The federal government is urging healthcare facilities to reopen in states that have relatively low and stable incidence of COVID-19 cases, illustrating a delicate balance between increasing access to care while ensuring providers are adequately prepared to mitigate contamination and safety concerns.
"Thanks to President Trump's unprecedented expansion of telehealth, many patients have been able to access their clinicians while staying safe at home. But while telehealth has proven to be a lifeline, nothing can absolutely replace the gold standard: in-person care," CMS Administrator Seema Verma said in prepared remarks. "Americans need their healthcare and our healthcare heroes are working overtime to deliver it safely. Those needing operations, vaccinations, procedures, preventive care, or evaluation for chronic conditions should feel confident seeking in-person care when recommended by their provider."
CMS offered a guide for the second phase of resuming in-person care, recommending maintaining adequate surge capacity regarding physical space, protective equipment, testing, staff and supplies, prioritizing care for at-risk populations, and participating in a national data collection system to track outcomes, system impacts and resource allocation, among others. But regions and states should only reopen if they have met the "gating criteria" proposed by the federal government—downward trajectory of COVID-19 cases and positivity rates over a 14-day period, downward trajectory of flu-like and COVID-19-like symptoms over that span, and having robust testing programs in place.
Healthcare providers are concerned that the significant decline of high-acuity care related to cancer treatment and heart procedures will lead to sicker patients and ultimately higher mortality rates. But they are also limited by available personal protective equipment and testing. In addition, some states and regions are still reporting spikes in COVID-19 cases and related hospitalizations.
Nearly 55% fewer Americans sought hospital care in the early stages of the pandemic, according to a recent Strata Decision Technology analysis of more than 2 million visits from 228 hospitals.
A decrease in procedures for life-threatening illnesses was particularly alarming, researchers said, noting a 57% decrease in services related to cardiology, 55% decline to breast health and 37% decrease to oncology.
Another study by Mayo Clinic found that visits to hospital emergency departments are down by as much as 40% while patient acuity has risen by 20%.
"We are concerned that there has been a missed opportunity to give appropriate care and that we will be seeing patients down the road who will be sicker and more complicated, unfortunately," Dr. Keith Churchwell, chief operating officer at Yale New Haven Health, told Modern Healthcare last month.
It has been hard to understand what happened to chronic cases like heart attacks and strokes, said Ken Wheat, chief financial officer of Palm Springs, Calif.-based Eisenhower Health.
"Where did those go?" asked Wheat, adding that there are worries about potential increases in mortality rates although he hasn't seen a change on a large scale. "That obviously is the big question: Will there be a large-scale change in mortality statistics?"
About 1 in 3 Americans have delayed care over the past several months, but hospital executives are assuring people that their hospitals are safe.
"The novel coronavirus has not gone away," Dr. Tom Mihaljevic, president and CEO of Cleveland Clinic, which resumed outpatient procedures on May 4, said in prepared remarks. "It is still in our communities. And it is still contagious. At Cleveland Clinic, you should feel confident that you are walking into a safe environment."
Sourcing PPE has still been an issue, providers maintain. The American Medical Association sent a letter on May 28 to Vice President Mike Pence urging the administration to provide more PPE to independent physicians.
"As non-hospital physicians return to work and reopen practices, the need for these supplies is rapidly expanding to these other care sites," the letter reads. "Given continued strains on the supply chain for these products, they are not readily available from the usual sources our physicians use. We are hearing significant and growing concern from our member physicians that they cannot secure needed supplies to safely reopen and that they are unsure where to turn for further guidance and assistance."
Meanwhile, almost half of U.S. states have not met the proposed World Health Organization benchmark for positivity rates for COVID-19 tests. Twenty-two states have higher than the recommended 5% or below positivity rate, which may indicate that the state is only testing the sickest patients who seek medical attention and is not casting a wide enough net to know how much of the virus is spreading within its communities, according to Johns Hopkins University researchers.
Last week, Phoenix, Ariz.-based Banner Health saw a record number of COVID-19-related hospitalizations, ICU bed and ventilator use. The number of ventilated patients, for instance, increased from around 40 on May 22 to nearly 120 on June 3, Dr. Marjorie Bessel, chief clinical officer at Banner, said at a June 5 press conference.
If these trends continue, Banner will soon need to exercise its surge plan to increase ICU capacity, she said.