Deborah Abrams Kaplan

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Early data from China suggested that CT scans of the lungs might be used to diagnose COVID-19. Recommendations to use CT scans came from both published and anecdotal reports, notes Harold Litt, M.D., Ph.D., division chief of cardiothoracic imaging at Penn Medicine in Philadelphia. “Colleagues of mine (in China) told me what their policies were. They were scanning everyone who showed up at the hospital because at that moment, they didn’t really know what they were dealing with and didn’t have adequate testing.” 

Several studies conducted early in the pandemic in China compared noncontrast chest CT scans to real-time polymerase chain reaction (RT-PCR) swab testing for diagnosing COVID-19. Published online in mid-February in Radiology, a study by Yicheng Fang, of Affiliated Taizhou Hospital of Wenzhou Medical University, and colleagues found chest CT 98% sensitive for COVID-19 compared with 71% for RT-PCR. The authors suggested using CT chest screening, especially if RT-PCR testing was negative. 

A study conducted by Tao Ai, of Tongji Hospital in Wuhan, and colleagues also published online in February in 

 and found chest CT sensitivity at 97% for those with positive RT-PCR results. In patients with negative RT-PCR tests, 75% had positive CT scans. Authors recommended CT as a primary COVID-19 diagnostic tool.

But as COVID-19 spread beyond China, RT-PCR testing improved, and researchers had more time to compare those initial studies with practices in other countries. The availability of RT-PCR is still an issue in the U.S., but recommendations for using CT scans to diagnose COVID-19 haven’t been adopted by major medical organizations and societies.  

The American College of Radiology  noted in a March 11 statement that CT scans should not be used to screen for COVID-19 or as a first-line test to diagnose the disease and that they should be used “sparingly and reserved for hospitalized, symptomatic patients with specific clinical indications for CT.” The Society of Thoracic Radiology and American Society of Emergency Radiology also do not recommend routine CT screening for COVID-19. Their joint statement said chest CT scans can be restricted to patients who test positive for COVID-19 and are suspected of having complications involving the lungs.

But the Fleischner Society, an international, multidisciplinary thoracic radiology society, took a more nuanced stance and included CT scans on its decision trees. The Fleischner group recommended against CT scans (and chest X-rays) for screening COVID-19 in patients with no or mild symptoms unless they show “worsening respiratory symptoms,” but recommended imaging - either CT scans or chest X-rays - for people with “moderate to severe features” of COVID-19.  The society’s recommendations say that chest X-rays are of little value early in disease but have a role in more advanced disease. 

Litt and other radiologists also see problems with study design, biases and selection criteria used in some of Chinese CT scan studies. 

Clinicians at the hospitals in China scanned any symptomatic patient, with little understanding of where patients are in the disease process, says Litt. In the U.S., patients with mild to moderate symptoms have been told to stay home unless they have trouble breathing. Litt also notes that the study showing 71% sensitivity for RT-PCR testing used throat swabs. “We know [throat swabs] will miss quite a few positive patients compared to nasopharyngeal swabs,” says Litt, who also questions the high sensitivity rate of CT scans, adding that, “98% sensitivity is too high for anything in medicine.”  

In addition, American College of Radiology says specificity is a problem with CT scans for COVID-19 because results can overlap with findings for pneumonia and lung issues stemming from other sorts of infections, including influenza. Moreover, says Litt, “we need to make a distinction between (the) coronavirus infection and COVID-19 pneumonia” because people can test positive for COVID-19 but haven’t developed pneumonia. 

Expense is another consideration. It is impossible to put a single price on a CT scan; it is going to vary depending on the payer. It’s not negligible, though,  and claims for CT scans range from several hundred dollars to several thousand. 

The availability of CT scanners hasn’t been an issue at most U.S. facilities, says Litt, because of canceled or postponed elective procedures and other ordinary medical care. What is an issue is that scanning  patients increases the likelihood of staff members contracting the virus. “We’ve instituted universal cleaning protocols because we don’t know who has the [undetected COVID-19],” says Litt.  

