No major healthcare reform initiatives will occur until the COVID-19 pandemic subsides. When Joe Biden becomes President, he’ll be too busy getting everyone vaccinated, helping the economy recover and fighting climate change to focus on his praiseworthy reform agenda.
Meanwhile, states are too hamstrung by COVID-19’s financial impact to promulgate strong reform measures. Legislators in several blue states who favor a government-run public option, for example, have had to scale back their plans because of pandemic-spawned budget crunches and concerns about their hospitals’ financial solvency. Washington State’s new public option, set to launch in 2021, now covers only a third of its counties, and hospitals no longer have to participate in it. Colorado’s public option bill is considered a long shot even if its sponsors make hospital and physician participation voluntary.
Still, the pandemic—as horrible as it is—has illuminated some of the paths forward for healthcare reform. Here are four lessons to be drawn from what has happened so far.
Telemedicine will change care delivery more outside of office visits
Much of the discussion around the rise of telemedicine has focused on how it may change the nature of office visits. Some observers even believe that most routine primary care will be done virtually in the future.
But at least in the short term, physicians don’t seem to be inclined to replace office visits with telemedicine encounters. A survey conducted in early October, before the current COVID-19 surge began, showed that the percentage of office visits that were virtual had dropped to 6% from 14% during the pandemic’s initial wave last spring. While telemedicine will be used more after the pandemic than before it, office visits won’t be where it will have the most impact.
Instead, telemedicine is likely to be used more commonly to support between-visit care as part of population health management. Care teams will utilize both virtual visits and telemonitoring capabilities to improve management of patients with chronic conditions and to facilitate periodic followup visits. Patients living in underserved areas will also use telehealth to gain access to specialists who are based elsewhere. New federal policies to expand broadband access and subsidize access to computers will be required to close the digital divide.
In addition, the nascent rollout of “hospital in home” programs to free up hospital capacity needed for COVID patients points the way to a new acute care paradigm. While a significant body of literature shows that hospital at home care is comparable in quality and cost to inpatient care for some conditions, only recently have studies shown that coupling HaH with telemedicine can have even more beneficial effects. To help hospitals expand their capacity, CMS recently launched a program that allows acute care to be provided in the homes of Medicare patients. Once telemedicine-enabled HaH has proved its worth and is routinely covered by insurance, it will become widespread.
Low-value care may become more visible
About half of Americans say they skipped or postponed medical care due to the coronavirus outbreak, a recent Health Affairs Blog post notes. Some of the foregone care was low value, and some was high value. According to the authors of the post, “The pandemic presents a natural experiment, where researchers could observe the consequences of stalled routine/elective care for patients’ short- and long-term health outcomes.”
The authors postulate that “if the care is low-value, we may expect minimal or no ill effects from its absence.” Further, they suggest that if it can be shown that withdrawal of such care wasn’t associated with poor outcomes, “these treatments should be subjected to additional scrutiny to determine whether they add value.”
Of course, this isn’t easy to do, and the research approaches the authors suggest may not work at the level of the individual patient. However, they point out that the latest iteration of the Medical Expenditure Panel Survey (MEPS) includes a series of COVID-19 questions regarding delayed medical care, dental care, or prescriptions. “Careful survey analyses could isolate and study health effects in households that experienced specific types of foregone care,” they note.
Such analyses would presumably also measure the effects of patients not receiving high-value care because of the pandemic. A CDC report estimated that from January 26-October 3, 2020, there were 299,028 excess deaths beyond what would been expected in the absence of the pandemic. Of these deaths, 198,081, or about two-thirds, were attributed to COVID-19. One possible explanation for this, some observers say, is that more people than anticipated died of conditions other than COVID-19, such as heart attacks and strokes.
In any case, the Health Affairs paper’s proposal is worth considering. Efforts to reduce the use of low-value care, such as the Choosing Wisely guidelines, have had little impact on healthcare waste reduction. Perhaps well-designed studies comparing how individuals’ health fared during the pandemic to how they were treated could help change that dynamic.
Prepaid care is more sustainable than fee for service
Before the pandemic, this statement would have been interpreted as a health policy position in favor of budgeting providers to reduce healthcare costs. During the past year, however, a number of observers have pointed out that physician practices with a significant percent of capitation did better economically than those whose revenues were purely fee for service. Whether that will bear out for the duration of the pandemic is unclear. Yet anecdotally, when patient volumes crashed last spring, the physician groups that seemed to suffer the least financial pain were those that had a guaranteed monthly income.
What will this mean going forward?
The value-based-care strategy of the Affordable Care Act has been continued under the Trump Administration. In some areas, the Centers for Medicare and Medicaid Services (CMS) has redoubled that effort. For example, CMS has restructured the Medicare Shared Savings Program to require participating ACOs to assume downside risk more quickly than before; more than a third of them already do. Meanwhile, the Center for Medicare and Medicaid Innovation (CMMI) has begun testing a Geographic Direct Contracting Model in which large integrated delivery systems will begin taking global risk for the cost of care.
On the other hand, most physician practices still derive less than 10% of their revenue from risk-based contracts. Whether or not the pandemic will induce doctors to become more accepting of risk is unclear. It’s also not evident that the healthcare systems that now employ the majority of physicians will move in this direction. However, the pandemic has at least proved that prepaid revenues are more secure than those that depend on visit volume or the number of hospital admissions.
Healthcare inequities must be reduced
The pandemic tore the mask off of the significant inequities between the care provided to white people and minorities. It also dramatized the role that social determinants of health played in those disparities.
One data set reveals how much more vulnerable minorities are to the virus than is the Caucasian majority. According to the CDC, age-adjusted COVID-19 hospitalization rates from March through December 2020 were 565 per 100,000 for Hispanics or Latinos, 554 for non-Hispanic American Indian or Alaska Native, 493 for non-Hispanic Blacks, 169 for non-Hispanic Asian Islanders, and 150 for non-Hispanic whites.
To my knowledge, there are no studies showing that anybody is more likely to get sick because of their race, although some ethnic groups and races are more susceptible to certain ailments. Therefore, something else must be responsible for the high percentage of minorities who have become seriously ill with COVID-19, compared to whites.
It’s known that Black Americans receive poorer healthcare than whites, partly because of lack of access. Many physicians don’t take Medicaid patients, many of whom belong to minorities. The high cost of healthcare deters the uninsured from seeking it, and minorities are more likely than whites to be uninsured. When people lack access to healthcare, they don’t receive proper preventive and chronic care. Those weakened by underlying chronic conditions, the CDC says, are more susceptible to COVID-19 and get sicker from it.
Poverty, one of the chief social determinants of health (SDOH), can also lead to bad health and therefore makes poor people more prone to get seriously ill with COVID-19. Minorities (other than Asians) are less affluent than whites, on average, and are more likely to be poor.
Even before the pandemic, a growing number of health plans, healthcare providers, and policy experts viewed SDOH as a challenge that had to be overcome to contain health costs. The prevalence of COVID-19 among poor, disadvantaged minorities has injected a new urgency into this movement. Healthcare providers’ role in addressing unmet social needs remains a matter of debate; but as hospitals and doctors embrace value-based care, it is becoming increasingly clear that they must work with communities to deal with patients’ social and economic factors.
These are just a few of the pandemic lessons that can be gleaned from what has happened so far in this disaster. When COVID-19 bites the dust and that dust settles, we’ll have a much better idea of where healthcare reform is going.
Ken Terry is a healthcare journalist and author. His latest book, Physician-Led Healthcare Reform: a New Approach to Medicare For All, was recently published by the American Association for Physician Leadership.