In reply to:

I am concerned about COVID in healthcare settings. I am at higher risk due to heart issues, but we also know that COVID infection — no matter how mild — puts people at risk of long-term health issues (Long COVID). We should not have to worry about getting COVID while receiving healthcare and healthcare workers should not have to fear contracting it at work.

For these reasons, I am writing to strongly urge The Centers for Medicare and Medicaid to include hospital-onset COVID-19 in the Hospital-Acquired Condition (HAC) Reduction Program part of CMS-1785-P.

  1. CMS should include COVID in its HAC Reduction Program and require hospitals to report and try to minimize hospital-onset COVID, using layered protections, such as universal mask wearing, universal screening testing, and improved air quality to promote patient and staff safety and health equity.
  2. Hospital-onset COVID should be defined as infections diagnosed after 5 days of admission or greater.1,2 Hospitals should report all hospital-onset COVID cases to CMS, and post these numbers publicly.
  3. Additional research is needed to better understand COVID transmission and to improve definitions of hospital-acquired COVID, using whole genome sequencing technologies and serial surveillance testing.1,3 The CDC currently defines hospital-onset COVID as cases diagnosed after 14 days of hospitalization, which is a huge underestimate. Even 5- or 7-day thresholds to define hospital-acquired COVID underestimate its true incidence.1,2 Hospitals should be required to report all COVID cases to CMS and the CDC and specify how many days patients have been in the hospital when diagnosed with COVID.

The evidence that informs these suggestions includes:

For only three months of 2023, the CDC tallied nearly 138,000 hospital-onset COVID infections, counting only those that arose after 14 days of hospitalization.4

COVID has been one of the top five major causes of death in the US since 2020,5,6 and many of those deaths were likely due to hospital-acquired COVID, which has a 5-10% mortality rate.7,8 This is significantly higher than several of the other infections CMS includes in its HAC Reduction Program. Catheter-Associated Urinary Tract Infection has a mortality rate of 2.3%,9 Surgical Site Infections for Abdominal Hysterectomy and Colon Procedures have a mortality rate of 3%,10 and Clostridioides-difficile (C. diff) infection has a mortality rate of 7.9%.11 Thus, hospital-onset COVID is well worth preventing.

Nearly 40% of all US residents are concerned about COVID outbreaks.12 Preventing COVID in the hospital is an equity issue. People of color continue to suffer high rates of COVID deaths.13 Half of health workers go to work with COVID symptoms,14 amid huge health worker shortages. CMS needs to protect both patients and health workers.

Even when community transmission is low, healthcare settings are the most likely place where people getting care for COVID could encounter vulnerable patients who could be harmed by COVID. Covid outbreaks are already happening in hospitals that ditched masks.15 If your hospital roommate has COVID, you have a 4 in 10 chance of catching it from them.16 No one should go to the hospital for a heart attack, an elective surgery, or to deliver a baby and catch COVID.

In spite of these facts, hospital administrators lobbied public health departments to end COVID protections in healthcare.17 Vulnerable patients can still become severely ill or die from COVID. Anyone can get Long COVID, which disables over 4 million people in the United States.18,19 Hospitals should be protecting us from COVID when we are in their care. But hospitals are in a “crushing” financial crisis.20 They lose money when they have to cancel procedures when patients test positive for COVID. We are concerned that hospitals are putting profits over patient safety.

Please protect vulnerable patients, prevent health worker shortages, and promote health equity by requiring hospitals to protect patients from hospital-acquired COVID.


