID-19 to date is in the chart below.

CMS Public Health Action for Nursing Homes on COVID-19 as of September 16, 2020

February 6, 2020

CMS took action to prepare the nation’s healthcare facilities for the COVID-19 threat.

March 4, 2020

CMS issued new guidance related to the screening of entrants into nursing homes.

March 10, 2020

CMS issued guidance related to the use of PPE.

March 13, 2020

CMS issued guidance on the restriction of nonessential medical staff and all visitors except in certain limited situations.

March 23, 2020

CMS announced a suspension of routine inspections, and an exclusive focus on immediate jeopardy situations and infection control inspections.

March 30, 2020

CMS announced that hospitals, laboratories, and other entities can perform tests for COVID-19 on people at home and in other community-based settings outside of the hospital – including nursing homes.

April 2, 2020

CMS issued a call to action for nursing homes and state and local governments reinforcing infection control responsibilities and urging leaders to work closely with nursing homes on access to testing and PPE.

April 15, 2020

CMS announced the agency will nearly double payment for certain lab tests that use high-throughput technologies to rapidly diagnose large numbers of COVID-19 cases.

April 19, 2020

CMS announced it will require nursing homes to report cases of COVID-19 to all residents and their families, as well as directly to the CDC. On May 1, CMS published the proposed policy in an Interim Final Rule. The rule became effective on May 8.

April 30, 2020

CMS announced the formation of an independent commission by a contractor that will conduct a comprehensive assessment of the nursing home response to COVID-19.

May 6, 2020

CMS released a memorandum to State Survey Agency directors providing more details on the new reporting requirements of the May 8, 2020, Interim Final Rule.

May 13, 2020

CMS published a new informational toolkit comprising recommendations and best practices from a variety of front line health care providers, governors’ COVID-19 task forces, associations and other organizations and experts that is intended to serve as a catalogue of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19. Toolkit is found here: Toolkit

May 18, 2020

CMS issued guidance for state and local officials on the reopening of nursing homes.

June 1, 2020

CMS issued guidance to states on COVID-19 survey activities, CARES Act funding, enhanced enforcement for infection control deficiencies, and quality improvement activities in nursing homes. CMS also issued a letter to Governors.

June 4, 2020

CMS posted the first set of underlying COVID-19 nursing home data and results from targeted inspections conducted by the agency since March 4, 2020, linked on Nursing Home Compare.

June 19, 2020

CMS announced membership of Independent Coronavirus Commission on Safety and Quality in nursing homes

June 23, 2020

CMS released FAQs on nursing home visitation.

June 25, 2020

CMS released a memo announcing the end of the emergency blanket waiver for the nursing home staffing data submission requirement.

July 10, 2020

CMS announced it will deploy Quality Improvement Organizations (QIOs) across the country to provide immediate assistance to nursing homes in hotspot areas.

July 14, 2020

HHS and CMS announced an initiative for rapid point-of-care diagnostic devices and tests in nursing homes.

July 22, 2020

CMS announced several new initiatives designed to protect nursing home residents from COVID-19, including new funding, enhanced testing and additional technical assistance and support.

August 7, 2020

HHS announced the distribution of $5 billion in Provider Relief Funds, consistent with the Administration’s announcement in late July, which will be used to protect residents of nursing homes and long-term care facilities from the impact of COVID-19.

August 14, 2020

CMS released nursing home enforcement actions during pandemic.

August 24, 2020

CMS issues informational bulletin on Medicaid Reimbursement Strategies to Prevent Spread of COVID-19 in Nursing Facilities

August 25, 2020

CMS announced an unprecedented national nursing home training program for frontline nursing home staff and nursing home management.

August 25, 2020

CMS strengthens COVID-19 Surveillance with New Reporting and Testing Requirements for Nursing Homes, Other Providers. On Aug. 26, CMS posted guidance for the new requirements.

