Gwen Darien is a three-time cancer survivor. When she was thirty-five, she was diagnosed with lymphoma; in her fifties, she was treated for breast cancer; two years ago, she learned that she had endometrial cancer. With curly black hair and an indomitable personality, she embodies vibrancy, courage, and resilience. Even so, last month, when she received a call from her doctor’s office about an upcoming visit, she decided to postpone it indefinitely. “I was very unnerved,” she told me. “I thought about all the risks. First, I’d have to get transportation—Uber or train or subway. Then I’d have to walk into the doctor’s office, near a hospital with COVID-19 patients. Then I’d have to be in the office with other people, even if they are socially distanced. I’d much rather just wait.”
During the pandemic, many patients and physicians have felt this kind of hesitation. Some people with chronic illnesses, fearful of entering a medical setting or even venturing outside, have stopped seeing doctors altogether. Others have tried to make appointments but found clinics closed and routine care suspended. At many hospitals, non-urgent or “elective” care has been postponed for months. It’s difficult to say for sure what the effects of such postponements have been and will be. But statistics show that, across the United States, so-called excess deaths—deaths beyond those that are historically typical—have surged. Although many of these deaths can be attributed to COVID-19, delayed or cancelled care is probably a contributing factor, too. An analysis of death certificates shows that a fifth of the twenty-four thousand excess deaths that occurred in New York City between March 11th and May 2nd were caused by factors other than COVID-19; according to a study currently in pre-publication review, hospitals saw a thirty-eight-per-cent drop in serious heart-attack cases in March alone, suggesting that even people with acute, life-threatening illnesses have been avoiding medical visits. (The American College of Cardiology has gone so far as to issue a statement urging people to seek medical attention if they’re having cardiac symptoms.) A nationwide survey conducted in April found that a quarter of cancer patients receiving active treatment had seen their care delayed. Ultimately, it’s not just people with COVID-19 who are suffering; those with other illnesses are affected by the pandemic, too.
The coronavirus crisis itself continues to deepen. Although the first peak has passed in a few major cities, cases have held steady in many parts of the country and are rising in twenty-six states. North Carolina saw its highest single-day increase in coronavirus cases on June 12th; Florida, Arizona, and Texas saw record spikes this week. Some of this growth reflects increased testing, but, in many places, deaths caused by the virus are also rising—a sign that the spike is real and not a statistical artefact. The U.S. still records more than thirty thousand new cases each day; according to projections from the Centers for Disease Control and Prevention, the national death toll could reach a hundred and forty thousand by the Fourth of July; the country’s public-health response remains scattershot, with grossly inadequate testing and contact tracing; and mass protests and planned reopenings, which are continuing despite the risks, have given the virus new breathing room. America as a whole seems to have entered a long viral plateau. The pandemic is now a rolling collection of mini-epidemics that surge and subside as the virus bobs and weaves its way across the country. It will be a long time before life returns to normal.
The persistence of the pandemic is creating serious challenges, many of them unforeseen, for the health-care system. Even before the pandemic, many hospitals were in precarious financial condition: in 2018, the average hospital had a two-per-cent operating margin and less than two months of cash on hand; the situation was worse for rural hospitals, a fifth of which were already at risk of closing due to financial problems. Having lost billions of dollars in revenue, hospitals must now figure out how to reintroduce routine care while keeping patients safe and preparing for possible surges of COVID-19. (As my colleague Atul Gawande has written, it is possible for hospitals to reopen without becoming vectors for the virus; doing so, however, requires time, resources, and personnel.) Hospitals in Massachusetts are losing $1.4 billion in revenue per month, and project total losses of five billion dollars by the end of July. The Mayo Clinic alone, which runs twenty-three hospitals nationwide, is set to lose three billion dollars this year. The American Hospital Association estimates that, altogether, U.S. hospitals are bleeding fifty billion dollars a month during the pandemic. The hundreds of thousands of doctors in independent practice have more limited capital reserves, and many may be forced to shutter their operations or merge them with others.
