Healthcare in a Post-COVID World
The United States will eventually get through the [COVID-19] crisis but not without fundamental changes to the medical care system.
-Cutler DM, Nikpay S, Huckman RS. The Business of Medicine in the Era of COVID-19. JAMA. 2020;323(20):2003-2004.
“All changed, changed utterly.”
There will be a vaccine – probably several. There will be effective treatments. There will be enough personal protective equipment. We will develop herd immunity. Toilet paper will stop being the punchline of late-night talk shows.
But something else is assured: the U.S. healthcare system will never be the same.
The pandemic has done what more than 30 years of policy attempts hasn’t been able to do: provide the impetus for dramatic improvement in our convoluted, fragmented healthcare system.
“I think COVID is exposing some of these really ugly parts of our system that seem unnecessary to everyone and that can affect anyone if you get sick enough,” said Albert Wu, MD, professor at Johns Hopkins Bloomberg School of Public Health in Baltimore.
As health policy gurus David Blumenthal, MD and his co-authors wrote in an October editorial in The New England Journal of Medicine, “We may now have the opportunity to reform a flawed healthcare system that made the novel coronavirus far more damaging in the United States than it had to be.”1
Here are some of the changes experts predict are here to stay:
The pandemic finally showed the true potential of telemedicine, defined as “the use of electronic information and telecommunications technologies to support long-distance clinical healthcare.”
The barriers to its wider application pre-pandemic – reimbursement, the ability of physicians to practice across state lines, provider reluctance – magically disappeared once shelter-in-place mandates began.
“Providers and patients came out of the woodwork to participate in what many thought was a new care model even though it had been done for decades,” said Joseph C. Kvedar, MD, president of the American Telemedicine Association and a Professor at Harvard Medical School.
“With telemedicine, we showed patients and providers that not everything needs to be in person and you can get perfectly good care over Zoom or the phone,” said Hu.
At one point, between 60 and 70 percent of ambulatory activity in his native Massachusetts was conducted via telemedicine, said Kvedar. Even by the fall, when most medical offices were open for in-person visits, about 25 percent of visits were virtual. “We feel like that’s the new normal,” he said. “There is a general consensus from all sides that going back to one channel is not an option.”
He’s also seen many previously skeptical colleagues won over. For instance, he said, orthopedic surgeons used to tell him telemedicine would never work in their field. Now they’ve changed their mind.
In fact, a recent study assessing 612 orthopedic telemedicine encounters found that 95 percent of patients rated surgeon sensitivity to their needs and response to their concerns as good or very good, and the surgeons themselves reported high satisfaction, noting that the encounter successfully replaced an in-person visit 80 percent of the time.2
There is still work to be done, said Kvedar. The speed at which telemedicine geared up in March meant one very important issue didn’t get addressed: the digital divide. “How do we deal with people who don’t have access to video or even a phone?”
There are also questions about the most appropriate uses for virtual visits, ie., when patients must be seen in person versus when a virtual visit is best.
Long-term use under Medicare will also require a change in existing law, under which the Centers for Medicare and Medicaid Services (CMS) only covers telemedicine for patients living in underserved areas. The requirement was waived during the pandemic but only temporarily.
Still, as CMS Administrator Seema Vermer put it: “The genie’s out of the bottle on this one. . . there’s absolutely no going back.”3
In addition to finally paying for telemedicine, government and private insurers also instituted several other policy changes likely to remain, including allowing clinicians to practice virtually across state lines, and nurse practitioners and physician assistants to practice without direct physician supervision.4
The crisis will likely also serve as a catalyst to speed the transition from free-for-service reimbursement to value-based reimbursement, most likely through a capitated model, and to “sever” the link between volume and payment.
This would have protected healthcare providers from the devastating financial blow most experienced during the first few months of the pandemic when they had no revenue coming in because they weren’t seeing as many patients or performing as many tests and procedures. 1
With elective surgeries and other procedures halted for months, as well as the public’s reluctance to see a doctor or go to the hospital even with serious issues like stroke and heart attack, the demise of the small practice and rural hospital has speeded up. Look for more consolidation among hospitals and health systems, as well as physician practices. The days of the small primary care practitioner practice are likely over. This, in turn, could increase health care costs by reducing competition.4
“Disparities in access and health outcomes are entrenched features of the U.S. healthcare system. They reflect a history of racism and discrimination that permeates society generally.”
---Blumenthal D, Fowler EJ, Abrams M, et al. Covid-19 — Implications for the Health Care System. New England Journal of Medicine. 2020;383(15):1483-1488.
Between May and August, 24.2 percent of COVID-19 deaths occurred among Hispanics and 18.7 percent in Black Americans, even though Hispanics represent 18.5 percent of the U.S. population and Blacks 12.5 percent.5
Most experts agree that these populations were more impacted because of systemic racism in the U.S. that limits their economic and educational opportunities. This, in turn, increases the impact of the social determinants of health (employment, housing, education, income, nutrition) which makes them more vulnerable to infection and serious illness.6
Blacks and Hispanics are also far less likely to have health coverage than whites, impacting their access to care and even COVID tests, and more likely to have chronic conditions such as obesity, diabetes, and hypertension, all of which are risk factors for more severe COVID-19 infections. They are also more likely to work in high-risk occupations, like farming, meat packing, and nursing homes, where the pandemic initially spread.1,6
The disparities in the infection and death rates, however, might finally bring serious efforts to reduce the entrenched racial and ethnic disparities in the U.S. healthcare system, experts said. One way to start is by addressing those social determinants of health, Dr. Wu said.