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Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter CMS Administrator @SeemaCMS and @CMSgov

ET3 Model Moves Forward Starting January 1, 2021

The Centers for Medicare & Medicaid Services (CMS) has announced that the first performance period for the Emergency Triage, Treat, and Transport (ET3) Model will begin on January 1, 2021. As we reported previously, CMS delayed the start of ET3 Model, consistent with its delaying or pausing other payment models, because of the COVID-19 public health emergency (PHE).

To start this effort, CMS has indicated that it will post a revised Participation Agreement (PA) to the ET3 Model Portal by mid-October 2020. Participants must upload signed PAs to the ET3 Model Portal by December 15, 2020. CMS will also post an Implementation Plan Template (IPT). Participants must submit their IPT CMS by November 15, 2020 to allow CMS to review and accept the IPT prior to beginning their participation in the Model.

CMS plans to provide additional guidance, including:  an Orientation Overview fact sheet, Billing and Payment fact sheets, Model Participation During the PHE fact sheet, a Who’s Who fact sheet, and an ET3 Model Portal User Guide. These documents will be available to participants through the ET3 Model Portal during the next several weeks.

The re-engagement on the ET3 Model prior to the end of the PHE is something that the American Ambulance Association (AAA) has supported in discussions with CMS. While it does not address some of the gaps in reimbursement and treatment that our members are seeing nationwide, for those who are participating in the model, it will be an enormous benefit.

The AAA also continues to work with CMS to identify new models that will allow other ground ambulance providers and suppliers to participate in innovative models, even though there were not able to meet the ET3 participation requirements.

Trump Administration Releases COVID-19 Vaccine Distribution Strategy

FOR IMMEDIATE RELEASE
September 16, 2020

Contact: HHS Press Office
202-690-6343
media@hhs.gov

Trump Administration Releases COVID-19 Vaccine Distribution Strategy

The U.S. Department of Health and Human Services (HHS) and Department of Defense (DoD) today released two documents outlining the Trump Administration’s detailed strategy to deliver safe and effective COVID-19 vaccine doses to the American people as quickly and reliably as possible.

The documents, developed by HHS in coordination with DoD and the Centers for Disease Control and Prevention (CDC), provide a strategic distribution overview along with an interim playbook for state, tribal, territorial, and local public health programs and their partners on how to plan and operationalize a vaccination response to COVID-19 within their respective jurisdictions.

“As part of Operation Warp Speed, we have been laying the groundwork for months to distribute and administer a safe and effective COVID-19 vaccine as soon as it meets FDA’s gold standard,” said HHS Secretary Alex Azar. “This in-depth, round-the-clock planning work with our state and local partners and trusted community organizations, especially through CDC, will ensure that Americans can receive a safe and effective vaccine in record time.”

The strategic overview lays out four tasks necessary for the COVID-19 vaccine program:

  • Engage with state, tribal, territorial, and local partners, other stakeholders, and the public to communicate public health information around the vaccine and promote vaccine confidence and uptake.
  • Distribute vaccines immediately upon granting of Emergency Use Authorization/ Biologics License Application, using a transparently developed, phased allocation methodology and CDC has made vaccine recommendations.
  • Ensure safe administration of the vaccine and availability of administration supplies.
  • Monitor necessary data from the vaccination program through an information technology (IT) system capable of supporting and tracking distribution, administration, and other necessary data.

On August 14, CDC executed an existing contract option with McKesson Corporation to support vaccine distribution. The company also distributed the H1N1 vaccine during the H1N1 pandemic in 2009-2010. The current contract with McKesson, awarded as part of a competitive bidding process in 2016, includes an option for the distribution of vaccines in the event of a pandemic.

“CDC is drawing on its years of planning and cooperation with state and local public health partners to ensure a safe, effective, and life-saving COVID-19 vaccine is ready to be distributed following FDA approval,” said CDC Director Robert Redfield. “Through the Advisory Committee on Immunization Practices, CDC will play a vital role in deciding, based on input from experts and stakeholders, how initial, limited vaccine doses will be allocated and distributed while reliably producing more than 100 million doses by January 2021.”

