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The Keckley Report

Patient Anxiety Needs Serious Attention in Hospitals

By June 1, 2020March 1st, 2023No Comments

On March 14, Surgeon General Jerome Adams urged a widespread halt of hospital elective procedures amid mounting concern that the health system did not have enough beds to manage a surge of coronavirus cases.

A month later, on April 17, the American College of Surgeons, the American Hospital Association and other key groups released their “Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic” laying out considerations for resuming procedures based on conditions in each state.

On April 19, CMS published its official guidance, “OPENING UP AMERICA AGAIN Centers for Medicare & Medicaid Services (CMS) Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I” providing a checklist for resumption of elective procedures in hospitals.

And as of two weeks ago, every state had lifted restrictions. Early indications are that office-based and ambulatory procedures and tests have been recovering but major procedures in hospitals lag.

To date, the focus for policymakers, public health officials, hospitals and physicians has been on re-opening hospitals safely. Their attention has been on the adequacy of PPE, masks, workforce safety, facilities, infection controls, testing and more. Their hope has been a return to normalcy that includes resumption of elective procedures. But it’s not happening.

The reason: patients are afraid. Consider:

  • In late March as the lockdowns began, 83% of Americans said they were concerned about being exposed to the coronavirus in a doctor’s office or hospital and 36% said that they would not go into a medical facility at all (Gallup)

  • As a result of the coronavirus pandemic, 72% of U.S. consumers have ‘dramatically’ changed their use of traditional healthcare services; 58% cite their doctor as the most trusted source of information about the virus, but only 31% feel “comfortable” visiting their doctor’s office and 42% say they feel uncomfortable going to a hospital for any kind of medical treatment. (Alliance of Community Health Plans)

  • 33% and 55% of adults who describe their financial situation as poor have experienced high levels of psychological distress at some point during the extended period of social distancing undertaken to slow the spread of COVID-19. (Pew Research Center)

  • 31% say they have fallen behind in paying bills or had problems affording household expenses like food or health insurance coverage since February due to the coronavirus outbreak. (Kaiser Family Foundation)

Patient anxiety is not new to healthcare. Medical students learn about ‘white coat anxiety’ that can invalidate vitals like blood pressure and potentially contribute to inaccurate diagnoses. Clinical research considers anxiety disorders as disabling as depression especially in populations with chronic co-morbidities or groups who feel socially disenfranchised—like persons of color, the uninsured or uneducated.

Anxiety and fear in the U.S. population is high: little wonder those considering their elective procedures are having second thoughts. For some, it’s a matter of personal safety. For some, it’s a matter of out of pocket cost as they face financial insecurity. For most, it’s reason to pause. Per the CDC, anxiety and stress during an infectious disease outbreak results in the worsening of chronic and mental health problems and increased use of alcohol, tobacco, or other drugs. So, delays can be problematic for patients and providers alike.

As it turns out, the demand for Covid-19 beds was lower than early projections had warned but the financial loss from cancellation of elective procedures is daunting. Moody’s Investor Services forecast they’ll exceed $200 billion through June 30 leaving the majority in dire straits. But they’re likely to be even higher if patient anxiety isn’t addressed better by hospitals and physicians.

In ACS’ Joint Statement and CMS’ Opening Up America Again, there’s no mention of patient anxiety. None. Both address prioritizing cases and preparing facilities and supplies, but not a word about the fears and anxiety of their patients.

To restore elective procedures, managing patient anxiety must be a priority, not an afterthought in hospitals. It requires thoughtful outreach to patients with specifics about safety measures, private helplines for worried patients and adequate time for dialogue with patients. These start before a patient darkens the hospital door—their interactions with their physicians and how their questions and concerns are addressed—and continue after they leave.  It’s not business as usual.

When U.S. Surgeon General Jerome Adams tweeted “Hospital & healthcare systems, PLEASE CONSIDER STOPPING ELECTIVE PROCEDURES until we can #FlattenTheCurve!” little did we know the challenge of patient anxiety would be the biggest barrier to restoring elective procedures.

Patient anxiety about hospital care is palpable. What’s at risk is more than revenue losses for hospitals and physicians who fail to regain elective volumes; it’s about the fundamental nature of patient relationships between patients, their physicians, and hospitals. 