Then there’s the incidental finding, a common problem with imaging tests. Determining how to report and share them led to Litt and his colleagues publishing a Radiological Society of North America expert consensus statement on incidental COVID-19 findings. The statement proposed categorizing them into one of four categories: typical (of COVID-19), indeterminate, atypical or negative. 

“This specific question of, ‘Is this abnormality reflective of COVID-19 pneumonia or something else?’ is going to be one with us for a while,” notes Litt, “and viral testing will be the way to resolve that.”   

Deborah Abrams Kaplan covers medical and practice management topics. 

Articles

Early studies from China suggested that CT scans of the lungs could be used to diagnose the disease. But as PCR tests became available, radiology groups said CT scans should be used more sparingly and in confirmed cases.

CT Scans for Diagnosing COVID-19? Not So Much. 

Jen Singer became sick with an unidentified respiratory illness while visiting Seattle in February, before many knew enough to be worried about COVID-19. The fever and coughing delayed the 53-year-old’s trip back home to New Jersey. 

During an April telehealth visit, Singer didn’t have traditional COVID-19 symptoms. She felt abdominal fullness and had difficulty breathing when climbing stairs. Suspecting a gallbladder issue, the doctor sent her to the emergency department (ED), where her heart rate hovered near 40 beats per minute. A normal resting rate is 60 to 100. Singer’s diagnosis? Fluid buildup in her liver from a third-degree heart block - and she tested positive for COVID-19. She was treated with a pacemaker.

“For the entire month of March, I was taking my temperature (at home), when I should have been measuring my heart rate. If I’d had a pulse oximeter, I would have known that my heart rate had dropped to 42, and I would have rushed to the hospital sooner,” Singer says. 

At-home pulse oximeter purchases have spiked more than 500% since the first COVID-19 case was identified in the U.S. The device can easily be purchased at drugstores and online retailers for as little as $40. But not all doctors agree that they’re helpful or that people need to self-monitor for potential COVID-19 exposure. False positives can cause unnecessary anxiety and lead people to seek unnecessary medical care. Many physicians, however, see pulse oximeters as an important way for people to identify declining lung function early and address the cause, including COVID-19, when it’s easier to treat. 

Pulse oximeters are noninvasive clips typically used on the finger or the earlobe that measure light wavelengths to determine blood oxygen level. More precisely, the light is a measurement of  the proportion of hemoglobin in the blood that is “saturated” with oxygen. A normal saturation level is 94% to 100%. Pulse oximeters also take a pulse, thus the “pulse” in pulse oximeter, and are commonly used in hospitals to monitor patients.

At-home pulse oximeters were in use before the COVID-19 outbreak, especially by people with chronic heart or lung problems. People getting supplemental oxygen use them to adjust the flow as needed, explains Albert Rizzo, M.D., FACP, chief medical officer of the American Lung Association. Some athletes use them for fitness monitoring.

Healthcare Leaders Form Taskforce On Telehealth

In late April, the American Lung Association put out a statement that quoted Rizzo as saying that “unless you have a chronic lung or heart condition that affects your oxygen saturation level on a regular basis, most individuals do not need to have a pulse oximeter in their home.” The same statement said the lung association advised against buying pulse oximeters unnecessarily.  

The role of pulse oximeters for people with chronic health problems that affect their lungs ad breathing is well established. Just as patients with chronic conditions use devices like blood pressure cuffs and glucose monitors, “home monitoring of oxygen is a way for patients to become familiar with their baseline saturation and to monitor themselves for decompensation,” says Lisa Moreno-Walton, M.D., FAAEM, a professor of emergency medicine at the LSU Health New Orleans School of Medicine and president-elect of the American Academy of Emergency Medicine. The patient and treating physician should determine a target number for when to seek medical help. Pulse oximetry can be a great adjunct to telemedicine, she says, providing useful information to inform further medical care. Ideally, patients should first use the device with guidance from a physician to be certain they’re using it correctly and that the readings are consistent with the pulse oximeters at the medical practice or hospital. 