Detailed planning is ongoing to ensure rapid distribution as soon as the FDA authorizes or approves a COVID-19 vaccine and CDC makes recommendations for who should receive initial doses. Once these decisions are made, McKesson will work under CDC’s guidance, with logistical support from DoD, to ship COVID-19 vaccines to administration sites.

“The Department of Defense is using its world-class logistical expertise to plan for distributing a safe and effective vaccine at warp speed,” said General Gustave Perna. “Americans can trust that our country’s best public health and logistics experts are working together to get them vaccines safely as soon as possible.”

Download the Strategy for Distributing a COVID-19 Vaccine – PDF*

Download the COVID-19 Vaccination Program Interim Playbook – PDF

About Operation Warp Speed:

OWS is a partnership among components of the Department of Health and Human Services and the Department of Defense, engaging with private firms and other federal agencies, and coordinating among existing HHS-wide efforts to accelerate the development, manufacturing, and distribution of COVID-19 vaccines, therapeutics, and diagnostics.

About HHS & CDC:

HHS works to enhance and protect the health and well-being of all Americans, providing for effective health and human services and fostering advances in medicine, public health, and social services. To learn more about federal support for the nationwide COVID-19 response, visit coronavirus.gov.

CDC works 24/7 protecting America’s health, safety and security. Whether disease start at home or abroad, are curable or preventable, chronic or acute, or from human activity or deliberate attack, CDC responds to America’s most pressing health threats. CDC is headquartered in Atlanta and has experts located throughout the United States and the world.

About DoD:

The Department of Defense’s enduring mission is to provide combat-credible military forces needed to deter war and protect the security of our nation. The Department provides a lethal and effective Joint Force that, combined with our network of allies and partners, sustains American influence and advances shared security and prosperity.

* People using assistive technology may not be able to fully access information in this file. For assistance, please contact digital@hhs.gov.

CO | Anesthesiologists want paramedics to stop injecting people with ketamine during arrests

From the Colorado Sun

A group of Colorado anesthesiologists wants paramedics to stop injecting people with a powerful sedative when police believe suspects are out of control until officials finish a review launched nearly a year after the death of Elijah McClain, a Black man put in a stranglehold by officers and injected with ketamine.

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Study | Vitamin D reduces risk of ICU admission

From The Journal of Steroid Biochemistry and Molecular Biology

“Of 50 patients treated with calcifediol [bloodstream-form Vitamin D], one required admission to the ICU (2%), while of 26 untreated patients, 13 required admission (50%)… Of the patients treated with calcifediol, none died, and all were discharged, without complications. The 13 patients not treated with calcifediol, who were not admitted to the ICU, were discharged. Of the 13 patients admitted to the ICU, two died and the remaining 11 were discharged.”

Read the full study> Castillo, Marta Entrenas, et al. “Effect of Calcifediol Treatment and best Available Therapy versus best Available Therapy on Intensive Care Unit Admission and Mortality Among Patients Hospitalized for COVID-19: A Pilot Randomized Clinical study.” The Journal of Steroid Biochemistry and Molecular Biology (2020): 105751.

CMS Updates Medicare COVID-19 Snapshot

From CMS on September 3, 2020

Today, the Centers for Medicare & Medicaid Services (CMS) released our monthly update of data that provides a snapshot of the impact of COVID-19 on the Medicare population. The updated data show over 773,000 COVID-19 cases among the Medicare population and nearly 215,000 COVID-19 hospitalizations.

Other key findings:

  • The rate of COVID-19 cases among Medicare beneficiaries grew 40% since the July release to 1,208 cases per 100,000 beneficiaries.
  • Similarly, the rate of COVID-19 hospitalizations among Medicare beneficiaries grew 33% since the July release to 338 hospitalizations per 100,000 beneficiaries.
  • Weekly counts of COVID-19 cases and hospitalizations reached the lowest point to date in late June and began to increase in July.
  • The rate of COVID-19 cases and hospitalizations grew the most among disabled beneficiaries, Hispanic beneficiaries, and Medicare-only beneficiaries (those who are not dually eligible for Medicaid).
  • Medicare Fee-for-Service (Original Medicare) spending associated with COVID-19 hospitalizations grew to $3.5 billion or just over $25,000 per hospitalization.
  • Data on discharge status and length of stay for COVID-19 hospitalizations remained similar to previously reported figures in the July release. 29% of beneficiaries went home at the end of their hospital stay and 24% died. Nearly half of the hospitalizations lasted 7 days or less while 5% lasted more than 31 days.

