Category Archives: Practice Enhancement

Emerging Theories That May Help Us Solve the COVID-19 Puzzle

April 22, 2020

Originally published at JillCarnahan.com

UPDATED 4-18-20

There is increasing evidence that COVID-19 isn’t your typical virus. Thankfully many researchers, scientists and doctors are observing trends that are changing the way we are treating it in hospitals and at home.

I should be writing this at the beginning of all my articles in the last month but due to the fact that we are all living in real time and the information coming out is changing moment by moment even the best scientist’s theories on how to combat this illness continue to evolve. Although things could certainly change as larger studies come forth, for the moment I wanted to share with you some exciting new details that are emerging theories, which could affect future treatment development.

Current Theory and Treatment for Coronavirus

Currently COVID-19 is being treated as a dysfunction of the lower respiratory tract. It’s primary symptoms are:

Fever
Cough
Shortness of breath

Interestingly, a large number of COVID-19 patients also report a loss of taste and smell. In mild cases of COVID-19, the virus will run its course and resolve on its own. But if this disease progresses to a critical level, patients spiral into a state of severe hypoxemia – where the body is unable to effectively deliver life-sustaining oxygen to the rest of the body. Without adequate oxygen delivery, vital organs and tissues are starved of oxygen and begin shutting down – which can eventually lead to death.

The current treatments assume that coronavirus is causing a build-up of liquid (instead of air) in the alveoli – making it difficult for oxygen to transfer through the fluid and make its way into the bloodstream. To counteract oxygen deprivation caused by this build up of fluid, COVID-19 is currently being treated as a case of acute respiratory distress, also known as ARDS. The standard treatment for ARDS is mechanical ventilation – which will force air into the alveoli in hopes of transferring oxygen into the blood.

The problem is, treating COVID-19 with ventilation isn’t working like it should. In fact, some doctors have observed that the use of ventilators may even be harming some patients. So that brings up the question – what if our current understanding of COVID-19 is wrong?

Emerging ideas on the virus…

There is mounting evidence suggesting that our initial understanding of exactly how coronavirus impacts the body may be incorrect.

Consider these mysteries of COVID-19:

Patients are showing blood oxygen levels so low that they should be life-threatening, but without showing the typical signs of distress that are expected when the same levels are reached due to lung dysfunction.
Doctors are saying that ventilators aren’t working as well as they should be and may even be harming some people.
Many patients report a loss of taste and smell, typically associated with zinc deficiency, not respiratory disease.
Researchers have noted that the pathological mechanism that causes the damage to the body remains a mystery.
Twenty percent of COVID-19 patients have cardiac damage.
Fatality rates, even among places with robust testing in place, are wildly different.

These discrepancies have hinted at a new culprit as well as new possible solutions. So, should we be treating COVID-19 differently? To answer that question, first let’s look at exactly how a healthy body is designed to deliver oxygen to your tissues.

How Our Cells Are Designed Carry Oxygen

As you inhale air, oxygen enters your lungs and reaches the alveoli which is lined with a layer of cells that creates the barrier between your lungs and your bloodstream. Oxygen molecules pass through this barrier and attach themselves to a protein called hemoglobin that is bound to your red blood cells. Once your red blood cells have picked up oxygen, they set off to begin delivering it to the rest of the tissues in your body.

Think of your red blood cells like little rafts that are responsible for picking up oxygen and carrying it to your tissues which rely on oxygen for survival. And think of hemoglobin like people on the raft working as a delivery crew – tasked with receiving, holding, and dropping off oxygen molecules. Without the “delivery crew” of hemoglobin proteins, the raft is useless.

It’s also important to understand a little more about the structure of hemoglobin. A vital component of hemoglobin proteins are heme groups – which are embedded in the hemoglobin and are responsible for binding and releasing oxygen molecules. These heme groups are a metal complex and contain iron as the central metal atom, with each iron molecule capable of carrying one oxygen molecule. These iron rich heme groups are critical – without them your cells are unable to transport the oxygen your tissues depend on.

This understanding the body carries oxygen has sparked speculation about how COVID-19 may be exerting it’s devastating effects by creating more reactive oxygen species causing tissue damage and hypoxia.

