The hidden COVID-19 crisis: The dangers of neglecting care

Andrew Pecora, M.D., the CEO of OMI (Outcomes Matter Innovations) and an oncologist/hematologist, discusses a potential crisis in the making when it comes to patients avoiding screenings and care for serious conditions as a consequences of the COVID-19 pandemic.

The following transcript has been edited for length and clarity.

Medical Economics: The first thing I wanted to talk with you about is how the healthcare systems across the country have performed when it comes to this pandemic. What have we done well? What have we done not so well?

Pecora: Well, when you think about it, COVID-19 is a brand new infection that previously never existed. And it came upon us like a wave. And so I think, overall, the health care systems around the globe have done a wonderful job, probably the best job they possibly could have done, because nobody knew what the size of the wave was going to be. Nobody really understood the disease process. There was no treatment. Diagnosis in the beginning was difficult.

I think the only problem was what happened in China. I think the Chinese did not do the right thing. And as a consequence of them not following what otherwise is standard World Health Organization practices — identify, isolate, and let the world know — they didn't do that for whatever reason. But other than that I don't see a real fault with anywhere in the world. People did the best they could.

Medical Economics: There's been a lot of talk about a new normal, and how some of the things that we're doing now, to deal with this pandemic, are going to change how we deliver healthcare going forward. I'm just wondering what you think of that, and how you think healthcare delivery is going to change post-COVID?

Pecora: Well, let's assume there is post-COVID, and that on this brand new virus that now lives in our ecosystem around the globe, we find an effective vaccine, and like polio, it goes away. Let's assume that happens, which by the way, may not happen.

I think the only change that I see that's going to be fundamental is we've accelerated a change that was happening already. And that is: How do you relate to patients without them literally being in front of you? So telemedicine, I do think that will have an increased role in health care delivery. One because of economics, because of convenience, but it's not going to replace (in-person) health care. I'm a cancer doctor. I can't take care of you if I can't examine you, I can't take care of you if I can't diagnose you. And I can't do that over a computer screen. So I think there'll be some change, but I think the extent of change right now is probably a bit exaggerated.

Medical Economics: Let’s talk a bit more about some of the strengths of telehealth and what are some of the weaknesses of telehealth?

Pecora: I see telehealth as an extension of health care, not as a replacement. If you have a patient that's stable, that maybe you're following their high blood pressure, and instead of having to have the patient drive to your office and the only thing you're checking in that particular moment is their blood pressure. You can have them hooked up to a machine in their home, you could see the blood pressure being taken and know it's being taken, right? You can ask the patient how they're feeling, are they having side effects from their medicine and look at the blood pressure and adjust their medications. That you can do very easily in their home.

What you can't do is if someone has a new growth, you can’t take care of it in their home. So it really is very situationally specific. And then the other thing is that medicine goes beyond the boundaries of just talking to a patient. Touching patients is a critical part of health care and healing. Examining patients is a critical part of the analysis of what we do, looking in their eyes and seeing them outside of the context of a computer screen and being able to relate to them face to face is a critical part of health care. I don't ever see that going away because healthcare is part of the human experience

Medical Economics: One of the challenges right now is that both hospital systems and smaller practices are really hurting financially because of the lockdowns that have been required to deal with a pandemic. What do you think will happen to the trend of consolidation in health care? Do you think small practices can survive these challenges?

Pecora: Health care is a component of the entire economy. What's going to happen to small retail, what's going to happen to mom and pop own businesses — whether or not it's a local food store or a restaurant — is the same thing as what is going to happen to a doctor's office or a dentist's office.

Do I see consolidation? Yeah, possibly. Do I see some people going out of business or retiring early? Yeah, probably. But do I see large scale change, that is going to be fundamental? I don't know that yet. I think it's too early to tell.

And I think a lot of it has to do with on how long this really last, and if we're able to prepare for it when it does come back, and particularly, if we find an effective vaccine. I think that's a very different narrative. So I think it's too early to tell. And I would follow the megatrends not just for health care, but for all small- to mid-size to large businesses.

Medical Economics: In terms of cancer care, your specialty, how has this changed how we approach treating patients with cancer? I wonder how cancer doctors are changing the way they care for these patients.

Pecora: It's a great question. I think it's has two parts.

Again, it's impossible to be critical of anyone in what happened with our need to shut down economies and shelter at home, because none of us knew what the surge would look like — not the experts, not not our political leaders. Would it really overwhelm our hospitals? Would it put lives at risk of the health care providers and the first responders in a much bigger way than it actually did? We didn't know so we did the right thing.

However, we're now potentially entering an error or a phase where we're doing the wrong thing. Right now, in the Northeast, up to three quarters of what be would expected new patients are not coming to cancer programs, they're sitting at home. Cancer doesn't take a vacation. Cancer doesn't wait. And I've done radio spots to try to bring this to life. You know, you may or may not get COVID-19. And if you do get COVID-19, you may or may not get really sick. And even if you get really sick, you may or may not die. If you have cancer and it advances you are going to die 100% of the time.

