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News & Press: Statements and Letters

APSHO Statement on Oncology APs During COVID-19

Thursday, June 4, 2020   (0 Comments)

The novel coronavirus SARS-CoV-2 and its resulting disease state, COVID-19, pose a direct threat to overburdened US healthcare systems, as well as to healthcare providers, including advanced practitioners (APs) in oncology. The threat is not only health-related, but also professional, psychological, and financial. The impact of such challenges on oncology APs directly impacts the delivery, access, cost-effectiveness, and quality of patient care.

US Unemployment Crisis

The US Department of Labor released the March 2020 unemployment numbers on April 3, 2020 (U.S. Department of Labor, 2020). This report noted that the unemployment rate rose to 4.4% during March. The number of unemployed persons rose from 1.4 million to 7.1 million between February and March 2020. This sharp rise was attributed primarily to the effects of the coronavirus and efforts to contain it. Much of this increase in unemployment occurred in persons who were on temporary layoff (including furloughed persons), increasing from 1.0 million to 1.8 million. There was also a 1.4 million increase in individuals working part time for economic reasons from February to March 2020, with the increase primarily occurring due to slack work or business conditions. It is imperative to note that the March reporting period predated many business and school closures that occurred in March after the survey. While job losses occurred among all major worker groups, the report stated that notable increases occurred in healthcare-related jobs.

 

Financial Impact in the Healthcare Setting

 

Physician practices are experiencing adverse financial repercussions, with decreases in revenue and declines in patient volumes. A recent survey by the Medical Group Management Association (2020) of medical practices stated that 22% of practices surveyed had laid off employees and 48% had furloughed employees. These practices projected that by the beginning of May 2020, 36% would have laid off employees and 60% would have furloughed employees. A  HealthLandscape (2020) report stated that the potential impact of medical office closures due to COVID-19 pandemic would increase the county-level shortages (counties with more than 3,500 people per family medicine provider) from 750 counties by the end of March 2020 to 1,841 counties.

Hospitals and healthcare systems across the United States are being negatively impacted by the COVID-19 pandemic and resulting financial crisis. Adding additional ICU beds and supplemental personal protective equipment (PPE) in preparation for an anticipated increase of intensive services has come with a high price tag (Bartsch et al., 2020; Neighmond, 2020; Society for Healthcare Organization Procurement Professionals, 2020). Revenues have decreased for elective surgeries and procedures, routine care, and screenings.

There are negative downstream financial concerns as well, with many Americans losing their healthcare insurance due to job loss. To meet immediate financial concerns, responses have varied, but in many instances, include laying off or furloughing healthcare workers, including oncology APs (Paavola, 2020). Other efforts to reduce costs include reassignment of healthcare providers, including those in oncology, to higher volume areas; reduction of pay; reduction of work hours; and reduction of benefits such as paid time off accumulation and employer retirement contributions.

On April 3, 2020, Alatrum, a nonprofit research firm for government insurers, released a report that revealed a loss of 43,000 healthcare jobs in the first month of the COVID-19 economic crisis (Turner, 2020). These losses were focused in ambulatory care settings that included physician and dental offices, as well as other practices. Conversely, one of the biggest challenges many healthcare systems face is the need to expand the workforce to accommodate increased patient loads due to the COVID-19 pandemic.

Expanding the Workforce

The US Centers for Medicare & Medicaid Services (CMS) issued a blanket waiver on March 30, 2020, that allows hospitals to utilize APs to the full scope of practice in accordance with a state’s emergency preparedness or pandemic plan (CMS, 2020a; CMS 2020b; US Department of Health and Human Services, 2020a). This waiver will allow APs to work at the top extent of their training and licensure, thus increasing the workforce capabilities (US Department of Health can Human Services, 2020b). This waiver allowed multiple other restrictions to be lifted as well. Services that required direct supervision by a physician or other practitioner can be provided virtually using real-time audio/video technology (CMS, 2020b). Patients may now be under the care of an AP (nurse practitioner or physician assistant) while hospitalized (in accordance with the state’s emergency preparedness or pandemic plan). Advanced practitioners do not have to be licensed by the state in which they are providing services and may seek an 1135-based licensure waiver from CMS (if allowed by the state). This CMS waiver allows healthcare systems and hospitals to hire clinicians by removal of previous barriers that may have existed. Healthcare providers may enroll in Medicare temporarily to provide care during this pandemic. Other restrictions have been lifted as well.

 However, states have restrictive laws that may prohibit instituting these waivers; such obstacles must be resolved at the state level. There are differing state legislation approaches occurring in this emergent time, particularly with regard to APs’ scope of practice (AANP, 2020; AAPA, 2020, NASPA, 2020). Multiple professional organizations have appealed to state governments to issue orders to allow full scope of practice for APs, and many states have successfully passed legislation or enacted executive orders to address the pandemic crisis (ASHP, 2020, APA, 2020). States may limit increased scope of practice in various ways, such as allowing only those with a certain number of years of experience to practice at higher levels.