A New Theory on COVID-19’s Mechanism of Injury

One the most puzzling aspects of COVID-19, is that despite fitting most of the criteria under the definition of acute respiratory failure there is one glaring contradiction. With the coronavirus, there appears to be hypoxia or low oxygen saturation in the blood rather than respiratory distress as seen in classic respiratory failure. Meaning many patients present with severe hypoxia with nearly normal respiratory function. This remarkable combination is almost never seen in severe cases of ARDS.

Interestingly, it may be creating a clinical picture similar to someone suffering from severe malaria or altitude illness.

Could COVID-19 Be affecting Oxygen Carrying Capacity?

In COVID-19’s final and severe stages, the lungs are severely damaged. But new information on this virus’s cellular process in the body is revealing that the final condition of the lungs and accompanying respiratory failure may actually be more of a case of massive oxidative stress overload disrupting the capacity of hemoglobin to carry oxygen to tissues rather than an outright attack on the air sacs in the lungs.

The theory on coronavirus affecting the bloods oxygen carrying capacity is related to the fact that increased intracellular oxidative stress is at the core of all pathogenic infections. This is often referred to as increase in reactive oxygen species or ROS. This ROS production is at the core of much of the damage we are seeing not only to the blood’s ability to deliver oxygen to the tissues, causing severe hypoxia or low oxygen but also damaging all tissues they come in contact with. As Integrative and functional medicine doctors, we often measure marker of oxidative stress in our patient’s urine to determine if this process is out of control. One such marker is lipid peroxides. According to Dr. Tom Levy the intracellular levels of Vitamin C, magnesium and glutathione largely affect the oxidative stress which could damage the tissues, one reason why you are seeing Vitamin C being used in hospitals to treat the virus. Stay tuned as I will be writing more about Vitamin C in upcoming blog articles.

This cascade of events would explain:

Why as many as one in five COVID-19 patients have cardiac damage.
Why IV nutrients that target cardiovascular function are beneficial.
Why many people experience a loss of taste and smell.
Why anti-malarial medications are showing promising results.

This would also explain why ventilators aren’t working quite like we’d expect. Ventilators work by forcing more air into the lungs, so more oxygen can be delivered to the blood. This is helpful when there’s liquid or inflammation in the lungs, and the blood is working normally – like in pneumonia. However, if there is an issue due to the fact that oxidative stress (ROS) has altered the blood’s ability to properly carry this oxygen, then a ventilator can’t do its job. Right now, the Journal of the American Medical Association indicates that COVID-19 patients are candidates for “early, invasive ventilation”. But if we’re ventilating patients who are struggling to keep their little oxygen boats afloat in the bloodstream due to massive oxidative stress, ventilation will do little good and could even cause damage.

This theory would also give us some more insight as to why certain populations may be more at risk of contracting COVID-19.

This Might Explain Why Anti-malarial Medications are Being Considered for Treatment.

Hydroxychloroquine, also known as Plaquenil, is an anti-malarial medication that is showing promise as a potential treatment for COVID-19. If coronavirus is in fact attacking red blood cells, similar to the way malaria does, then it would make sense why an anti-malarial drug would be beneficial for coronavirus patients. But how exactly could hydroxychloroquine be exerting these antiviral effects?

Research is finding that it might be due to hydroxychloroquine’s relationship with the mineral zinc. You see, hydroxychloroquine is a zinc ionophore – meaning it enhances your body’s ability to allow zinc into your cells. When intracellular concentrations of zinc are increased, it displays broad spectrum antiviral activity in a few ways:

Zinc inhibits the actions of certain proteins necessary for the completion of different phases of the virus’s life cycle – essentially halting its ability to reproduce10
Zinc supports a robust immune response by aiding in the production of cytokines and the modulation of immune cells10
Zinc acts as a powerful antioxidant and prooxidant – neutralizing the oxidative stress caused by toxic overload of iron that has been dumped into the blood from the burst cells

Interestingly, one of the initial symptoms reported by many coronavirus patients is a loss of taste and smell. This lack of taste and smell can be caused by a zinc deficiency. Perhaps the action of hydroxychloroquine helping zinc enter cells is part of the reason the drug has benefitted some COVID-19 patients. It’s important to note that in order for hydroxychloroquine to work, there must be adequate zinc levels available to allow into the cells – so hydroxychloroquine must be administered in conjunction with zinc to be most effective against COVID-19.

