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How federal rules for reporting COVID-19 data could threaten hospital funding

The Trump administration says requirements for how hospitals report COVID-19 data are critical to keeping them prepared for potential surges this winter, but health experts warn the rules can also be overly burdensome, and that new consequences for failing to comply could lead to critical losses in funding that may put communities at risk.

More than 6,000 hospitals nationwide received letters from the Department of Health and Human Services last week letting them know whether they are in compliance for reporting data during the COVID-19 pandemic. If, after several notices over 14 weeks, hospitals do not fully report their COVID-19 data to HHS, they could be cut off from Medicare and Medicaid, said Seema Verma, administrator for the Centers for Medicare and Medicaid Services. For many hospitals, Medicare and Medicaid reimbursements are vital to an institution’s financial survival, making up between 40 percent and 60 percent of total revenues, according to the American Hospital Association.

Under the rules, hospitals across the United States have to submit inventories and patient totals for dozens of different coronavirus-specific categories, many of which need to be submitted daily, plus six new influenza questions. Some data are fairly straightforward, but the categories don’t always align with the way hospitals are tracking data themselves, and the staffing required to complete some of the reporting can in some cases stretch already-strapped hospital workers thin, experts say.

Nearly 98 percent of hospitals already report their data at least weekly and 86 percent of hospitals report at least daily, said Dr. Deborah Birx, a U.S. ambassador who has helped coordinate global AIDS response and now serves the White House Coronavirus Task Force. She did not elaborate when a reporter asked during a press call last week if they were reporting a single variable, or a complete rundown of data points. Senior HHS officials, including leadership, did not say last week how many hospitals were out of compliance.

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Early on during the pandemic, frontline health care workers struggled to secure enough tests, testing supplies, personal protective equipment and more amid surging cases. Birx told reporters this week that data reporting is vital to keeping hospitals properly equipped and ready to face the virus going into the fall and winter months, when experts suggest the nation could see numbers again rise.

“This daily data is really critical for decision-making,” Birx said during a press call last week.

The government was already requiring each hospital to document its supplies of medication, like Remdesivir, as well as PPE for staff. They will also need to report daily confirmed and suspected cases of COVID-19.

The Trump administration also wants hospitals to report influenza cases so officials can track to what degree the flu may weigh upon the nation’s health care system while the coronavirus continues to sicken and kill Americans. So far, more than 213,000 Americans have died from COVID-19 and more than 7.5 million have been infected with the virus.

Hospitals directly submit the data to HHS, per a March 29 directive from Vice President Mike Pence. That order sidesteps the Centers for Disease Control and Prevention, which had traditionally collected and analyzed much of those figures. Some states also have their own reporting requirements, which can mean hospitals are generating reports for multiple entities each day.

This requirement comes when there’s heightened concern about the role political influence has played in the nation’s public health response to the COVID-19 pandemic. Most recently, President Donald Trump has continued to claim that a vaccine would be available in October, days ahead of the 2020 presidential election. That message contradicts statements made by Dr. Anthony Fauci, one of the nation’s foremost infectious disease doctors, who has said a vaccine could be ready by late 2020 or early 2021 and the public effectively inoculated in after summer 2021. Scientists and doctors have warned political pressure could interfere with the vaccine development process, and Americans’ trust in it.

While hospitals want to get the federal government whatever data is necessary to inform the nation’s pandemic response, and the government is giving hospitals time to raise issues, threatening to withdraw funding for hospitals due to clerical errors that may not be the fault of the hospital is heavy-handed, Foster said — especially during a pandemic.

“It’s not like hospitals aren’t plenty busy,” she said.

What must hospitals report?

Under the requirements, hospitals around the country must report on 32 coronavirus-specific data variables, 25 of which must be sent each day. Hospitals that must report include critical access hospitals, children’s hospitals, Veterans’ Administration hospitals and more.

Some of the HHS questions are straightforward and clear in purpose, such as how many ICU patients are being treated for COVID-19.

But other questions harken back to out-of-date priorities and are “a hangover from the good ole days of six months ago,” said Joe Antos, health policy scholar at the American Enterprise Institute who worked at the Office of Management and Budget and the Department of Health and Human Services under the Reagan administration.

One such question, he said, asks hospitals to log how many total mechanical ventilators are in use or not in use. Though ventilators were seen as a crucial tool at the outset of the pandemic, increasingly, research has shown that ventilators are not effective for treating patients for COVID-19.

Flu variables that hospitals must report include how many people are hospitalized, the previous day’s admissions for flu, ICU patients with flu, which patients in hospital have both influenza and COVID-19 and influenza deaths. Those questions make sense, Antos said, but some related to coronavirus “look like the kinds of questions you ask when you really have no idea what’s going on.”

Moreover, hospitals are still reeling from the pandemic, even if they are not currently overwhelmed by a surge in patients, and there are better ways to coax much-needed data from them, Antos said. Simply put, providing health care often takes longer during a pandemic. Spaces must be cleaned before and after a patient is examined. Health care workers and patients alike must wear face masks for routine procedures and interactions. Staff had to rethink the logistics of caring for patients to identify places where the virus could be inadvertently spread. Many clinics and hospitals ditched waiting rooms or scheduled well patients to visit at different times or locations than sick patients.

The Trump administration has been working with hospitals on these requirements for six months, Verma said during the call with reporters. But it’s unclear why all the data variables are needed or how they will be used, said Nancy Foster, the American Hospital Association’s vice president of quality and patient safety policy, agreed And even when hospitals do fill out the information, the correct way to report each data field is not always clear, Foster said.

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In one instance, federal health data contractors told small hospitals without intensive care units to enter no data when asked how many COVID-19 patients were being treated in ICU beds. They shouldn’t enter zero because that would mean they have ICU beds but no one is there, Foster said. But government workers interpreted those empty blanks as missing data, meaning the hospital failed to submit a complete report. Under the current system, Foster said that error could get a facility dinged for falling out of compliance. She added that there have been several reported instances where a hospital’s record-keeping criteria doesn’t exactly sync with these new federal data-keeping requirements, ultimately leading to lost data. So, the hospital thought it answered the question, but got dinged for not reporting.

While most hospitals, especially larger facilities with more staff and in urban areas, are filling out and submitting these numbers in a timely fashion, Antos said rural hospitals are likely to feel the pinch and face higher likelihood of failing to comply, running the risk of losing vital federal funding. Long before the pandemic, many rural hospitals were perched on precarious finances with nearly half operating at a loss.

“Paper requirements should not close a small rural hospital where there aren’t other choices for people living within a hundred miles of a hospital,” Antos said. He said there are better ways to get a hospital’s attention without their potentially losing federal funding. A letter from an inspector general is usually more than enough to do the job, he said.

Hospitals that lose that money because they consistently failed to comply with these data requirements would be forced to close, Foster said. Such an outcome could have far-reaching health implications, Foster said, if the loss of Medicare and Medicaid funding means preventative and emergency health services are shut down. By mid-January — days before the inauguration of the next president — care could be jeopardized for entire communities if they don’t catch up with these data reporting requirements.

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