Some physicians believe that pulse oximeters can save lives amid the COVID-19 outbreak by prompting people to get medical help sooner.  COVID-19 patients (how many is unclear) have shown up at the ED with “silent hypoxia,” abnormally low oxygen saturation levels without breathing difficulty. Silent hypoxia is not specific to COVID-19, but it may be more common than with other lung infections. 

Over-reliance on a pulse oximeter and a good saturation rate can give a false sense of security, warns Rizzo, because oxygen saturation and heart rate are only two factors for  determining a person’s condition. For COVID-19, Rizzo says that a doctor would also consider shortness of breath, fever, cough, gastrointestinal symptoms and headache.  

Pulse oximeters are available for as little as $25. It’s simple technology, says Rizzo. “You get what you pay for, but spending a couple hundred dollars isn’t necessary,” he explains, adding that if a cheaper one gives consistently accurate levels, it’s probably fine. 

Patients should know that a pulse oximeter may be less accurate if they’re wearing dark or gel nail polish, says Rizzo. Cold fingers
	or poor circulation may also affect pulse oximeters. People should
	not rely on a single reading and should take measurements multiple times throughout the day to
	evaluate trends. 

Now home from the hospital, Singer uses her $50 Ankovo pulse oximeter regularly. She also sent one to her college-age son as part of a care package - along with heart-healthy oatmeal.   

Deborah Abrams Kaplan covers medical and practice management topics.   

Early detection of low blood oxygen levels may detect ‘silent hypoxia’ seen in some patients with COVID-19. But the American Lung Association advises against buying a pulse oximeter unnecessarily.

At-Home Pulse Oximeters: The ‘It’ Gadget of the COVID-19 Outbreak 

By almost any measure, these are good times for Medicare Advantage (MA). Enrollment is growing, the number of insurers in the market is increasing, and gross margins are higher than in other health insurance markets. Some critics say the deck has been stacked in favor of MA and that the federal government is overpaying the insurers who offer MA plans relative to traditional Medicare. But for the legions of baby boomers who have become eligible for Medicare once they turn 65, the allure of MA plans - many with low or zero premiums, built-in Part D coverage, dental coverage, and other additional benefits - is strong. The trade-offs for beneficiaries are a narrower network of providers and managed care hoops to jump through, such as prior authorization and step therapy. 

The boom times are enticing new, smaller companies into the MA market, and some are bringing innovative offerings into the market. Meanwhile, private insurers, such as UnitedHealthcare and Humana, are working to move members over from employer-
	sponsored plans into MA plans when they hit their 65th birthday, and the federal government is making some effort to expand MA into rural and low-income populations where MA availability lags.

Mark Farrah Associates Assessed MA, Stand-Alone PDP Membership Trends

Medicare Advantage used to be called Medicare Part C, and it used to be the overlooked “middle child” of the Medicare program, sandwiched between Part A (for hospital coverage) and Part B (for physician services), and the upstart, Part D (for prescriptions), which became available in 2006. But according to data compiled by the Kaiser Family Foundation, enrollment in Medicare Advantage has been climbing steadily since 2004, when 5.3 million Medicare beneficiaries (13% of the total) were enrolled in MA plans. By 2019, that number had quadrupled to 22 million, and the proportion had grown to 34%. The Congressional Budget Office has projected that enrollment will continue to climb, so that by 2029, close to half (47%) of Medicare beneficiaries will be in MA plans. Twenty years from now, when the youngest baby boomers will be turning 76 and the oldest, 94, some projections show that 70% of Medicare beneficiaries in
	MA plans.