The updated data on COVID-19 cases and hospitalizations among Medicare beneficiaries covers the period from January 1 to July 18, 2020. It is based on Medicare Fee-for-Service claims and Medicare Advantage encounter data CMS received by August 14, 2020.

For more information on the Medicare COVID-19 data, visit: https://www.cms.gov/research-statistics-data-systems/preliminary-medicare-covid-19-data-snapshot

For an FAQ on this data release, visit: https://www.cms.gov/files/document/medicare-covid-19-data-snapshot-faqs.pdf

NHTSA: EMS Accessing PPE

The National Highway Traffic Safety Administration has released a memo reinforcing the best methods for EMS agencies to request PPE supplies:

  • The preferred method of EMS agencies to obtain PPE is via ordering through the normal supply distribution chains from which they normally order EMS supplies and equipment. The supply chain distributors are becoming more stable in their access to PPE components. In addition, in the near future, Boundtree will have available a larger supply of N95 NIOSH Tested/Approved respirators for purchase, which EMS can tap into
    purchasing;
  • PPE push at the national level is not possible without a Resource Request from the States. Local EMS agencies should work with their local emergency management agency with requests pushed up to the state emergency management agency or for EMS PPE Resource Requests where there are still elevated (albeit decreasing or stabilizing) COVID-19 cases. Once those formal Resouce Requests are received at the federal level,
    they will be reviewed and acted upon.

Download Memo

NHTSA COVID PPE & Resource Reporting Tool

NHTSA asks EMS agencies across the U.S. to take a few minutes each week to report PPE, personnel status within their agency.

EMS and its public safety colleagues continue to serve at the frontlines in the fight against the COVID-19 pandemic. Resource procurement and distribution of personal protective equipment and staffing shortages continue to challenge EMS leaders. It is vital that local, State and Federal officials have the information they need to help address these issues.

The NHTSA Office of EMS, with support from the team at the NEMSIS Technical Assistance Center, has designed a reporting tool to allow for a consistent, real-time method of reporting PPE supply status and personnel shortages. Your participation in the EMS COVID Resource Reporting Tool provides objective evidence to ensure your local agency’s resource status is understood by State and National EMS leadership, and that your resource needs are being prioritized.

While this information will be available to State and Federal Officials, this reporting tool does not supersede coordination with local and state emergency management, public health, or healthcare coalitions. Organizations should still follow local and state procedures for reporting information and requesting supplies or other additional resource needs.

NHTSA is asking agencies to take a few minutes each week, preferably on Monday mornings, to complete the online form. You can find the form, as well as a video and other information explaining how the information is used and how to complete the form, here.

For questions regarding this process, please contact nemsis@hsc.utah.edu.

EMS COVID Resource Reporting Tool

NYT | FDA Allows Expanded Use of Plasma to Treat Coronavirus Patients

From the New York Times

F.D.A. Allows Expanded Use of Plasma to Treat Coronavirus Patients

The Food and Drug Administration on Sunday gave emergency approval for expanded use of antibody-rich blood plasma to help hospitalized coronavirus patients, allowing President Trump, who has been pressuring the agency to move faster to address the pandemic, to claim progress on the eve of the Republican convention.

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Interim Guidance: COVID-19 and Field Trauma Triage Principles.

