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Analysis

CMS Rolls Out Recommendations for Elective Surgeries

By Mandy Roth  
   March 19, 2020

Guidelines offer a decision-making framework, yet decisions remain the responsibility of local healthcare delivery systems. CMS deems all dental procedures as high risk.

The Centers for Medicare & Medicaid Services on Wednesday rolled out voluntary recommendations for elective surgeries in an effort to nudge providers to cancel non-essential procedures until the coronavirus epidemic subsides. The administration is attempting to conserve critical resources such as ventilators and Personal Protective Equipment (PPE), while limiting the spread of COVID-19.

"Decisions remain the responsibility of local healthcare delivery systems, including state and local health officials, and those surgeons who have direct responsibility to their patients," according to the recommendations. "However, in analyzing the risk and benefit of any planned procedure, not only must the clinical situation be evaluated, but resource conservation must also be considered."

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CMS offers a tiered framework to help health systems consider the best use of resources. It is designed to guide decisions about how to provide surgical services and procedures to those whose condition requires emergent or urgent attention to save a life, preserve organ function, and avoid further harms from underlying condition or disease. Further refinements to the guidelines may be issued in the weeks ahead.

The guidelines also address dental procedures, warning that they use PPE and "have one of the highest risks of transmission due to the close proximity of the healthcare provider to the patient." CMS recommends that all non-essential dental exams and procedures be postponed until further notice."

Among the factors to weigh in considering cancelling all procedures:

  • Current and projected COVID-19 cases in the facility and region
     
  • Supply of PPE to the facilities in the system
     
  • Staffing and bed availability, especially intensive care unit (ICU) beds
     
  • Ventilator availability
     
  • Health and age of the patient, especially given the risks of concurrent COVID-19 infection during recovery
     
  • Urgency of the procedure.

"We're asking every American, and our medical community leaders, and hospitals to partner with us and [delay] elective procedures across the country and our healthcare system to ensure that medical supplies and medical capacity go where they're needed," said Vice President Mike Pence yesterday in a press conference. He leads the administration's Coronavirus Task Force.

The initiative has the support of the American Medical Association (AMA), according to Centers for Medicare & Medicaid Services Administrator Seema Verma, who also said the American College of Surgeons and the American Dental Association have taken a "proactive approach and already posted these recommendations."

A statement released last night by AMA President Patrice A. Harris, MD, MA, expressed support for the CMS actions. "As hospitals and physician practices plan for anticipated surges of patients needing care for COVID-19 infections, health professionals must use their expertise to develop allocation policies that are fair and safeguard the welfare of patients," Harris said. "The CMS guidance offers needed flexibility to physicians by allowing them to consider the imperative of resource conservation, especially personal protective equipment."

The AMA Code of Medical Ethics offers detailed advice to physician regarding how to approach the allocation of limited healthcare resources.

In a statement issued yesterday, Rick Pollack, president and CEO of the American Hospital Association (AHA) said, "As we make additional preparations, it’s important to recognize that the cancellation of elective procedures—which the medical community needs to be prepared to implement—should be determined at the local, community level in consultation with hospitals and the clinical recommendations of physicians and nurses. It is important to recognize the definition of 'elective' procedures includes important life-saving measures that will continue to be necessary. In issuing this framework, CMS took an appropriate step that provides a balanced approach to address this matter."

Earlier in the week, HealthLeaders reported that the nation's largest hospital associations, including the AHA pushed back against a recommendation from U.S. Surgeon General Jerome Adams that providers "consider stopping elective surgeries" until the coronavirus threat subsides. The Federation of American Hospitals, the Association of American Medical Colleges, and the Children's Hospital Association joined the AHA in signing a letter to Adams.

"We're making sure that the healthcare system is prepared, and that those on the front lines have the support that they need," Verma said in a White House conference yesterday. "The reality is the stakes are high, and we need to preserve personal protective equipment for those that are on the front lines of this fight."

"We fully appreciate that this is going to have a major impact on the healthcare system," said Verma, "but the shared sacrifice is essential to help those that are on the front lines."

“Decisions remain the responsibility of local healthcare delivery systems”

Mandy Roth is the innovations editor at HealthLeaders.


KEY TAKEAWAYS

Guidelines are designed to conserve crucial resources including ventilators and Personal Protective Equipment.

Decisions remain the responsibility of local healthcare delivery systems.

In addition to evaluating the clinical situation, resource conservation should be part of the consideration.


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