It needs attention in hospitals, perhaps now more than ever.

P.S. In retrospect, the decision to cancel elective procedures across the board might have been premature. Data showing widespread variability in infection rates state by state suggest the decision was a blunt instrument that might have caused more harm than good in many places. Like patient anxiety about hospital care, it deserves more attention.


“Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic” American College of Surgeons, American Society of Anesthesiologists, Association of Perioperative Registered Nurses, American Hospital Association April 17, 2020;

CMS published “OPENING UP AMERICA AGAIN Centers for Medicare & Medicaid Services (CMS) Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I”.

“Resuming Elective Procedures: A Checklist of Considerations” Healthcare Advisory Board April 2020

“A third of Americans experienced high levels of psychological distress during the coronavirus outbreak” Pew Research Center May 7, 2020

Reed Abelson “Hospitals Struggle to Restart Lucrative Elective Care After Coronavirus Shutdown” New York Times May 9, 2020

Katon W, Roy-Byrne P, Russo J, et al. Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder. Arch Gen Psychiatry. 2002;59:1098–1104.

“COVID-19 Shifts Consumer Behavior, Attitudes Toward Health Care Services” Alliance of Community Health Plans May 21, 2020

“Impact of Coronavirus on Personal Health, Economic and Food Security, and Medicaid” Kaiser Family Foundation May 27, 2020


Stay-at-Home Orders Correlate to Lower Hospitalizations

As of April 18, 2020, governors in 42 states had issued statewide executive “stay-at-home” orders to help mitigate the risk that COVID-19 hospitalizations would overwhelm their state’s health care infrastructure. The researchers examined data from 4 states where hospitalization data for at least 7 consecutive days prior and 17 days after the state’s stay-at-home order was issued. States included in this sample were Colorado, Minnesota, Ohio, and Virginia. Findings:

  • In all 4 states, cumulative hospitalizations up to and including the median effective date of a stay-at-home order closely fit and favored an exponential function over a linear fit. However, after the median effective date, observed hospitalization growth rates deviated from projected exponential growth rates with slower growth in all 4 states.

  • In 4 states with stay-at-home orders, cumulative hospitalizations for COVID-19 deviated from projected best-fit exponential growth rates after these orders became effective. The deviation started 2 to 4 days sooner than the median effective date of each state’s order and may reflect the use of a median incubation period for symptom onset and time to hospitalization to establish this date.

Soumya Sen, PhD; Pinar Karaca-Mandic, PhD; Archelle Georgiou, MD Association of Stay-at-Home Orders With COVID-19 Hospitalizations in 4 States JAMA. May 27, 2020. doi:10.1001/jama.2020.9176

State Reports on Testing Levels Misleading

At least 12 states have inflated testing numbers or deflated death tolls. At issue, the co-mingling of diagnostic tests that determine is the virus is active in the person being tested and antibody testing that reveals who might have been infected previously. Complicating matters, HHS has repeatedly used misleading data and the CDC has given states wide latitude in reporting. 

Johns Hopkins Coronavirus Resource Center May 31, 2020

Emergency Relief Meals Program Mired in State Administrative Red Tape 

Child hunger is soaring, but two months after Congress approved the Pandemic-EBT program to replace school meals, only 4.4 million (15%) of the 30 million eligible children have received benefits.

The program, approved as part of the Families First Act in March, provides electronic cards that families can use in grocery stores, but often-outdated state computers have debilitated/delayed the program’s launch. By May 15, only 12 states (mostly Blue states) had started sending money, and Michigan and Rhode Island alone had finished; 16 states still lack federal approval to begin the payments and Utah declined to participate citing administrative capacity to distribute the money as the reason.

The program serves families with incomes up to 185% of the poverty line, or $48,000 for a family of four. The Census Bureau reported last week that 31% of households with children lacked the amount or quality of food they desired because they “couldn’t afford to buy more”.

Jason DeParle “Hunger Program’s Slow Start Leaves Millions of Children Waiting” New York Times May 26, 2020;

Anxiety, Stress Force Many to Defer Medical Care

Per the Kaiser Family Foundation Health Tracking poll of 1189 adults conducted May 13-18 and released last Wednesday:

  • 48% say they or someone in their household have postponed or skipped medical care due to the coronavirus outbreak. 68% of these who delayed care expect to get the delayed care in the next three months.