Provisions of the ACA that had the effect of lowering payments for MA plans were expected to reduce MA enrollment because it would make the program less attractive to insurers and beneficiaries. Quite the opposite has happened: Enrollment has doubled since 2010. Experts are still trying to figure out why. A 2019 Urban Institute report on the MA payment and enrollment question concluded that the payment cuts to the plans under the ACA weren’t as deep as expected for a variety of reasons. Indeed, the Kaiser Family Foundation’s math shows that between 2015 and 2018, the total of annual quality bonuses paid to Medicare Advantage plans has more than doubled, from $3 billion to $6.3 billion. The bonus payments are tied to quality scores, but some critics say they are flawed as indicators of the MA plan performance, instead rewarding plans for other factors, such as the relationship they have with providers and demographics of the beneficiaries. 

The overall upswing in MA enrollment does obscure some of the underlying variability. For example, geographically, enrollment is quite uneven. In six states (Florida, Hawaii, Minnesota, Oregon, Pennsylvania, and Wisconsin), more than 40% of Medicare beneficiaries are in MA plans, while in two states (Wyoming and Alaska), virtually none are. 

The Medicare Advantage market is brimming with plans today. For this plan year, over 3,000 plans were available, according to a Kaiser Family Foundation tally. CMS says that the average number of Medicare Advantage plan choices per county increased from 33 plans in 2019 to 39 plans this year. Kaiser’s numbers are lower (28 instead of 39) but still show an uptick. 

Insurance start-ups, such as Oscar and Bright Health, who were originally targeting the individual ACA exchange market, are part of the MA land rush. Oscar, based in New York City, started selling MA plan coverage in New York City and Houston this year. Bright Health, a Minneapolis company, started selling MA plans in seven additional markets. Devoted Health, in Waltham, Massachusetts, which bills itself as a “next-generation” MA plan, got started out in Florida markets and expanded into Houston for this plan year. 

Meanwhile, the large insurers continue to be the dominant players in the Medicare market, and they are adding hundreds of thousands of beneficiaries to their MA plans. UnitedHealthcare is the leader by far, with 26% of MA enrollees, followed by Humana, with 18%. Those two companies, along with CVS/Aetna and Blue Cross Blue Shield, have about 70% of MA enrollees in their plans.

The smaller companies bring innovations, while traditional healthcare companies cover the mainstream, observes Katie Guhr, president of Advantasure, a healthcare technology and information MA company in Glen Allen, Virginia. “It keeps the product from getting stagnant.”

Some of the major insurers that have been less active in MA market are recognizing the opportunity to provide coverage from the commercial market on through the MA, observes Guhr. She sees a resurgence of healthcare insurance companies recognizing that they have a place in the MA market: “There are more joint ventures than I’ve seen in a long time, leveraging subject matter expertise with unique fit in [the] marketplace.” 

Additionally, provider-insurer partnerships are popping up in the MA markets. Ascension Complete is an MA plan that is a partnership of Ascension, the large, not-for-profit Catholic health system, and Centene, which has expanded beyond its home turf, Medicaid managed care, into MA and other markets. Acquisitions are also reshaping the contours of the MA market, notes Guhr. Centene completed its acquisition of Wellcare in January. Anthem purchased a fast-growing MA plan in Florida called HealthSun in 2017; it bought another Florida plan, America’s 1st Choice, about a year later. 

MA enrollment tends to lag in rural areas. Many of the roughly 700 “low-penetration” counties, where 10% or less of Medicare beneficiaries are enrolled in MA plans, are in rural areas. Ramping up telehealth is one of the main goals of the Trump administration’s Rural Health Strategy. And starting this year, MA plans are allowed to include telehealth as part of their basic package, not just in the supplemental benefits.

In the past few years, CMS has also focused on “dual eligibles,” low-income seniors who qualify for Medicaid as well as Medicare coverage. Dual eligibles make up roughly 20% of the Medicare population. According to a 2019 report on MA by L.E.K. Consulting, enrollment in Dual Eligible Special Needs Plans, which are a kind of MA plan for dual eligibles, has been growing faster than enrollment in MA overall. 

