What Health Systems Need to Know About COVID-19 Relief Funding

According toKaiser Health News, almost half of U.S. adults report a member of their household has postponed healthcare during the pandemic. For healthcare organizations, the deferral of routine and non-emergent care has meant steepdeclinesin volumes, and therefore revenue, across the healthcare setting, from regular primary-care and specialist visits to emergency and surgical care.

作为3万亿美元COVID-19刺激方案的一部分，美国国会为医院和其他医疗保健提供商提供了1000亿美元的资金，以应对医疗保健行业的财务压力。虽然这种援助显然解决了一种财政需求，但有关资金使用的规章制度却不那么直接。有关合格支出、风险和合规要求的条款和条件没有得到很好的定义，导致卫生系统没有明确的前进道路。

Prevent, Prepare, Respond

There are many sources of funding support from federal agencies (e.g., the CDC, HHS, U.S. Treasury, and more), which distribute the funds in many ways. Funding covers both short and long-term relief.

For providers to use COVID-19 stimulus funds to keep organizations financially viable and able to serve their communities, financial leaders need to understand where they can apply each type of loan or grant and how to stay within legal compliance. Effectively leveraging these stimulus funds early will help organizations resume effective, profitable operations and prepare for healthcare’s post-pandemic landscape, while properly documenting the use of the relief will help providers stay within compliance.

New Laws Aim to Promote Healthcare Economic Recovery

The following laws passed between March and June 2020 aim to help healthcare organizations recover financially from COVID-19-related drops in volume and best respond to the emergency and the new healthcare landscape.

The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020

Congress launched relief efforts with a March 6, 2020, bill for $8.3 billion, theCoronavirus Preparedness and Response Supplemental Appropriations Act, 2020(H.R. 6074). This bill provides money for theDepartment of Health and Human Services(HHS), the Department of State, and the Small Business Administration. Funding covers vaccines and other medicines; grants for local, state, and tribal public health agencies; loans for affected small businesses; and evacuations and emergency preparedness activities at U.S. embassies and other State Department facilities. H.R. 6074 also allowed HHS to waive restrictions for telehealth (e.g., extending telehealth benefits to all Medicare beneficiaries).

Families First Coronavirus Response Act

Congress passed theFamilies First Coronavirus Response Act(FFCRA), or H.R. 6201, on March 18, 2020, for $3.5 billion. The bill focuses on COVID-19 testing (reimbursingcost for uninsured individuals), unemployment, and sick leave. It also offers tax credits for sick and family leave, increased theFederal Medical Assistance Percentage(FMAP) for Medicaid by 6.2 percent, and expanded food assistance through theSupplemental Nutrition Assistance Program(SNAP).

The CARES Act Provider Relief Fund

TheCoronavirus Aid, Relief, and Economic Security Act(第748号决议)，更广为人知的名字是《关怀法案》，于2020年3月27日通过。该法案耗资2.2万亿美元(迄今为止最大的一揽子救助计划)，重点是为受2020年冠状病毒大流行影响的个人、家庭和企业提供紧急援助和医疗响应。这些基金适用于个人失业、大小企业、公共卫生和教育，并为州和地方政府提供了安全网。

For the healthcare industry, the CARES Act offers a $100 billion Provider Relief Fund, with $10 billion earmarked for rural grants, $.4 billion forIndian Health Services以及296亿美元用于专业护理设施(SNFs)、未来的热点地区和未参保人群。在这笔资金中，500亿美元以“总分配”形式分配，用于支付与医疗相关的费用或与冠状病毒相关的收入损失。要符合总分配的资格，提供商必须在2019年支付医疗保险服务费用，并在2020年1月31日或之后为可能或实际感染COVID-19的个人提供诊断、检测或护理。供应商救援基金还向受COVID-19严重影响的医院、农村供应商和其他方面发放了救济品(“定向救济品”)。

The Provider Relief Fund General Distribution funding is a grant, not a loan; meaning recipients don’t have to repay it. The $50 billion was distributed in two rounds:

• 2020年4月10日，300亿美元汇至供应商账户。
• 200亿美元的拨款，从2020年4月26日开始。

As a grant, Provider Relief recipients must sign in and attest to terms and conditions within 90 days of receiving payment. According to public distribution data, for the $30 billion round,318,168截至2020年5月底，供应商已认证/收到一笔拨款。提供者救助基金的分配基于2019年提供者在医疗保险按服务收费补偿总额中的份额，目前不得将受助人排除在医疗保险参与之外。提供商只能将支付用于预防、准备和应对冠状病毒，以及报销医疗相关费用或收入损失。提供商同意接受付款，不向COVID-19的投保患者发送意外账单(“意外”账单)。提供者不能收取高于患者支付的网络内医疗费用的费用分摊。

收到超过15万美元的供应商必须在季度结束后不迟于10天提交报告。报告包括收到和支出的资金数额、行动、项目、创造或保留的就业机会、分包合同以及审计合作协议的详细清单。卫生与公众服务部推迟了6月30日的报告提交时间。该机构将在接下来的几个月发布额外的指导意见。

The Provider Relief Fund includes aCOVID-19 High-Impact Allocationof $12 billion, intended for testing, staffing, and lost revenue. High-impact dollars went to395 hospitalswith the highest proportion (70 percent) of COVID-19 inpatient cases, and the fund also has provisions for rural facilities, skilled nursing facilities, and health centers.