  1. Lumley SF, Constantinides B, Sanderson N, et al. Epidemiological data and genome sequencing reveals that nosocomial transmission of SARS-CoV-2 is underestimated and mostly mediated by a small number of highly infectious individuals. J Infect. 2021;83(4):473-482. doi:10.1016/j.jinf.2021.07.034
  2. Wu Y, Kang L, Guo Z, Liu J, Liu M, Liang W. Incubation Period of COVID-19 Caused by Unique SARS-CoV-2 Strains: A Systematic Review and Meta-analysis. JAMA Netw Open. 2022;5(8):e2228008. doi:10.1001/jamanetworkopen.2022.28008
  3. Rhee C, Baker MA, Klompas M. Prevention of SARS-CoV-2 and respiratory viral infections in healthcare settings: current and emerging concepts. Curr Opin Infect Dis. 2022;35(4):353-362. doi:10.1097/QCO.0000000000000839
  4. U.S. Department of Health and Human Services. COVID-19 Reported Patient Impact and Hospital Capacity by State Timeseries (RAW). Accessed May 21, 2023.
  5. COVID-19 was third leading cause of death in the United States in both 2020 and 2021. National Institutes of Health (NIH). Published July 5, 2022. Accessed October 13, 2022.
  6. McPhillips D. Covid-19 was the fourth leading cause of death in 2022, CDC data shows. CNN. Published May 4, 2023. Accessed May 21, 2023.
  7. Otter JA, Newsholme W, Snell LB, et al. Evaluation of clinical harm associated with Omicron hospital-onset COVID-19 infection. J Infect. 2023;86(1):66-117. doi:10.1016/j.jinf.2022.10.029
  8. Cook AD Henrietta. Hundreds die of COVID after catching virus while in hospital. The Age. Published March 30, 2023. Accessed May 21, 2023.
  9. Centers for Disease Control and Prevention. Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009). Infection Control. Published March 28, 2019. Accessed May 21, 2023.
  10. Lantana Consulting Group, Centers for Disease Control and Prevention. American College of Surgeons–Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure Technical Report. Centers for Disease Control and Prevention; 2021. Accessed May 21, 2023.
  11. Yu H, Alfred T, Nguyen JL, Zhou J, Olsen MA. Incidence, Attributable Mortality, and Healthcare and Out-of-Pocket Costs of Clostridioides difficile Infection in US Medicare Advantage Enrollees. Clin Infect Dis Off Publ Infect Dis Soc Am. 2023;76(3):e1476-e1483. doi:10.1093/cid/ciac467
  12. Civiqs. Coronavirus: Outbreak concern. Accessed May 21, 2023.
  13. Lundberg DJ, Wrigley-Field E, Cho A, et al. COVID-19 Mortality by Race and Ethnicity in US Metropolitan and Nonmetropolitan Areas, March 2020 to February 2022. JAMA Netw Open. 2023;6(5):e2311098. doi:10.1001/jamanetworkopen.2023.11098
  14. Linsenmeyer K, Mohr D, Gupta K, Doshi S, Gifford AL, Charness ME. Sickness presenteeism in healthcare workers during the coronavirus disease 2019 (COVID-19) pandemic: An observational cohort study. Infect Control Hosp Epidemiol. Published online 2023:1-4. doi:10.1017/ice.2023.47
  15. Lee BY. Bay Area Hospital Reinstitutes Face Mask Mandate After Covid-19 Outbreak. Forbes. Published online April 22, 2023. Accessed May 22, 2023.
  16. Karan A, Klompas M, Tucker R, Baker M, Vaidya V, Rhee C. The Risk of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Transmission from Patients With Undiagnosed Coronavirus Disease 2019 (COVID-19) to Roommates in a Large Academic Medical Center. Clin Infect Dis. 2022;74(6):1097-1100. doi:10.1093/cid/ciab564
  17. Lazar K. Health groups call on Mass. to keep mask mandates in health care settings - The Boston Globe. The Boston Globe. Published April 5, 2023. Accessed May 21, 2023.
  18. Centers for Disease Control and Prevention. Long COVID - Household Pulse Survey. Published February 21, 2023. Accessed March 6, 2023.
  19. Bach K. New Data Shows Long Covid is Keeping as Many as 4 Million People Out of Work. Brookings. Published August 24, 2022. Accessed October 13, 2022.
  20. Thomas N. Congress can take action to help healthcare deal with “crushing” financial challenges, AHA urges. Published online October 25, 2022. Accessed May 21, 2023.

This comment is for:
Document ID: CMS-2023-0057-0003
Federal Register Number: 2023-07389
Agency: Centers for Medicare & Medicaid Services
Parent Agency: U.S. Department of Health & Human Services