In the context of the economy as a whole, these losses are substantial. According to the Department of Commerce, the American economy shrank by nearly five per cent in the first quarter of 2020. Nearly half of this change—the biggest single-quarter drop since the Great Recession—had to do with reductions in health care. In a few months’ time, the coronavirus has accomplished what lawmakers have been trying to do for decades: by flattening the curve of infection, we have bent the curve of health-care spending. But it’s been bent haphazardly, by the hurried cancellation or postponement of colonoscopies and mammograms, hip replacements and cataract surgeries, stress tests and root canals—and those unsustainable choices will have real consequences for the health of patients. As the virus continues to spread, the clinical damage will almost certainly compound.
It’s vitally important, therefore—both for the health of individuals and of the system as a whole—for doctors to resume seeing patients who don’t have COVID-19. In April, medical organizations, including the American Hospital Association, began releasing road maps for the resumption of regular care; since then, governors have announced various protocols in their own states. The details vary, but the basic principles are the same: wait for a sustained reduction in COVID-19 cases; insure an adequate supply of personal protective equipment (P.P.E.); test constantly; and plan to throttle back on the expansion of services if the virus surges again. The more fine-grained question, of exactly which procedures should be prioritized and which delayed, is usually left unanswered.
Vivek Prachand, a surgeon at the University of Chicago, has been thinking about this problem since early March, when hospitals first started grappling with how to rank procedures in terms of their clinical urgency. Often, he told me, the decisions were being made by individual physicians or small committees within hospitals. “It was really just surgeons saying, ‘O.K., go ahead,’ or, ‘No, we need to hold off,’ ” he said. “You can imagine the emotional and ethical challenges of being in that position.” He and his colleagues have developed a rubric to help guide such decisions during the pandemic, which they call the Medically Necessary, Time-Sensitive System, or MENTS.
Prachand dislikes referring to care as “elective,” because the term suggests that procedures are optional or unnecessary; really, elective care is just care that can be scheduled. (Setting a broken arm is “urgent” care; brain surgery, most of the time, isn’t.) To help set the schedule, the MENTS protocol asks three kinds of questions. First, it assesses procedural factors, such as how long the surgery will take, how many clinicians will be exposed, how much P.P.E. will be used, and how likely the patient is to be intubated or require a prolonged stay in the hospital. Second, it grades the dangers presented by the problems the surgery hopes to solve, asking how bad the condition will get if doctors wait, and whether there are any effective non-surgical remedies. Finally, it sizes up how much viral risk the operation poses to the patient. Is she immunosuppressed? Does she have an underlying lung disease? What are the chances that she’s already been exposed to the virus? The answers to all of these questions are combined into a formula that yields a recommendation about when the team should proceed.
After Prachand published the scoring system, it was adopted by other departments in his hospital. He received e-mail inquiries from American hospitals, and from places as far afield as London, Gibraltar, and South Africa. The American Hospital Association included the system in its statement about how to reopen. In theory, the tool can be used at any time during the pandemic: during a coronavirus spike, on a plateau, or when the virus is quiescent. Surgeons simply adjust the “score threshold” at which they are willing to operate.
MENTS holds a broader lesson for reopenings generally. It’s important to have a decision-making system that’s transparent, that anyone can understand, and that takes into account all of the relevant factors. Without such a system, those in charge could be seen as acting arbitrarily, and consumers will feel hesitation and fear. “This is meant to reassure patients, clinicians, and hospital leaders that the choices we’re making have some basis other than our gut feelings,” Prachand said. “It’s really a microcosm of what we need to do to open the economy. If we do it in a way that makes sense to people, that’s transparent, that’s dynamically adjustable, the public can feel confident that we know what we’re doing.”
Smaller, independent medical practices face a different sort of problem: they must resolve many practical issues for themselves while staying solvent. Ripley Hollister, a native Californian with an easygoing drawl and an independent streak, runs a five-clinician family-medicine practice in Colorado Springs. On March 17th, within hours of the announcement that the federal Centers for Medicare and Medicaid Services would be significantly increasing its reimbursements for telemedicine, he began seeing patients via videoconference. (In the past, Medicare paid for telemedicine only if patients lived in a rural area, or if they were in a medical facility when they received the service—an odd requirement that undermined the point of virtual care.) Hollister, who’s been in practice for more than thirty years, had never done a virtual visit before the pandemic; when we spoke, about two-thirds of his practice had gone remote. “I have millennials who work for me,” he explained.