Hydroxychloroquine has shown promise (as well as a risk of severe cardiac arrhythmia in certain patients) but the way the drug functions has given us some powerful insights and may give us answers into how we can save more lives.

The Connection Between COVID-19 and Altitude Sickness

Another interesting connection is the fact that COVID-19’s clinical presentation is quite similar to another respiratory illness – high altitude pulmonary edema, also known as altitude sickness. In both COVID-19 and high altitude pulmonary edema clinical findings include:

A decreased ratio of arterial oxygen levels to inspired oxygen
Hypoxia (low oxygen levels) and tachypnea (abnormally rapid breathing)
Low carbon dioxide levels
A ground glass appearance in the lung tissues
Elevated fibrinogen levels
Diffuse alveolar damage

In altitude sickness, the lungs are functioning fine – there are just inadequate levels of oxygen to process to properly meet the needs of the body. Clinical findings similar to altitude sickness would make sense if COVID-19 is in fact causing a dysfunction of red blood cells through production of massive oxidative stress rather than a direct problem with the lungs.

So What Are Potential Options to Quench Oxidative Stress?

Even with all of the information that points to COVID-19 creating massive oxidative stress, there are still a lot of unknowns. The downside of this is of course the trial and error and continued research that needs to take place before we have real answers. The upside, is that this information gives us an array of new potential treatment options to consider:

High Dose Vitamin C:

High doses of vitamin C are garnering attention as a powerful way to potentially mitigate the effects of coronavirus. These ultra-high doses of vitamin C are speculated to fight the massive immune response and subsequent respiratory failure seen in coronavirus infection by:

Suppressing the over-reactive inflammatory response in the lungs
Minimizing the accumulation of immune cells in the tissues of the lungs
Decreasing the release of cytokines (chemical messengers involved in the immune response)
Slowing down the viruses ability to reproduce and spread
Neutralizing the oxidative stress caused by the massive amounts of iron floating around in the bloodstream

Ideally, high dose vitamin C can be delivered intravenously, where it is more easily absorbed and utilized intracellularly. But oral vitamin C can also be beneficial if taken correctly. While regular over the counter oral vitamin C causes diarrhea, liposomal Vitamin C at frequent intervals does not, and is an effective way to increase intracellular levels. Several New York hospitals have approved intravenous vitamin C as a therapy for the first time ever in studies being conducted on the virus.

Glutathione:

Glutathione is a potent antioxidant naturally found in most of the cells in your body. Glutathione plays a few major roles in immune function including:

Functioning as a signaling molecule – helping balance inflammation levels and modulating immune system response
Reducing oxidative injury by neutralizing harmful toxins
Regulating cellular proliferation and apoptosis

There is a growing mountain of evidence finding that the most effective way to take glutathione may be through inhalation. Inhaled glutathione (aerosolized or nebulized) is already being used in the treatment of a variety of respiratory-related conditions and has been garnering attention as a possible treatment option for COVID-19.

Inhaled Hydrogen:

The inhalation of concentrated hydrogen gas is another potential treatment option due to its powerful antioxidant properties. Inhaling hydrogen gas has been found to:

Reduce oxidative-stress induced damage
Reduce cellular apoptosis
Improve gas exchange in the lungs
Block the production of proinflammatory mediators
Inhaled hydrogen gas may be particularly effective when paired with other anti-oxidative therapies such as IV vitamin C and inhaled glutathione.

Other Antiviral Drugs:

A number of other antiviral medications are being studied for their potential to treat COVID-19. These include:

Methylene Blue: Methylene Blue is a medication that has been used in the treatment of malaria due to its powerful antiviral properties – killing the virus at an impressive speed. It’s also used in the treatment of a condition known as methemoglobinemia – a condition in which individuals have too much methemoglobin which is a form of hemoglobin that is much less effective at carrying oxygen. Methylene blue works by converting methemoglobin into a type of hemoglobin that can more effectively transport oxygen.
Remdesivir: Remdesivir is another antiviral drug used for Ebola. Remdesivir is showing benefit in solid studies – a small but well-conducted study on severe cases in the US, Canada, Europe, and Japan concluded that Remdesvir caused clinical improvement in 68% of patients.
Favipiravir: Favipiravir is a powerful anti-viral agent that inhibits the virus from replicating and spreading. It has been approved in China and Japan for the treatment of influenza and is undergoing research to determine its potential efficacy in treating COVID-19.
Hyperbaric Treatment: Hyperbaric treatment works in two ways. First, inspired oxygen concentration is increased to nearly 100%. Secondly, ambient pressure is increased to about three times higher than the air pressure we normally breathe. This combination is designed to essential “hyper oxygenate” your blood – improving oxygen delivery to your tissues. Hyperbaric treatment may be an effective adjunct therapy to help COVID-19 patients recover, especially when administered early.

