South Florida Hospital News
Saturday September 19, 2020
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September 2020 - Volume 17 - Issue 3
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http://dannagracey.com/

Effects of COVID-19 on the Healthcare Delivery System

The Good, The Bad, and the Ugly

A year ago, many healthcare transformation thought leaders were predicting that the greatest disruptors in our industry would be healthcare company megamergers or blue chip tech companies entering the healthcare delivery market—like CVS’s acquisition of Aetna, Apple’s foray into personal health records and interoperability, or Amazon’s empowerment of Alexa and acquisition of PillPack. Probably none of them would have named the novel coronavirus as the biggest prospective change agent in the industry. But here we are—smack in the middle of a COVID-19 pandemic—and many of the medium- to long-term effects of the virus have become apparent to those of us in the field. Here’s a glimpse at some of the trends and impacts on the healthcare industry from COVID-19: the good, the bad, and the ugly.
 
The Good:
Telehealth: From Wall Street to Main Street, one of the most significant effects of the pandemic has been the explosive adoption and acceptance of telehealth as a means of delivering healthcare services. Healthcare delivery was already moving out of the four walls of the hospital into outpatient sites of care and even into retail settings. But COVID has brought providers to the desktops and mobile devices of mainstream America. Some estimates indicate that, as of April 2020, telehealth (defined as synchronous video conferencing, “store and forward” of digital medical data, and remote patient monitoring) has grown by 80% year over year1, spurred on by the relaxation of telehealth guidelines and reimbursement restrictions previously adopted by public and private insurers. Sure, there are still challenges to address—like continuation of these looser reimbursement policies, interstate licensure and credentialing issues, broadband access in rural areas, etc.—but the horse is out of the barn and there’s no turning back now. Telehealth has the ability to positively impact healthcare in many ways, including creating greater access to primary care, abating the overcrowding in the ED, and enabling a better quality of life for chronic disease patients. Most systems have already invested heavily in telehealth; those that haven’t need to catch up quickly.
 
Self-care and family care: Despite some mixed and often diffuse messaging from public health authorities early in the pandemic and the occasional deliberate flaunting of social distancing guidelines by segments of the population, by and large, most Americans are embracing more personal responsibility in the care of themselves and their loved ones. Mainstream America is now adopting many of healthcare’s sacred principles like frequent handwashing, cleaning and sterilizing one’s immediate environment, and adopting practical infection control practices (think masks, gloves, etc.). In addition, baby boomers and Gen X-ers are becoming steadily aware of the hidden hazards of congregate living for their parents, and they are increasingly choosing noninstitutional settings for their aging or disabled family members. Even though these family members may be homebound, they often lead a more dignified, more comfortable, and happier life than their counterparts in more institutional settings. Innovative hospital systems like Johns Hopkins Hospital in Baltimore or Adventist Health in California have created Hospital-at-Home programs (virtual hospitals) which feature video visits and remote patient monitoring by hospitalists to enable patients to remain in the comfort of their own homes during their hospitalization and convalescence.2
 
Occupational Health and Safety: Employers are becoming increasingly aware of their new responsibilities to provide a COVID-free work environment (and their potential liabilities if they do not). Federal and state courts are already seeing a dramatic rise in the number and types of COVID -related lawsuits, including cases related to workplace safety, workers compensation, and employees in high risk settings.3 Many employers have responded by dramatically reducing business meetings and travel and by converting as much interaction as possible to virtual settings. For those employers who need on-site employees, there is a renewed interest in employee health and safety, to wit, a dramatic rise in plastic protective shields for frontline personnel, the provision of PPE for essential workers, more robust disinfectant processes for common areas and equipment, and the reconfiguration of offices spaces to allow for more social distancing. The pandemic provides the opening for health plans, healthcare providers, and occupational health and safety professionals to play a larger role in executive conversations, facility design, and employment practices.4
 
Artificial Intelligence: Before the pandemic, we had already seen the promise of AI in healthcare applications like using supercomputers to interpret radiology scans or identify skin lesions5, employing machine learning to aggregate and analyze huge amounts of diagnostic data to aid in accurate cancer diagnosis6, and applying real-time data analytics to speed up the healthcare revenue cycle7. But the pandemic has hastened the adoption of AI areas not heretofore imagined. For example, health departments are using AI to analyze large amounts of public health data to identify and predict new virus hot spots and to develop early warning systems, clinicians are using chest imaging data along with AI-enabled EHR data to improve risk stratification and to categorize the type of care COVID-19 patients receive8, and pharmaceutical manufacturers are using AI to accelerate vaccine research. Look for AI to be adapted to many more clinical and operational aspects of healthcare delivery in the future.
 
The Bad:
Effect on Medical Practices and Hospital Volume: The traditional bastions of healthcare delivery—the doctor’s office and the hospital—have been hit particularly hard during the pandemic. One MGMA study showed that 97% of all medical practices have endured a financial hit, some with revenue declines of 60% or more.9 Many physician practices have had to furlough or eliminate staff and cut their own salaries; many will not survive at all. This will further exacerbate the already growing physician shortage and further limit access to those needing care. Hospitals have had a double whammy: eliminating or reducing profitable elective surgeries while simultaneously treating resource-intensive (but comparatively low-reimbursing) COVID patients. And despite the CARES Act and other federal assistance, many hospitals, particularly safety net institutions, are facing huge cash shortfalls and will be severely limiting capital expenditures for growth initiatives for the foreseeable future. Smaller, independent, and rural hospitals are particularly at risk for their survival. M & A activity, which was already strong prepandemic, is likely to increase as stronger organizations and institutions absorb the more financially-strapped providers. Government officials and private insurers should closely monitor the situation and be prepared to provide relief in the form of advance payments, expedited reimbursement, and grant funding when warranted.
 
