June 22, 2020
As we continue to navigate our way through the global pandemic, people everywhere are looking to the health care industry to both address the current crisis and help us be better prepared for what comes next. In many ways, COVID-19 has been a catalyst for change.
Initially, health care resources were focused on treating COVID-19 patients and building system capacity. Furthermore, shelter-in-place restrictions have resulted in a potential backlog of delayed elective procedures and appointments. Employees have likely forgone preventive screenings and delayed routine chronic condition management. At the same time, innovation accelerated. Greater adoption of virtual care and patient awareness of virtual options created higher demand for solutions which, where appropriate, can be used for services ranging from routine to specialty services. This may remain after COVID-19 cases begin to decline nationwide. In fact, there is a great deal of hope that some of the positive change in health care will become permanent.
As health care providers reopen and patients return for their office visits, what changes can we expect in member utilization patterns and needs? How can employers support their employees and adjust their strategic priorities?
What Can Employers Expect from Their Members?
Continued unease about in-person visits to health care providers: While re-engaging with the health care system, many patients will proceed with an abundance of caution, even if they do not have any preexisting conditions. More vulnerable members, especially those with conditions that put them at higher risk of adverse effects of COVID-19, might continue to be hesitant to complete preventive screenings or chronic condition care as they seek to limit their exposure.
For some, this may have lasting implications for overall health and health outcomes. Mammograms, colonoscopies, and other preventive screenings are essential for early detection of various cancers. Therefore, screening delays can lead to an increased risk that malignancies that otherwise would have been caught sufficiently early end up causing bigger problems for these patients. Similarly, those postponing joint replacement or other orthopedic surgeries may see their conditions worsen. Delays in pediatric screenings may result in delays in vaccinations.
Willis Towers Watson offers an illustration (Figure 1) of the impact of the pandemic on health care utilization by grouping the types of services by the likelihood of care returning and the impact on cost.
Emergency room avoidance: For years, employers have sought to reduce overutilization of inappropriate emergency room (ER) visits, albeit with mixed results. Greater member awareness of the risk associated with long wait times in crowded emergency rooms may lead to a permanent reduction in unnecessary ER visits. However, there are also concerns that some patients experiencing symptoms that should send them to ER in more “normal times” are now delaying acknowledging dangerous symptoms of heart attacks or strokes for example. There may be an opportunity to communicate to members how to seek appropriate care for such symptoms, including refreshing their memory about available navigation and telemedicine resources. Second opinion, concierge services and other solutions can also help members determine whether to seek further care and may likely see higher utilization going forward.
Higher demand for behavioral health services: From a patient perspective, living in a heightened state of quarantine/social distancing for sustained periods of time has disrupted daily routines and other activities that serve to relieve stress. Coupled with the widespread economic pressures the pandemic has created, many are experiencing heightened feelings of uncertainty, isolation, and anxiety. For those individuals suffering from existing mental health conditions, anxiety surrounding COVID-19 has likely exacerbated them. Many people who may not have sought out behavioral health services may do so now to find ways to cope with being alone, serving as a caretaker for family members, or managing virtual education for their children, among other stressors.
How Is the Health Care System Adapting?
Short-term bottlenecks as patients return to care: Consolidating months’ worth of cancelled elective visits and procedures into the last quarter of the year may present a challenge for most health care systems and providers. Members might face some difficulty scheduling appointments as physician offices open back up for face-to-face visits and space out appointment times to allow for physical distancing and adequate facilities cleaning.
Serving the emerging member cohort with long lasting health consequences due to COVID-19: Lasting organ damage from lung scarring to acute kidney injury (AKI) have been observed in those who survive a severe COVID-19 infection.1 Nationwide shortages of dialysis fluids and other supplies are possible as unforeseen consequences of the global pandemic caused by the novel coronavirus: approximately 3% to 9% of patients with confirmed COVID-19 develop an AKI, with many requiring dialysis treatments. Chronic disease management initiatives will be essential in managing this influx of patients and ensuring that they learn how to manage their symptoms and maintain their quality of life.
Shifts in how we handle infectious disease: We’re already starting to see changes in how health care practices conduct their visits, from instructing patients to wait in their cars and calling them straight into exam rooms to more widespread utilization of virtual and phone visits and mail-order pharmacy solutions.
Widespread provider adoption of telehealth: Many providers have focused on meeting patient demands for virtual care delivery by creating a seamless care journey, where members can still receive team-based care while assuaging fears of completing in-person visits. Many of these strategies streamline the patient experience and reduce unnecessary exposure to risk while not significantly increasing practices’ administration burden. There are signs that this shift to telehealth may become more widespread, but it remains to be seen whether telemedicine reimbursement changes and plan designs encouraging the use of telemedicine will became permanent.
However, in the absence of national parameters for provider scope of practice. licensure for telehealth across state lines remains an issue for specialty providers. States have broad regulatory authority and influence over the practice of medicine within their boundaries, including the availability and types of telehealth services accessible to their residents; under what conditions health care professionals can offer them; and how patients can access them. Differing state laws that regulate the licensure of health care providers, practice standards and other aspects of health care, as well as positions taken by state medical associations representing local doctors, may create barriers to enabling greater use of telehealth across state borders. Additionally, other laws or rules regarding provider payments, online prescribing, medical malpractice liability and privacy and security concerns can also impact availability and utility of telehealth.