The Federal Healthcare Resilience Task Force has released interim guidance on COVID-19 and Field Trauma Triage Principles. This document provides a brief overview of how the Coronavirus Disease 2019 (COVID-19) impacts trauma triage for first responders, including Emergency Medical Service (EMS), fire & rescue, and law enforcement. The contents of this guidance document do not have the force and effect of law and are not meant to bind the public in any way. This guidance document is intended only to provide clarity to the public regarding existing requirements under the law or agency policies.

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CMS Updates Cost Data Collection FAQs and Data Collection Instrument

The Centers for Medicare & Medicaid Services (CMS) has released printable version of the ground ambulance data collection instrument and an expanded FAQ. Both updated documents address some of the more common questions that CMS has heard over the past months, many of which the American Ambulance Association raised.  Importantly, CMS announces through the FAQs the registration process will begin December 2021.

The topics covered in the FAQs include:

  • General questions related to the rationale for collecting data, definitions, and how the information will be used and reported;
  • Sampling and notification questions related to how ground ambulance organizations will be selected to participate in the data collection system;
  • Data collection and reporting timelines and effort questions, which focus on the timelines for collecting and reporting the information, as well as the projected effort required;
    • There are three new FAQs in this section about the impact of the delay due to the pandemic (the questions and answers are below)
  • Requirement to report questions, which focus on the types of information that must be reported and responding to requests from MACs;
    • There is a new FAQ in this section about applying for a hardship exemption (the questions and answers is below)
  • Reporting information questions, which include who within an organization should report the information, the data tool, and how to address technical problems;
    • There are two new FAQ in this section about the pause in data collection due to the pandemic (the questions and answers are below)
    • Importantly, CMS announces that the registration will begin December 2021
  • Data collection scope and principles questions, which discuss the specific type of information and level of specificity that is required;
    • There are several new FAQs in this section about using current accounting practices, municipality practices, and accounting good and services provided by another organization (the questions and answers are below)
  • Reporting information on staffing and labor costs questions, which address issues such as volunteer staff, staff with multiple duties, calculating hours worked;
    • There are three new FAQs in this section about total hours worked, staff training, and paid time off (the questions and answers are below)
  • Reporting other information, such as service area, service mix/service volume, facilities, vehicles, equipment/supplies, and revenue.


New FAQs

 Question: Will the modification listed in the COVID-19 Emergency Declaration Blanket Waiver issued by CMS on May 15, 2020 allow ground ambulance organizations selected in year 1 the option to continue with their current data collection period that started in early 2020 or choose to select a new data collection period starting in 2021? [Added 7/31/2020]

    • Answer: No. The ground ambulance organizations that were selected in year 1 do not have an option and must select a new data collection period starting in 2021. CMS cannot permit this option because the data collected in 2020 during the public health emergency may not be reflective of typical costs and revenue associated with providing ground ambulance services.
  • Question: When will sampled organizations report information? [Updated 7/31/2020]
    • Answer: Sampled organizations will report information within a 5-month reporting period that starts at the end of the organization’s collection period. For example, if your organization begins collecting information on January 1, 2021, your organization’s collection period will run until December 31, 2021 and your organization must report information during the 5- month period between January 1, 2022 and May 31, 2022.
  • Question: How are data collection and reporting dates adjusted for organizations selected in Year 1 given the modification listed in the CMS COVID-19 Emergency Declaration Blanket Waiver? [Added 7/31/2020]
    • Answer: CMS issued a COVID-19 Emergency Declaration Blanket Waiver delaying data collection and reporting requirements for ground ambulance organizations selected in Year 1 by one year. The organizations selected in Year 1 will now collect data during a continuous 12-month period starting in 2021 (rather than 2020) and will now report information during a 5-month period starting in 2022 (rather than 2021). As an example, a Year 1 organization that previously would have collected information from January 1, 2020 to December 31, 2020 and reported information between January 1, 2021 to May 31, 2021 will now collect information from January 1, 2021 to December 31, 2021 and report information between January 1, 2022 and May 31, 2022. Organizations in the Year 1 sample will not report any information collected to date in 2020.
  • Question: Can you provide examples of different data collection periods and the data reporting periods depending on my accounting period start date? [Updated 7/31/2020]
    • Answer: Example of a Data Collection and Reporting Period for a Ground Ambulance Organization with a Calendar Year Accounting Period:

