There Will Be Consequences

Crises -- like our current COVID-19 pandemic -- force people to come up with new solutions.  They slash red tape, they improvise, they innovate, they collaborate, they cut corners.  Some of these will prove inspired, others will only be temporary, and a few will turn out to be misguided.  We may not know which is which except in hindsight.

I covered some of these in a previous article, but let me highlight a few:

• Hospitals: we're building new hospitals, such as in convention centers, to address the expected shortage of beds.  Hospitals are also coordinating where to send which types of patients.
• Testing: we're creating drive-through testing centers in parking lots and elsewhere.
• Telehealth: we've loosened the restrictions on telehealth, improving reimbursement and rules about when it can be used.
• Coverage: we're trying to ensure that deductibles/copayments do not pose barriers to people getting tests and treatment, even for those without insurance.
• Clinicians: we're looking for clinicians everywhere we can -- allowing licensed ones from other states to practice, letting people who were health care professionals in other countries practice here, calling retired ones back into service even if their license had expired, even letting almost-graduated medical professionals start practicing.  
• FDA approvals: The FDA is using its "emergency use guidance" authorization to start allowing use of drugs and other treatments much quicker, and with much less evidence, such as for hydroxychloroquine, diagnostic testing, and ventilators. 

This is certainly not a complete list, and people are still developing new ones.  Kudos to all the people working long hours to try to do what is necessary, even if it means doing things that are unconventional.  We are not in conventional times.    

That being said, we should not ignore the fact that these solutions will have consequences, and some of those may not be good ones.  I'll quickly discuss a few of the things that could result in problems:

Networks

When I read about these new hospitals, I immediately think, hmm, I wonder whose networks they're in, and what the payment rates for them will be.  Same for hospitals cooperating about which hospitals do which patients, or for the new drive-through testing centers.

So is this field hospital in-network? Photo: AFP/Bryan R. Smith

I.e., I may want to go to an in-network hospital, but get sent to some other hospital, possibly one of the new, a jury-rigged ones.  Am I going to get billed out-of-network charges? 

Similarly, it's great that so many healthcare professionals are flowing to where the needs are, but I suspect that most of the "new" ones are not credentialed/considered in-network for most health plans,  What will they charge, and will those charges be considered out-of-network?

I think networks should be a thing of the past, but we can't ignore that they do still exist.

Licensure

Some of the health care professionals who are being recruited to start practicing in order to help out aren't licensed in that state.  Aside from the network problem discussed above, that means that patients may end up getting some portion of their care from clinicians who have not demonstrated to their state's licensing bodies that they are qualified to do so.  

Many will prove to be eminently qualified, but a few may not, especially as the surge of COVID-19 patients overwhelm parts of the health care system.  Mistakes will be made, some care will be substandard, and when this is all over some injured parties may seek remedies via medical malpractice or other lawsuits.  Those without current "proper" licensure would be an obvious target.

I personally do not think our current system of licensing for health care professionals is particularly effective, nor appropriate for today's connected world, but I am not enough of a libertarian to believe that there shouldn't be any kind of licensing.  

Coverage

It is understandable that during a pandemic we can't afford to let cost be a barrier to necessary testing, and it's only compassionate that we don't want treatment to be unaffordable for COVID-19 patients, but it creates inequities for patients with other conditions.

The health plans that are waiving deductibles and copayments for COVID-19s are essentially unilaterally revising their contracts during the contract year.  There are other patients with critical needs who may not think COVID-19 patients should get such preferential treatment, and it's hard to say they're wrong, especially since coronavirus coverage may increase everyone's premiums.

Moreover, since we have not had anything like universal testing, there are COVID-19 patients who have never actually tested positive for it.  When it comes to covering COVID-19 preferentially, how do we distinguish those patients from others who might have had similar symptoms and treatments?  We're not even counting deaths accurately.

Safety

Maybe hydroxychloroquine will be the solution some believe it will be.  Maybe GM, Ford, and others can make ventilators just as well as their usual manufacturers.  Maybe the new coronavirus tests will each prove equally accurate.  But, chances are, some of the shortcuts the FDA is allowing will result in some harm.  

The FDA has sometimes been criticized for taking longer to approve new drugs, treatments and devices than other countries, but, in this crisis, it is understandably taking actions at what is, for it, a breakneck pace.  But we should not be naive; the normal FDA review processes are in place for reasons.  Even if there are not always perfect, they serve as guardrails for patient safety -- and we're now removing some of those guardrails.  

There will be some patients who suffer, perhaps even die, as a result of some of these shortcuts.  Who will we blame?  

Privacy

Telehealth companies have spend many years trying to make their platforms HIPAA-compliant and, ideally, integrated with other health platforms.  Now, though, we're using FaceTime, Skype, Zoom, and other video platforms to do telehealth, even though some of these (I'm taking to you, Zoom!) have prioritized ease-of-use over privacy, much less adherence to HIPAA.   

This is a time for telehealth, but when this is all over we may wonder whether the cost to our privacy was worth it.

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There is nothing about the current pandemic that allows us to be business-as-usual.  It's natural in a crisis to focus on the short-term problems, especially when there are so many and they are so big.  Each of the solutions being developed is being done with good intentions to address immediate problems.  But it's not too early to be thinking about what the longer-term implications of these solutions might be.  

Crises demand action, but actions have consequences.