The Downsides of Financial Incentives to Diagnose COVID | Opinion

What likely began as a good-faith effort by Congress to comfort grieving families has turned into a runaway train of data obfuscation.

When Congress passed the Coronavirus Response and Relief Supplemental Appropriations Act in December 2020, it authorized the Federal Emergency Management Agency (FEMA) to reimburse up to $2 billion in funeral expenses for deaths related to COVID-19 incurred through December 31, 2020.

Then, in March 2021, Congress extended this financial incentive, allowing FEMA to pull from $50 billion in general disaster relief funding through September 30, 2025, as part of the American Rescue Plan Act. So long as there is a National Emergency, families are empowered to seek financial reimbursement for the loss of their loved ones where COVID is present.

This well-intended gesture has created a strong incentive to conflate dying from COVID-19 with passing incidentally while infected with the SARS-CoV-2 virus.

Undeniably, COVID is a deadly disease that has taken the lives of countless friends and relatives. But there is good news to start 2023. Deaths attributed to COVID after the Omicron variant fully displaced the more dangerous Delta variant decreased 76 percent from April through November 2022, the most recent full month for which data are available, compared with the same months in 2021.

Americans have strong protection against severe COVID disease thanks to immune responses from prior infections and the COVID vaccine. Treatment options for high-risk patients are also widely available. The risk from infection is nowhere near what it was in March 2020.

Unfortunately, these reassuring facts are easy to miss, given continuing media reports of high COVID death rates this winter.

One reason is the added incentive for hospitals to screen nearly every hospitalized patient for COVID, no matter what the underlying diagnosis, whether it is a broken tibia or a gallstone, even for patients with no COVID-like symptoms. Sec. 3710 of the CARES Act stipulates when a Medicare patient tests positive for COVID-19, the facility receives a 20 percent add-on reimbursement as long as there is a National Emergency.

COVID mask required sign
NEW YORK, NEW YORK - JULY 09: Masks required sign is displayed, on July 09, 2022 in New York. New York City public health officials urged people to return to mask-wearing to help slow the spread seeing high levels of COVID-19 variants infection. John Smith/VIEWpress/Getty Images

When a patient dies, the incentive to diagnose COVID grows stronger. Suppose the doctor or medical examiner fills out the death certificate and notes that COVID could plausibly have contributed to the patient's death. In that case, the deceased patient's family stands to gain up to $10,000 for funeral expenses from FEMA. Often all that is needed is for the patient's physician to note a positive COVID test on the death certificate, even if COVID had little to do with the patient's death.

Through January 1, more than 445,000 Americans received COVID funeral benefits, totaling almost $2.9 billion.

The FEMA website counsels families on how to push physicians to amend death certificates to include COVID as a diagnosis. "The death certificate amendment process starts by contacting the individual who certified the death," reads a dedicated webpage on the FEMA website. "You may provide them with evidence supporting your claim the death was attributable to COVID-19."

Another page on the FEMA site adds that families may be eligible for funeral expense reimbursement if the death certificate states the death "may have been caused by" or "was likely the result of" COVID or COVID-like symptoms.

We are sympathetic to the plight of families who have lost a loved one due to COVID. But why extend benefits for just COVID? Why not make the same consideration for victims of cancer, heart disease, stroke, or the flu? Is a COVID death worse than death from these other diseases? If Congress wants to create a new federal funeral benefit, it should do so equitably so that the government treats every death equally.

There are perils to this extreme focus on COVID. Overstatement of mortality can lead to undue fear and misrepresent risk. It can disrupt scientists' ascertainment of true causes and delay needed health policy investments.

For instance, according to CDC Wonder, in the first 11 months of 2022, there were 197,658 deaths among people between the ages of 15-44 in the U.S. That's an increase of 40,904 from 156,754 during the same months in 2019 (a 26 percent jump). Just 5,659 deaths had COVID-19 listed as the underlying cause of death. We must know what other policy-related harms could have contributed to this dramatic increase in mortality among younger Americans so that we can work to address the problem. It was not due to COVID alone.

We must break free of the fear caused by inaccurate COVID death counts. This will only begin when we can assess accurate data. Until we end the financial incentive to exaggerate COVID mortality, we cannot close the door on the pandemic or find relief in the progress made against COVID.

Dr. Jay Bhattacharya, M.D., Ph.D. is a Professor of Health Policy at Stanford University. Kyle Lamb is a former data analyst for Florida's Executive Office of the Governor.

The views expressed in this article are the writer's own.