Q 2 Lider

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April 13, 2020

The Honorable Nancy Pelosi Speaker of the House United States House of Representatives H-222, US Capitol Washington, DC 20515

The Honorable Kevin McCarthy Minority Leader United States House of Representatives H-204, US Capitol Washington, DC 20515

The Honorable Mitch McConnell Senate Majority Leader United States Senate S-230, US Capitol Washington, DC 20510

The Honorable Charles E. Schumer Senate Minority Leader United States Senate S-221, US Capitol Washington, DC 20510

Dear Speaker Pelosi, Leader McConnell, Leader McCarthy, and Leader Schumer, On behalf of the undersigned organizations, we are writing today to thank you for your leadership in response to the ongoing COVID-19 pandemic. We know that these are difficult times for so many, and we appreciate the bipartisan efforts by Congress to help healthcare providers, facilities and small businesses in these trying times. While we recognize that Congress has taken important steps to help mitigate this crisis, COVID-19 continues to spread and there is need for more protections and relief efforts to help our healthcare workforce.

As member organizations of the Patients Access to Responsible Care Alliance (PARCA), we represent non-MD/DO Medicare recognized healthcare providers who provide high-quality, evidence-based care to millions of Americans, especially to those living in rural and underserved areas. As the provider of choice for many patients, our members are serving countless essential and nonessential but critical healthcare roles during the pandemic. Many of the providers that we represent are working to the full extent of their clinical training during this crisis, stepping in to mitigate provider shortages by providing care that is within their scope but outside of their primary day to day responsibilities prior to the outbreak.

As you look to prepare the next relief package, we hope that you’ll keep these concerns in mind:

Hazard Pay for Healthcare Workers

All of the providers that we represent are working in situations where there is an increased risk of infection from COVID-19, often exacerbated by the lack of Personal Protective Equipment (PPE). Some are on the front lines performing intubations and treating COVID patients, while others are working day and night outside of the ICU to ensure that patients have access to the important and ongoing care that they need.

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We think that it’s important, as Congress considers hazard pay measures to support our healthcare workforce, that these measures be inclusive of all types of healthcare providers. We stand united in our support for hazard pay that includes all providers, in all settings, as no one who works in the healthcare space is immune from the heightened threat of COVID infection.

Data has shown that healthcare and mental health workers are particularly susceptible to COVID-191. As our providers work to continue care to as many people as they can, they are being asked to work longer hours, with greater exposure and a lack of available testing and PPE. We need to make sure that all healthcare providers are included in any hazard pay relief efforts and urge you to ensure that any package contains inclusive language.

Ensuring Access to Personal Protective Equipment, Testing, and Provider Safety

Unfortunately, we continue to see a lack of Personal Protective Equipment available for providers, especially providers who are continuing to interact with patients outside of the ICU setting. With continued concerns about the National Strategic Stockpile, states and facilities still struggling with limited resources, and a backlog in the production of new PPE, we are calling on Congress and the Administration to use their full powers to secure additional PPE through all available avenues.

We believe it’s important that the authorization within the Defense Production Act be utilized to its utmost extent to produce critical PPE and ventilators. With many locations expecting to reach peak COVID caseloads in the coming weeks and the possibility that other locations, especially rural locations, could peak later, it’s critical that we open the pipeline for PPE production as fast as possible.

It’s also important to ramp up production of PPE to ensure that all providers have access to needed protection. While we understand the need and urgency of getting PPE to the frontlines in hospitals and ICUs, this is leaving a dangerous gap in PPE for other providers. Many providers are caring for patients who have urgent and critical healthcare needs outside of the pandemic, but who are unable to access necessary PPE. The lack of PPE for these providers, coupled with the continued backlog and lack of readily available COVID-19 testing, creates a dangerous environment where healthcare providers may be unwittingly exposing themselves to infection while providing care to patients.

The lack of testing for healthcare workers is particularly concerning, leaving many providers interacting with patients who may infected but may not be symptomatic and unable to be tested. This lack of testing has the potential to increase transmission among both healthcare and mental

1 https://www.washingtonpost.com/health/health-care-workers-worry-about-coronavirus- protection/2020/03/05/be04d5a8-5e33-11ea-9055-5fa12981bbbf_story.html

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health providers and their patients, opening up unnecessary risks to everyone at a time when the healthcare system is already stretched thin.

Additionally, it’s important that healthcare providers who feel unsafe in their work environment have the ability to protect their own health. Providers who may be immunocompromised in a way that would normally not affect their job, may be at a highly increased risk due to COVID- 19. It’s paramount that as we watch so many healthcare providers step up to take on the challenge of COVID-19, that we provide more robust protections for those providers for whom this is an unsafe and potentially life-threatening situation. We call on Congress to enact further protections for these healthcare workers, by requiring the Occupational Safety and Health Administration to create more vigorous protections for healthcare workers, including those for whom going to work may be unsafe, through emergency temporary standards to protect workers from the potential COVID-19 pandemic.

Aid for Unemployed and Underemployed Healthcare Providers

While the CARES Act provided significant relief for small businesses and independent contractors, we are still seeing many healthcare providers and practices fall through the cracks. With the reduction and cancelation of elective procedures, many providers are now unemployed or underemployed. Compounding this issue, we have seen healthcare providers and other small businesses struggling to navigate the Paycheck Protection Program loan process, or be turned away by lenders, leaving them stranded and helpless. We cannot ask our healthcare providers to risk their lives caring for patients in their time of need, only to be abandoned when they’re struggling.