CMS has also opened up MA rules so plans can now cover services to address the social determinants of health, including transportation, meals, and even cleaning. “We’re seeing a lot of organizations really trying to get their arms around community health,” says Guhr. And they’re recognizing the large variability in communities; a cookie-cutter approach doesn’t work for the dual eligibles. 

Both CMS and the Medicare Advantage plans understand that the senior population they serve is chronologically the same but changing in other ways. More marketing campaigns are conducted digitally and contain social media dimensions, says Guhr. The MA plans see that they need to get smarter about how they approach the consumer. “There’s recognition that a 65-year-old today is still relatively young, healthy, and active. The way 65-year-olds saw themselves in the 1990s or early 2000s is maybe in a state of relaxation - they earned their retirement,” Guhr says. MA plans have started to adjust by changing their marketing and communication strategies and adding benefits designed to prevent disease, not just treat it. 

Deborah Abrams Kaplan covers medical and practice management topics.

By almost any measure, these are good times for Medicare Advantage. Enrollment is growing, the number of insurers in the market is increasing, and gross margins are higher than in other health insurance markets.

These Are Boom Times for MA

There’s a reason that healthcare systems address social determinants of health (SDoH): Studies show that when patients have stable housing, nutritious food, and transportation to medical visits, their health improves and their use of the most expensive medical services, like visits to the emergency department (ED), decreases. SDoH are conditions that affect a person’s health, like where they live, their educational and socioeconomic status, and their social support networks. Healthcare systems around the country address various aspects of SDoH, whether in new, small pilot programs, or larger well-established ones.

Some of the most innovative programs are run through Medicaid plans. The Kaiser Family Foundation conducted a 2017 national survey of Medicaid managed care organizations, showing that more than 

90% of plans run at least one SDoH program

. “They are responding to what they see as needs in their community, and building around those needs,” said Jennifer Babcock, vice president for Medicaid policy at the Association for Community Affiliated Plans (ACAP), a national trade association representing not-for-profit safety net health plans, located in Washington, D.C.

Here are four programs making a difference.

 IPA practices in upstate New York wanted to make a referral to a social services organization, they consulted a resource guide. The problem? The resource guide was out of date even before it was published, as new programs popped up frequently.

Considering Social Determinants of Health in Reimbursement

“If we, as providers, struggle with that, you can imagine the burdens that our community members have accessing them,” says Michele Horan, the director of operations for the Healthy Together platform. Instead of providers calling, faxing, and emailing community-based organizations (CBOs) for referrals, they can now go through a web-based platform tying them all together. Healthy Together is the Alliance’s branded name for the 

 platform, integrating health and social care. Providers can now send and track referrals in a closed loop, documenting patient situations once so they don’t have to repeat their stories to every new agency.

“All the partners can communicate with one another (in Healthy Together) to ensure that someone doesn’t fall through the cracks,” says Keshana Owens-Cody, Alliance’s senior director of partner success.

Social service providers enroll in the network for free. Healthy Together currently has 20 service categories, 132 subcategories, and 75 enrolled organizations with 275 programs included. It actively recruits organizations to join the network and help onboard them. Given the relatively short time frame it’s been live, Healthy Together has not yet parsed the data to look at outcomes, but anecdotally it is thrilled with its connectivity, transparency, and ease of use.

Since starting its Wellness on Wheels mobile primary care clinic three afternoons a week in January 2017, OhioHealth decreased inappropriate ED visits by 50%. The healthcare system started its 

 in the YMCA parking lot in an impoverished and medically underserved neighborhood not far from one of its hospitals. Community health workers in the hospital setting encouraged patients to establish care at the mobile clinic, as many don’t have primary care physicians.

