May 27, 2020, Alex Spanko, Skilled Nursing News - Over the holiday weekend, the Associated Press published an article on the frustratingly slow progress of universal COVID-19 testing in nursing homes. The news agency rightfully pointed out that due to the logistical challenges of supplying and executing 1.3 million tests for each of the nation’s nursing home residents, such a task would be difficult to achieve — not to mention the estimated one-time cost of $440 million, as well as persistent shortages of testing equipment and processing delays.
But the AP’s framing, which I’ve seen other news sources mirror in their coverage, contains a fatal flaw as evidenced by its headline: “White House goal on testing nursing homes unmet.”
As someone who covers the industry, my first reaction when scrolling past this headline on a lazy Memorial Day weekend was that of panic: Had I missed some kind of formal announcement on COVID-19 testing weeks before? Was there a major deadline that I had somehow neglected to hear about?
The answer, as I read through the article, turned out to be no on both counts. This “White House goal” amounted to nothing more than internal comments that were amplified by a president prone to making bold, off-the-cuff declarations — then repeated by a press that didn’t completely dig into the details.
At best, calling it a “White House goal” is a misleading oversimplification. At worst, it’s a dangerous misunderstanding of a landscape in which leaders are demanding specific actions from a beleaguered health care industry without any material support to back up their rightful calls for swift results.
Let’s break down the timeline of this White House goal. On May 11, the AP reported the contents of a COVID-19 conference call with state governors, Vice President Mike Pence, and White House Coronavirus Task Force coordinator Dr. Deborah Birx.
During the call, both Pence and Birx told the governors to prioritize testing all nursing home residents within the following 14 days, with the leaders pledging support to states that needed additional testing capacity.
“Start now,” Pence said, according to the AP report.
Later that same day, a reporter asked President Trump about the leaked guidance — specifically why it amounted only to recommendations and not a formal mandate.
“I would certainly consider that. I will mandate it if you’d like,” Trump said. “I think it’s important to do, and I think frankly some of the governors were very lax with respect to nursing homes.”
The president never followed up on that comment with an edict, and in fact no actual written guidelines on nursing home testing ever emerged from the White House.
When asked about the timeline in a Friday news conference, Birx described her previous comments on testing in largely aspirational terms.
“We only have a million nursing home residents,” Birx said. “We’re testing way over a million people per week, getting closer to over two million people a week. So over that four million per two weeks, I was hoping that a million of those could be our nursing home residents.”
The Centers for Medicare & Medicaid Services (CMS) recommended a single baseline test of all nursing home residents as part of its framework for resuming visits, released last week — but, again, the agency took pains to emphasize that it’s only guidance, and not a requirement. The final call on reopening nursing homes to families and other visitors rests with states, CMS administrator Seema Verma has repeatedly asserted.
It’s not hard to see how, through a perverse game of Telephone, a leaked recording of a conference call turned into a failed mandate over the course of just two weeks. But calling it a goal at all, and then reporting on nursing homes’ failure to meet it, is giving the administration far too much credit, and obscuring the systemic failure to prioritize long-term care in the distribution of tests and personal protective equipment (PPE).
Part of the reason that we’re in the midst of this national tragedy — with more than 35,000 deaths in long-term care facilities and counting, according to the Kaiser Family Foundation’s most recent data — is a lack of clear, concise, and decisive leadership.
The White House has repeatedly put the onus on states to sort out testing and PPE issues. But it cannot escape the fact that the federal government, through both CMS and the Department of Health and Human Services, has the ultimate authority over nursing homes. These executive-level departments roll all the way up to the president, and all the way down to each individual nursing facility’s license, which CMS can take away.
Dr. Nimalie Stone, an epidemiologist with the Centers for Disease Control & Prevention (CDC), acknowledged the difficulty in assigning a one-size-fits-all testing mandate during a Wednesday afternoon call with nursing home stakeholders hosted by CMS.
“The circumstance that a particular facility might be in should be considered as part of the decision about deploying these large-scale testing efforts,” Stone said in response to a question about a lack of consistent guidance around testing. “For example, the value of doing a snapshot of all the residents in a building that’s already had a known, very large-scale outbreak of COVID — it may not be quite as valuable, because we have to ask the question, well, what are we going to do differently at this point with that data?”
Conversely, widespread testing at a facility with a recent report of exposure has “tremendous value” in informing cohorting decisions and other safety measures, Stone said.
CMS officials on the call indicated that the agency continues to develop and refine its testing protocols, with more information forthcoming.
But that brief exchange illustrates something that we all already know about COVID-19: It’s a disease caused by a novel virus that even the top scientists in the world are still working to figure out, and there are no off-the-cuff answers that will lead to perfect results.
Nursing facilities, already battered by months of death and skyrocketing costs and staffing struggles, need more than the hope of White House officials. They need more than vague guidance publicized by press leaks and flippant comments during press conferences.
They need, and our elders deserve, more than an ephemeral goal that the press largely willed into existence. They need clear, unified guidelines in writing with easy-to-understand benchmarks — and without conflicts between federal and state recommendations.
Then they need the financial, logistical, and staffing support to back it up; states have already deployed National Guard staff to bolster testing and cohorting capabilities with success, and the federal government has far deeper resources at its disposal.
In short, our nursing homes need leadership. Long-term care facilities are going to be in this pandemic for a long time, even when things return to some kind of normalcy in the wider community. Hope always helps in a crisis, but only leadership gets things done.