Caring for Individuals at Highest Risk

Another significant challenge during the COVID-19 pandemic is how best to care for a vulnerable population during this time. Individuals with cancer who are infected with COVID-19 are at higher risk for severe events, including death (Liang, et al, 2020). Those who have had chemotherapy within a few weeks of infection have poorer outcomes. Because of this, oncology healthcare providers are taking tremendous defensive measures. Personal protection provisions for cancer patients are essential. Oncology healthcare providers must have adequate personal protective equipment. Across the country, cancer centers are restricting visitors and companions in response to the known vulnerability of this population. Clinical trials are affected: recruitment may be hampered, protocols have deviations, and some patients may have to discontinue study drugs.

Prior to the COVID-19 pandemic, many Americans did not have affordable access to primary care. As noted above, there has been an unprecedented rise in the unemployment rate. It is projected that more than 7 million Americans will lose their healthcare insurance during this pandemic (Woolhandler & Himmelstein, 2020). States that turned down the Medicaid expansion through the Patient Protection and the Affordable Care Act will likely be the hardest hit, with the potential of a 40% uninsured rate. Prior to the pandemic, more than 25% of those with private insurance had an insurance policy deductible of $2000 or more (Kaiser Family Foundation, 2019).

 

 

Converging Issues and Unintended Consequences

 

Prior to the COVID-19 pandemic, there were shortages of oncology healthcare professionals in the United States. During this pandemic many hospital systems, academic institutions, and practices are furloughing staff, decreasing salaries, and cutting benefits to offset the loss in revenue as a result of mandatory limited exposure practices. Millions of Americans are losing their healthcare insurance. There are shortages of personal protective equipment. Oncology professionals are being diverted to treat COVID-positive patients, including APs, who are expected play a vital role in oncology care due to the projected (and current) shortages of oncologists. All of these converging issues could lead to the following unintended downstream consequences with the potential to adversely affect healthcare systems, medical professions, and patient outcomes:

 

1.     Increased exposure risk for oncology patients due to:

a.     Need for ongoing treatment requiring essential in-person visits to medical facilities for provider visits, diagnostic testing, and infusion services

b.     Limited personal protective supplies for patients and oncology professional

c.     Oncology professionals increased exposure to COVID-19-positive patients

2.     Decreased access to healthcare services related to pandemic delays and financial distress will lead to:

a.     Postponed cancer screenings that will lead to delays in cancer diagnosis, resulting in poorer outcomes

b.     Changes in the public’s view of the types of healthcare that should be required versus what can be considered discretionary

3.     Layoffs, furloughs, pay cuts, and loss of benefits to an already stressed workforce may contribute to:

a.     Increased shortages of oncology healthcare clinicians, including APs

b.     Increased shortages of primary care and subspecialty providers required for interdisciplinary management of complex oncology care

c.     Difficulty recruiting healthcare professionals, including hematology and oncology

d.     Financial burden associated with recruitment and retention of skilled, knowledgeable oncology healthcare practitioners

e.     Loss of trust in the healthcare system by patients, providers, healthcare workers, and the general public

4.     Increased “burnout” among healthcare professionals due to:

a.     Increased workloads with workload surge expected after COVID-19 crisis subsides

b.     Increased financial distress

c.     Loss of paid time off and/or sick leave to relieve furlough-related financial distress

 

APSHO’s Position

 

Based on these converging issues and the anticipated unintended downstream consequences of the COVID-19 pandemic, it is the position of APSHO that:

 

1.     All advanced practitioners should be allowed to practice at the top of their licensure.

2.     Oncology patients should be protected from potential COVID-19 exposure while receiving cancer treatment during the immediate crisis, reopening phases, and any potential surge. Methods employed should include:

a.     Screening of all staff and patients for COVID-19 symptoms

b.     Limiting visitors to the oncology care facility

c.     Supplying adequate personal protective equipment for oncology professionals, staff, and patients

d.     Providing oncology professionals the option to opt out of COVID-19 care without fear of retribution

3.     Healthcare facilities and employers should consider creative alternatives to revenue recovery methods, such as:

a.     Labor pools to redeploy and assign employees

b.     Optimizing outpatient services while maintaining COVID-19 precautions by extending hours, adjusting staffing, etc.

c.     Utilizing “downtime” to increase skills/knowledge of health-care providers

d.     Offering early retirement incentives for eligible staff and providers where volume recovery is not anticipated

4.     Healthcare facilities, employers, and government officials should consider:

a.     Offering disaster pay for hours lost

b.     Creating a relief fund for employees

c.     Providing retroactive pay for furloughed employees

d.     Permitting furloughed employees to work in other healthcare systems without fear of reprisals.

