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Addressing a Dysfunctional Healthcare System During a Pandemic

In the battle against the novel coronavirus (COVID-19) outbreak sweeping across the globe, healthcare workers are the frontline fighters saving countless lives with their tireless efforts. Grueling hours, equipment shortages, increasing patient needs, and dangerous working conditions on top of already demanding job requirements are contributing to unprecedented levels of physician burnout at this time.

Not only are healthcare workers facing the global pandemic head on, they are doing so without the necessary safety precautions, as part of a healthcare system that is proving more dysfunctional and ill-equipped to handle a public health emergency than would have been assumed. The precarious situation is made worse by mounting evidence of the censorship and exploitation of medical professionals, who are in some circumstances being forced to choose between their jobs and sharing accounts of what the battle within hospitals really looks like. The issues coming up as a result of the pandemic devastating healthcare systems across the globe is an extension of a greater, long-term problem within the healthcare system that must be addressed.

Growing Censorship

It has become commonplace for hospital and healthcare organization leadership to take on press and media responsibilities, while the voices of physicians tend to be largely omitted in the news landscape.

Now due to the COVID-19 pandemic, news channels and other media are actively seeking input from physicians fighting the global health crisis, giving them an unprecedented opportunity to air their concerns about the state of the healthcare system on a public platform. Unfortunately, their employers and hospital leadership are actively working to suppress their ability to speak out and provide honest depictions of working conditions.

More frequently, stories are emerging of physicians who have lost their jobs for speaking out against hospital protocols, posting their stories on social media, or releasing information to the media. Dr. Esther Choo, emergency physician at Oregon Health & Science University, revealed she has been told by many fellow healthcare providers about their fears of speaking up about the challenges they are facing due to the risks involved.

Some physicians have been taking their concerns to social media, posting about dangerous shortages of personal protective equipment, unsafe hospital protocols, a lack of communication from leadership, as well as growing censorship and restrictions on their freedoms. According to reports, hospitals across the nation have been warning, disciplining, and even terminating employees who publicize their workplace concerns about coronavirus-related challenges.

Accounts reported in The Washington Post and The New York Times, describe several instances of physicians being threatened with disciplinary action, restricted from appearing on television, reprimanded for their behaviors, and even terminated for sharing glimpses into their hospital’s conditions. While other institutions such as NYU Langone Medical Center in New York have gone so far as to forbid staff members from “contacting the media without permission under threat of termination” according to an article published in The Washington Post.

During a worldwide pandemic, the worst thing that can be done is to render clinicians inconsequential and sequester them from the rest of the world when knowledge of the realities is critical to improving population health outcomes worldwide. Their first-hand perspective from the frontline is necessary both in terms of guaranteeing freedom of speech as well as providing an accurate depiction of the handling of COVID-19 within the healthcare system.

Increased Press Access

Hospitals, while not in the business of sharing information about their patients, currently face growing pressure to provide insight into the situation at hand. Protecting the privacy and dignity of patients is paramount, however, Dr. Esther Choo told CNN she believes this unprecedented situation warrants an alternative approach to sharing healthcare information.

“In this crisis, I think it creates a barrier between what is happening inside, what our healthcare workers are seeing, and what the public needs to know in terms of how bad this disease is,” Dr. Choo commented on the lack of insight provided from within the healthcare system,  “I think without seeing it, it’s hard for people to understand what we’re trying to avoid with measures like stay-at-home.”

While for both safety and privacy reasons journalists are unable to report from emergency departments or within hospitals, media professionals are calling for more access and exposure to vital information. This makes the first-hand, honest reports from physicians and nurses essential at this time – they have the power to inspire widespread reform, motivate support and donations, and underscore the importance of staying home.

Relaxing HIPAA regulations and revisiting press restrictions at hospitals may be necessary at this time to provide the public with an honest view inside emergency rooms. “I think we need to make a decision as hospitals, as healthcare systems, we are going to be a little bit more open about the challenges we’re facing,” Dr. Esther Choo told CNN, highlighting the systemic effort needed to change the status quo.

