Coronavirus creates shortages of drugs and sedatives for ventilator patients

Concern about the availability of medications that are used to treat specific chronic diseases such as lupus and rheumatoid arthritis that have been diverted for the treatment of COVID-19 patients was subject to a hearing in the Senate Health and Welfare Committee on Wednesday. Committee members want to ensure that there is an adequate supply of those medications, specifically hydroxychloroquine, for individuals who have been dependent on them for their chronic diseases.

University of Vermont Larner College of Medicine Dr. Lindsay Smith and University of Vermont Medical Center Director of Pharmacy Dr. Wes McMillian participate on a University of Vermont Health Network therapeutics working group that plans for hospital COVID-19 admissions and drug supply issues. They said the hospital has put in place policies to restrict providers from ordering hydroxychloroquine for off-label indications and has developed a treatment algorithm to guide physicians on when a COVID-19 patient should receive hydroxychloroquine. McMillian said UVMMC has enough hydroxychloroquine at the hospital pharmacy and hospital retail pharmacy for the treatment of lupus and rheumatoid arthritis inpatients, for COVID positive inpatients, and for the maintenance treatment of lupus and rheumatoid arthritis individuals to continue home medication.

Office of Professional Regulation Lauren Hibbert and Secretary of State Board of Medical Practice General Counsel Gabe Gilman informed the committee of its Emergency Regulatory Order issued on April 10 to Vermont pharmacies and pharmacists to employ enhanced drug utilization review to curb inappropriate prescribing of drugs believed to be under investigation for COVID-19 indications. Hibbert said interest in these potential therapeutic drugs has contributed to unjustified off-label use in patients. Gilman said the order requires pharmacists to perform a review to make sure the script makes pharmacological sense. Guidance released by the Vermont Department of Health did influence the conduct of instate physicians, but Vermont pharmacies on border states are seeing and reporting troubling stories. This action was needed to empower pharmacists to put a decisive halt to this inappropriate prescribing activity.

Vermont Association of Hospitals and Health Systems Vice President of Government Relations Devon Green said her organization worked with its counterparts in Maine and New Hampshire to send a letter to the state emergency management offices in each state requesting the immediate release of critical drugs from the Strategic National Stockpile. Green said hospitals are experiencing a surge of coronavirus patients and are struggling to maintain supplies of antibiotics, antivirals, sedatives and paralytic agents required for patients on ventilators. Green said even prior to the surge, demand is already outpacing supply and exhausting current allocations.

The committee will take more testimony next week.

Agency of Human Services Secretary updates health care committees on COVID-19 response

The House and Senate Health Care Committees held a joint meeting on Tuesday to hear a COVID-19 response update from Agency of Human Services Secretary Mike Smith. Smith began by praising the his agency’s work over the past few weeks and thanking the legislators for the quick passage of H.742, an omnibus health care and human services bill that addresses the state’s response to COVID-19.

During his high level overview of the agency’s COVID-19 response measures, Smith reported that 13 providers have received a total of $825,000 in funding from the Medicaid retainer process for providers – one of several provider financial relief mechanisms that the agency is pursuing as part of a multi-phased plan with tracks for different types of provider organizations. Thirty-five more applications are pending, and Smith said that although there is no set cap on the total funding amount, the agency “isn’t giving everyone the amounts they asked for.” Smith added that they are “hoping to recoup some of the funding from future Medicaid payment,” suggesting that the relief payments are at least partially loans.

Smith also stated that the “state is in pretty good shape with personal protective equipment” and if people are saying that they don’t have PPE, they need to contact the state, because “we have PPE.”

Additional measures that Smith reported that AHS is taking is the expansion of the Vermont Health Connect Qualified Health Plan open enrollment period to May 15, and a plan to provide some sort of aid for the designated mental health agencies and specialized services agencies to provide a pay bump for staff. Smith said that details on that plan will likely be released at the end of the week.

A detailed report on the measures that AHS has taken to implement Act 742 (Act 91 of 2020) can be found here.

New incentive pay program for essential workers proposed

The Senate Appropriations Committee met on Friday to consider a new grant program that would provide incentive pay to essential workers identified in Executive Orders issued by Gov. Phil Scott. Committee Chair Jane Kitchel, D-Caledonia, said that a special work committee established by Senate President Tim Ashe, D/P-Burlington, is attempting to address the issue of essential workers who continue to work, risking exposure to the COVID-19 virus, but who are in a worse financial position than individuals who held similar jobs and choose not to work and receive unemployment benefits.

The voluntary program would be employer-based and would require employees to meet certain criteria. Employers would have to verify employee information. Monthly grants would be provided to eligible workers at the end of each month.

