The United States surpassed 400,000 COVID-19-related fatalities Tuesday, making the novel coronavirus one of the nation’s leading causes of death.
In Pennsylvania, the death toll had approached 19,500, with more than 800 in Lancaster County, according to data compiled by the coroner’s office.
But those numbers — in some corners — are in dispute, despite widespread agreement.
It started on “The Ingraham Angle” cable TV program, with the notion that federal stimulus money incentivizes health care professionals to inflate their COVID-19 numbers. The thinking goes like this: Because most COVID-19 fatalities are among those 65 years and older with comorbidities, does the tally overstate the number killed by the virus by counting the fatality as COVID-19-related when in actuality the patient died of something else?
The short answer — according to a number of experts with whom LNP | LancasterOnline spoke — is no.
But not everyone agrees.
“The big controversy is: Do you die of COVID or with COVID?” said Dr. David A. Nace, chief medical officer of UPMC Senior Communities and a geriatric professor at the University of Pittsburgh School of Medicine.
Lancaster County Coroner Dr. Stephen Diamantoni, sees it this way: When an individual with stage-four cancer dies in a car wreck, the crash, not the disease is the cause.
The same is true for COVID-19.
“If not for the disease in this instance, would they still be alive?” Diamantoni asked. “If the answer is yes they would, then the disease is the cause of the demise.
‘It’s a medical judgment’
So, how is a COVID-19 death determination made?
It’s important to note that the cause of death is primarily determined by the attending physician. Under Pennsylvania law, a coroner investigates suicides, criminal violence, accidental deaths and those that occur when a physician is not present.
Death certificates also show when there are multiple, contributing medical conditions.
While the Centers for Disease Control and Prevention does not dictate how to determine the cause of death, the agency does provide reporting guidance.
“The determination is solely the responsibility of the coroner or the physician,” said Robert N. Anderson, head of the Mortality Statistics Branch for the National Center for Health Statistics.
Anderson added, “They have to make a judgment, and with COVID-19 it’s a medical judgment.”
It is also critical to note that COVID-19 can be particularly severe for patients with underlining health conditions such as diabetes, chronic obstructive pulmonary disease, heart disease and cancer. The death certificates for these COVID-19 patients will reflect all these comorbidities. But for categorizing without duplicating, certifiers — physicians, coroners and medical examiners — will assign the underlining or predominant cause of death.
Said another way, certifiers select the disease or condition that started the chain of events that lead to death.
“When they die, they almost always die because of the virus, not the chronic condition,” Anderson said, noting patients with these diseases can live for decades.
‘Likely an under estimate’
Epidemiologists are confident that the COVID-19 death toll accurately represents the coronavirus casualties.
“If anything, it’s likely an underestimate,” said Dr. Amesh Adalja, a Pittsburgh-based infectious disease expert and a senior scholar at the Johns Hopkins Center for Health Security.
The CDC estimates that since the virus emerged in the United States last year, there have been about 500,000 deaths nationally in excess of what was expected.
The roughly 400,000 COVID-19 deaths likely accounts for this.
The remaining 100,000 excess deaths could still be pandemic-related, Anderson said pointing to anecdotal reports of patients unable to get or putting off medical care because of the virus.
What health officials are battling is perception — raised early in the pandemic on “The Ingraham Angle” show by a Minnesota physician — that organizations benefit financially from a COVID-19 diagnosis.
In April, the Centers for Medicare and Medicaid Services did increase reimbursement by 20% for inpatient hospital payments. As of Sept. 1, eligible claims must include a positive COVID-19 laboratory test in the patient record, a CMS spokesperson told LNP | LancasterOnline in an email.
The Lancaster County Coroner’s Office received roughly $45,000 from CARES Act funding directed to the county, Eric S. Bieber, chief deputy coroner said. This money was used for testing; disposable and nondisposable personal protective equipment, such as air purifying respirators; BioSeal body bags and biohazard cleaning,
“Nobody is falsifying data,” Adalja said. “That’s just insulting.”
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