SHM Sends Letter to the Administration and Congressional Leaders Regarding COVID-19 Policy Changes

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The Honorable Nancy Pelosi
Speaker of the House of Representatives
U.S. Capitol Building, H-222
Washington, DC 20515

The Honorable Kevin McCarthy
House Republican Leader
U.S. Capitol Building, H-204
Washington, DC 20515

The Honorable Mitch McConnell
Senate Majority Leader
U.S. Capitol Building, H-230
Washington, DC 20510

The Honorable Charles Schumer
Senate Democratic Leader
U.S. Capitol Building, S-221
Washington, DC 20510

Dear Speaker Pelosi, Leader McConnell, Leader McCarthy, Leader Schumer,

The Society of Hospital Medicine (SHM), which represents the nation’s hospitalists, is writing to urge additional action to aid in the fight against the novel COVID-19 pandemic.

Hospitalists are clinicians whose professional focus is the care of hospitalized patients and are one of the specialties of frontline providers during the COVID-19 pandemic. They are and will be the primary attending physicians directly responsible for the large majority of hospitalized COVID-19 patients.

Hospitalists continue to provide the best care possible under these difficult circumstances. However, COVID-19 has exposed critical vulnerabilities in our healthcare system—chiefly, shortages of crucial medical and protective equipment, as well as difficulties in mobilizing hospitalist and intensivist physicians to meet demand. These are challenges that are now limiting the ability to respond to COVID-19 and are creating tremendous professional and financial hardships for hospitals and hospitalist practices. We propose a continued aggressive response that will meet the clinical and financial challenges posed by COVID-19.

We recognize and appreciate the important steps taken by the Administration and by Congress, most recently with passage of the CARES Act, to address many pressing needs in the healthcare system. However, as this is an evolving situation, we recommend continued policy action to ensure hospitalists are able to adequately and safely care for their patients throughout the duration of this pandemic.

Increase the Supply and Production of Personal Protective Equipment (PPE) and Ventilators

Hospitalists are on the frontlines of patient care and are working tirelessly to care for as many patients as possible. Their safety is of paramount importance. Hospitalists around the country report acute shortages of critical PPE, including N95 masks. Clinicians are being told to reuse single use face masks for an entire shift, while others are being told to forego or ration the use of PPE whenever possible. Additionally, hospitalists are reporting shortages of ventilators, which will be needed to care for critically-ill patients. As the equipment scarcity continues to grow, clinicians and the patients they treat will be at increasingly greater risk.

To effectively combat this pandemic, providers must have access to PPE to reduce the likelihood of contracting the virus themselves. As PPE supplies in the Strategic National Stockpile or from other sources are distributed, we must ensure frontline clinicians have first priority in receiving this equipment. We appreciate that the CARES Act included additional funding for the Strategic National Stockpile, but more must be done. We urge policymakers to continue to do everything in their power to dramatically increase production of PPE, ventilators, and other crucial medical supplies. Additionally, the Federal Government must make efforts to control distribution of these supplies to ensure the hardest hit communities get access to PPE and ventilators they desperately need.

As COVID-19 continues to spread throughout the country, continued shortages of critical equipment will limit our ability as a nation to combat this virus.

Increase Access to Testing Supplies and Improve Efficiency of Testing Equipment

To slow the spread of COVID-19, we need to dramatically increase access to COVID-19 testing. Widespread reliable and rapid testing will enable those who are infected, and those have been in contact with the infected, to self-isolate, limiting further spread of the virus. Until there is widespread and consistent access to reliable COVID-19 testing, the only tool we have to combat this pandemic is extreme social distancing. It is clear that there is considerable variability in how local and state governments are enforcing this, increasing the urgency of making testing available broadly. We should be achieving testing levels per-capita of other nations that have been able to control the spread of this deadly disease.

Ensure Provider Availability

Prior to the outbreak of COVID-19, the United States was already facing a physician shortage. Immigrant physicians are crucial in providing quality care throughout the United States, particularly in rural and underserved communities. However, visa restrictions are limiting the ability to effectively utilize and deploy these physicians in communities with the greatest need. For example, physicians on an H-1B visa are only allowed to work in hospitals listed on their visa. Therefore, these physicians, many of whom are young and trained in the United States, are unable to provide care in nearby hospitals where other physicians may be quarantined due to exposure to COVID-19. We have recently heard calls from New York and California for physicians from out of state to help them care for patients, and there will certainly be more areas of great need looking for help. In light of the declaration of national emergency, we recommend allowing clinicians on H-1B visas to work in hospitals that have not sponsored their visas.

To further increase physician capacity, we recommend the following policy changes to H1-B visas:

1. Allow electronic filings for H-1B’s for physicians. Currently, all H-1B filings are full physical copies, which typically consist of hundreds of pages. Electronic filing will speed up the application process.
2. Allow premium processing for physicians. Premium processing forces the government to adjudicate an H-1B within 15 calendar days. However, the government just suspended premium processing for all petitions. Premium processing will ensure rapid approval for these much-needed clinicians.
3. Institute an immediate and automatic 6-month (or yearlong) extension for all physician and health care workers on an H-1B visa. An automatic 6-month extension will alleviate the worry that immigrant physicians will lose their work authorization while in the midst of this pandemic.
4. Limit Requests for Evidence (“RFE”) for physicians. The RFE rate for H-1B’s has skyrocketed (increasing from under 20% to over 65%) under the current administration. Limiting RFE’s during this pandemic will allow the U.S. Citizenship and Immigration Services (USCIS) to adjudicate H-1B petitions more quickly. This will ensure the United States can expand its workforce rapidly.