The Paycheck Protection Program and Health Care Enhancement Act

Signed on April 24, 2020, for $484 billion, thePaycheck Protection Program (PPP) and Health Care Enhancement Act是《关怀法案》的延续该计划为农村和印度医疗服务机构设立了专项拨款，明确了获得救济的资格，并围绕净收入和受灾最严重地区对医院的拨款进行了调整。

Congress continued economic stimulus with thePaycheck Protection Program Flexibility Act of 2020(H.R. 7010), which passed on June 3, 2020. This bill extends PPP coverage from 8 to 24 weeks and maturity from two to five years, reduces minimum spend on payroll from 75 percent to 60 percent, and establishes new safe harbors for forgiveness.

More Provider Support

In addition to grants and loans, providers have more ways to access COVID1-19-related funding:

• UnderCOVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured在美国，卫生系统可以申请报销2020年2月4日以后未参保的COVID-19检测和服务。
• CMS suspended the加速和提前付款计划for re-evaluation in April 2020, but the loan aimed to accelerate health system cash flow, with for COVID-19 expenses, lost revenue, personal protective equipment, other supplies, construction, and capacity surge.
• 医疗服务提供商也可以通过账单流程获得资金，因为联邦医疗保险已经暂停了计划中的较低支付，并将为COVID-19患者增加20%的MS-DRG支付计划。
• Physicians and small providers(i.e., small businesses) with fewer than 500 employees can apply for funding via the PPP.
• Under the Federal Communications Commission, theCOVID-19 Telehealth Programprovides $200 million in funding to help healthcare providers offer connected care services to patients at their homes or mobile locations.
• State and local governments and private nonprofit groupscan apply for assistance for public health emergency management activities for prevention and response to COVID-19 through theFederal Emergency Management Agency(FEMA).
• Waivers are not a direct source of funding. However, during an emergency, they put aside some of the regular compliance requirements for provider reimbursement. Examples include increasing hospital capacity (temporary sites), removing barriers for hiring and retaining professionals, and expanded telehealth services.

Compliance: Using Provider Relief Fund Dollars

美国卫生与公众服务部表示，根据提供者救济基金的总分配(500亿美元)，它将每个患者视为COVID-19的可能病例，从而对潜在患者进行了广泛的定义。这扩大了法定语言中可能的资格费用范围。然而，更多的解释和更多的资源正在出现，以帮助提供者了解刺激计划的条款和条件。

The General Distribution calculates distribution based on the lesser of 2 percent of a provider’s 2018 net patient revenue or the sum of incurred losses for March and April 2020. For the Targeted Distributions, each grant/loan has its own payment methodology (e.g., rural hospitals have a base payment plus a percentage of operating expenses and so forth and high-impact stimulus is based on a fixed amount per admission).

The key HHS term regarding appropriate use of Provider Relief Funds has two parts, operating on the principle that any patient is a possible coronavirus patient:

1. The funds have to be used to prevent, prepare for, and respond to coronavirus (i.e., direct expenses for COVID-19 or probable COVID-19 patients).
2. The funds will reimburse only for healthcare-related expenses or lost revenues attributable to coronavirus (requiring providers to demonstrate and document lost revenues during the COVID-19 emergency period).

The Fine Print: Statutory Language and Provider Relief Fund FAQ

As health systems enter the post-emergency period, many are wondering what they can spend the money on. This is where it helps to dig into some of the statutory language and FAQ guidance.

The statutory language has not provided that clarity that health care organizations need. HHS has provided more clarity in its FAQs on what healthcare-related expenses are appropriate expenses for use of the funds.

The term “healthcare-related expenses attributable to coronavirus” is broad and may cover a range of items. The FAQ provides that qualifying expenses include the following:

• 用于向可能或实际的COVID-19患者提供医疗保健的用品和设备。
• Workforce training.
• Reporting COVID-19 test results to federal, state, or local governments.
• Acquiring additional resources, including facilities, equipment supplies, healthcare practices, staffing, and technology to extend or preserve care delivery.

The above are examples as well as other documented healthcare expenses incurred to prevent, prepare for, and respond to coronavirus qualify as healthcare-related expenses attributable to coronavirus.

Lost Revenue

Providers can also use the Provider Relief Fund to cover any costs that lost revenue otherwise would have included—within the qualification of preventing or preparing for the response to coronavirus. These costs do not need to be specific to providing care for possible or actual coronavirus patients.

