Across the country, as the novel coronavirus and resulting economic recession have disrupted nearly every aspect of life, they have also laid bare both the strengths and the shortcomings of America’s health care system.
Even as providers have treated patients with awe-inspiring dedication, the virus has changed the face of patient care for the foreseeable future (if not for good), strained hospitals to their limits and spotlighted shocking gaps and disparities. “COVID-19 ripped the Band-Aid off of the structural inequities that exist within our society,” says Dr. Stephen H. Lockhart, chief medical officer of Sutter Health, a health system in Northern California.
What’s become evident are the ways in which the system will — and must — respond, experts say.
Most immediately visible to patients, medical care will continue to look and feel different, certainly as long as the pandemic is a threat and perhaps well beyond. One of the most dramatic shifts, to virtual care, has been a rapid acceleration of a trend already underway and promises in many circumstances to be lasting. Helped by temporarily higher reimbursement and relaxed government restrictions, some 42% of Americans reported having used telemedicine during the early months of the pandemic, according to a survey from Updox conducted by The Harris Poll in mid-May.
Sutter Health in California, for example, quickly went from an average of 20 video visits per day pre-pandemic to 7,000; the number of physicians trained and equipped to conduct them rose from 50 to more than 4,700. Such rapid acceptance may speed the use of sophisticated remote monitoring to follow and treat people in their homes. When COVID-19 cases surged this spring in the Northeast, Mount Sinai in New York and Atrius Health in Boston took advantage of their “hospital at home” programs to free up beds for COVID patients and keep others safe from exposure.
Shorter term, providers are grappling with the need to bring people safely in for delayed and important non-COVID care, such as needed surgeries, vaccinations and cancer screenings. Hospitals have learned a great deal about how to identify COVID patients as quickly as possible — though this depends on sufficient testing supplies and quick turnaround times — and physically separate them from other patients, says Michelle Hood, executive vice president and chief operating officer of the American Hospital Association.
“Philosophically, we start with the statement that we need to be able to care for non-COVID patients no matter what comes at us from a COVID point of view,” says Dr. Marc Boom, a physician and president and CEO of Houston Methodist, which saw COVID hospitalizations surge in July. Across the system’s hospitals, COVID patients are cohorted in designated areas, including in the ER. To increase capacity, “we’re spreading out appointments on weekends and in the evenings, and doing surgeries on weekends,” he says. Elective cases can be canceled system-wide as necessary, he says. More restrictive visitor policies are here for the time being.
Mayo Clinic has made videos to show people “how things will change when they come back on campus,” says Amy Williams, executive dean of practice and a nephrologist at Rochester, Minnesota-based Mayo. Changes include COVID screening on entering the building, universal masking and socially distanced waiting rooms.
People considering a routine visit should ask about safety practices and separation of possible COVID patients, advises Dr. Jacqueline W. Fincher, a general internal medicine specialist and partner at Center for Primary Care-McDuffie in Thomson, Georgia, and president of the American College of Physicians.
One long-time system failure the pandemic has brought into sharp relief: the adverse health impacts of racial and socioeconomic inequities, previously well-documented in heart disease, diabetes, cancer and infant and maternal health. It turns out COVID is no exception.
According to a July New York Times analysis of data from the Centers for Disease Control and Prevention, African-American and Latino people in the U.S. have been three times as likely as white people to become infected with the virus. And they are almost twice as likely to die from COVID-19, the paper found.
Changing these realities requires taking aim at the social determinants of health — such factors as economic and housing stability, education quality, and access to health care, healthful food and safe places to get exercise. Numerous health systems and payors across the country, from Kaiser Permanente and UnitedHealth Group to ProMedica, Nationwide Children’s Hospital and Montefiore Health System, were already investing in such areas pre-pandemic as part of their efforts to improve population health and keep people out of the hospital.
“Both food insecurity and housing instability are clearly linked to preventable health conditions that can result in emergency room visits and inpatient admissions,” observes Alexandra Schweitzer, senior fellow at the Mossavar-Rahmani Center for Business and Government at Harvard Kennedy School. Such needs are becoming dramatically more widespread and dire because of the pandemic, she notes, at the same time that it’s increasingly necessary to limit avoidable hospital use.
What may give such efforts added impetus going forward is the wave of acknowledgment this spring that so many of those disparities are fueled by racism, and a recommitment by many groups to fight racism itself.
In June, the board of trustees of the American Medical Association said the group “recognizes that racism in its systemic, structural, institutional, and interpersonal forms is an urgent threat to public health, the advancement of health equity, and a barrier to excellence in the delivery of medical care.” The group vowed to “actively work to dismantle racist and discriminatory policies and practices across all of health care.”