Access to information is not only vital for preserving democracy within the nation, but it is critical for public health, keeping the population informed and aware of the devastating failures of hospital protocols as evidenced by the COVID-19 response. This can be achieved while still protecting patient privacy and anonymity, if healthcare professionals are allowed to speak out. As reporter Chandra Bozelko argues in a recent Washington Post article, “Patient care includes public advocacy, minus the personal details.”

Emotional Exploitation

Alongside the censorship of medical professionals, the exploitation of physicians is another problem emerging as a result of the dysfunctional system. Viewed as a perpetual resource, healthcare staff members, their innate professionalism, and their work ethic are what keeps the healthcare industry in operation. The system itself runs on the altruism of its practitioners; if medical professionals worked their number of allotted hours and went home at the end of their shift – instead of working endless hours overtime to preserve patient health – the healthcare system and its patients would suffer greatly.

The COVID-19 pandemic has revealed how medical staff members are treated as an endless resource, used to maximize efficiency of the system, constantly being faced with added responsibilities and a growing workload – additional patients, paperwork, and procedures. For the majority of healthcare workers, walking away without completing their job and thus, endangering patients is unthinkable. Meanwhile leadership continuously exploits this ethic.

Over the past few years, demands have escalated without an equivalent rise in time or resources. At the same time, the medical complexity of patients has increased with the number and severity of chronic conditions steadily rising in prevalence. Medical encounters are more involved than ever before with more illnesses, medications, and complications, while the duration of office or hospital visits remains the same.

In times of the COVID-19 pandemic, the demands on healthcare workers have only increased, while resources continue to decrease at alarming rates and exploitation of the workforce continues. According to data from The New York Times, physician burnout levels are at an all-time high caused in part by chronic workplace stress, as are burnout rates among nurses. Physicians and nurses on the frontline of patient care experience the highest levels of burnout, which are associated with increased medical errors and thus, present threats to patient health and safety. Data suggest that doctors and nurses commit suicide at higher rates than in almost any other profession and recent examples of medical workers taking their own lives as a result of working conditions signal an urgent need for change.

Based on an unrelenting belief in the unwavering professionalism of its workers, the current healthcare model is proving unsustainable for both providers and their patients. As such, the system must be restructured to reflect the current realities of patient care. The healthcare model is  imperfect and is only able to function due to the valiant efforts of its workers who prize patient caregiving above all else. Exploiting the altruistic ethic of healthcare professionals to keep a broken system from collapsing in on itself is not just unsustainable, it goes against its very mission.

Though limited due to censorship restrictions, reports emerging from the frontline indicate a persisting problem. The COVID-19 pandemic has revealed the unpreparedness of many healthcare systems across the world to handle unprecedented spikes in demand. However, in the United States it has also presented an ominous example of dysfunction and an extension of a greater, long-term problem within the system that must be addressed. The number of challenges facing healthcare workers will continue to grow as long as the enterprise can exploit its labor force unpenalized and the repercussions of this model will continue to emerge. Silencing staff members will only further the problem while promoting an unrealistic image of the state of healthcare thereby hindering potential efforts to help those in need – which right now are not just the patients fighting for their lives against COVID-19, they are also the physicians risking their lives to protect them.

 

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Medicare COVID-19 Telemedicine Factsheet

The COVID-19 outbreak has not only disrupted daily life across the globe, but the contemporary healthcare model as well, with an urgently needed shift to digital medical solutions. Federal regulations are changing continuously, insurance coverage has greatly expanded, and the use of telemedicine is growing at a tremendous rate assisted by new policies and a widespread loosening of restrictions previously impeding access to care.

As part of the battle against the novel coronavirus pandemic, the Centers for Medicare & Medicaid Services (CMS) have expanded access to Medicare telehealth services on a temporary and emergency basis and lessened HIPAA enforcement effective as of March 6, 2020. These updates offer Medicare beneficiaries – many of whom are at an increased risk for serious COVID-19 illness – a safe, alternative model of care in the form of a wider range of remote services. During the COVID-19 crisis, innovative uses of telemedicine technology are driving routine care, keeping vulnerable demographics safe, and expanding access to health care. 

“The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19  – are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus,” a statement from the CMS on the promotion of telemedicine reads. Further information about the newly implemented guidelines for patient care and their implications on telehealth services during the COVID-19 outbreak are outlined below.

