Ophthalmology community navigates upheaval, uncertainty wreaked by COVID-19
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Every day is a new normal.
By the time this issue of Ocular Surgery News is delivered, today’s new normal will be another new normal. OSN Senior Staff Writer Michela Cimberle knows this well. Upon returning to her home in the province of Treviso, Italy, after attending the European Society of Cataract and Refractive Surgeons Winter Meeting in Marrakech, Morocco, Cimberle was only mildly concerned about the COVID-19 outbreak, which had not yet been declared a pandemic.
“I came back to a war-like situation because of the coronavirus. Schools are closed, all public events have been canceled, even religious ceremonies cannot take place. We have never been through anything similar, and it is difficult to understand whether we are facing a real emergency or an overreaction,” she said at the time.
Source: David W. Mullin
That was Feb. 24; the total number of deaths attributable to the virus in Italy was seven.
Two weeks later
On March 9, when the death toll reached 463 and cases of infection were confirmed in all 20 regions of Italy, Cimberle wrote of the situation in the U.S., which had just seen the death toll in Washington state reach 22 and the number of infected people in New York state reach 142: “You’ll see that things develop very fast. Two weeks ago, I had just come back from the ESCRS meeting, and none of us was truly concerned about flying and being at a meeting. Even at the beginning of last week, the precautions they had suddenly imposed on us here seemed excessive. Now the perception we have of the magnitude of this event is entirely different. Two weeks ago, I talked with doctors in hospitals, and they were quite calm and reasonably optimistic; now they say it is a disaster. ... We must now make a serious and big effort to contain the transmission of this virus because hospitals and intensive care units are full, and they are running out of protective equipment for doctors. The speed of transmission of this virus is really quite amazing.”
Indeed.
By March 21, the Italian death toll attributed to the virus was more than 4,800, having surpassed the number reported in China, where the virus originated. In the U.S., the American Academy of Ophthalmology had just made the recommendation that ophthalmologists only treat urgent cases, and the American Society of Retina Specialists issued guidance for identifying emergent, urgent and nonurgent, nonelective indications for surgery.
From the last day of February, when the first death in the U.S. attributable to the virus was reported in Seattle, to late March, much changed in the ophthalmology community and quickly. As Healio/OSN attempted to gauge the impact of the virus on ophthalmologists and their practices across the country, it was clear that perspectives were changing daily.
Private practice in Seattle
Healio/OSN Board Member Laura M. Periman, MD, who practices in Seattle, told Healio/OSN that her practice canceled all elective procedures and nonurgent visits in accordance with the March 18 letter from the AAO.
“Our practices and our lives have changed dramatically from early to late March and continue to rapidly evolve,” she said. “Doctors are concerned about the rate of spread, the high contagion factor and the high mortality rate in the vulnerable population. Additionally, we now know that infected patients do not always have a fever (thus, temperature screening is insufficient for protecting our other patients in the clinic), and we now know that healthy people well younger than age 70 years are vulnerable and dying (thus, age screening is insufficient). The rate of viral shedding and infection from asymptomatic individuals is much higher than previously estimated. ... Doctors are also concerned with conserving resources. Washington State Department of Health is calling for inventory of equipment in our ASCs in case we need to convert to makeshift critical care facilities. I have enormous respect for our Italian colleagues who have come together and leaned into the crushing workload of the hospitalized and critical care patients.”
Private practice in New York
Meanwhile in New York, currently the epicenter of infection in the U.S., OSN Cornea/External Disease Board Member Eric D. Donnenfeld, MD, a managing partner at Ophthalmic Consultants of Long Island, wrangled with the need to protect patients and employees.
“We closed 80% of our offices Friday, March 13, and we are only doing emergency surgery,” he said. “We have taken any physician older than the age of 68 years and are not allowing them to see patients for any reason. ... We have had to furlough many of the staff. Partners are not taking a paycheck, and associates are continuing to be paid based on productivity, which is not a lot. We are continuing health insurance for all. Our management is doing an exceptional job, and they could write a book about how to respond to a crisis. As a managing partner, I have an update twice a day with our management leadership, and we keep our lines of communication open with physicians and staff through frequent emails and personal calls when needed.