Could This Bring Us One Step Closer to Finding a Cure for COVID-19?

There are still many unknowns when it comes to coronavirus. The only thing we know for certain is that we are in a race against time. I hope we will continue to search for clues and change course when wrong.

I urge my fellow clinicians and researchers to examine this virus and its mechanism of action with fresh eyes. We entered into this field knowing we were signing up for being lifetime students. This current pandemic is calling us to rise to the occasion – the world is counting on us to find the answers it needs.

In my own practice, I will continue to give my patients and readers the most up-to-date tools they need to protect themselves amidst this pandemic. Until we have a solid understanding of this virus, I will continue to seek new information to do my part in fighting back against COVID-19 and update you when we find more information to help patients get well.

Give Your Immune System the Support It Needs

Along with continued research to identify the root cause of COVID-19, I am also working on equipping our clinic to offer treatments to support your immune system during this time. Based on our current understanding we may consider offering some of the following options.

IV Vitamin C and Glutathione: A powerful combination of two of the most potent antioxidants delivered intravenously so they can be immediately used by the cells to combat oxidative damage.
Inhaled Glutathione: Inhaling glutathione delivers it directly to your lung cells – replenishing their antioxidant stores that are quickly used up when fighting inflammation.
Inhaled Hydrogen: Pairing inhaled hydrogen’s impressive anti-inflammatory effects with Vitamin C and glutathione makes for a robust and powerful trio of antioxidant therapies.
Nasal Ozone: Ozone gas held in the sinuses helps your body more effectively uptake oxygen and activates a healthy immune response. Ozone should not be inhaled as may damage the lungs.

And fortunately, Flatiron Functional Medicine is certainly not the only place that you may be able to receive these powerful therapies to support the immune system. Many other providers have the resources and training to deliver them as well – so please seek out a reputable and trusted clinician in your area to learn more about these options.

References:

What Private Practices Need to Know About the U.S. Relief Package

April 15, 2020

There is a dire need for financial support of healthcare providers and facilities as they continue to battle the COVID-19 pandemic, now affecting the United States the most drastically. In response, the President signed the bipartisan CARES Act on March 27, 2020, providing much-needed relief funds to hospitals and other healthcare providers on the frontlines of the fight against coronavirus. As part of the recently announced CARES Act, $100 billion will be appropriated to create a Public Health Social Service Emergency Fund with an ultimate goal of preventing, preparing for, and responding to the coronavirus outbreak both domestically and on an international scale.

Per the Act, funding will be dedicated to reimbursing healthcare-related expenses or lost revenue attributable to COVID-19 to alleviate some of the financial burden many providers are experiencing. Part of this relief payment will focus on ensuring that uninsured Americans have access to testing and treatment, and that medical professionals providing the care are reimbursed for their work. The Department of Health and Human Services has published detailed criteria for the process of distribution of funds under the Act as well as information about eligibility requirements, outlined below.

Immediate Relief Funding

Recognizing the urgent need for the delivery of financial relief, the HHS immediately infused $30 billion into the American healthcare system. Payments are slated to arrive via direct deposit beginning April 10, 2020 to eligible providers throughout the system. Note, these are direct payments, not loans and will not need to be repaid, the HHS emphasizes.

Eligibility for Immediate Relief Payments

Per guidance from the HHS, all facilities and providers that received Medicare fee-for-service (FFS) reimbursements in 2019 are eligible to receive payments from this initial rapid distribution. Payments to practices that are part of larger medical groups will be sent to the group’s central billing office, while all relief payments will be made to the billing organization according to its Taxpayer Identification Number (TIN).

