I do not think anyone could have predicted, nor will ever truly realize, the impact of COVID-19 upon the health care industry. Perhaps we have been in a “state of complacency” for too long, and our arrogance would not allow us to admit just how ill-prepared we are to handle such global situations; that we have a health care system that is in need of controlling costs while achieving better outcomes; and we are creating our own barriers to restructuring the future of health care services. While the US leads the world in per capita spending for health care services, we are far from the top in health care quality.
In the opening presentation of the virtual AMCP meeting in April, which was followed by the release of IQVIA’s Shifts in Healthcare Demand, Delivery and Care During the COVID-19 Era report, Doug Long posited that due to the government imposing movement restrictions, there was a 70% to 80% reduction in the number of patient offices visits – which included a 76% decline in patients presenting with asymptomatic conditions. Counterbalancing the reduction in office visits, telemedicine accounted for 25% of the patient consultations that occurred. The fall-out from the reduction in office visits was a significant reduction in laboratory testing. Emergency room testing, as well as inpatient testing, declined by 90% from the beginning of February through March, mirrored by a 75% to 80% reduction of testing initiated by office visits and urgent care centers. While there was a reduction in new prescriptions being filled, there was an increase in refills through March, possibly in anticipation of difficulty in accessing pharmacies. Mail order utilization increased.
Focusing on cancer care, practices modified their level of direct patient interactions based upon recommendations provided by ASCO, NCCN, and other organizations. Schedules were reduced with prioritization being assigned based upon tumor type and staging. High level observations showed on average a 20% reduction in patient and prescription services through early April, but services related to aggressive cancers or cancers in advance stages have maintained. Cancer screening appears to have fallen significantly by 80% to 90% for the typical “screening” type testing, while “diagnostic” testing was not down as drastically.
In late April, the Cancer Letter provided more detailed information on COVID-19’s impact from the community practice perspective. Using data provided by Flatiron, new patient visits decreased by 40% from February through the end of April. Cancellation and no-shows nearly doubled. Patient visits involving treatment infusion decreased by 17% in the Northeast. In short, fewer patient visits, increased cancellations, and no-shows have been a reality. As noted, telehealth services increased industry-wide. However, unlike academic centers and primary care practices, telehealth services in oncology community practices was not common. Thanks to today’s connectivity technology, it appears that community oncology practices were able to get up and running with telehealth services relatively quickly. What we do not know, and will probably not know for quite a while, is what will be the impact to mortality, resulting from delayed diagnosis, treatment, and financial toxicities escalated by furloughs, layoffs, and consequential loss of health insurance.
From the patient perspective, there is a heightened concern for “access to care.” Patients employed on an “hourly” basis appear to be the most impacted due to furloughs and layoffs, resulting in unemployment with subsequent shifting within the various lines of insurance coverage. It is anticipated that we will see a shift from commercial lines of insurance to Medicaid or the uninsured ranks as unemployment continues to rise. Financial stress is now becoming obvious, as evidence by the increased abandonment rate by 7-times for prescriptions with a copay/coinsurance of greater than $150 compared to prescriptions with less than a $30 liability. The American Cancer Society (ACS) reports that 38% of patients surveyed acknowledged that reduced work hours had an impact on their ability to afford and access care. Of those reporting a job loss, 43% reported having employer-sponsored health coverage, thus the loss of health insurance coverage was due to a combination of individual coverage and employer-sponsored coverage. All too often, we tend to overlook the significance of individual coverage to the health care coverage landscape. ACS goes on to report that 25% of their respondents experienced a delay in care or treatment. Most common delays were in regard to imaging services (50%), supportive services (20%), and surgical procedures (8%).
Finally, from the payer perspective, as of early May, there is little indication that at least the publicly traded insurers have had any impact to their bottom line. Premium revenue will potentially be lower due to loss of coverage. While there is an increase in cost for COVID-19 patients, these unanticipated higher costs appear to be more than a cost offset by the reduced use of non-urgent health care services. This trend is expected to continue through at least Q2 of 2020. While it is still unclear what the long-term impact will be with regard to continued loss of employment and health insurance, premiums will still be collected for those able to maintain coverage, of which service utilization will be lower than projected and will most likely not be offset by those being treated for COVID-19.
In short, while institutions and practices are being forced to reprioritize their services to those of the most acute need, payers are benefiting from the reduced utilization. One can argue that while it appears that payers may be benefiting at the expense of the health care system, others remind us that that payers are able to maintain stability through their investment income. We all know that the investment community has taken a major hit, surpassing the 2008 recession, and payers are not immune to this hit. Only time will tell as to how payers will fare. Of all the payers, there is no doubt Medicaid plans will be the hardest hit.
The current state of affairs looks bleak for patients, community practices, institutions, and Medicaid plans. Perhaps this is the exact event we needed to take a hard look at our current health care system without all of the political barriers in place. Everyone seems to be using the theme of “We Are All in This Together,” so maybe we should all together work to take what we have learned from this event, see what has worked and what has not, and work toward a new future.
We are seeing a reduction in non-essential services. While we do not know the clinical impact of this reduction, surely there must be some percentage of these services that can be deemed superfluous.
We have seen an increase in telehealth services. While we were starting to see increases prior to COVID-19, I would venture to say that COVID-19 significantly expedited utilization well beyond what would have been projected if COVID-19 had not occurred. Do we really need a face-to-face office visit for follow-up? Perhaps a more cost-effective telehealth visit can be utilized instead.
Along with telehealth services, we are seeing increased patient engagement through the use of electronic apps. CMS even created CPT codes for the use of remote patient monitoring via electronic connectivity. With clinical monitoring apps, we might not even need the follow-up visit.
We need to continue to grow in areas like this. We have limited resources, as well as limited dollars to pay, for services. It is incumbent upon us to change the system to be the most responsible from a resource and financial standpoint while improving our quality of care. Due to COVID-19, we have had to take a hard look at what we do, and to quickly implement changes to adapt. Let’s not lose this momentum, and most of all, let’s not settle back into our old habits and processes we use to call “normal,” mainly because we will probably never get back to a “normal” state.