“New York is exploding with new cases, and there is a sense of dread as hospitals are being overrun with new cases. Keeping the subways, theaters and schools open so long was, in my opinion, a bad decision that is now affecting the entire population.
“We are taking draconian steps, but I believe they are necessary, and we are confident we will come out the other side stronger than ever, but there is a good deal of pain right now. ... This is a time of concern in ophthalmic practices, and the key to our success is to limit exposure and continue our vigilant action plan to stay abreast of CDC and local department of health guidelines as they are released.”
Private practice in Ohio
In the week following the WHO’s declaration on March 11 that the epidemic was deemed pandemic, Healio/OSN Board Member Darrell E. White, MD, founder of SkyVision Centers in Ohio, made the “single hardest decision” of his career to shutter his offices and furlough his staff.
“It became clear that our little practice was just not going to be able to survive if we stayed open,” White told Healio/OSN in a video interview.
“I furloughed about 80% of my staff, including one of my children,” he said. “We pledged to our employees that we would cover the health insurance premiums for as long as we could, that we would continue to cover them until the till ran dry. So, our practice is closed. I can’t imagine a greater impact on the practice.”
Short term, White’s concern is for his staff and how they will manage.
“What’s going to happen in 2 weeks? What’s going to happen in 4 weeks if we can’t get going?”
Long term, White’s concern is whether his private practice will stay open.
“When the Affordable Care Act was passed and incentives were placed in the system for a massive increase in the size of accountable care organizations, all of the incentives in the ACA were to get bigger, bigger, bigger bigger. And what that did was gobble up a huge portion of the private practices. ... But the ACA didn’t kill the private practice of ophthalmology,” he said.
“My concern is that COVID-19 will see the demise of private practice, will see the demise of the small, personal, hands-on practice of medicine across the board. I’m deeply concerned about that,” he said.
University medical centers
On March 19, California Gov. Gavin Newsom issued an executive order for all residents of California to “stay home or at their place of residence except as needed to maintain continuity of operations of the federal critical infrastructure sectors.”
At University of California at Irvine, OSN Cornea/External Disease Board Member Marjan Farid, MD, reflected on the snowballing effect of the pandemic:
“There is a daily shift in the COVID-19 climate here at University of California, Irvine. The undergraduate campus has now shut down all face-to-face classes and has gone to an online system for an indefinite length of time. The university campus and UCI Medical Center are taking every precaution in terms of isolation of patients at risk. We are seeing more testing happening on site, and the hospital is prepared for large numbers of COVID-19-positive patients. UCI has closed to all nonurgent cases at this time.”
Healio/OSN Section Editor Uday Devgan, MD, balancing private practice and work at UCLA, had already sent staff home. He told Healio/OSN:
“Recently, California enacted a statewide stay-at-home order in an effort to limit the spread of COVID-19. This means canceling all elective ocular surgery as well as nonurgent clinic visits. My private practice, which specializes in just cataract and refractive surgery, is closed for now, and our surgery center is only doing the rare urgent case. At our large teaching hospital, Olive View-UCLA Medical Center, we have taken similar measures, and we are only seeing urgent or emergency patients and performing required emergency surgeries such as retinal detachment repair, ruptured globes and certain glaucoma cases.
“This pandemic is likely going to be more severe than many are expecting, and we want to minimize the risks to our patient population, which is largely elderly. Initial statistics show about a 10% mortality rate in people older than age 70 years, such as our cataract surgery patients. There is no need to expose our patients to this potential risk when the cataract surgery can be delayed without consequences. Now we must focus our attention on limiting the severity of COVID-19 transmission and trust our leaders and infectious disease specialists.”
Meeting cancellations and postponements
The first major meeting in the U.S. canceled for fear of spreading the COVID-19 virus and prompting rapid subsequent shutdowns could arguably be cited as not a medical conference but the arts and technology festival South by Southwest.
Scheduled for March 13 to 22 in Austin, Texas, the festival would have attracted an international crowd numbering in the hundreds of thousands.