Eligible employees would include frontline workers earning $20 an hour or less as a base wage who are employed by nursing homes, residential care homes, assisted living residences, home health agencies, health care facilities, community health centers, therapeutic community residences, dental and physician offices, child care facilities, ambulance services, grocery stores, pharmacies, mortuaries, and certain retail entities. 

Kitchel told the committee that the program would be paid for with federal COVID-19 relief funds. Given the urgent nature of the problem, the committee would like to get the program set up quickly to begin making the payments and backfill the funds when federal funds arrive.

The committee will meet again early next week to consider whether $20 an hour is an appropriate base wage or if it should be higher, and whether an employee would be excluded from the grant if their employer has already provided a financial incentive.

The Senate has begun discussions with the House and the governor in an effort to expedite the proposal. Committee members questioned if this could be done faster administratively versus through the legislative process.

Health panels receive update on federal funding

The Senate and House Health Care Committees met jointly on Thursday for an update on federal funds available to Vermont. Agency of Human Services Chief Financial Officer Sarah Clark reported to the committee that AHS has been working with the Department of Finance and Management to establish a federal funding hierarchy for the state.

The state is prioritizing AHS specific grants that require no state match and cover known expenditures. The state has already received a $4.3 million grant to stabilize the child care system and provide child care for essential workers, and a $4.9 million Centers for Disease Control Public Health Emergency Response Grant that the Vermont Department of Health is using for disease testing and monitoring. The Department of Disabilities, Aging and Independent Living has also received funding for family caregivers.

The state will next be looking to Vermont’s $1.25 billion share of the Coronavirus Relief Fund for areas of need not covered by the block grants or to cover block grant short-falls. The state is waiting for more specific details on how the funding can be spent, but it cannot be used to replace lost state revenues or supplant previous appropriations. Sen. Ginny Lyons, D-Chittenden, said that the Joint Fiscal Committee will be working closely with the administration on prioritizing spending, and that it will be key to have recommendations from legislative committees. Medicaid has also provided a 6.2 percent Federal Medical Assistance Percentages bump, which brings federal Medicaid participation to roughly 60 percent. Because of the required $38 million state match, the Agency of Administration is preparing a FY 2020 Budget Adjustment Act supplement.

Additional federal relief funds that are being paid directly to providers include two separate pools of money released by the Health Resources and Service Administration for federally qualified health centers, and provider relief distributed based on Medicare fee for service payments from 2019. So far, 1100 Vermont providers have received a total of $54 million through the fund and the state is still working with the federal Health and Human Services to resolve underpayment due to Vermont’s All Payer Model.

Hospitals in the midst of COVID-19

The House and Senate Health Care Committees met jointly on Thursday to take testimony on the status of hospitals in the midst of the COVID-19 crisis. Vermont Association of Hospitals and Health Systems Vice President of Government Relations Devon Green reported that hospitals have been able to move quickly to respond to the crisis by taking steps such as establishing parking lot testing, executing surge planning, housing providers, and working on personal protective equipment procurement. Vermont hospitals are working in a coordinated manner with other provider communities and the state and are sharing data and resources.

Green noted that the “hospitals have been investing in these efforts to ensure proper care through the epidemic while seeing a 50-70 percent loss in revenue due to the suspension of non-essential procedures.” Hospitals have been able to receive some federal financial relief from the Accelerated/Advance Payment Program, but some hospitals must pay back the funding within 210 days and other hospitals must pay back within 365 days or else be subject to a 10.25 percent interest rate. Almost all of the hospitals have also received some Coronavirus Aid, Relief, and Economic Security Act funding, but complications with the calculation of the payment resulted in a lower than expected payments. VAHHS, OneCare Vermont, and state partners are working with the U.S. Department of Health and Human Services to remedy the issue.

Brian Nall, President and CEO of North Country Hospital, emphasized the economic hit that his hospital is taking saying it had a positive operating margin in 2019, but will likely lose $21 million in FY2020. The revenue loss is due to the suspension of all of their “bread and butter services,” including elective surgeries. More than 145 hospital staff have been furloughed, which represents 35 percent of their workforce. The hospital has received $8 million in federal loans, and $1.3 million in federal relief money. With this, Nall said the hospital could operate at their current state through June.

Panel seeks funding for Emergency Medical Services

The Senate Committee on Government Operations is drafting language that will direct the Department of Health to immediately disburse unencumbered money from the Emergency Medical Services Fund to help EMS providers with crisis response costs. The money would be disbursed through the EMS Advisory Council. The committee is also asking EMS providers what level of financial assistance they will need through September and will be writing a letter to the Department of Finance and Management and Gov. Phil Scott requesting that the needed amount be taken from about be placed in the EMS fund from Vermont’s $1.25 billion CARES Act funding and be placed in the EMS Fund.