Examples of Data Collection and Reporting Periods for a Ground Ambulance Organization with Accounting Period not based on a Calendar Year:

  • Question: Can my organization request a hardship exemption from the payment reduction? [Updated 7/31/2020]
    • Answer: Yes. Organizations that did not report sufficient data due to a significant hardship, such as a natural disaster, bankruptcy, or other similar situations may request a hardship exemption. To request a hardship exemption after the ground ambulance organization receives notification that it will be subject to the 10 percent payment reduction as a result of not sufficiently submitting information under the data collection system, organizations should complete a request form that will be available at the end of the data reporting period on CMS’s Ambulances Services Center website at https://www.cms.gov/Center/Provider- Type/Ambulances-Services-Center.html. Organizations can request a hardship exemption within 90 calendar days of the date that CMS notified the organization that it would receive a 10 percent payment reduction as a result of not submitting sufficient information under the data collection system. Your organization will be asked to supply information such as reason for requesting a hardship exemption, evidence of the hardship (e.g., photographs, newspaper, other media articles, financial data, bankruptcy filing, etc.), and date when your organization would be able to begin reporting information. All hardship exemption requests will be evaluated based on the information submitted that clearly shows that they are unable to submit the required data.
  • Question: Where and how does my organization report information? [Updated 7/31/2020]
    • Answer: No information will be reported until 2022. As we stated in the CY 2020 Physician Fee Schedule Final Rule (84 FR 62867), a secure web-based data collection system will be available before the start of your data reporting period to allow time for users to register, receive their secure login information, and receive training from CMS on how to use the system. CMS will provide separate instructions on how to access the online Ground Ambulance Data Collection System. You can view a printable version of the ground ambulance data collection instrument at: https://www.cms.gov/Center/Provider- Type/Ambulances-Services-Center for the data collection requirements.
  • Question: My organization was selected in the first group to collect and report cost and other required data. When will we be able to register for the data collection system? [Updated 7/31/2020]
    • Answer: Registration for the system will begin in December 2021. Please check the Medicare Ambulance Services Center website at https://www.cms.gov/Center/Provider- Type/Ambulances-Services-Center.html for updates.
  • Question: Can my organization collect information using our current accounting practices? [Added 7/31/2020]
    • Answer: In general, you will be able to report information collected under your organization’s current accounting practices. CMS understands that some ground ambulance organizations use accrual-basis accounting while others use cash-basis accounting. Please follow the instructions in each instrument section.
  • Question: My ground ambulance organization is owned and/or operated by our local municipality. The municipality pays directly for some costs associated with our ground ambulance operations (e.g., facilities costs, utilities, fuel, benefits, etc.). Do we need to report on these costs? [Updated 7/31/2020]
    • Answer: Yes. You must work with your municipality to report the costs that are relevant to your ground ambulance service. Otherwise, the costs that you report will be incomplete and not reflect your organization’s total costs. This would also apply if your ground ambulance organization is part of a broader organization that pays directly for some of your organization’s costs (e.g., a hospital Medicare provider that also owns and provides ground ambulance services). The specific information that you will need to collect and report might include information on labor costs (Section 7); facilities costs (Section 8); Vehicle costs (Section 9); equipment, consumable, and supply costs (Section 10), and other costs (Section 11). If you are a fire, police, or other public safety-based ground ambulance organization, please report labor hours and compensation associated with both ground ambulance and other public safety roles per the data collection instrument instructions.
  • Question: How should we account for goods or services provided by another organization (e.g., hospital, local government)? [Added 7/31/2020]
    • Answer: Whether and how to account for costs realized by an entity other than your ground ambulance organization depends on the nature of the relationship with the other entity. CMS has heard that it is relatively common for some costs – for example dispatch, vehicle maintenance, or administrative costs – to be borne by an organization’s local municipality or a part of a local municipal government (such as a police department):
    • If your ground ambulance organization is part of or associated with a local municipality, you need to report these costs. For example, if dispatch services are provided by your municipality’s police department and your ground ambulance organization is part of or associated with the same municipality, then you must collect and report a share of dispatch costs associated with ground ambulance operations. See the related question “My ground ambulance organization is owned and/or operated by our local municipality. The municipality pays directly for some costs associated with our ground ambulance operations (e.g., facilities costs, utilities, ambulance fuel, benefits, etc.). Do we need to report on these costs?”
    • If your ground ambulance organization is NOT part of (i.e., owned or operated by) a local municipality, you do NOT need to report costs associated with services provided by your local municipality other than costs (if any) paid directly by your organizations for the service. If your municipality provides dispatch services for your community and your organization does not pay for this service, then no costs related to dispatch are reported. See the related question “My organization received donations during the data collection period (e.g., an ambulance donated by the community, medicines or medical consumables provided by hospitals, or cash donations). How should these donations be reported?” If your organization makes a payment in exchange for a service, report the payment as a cost under the appropriate section of the data collection instrument.

