AMA experts on easing patient concerns about the safety of preventive exams

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

As we mark the somber milestone of more than 200,000 deaths due to COVID-19, AMA recognizes physicians, nurses, health care workers and staffs for their continued sacrifices during the pandemic. AMA also talks to health experts about the importance of preventive care and how physicians can ease patients' concerns about the safety of preventive exams and procedures.

Learn more at the AMA COVID-19 resource center.

Speakers

• A. Patrice Burgess, MD, member, Council on Medical Service, AMA
• Alexander Ding, MD, chair-elect, Council on Science and Public Health, AMA
• Julie Marder, JD, senior policy analyst, Socioeconomic Policy Development, AMA

Unger: Hello, this is the American Medical Association's COVID-19 update. As we mark the somber milestone of 200,000 deaths in the U.S from COVID-19, we wanted to recognize the physicians, nurses, health care workers and staffs for their continued sacrifices encouraged during the pandemic. Many of them have lost their lives, including Adeline Fagan, a 28 year old OBGYN resident, and AMA member, who died from complications of the coronavirus on September 19. Dr. Fagan had been treating COVID positive patients in the emergency room of her hospital in Houston when she became ill.

With that, I'll turn to today's discussion on the importance of preventive care during COVID-19 and how to talk to your patients about it. I'm joined today by Dr. Alexander Ding, diagnostic and interventional radiology specialist and chair-elect of the AMA Council on Science and Public Health in Louisville, Kentucky. Dr. A. Patrice Burgess, family medicine physician, and member of the AMA Council on Medical Service, in Boise, Idaho. And Julie Marder, a senior policy analyst in socio-economic policy development at the AMA in Chicago. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Burgess, let's start with you. Can you tell us why preventive care is so important during COVID-19?

Dr. Burgess: Well, thank you, Todd. In primary care, we always feel preventive care is very important to catch things early before they become a problem. But with COVID-19 any secondary issues are going to make a person more vulnerable to the disease. So the more we can keep people healthy by avoiding problems, the less likely they are to get very sick with COVID.

Unger: Dr. Ding.

Dr. Ding: Yeah. I appreciate that question, Todd, and I want to focus a little bit on talking about the flu shot, particularly as we enter the fall season. I think this year, in particular, it's extremely critical that we talk about this. Vaccines are evidence-based preventative services, and they're really essential services in normal years, but even more so during the COVID pandemic. I think what's a little bit uncertain is what will happen with the seasonal flu this year in the fall and in the winter. But I'm concerned that seasonal flu activity with the COVID pandemic, with the two of them, there's really a lot of potential to create greater strain on our health care system than we've seen so far in 2020. And that to me is somewhat scary. And so this year, I think, getting a flu vaccine will be more important than ever for protecting your own health, the health of people around you and to really conserve scarce health care resources to fight COVID-19. I think that's something that I really want physicians to emphasize to their patients as well.

Unger: Ms. Marder, can you speak to the impact the COVID pandemic has had on preventive care?

Marder: Yes, absolutely. And despite the incredible importance of preventive care. We do have data recently showing just how much preventive care declined during the height of the pandemic. There was a study that just came out a couple of weeks ago from the Health Care Cost Institute that looked at the decrease and utilization of some key preventive services during the height of the pandemic. And some of the results were really striking. So for example, they found that childhood vaccinations on the aggregate were down about 60% in mid-April of 2020, compared to 2019. And even more dramatically, they found that mammograms and pap smears were down nearly 80% in April of 2020, compared to where they were in June, I'm sorry, of April, 2019. And those results came up a little bit over the summer, but they were still significant declines. By June, they were still down about a quarter from where they were in 2019. And similarly, colonoscopies were down almost 90% in mid-April of 2020 compared to 2019. And they were still down by about 30% as of June compared to last year.

Unger: Those are incredible decreases. Dr. Burgess, is that what you're seeing in your practice?

Dr. Burgess: Yeah, actually. Early on we were doing telemedicine only, telehealth visits only, which is great for keeping some chronic diseases under control, but you can't do a pap smear by telehealth, and obviously they can't do a mammogram that way either. Our mammogram facilities were actually shut down temporarily and have since reopened with a lot of safety precautions and are trying to catch up by doing some Saturday mammograms and other expanded hours. But it's legitimately concerning for patients. And I think it takes a little while to build confidence that all of our safety precautions are in place, but we are really trying to make up for that backlog.

Unger: What are you telling your patients who have concerns about seeing their physician right now?

Dr. Burgess: So, what we've done, and I'm sure other systems have done, is really isolated people with any symptoms that might be related to COVID, to certain clinics so that those clinics are solely focused on infection. And our regular clinics are COVID-free as much as we can. And we screen everybody with temperature and everybody wears a mask and do everything we can to keep those clinics safe, so that our elderly folks, our younger children, people can feel comfortable that they're less likely to get infected when they come in for their visit. And we're doing everything to keep everything safe.

Unger: Dr. Ding, any insight there, particularly around telemedicine?

Dr. Ding: I think one of the few silver linings that we've seen with COVID has really been the acceleration of some innovation in health care. And in particular, as you mentioned, telemedicine. This is something where the technology has been there for a couple of years, but the adoption has really been steady but slow. And I think when COVID hit that really accelerated and took off.