The American Glaucoma Society had finished its annual meeting March 1 in Washington, but subsequent spring meetings of the American Association for Pediatric Ophthalmology and Strabismus, Association for Research in Vision and Ophthalmology, American Society of Cataract and Refractive Surgery, Kiawah Eye 2020 and OSN Italy have all since been canceled or postponed.
#StayHome
As the need for “social distancing” is impressed on every community across the nation, the need for telehealth solutions and virtual house calls has burgeoned.
To heed the need, the ASCRS Cataract Clinical Committee hosted a remote webinar to answer questions about implementing teleophthalmology during the COVID-19 pandemic.
CMS regulatory changes made to expand telehealth guidelines and benefits during the outbreak include making payments for professional services nationwide in all settings including the patient’s home and waiving HIPAA requirements such that penalties for violations would not be imposed, Ranya Habash, MD, medical director of technology innovation at Bascom Palmer Eye Institute, said in her presentation.
“There is a lot more laxity where the guidelines are concerned, which should enable us to perform more telemedicine,” she said. “They wanted us to have the tools in place and to be able to perform telemedicine, because if we can’t do it, then there’s no one there to help our patients in this time of need.”
Medicare telemedicine services now include HCPCS/CPT codes for Medicare telehealth visits, virtual check-in and e-visits, using “everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency,” CMS posted on its website.
Uncertain economic impact
In this issue, OSN reintroduces the O.S.N. Stock Index, a representation of the trending values of a cross-section of big and small ophthalmology-focused companies developing or producing devices or drugs in the eye care space.
The O.S.N. index shows an aggregation of 13 weeks of data, starting in January. The first death in China was reported Jan. 11, and the first case reported outside of China was in Thailand on Jan. 13. The U.S. stock market was still strong. By March 21, 3.3 million people in the U.S. had filed for unemployment benefits. The index illustrates strong confidence at the beginning of the year and the gravity of the financial uncertainty by end of March.
These are unstable times. Stay safe. Be well. – by Rebecca Forand, Robert Linnehan, David W. Mullin and Patricia Nale, ELS
Editor’s note: This article is compiled from various media reports as well as original reporting on Healio/OSN and personal correspondence.
- References:
- At issue: How ophthalmologists are handling COVID-19. www.healio.com/ophthalmology/practice-management/news/online/%7B81fbced9-8f99-439b-bc3c-ad6e9431c321%7D/at-issue-how-ophthalmologists-are-handling-covid-19. Published March 23, 2020.
- CMS payment policies & regulatory flexibilities during COVID-19 emergency. www.ama-assn.org/delivering-care/public-health/cms-payment-policies-regulatory-flexibilities-during-covid-19. Published March 25, 2020.
- Coronavirus: Death toll jumps again in Italy’s ‘darkest hour’. www.bbc.com/news/world-europe-51805727. Published March 9, 2020.
- Cox Media Group National Content Desk. Coronavirus outbreak: What you need to know. www.wsbtv.com/news/trending/coronavirus-live-updates-cases-top-100000-globally/CYL4I5DJXBHDJEPHXUMB6V3JYU/. Updated March 9, 2020.
- First U.S. coronavirus death is recorded near Seattle. www.nytimes.com/2020/02/29/world/coronavirus-news.html#link-3f8f1f4b. Published Feb. 29, 2020.
- Italy’s coronavirus death toll feeds fear of what lies ahead in Europe and the U.S. www.washingtonpost.com/national/italy-coronavirus-death-toll/2020/03/21/e6426d82-6b85-11ea-abef-020f086a3fab_story.html. Published March 21, 2020.
- Medicare telemedicine health care provider fact sheet. www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. Published March 17, 2020.
- State of California Executive Department. Executive order N-33-20. www.gov.ca.gov/wp-content/uploads/2020/03/3.19.20-attested-EO-N-33-20-COVID-19-HEALTH-ORDER.pdf. Published March 19, 2020.
- Timeline: How the coronavirus spread. https://www.aljazeera.com/news/2020/01/timeline-china-coronavirus-spread-200126061554884.html. Published March 29, 2020.
- Worldometer. www.worldometers.info/coronavirus. Accessed March 25, 2020.
Disclosure: No products or companies that would require financial disclosure are mentioned in this article.
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