A cardiologist looks at the policy response to COVID-19 and its impact on health and human flourishing

As a physician and business owner, I am exposed to and impacted by the COVID-19 virus in a host of ways. As we condition our workplace and our 75 employees to mitigate the risk of exposure to the virus, or the propagation of the COVID-19 virus (or any virus) to our patients with heart diseases, we are also faced with the task of maintaining our economic viability. As a health care provider entity, with the “essential service” of reducing cardiovascular morbidity and mortality for the people of Oklahoma, we are doing our best to be open in the future, after the pandemic.

As a consequence of being responsibly compliant with the “elective procedure” edicts from our professional societies and the Oklahoma State Department of Health (OSDH), we anticipate a 60 percent reduction in office-based visits, tests, and surgical procedures in the ambulatory surgery center portion of our facility. We are converting as many office visits as possible to telemedicine visits, which is appreciated by many of our patients but inadequate for many more who have ongoing cardiovascular health concerns that cannot be sufficiently evaluated or treated over the phone, regardless of a face-to-face “virtual” visit.

A secondary issue of the telemedicine approach is the potential impact on revenue. For example, neither Medicare nor the commercial insurers have delineated how the usual office copays and individual patient out-of-pocket costs (deductibles and coinsurance with Medicare) will be handled for this service. The initial statements from the insurers and MCR, not yet codified, is that these “fees” will be waived for those encounters. If that is indeed the case, the business will likely have a net loss of revenue for the provision of this service—the office copays and coinsurance dollars is where our only “margin of profit” exists for in-office encounters. Those visits require infrastructure, medical assistants to prepare the charts, scheduling personnel to schedule the visits and potential revisits, and the professionals’ time. This “social distance” clinic visit may in fact be a net negative for the “business” of medicine.

We are certainly hopeful and optimistic that the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the attendant Payroll Protection Program loan through the Small Business Administration, as well as the significantly underserved need for our services waiting for us at the end of the pandemic, will help us maintain our economic viability. However, my greatest fear is not the direct medical impact of the actual COVID-19 infectious illness over the spring of 2020. My greatest concern is our approach, as a medical and business community, to the fear impact of the infection and the longterm unintended consequences of our reactionary approach. I will mention a few clinical scenarios to add texture to this concern.

Unintended Consequences

My partners and I have diligently elected to screen all of our office cases and invasive procedure cases and reschedule all but those that we deem urgent from a cardiovascular health mortality/morbidity risk perspective. In addition, some of the hospitals where more extensive surgeries (requiring more than 24-hour nursing care) must be done have unilaterally canceled or deferred scheduling our cases, regardless of the acuity of the individual case.

Patients with large, highrisk aneurysms, with an extremely high short-term mortality risk if left alone, have been deferred by the authorities in charge of these facilities (by OSDH edict). Patients with ex-tremely high-risk carotid artery disease and lesions, who unnecessarily risk lifestyle-changing or life-ending strokes if left untreated, have also been deferred. No one can reliably predict when these aneurysms will rupture or the carotid lesions will embolize or occlude. Ordinarily, these cases are considered “highly urgent,” if not emergent, depending on the symptoms. I have personally deferred a growing number of “elective” cardiac catheterization cases in patients with abnormal stress tests and symptoms deemed to be “stable.” Unfortunately, I have already had one of these cases suffer a life-changing heart attack at home.

This situation of health care deferment needs to be very carefully examined and discussed in a more public forum. The current economic dislocation that is happening with the population at large, along with its attendant health-related consequences, also needs a more rational conversation in the public domain. Unfortunately, political expediency and informational biases, in a setting of statistically inadequate information, have created a public policy that I am very afraid could be more lethal than the virus itself.

It is very true, in a graphic way, that the COVID-19 virus is having a serious and deadly impact on some of those infected. It is truly a very nasty virus with which we must contend. But the impact of this nasty disease needs to be examined and presented to the public in the greater context of all the other causes for morbidity and mortality in a modern society.