And so, interestingly, telemedicine actually might be an option for some preventative care services. Some of these services you can actually do without leaving the home. So for example, patients who might need a colorectal cancer screening, you can actually get a consultation by a telemedicine and then you get a Cologuard test sent over to your house. You can do the test at home, send it right back in the mail for analysis. But of course there are plenty of preventative services that you can't do over telemedicine and patients do need to come in. And I think really the important thing to emphasize there is really discussing what are the things that you have proactively done as a health care system, as a clinic, as a provider, as a doctor to make it as safe as possible. And frankly, if you were to ask me, I really think a health care facility is one of the safest places you can go to right now because I think everyone who's working there is taking safety so seriously.

Unger: With addition to the safety concerns, many patients have been hit hard financially by the pandemic. What do you tell your patients who are delaying or avoiding preventive care because they're afraid they can't afford it?

Dr. Ding: Yeah, I really appreciate you bringing up that question, Todd, because I think we really have to be sensitive to the fact that COVID is not only affected the health of Americans in this country, but it's also made a significant impact on the economy. And so there are a lot of patients who are now facing financial insecurity, and we really have to be cognizant and sensitive to that. But I think one thing that a lot of patients don't realize is, because of the Affordable Care Act, there are certain preventative care services for some certain populations where those services actually have to be provided without any cost to the patient. We talked to some policy people or some health insurance people, some people refer to these, as zero-dollar, or first-dollar coverage. But what it really means is that nothing is out of pocket for the patient.

Unger: Dr. Burgess, any advice—

Dr. Ding: And so.

Unger: I'm sorry. Go ahead, Dr. Ding.

Dr. Ding: And so I was going to say for vaccines specifically, obviously you do have to come in, in person for that. And there are a lot of safety protocols that have been put in place. But here again, we're seeing some innovative things that people are doing. You can still get your flu shots in the usual way, but now we're seeing drive-through immunization centers, curbside clinics, mobile outreach units and even the traditional home visit is making a comeback.

Unger: Mm-hmm. Dr. Burgess, any comment on patients and their concerns about the financial implications of preventive care.

Dr. Burgess: Yeah, absolutely agree with everything Dr. Ding said. The confusion, I think, can be different insurance policies do cover different criteria. So some will cover only a high-risk patient for their preventive services. Others will cover average risk, and that can be very confusing, not just to patients, but also to the primary care provider. So we have to work together to figure out what the coverage is for the patient so they don't get surprised by a bill over something that thought was covered. So we're very careful about that. And it's specific to policies, to age, some go by different criteria from different recommendations from either the USPSTF or medical societies.

Unger: Ms. Marder. These are huge issues. How's the AMA helping physicians navigate them?

Marder: Absolutely. So the AMA Council on Medical Service and the Council on Science and Public Health study these issues and found that even though the Affordable Care Act, zero-dollar preventive services provision is exceptionally popular among those who are really familiar with it, there's a lot of confusion about how it works. Just like what Dr. Burgess was referring to, there can be a lot of confusion and some of this confusion, again, goes back to the billing that Dr. Burgess was just speaking to. So it's really critical with these zero-dollar services that physicians and other health care providers and their staff, very clearly communicate precisely with health insurance companies when they're coding these services, to ensure that the coding matches up with the service that was provided and that it signals to the insurance company that a zero-dollar service was provided. And therefore they, the insurance company, are solely responsible for paying that patient's bill and the patients aren't asked to share in the cost of a service that they don't have cost sharing for.

So to help reduce some of this confusion, the AMA published some really great resources, and they're free and available to the public on our website. And these are some coding guidance documents and other guides that physicians can look to as they're thinking through the nuances of these services and identifying which patient populations are qualifying for the zero-dollar services. And to help them think about how they can counsel their patients regarding these services, the value of them, both clinical and financial. So I understand that a link is going to be provided alongside this video. So no one has to write it down, but the resources will be available at ama-assn.org/preventive-coding.

Unger: Thank you so much. Dr. Ding, any comment?

Dr. Ding: Yeah, I think the most important thing that I really want to emphasize at this time is really to communicate about the importance of preventative care to your patients. And I think it's really important to get them back on track with their preventative care services. And I think the main point to make is, after six months in a pandemic, I think there's no more time to wait. There's no more time to delay getting your preventative health care to get taken care of.

Unger: Dr. Burgess, any final thoughts?

Dr. Burgess: Yeah, I absolutely agree. And we've really moved to a hybrid model of some telehealth some in-person visits for the reasons that we've described. And just really want to reemphasize immunizations because a pneumonia immunization is also important as well as the flu vaccine. Because you want to have another respiratory illness and then be more susceptible to COVID even the Tdap, which protects against pertussis can be an important thing. And these are all things that we cover in those preventive visits.

Unger: Well, thank you very much. That is tremendous advice. Dr. Ding, Dr. Burgess, Ms. Marder, thanks so much for being here today and sharing your perspectives. That's it for today's COVID-19 update. We'll be back with another segment soon. For updated resources on COVID-19, go to ama-assn.org/COVID-19. Thanks for joining us and please stay safe.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.