Yul Ejnes, a primary-care doctor in Rhode Island, told me in May that he had not seen a patient face-to-face in two months. “My stethoscope has been very lonely,” he said. As he contemplated moving back to in-person visits—he recently started seeing patients again on a trial basis—his chief concern was the waiting area. “The waiting room was a problem even before COVID-19,” he told me. “You’d have twenty-five people sitting next to each other. Some of them were there for a flu shot, others were there with the flu—throw in coronavirus and that setting is totally unacceptable.” His office has been doing its research. “We’re borrowing from the airlines. We’ll have online check-in. We’re borrowing from restaurants—wait outside and we’ll text you when your exam room is ready. We’re going to experiment with things like dedicated hours for sick visits and other times for well visits. Some futuristic practices probably already do this stuff, but we’re an old-school office, and this is new for us.”
These success stories are heartening—but many other practices, even very successful ones, are struggling. Gary Price, a surgeon in solo practice in Guilford, Connecticut, employs seven people; when we spoke last month, I asked him what proportion of his usual patient volume he’d been seeing. “Somewhere between zero and one per cent,” he said. As a surgeon, Price cannot pivot to telemedicine. During the pandemic, he has performed a few minor surgeries—treating a three-year-old with a facial laceration, for example, and an older patient with a cancerous ulcer of the scalp. “The complete absence of income has forced me to consider, for the first time, a scenario in which my practice might not survive,” he said. His patients are trickling back, but the Paycheck Protection Program—the part of the CARES Act passed by Congress that offers forgivable loans to help small businesses keep employees on payroll—was all that kept his practice afloat.
Of the ten major flu pandemics since the late eighteen-nineties, seven had a second, deadly peak within a year of the first. Compared to the flu, the coronavirus appears to be harder to contain: it has a longer incubation period, more asymptomatic infections, and a higher reproduction rate. On May 28th, the United States reached a sombre milestone: a hundred thousand COVID-19 deaths. In the days since, twenty-two thousand more people have died. And yet the virus’s harm extends to individuals whose lungs it never reaches, and who aren’t included in those grim totals: patients with diabetes, depression, cancer, and high blood pressure; people suffering heart attacks and strokes; families who can’t hold their dying loved ones, and the nurses who must hold the phones through which people say goodbye. There are doctors who can’t keep their COVID-19 patients alive, and others who can’t keep their practices open.
Even before the pandemic, American health care was in trouble. Although it is the most expensive system in the world, with a cost roughly equivalent to Germany’s G.D.P., it has delivered variable quality, produced mediocre outcomes, and left millions of people behind. Now the coronavirus has shaken its unsteady foundation, siphoning attention and resources away from patients who need other types of care. We tend to follow the virus’s toll narrowly—cases, hospitalizations, deaths—but the damage to public health is also vast, and the longer the pandemic persists, the larger it will grow. Children go unvaccinated; blood pressure is left uncontrolled; cancer survivors miss their checkups. The extent of the collateral damage won’t be known for years, if ever. But it’s clear that mitigating the harm starts by getting the virus under control.
More Medical Dispatches
- Surviving a severe coronavirus infection is hard. So is recovering.
- Some hospitals have postponed cancer surgeries because of the coronavirus crisis. How do doctors assess urgency during a pandemic?
- It is not too late to go on the offense against the coronavirus. This five-part public-health plan may be the key.
- The loneliness and solidarity of treating coronavirus patients in New York.
- To fill the vacuum left by the federal government, doctors are relying on informal networks to get the information and support they need.
- Conflict and confusion reign at New York hospitals over how to handle childbirth during the pandemic.
- In countries where the rate of infection threatens to outstrip the capacity of the health system, doctors are confronting ethical quandaries for which nothing in their training prepared them.
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The Coronavirus Pandemic’s Wider Health-Care Crisis - The New Yorker
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