Close attention to population data patterns and targeted community outreach offer one way to make progress against disparities. In Georgia, Navicent Health had previously identified 15 ZIP codes where outcomes were quite unequal for white and Black patients with chronic heart failure, COPD and diabetes; the system was able to close the gap for COPD within six months by engaging patients early on, getting accurate diagnoses, making sure affected patients got treatment and connecting them to its Healthy Communities program, which works with local partners to help people get needed services. The system noticed promptly, as cases began to surge in the state and as patients have filled beds this summer, that disparities in COVID follow the same pattern.
“I said to our team, it would be insurmountable to think about the world, the U.S. or Georgia, but if we focus on the population within the communities we serve, it is very doable,” says Ninfa M. Saunders, president and CEO of Navicent Health, where early data showed that more than half of COVID patients were African-American, disproportionate to the demographics of the surrounding population.
Efforts have included presenting up-to-date public health guidance in layperson-friendly terminology, educating ER and urgent care patients about the disease, expanding drive-through testing hours and using a community health partner’s mobile program to reach out to vulnerable communities.
Sutter Health, which since 2017 has been focused on bringing down the disproportionately high rate of ER visits by African-American adults with asthma, conducted research this spring, published in Health Affairs, which found that Black COVID patients were almost three times as likely as white patients to require hospitalization. Sutter is expanding its testing, outreach and education efforts for the people who are most likely to be adversely affected, Lockhart says.
Preparing for the Next Pandemic
Another area ripe for improvement as hospitals look ahead is how best to prepare for the next surge — and the next pandemic. This one has highlighted the downsides of the overall health system’s decentralized and often fragmented nature, and the difficulties of managing through a national crisis without centralized leadership and strategic planning when resources like ventilators, beds and staff are a critical issue, and without a well-funded and robust public health infrastructure to coordinate systematic testing and contact tracing. Large integrated health systems have more flexibility to acquire and deploy resources where needed; the 16-hospital Indiana University Health System, for example, was able to use its scale to get medicines and personal protective equipment and to develop in-house testing capabilities, and shifted staff and equipment from Riley Hospital for Children to other sites.
But generally speaking, most institutions and systems aren’t organized so that they can easily coordinate with each other, says Susan Dentzer, senior policy fellow at Duke University’s Robert J. Margolis Center for Health Policy. There have been some exceptions, such as in Boston, where hospitals have to a large degree coordinated their responses. New York State implemented a plan for hospitals across the state to share information, supplies, staff and patients almost as if they were one system. Among the findings in a June RAND Corp. report on creating critical care surge capacity was a recommendation that state, regional and federal entities consider developing protocols for quickly sharing resources across regions based on need.
How financially able the health care industry will be to invest in change post-pandemic is an open question. While the industry has often been described as recession-proof, as David Blumenthal, physician and president of the Commonwealth Fund, notes, “recession-proof” isn’t the same as “pandemic-proof.” The CARES Act provided $175 billion in emergency funding to hospitals and health care providers, but that won’t entirely fill the gaps.
According to the American Hospital Association, COVID-related expenses (including the cost of virus-related hospitalizations and of personal protective equipment) plus lost revenue (as elective procedures were halted and then cash-strapped, fearful Americans skipped care) added up to $202.6 billion between the beginning of March and end of June at U.S. hospitals. An additional $120.5 billion in losses was expected in the second half of the year.
Children’s hospitals, which also cut non-urgent procedures to avoid the spread of infection, and in some cases became part of surge capacity for adult patients, collectively were losing $2 billion per month in revenues as of mid-July, says Mark Wietecha, president and CEO of the Children’s Hospital Association.
The financial structure of health care isn’t likely to change overnight. But the crisis may accelerate the shift to alternatives to the fee-for-service model, says Jose Figueroa, a physician and assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health. One possible approach for hospitals is global budgets. As described by the Urban Institute, this model “provides a fixed amount of funding for fixed period of time (typically one year) for a specified population, rather than fixed rates for individual services or cases.” It’s been part of Maryland’s hospital payment system since 2014 through an agreement with the Center for Medicare and Medicaid Innovation. In that state, public and private insurers are required to pay the same price for hospital services, with rates specific to the hospital based on its global budget. An article published in NEJM Catalyst in June argued that the recent plunge in the volume of non-COVID care makes the time ripe for hospitals to look to other forms of population-based revenue, such as capitation arrangements that provide a flat amount per patient for a specified period.
Alternative payment models might help the many primary care providers, too, who have been badly hurt by cancellations and deferred care, Fincher says. A study published online in late June by Health Affairs estimated that primary care practices will lose nearly $68,000 in revenue per physician in 2020. Blumenthal thinks that prospective payments — with insurers paying a set monthly fee in advance for each patient in a practice, on a risk-adjusted basis — might better cushion that sort of blow during the pandemic and beyond.
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How the Pandemic Is Changing the Way Hospitals Care for Patients originally appeared on usnews.com