5.     Healthcare facilities, employers, and government officials should consider ways to assist employees to continue working under stressful working conditions by:

a.     Offering staff childcare

b.     Offering alternate housing for COVID-19-exposed employees to avoid the stress to the healthcare provider of potentially infecting their family

c.     Providing appropriate personal protective equipment

d.     Providing real-time, accurate and transparent information

6.     Healthcare facilities/systems should continue to provide essential medical services in the community while maintaining COVID-19 precautions by:

a.     Allocating healthcare resources including healthcare providers in a rational, ethic and organized manner

b.     Creative scheduling of patients/testing to continue required screenings and diagnostic testing

 

Statement published by APSHO Board of Directors, June 2020.

 

References

 

American Academy of PAs. (2020). COVID-19 state emergency response: Suspended/waived practice requirements. Retrieved from https://www.aapa.org/news-central/covid-19-resource-center/covid-19-state-emergency-response/

 

American Association of Nurse Practitioners. (2020). COVID-19 state emergency response: Temporarily suspended and waived practice agreement requirements. Retrieved from https://www.aanp.org/advocacy/state/covid-19-state-emergency-response-temporarily-suspended-and-waived-practice-agreement-requirements

 

American Pharmacists Association (APA); . (2020). Pharmacists as front-line responders for COVID-19 patient care. Retrieved from https://www.pharmacist.com/sites/default/files/Pharmacists_COVID19_4_3_2020.pdf

 

American Society of Health-System Pharmacists (ASHP). (2020). Pharmacy readiness for coronavirus disease 2019 (COVID-19). Retrieved from https://www.ashp.org/-/media/assets/advocacy-issues/docs/Pharmacy-Readiness-for-Coronavirus-Disease-2019-COVID-19-STATE.ashx

 

Bartsch, S., Ferguson, M. C., McKinnell, J., O’Shea, K., Wedlock, P. T., Siegmund, S. & Lee, B. (2020). The potential health care costs and resource use associated with COVID-19 in the United States. Retrieved from https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2020.00426

 

Centers for Medicare & Medicaid Services. (2020a). Coronavirus waivers & flexibilities. Retrieved from https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers

 

Centers for Medicare & Medicaid Services. (2020b). Physicians and other clinicians: CMS flexibilities to fight COVID-19. Retrieved from https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf

 

HealthLandscape. (2020). Potential impact of family medicine practice closures during COVID-19 pandemic. Retrieved from https://healthlandscape.org/covid19/PotentialImpactofFamilyMedicinePracticeClosuresDuringCOVID_20200408.pdf   

 

Kaiser Family Foundation. (2019). 2019 employer health benefits survey. Retrieved from http://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2019  

 

Liang, W., Guan, W., Chen, R., Wang, W., Li, J., Xu, K.,…He, J. (2020). Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China. Lancet Oncology, 21(3), 335–337. https://doi.org/10.1016/S1470-2045(20)30096-6

 

Medical Group Management Association. (2020). COVID-19 financial impact on medical practices. Retrieved from https://mgma.com/getattachment/9b8be0c2-0744-41bf-864f-04007d6adbd2/2004-G09621D-COVID-Financial-Impact-One-Pager-8-5x11-MW-2.pdf.aspx?lang=en-US&ext=.pdf

 

National Alliance of State Pharmacy Associations. (2020). COVID-19 information from the States. Retrieved from https://naspa.us/resource/covid-19-information-from-the-states/

 

Neighmond, P. (2020). Growing costs and shrinking revenues squeeze hospitals as they brace for coronavirus. NPR. Retrieved from https://www.npr.org/sections/health-shots/2020/04/06/828108255/growing-costs-and-shrinking-revenues-squeeze-hospitals-as-they-brace-for-coronav

 

Paavola, A. (2020). 150 hospitals furloughing workers in response to COVID-19. Retrieved from https://www.beckershospitalreview.com/finance/49-hospitals-furloughing-workers-in-response-to-covid-19.html

 

Society for Healthcare Organization Procurement Professional. (2020). PPE cost analysis. Retrieved from http://cdn.cnn.com/cnn/2020/images/04/16/shopp.covid.ppd.costs.analysis_.pdf

 

Turner, A. (2020). Health sector won’t be the backstop in this downturn. Retrieved from https://altarum.org/news/health-care-sheds-43000-jobs-march-biggest-loss-least-three-decades

 

U.S. Department of Health & Human Services. (2020a). Guidance for licensed pharmacists, COVID-19 testing, and immunity under the PREP act. Retrieved from https://www.hhs.gov/sites/default/files/authorizing-licensed-pharmacists-to-order-and-administer-covid-19-tests.pdf  

 

U.S. Department of Health & Human Services. (2020b). Topic collection: COVID-19 scope of practice expansions. Retrieved from https://asprtracie.hhs.gov/technical-resources/135/covid-19-scope-of-practice-expansions/99

 

U.S. Department of Labor. (2020). The Employment Situation — March 2020. Retrieved from https://www.bls.gov/news.release/pdf/empsit.pdf

 

Woolhandler, S., & Himmelstein, D. U. (2020). Intersecting U.S. epidemics: COVID-19 and lack of health insurance. Annals of Internal Medicine. https://doi.org/10.7326/M20-1491


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