Delays in Care: Some studies indicate that near 1/2 of all Americans have delayed seeking care because of loss of income and the fear of infection from COVID.10 The negative consequences to the patient for not obtaining timely care can result in needless suffering and death. There are already signs that cancer rates are rising rapidly and caregivers are seeing more deaths from heart disease than expected.11 In addition to patient effects, the impact to healthcare organizations will also be significant. Time and again, research shows that delays in seeking care result in poorer clinical outcomes and more expensive hospitalization costs. Despite losing their profitable selective surgeries and service lines, healthcare organizations need to prepare now for the demand that has been suppressed by the pandemic. When bed capacity allows, healthcare organizations need to encourage and reassure those who have delayed care; to do so, they need to beef up their infection control processes and convince their patients that they are ready for the “new normal” of treating patients in an institutional setting. As they do so, recognize that this pent-up demand will probably result in more acute care episodes, longer lengths of stay, and higher costs.
 
Uptick in mental health and substance abuse conditions: The pandemic has not only created a greater need for behavioral health interventions; it has simultaneously upended the already patchy and fragile continuum of care for mental health and substance abuse patients. Even as 40% of Americans have reported that stress related to the coronavirus has negatively affected their mental health,12 staffing crises and shortages of protective supplies have caused a reduction in mobile crisis teams, residential programs, and behavioral health call centers. Also, during the pandemic, there has been a surge in alcohol sales and a dramatic spike in opioid deaths. Social distancing, for all the good that it has done in society at large, has imperiled social connection and support for addicts and has jeopardized their recovery. Some relatively novel interventions have cropped up, including community-led and family-led interventions, more robust remote therapy, and technology-enabled collaboration platforms for primary care and behavioral health providers.13 We as a healthcare system need to continue to find new ways to address the depression, isolation, and drug use exacerbated by the pandemic and to create treatment modalities which are safe and effective in dealing with behavioral health conditions.
 
The Ugly:
Disparities in Care: COVID-19 has laid bare the ignominious underbelly of our healthcare delivery system; that is, that vulnerable populations are more at risk for contracting the virus and less likely to recover. COVID-related morbidity and mortality for Black, Latino, and native Americans are three to four times higher than for white Americans.14 Although genetic or biological factors may have some small bearing on these statistics, the more likely explanation lies in the longstanding cultural, social, and environmental conditions associated with these ethnic and demographic groups. Societal factors contributing to these disparities in disease incidence and hospitalization rates include housing conditions, income, education, and wealth gaps, access to healthcare providers, and inherent societal discrimination.15 Healthcare executives alone can’t be expected to fundamentally undo the years of socioeconomic injustice. They can, however, be vocal proponents of health equity and should be proactive in identifying and rooting out any vestige of inequitable care in their organizations. They can also use their position in the community to reach out to underserved populations, to promote positive policy changes, to address social determinants of care, and to espouse socially-conscious healthcare delivery.
 
Public Health and Health System Preparedness: Finally, COVID-19 has also exposed the potholes and gaps in our public health system. Clearly, there were miscommunications in our early minimization of the potential magnitude and dangers of the virus and missteps in our uncoordinated response efforts. Confusion between state and federal responsibilities, lack of communication among large federal agencies (such as the CDC, the FDA, and FEMA), state public health departments, hospitals, private laboratories, and equipment suppliers led to a suboptimal rollout of diagnostic testing and a lag in ensuring that hospitals had adequate personal protective equipment and ventilators. Ultimately, this delay and confusion resulted in lost time and lives. But the problem goes deeper than interagency or state/federal miscommunication. Simple complacency or a false sense of security led to an erosion of our public health infrastructure. As far back as 2000, the Institute of Medicine issued a report entitled “Public Health Systems and Emerging Infections: Assessing the Capabilities of the Public and Private Sectors,”16 warning that diminished funding levels and lackluster support for the American public health system, particularly at the state and local levels, would lead to diminished capacity to predict, detect, and respond to an emerging infectious disease. Despite this warning and others like it, the last decade has seen a further reduction in the spending on the public health infrastructure and a decline in the public health workforce by more than 15%.17 Even in the wake of SARS, Zika, Ebola, H1N1, and now COVID-19, the CDC has seen relatively flat funding for the past 10 years.18 As citizens, we should demand accountable leadership; and as healthcare leaders, we should rally for appropriate reinvestment in our federal, state, and local disease surveillance and response systems.
 
So there you have it. COVID-19 is a devastating and deadly disease, and it has tragically impacted us (as of late July) with over 4 million cases and over 146,000 deaths19—and that’s just in the United States. It continues to dominate our news cycle, our economic recovery, and, indeed, our very lives and livelihood. But it has also impacted us in ways we never imagined. We have learned that the pandemic has implications not just in healthcare, but in social justice, economic well-being, international cooperation, and world order. As much as we might want to put the pandemic in our rear-view mirror, let’s not let this experience be for naught. Let’s capitalize on our successes, learn from our failures, and candidly look at the opportunities to improve our preparedness and response efforts for the next inevitable disruptor in healthcare. 

Calvin Glidewell is President and CEO of inspirEx Healthcare Strategies.

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