Expansion of Telehealth Services

1135 Waiver

As part of the program, the 1135 waiver was introduced to lessen prior restrictions and promote wider access to remote care. Prior to the waiver, Medicare was only able to pay for telehealth on a limited basis, for example, when a patient was receiving care in a designated rural area or when received the service in a healthcare facility. Under this waiver, the following changes have taken effect:

•   Office, hospital, and other telehealth visits will now be covered and reimbursed for the same amount as an in-person visit.
•   A wide range of providers can offer telehealth services across the nation, including nurse practitioners, psychologists, and licensed social workers.
•   Medicare beneficiaries are now be able to receive a wider variety of services through telemedicine – such as evaluation and management visits, mental health counseling, and preventative health screenings.
•   The HHS Office of Inspector General is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs during this time.

Virtual Services 

Medical professionals can provide their Medicare patients with a range of virtual services as part of the telehealth program, including Medicare telehealth visits, virtual check-ins, and e-visits. Specific requirements for each service are outlined below.

Medicare Telehealth Visits

Throughout the course of the COVID-19 outbreak, Medicare patients may use digital technology for office, hospital visits, and other services previously rendered in-person. The recent changes include:

•   A wider range of practitioners is now able to get payment covered for telemedicine services – including physicians, nurse practitioners, physician assistants, midwives, anesthetists, psychologists, clinical social workers, registered dietitians, as well as nutritional professionals.
•   Virtual visits will now be paid at the same rate as regular, in-person visits.
•   Providers must use an interactive audio and video system permitting real-time communication during Medicare telehealth visits in order to be reimbursed appropriately.
•   New CMS guidelines remove the requirement of an established patient-provider relationship for the duration of the public health emergency, further details below.

“The Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act.  To the extent the waiver (section 1135(g)(3)) requires that the patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency,” the CMS statement reads.

Virtual Check-ins

In all areas of the country, Medicare beneficiaries will be able to have brief online check-ins with practitioners – or brief communication technology-based services. Policy changes related to this include:

•   Medicare will now pay for virtual check-ins for patients with established relationships with their physicians to prevent unnecessary travel and office visits.
•   Brief virtual check-ins can be conducted using a broader range of communication methods than Medicare telehealth visits; medical practitioners may bill for virtual check-in services provided via several telecommunication technologies – including telephone, audio/video, secure text messaging, email, and patient portals.
•   Services cannot be related to a medical visit within the previous 7 days or lead to a medical visit within the following 24 hours, or the soonest available appointment.
•   Patients must verbally consent to receive virtual check-in services.
•   Patients can submit video/images using store and forward methods to be interpreted by physicians within 24 business hours.
 

E-Visits

As part of the updated guidelines, established Medicare patients in all types of locations can have non-face-to-face patient-initiated communications with their providers using online patient portals. These services can only be rendered in accordance with the following guidelines:

•   E-visit services can only be reported to Medicare if the billing practice has an established relationship with the patient.
•   E-visits must be initiated by the patient although, practices may educate patients on the availability of these services prior to their initiation.
•   Communications can occur over a 7-day period and only after the patient provides verbal consent to receive telehealth services.
•   These services may be billed using CPT codes 99421-99423 and HCPCS codes G2061.
More information on relevant billing codes for e-visits and other virtual care services can be found on the CMS’ website.

Health Insurance Portability and Accountability Act (HIPAA) Updates 

In addition to the amendments above, the HHS Office for Civil Rights will lessen restrictions and waive penalties in association with HIPAA compliance for health care providers that serve patients in good faith through virtual communication technologies during the COVID-19 outbreak. More information on the latest HIPAA updates can be accessed here.

Although Medicare already offers flexibility to states that wish to implement telehealth services, the most recent developments signal a major step forward in the direction of telemedicine, despite the temporary nature of federal guidelines. With the help of changes in regulations and the strategic expansion of telehealth, patients can now reach providers easily via a range of tele communication options from the comfort and safety of their homes, while medical professionals can readily provide care without reimbursement concerns. As the COVID-19 public health emergency continues to evolve rapidly, regulations and guidelines may change; clinicians are encouraged to stay up-to-date on the latest medical guidance.