In order to be eligible to receive these funds, providers must not seek to collect of out-of-pocket payments from a COVID-19 patient that are greater than what they would be otherwise had the care been provided by an in-network practitioner. If a practice had to halt business operations as a result of the COVID-19 outbreak, providers may still be eligible to receive funds if they provided diagnoses, testing, or care for patients with possible or confirmed cases of COVID-19. Per the HHS, “Care does not have to be specific to treating COVID-19. HHS broadly views every patient as a possible case of COVID-19.”

The immediate relief payments hope to alleviate providers in hard-hit COVID-19 areas and those who are struggling to keep their practice open due to delayed care and widespread cancellations of elective procedures.

Payment Distributions

Payment distributions will be based on the provider’s or practice’s share of total Medicare FFS reimbursements for the year 2019; that year, the total FFS payments were approximately $484 billion. Providers can estimate their anticipated payment by dividing their 2019 Medicare FFS (excluding Medicare Advantage) payments – which can be obtained from their organization’s revenue management system – by $484 billion and multiplying that ratio by $30 billion.

Receiving Payments

In partnership with UnitedHealth Group (UHG), the HHS will provide rapid payments to eligible providers, as described above, to distribute the initial round of funding. Providers will be paid via their Automated Clearing House account information on file with UHG or the Centers for Medicare & Medicaid Services (CMS) and can expect to receive payments via Optum Bank with “HHSPAYMENT” as the payment description. Providers who receive reimbursements from CMS via paper check can expect to receive a paper check in the mail within the next few weeks.

Providers must sign an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment within 30 days of receipt. The Terms and Conditions of the funding can be found on the CMS website. If the payment is not returned within 30 days, the HHS will view this as an acceptance of the Terms and Conditions. However, if a provider does not wish to comply with the Terms and Conditions, they must contact HHS within 30 days of receipt of payment and then return the full payment to HHS.

Different Types of Providers

All relief payments are being made to providers according to their tax identification number (TIN). Large organizations will receive payments for each of their billing TINs that bill Medicare, and should look to the part of their organization that handles Medicare billing to identify details on Medicare payments for 2019. Employed physicians should not expect to receive an individual payment directly; instead, their employer’s organization will receive the relief payment as the billing organization. Similarly, individual physicians and providers in a group practice are unlikely to receive individual payments directly; the group practice will receive the relief fund payment as the billing organization. Solo practitioners who bill Medicare will receive a payment under the TIN they use to bill Medicare.

The Remaining $70 Billion

As part of the $100 billion guaranteed by the CARES Act, the remaining $70 billion will be comprised of targeted distributions focused on providers in areas particularly impacted by the virus, rural providers, providers of services with lower shares of Medicare reimbursement or who predominantly serve the Medicaid population, as well as providers requesting reimbursement for the treatment of uninsured Americans. More guidance is expected on the structure of these payments in the coming weeks.

COVID-19 Medical Expenses

The federal government is taking measures to ensure Americans are not surprised by medical expenses and are protected against financial obstacles that might prevent them from seeking care or getting tested and treated for COVID-19. A portion of the Provider Relief Fund will be used to reimburse healthcare providers at Medicare rates for COVID-related treatment of the uninsured. However, providers are prohibited from “balance billing” any patient for COVID-related treatment in order to be eligible.

In addition, the Families First Coronavirus Response Act requires private insurers to cover an insurance plan member’s cost-sharing payments for COVID-19 testing. Further, the government has secured commitments from private insurers – such as Humana, Cigna, UnitedHealthGroup, and the Blue Cross Blue Shield system – to waive cost-sharing payments for treatment related to COVID-19 for its members and make medical care more accessible.

Heavily anticipated by providers across the nation, the latest guidance helps to clarify eligibility, distribution, and payment concerns regarding the Provider Relief Fund. Eligible practices and providers may soon expect to receive payments from the immediate round of funding. In the meantime, medical professionals can access more information about and the latest developments concerning the CARES Act Provider Relief Fund here.

COVID-19 Insurance Coverage Changes

April 9, 2020

Requiring a coordinated response from the government, healthcare system, and private sector, the COVID-19 outbreak has placed an unprecedented burden and stress on countries across the globe. In the United States, federal policies are being updated rapidly in response to the shifting demands of the healthcare system as it fights to curb the virus. As such, insurance providers are playing a critical role in ensuring widespread access to care and have taken decisive action to help both patients and providers in combating the novel coronavirus.

