In the early weeks and months of the pandemic, there was a dramatic decline in the utilization of health care for emergent needs, elective procedures, and preventive care such as well visits and vaccinations. Beyond the direct impact of COVID-19 on individuals affected with the virus, what is the broader population health and financial impact of foregone care during this pandemic?
It will be some time before we know the full impacts, but clinicians, public health professionals, payers, and other stakeholders in North Carolina health care are sounding the alarm.
During the NCIOM’s annual health policy meeting on December 8, presenters and panelists from across the state described the negative clinical, financial, and social impacts of foregone care that they are already seeing in their work. They also highlighted some good news, however, including increased uptake of the flu vaccine and the embrace of telehealth by clinicians, patients, and payers alike.
Board Chair David Sousa, JD, MBA, welcomed attendees and highlighted the NCIOM’s Legislative Health Policy Fellows program. He noted that, “one of the ways to bring about change in health care is to make sure that the body that helped to form the institute (the North Carolina General Assembly] remains informed by the work of the institute.”
Sousa also announced the hiring of our new President and CEO Kathy Colville, MSPH, MSW, who will take the helm of the NCIOM on January 4.
Secretary of the Department of Health and Human Services Mandy Cohen addressed the group via a pre-recorded video, then Interim Director Michelle Ries, MPH, provided an overview of the NCIOM’s work over the past year before introducing keynote speaker Cynthia Cox, MPH.
Cox, vice president and director for the Program on the ACA at the Henry J. Kaiser Family Foundation, presented on how the pandemic has changed health costs, quality, access, and outcomes.
“It’s no surprise that the pandemic has affected virtually every aspect of our health care system,” Cox said. “But some of the ways it’s changed the system are surprising and unintuitive.”
One surprising impact: health care employment has dropped, despite typically being high even in periods of broader unemployment.
Health services revenue plummeted in Spring 2020, she reported, but claims and spending have since rebounded significantly. Physician and dentist offices have seen the sharpest decreases in health spending. Cox described the declining rates of specific types of care during this time, as well as ethnic and racial disparities in missed care.
While health care economists have been talking about ways to lower health care spending for decades, Cox noted, “this is not what anybody had in mind.”
How will all this impact costs for next year? Cox said insurers still don’t know, as some COVID-19-related factors might drive costs up while others would drive them down.
Cox ended her presentation with a bit of good news: the number of people with employer-based coverage has dropped less than expected, showing that many employers have tried to keep people on benefits even while furloughed, and/or many people have taken on temporary insurance as they expect to return to work soon.
Emmanuel Zervos, MD, surgical oncologist at Vidant Health, began his discussion of the clinical impacts of foregone care with a patient story. A 71-year-old African American woman was diagnosed with triple negative breast cancer just before the pandemic began. Her care team initiated chemotherapy and planned a curative surgery to remove a large tumor. But a month after the pandemic began, the patient started to experience obstacles to receiving her care. She was afraid of contracting COVID-19 at the hospital, and was unable to bring her support person with her to appointments.
“This has played out over and over again in our service line,” said Zervos. “We won’t know the impact for quite some time, but we know there will be a detrimental effect on outcomes for what is considered routine cancer care.”
Vidant saw an abrupt dropoff of cancer screening in April, and while Zervos said screening has begun to return to normal levels, nearly 4,500 patients missed being checked for cancer in Vidant’s service line alone.
“Because we don’t know who they are, we don’t know if they dropped off altogether or rescheduled their screening.”
Ophelia Garmon-Brown, MD, chief community wellness and health equity executive at Novant Health, then discussed the racial and socioeconomic inequities at the heart of the impacts of foregone care.
Garmon-Brown emphasized the disproportionate impact of COVID-19 on people of color in North Carolina and around the country. She noted that more people of color have conditions like hypertension and heart disease that can make COVID-19 more severe; many work in “essential” jobs that make social distancing difficult; and longstanding gaps in health care access exist for communities of color. In Mecklenburg County, for example, 120,000 residents are uninsured, and more than 160,000 reported not being able to see a doctor due to cost, even before the pandemic.
Lisa Shock, DrPH, MHS, PA-C, executive director of clinical delivery at Babylon Health and NCIOM board member, moderated a panel about the financial impacts of foregone care in North Carolina due to COVID-19. Panelists included Ish Bhalla, MD, associate medical director of behavioral health value transformation at Blue Cross NC, and Karen Smith, MD, FAAFP, family physician in private practice in Raeford.
At Blue Cross NC, according to Bhalla, telehealth claims have risen by about 7000% this year – a massive increase. The company has made an effort to minimize cost impacts of the pandemic on providers and patients, and created new incentives to move toward value-based care. Blue Cross has also created a COVID inequity task force to examine the payer’s role in addressing those issues, and committed $600 million to providers as they grapple with this crisis.
Smith noted that her practice had already been using telehealth to address the opioid epidemic, but moving one-third of her visits to telehealth had not been part of the five-year plan. Her practice has rebounded from a difficult spring, but she said she worries the same resources provided at the beginning might not come during this next wave, and, “we actually might see ourselves go back down and have difficult providing services”.
On top of financial concerns, Smith emphasized the impact of burnout, especially the lack of time to bereave so many patients who have died from COVID-19. Bhalla, a psychiatrist, echoed those concerns, as well as worries about the mental health and well-being of patients stuck at home.
“The fabric of our culture and our society is really interacting with each other,” he said.
The final presentation of the day came from Corinna Sorenson, PhD, MHSA, MPH, assistant professor in population health sciences and public policy at the Duke-Margolis Center for Health Policy at Duke University. Sorenson noted that the pandemic has highlighted the clinical and financial impacts of low-value care, such as unnecessary labs or antibiotics, and also provided an opportunity for change.
About $100 billion is estimated to be wasted annually on low-value care in the United States. “COVID-19 is maybe the strongest impetus yet to really rethink how best to prioritize what and how much care to provide, to and by whom, and in which settings,” she said.
As health care services rebound in some sectors, Sorenson noted the risks of returning back to business as usual. Instead, she suggested, providers can work with patients to develop care plans that weigh the benefits and harms of various services in the context of COVID-19; payers can cease or reduce payment for low-value care services; policymakers can direct additional COVID-19 relief to systems that agree to pilot new models of care; and patients can maximize the use of telehealth services and participate in shared decision-making.