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Self-Care Strategies For Medical Practitioners

As the population enters another month of social distancing and self-isolation in an effort to combat the COVID-19 outbreak, it is becoming increasingly important for individuals to prioritize their physical, mental, and emotional health. The so-called “new normal” many find themselves living in has been characterized by heightened stress levels, long work hours, increased feelings of loneliness and hopelessness, as well as a persisting need to support and care for loved ones. During such an overwhelming time, it is important to take the necessary self-care measures that can work to mitigate negative emotional and physical responses to the pandemic – many of which may be happening subconsciously.

Both deteriorating physical and mental health can impede the ability to provide much-needed medical and home care, give and receive support, and to fulfill the needs of a growing number of patients. Whether you are one of the healthcare providers braving the crisis and fighting the virus on the front lines, a first-time telemedicine practitioner, or a medical professional with a practice currently closed, it is essential to take the time to incorporate some of the self-care strategies listed below when possible.

Self-Care Strategies

Boosting both physical and mental health requires regular check-ins throughout the day. Make sure to check in not only with your family and friends, but equally as importantly with yourself – how are you feeling physically, mentally, and emotionally? Paying attention to your current state will help identify what you may need at that moment, whether that is a walk around the neighborhood, a nutritious meal, or some physical exercise. The recommendations below are simple to incorporate into a daily routine yet may prove tremendously effective in improving overall wellbeing.

Physical Health

Supporting physical health is vital to ensure a well-functioning immune system and to protect it from the risk of COVID-19 infection. Several ways to maintain a healthy lifestyle despite the circumstances – inclusive of regular physical activity and a well-balanced diet – are listed below:

•   Maintain a sleeping schedule and get enough rest; aim to sleep for around 7 to 8 hours per night.

•   Engage in physical activity every day – this can include walks around the block, jogging, or exercising at home.

•   Spend time outside (following social distancing guidelines) and in nature; studies have found that being outdoors is one of the quickest methods of improving health and wellbeing.

•   Eat regularly and fuel your body with a healthy, nutritious diet.

•   Make sure to hydrate as dehydration can have noxious effects on physical health; aim for about 2 liters of water per day.

•   Avoid substance use and destructive behaviors; abusing alcohol or drugs at this time may worsen both physical and mental health, take a toll on the immune system, and lead to other repercussions.

Mental Health 

Taking care of your mental health is equally as important; the heightened stress levels and rising feelings of loneliness can contribute to declines in immune system functioning as a result of related hormonal changes.

•   Find ways to connect with yourself and those around you – this can include regular phone or video calls, communicating throughout the day, and mindful personal check-ins.

•   Set a routine and try to maintain it; devoting specific times of the day to work, chores, home life, and self-care can help provide much-needed structure.

•   Instead of worrying about the public health crisis at hand, focus on things you can control, including work-related tasks, healthy lifestyle habits, and time spent connecting with the people around you.

•   Consider introducing relaxation techniques throughout the day, such as deep breathing, stretching, meditation, and yoga practice.

•   Use technology mindfully; many individuals are increasingly turning to social media, television, and their computers as a way of spending idle time. While it is needed to maintain social interactions and continue business operations, the amount of unnecessary time spent in front of a screen should be minimized.

•   Listen to music, read books, and pursue other stimulating activities instead.

•   Explore online resources and applications for managing anxiety and other mental health concerns at this time; the CDC has compiled a list of helpful coping strategies, accessible here. 

To be best equipped to provide health care and other support services, medical practitioners must prioritize their physical health and emotional wellbeing, which can be extremely difficult for those working within the healthcare system. While the consistent efforts of healthcare practitioners of all backgrounds are invaluable, the demands of the oft-dysfunctional healthcare system can take a significant toll on their physical and mental health. Many are struggling with traumatic stress responses or battling the infection themselves. As integral members of our shared communities, medical workers are encouraged to remember that they are not alone and to seek the therapeutic support and medical care they need.

Regardless of specialty, finding the time to practice self-care is now more important than ever; introducing some of the above strategies into your daily routine can significantly improve overall health and wellbeing. Additional recommendations, including specific tips for first responders and health care providers, have been made available by the CDC and can be found here.

If you or someone you know is considering suicide please contact the National Suicide Prevention Hotline at 1-800-273-8255 or through chat on https://suicidepreventionlifeline.org/

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