The same principles apply to similar cases, for example when the other entity is a hospital, non-profit organization, or other type of entity.

  • Question: Should hours on call be included in total hours worked? [Added 7/31/2020]
    • Answer: When reporting hours worked, whether for paid or volunteer staff, do not include hours on call toward hours worked.
  • Question: How should we report staff training in the data collection instrument? [Added 7/31/2020]
    • Answer: There are two ways that you can report training. If training is conducted by your organization’s staff, you would include hours worked and compensation for training staff in your calculations of total hours worked and total compensation. Employees would report hours spent and compensation (if any) for attending trainings. If the training is not just on ground ambulance topics, the reported total hours and compensation would reflect an estimate the percent of time related to ground ambulance. If you have other training expenses or pay money to an outside organization for training activities, these can be listed in Section 11, Question 3 under the category “Training and continuing education costs (e.g., costs for materials, travel, training fees, and labor).” Costs related to collecting and reporting data to the Medicare Ground Ambulance Data Collection System should not be reported.
  • Question: How should we report paid time off (PTO) in the data collection instrument? [Added 7/31/2020]
    • Answer: Paid time off (PTO) is not included in the hours worked section in the labor portion of the data collection instrument. However, PTO is a benefit that should be included in the total compensation questions of the labor section.
  • Service Area: Question: How should our organization define the primary and secondary service area for our particular circumstances? [Updated 7/31/2020]
    • Answer: For the purposes of this data collection effort, use your best judgement. In general, your primary service area is the area in which you are exclusively or primarily responsible for providing service at one or more levels and where it is highly likely that the majority of your transport pickups occur. A secondary service area is outside your primary service area, but one where you regularly provide services through mutual or auto-aid arrangements or at a different level of service compared to your primary service area. When reporting service areas using ZIP codes, it is possible that you will report the same ZIP code as belonging to both your primary and secondary service area, for example in a case where a town and a township share a ZIP code and your organization is primarily responsible for service within the town but has mutual or auto aid agreements with the surrounding township. Please list all ZIP codes in your service area, even if they cross over into another county or municipality. For the service volume section of the instrument, responses, transports, etc. to both primary and secondary service areas should be included in the totals reported.
  • Service Mix/Service Volume: Question: How should my organization count ground ambulance responses and/or transports if more than one vehicle is sent to the scene or if more than one patient is transported? [Added 7/31/2020]
    • Answer: If more than one vehicle is sent to the scene, count this as one response. Organizations should count the total number of patients transported. A single response may result in multiple transports in cases where multiple ambulances are deployed or when multiple patients are transported by the same ambulance.
  • Question: How should our organization report on situations where we respond to calls for service in conjunction with staff from another organization? [Added 7/31/2020]
    • Answer: In Section 5, Question 3, you can report that your organization responds to calls for service in conjunction with vehicles and/or staff from another organization. You must report payments that you make to the other organization (as “other costs” in Section 11) and payments received by your organization (as revenue in Section 13). You will not need to report specific labor or other costs from the other organization. Report the total revenue that your organization receives from payers and other sources, even if you later share the revenue with the other organization.
  • Facilities: Question: My organization does not record buildings as assets or calculate depreciation for buildings. Do we need to report depreciation for buildings? [Added 7/31/2020]
    • Answer: No.
  • Vehicles: Question: How should we calculate annual depreciation expenses for vehicles and capitalized equipment? [Updated 7/31/2020]
    • Answer: In general, you will be able to use your organization’s standard approach to calculating depreciation expenses. If your organization calculates depreciation expense for multiple purposes (e.g. depreciation for tax incentive purposes vs. Generally Accepted Accounting Principles (GAAP) for standard auditing purposes), please report the depreciation expense captured for standard auditing purposes. There are several presentations, such as the December 5, 2019 National Provider Call, that provide examples of reporting annual depreciation expenses in Section 8 (Facilities Costs), Section 9 (Vehicle Costs), and Section 10 (Equipment, Consumable, and Supply Costs) of the data collection instrument. These presentations are available on the Ambulances Services Center website at https://www.cms.gov/Center/Provider-Type/Ambulances-Services-Center.html.
  • Equipment: Question: My organization uses a cash basis for accounting and does not depreciate equipment or supplies. Do we need to start calculating annual depreciation? [Added 7/31/2020]
    • Answer: No. If your department is a cash basis entity and doesn’t calculate depreciation, you do not have to report depreciation. Please report the entire purchase costs in the relevant sections.
  • Revenue: Question: How is revenue defined for the purposes of collecting and reporting data? [Added 7/31/2020]
    • Answer: Report gross/total revenue received from all sources during the data collection period. You may need to collect information from a billing company or your municipality in order to report this information. Do not report charges, billed amounts, or bad debt. Depending on your organization’s accounting practices, CMS understands that the revenue received during the data collection period may not perfectly align with the services provided during the data collection period.
  • Question: My organization is unable to separate revenue from payers related to transports and non-transport services. How should we report revenue for non-transport services? [Added 7/31/2020]
    • Answer: If possible, report only revenue from transports in Section 13, Questions 2-4. Report revenue from non-transport EMS and ground ambulance services in Section 13, Question 5.
  • Question: My organization shares revenue from billed service with another organization. Should we report the revenue we receive from payers or the share we retain? [Added 7/31/2020]
    • Answer: Report the revenue that you initially receive from payers. Do not subtract the amount that you share with another organization. Report the amount you do share in Section 11 (“Other Costs”) as a cost.