We are asking Congress to create a grant program that would specifically help healthcare providers remain whole during these tough times. We know that so many of our nation’s healthcare providers who are currently sidelined or facing significant reductions in their work and pay will become urgently needed again, should their communities face a COVID outbreak, or when facilities return to performing elective procedures faced with a major backlog. We hope that Congress will consider grants to healthcare providers and practices similar to what has been proposed by Senators Bennet and Barrasso in S. 3559/H.R. 6365, a bill with broad bipartisan support. We also encourage Congress to increase the cap on salaries that these grants can cover, as the proposed grants are below the level set in the Paycheck Protection Program. We think allowing healthcare providers to receive a certain percentage of their salary at the time of disruption would provide much needed relief.

Lenders are overwhelmed with a number of applications for assistance in these tough economic times. We are encouraged to see Congress considering increasing funds for the loan programs and lifting caps on what these institutions may lend, but there is an urgent need to provide relief specifically for our healthcare workforce now, through a grant program.

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Support for Rural Facilities

While the money provided through the CARES Act for hospitals was an important step towards ensuring that hospitals can remain open and solvent, it has created fierce competition among hospitals, with rural and critical access hospitals forced to compete with larger urban hospitals who typically have more resources. With this in mind, we are calling for a direct grant and loan program to help these smaller rural and critical access facilities.

These rural hospitals were already facing critical shortfalls and financial distress even before the current pandemic. A recent study by the Chartis Center of Rural Health showed that 120 rural hospitals have closed in the last decade and the rate of closures continues to increase.2 The problem is getting worse, with one out of every four rural facilities at risk for closure.3

Unfortunately, the COVID-19 pandemic will only exacerbate this problem, as rural and critical access facilities face the double hit of being forced to cancel elective procedures which provide revenue, and the potential that COVID-19 cases could start to rise in the coming weeks, just as these facilities are in dire economic straits4.

The providers we represent tend to predominate in these facilities, which serve populations that tend to be older and more susceptible to the COVID-19 virus. With their resources already spread thin, a surge of COVID cases could prove disastrous to many of these facilities. We have also witnessed the reallocation of resources from these facilities to help urban facilities that are overwhelmed, such as in New York state, which in turns leaves these facilities even more vulnerable to a potential future spike. We must make sure that these facilities have the resources they need to stay open, to prepare for a surge in COVID-19 cases, and to avoid detrimental layoffs of staff, so that they can continue to serve our most vulnerable populations.

Increased Access to Telehealth Services

Finally, there is a need to continue to increase access to telehealth services. As healthcare and mental health providers work to continue to provide care for our patients in the safest way possible, it’s clear that removing barriers to telehealth practice and ensuring that all providers are able to treat patients and be properly reimbursed for those services is crucial.

Many of the providers that we represent offer important healthcare and mental health services that can be delivered by telehealth. Telehealth should be implemented to the full extent and made as flexible as possible. Unnecessary barriers in the delivery of telehealth should be removed and telehealth access should be expanded by establishing coverage of audio-only services. Millions

2 https://www.ivantageindex.com/wp-content/uploads/2020/02/CCRH_Vulnerability-Research_FiNAL- 02.14.20.pdf 3 https://www.forbes.com/sites/claryestes/2020/02/24/1-4-rural-hospitals-are-at-risk-of-closure-and-the- problem-is-getting-worse/#4abd2b3d1bc0 4 https://thehill.com/homenews/state-watch/491032-rural-america-braces-for-coronavirus

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of Americans do not have the reliable broadband access needed to support full audio-visual telecommunications. Expanding access to telehealth will help minimize the disruption to the healthcare system, allowing some patients to continue to access healthcare in a safe manner during the pandemic. We support including the Creating Opportunities Now for Necessary and Effective Care Technologies Act or CONNECT for Health Act (S.2741/H.R.4932), in the next COVID relief package. Additionally, Congress should continue to encourage the Administration to use the authority granted to it under section 3703 of the Coronavirus Aide, Relief, and Economic Security Act to make as many healthcare providers eligible to provide telehealth services as possible.

As a coalition, PARCA wants to make sure that any relief efforts are inclusive of all provider types. It’s important that we care for all our providers during this emergency to ensure that we are able to provide the highest level and the widest breadth of care to those in need. The suggestions that we have made are necessary for the healthcare industry, to keep providers protected, safe and able to care for patients.

We hope that you and your colleagues will consider these ideas as you work on developing the next package of COVID relief. As always, the PARCA coalition and our members organizations stand ready to be a resource to Congress and the Administration as you continue these important updates. Please don’t hesitate to reach out to PARCA Chair Ben Wallner at [email protected] or to any of our member organizations if we can be helpful.

Signed,

American Academy of Audiology American Academy of PAs American Association of Nurse Anesthetists American Association of Nurse Practitioners American Chiropractic Association American College of Nurse-Midwives American Nurses Association American Occupational Therapy Association American Physical Therapy Association American Psychological Association American Podiatric Medical Association American Speech-Language-Hearing Association National Association of Pediatric Nurse Practitioners National Association of Social Workers National League for Nursing