For instance, during the pandemic, cities rented out entire hotels for the homeless, and companies granted emergency sick leave for hourly workers who typically didn’t have access to any sick leave, actions that served to slow the spread among those populations.
Wu expects to see more of that type of social intervention because it will be seen through a public health lens versus a cost lens. “If you can’t take days off from work because you’re sick, then people go to work sick and it affects everyone,” he said.
Comprehensive Health Care Coverage
By the end of the summer, about 6.2 million Americans had lost access to their employer-sponsored health insurance, demonstrating the risks of relying on this form of health coverage for large swaths of the population.7
“I think there’s the possibility that there will be a movement towards more comprehensive coverage,” said Dr. Wu, including some form of a single-payer system. “We may ultimately see some uncoupling of health insurance from jobs, which could help the economy and businesses."
A report from Morgan Stanley highlights several things the federal government could do, including expanding the Affordable Care Act, waiving Medicaid work requirements, and lowering Medicare eligibility to age 60.8
In addition, expanding health coverage would also go a long way towards addressing the healthcare disparities discussed above.1
Everyone agrees we can’t go through another period of cancelling and delaying elective surgeries and procedures, including cancer screenings and surgeries, when infections surge or there’s another pandemic (as there will be). That requires reconfiguring hospitals to provide COVID-free zones. The University College London Hospital, for instance, created a “super-cold” physical space that admitted only patients who had quarantined for two weeks and tested negative.9
Big Data and Digital
The pandemic showed the importance of big data and its ability to help us see patterns quickly. It also laid bare the repercussions of our fragmented digital system, in which there is little interoperability between private, local, state, and national systems. Hospitals scrambled to find empty beds, and systems that should have tracked supplies failed because they couldn’t “speak” to each other.10
One exception was New York state, which created a statewide system so hospitals could share patient data and information on equipment, supplies, and staff.8
New interoperability rules put into place just as the pandemic began require hospitals to electronically notify other caregivers when patients are admitted, discharged, or transferred. They also standardize the application program interfaces to allow communication between disparate computer systems.11 While the law won’t magically solve the digital communication problems the pandemic laid bare, it is a start.
The Supply Chain
With nurses wearing garbage bags because they had no protective gowns and reusing N95 respirators, the pandemic clearly exposed the weaknesses in our just-in-time supply chain, one that is dependent on China not only for medical supplies but for the raw ingredients for most drugs.
That will change, predicts Dr. Wu. “Preparedness is going to come into fashion.” Hospital systems, he said, may need to conduct “stress tests” just like banks do to ensure they have adequate reserves in case of another emergency.
“This is not the last wave of COVID,” he said, “and we could face something like this again.”
- Blumenthal D, Fowler EJ, Abrams M, Collins SR. Covid-19 — Implications for the Health Care System. New England Journal of Medicine. 2020;383(15):1483-1488. 10.1056/NEJMsb2021088.
- Rizzi AM, Polachek WS, Dulas M, Strelzow JA, Hynes KK. The new 'normal': Rapid adoption of telemedicine in orthopaedics during the COVID-19 pandemic. Injury. 2020. 10.1016/j.injury.2020.09.009.
- Dyrda L. ‘The genie's out of the bottle on this one': Seema Verma hints at the future of telehealth for CMS beneficiaries. Beckers Hospital Review. June 3, 2020. https://www.beckershospitalreview.com/telehealth/the-genie-s-out-of-the-bottle-on-this-one-seema-verma-hints-at-the-future-of-telehealth-for-cms-beneficiaries.html.
- Cutler DM, Nikpay S, Huckman RS. The Business of Medicine in the Era of COVID-19. JAMA. 2020;323(20):2003-2004. 10.1001/jama.2020.7242.
- Gold JAW, Rossen LM, Ahmad FB, et al. Race, Ethnicity, and Age Trends in Persons Who Died from COVID-19 — United States, May–August 2020. MMWR Morb Mortal Wkly Rep. October 16, 2020.
- Egede LE, Walker RJ. Structural Racism, Social Risk Factors, and Covid-19 — A Dangerous Convergence for Black Americans. New England Journal of Medicine. 2020;383(12):e77. 10.1056/NEJMp2023616.
- Bivens J, Zipperer B. Health insurance and the COVID-19 shock. Economic Policy Institute;August 26, 2020.
- Morgan Stanley. Why COVID-19 Could Reshape the Future of Health Care. May 11, 2020; https://www.morganstanley.com/ideas/coronavirus-us-healthcare-trends. Accessed October 20,2020.
- Eardley I. A New Normal?: The COVID-19 pandemic has heralded different ways of working, triage of workload, collaborative research and cold-site surgery. BJU Int. 2020;126(2):215-217. 10.1111/bju.15179.
- Evans M, Berzon A. Why Hospitals Can’t Handle Covid Surges: They’re Flying Blind The Wall Street Journal. September 30, 2020. https://www.wsj.com/articles/hospitals-covid-surge-data-11601478409?st=wjighilfahojvz6&reflink=article_email_share.
- Centers for Medicare & Medicaid. CMS Interoperability and Patient Access final rule 2020; https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index. Accessed October 20, 2020.
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