From state insurance regulators, who are limiting the amounts patients can owe for COVID-19 care, to insurance companies and employers who have amended many rules to eliminate deductibles and co-payments, coverage changes have been occurring on a large scale. As the outbreak is developing and dynamically changing the medical landscape, below are some of the latest policies to go into effect in response to COVID-19.

COVID-19 Testing

Per the latest legislation passed by Congress, coronavirus testing is free for all individuals regardless of insurance status – as is the cost of a doctor’s visit or trip to the emergency room to receive the test. The recently passed Families First Coronavirus Response Act requires all group health plans and individual health insurance providers to cover testing and associated visits related to the diagnosis of COVID-19. In addition, several states, including California, New York, and Washington have implemented additional requirements on insurance companies to cover testing costs.

Both private insurance companies and employers have volunteered to waive the costs of testing. In addition, the Families First Coronavirus Response Act requires most private health companies to cover testing for COVID-19.

Medicare and Medicaid will also cover the costs of a coronavirus test, while the uninsured should also be able to get tested at no cost per the latest guidelines. Patients who recently lost their jobs may qualify for Medicaid or be able to sign up for a health plan under the Affordable Care Act to gain access to free testing.

COVID-19 Treatment Costs

In response to the COVID-19 outbreak, health insurance providers are waiving out-of-pocket costs for hospital visits and many are funding treatment of COVID-19 as well. Cigna and Humana have waived out-of-pocket costs for treatment, as have Aetna, Florida Blue, Harvard Pilgrim and UnitedHealth Group. One of the largest insurers in the nation, Blue Cross and Blue Shield, covers nearly 6 million individuals under its Federal Employee Program and has said it would waive co-payments and deductibles for medically necessary treatment.

Although, there are restrictions to the coverage of treatment costs as some insurers have waived cost sharing only for the upcoming two months while others have eliminated expenses only for hospital stays. In addition, it remains unclear how much patients may be required to pay out of pocket; the Kaiser Family Foundation estimates COVID-19 care can cost around $20,000, bringing potential out-of-pocket bills to around $1,300 depending on the patient’s plan, location of care, and disease severity.

COVID-19 Complications Care

Most private insurance plans will likely cover services needed to treat COVID-19 complications although, there is currently no federal guidance requiring them to do so. In addition to covering testing, Medicare will cover both outpatient and hospitalization services. During the COVID-19 crisis, Medicare patients are covered if they need to be transferred to skilled care regardless of previous hospitalization. However, the program does not cover long-term stays in long-term care facilities at this time.

Telemedicine Coverage

According to the latest policy changes, telehealth will now be covered under Part B for all traditional Medicare enrollees for services not limited to COVID-19 care. The definition of telemedicine will be expanded to allow patients to connect with healthcare providers from their homes via video conferencing or other digital methods. To further ease access to care, the requirement that telemedical care be provided by a medical professional the patient has seen within the last three years has been waived.

The widespread shift to telehealth has proven critical to easing the burden on the U.S. healthcare system by “allowing hospitals to care for people who need it most, while limiting the exposure of health care workers and patients to the disease,” explains a one-pager published by America’s Health Insurance Plans. “Telehealth is especially beneficial for patients who are at a higher risk when leaving the home to commute to the doctor’s office.”

Out-of-Network Bills

Despite the significant efforts made toward expanding insurance coverage at this time, patients may still be required to pay out-of-network bills, for example, when they are treated by an out-of-network physician. Data from the Kaiser Family Foundation indicate that nearly one in five patients admitted to the hospital with serious cases of pneumonia were faced with out-of-network bills after treatment. To further ease patients’ financial burden related to COVID-19, some hospital systems are pausing collections for the foreseeable future.

Alongside the aforementioned updates, many insurance coverage providers are proposing further changes to expand coverage and ease the financial burden during this COVID-19 crisis. Healthcare providers should remain current on the latest developments in coverage policies as they may affect both themselves as well as their patients.

For further assistance with navigating the changing insurance coverage landscape, the America’s Health Insurance Plans’ website offers a comprehensive list of providers and their responses to COVID-19, which can be accessed here.

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