Qualifying lost-revenue expenses include the following, without limitation:

• 雇员或承包商的工资表。
• Employee health insurance.
• 房租或抵押贷款。
• Equipment lease payments.
• 电子健康记录许可费。

以上是常见问题中提供的例子，但是，一系列其他业务费用也属于收入损失类别。收入损失类别不受直接医疗报销条款的某些限制，这意味着它涵盖更广泛的运营费用。Organizations need to demonstrate the amount of lost revenue and must be able to track their expenses.

Additional terms and conditions of note include using funds to reimburse healthcare expenses (i.e., a payer of last-resort provision). Providers can’t have another payer reimbursing them for those same expenses. There is a no balance billing provision, which applies to COVID-19 patients. There are also political limitations that prohibit the use of the money for executive pay, gun control, advocacy, lobbying, and more.

Compliance with the Provider Relief Fund Terms and Conditions

卫生系统必须按照法定要求和卫生与公众服务部的条款和条件使用提供者救济资金。要求包括验证条款和条件，定期报告(跟踪费用)和准备审计。

Healthcare organizations may find themselves in one of three situations regarding compliance:

1. Comfortable, with good staff to support compliance.
2. In need of some help (e.g., external consultants and advisors).
3. Concerned about returning the funds due to a lack of understanding and guidance.

HHS intends for relief funds to help, not penalize providers (i.e., keep them out of the third category above). There will be audits and accountability, but there is also a lot of flexibility built into compliance. The Provider Relief Fund FAQs provide more guidance on the Provider Relief Fund terms and conditions.

Attestation and Reporting

如需核实及报告，基金受助人必须以书面证明确认同意上述条款及条件。这个截止日期(可能会再次改变)是90天。例如，4月10日收到的资金延期至7月11日，4月24日收到的资金延期至7月23日。在报告方面，收到15万美元以上的提供者必须提供其使用资金的所有项目和活动的季度报告。Quarterly reports must include the following:

• The total amount of funds received.
• Amount of expenditures.
• 所有项目和活动的详细清单。
• Estimated number of jobs created, only if applicable.
• Detailed information on subgrants and subcontracts awarded.

Policy Changes: What’s Coming and What’s Needed

From a data and analytics perspective, one of the critical opportunities COVID-19 has exposed is the need to share data better—making available aggregated and de-identified information to public health authorities, research organizations, and academic medical centers. The crisis has made existing barriers stark, as they’ve prevented disclosure of de-identified and limited dataset information that could be vital in pandemic management and recovery. TheHHS Office for Civil Rights(OCR) has waived certain HIPAA provisions, but researchers and providers need greater access to information to make an impact.

The Provider Relief Fund and other relief dollars became available rapidly. In the next round of legislation, there may be a more-targeted, grant-based process for funds distribution, as well as infrastructure for public health development, data infrastructure development, and reporting surveillance, both for health and hospital systems, as well as for localities and states. As some of those funds have already come through to states and localities for further distribution, it’s worth questioning whether the existing systems the CDC, states, and other federal agencies have in place are sufficient. The infrastructure to quickly aggregate and report data in an emergency is generally lacking.

As part of the infrastructure, thenational patient identifieris controversial. It was frozen in Congress two years after HIPAA was enacted in 1996 but is re-emerging in 2020. Nothing could have put the choice between more privacy restrictions and saving lives more starkly than the COVID-19 emergency—both on the policy side, as well as the provider side. Privacy advocates may now realize better data infrastructure will help them find their patients across a longitudinal care journey and use that information in an emergency and for non-emergency public health purposes.

未来一两年的立法可能涉及进一步扩大数据共享，至少在紧急情况下，以及出于公共卫生监督的目的。这些规定对于应对未来一波又一波的COVID-19或其他突发公共卫生事件具有重要意义，并将随着时间的推移改善公共卫生应对和监督。

Preparing for an Extensive, Dynamic Process

With no known endpoint to COVID-19’s impact on healthcare delivery, healthcare organizations must prepare for an ongoing economic recovery process. If the many new bills and policy changes of March through June 2020 are any indications, the industry can count on continued refinement of existing acts, possible additional stimulus dollars, infrastructure for public health development, and changes in policy to remove barriers to data sharing both during a public health emergency as well as in the new normal. As the funds from the various COVID-19 packages are subject to audit and review for several years, providers must continue to document the usage of the funds for the foreseeable future. Further clarification from HHS on qualifying use of the funds and on reporting requirements is likely.

Also, based on the impact of COVID-19 on older Americans and the highest risk for those with chronic conditions as well as disparities in health outcomes for racial and ethnic minority groups and low-income populations, theCMSis asking for a renewed commitment tovalue-based care.

Additional Reading

你想了解更多关于这个话题吗?Here are some articles we suggest:

1. Activity-Based Costing in Healthcare During COVID-19: Meeting Four Critical Needs
2. How to Scale Telehealth Solutions to Increase Patient Access During COVID-19
3. How Data Transforms the Hospital Command Center to Pandemic Proportions
4. Restarting Ambulatory Care and Elective Procedures: Analytics Guide Safe, Pragmatic Decisions
5. Health Systems Share COVID-19 Financial Recovery Strategies in First Client Huddle