So while people are afraid of something that might be, they're allowing something to grow inside their bodies, and they're not seeking care. We have to do a way better job of highlighting that now and bringing people out of their fear and back to be evaluated and treated and screened for cancer.

Having said that, how will cancer care change in the era of COVID? Well, we and other cancer centers are taking ultimate precautions. Every patient that walks into our doors has their temperature checked, they're given a mask. All of our health care providers, every morning, have their temperature checked and their given a mask. Now that we have rapid screening, we're periodically screening our healthcare providers for COVID-19. Any patient that has symptoms, has been exposed to someone who has COVID-19 or has a fever, they get isolated in a separate area in the cancer center that's now carved out for COVID-19 patients or potential patients. So they're isolated from the rest of the community. I don't see that changing for a long time on and that's what I think the major change will be.

Medical Economics: Let's dig into what you were saying about needing patients to come and get treatment for cancer. What should doctors do? What should they say to their patients and communicate this message to them about this important topic?

Pecroa: Don't be afraid of what you might get and be concerned about what you have or what you're at risk for. I am not at all suggesting ignore COVID-19. Take the precautions, wear facial coverings, wash your hands, socially distance. These have been proven already. I don't think any rational person disagrees that that has been an effective approach to blunt the wave of the infection rate and the virus. Having said that, that's not synonymous with stay home and ignore everything else. And that's what's happening. Primary care offices are closed. People are canceling their doctor visits. People at risk for breast cancer are not going from mammography. People who are risk for colon cancers are not having screening colonoscopies. People who have pigmented moles are not going to their dermatologist to see whether or not they have a melanoma. That has to change now.

At the same time, people with chest pain are sitting at home instead of going to the emergency room and instead of having a small heart attack or not one at all, they're having big heart attacks or strokes and on and on. That has to change now. Because if you look at the incidence and prevalence of these other diseases, if they are ignored for any more significant period of time, this will far surpass what we've seen as an adverse consequence of COVID-19. And it'll become a real national tragedy.

Medical Economics: What do we need to do, both the healthcare system and as a country, to support physicians and other providers to make sure they get any kind of care they needs that they might have as a result the pandemic?

Pecora: I'm going to state the obvious: Doctors and nurses are people too, and so have their own personal issues, their own family stresses, their own life stresses. And when they come to work, they give up part of themselves because that's the life they've chose. And that's the profession they've chosen. They (risk their lives) knowingly, but they have a mindset of this as a normal day. So if you're an emergency room physician, you probably have a different construct than if you're a dermatologist versus a cancer doctor.

Having said that, when you have a wave of severe illness, leading to rapid deterioration, and lots of people going from sort-of sick to critically ill on respiratory ventilators, and then a lot of people dying all at once, no one's been trained to deal with that no one's prepared for that. So many of my colleagues, nurses, doctors, have felt distress they've never felt before. And I think we're spirited by the support, you see the television commercials about respect our heroes, you literally see people outside of fire departments, police departments, emergency rooms, when nurses and doctors are changing shifts standing there and applauding. It's been wonderful to receive that recognition. But those that need mental health support should get it. And I do think there will be, I don't want to say post traumatic stress, but similar to that, I do think there'll be some of that as time goes on, and we need to address it as a society.

Medical Economics: We all hear how long a vaccine typically takes to develop. It seems like there's early indications that development on a COVID-19 vaccine is moving quicker than normal. What are your thoughts on this news?

Pecora: Vaccine development is very complex. And vaccine development is fraught with peril. Not all vaccines work. And I won't go into the technical reasons, but not all vaccines work. What's new now is we have a new approach to vaccines. And instead of giving just a sort of ground-up virus, where we make the virus incapable of replicating, and we throw in something else to sort of boost up the immune system called an Agilent. We're now taking pieces of messenger RNA, and hijacking the genetic code of the virus. The virus, remember, comes in and hijacks our genetic code to replicate itself inside us. We're doing that to the virus. And we're allowing our bodies to make proteins that the virus expresses by putting in small pieces of the viral genome, not the pieces that cause the full virus and illness, but the pieces that cause the proteins of the surface of the virus to be produced. That's new and never been done before. Now that has the promise of going a heck of a lot quicker than standard virus vaccine development, but also has the parallel that it's never been done before. It may not work. So the very early returns are looking promising and it's exciting. But, you know, you’ve got to be from Missouri on this one: Show me that it really works.

Watch other episodes of Medical Economics Pulse on various topics, including:

• How value-based care can save your practice
• New malpractice risks
• Getting paid for telehealth
• Saving primary care

See all Pulse episodes here.