No, California Nursing Homes Won't Really Have to Test Everyone for COVID-19

Hopes are for wider and regular COVID-19 testing at nursing homes to shine some light into California’s skilled nursing facilities - which have been closed to family members, regulators and public advocates since March. (Illustration by Teodros Hailye)

The White House asked for it; Newsom promised it. Experts say testing everyone is essential to controlling the virus in care homes. So why can’t we do it?

 

To fight the spread of coronavirus in skilled nursing facilities, California has not created one universal testing plan. Instead, it is permitting the creation of 1,224 of them. Plans for controlling the spread of COVID-19 are required; testing itself, for reasons both logistical and economic, is not.

A “phased” approach promoted by the state leaves creating and designing testing plans to nursing home administrators, advised by state and local health officials. Regulators have made every nursing home in California responsible for a coronavirus mitigation plan. But neither state guidance nor county advisories demand that skilled nursing facilities test every worker and resident on an ongoing basis. They also don’t set a goal for how long that testing will continue, whether for a period of time, or until certain public health goals are met, or until a vaccine exists.

Political and public health leaders say testing is essential to getting a handle on the coronavirus in nursing homes. Patient advocates and family members have criticized nursing homes as "black boxes," hard to see inside of, because of health orders demanding that regulators and visitors stay away.

As of June 10, long-term care residents and deaths make up 52% of California’s COVID-19 casualties during the pandemic. Nursing homes serving more black and brown residents have been harder hit.

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The California Department of Public Health said in a statement that developing testing in nursing homes “is a massive undertaking. ... It is not something that can be done well overnight.”

It’s been a heavy lift in other states, too. Only some have tested every nursing home resident in response to the pandemic; others say they won’t even try. Some of them, like West Virginia and Rhode Island, did so early. Pennsylvania has plans to implement universal testing by midsummer, but just once.

The White House urged state governors to mandate universal testing a month ago. But “universal” is a confusing term and subject to different interpretations. Some public health departments sent tests to every facility. Some have asked every facility to submit results or partnered with private labs to get tests done.

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California’s guidance-centered approach raises questions not only about the purpose and frequency of testing, but also about the efficacy of testing strategies in combating the spread of the coronavirus.

“It’s complicated and all over the map,” said Deborah Pacyna, spokeswoman for the California Association of Health Facilities, which represents about three-quarters of the state’s nursing homes.

A letter from the California Department of Public Health in early May requires nursing homes “to expand their existing infection control policies” within three weeks, developing a plan for testing residents and separating, or cohorting them, according to their COVID-19 status. Each nursing home also must have an infection preventionist, access to sufficient PPE, and policies to address staffing shortages. Later, the department followed up with testing and reporting recommendations. Nursing homes were supposed to submit COVID-19 mitigation plans to the state last week. It's not clear whether they'll be published.

Recommendations from public officials suggest “baseline” testing of all residents and workers in facilities where no cases are reported. If COVID-19 cases are then found, the state suggests surveillance testing every seven days among workers. To respond to an outbreak, the state suggests repeatedly testing among workers until no one tests positive for the virus. It’s not clear whether failing to do so will have consequences.

Nowhere does the state specify who’s paying for all of this — and that’s a concern for nursing home operators, most of whom are for-profit entities, arguing through national and local trade groups that they’re already operating on the slimmest of margins to stay in business.

“We have been estimating a minimum of $100 per test,” Pacyna said. Generally, nursing homes and state officials believe that testing for many nursing home patients may be billed to private insurance. But that’s not clear, and repeat testing for workers may not be easily covered.

The federal government recently provided $5 billion in public funds to nursing homes as emergency aid. The American Health Care Association and the National Center for Assisted Living, a national trade group, say that translates into potentially several hundred thousand dollars of funding  per facility. Trade groups are also lobbying for aid to assisted living or residential communities for the elderly, which count more beds and facilities in California, though fewer reported outbreaks.

Testing supplies themselves are often scarce, with counties and private companies scrambling to access them. That’s one of several reasons advocates criticize California’s plan as an unmanageable patchwork.

“The biggest problem is that there is no clear path to execution and enforcement of the mitigation plans,” said Mike Dark, an attorney with the California Advocates for Nursing Home Reform. In that respect, the new mandates leave us almost worse off than we were before, because they provide the illusion that comprehensive testing in nursing homes is underway when it is not.”

“I just worry about facilities all over the state,” said Maya Altman, who runs the Health Plan of San Mateo, which provides health coverage to underserved residents of that county, including in nursing homes. “It’s left up to the local jurisdictions how aggressive they’ll be.”

Larger and wealthier counties, like San Francisco, say they have paid for all or most testing in nursing homes. But they say they can’t afford such support forever. And advocates like CANHR’s Dark say they worry about what smaller and rural counties can afford. There’s no clear plan in any of these places when the money runs out.

“There needs to be an ongoing effort on the part of the state to get this done, with or without county cooperation, and these efforts must go on for months and maybe years,” Dark said.

As with all aspects of coronavirus response so far, county health departments in the Bay Area have each made their own recommendations. No Bay Area county says it has paid for all nursing home testing. Here’s how some counties that have experienced multiple outbreaks in nursing homes say they’re reacting.

  • Alameda County: The county says it has paid for nursing home tests when other resources were not available, but is offering no estimates about the cost to the county so far. “While there are federal resources to help cover laboratory costs, this resource may not continue indefinitely,” the county said in a written statement.
  • Contra Costa County: Contra Costa’s position is that facilities should bill the cost of tests through insurance; for uninsured residents of skilled nursing, costs can be recouped through the U.S. Department of  Health and Human Services.
  • Marin County: A new order requires congregate living facilities to “cooperate” with efforts to test residents and workers with their consent, with a goal of testing workers by July 6, and residents by the end of July. Facilities must report their testing data. The order doesn’t say who covers the cost of testing, but county health officer Matt Willis has said that facilities should be primarily responsible for testing costs.
  • San Francisco County: County health officials have funded some nursing home coronavirus tests at the Zuckerberg San Francisco General Clinical Lab and the county’s public health lab. Officials say they also expect to obtain reimbursement from insurers and from the federal government.
  • San Mateo County: The county isn’t tabulating testing costs, but facility assessment and overhead costs for supporting testing at all congregate living facilities has cost the county about $3.4 million a month so far, according to a spokesman for the county’s joint information center. San Mateo is expecting the Federal Emergency Management Agency to pick up half, and possibly as much as three-quarters, of this cost. But it’s not clear how long FEMA funding would support the county’s advising efforts. “We are looking for ways to continue the work within our current financial structures,” says the county’s statement.
  • Santa Clara County: The county has paid for some COVID-19 tests at long-term care facilities; it has received some testing for free from the Chan Zuckerberg Biohub laboratory. “The SNFs need to ramp up to be autonomous,” a spokesman said, “and the county is assisting them as they strive to reach that goal.”

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