Over the past few decades, the world has endured a number of disease outbreaks including SARS in 2003 and N1H1 in 2009. Now once again our ability to contain a pandemic is being put to the test, but this time the problem with Coronavirus Disease 2019 (COVID-19) has brought the world into a much more difficult situation as it impacts not only public health affair but also threatens to cripple the economy to a dire extent.
As of April 1, 2020 the virus has spread to 203 countries with 754,948 confirmed cases of infection including 36,571 confirmed deaths, according to WHO. During the early phase of the pandemic, public officials may encourage non-essential workers to stay home; as the outbreak seems to only get worse by the day, many countries actually implement lockdown policiesunder which most people are ordered to stay home – with few exceptions such as healthcare professionals, and those engaged in essential businesses. While the exact implementation differs from country to country, the policies generally require restrictions of public transportation, cancellation of large events or public gatherings, and schools shut down.
In the United States, a total lockdown – as suggested by some experts – is not entirely impossible but that does not mean the policy is the most feasible at the moment for several reasons.
There are more than 52 million Americans aged 65 or older; at least 1.2 million among them require nursing home care. Based on what we know so far about COVID-19, this particular demographic is at high risk for severe illness from the disease. People who live in long-term care facility or nursing home as well as those with underlying medical condition are equally prone to getting infected. In fact 8 out of 10 deaths reported in the U.S. have been in adults aged 65 and older.
The combination of those factors put Home Health Agencies (HHAs) in a rather tricky circumstance. Home health care workers provide important services to some of the most frail and dependent clients. Allowing these workers to stay home to prevent an escalation of confirmed cases of infection(or death) would be ideal for them, but at the same time as caregivers they should not neglect their clients in need of basic personal care and medical assistance such as feeding, grooming, administering medicines, and physical therapies. Let us not forget that in the midst of COVID-19 pandemic, there will be additional homebound patients beyond the workers’ usual caseload including clients who prefer staying at home to visiting primary care physicians’ offices because the government urges people to practice social distancing measure.
And then there is the problem with home health aides’ place in the larger scheme of health care system in the country as a whole. HHAs all across the nation employ more than 820,000 people; although these workers undoubtedly provide individualized healthcare services to elderlies and people with disabilities (in addition to personal care), they are not necessarily considered healthcare professionals. Just because they do not work in hospital settings, it does not mean they are less important than nurses or physicians’ assistants employed inactual healthcare facilities.
In the midst of Coronavirus outbreak, CMS (Centers for Medicare & Medicaid Services) apparently recommends HHAs to remain active and vigilant by monitoring patients for any symptoms of the virus and communicating with patients including family members and other caregivers, so that the agency can better understand individual patient’s needs and effective treatment methods.
With a mean hourly wage of just under $12, according to U.S. Bureau Labor of Statistics, home health aides are at the moment standing right on a treacherous spot in the front line yet also somewhat invisible. They are vulnerable low-wage workers who provide caregiving services to equally vulnerable clients: elderly and people with disabilities and underlying medical conditions.
CMS has also published a new guidance specifically for HHAs amid the virus outbreak. The guidance addresses many things. Although it does not contains anything new, there is one problematic (and contradictory) section:
How should HHAs monitor or restrict home visits for health care staff?
· Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report to work.
· Any staff that develop signs and symptoms of a respiratory infection while on-the-job, should:
o Immediately stop work, put on a facemask, and self-isolate at home;
o Inform the HHA clinical manager of information on individuals, equipment, and locations the person came in contact with; and
o Contact and follow the local health department recommendations for next steps (e.g., testing, locations for treatment).
· Refer to the CDC guidance for exposures that might warrant restricting asymptomatic healthcare personnel from reporting to work
Full-time home health aides work for low-wage, which means they may not be able to afford to leave work and self-isolate for a prolonged period. They do have paid sick leave, but since the pandemic is currently nowhere near containment, home health aides can easily blow through their sick leave and find it hard to pay their bills. Considering they work and almost in direct contact with high-risk demography, chances of getting infected is not slim by any measure.
In terms business impacts, the situation for HHAs is not any easier either. On one side, HHAs may take new clients who have been brought by the family from assisted-living facilities, so they can stay home in more isolated environment to reduce chances of getting infected. Then the families hire home health aides to provide the necessary medical and personal care. On the flip side, a surge of new clients translates to heavier workload, which may reduce duration per visit; if just a few of home health aides are on paid sick leave, the remaining workers are easily overwhelmed by the number of patients to attend to.
There is good news. Just last week, the House of Representative passed a record-breaking $2 trillion stimulus package to help companies and individuals during the pandemic, and it is good to see that some provisions aim at HHAs. Hours before the House vote, President Trump signed it into law.
Specifically for healthcare providers, the bill – now known as the CARES (Coronavirus Aid, Relief and Economic Security) Act is helpful in several different ways:
· It encourages the use of telehealth in home health care services
· The bill suspends the 2 percent Medicare sequestration, so in practice the reimbursement is higher
· There is a $100 billion health care fund to be used as recovery fund for COVID-19 cost
· Higher reimbursement for providers who take care of COVID-19 patients
CARES Act gives broader authority to the Secretary of U.S. Department of Health and Human Services to waive restriction on who may provide telehealth services under Medicare coverage. There are only two problems: (1) it does not provide reimbursement for the equipment required for telehealth services and (2) while HHS Secretary now has the authority to expand types of providers that can provide Medicare-covered telehealth services, the bill does not specifically state that such action on the Secretary’s part is mandatory.