  • 39% say worry or stress related to coronavirus has had a negative impact on their mental health, including 12% who say it has had a “major” impact–down slightly from early April (45%).

  • Women are more likely than men to say it has negatively impacted their mental health (46% vs 33%) and urban (46%) and suburban (38%) residents are more likely than those in rural areas (28%) to say coronavirus has had a negative impact on their mental health.

  • 26% say they or someone in their household have skipped meals or relied on charity or government food programs since February, including 16% who say this was due to the impact of coronavirus on their finances.

“Impact of Coronavirus on Personal Health, Economic and Food Security, and Medicaid” Kaiser Family Foundation May 27, 2020

Pew: Stress Widespread

33% of all Americans and 55% of adults who describe their financial situation as poor have experienced high levels of psychological distress at some point during the extended period of social distancing undertaken to slow the spread of COVID-19.

“A third of Americans experienced high levels of psychological distress during the coronavirus outbreak” Pew Research Center May 7, 2020


US Preventive Services Task Force Recommendation: Interventions for Illicit Drug Use Among Children and Youth Inconclusive

In 2017, an estimated 7.9% of adolescents aged 12 to 17 years and 23.2% of young adults 18-25 reported illicit drug use in the past month. An estimated 50% of adolescents in the US had used an illicit drug by the time they graduated from high school. Illicit drug use is associated with many negative health, social, and economic consequences and is a significant contributor to 3 of the leading causes of death among young persons (aged 10-24 years): unintentional injuries including motor vehicle crashes, suicide, and homicide.

“Because of limited and inadequate evidence, the USPSTF concludes that the benefits and harms of primary care–based interventions to prevent illicit drug use in children, adolescents, and young adults are uncertain and that the evidence is insufficient to assess the balance of benefits and harms. More research is needed.”

“Primary Care–Based Interventions to Prevent Illicit Drug Use in Children, Adolescents, and Young Adults” US Preventive Services Task Force Recommendation Statement May 26, 2020 JAMA. 2020;323(20):2060-2066. doi:10.1001/jama.2020.6774

Blues Sue CVS Over Alleged Generic Drug Price Disclosure

The Blue Cross and Blue Shield plans in Alabama, Florida, Minnesota, Missouri, North Carolina, and North Dakota filed a lawsuit against CVS Health for inflating the price of generic drugs. At issue: agreements between pharmacy benefits managers (PBM) and insurers. If the usual and customary price, or the price offered to the uninsured or anyone paying cash, is lower than the price pharmacy benefit managers negotiate with health plans and employers, payers like the Blues are only required to pay CVS the former. This ensures that health plans and their members do not pay more for a given generic drug than those who pay cash. CVS allegedly worked with its pharmacy benefit manager, Caremark, to avoid reporting its cash discount prices as its usual and customary prices.

Alex Kacik “Blues plans sue CVS over alleged generic-drug price inflation” Modern Healthcare May 28, 2020

Primaries Tomorrow in 9 states, Washington, D.C.

Nine states and Washington, D.C., will hold presidential and congressional primary elections tomorrow:

  • 7 states and the District of Columbia are holding presidential primaries: Indiana, Maryland, Montana, New Mexico, Pennsylvania, Rhode Island, and South Dakota.

  • 8 states and the District of Columbia are holding congressional primaries: Iowa, Idaho, Indiana, Maryland, Montana, New Mexico, Pennsylvania, and South Dakota.

  • In the 8 holding June 2 primaries, 46 House and five Senate seats are up for election (10.6% of all House seats and 15.2% of all Senate seats up for election in 2020).

  • Incumbents are running for re-election in 41 of the 46 U.S. House races and four of the five Senate races in the states holding primaries on June 2.

Ballotpedia Federal Tap

Study: Out of Network Billing Widespread Among Pathologists

The analysis is based on 13.8 million visits by those with employer-sponsored insurance coverage:

  • Among providers with one of the specialties we examined, the share with at least one out-of-network claim associated with an in-network inpatient stay ranged from 18% for cardiology to 44% for emergency medicine.

