The Executive Suite: “Waiting out” COVID-19 is not a solution for outpatient care

Outpatient providers must make a concerted effort to inform patients that the instructions to avoid all “nonessential” healthcare procedures are no longer relevant.

Outpatient clinics have taken significant steps over the last six months to limit disease spread within their facilities and ensure that patients can safely seek in-person care. Now, patients have few reasons to delay crucial—if not immediately time-sensitive—procedures. However, convincing patients of that truth may prove difficult.

When the Centers for Medicare and Medicaid Services advised the postponement or cancellation of all non-emergency, in-person procedures in March, their rationale was twofold. First, the limitations would reduce in-person contact and enforce social distancing. Second, postponing elective procedures would leave beds open for COVID-19 patients and reduce the strain on hospitals’ already-taxed resources.

This reasoning makes sense. However, the implication that it was no longer safe to seek inpatient care ultimately caused patients to flee outpatient and primary care centers in droves. In turn, this led to a massive drop in patient traffic and put many outpatient clinics at a real risk of going out of business.

According to data published by the Commonwealth Fund, visits to ambulatory care centers declined by nearly 60% in early April. These numbers have rebounded in recent months—today, the Fund reports a 30% decline from pre-COVID traffic—but remain troubling.

Researchers for Strata Decision Health further note that some specialties have fared worse than others. As they write, “health screenings that are designed to provide early detection but are often seen as less urgent were down significantly in volume, increasing the risk of undiagnosed disease. Preventive wellness visits, gynecologic wellness and screenings, and GI benign neoplasms and polyps [...] all saw volumes drop by over 75% in the cohort group.” Other concerning drops also included a 55% decrease in breast health screenings and a 37% decline in cancer visits overall.

All of these drops indicate a pattern of widespread anxiety around seeking in-person care. In early August, a survey conducted by Harmony Healthcare IT confirmed this appearance, noting that 71% of surveyed Americans say that they are afraid to visit the doctor’s office because of COVID-19.

Given all of these findings, it seems likely that many patients will adopt a “wait and see” mentality and avoid care until COVID-19 is over. Unfortunately, the reality of the matter is that our current pandemic worries likely won’t resolve itself for at least another year—and the COVID-19 virus will probably be around for even longer.

“It is going to become part of our daily, or certainly seasonal, reality within the healthcare system and within the country,” Megan Ranney, an emergency physician and associate professor at the Brown University department of emergency medicine, recently commented for The Verge.

It is worth noting that this long-lasting transition from pandemic mitigation to routine management isn’t new. After emerging as a pandemic in 2009, H1N1 became a familiar seasonal flu strain, for example. While it is impossible to guess how long it will take for COVID-19 to recede into familiarity, the transition will likely require a better understanding of the disease, a vaccine, and new treatments at minimum.

Given this context, it becomes clear that “waiting out” COVID isn’t a realistic strategy. While the healthcare sector’s initial call to postpone elective care procedures was understandable at the time, it was never meant to develop into a long-term policy. But patients remain afraid, and it appears that unless providers go out of their way to reassure patients of clinic safety, patients will continue to avoid in-person care. This is problematic both from a business perspective and for public health overall.

“If you don’t go for your physical and you don’t go for your annual shots, that puts you at an increased risk,” Dr. Mary Odofin, a physician at Huntsville Internal Medicine Associates, told a local newspaper in Alabama. “Your immunity is not good enough. And of course now, you're probably going to be sicker.”

Appointment anxiety is understandable, given the current circumstances. But patients need to understand that outpatient clinics are significantly better-prepared than they were when COVID took the healthcare industry by surprise in March. In the months since then, they have had time to develop policies that can insulate patients against the risk of in-office disease transmission.

In early August, the Centers for Medicare and Medicaid Services released new guidance on how outpatient clinics can better separate patients with COVID-19 from those without it. A few of these recommendations include new screening procedures, increasing the frequency of cleaning and disinfection, and addressing potential supply scarcities.

There are other tactics that outpatient clinics have deployed beyond those listed by CMS. Virtual waiting rooms, for example, have experienced an uptick in popularity. Providers who use these digitally-facilitated solutions typically ask patients to check in on their mobile device and remain in their vehicle until an exam room is available. By isolating patients until the moment of their appointment, providers drastically reduce the chances that they will come into contact with other patients or be exposed to germs on shared surfaces such as clipboards, pens, kiosks, or waiting room magazines.

Some outpatient facilities may choose to take these measures further by reimagining their traffic flow and design. In May, Healthcare Design Magazine published a feature by James Alpert that outlined the adaptations that clinics would likely implement post-COVID. These included limiting shared staff space, redesigning public areas to facilitate safe physical distancing, and reimagining foot traffic patterns to limit unnecessary crowding or interaction between patients. Newer clinics may even incorporate design features that are easier to clear and use finishes that can withstand harsher chemicals.

“In the coming years, these organizations will need to adjust their operations for future pandemics,” Alpert wrote. “Codes will need to be rewritten to safely meet these new situations, and government grants will be necessary to encourage hospitals to make these changes permanent.”

While it remains to be seen which design measures will become permanent staples in outpatient clinics, there is little doubt that providers can provide patients with safe, in-person care. However, it is equally clear that patients will need reassurance from their providers to overcome overblown fears about seeking care during a pandemic. Delaying care until the end of the pandemic is a dangerous, unrealistic approach based on faulty assumptions; left unchallenged, it will lead to poorer public health and drive outpatient clinics out of business.

Outpatient clinics are healthier and better prepared for the pandemic than ever; it seems ill-advised not to make that fact known.