RHIhub | Rural Surge Toolkit

Developed by the Rural Health Information Hub: This toolkit provides rural communities with the information, resources, and materials they need to develop a community health program in a rural community.

Each of the toolkit’s six modules contains information that communities can apply to develop a rural health program, regardless of the specific health topic the program addresses. The toolkit also links to issue-specific toolkits for more in-depth information.

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Income Disparities In Access To Critical Care Services

From Health Affairs

Income Disparities In Access To Critical Care Services

Genevieve P. Kanter, Andrea G. Segal, and Peter W. Groeneveld

ABSTRACT
The coronavirus disease 2019 (COVID-19) pandemic has highlighted the importance of intensive care unit (ICU) beds in preventing death from the severe respiratory illness associated with COVID-19. However, the availability of ICU beds is highly variable across the US, and health care resources are generally more plentiful in wealthier communities. We examined disparities in community ICU beds by US communities’ median household income. We found a large gap in access by income: 49 percent of the lowest-income communities had no ICU beds in their communities, whereas only 3 percent of the highest-income communities had no ICU beds. Income disparities in the availability of community ICU beds were more acute in rural areas than in urban areas. Policies that facilitate hospital coordination are urgently needed to address shortages in ICU hospital bed supply to mitigate the effects of the COVID-19 pandemic on mortality rates in low-income communities.

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