AMA: Medical community paying ‘terrible price’ for lack of COVID-19 preparations in US
During a virtual Town Hall meeting recently hosted by the AMA, experts reviewed the latest research on COVID-19 and addressed questions from health care providers on the front lines about the availability of personal protective equipment, treatments for COVID-19 and efforts to secure the financial stability of private practices.
AMA President Patrice A. Harris, MD, MA, said physicians, nurses and other health care workers are exhausted from working “extremely long hours under intense pressure, and sometimes dangerous conditions.”
“You have already paid a terrible price for our nation’s lack of preparation — for its inability to get you the basic supplies and protective equipment you’ve been pleading for,” she said during the meeting. “Many in our medical community have fallen seriously ill. Some have died. This is the reality as we show up for work today... facing an enormous public health threat seemingly with an arm tied behind our back.”
Early reports from China gave the United States at least 3 to 4 weeks to prepare for the outbreak, according to Howard Bauchner, MD, JAMA editor-in-chief and professor and vice chair of the department of pediatrics at Boston University School of Medicine and Public Health.
“Unfortunately, I think it’s quite clear that the U.S. for many different reasons squandered that time,” he said. “The lack of rapid testing has led to organizational and logistical nightmares, and it has clearly fueled health care worker infections [and] probably has led to increased disease amongst patients.”
Latest COVID-19 research
Bauchner reported receiving a “staggering” number of submissions to JAMA for research letters, reports and opinion pieces on COVID-19. Since January, about 2,000 of these manuscripts have been submitted. Of those, about 60 have been published.
These papers have provided “a wealth of information” on COVID-19, Bauchner said. But many important questions about treatments remain unanswered.
“There is tremendous tension over the use of unapproved therapies,” Bauchner said. “Patients are really sick in the ICU; some are going to go on to die. People really want to help them, and patients want to try something if they realize the potential outcome is death. But on the other hand, without the appropriate evidence, we’re reaching for straws.”
When asked about the AMA’s position on off-label treatments for COVID-19, Harris said the organization supports randomized controlled trials evaluating the safety and efficacy of these drugs. Although the FDA has authorized emergency use of hydroxychloroquine and chloroquine for certain patients with COVID-19, Harris said it is important for physicians to ensure there are enough of these drugs available for patients who rely on them, such as those with lupus and rheumatoid arthritis.
“We have to make sure that we are looking at all of this in context and for the well-being of all of our patients,” she said. “We really do need to let the process go through regarding randomized controlled clinical trials.”
Bauchner warned that there has been “an enormous amount of selective reporting” on the success of investigational COVID-19 treatments. Some of the authors of JAMA submissions have admitted to limiting their analyses to include only patients who did well after receiving treatment, he said.
“That’s what the concern is when you see small case series that are uncontrolled,” he added.
Another challenge with smaller case reports is that the prevalence of adverse events may be underestimated, Bauchner said. For example, if a patient’s health declines after receiving an investigational treatment, it could be attributed to the severity of COVID-19 disease instead of recognizing the possibility of a treatment-related adverse event.
“I can’t emphasize that I strongly support the AMA’s position that to the extent possible, decisions have to be based upon science and evidence,” Bauchner said. “We are doing no service to the people infected in the future if we can’t resolve some of those issues today.”
There is confusion about whether hypertension treatment with renin-angiotensin-aldosterone system antagonists such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) increases the risk for COVID-19 as well as the severity of the disease for those who become infected. These questions remain unanswered, Bauchner said. But based on current evidence, major professional cardiology societies are recommending that patients with hypertension remain on ACE or ARB therapy, even when they are admitted to the hospital for COVID-19.
Availability of PPE
The AMA and other health care organizations are pressuring President Donald J. Trump and his administration to invoke full powers of the Defense Production Act to accelerate the production of personal protective equipment (PPE), according to Harris. The AMA is also asking the federal government to coordinate a tracking system so that these resources are distributed to areas with high demand.
Todd Askew, senior vice president of advocacy at AMA, said an airbridge has been established to feed PPE into the U.S. supply chain, but “it is not enough.”
“HHS and CMS are looking for ideas and best practices for preservation and reuse of PPE,” he said. “Far from ideal, but it’s unfortunately where we find ourselves right now. We will continue to press the federal government to use every lever they have to increase both acquisition and production of PPE.”
Financial stability for private practices
AMA is working with Congress to protect private practices from the financial impact of COVID-19. The CARES Act passed earlier this month includes $100 billion that Harris said is often mistaken as hospital-only funds; however, she said it can also be used to support private physicians who are treating patients with COVID-19, as well as those who need to recoup losses caused by a sharp decline in office visits and elective procedures.
The specific distribution plan for the $100 billion emergency fund is still underway, Askew said, and there are additional efforts to increase the fund because “it is not enough” to fully sustain financial stability. Small business loans are also available for practices with fewer than 500 employees.
“These loans, for the most part, will be forgivable, meaning they act almost as a grant for the practice to maintain a payroll and other overhead costs,” Askew said.
Medicare-advanced payments are another option for private practices that are struggling financially. Through this program, physicians can receive an upfront payment for future Medicare claims. The payment is based on revenue from the last quarter of 2019, Askew said.
“There are some considerations there in terms of the recoupment of those claims, which will start fairly soon,” he added. “After 210 days, the interest rate is quite high. We are working with Congress and the administration to see if we can make the terms of that program a little more favorable.”
‘You have answered the call’
Despite the dangers and uncertainties among health care workers, Harris acknowledged that the medical community has “stood tall” and “risen to this moment.”
“You have shown this nation who we should be listening to: Physicians, public health experts and scientists,” she said. “Time and again, you have answered the call despite breakdowns in leadership, despite conflicting messages and despite severe shortages of resources and life-saving equipment. The coronavirus pandemic presents a challenge our country has not faced on this scale for generations. But let me be clear: You are not shouldering it alone...We are fighting for your safety, your peace of mind and your livelihood.” – by Stephanie Viguers
For more information:
AMA. COVID-19 (2019 novel coronavirus) resource center for physicians. https://www.ama-assn.org/delivering-care/public-health/covid-19-2019-novel-coronavirus-resource-center-physicians. Accessed April 10, 2020.
Disclosures: Healio Primary Care was unable to confirm relevant financial disclosures at the time of publication.