By one estimate 70,000 Americans will die in the first wave of the COVID-19 pandemic. This is a shocking number, of course, but it is far fewer than the 650,000 expected deaths from heart diseases this year. Naturally government leaders, health care workers and the general community should do everything in their power to reduce the spread of COVID-19. But we should do this without exacerbating the public health challenges that already existed before the coronavirus arrived.
One specific policy that needs further evaluation is the Centers for Medicare and Medicaid Services (CMS) recommendation to delay all nonurgent and elective procedures. But many of these, while not emergencies, are scheduled in advance to prevent or manage chronic diseases. They are not optional.
The need for chronic disease management and prevention does not disappear during a pandemic. As I am a gastroenterologist and colon cancer researcher, the irony of cancelling procedures meant to detect colorectal cancer at an early stage during Colon Cancer Awareness Month was not lost on me. Infusion centers where patients receive treatment for rheumatoid arthritis; radiology centers that perform mammograms to detect breast cancer; and offices that perform cardiac echocardiograms to diagnose heart diseases are closing. A federal waiver though Medicare that covers telehealth visits now allows patients with chronic conditions to receive medical care without traveling to a clinic. But this does not address the need for outpatient surgeries and procedures that often accompany medical management.
Closure of outpatient facilities will lead to more emergency room visits as growing numbers of patients with unchecked symptoms require urgent care. Outpatient clinics triage patients into high and low risk of poor medical outcomes and decrease emergency room traffic by helping low-risk patients manage their symptoms at home. But without this triage and management, these patients are more likely to show up to emergency departments critically ill and medically unstable. Together, this will defeat the purpose of the CMS recommendation, which is meant to decrease hospital volumes, preserve protective patient equipment and conserve the medical workforce to treat those diagnosed with COVID-19.
Colorectal cancer is just one of many preventable diseases impacted by the new policy. Screening colonoscopies, the most common test used to detect and prevent colorectal cancers in the United States, are now delayed. Nearly 23 million adults aged 50 to 75 are past due for screening and an estimated 53,000 Americans will die from colorectal cancer this year. To address this problem, the National Colorectal Cancer Round Table, a coalition established by the American Cancer Society (ACS) and the Centers for Disease Control and Prevention (CDC), launched its “80% in Every Community” campaign, aimed at substantially reducing colorectal cancer as a major public health problem. The CMS recommendation to postpone screening colonoscopies during the COVID-19 pandemic, which could last 18 months, makes achieving this goal even more challenging.
It is critical that medical specialties identify and develop plans to mitigate the unintended consequences of the CMS recommendation that was meant to help manage limited health care resources at the peak of the pandemic. To prevent the resurgence of other infectious diseases such as measles and polio, pediatricians are promoting strategies that minimize the impact of COVID-19 on childhood immunization schedules.
These include scheduling well visits in the morning and sick visits in the afternoon, placing sick visits and well visits in different clinic locations, and conducting portions of the visit via telehealth with parents only entering clinics for brief physical examinations and immunizations. Gastroenterologists can consider increased use of noncolonoscopy colorectal cancer screening tests and plan for increased staffing and after-hours endoscopy blocks when procedures are resumed. All medical specialties will need innovative solutions to deal with the adverse effects of COVID-19.
The federal government will also need to consider the potential collateral damage of new public health crises and revisit its single-minded focus on minimizing COVID-19 fatalities. Delays in surgical and medical procedures will lead to delayed diagnoses of, and ultimately deaths from, unmanaged chronic and preventable diseases. They will also widen persistent racial, ethnic and socioeconomic mortality disparities that have surfaced as well in COVID-19 data, as record unemployment rates and loss of health insurance further limits access to medical care.
Delays will also overwhelm health care systems, which will be burdened with long backlogs when procedures are resumed. The longer the moratorium on procedures lasts, the more challenging the situation will become. Instead of the current federal moratorium, states and health care systems should decide how to balance the fight against COVID-19 with the imperative of completing procedures to prevent and manage chronic illnesses, taking into consideration the severity of COVID-19 cases, supplies of personal protective equipment, and workforce capacity.
Our COVID-19 response is not complete without identifying and, to the extent possible, mitigating the unintended consequences these strategies will have on public health. In the midst of a pandemic, we cannot and should not abandon chronic disease management or disease prevention. As businesses find new creative ways to fulfill their missions and deliver services to their patrons, so too should government and medical leaders. Now is the time for ingenuity, because failure to prevent and manage chronic medical conditions will lead to other public health crises long after COVID-19 is contained.