Amid a steep rise in COVID-19 cases in Santa Clara County, local hospitals are reportedly violating a local health order requiring them to provide free tests to residents at higher risk of contracting the virus.
County officials in recent weeks have pressed some of the largest health care providers in the state, notably Kaiser Permanente and Sutter Health, on an apparent failure to ramp up testing several months into the pandemic. Large hospitals have been obligated since June 10 to provide tests to residents who are at increased risk of exposure to the virus -- regardless of whether they show any symptoms -- yet the county has received numerous reports of hospitals flouting the public health mandate.
Hospital leaders say that their hands are tied, and that a chronic shortage of testing supplies and reagents means COVID-19 tests must be triaged only to those who need it most. But county Supervisor Joe Simitian said that's not an excuse, and that more can and must be done to increase testing capacity if there's any hope of controlling the virus.
"What's baffling to me is why this is even a question," Simitian said. "The public health officer issued the order more than two months ago, and yet we continue to get reports and complaints from people who cannot get a test from their provider."
Starting June 10, Santa Clara County's public health officer, Dr. Sara Cody, announced an order requiring that all acute care hospitals in the county provide free COVID-19 testing to a broad range of residents. Anyone who is showing symptoms of COVID-19, has been exposed to someone with a confirmed case, or is "at increased risk of exposure" is entitled to a test.
It's that third "higher risk" category that vastly expands the eligibility and is causing consternation among hospital officials. It includes those who take public transit, first responders, pharmacy employees, food service workers, grocery store clerks, delivery workers and anyone who has frequent face-to-face interaction with the public.
The county's testing order is asking a lot of hospitals, well above what is required by the California Public Health Department and other counties across the state, said Jo Coffaro, regional vice president of the Hospital Council, a trade organization representing northern and central California hospitals. While there's a desire to expand COVID-19 testing as much as possible, she said there's a "pipeline" problem with testing supplies. Potential sticking points include difficulty in getting swabs, specialized pipettes and reagents.
"We may have two or three of those things on hand, but we don't have one -- maybe a reagent or a testing cartridge -- so the whole test can't be completed," she said.
During the week of Aug. 4, Santa Clara County's own public health system conducted 12,221 COVID-19 tests, vastly outperforming private hospitals including Stanford (3,360), Sutter (1,728), Kaiser (1,457) and El Camino Health (960). Since the start of the pandemic, the county has more than doubled the testing of any private health care provider.
The test counts are disappointing to Simitian, who has been a staunch advocate for increased testing since March. Simitian said he and other county officials have had repeated conversations to prompt hospitals to voluntarily ramp up COVID-19 testing and comply with the public health order, but he is not optimistic that it's going to happen. Some of these organizations clearly have the scale and the resources to comply but have yet to make it a priority, he said.
"These are not mom-and-pop operations. Kaiser is the largest HMO in the country, Sutter has 24 hospitals and 200 clinics just in Northern California," Simitian said. "If the county can manage to build it, buy it or pool tests -- and the county has done all three -- I think these organizations can do the same if the will is there."
A push for more tests
In normal times, Dr. Ahmad Kamal is a gastroenterologist with Santa Clara Valley Medical Center. But during the worst global pandemic in more than a century, he shifted gears to become the county's director of health system preparedness, assisting hospitals in safely taking care of COVID-19 patients and coping with the sudden demand for more tests.
While Kamal said he sympathizes with the challenges that private hospitals face, he said there is a clear contrast in the way that private hospitals are responding when compared to Santa Clara County's health system. In July when cases were surging, he recalled a disastrous situation in which the company Hologic, which provides COVID-19 testing equipment, couldn't make a shipment because it was completely tapped out.
County staff began frantically calling testing labs across the country and, within a couple of days, was able to farm out samples to prevent a backlog. Top-of-the-line, premium testing machines that required proprietary reagents were swapped out for open platforms, which Kamal said are more labor intensive and required overtime and additional staffing.
