key: cord-0762616-9anuq5bt authors: Billig, Jessica I.; Sears, Erika D. title: The Compounding Access Problem for Surgical Care: Innovations in the Post-COVID Era date: 2020-06-02 journal: Ann Surg DOI: 10.1097/sla.0000000000004085 sha: 6cd08886f18218113b29019d774d5f55d20d61a3 doc_id: 762616 cord_uid: 9anuq5bt nan Surgical outcomes, such as mortality and complication rates, can be substantially affected by delays in care. For emergency surgery, access to "round-the-clock" operating rooms, personnel, and surgeons is associated with lower mortality rates. 1 Long delays in care for essential non-urgent surgery, including cancer operations, can lead to lower overall survival and higher complication rates. 2, 3 The reasons behind surgical delay are multifactorial, including patient, provider, and health system characteristics. 4 Improving overall access to surgical care is important for patient outcomes. However, the U.S. health system is on the precipice of a post-coronavirus (COVID-19) surgical access crisis as a result of ongoing mitigation efforts. During the pandemic, many hospitals have halted all non-urgent operative cases, including cancer operations, aiming to reserve beds for COVID patients. This has led to a substantial backlog of procedures, which will only continue to grow. Moreover, patients who were scheduled to have surgery during the pandemic may have progression of their disease, likely resulting in more complex and higher risk procedures. Many patients are also financially strained given the economic downturn from COVID-19. Barriers to access will be multiplied as patients have become furloughed or terminated, have taken on additional childcare, elder care, and sick care responsibilities, and have lost health insurance coverage. This "perfect storm" puts patients at risk of further delays in care. As we surface from the COVID-19 pandemic, surgeons will face the dilemma of scarce operative resources (i.e.: time, operating room space, surgical workforce, etc.) and how best to provide for the multitude of patients who had their surgical care delayed. Expansion of surgical access will need to be in the context of continuing COVID-related constraints, including limited hospital bed and intensive care unit capacity and a possible "second wave" of infections. Reinstating surgical services will be different for each health system and will need to be weighed against the risk of COVID resurgence. Given this compounded access problem, we need to evaluate Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. access to surgical care from a larger societal perspective and consider the added financial and time barriers that patients will be facing in what becomes the new normal as a result of COVID-19. What new strategies are needed to improve access to surgical care in the post-COVID-19 era? To improve surgical access, an integrated health system approach is needed with proactive and innovative strategies to provide surgical care for all people. We have detailed three solutions to increase access to surgical care: continued growth of telemedicine, expanded operating room schedules and settings, and transparent surgical billing. During COVID-19, there has been an explosion of telemedicine. On March 6, 2020, the Coronavirus Preparedness and Response Supplemental Appropriations Act was signed into law and waived Medicare telehealth payment requirements, permitting all Medicare patients to receive telehealth in their place of residence. 5 Though this act expanded telehealth on a temporary and emergent basis, telehealth should continue to be available for all patients in the post-COVID era without barriers. Telehealth can improve access to surgical care through minimizing patient travel, obviating the need for significant time off of work, and promoting flexibility in time of day that visits are scheduled. This is especially important for hourly wage earners, those furloughed and returning to work after social distancing restrictions are relaxed, and patients with childcare, elder care, and sick care responsibilities. Previously, telehealth has been implemented in several health systems for postoperative care, which should be broadly adopted. 6 However, there are instances where initial surgical consultation can be done via telehealth, such as routine evaluation of biliary colic. Certain surgical conditions (i.e.: melanoma excision with previous biopsy) do not need a physical examination Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. during initial consultation, and physical examinations can be deferred to the preoperative holding area where the operative plan can be adjusted accordingly. To continue the expansion of telehealth for surgery, sustained telehealth payments are needed. After the pandemic has subsided, the Centers for Medicare and Medicaid should continue to pay for telehealth visits, including phone visits. Surgical offices and health systems will need to broaden telehealth platforms to adequately handle an increased volume of virtual visits from multiple providers at the same time. With the rise in telehealth, strategies to streamline care will be essential. To reduce travel time and time off work, patients can have their surgical work-up (i.e.: imaging for cancer staging, biopsies, etc.) at a local facility. Physicians and practices will need to implement approaches for easy transfer of medical information across providers or health care systems to avoid additional delays. This could include joining cloud image transfer networks, permitting interoperability among previously siloed health systems and real time access to imaging exchanges. Given scarce operative resources in the post-COVID era, innovative solutions are necessary to expedite surgical care. First, expansion of operating room time can be implemented to increase the overall number of cases performed. This includes operating beyond the usual working hours. Hospital systems may need to expand availability of surgeon block time that may include evening or weekend hours, especially for elective procedures. Expansion of operating room hours and resources will need to be informed by the Efforts to improve access to surgical care must also include financial considerations. through June 30, 2020 to allow patients to obtain health insurance. 7 Reopening the ACA marketplaces in all states can help provide patients with insurance coverage, which will improve access overall. The post-COVID era will put unprecedented stress on surgical care, resulting in a compounding surgical access crisis. Innovative strategies to improve access to surgical care can lead to better postoperative outcomes. Fortunately, the pandemic has resulted in the Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Association between operating room access and mortality for life-threatening general surgery emergencies Time to Surgery and Colon Cancer Survival in the United States Postoperative complications reduce adjuvant chemotherapy use in resectable pancreatic cancer Access to Health Care in America Medicare Telemedicine Helath Care Provider Fact Sheet Pilot Study to Evaluate the Safety, Feasibility, and Financial Implications of a Postoperative Telemedicine Program California Responds to COVID-19 Emergency by Providing Path to Coverage for Millions of Californians Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited expansion of telemedicine, which must continue in the post-COVID era. However, telemedicine is only the beginning. Surgeons and health systems must take proactive and immediate action to reduce post-COVID surgical access challenges.