  • The share of providers with at least one-out-of-network claim associated with an in-network outpatient visit ranged from 15% for behavioral health to 49% for emergency medicine.

  • Among providers with one of the six specialties, the plurality billed out of network less than 10% of the time. 36% of pathologists billing out of network for inpatient visits and 20% of pathologists billing out of network for outpatient visits did so more than 90% of the time. In contrast, virtually no cardiologists billed out of network this often.

  • The share of providers billing out of network more than 90% of the time was similar, ranging from 5-8% for inpatient visits and 10-16% for outpatient visits.

Jean Fuglesten Biniek, John Hargraves, Bill Johnson, and Kevin Kennedy “How often do providers bill out of network?” Modern Healthcare May 28, 2020

CMS Announces Change to Insurer Risk Ratings

Friday, CMS issued a proposed rule to change the way it audits the Affordable Care Act’s risk-adjustment program used to discourage health insurers from cherry-picking the healthiest, low-cost plan members to reduce their medical costs.

Shelby Livingston  “CMS proposes tweaking ACA risk-adjustment audit methodology” Modern Healthcare May 29, 2020;

JAMA Study: Workplace Wellness Programs Get Mixed Results

A study in JAMA Internal Medicine last week concluded workplace wellness programs do virtually nothing to improve the health status of employees based on a two-year test at the University of Illinois.

In its program, U. of I. gave 4834 employees paid time off or annual cash awards of up to $200 to have annual health risk assessments done, undergo annual biometric screenings and participate in wellness activities like exercise programs, disease management programs and smoking cessation classes.   Then they compared the health outcomes at 12- and 24-month intervals of the 3,300 employees who participated in the voluntary workplace wellness program with those of 1,534 employees who didn’t.

The researchers found no significant effect of the wellness program on biometrics, claims and utilization at either the 12-month or 24-month mark. Employees in the program reported they felt better about themselves and employers reported the proportion of employees with a primary care physician increased.
Reif et al “Effects of a Workplace Wellness Program on Employee Health, Health Beliefs, and Medical Use: A Randomized Clinical Trial” JAMA Intern Med. May 26, 2020. doi:10.1001/jamainternmed.2020.1321

Analysis: Medicaid Expansion not Associated with Increase in Community Benefit Spending by Nonprofit Hospitals

In this cohort study of 1666 nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017, Medicaid expansion was associated with a 0.68-percentage point decline in spending on charity care and a 0.17-percentage point decline in bad debt. These declines in uncompensated care were offset by an increase of 0.85 percentage points in unreimbursed Medicaid-related spending, while non-care direct community spending decreased by 0.24 percentage points. Even without a mandated minimum, IRS reports show that pre-ACA community benefit spending in 2009 averaged 7.5% of hospital operating expenses, approximately 85% of which were in the form of charity care and other care services.

“The results of this study suggest that although Medicaid expansion alleviated the financial stresses faced by hospitals in providing uncompensated care, these savings did not translate into additional direct community spending.”

A second, very different reason for the decline in community-directed spending might be increasing hospital costs; between 2007 and 2014, inpatient hospital prices increased by 42% and outpatient hospital prices by 25%.

Genevieve P. Kanter, Bardia Nabet, Meredith Matone, David M. Rubin “Association of State Medicaid Expansion With Hospital Community Benefit Spending” JAMA Netw Open. May 29, 2020;3(5): e205529. doi:10.1001/jamanetworkopen.2020.5529

Meaning of Wellbeing Changing, Whole Person Focus Critical

  • 37% of U.S. adults say they feel less connected to family and friends.

  • 84% say they are avoiding small gatherings.

Gallup found the common elements of wellbeing — physical, career, social, financial and community — need to be fulfilled for people to thrive. Employees thriving in all five elements of wellbeing…

  • are 36% more likely to report a full recovery after an illness, injury, or hardship

  • are more than twice as likely to say they always adapt well to change

  • miss 41% less work as a result of poor health

  • are 81% less likely to seek out a new employer in the next year

“What Wellbeing Means in the Coronavirus Era” Gallup May 15, 2020