Another strategy used by the county was to "pool" samples, running a COVID-19 test on multiple people's samples batched together. Pooling means limited resources can be stretched much farther -- four or even eight people can be included all in one test. If the pooled test comes back positive, everyone in the group has to be individually retested.
Kamal said the same cannot be said for private hospitals, despite the important public health role they play in controlling the virus. When faced with missing reagents, Kaiser and others simply stop testing large numbers of people, he said, taking the ill-advised approach of testing only those who are showing symptoms.
"To say you have to wait to get sick in order to get a COVID test is absolutely the wrong approach," Kamal said.
There have been some slivers of hope. Kamal said Stanford has been approved for pooling tests by the FDA, and El Camino Hospital is setting up drive-thru testing sites that are easy and convenient. Stanford has also sought help from 3D printing companies to fabricate some of the most sought-after materials. But in the case of Kaiser, he said there have been continued complaints of doctors dissuading residents from getting a test or outright refusing to provide one in violation of the health order.
When asked for comment, Kaiser officials said they are currently prioritizing residents most in need of tests, including those with symptoms, frontline health workers, first responders and patients prior to undergoing surgeries and certain procedures. Irene Chavez, the vice president and area manager of Kaiser's San Jose Medical Center, said the organization is "marshaling all of the resources and influence we can bring to bear" in order to increase testing capacity.
"We are optimistic that we will be able to double the number of tests we are doing by end of September," Chavez said. "As our capacity grows, we will expand testing to more categories of those at risk of exposure."
Kaiser's website does not say that Santa Clara County residents are entitled to a test if they meet the public health order's criteria. And while there's a clear divergence between which patients are theoretically entitled to a test and which ones are actually getting tested, Coffaro sent a letter to the board of supervisors on July 21 stating that "all hospitals and healthcare systems offer COVID-19 testing to their patients in accordance with this order."
In an interview, Coffaro said the June 10 order is no longer realistic. The spread of the virus and new COVID-19 cases were on the decline when the order was issued, but times have changed and supplies are again running thin. The state's testing requirements have changed significantly since June and have been fluid based on the supply shortage, she said, yet Santa Clara County's have remained constant.
"We want to test every person who needs a test, but in reality it's a matter of availability of supplies, personnel and lab equipment," Coffaro said. "It's very hard to be accountable to something that we just can't get."
Sutter representatives declined to comment, instead referring this reporter to the Santa Clara Medical Association and the Hospital Council. An Aug. 11 letter to the county by the Santa Clara Medical Association suggested that the public health order would lead to "dire consequences" and threatens to divert tests away from those who need it most.
Help from the private sector
Under the public health order, Santa Clara County can start penalizing hospitals for failing to provide tests. On top of civil fines approved last week, violations can also be enforced through the criminal system, carrying a misdemeanor charge.
So far, county officials have taken a softer touch, attempting to work behind the scenes to gain compliance from private hospital systems. A memorandum of understanding (MOU) between the hospitals and the county is currently in the works to determine just how bad the flouting of the public order has to get in order to start incurring fines.
After talking with hospital officials over Zoom on Monday, Simitian said he is not optimistic that the MOU will alleviate the dearth of testing. While nobody wants to go down the route of penalizing hospitals, he said it's essential to get these major health care providers to comply if there is any hope of getting a handle on the virus. Kaiser covers anywhere from 30% to 40% of the county's entire population, he said, while Sutter covers a large portion of his constituents through the Palo Alto Medical Foundation. Both need to step up and do their share, he said.
"Testing is the necessary precondition to working our way out of the condition we're in," Simitian said. "Without testing, you can't do contact tracing, which means you can't ask people to isolate and quarantine, which means people are going to be out there moving the virus around."
Kamal said the county has a symbiotic relationship with these large health care systems, and must rely on them to scale up COVID-19 testing. What's really needed, he said, is for these private hospitals to follow in the footsteps of the county and take emergency measures to ramp up testing capacity, responding to the global health crisis with a commensurate response.
"The mobilization we need to see is the type of mobilization we had during World War II, and that's what we need from our health care partners," Kamal said. "We need them to pitch in and take care of their patients."