The Hilltop clinic is an expansion of the OhioHealth women’s health clinic, with a 26-year history. The 54-foot mobile unit has two exam rooms, housing clinicians and a social worker who screens for SDoH and make referrals in both settings, says Shannon Ginther, OhioHealth senior director of community health partnerships.  

 began offering the mobile unit and medical care for 225 Holocaust survivors in Central Ohio, partnering with Jewish Family Services (JFS) who provides wraparound services. About 225 survivors live in the area and “have an understandable mistrust and fear of healthcare providers,” Ginther says. Bringing the unit to the JFS parking lot and having JFS refer patients provides that trust. Most of the survivors live below the poverty level and have other social needs, with which JFS assists.

The programs are partly supported by outside philanthropic funding, and partly by OhioHealth itself. The clinic accepts insurance, if the patient has it.

The Sinai Urban Health Institute (SUHI), located in Chicago, started multiple SDOH programs over the years, based on where it sees community needs. That includes programs focused on diseases like diabetes, breast health, and asthma. They reduced asthma-related ED visits 

 and hospitalizations by 75% during the program’s first year, sending community health workers into patient homes for one-on-one education and assistance. 

SUHI recently did two large door-to-door surveys in different Chicago communities to pinpoint current needs and analyzed Chicago Department of Public Health data as well. As a result, the latest program is also using community health workers, often starting in the ED. SUHI trains them in core skills for motivational interviewing, home visits, and cultural competence.

“Utilizing healthcare workers can be a cost-effective way to reduce utilization,” says Stacy Ignoffo, SUHI’s director of community health innovations. “Our own research shows if we do some interventions, they can decrease healthcare utilization in expensive hospital and emergency room usage,” while increasing the less expensive outpatient care.

Like the OhioHealth Hilltop program, SUHI community health workers identify patients in the ED without primary care physicians, screening them for SDoH. After identifying needs, they provide referrals and follow up with patients in the home setting if possible, to ensure they’re connecting with the agencies, as well as with primary care providers. “We’re finding that primary care and food insecurity are up there in needs, as well as housing,” she says.

Housing is an important issue in Pittsburgh as well, and Medicaid plan 

 took this issue on for some of its patients in the Cultivating Health for Success (CHFS) program. “When looking into how to make an impact up to a decade ago, housing was number one,” says Dan LaValle, director of government programs, UPMC Health Plans. Until recently, the program targeted those who met the strict U.S. Department of Housing and Urban Development (HUD) definition of homelessness, with a goal of finding and placing up to 25 individuals in housing that year. Some stay with the housing program permanently, some move on, and UPMC is fine with either-it doesn’t place conditions on the patients.

Using a team and partnership model, UPMC community health workers, clinicians, and its partner, the local HUD vendor Community Human Services, work together to ensure the patients in the program get needed housing, medical care, transportation, food, and any other needs met. “The vast majority of individuals we serve have a significant number of chronic conditions and co-occurring behavioral health diagnoses,” LaValle says.

UPMC found it took 10 months of consecutive stable housing to get to the changes it wanted to see: better primary care trends and less ED utilization. “We now know that if we can get someone housed for 10 months, that will change their trajectory,” he says. With the program, those enrolled saved about $6,000 per member per year on expenses, which UPMC put back into the program.

It is starting to expand the program to those who don’t meet the HUD definition of homelessness but qualify for Section 8 housing vouchers. This population also has high needs, is not getting recommended medical screenings, and goes to the ED frequently. UPMC is using the same agency and model for partnership and case management, with some funding differences. One change is incentivizing providers with shared savings in a pay-for-performance model.

While 72% of hospitals are not investing in SDoH programs, according to a 2017 

 survey of 300 hospitals and health system, most that do limit their investments to a targeted small patient population, which may include high healthcare utilizers, or those who may be frequent ED visitors. Healthcare organizations don’t have to do it all by themselves, as UPMC showed. Partnering with other organizations can make a big difference.

Author | Deborah Abrams Kaplan

Articles

CT Scans for Diagnosing COVID-19? Not So Much.

At-Home Pulse Oximeters: The ‘It’ Gadget of the COVID-19 Outbreak

These Are Boom Times for MA

4 Top Successful Social Determinants of Health Programs