Scarce Medical Resources Caused by COVID-19 Lead to Difficult Allocation Decisions

September 16, 2021 | Andy Baker-White, Maggie Davis

As the Delta variant spreads across the country and increases the number of COVID-19 cases, the strain it is placing on the nation’s health system continues to grow. The surge of COVID-19 patients is contributing to a shortage of the medications and equipment used to treat the disease, such as monoclonal antibodies and ECMO machines. In many places, the need for intensive care unit beds has neared or reached capacity, sometimes leading to patients being transferred to hospitals in faraway states or not being able to receive needed care where they are.

As these limitations grow, decisions will need to be made as to which patients receive resources and care and which patients don’t. To guide these decisions, policies are often established to maximize resource benefit and ensure they are distributed equitably. These policies are often referred to as crisis standards of care, as they are used during a situation that prevents the normal standards of care for patients.

Several states and health systems have developed and adopted crisis standards of care. A recent National Academy of Medicine article examining the application of crisis standards of care suggests the key focus areas for developing the standards include considerations of equity, politics, provider training, understanding of surge capacity, the coordination of care and information sharing, alternative care sites, clinical decision making, triage, supply chains, and healthcare facility staffing.

Crisis Standards of Care Activations

Throughout the waves of COVID-19 experienced in 2020, two states—Arizona and New Mexico—officially activated crisis standards of care. More recently, Idaho activated its crisis standards of care for hospitals in the northern part of the state. In doing so, the state used a rule initially adopted by the Idaho Department of Health and Welfare in December 2020.

Under the rule, after receiving a request to activate crisis standards of care, if the state health department determines that all options for addressing resource scarcity are expended and that shortages persist, the department will convene the Crisis Standards of Care Activation Advisory Committee. The committee, comprised of representatives from the state health department, state emergency response entities, local health agencies, healthcare entities and providers, long-term care facilities, and others, may then, after considering the resource limitations and available contingencies, recommend that the state health department activate crisis standards of care. The rule also requires that the public and media be notified of the activation and that resource shortages be monitored daily by the state health department.

According to news reports and press releases, other jurisdictions and health systems are considering or activating crisis standards of care. For example, last week, Washington state released a statement on hospital capacity and crisis standards of care. In Alaska, the states largest hospital announced this week that it is activating its crisis standards of care.

COVID-19 Crisis Standards of Care and Civil Rights

In March 2020, the United States Department of Health and Human Services Office for Civil Rights (OCR) issued Bulletin: Civil Rights, HIPAA, and the Coronavirus Disease 2019 (COVID-19), which highlights civil rights protections for individuals with disabilities under the Affordable Care Act and other federal laws. Based on OCR’s guidance, all COVID-19 treatment decisions “should be based on an individualized assessment of the patient based on the best available objective medical evidence.”

HHS also created a guiding document to be used when creating crisis standards of care policies. Specifically, crisis standard of care policy cannot be based on:

• Generalizations and judgements about perceived quality of life
• Judgements on relative value to society
• Disability status
• Age

With the onset of the COVID-19 pandemic, OCR received several complaints alleging that statewide or regional crisis standards of care discriminated against people with disabilities. Four of the complaints were resolved in 2020 and another three were resolved this year. In resolving the complaints, states agree to change their crisis standards of care so that they do not discriminate against persons based on disability or age.

For example, state guidance has been altered so that use of a patient's long-term life expectancy as a resource allocation factor is prohibited, and protections were added against providers "steering" patients toward the withdrawal or withholding of life-sustaining treatment. Other updates removed categorical exclusion criteria that prohibited people with disabilities from receiving care on the basis of their diagnosis.

Striving for Equity in Times of Limited Resources

The need to ensure equity when allocating scarce medical resources is highlighted given the pandemic’s exacerbation of existing health inequities in the United States. State health agencies are showing their receptiveness to these concerns.

For example, in September 2020, the Oregon Health Authority (OHA) announced that the state’s crisis standards of care did not “adequately take into account the viewpoints of Oregon’s diverse cultures and communities” and ceased to utilize the guidelines. A few months later, OHA released a set of Principles in Promoting Health Equity During Resource Constrained Events that focuses on non-discrimination, health equity, patient-led decision making, and transparent communications.

As COVID-19 surges again across the country, more states and health systems will face the decision of whether to activate crisis standards of care. ASTHO aims to keep its members informed as they confront these challenges and work towards protecting the health of their communities.