The J-1 visa is another tool that can enable the United States to quickly increase its clinician workforce. We recommend enacting the following policy changes:

1. Adjudicate J-1 waivers more quickly. It currently takes approximately 8 months from the time physicians file a waiver until the time a J-1 recipient can actually begin working.
2. Increase available J-1 waiver slots. The J-1 waiver slots are currently capped at 30 per state and virtually every state fills up right away.
3. Relax restrictions related to primary and secondary work sites. J-1 waiver physicians must work 160 hours at their primary facility. This makes it nearly impossible to empower hospital systems to shift these providers to hospitals and areas with the greatest need.
4. Relax requirements about the types of physicians (primary care vs. specialists) that can apply for a J-1 visa. Some states do not let specialists apply for a J-1 waiver, while other states limit the amount of the 30 available J-1 waivers to non-primary care physicians. This limits hospitalists that are employed by large groups to apply for J-1 waivers, as they are sometimes classified as specialists.

Further, the United States currently has more than 10,000 US-trained international medical graduates who are caught in a green card backlog and are thus unable to assist outside their worksite during the COVID-19 public health emergency. If each of these physicians could work only one extra day in locations where the need is greatest, the United States would have an extra 10,000 physician-days available. Not only are these physicians prevented from helping at a greater level, they are putting themselves and their families at risk by doing so. Should any of them contract the COVID-19 and be out of work or sadly, pass away as a result of contracting the virus while caring for patients, they and their families could be forced to return to their home country.

We ask that you act now to give these doctors permanent resident status (green cards). This would boost the flexibility of the healthcare workforce, and give these providers and their families peace of mind while putting themselves at risk in caring for our nation’s populace.

Mitigating Financial Hardship for Providers through Appropriate Reimbursement Rates

In an effort to reduce the transmission of COVID-19, numerous hospitals and practices have suspended or canceled elective procedures and surgeries. Furthermore, many practices have shifted all of their normal appointments to telemedicine appointments. These decisions are necessary to slow the spread of COVID-19. However, hospitals and physician practices rely on these appointments and surgeries to stay financially solvent. While the Centers for Medicare and Medicaid Services (CMS) has instituted welcome flexibility and some level of payment parity for certain telehealth services, to mitigate financial hardship, we recommend continued reimbursement of telemedicine services provided in a hospital or skilled nursing facility (SNF) at the same rate as in-person visits.

The CARES Act temporarily ended the mandatory Medicare sequestration until the end of the calendar year and instituted a 20% add-on hospital payment for Medicare discharges of patients with COVID-19. We note that hospitalists are paid under the Medicare Physician Fee Schedule (PFS) and predominantly bill inpatient and hospital outpatient Evaluation & Management (E&M) codes, which have historically been undervalued by as much as 35%. Hospitals typically employ hospitalists or contract with other physician groups, and in general, hospitals essentially subsidize each physician (above their reimbursement for E&M codes) approximately 35% or more of a typical hospitalist’s compensation.

Nationally, demand for hospitalists and Advanced Practice Providers has risen dramatically in the pandemic, both because of additional patient loads in some locations, but also because of physicians being exposed and subsequently quarantined, effectively removing them from the workforce. The cost incurred to staff hospitals with physicians to care for patients has skyrocketed, for all of these reasons.

Therefore, we ask that PFS E&M rates for hospitalizations be increased to ensure financially sustainable practices for hospitalists who are putting themselves at risk by providing frontline care during this pandemic.

Reduce administrative burdens

We also encourage policymakers to further reduce administrative burdens to ensure providers are adequately paid for the services they provide while spending as much time as possible on direct patient care. We recommend that CMS be urged, if not required, to look at relaxing documentation requirements for certain kinds of billing to ensure that adequate information is captured but that providers are not spending undue amounts of time meeting documentation requirements. For example, the required physical exam portion for billing E&M codes should be eliminated to allow hospitals to use a “single examiner” approach in which one physician examines a COVID-19 patient per day, even though more than one physician may participate in the care of the patient on that same day. This directly reduces PPE utilization and decreases exposure risks for clinicians. Another approach would be to expand the relaxed outpatient E&M billing documentation standards to facility-based E&M codes.

Conclusion

We thank you for your leadership and continued support during this unprecedented point in American history. Congress and the Administration has already taken significant steps to help end this crisis and we recommend taking additional action to help further improve our nation’s ability to combat this pandemic and provide quality care across the United States.

If you have any questions or would like additional information, please reach out to Josh Boswell, Director of Government Relations, at jboswell@hospitalmedicine.org or at 267-702-2632.

Sincerely,

Christopher Frost, MD, SFHM
President
Society of Hospital Medicine

CC:

 

Chairman Frank Pallone, Jr, Committee on Energy and Commerce
Ranking Member Greg Walden, Committee on Energy and Commerce
Chairman Jerrold Nadler, Committee on the Judiciary
Ranking Member Doug Collins, Committee on the Judiciary
Chairman Richard E. Neal, Committee on Ways and Means
Ranking Member Kevin Brady, Committee on Ways and Means
Chairman Chuck Grassley, Committee on Finance
Ranking Member Ron Wyden, Committee on Finance
Chairman Lamar Alexander, Committee on Health, Education, Labor, and Pensions
Ranking Member Patty Murray, Committee on Health, Education, Labor, and Pensions
Chairman Lindsey Graham, Committee on the Judiciary
Ranking Member Dianne Feinstein, Committee on the Judiciary