Increased emphasis on home-based care: Sheltering vulnerable populations from visiting hospitals and large health care facilities in person whenever possible is crucial to maximizing the capacity of inpatient facilities in the event of a “second wave” or surge of COVID-19 cases. Similar to how the pandemic increased awareness of virtual services, the same may occur for health care services that can be administered in home settings. For example, infusions, dialysis services and other procedures can often be completed at home, where they are not only more convenient but also and comfortable for patients. These services can also better cater to those with limited mobility or without consistent means of transportation. While emerging solutions have introduced innovation into this space prior to the novel coronavirus pandemic, their adoption may be accelerated as an indirect result.
Emergence of new physician reimbursement models: For many “brick and mortar” providers, services administered in-person are typically reimbursed at higher rates than those administered by virtual means (e.g., phone, email, or other virtual platforms). Payment parity for telehealth services might lead to increased costs in that telehealth visits may occasionally duplicate in-person services (e.g., initial telehealth visits that are followed up with an in-person visit for more services, with the provider billing both visits at the same rate) rather than replacing them. However, increased flexibility on reimbursement structures for providers who have already implemented value-based arrangements can promote a more efficient care pathway for patients.
There could also be a shift toward salary-based physician reimbursement, as provider consolidation is likely to accelerate. Independent practices have been hit hard financially by prolonged shelter-in-place restrictions and by bans on elective procedures in certain geographies, with many long-time providers choosing to retire. Other smaller practices in financial duress may be acquired by larger health systems. Salary-based models more prevalent in larger provider groups may result in a lower risk of the perverse incentives inherent within fee-for-service; however, to date, the health care industry has seen little evidence of price reduction and an increase in care efficiency as a result of consolidation.
What Does This Mean for Employers’ Health Care Strategy?
As nearly every aspect of health and health care seems to be impacted by COVID-19, employers will likely look at key aspects of their communications and overall strategy to reprioritize the initiatives that are of greatest need. Here are some key considerations:
Support innovation: Maximizing value with your existing partners may mean looking for ways to challenge those whose business is lagging to support your employees in new and different ways. For example, can your travel Center of Excellence (COE) partners expand their virtual services and/or second-opinion offerings? Can health plans do more to support chronic condition patients with virtual care while in-person visits lag? How can your employee assistance plan (EAP) vendor better support the everyday needs of those impacted the most by shelter-in-place orders or a quarantine?
This could also be an ideal time for additional communications featuring existing resources that may now be in higher demand, such as virtual behavioral health offerings or patient navigators. Many employers are supporting innovation by implementing new solutions that may help those who were affected either directly by the virus or by avoidance/postponing of care in such a way that their overall health status has worsened. Those options may include virtual primary care solutions, greater support for kidney care and diabetes and introducing musculoskeletal (MSK) virtual providers.
Reassess high performance networks/COEs: As expected, many employers have suspended their travel programs with the introduction of stay-at-home orders throughout the country. As the U.S. slowly attempts to reopen, these programs will have to be nimble and able to adapt to evolving circumstances across different markets and geographies. For example, employers previously considering implementing high performance networks will need to do so while being sensitive to employees potentially being directed to different facilities based on availability or for infection risk management. As mentioned above, some members may be reluctant to travel to COE facilities, which may also impact overall utilization.
Recommit to value-based care: Success in value-based care arrangements require effective collaboration between payers and providers. There’s no time like the present to create or strengthen your relationships with local systems. However, COVID-19’s impact on utilization and care patterns is disrupting ACOs’ ability to perform population health management, and therefore reach quality and performance benchmarks.2 Now, more than ever, creating and advancing reimbursement models based on performance rather than volume is crucial; however, sharing downside risk may become more complicated as health systems struggle financially from sustained decreases in specialty practice revenue.
Step up utilization management efforts: The sudden and dramatic decrease of patients pursuing nonurgent, elective health care services have resulted in significant revenue losses for health systems across the country. As hospitals and other facilities begin scheduling these procedures during the remainder of 2020, overutilization is a risk as providers may attempt to recoup revenue shortfalls. Consider increasing the frequency of claims data review and otherwise amplify utilization management efforts to monitor trends to mitigate this concern.
Renewed interest in behavioral health solutions: The mental and emotional well-being of employees is a top concern for employers across industries, geographies, and employee demographics. Raising awareness of existing resources and/or introducing new programs supporting employees’ mental health during this difficult time can help employees adjust to the shifts in workplace environment caused by the pandemic. When it comes to behavioral health supports, there is no “one size fits all” approach. An employer’s population likely consists of essential employees that may feel overworked and anxious about having to be at work or those dealing with having to stay at home. Financial and economic uncertainties as well as feelings of isolation and loneliness have likely amplified these existing mental health challenges.
Preparing for the Post-COVID Health Care Landscape
COVID-19’s impact will continue to be felt across the health care continuum. Its emergence has placed a spotlight on the importance of population health-oriented solutions, data, and system readiness. Our enhanced understanding of infectious disease has changed common behaviors, from lessening physical contact with others to a more universal adoption of basic hygienic practices. Among other things, it has the potential to change what the next flu season might look like. While the health care experience will likely change as we emerge from this global pandemic, employers are uniquely situated to ease the transition for their employees after the worst of the pandemic has passed. Through flexible benefits strategy and keeping abreast of the changing dynamics and stakeholders within the health care industry, employers will continue to be important allies for employees.