Healthcare After COVID-19

From both clinical and political points of view, the COVID-19 pandemic is the most challenging medical problem in decades. Morbidity and mortality rates have been staggering, and the impact on individuals, families, businesses, and communities is unlike anything we’ve experienced in our lifetime.

That the pandemic has caused the practice of medicine to shift significantly is indisputable. Healthcare systems and clinical practices have had to turn on a dime and, with patients and clinicians willing to embrace change as never before, the use of digital medicine and mobile apps has skyrocketed.

It’s difficult to predict what even the near future will bring. But in several areas, healthcare is clearly moving forward.

Virtual visits were being adopted even before the pandemic, but at a relatively slow rate because of uncertainty about how to fit them into the flow of daily practice, doubts as to whether Medicare and commercial health insurance would cover them, and limited ease of use by practitioners and patients. In 2019, only 3% of patients responding to an industry survey reported that they’d had a virtual visit. In a survey of the same patients in early 2021, 47% of respondents said that their most recent visit had been virtual.

After an initial surge, the rate of virtual visits has stabilized at between 13% and 17% of all clinician encounters.[1] Clinicians and patients alike are learning to recognize when a virtual visit is more appropriate than an in-person visit. As the pandemic wanes, however, uncertainty remains as to whether Medicare and commercial payors will continue to use the expanded codes and reimburse for telehealth visits.

Some health-insurance plans report an increase in overall utilization: more virtual visits were followed by in-person visits for the same conditions. In ordinary times, the same conditions might have required two in-person visits—but it’s difficult to know. Most likely, we’re seeing a learning curve that will settle down over time.

I recently spoke with a dozen or so physicians, all of whom said they prefer virtual visits for many conditions that don’t require a “laying on of hands,” including follow-up appointments after an in-person visit and ongoing management of chronic diseases such as diabetes. Most of these physicians estimated that, in the future, about 20% of visits will be virtual, thus setting a new standard of care.

The pandemic has significantly affected behavioral and mental health. Quarantining and social distancing have exacerbated anxiety and depression in many people with existing mental health conditions, and led to an increase in newly diagnosed individuals.

To gain some understanding about how its member psychiatrists were using virtual psychiatry visits, the American Psychiatric Association surveyed them in June 2020 and again in January 2021. In the survey taken before the pandemic, 64% of APA psychiatrists reported seeing no patients via virtual visits. In the second survey, 81% of the organization’s psychiatrists reported seeing 75% to 100% of their patients virtually.

With flexibility of licensure during the pandemic playing a significant role, access to mental healthcare has also improved. Eighty-four percent of the respondents reported seeing new patients via virtual visits. Sixty-four percent of psychiatrists reported treating patients located in another state, while prior to the pandemic, only 25% had out-of-state patients.[2] In addition to improved access to care, no-show rates have decreased and patient satisfaction has increased.

Home healthcare encompasses many services, including physician visits, IV fluid and medication therapy, care of chronic disease and wounds, rehabilitation, and physical therapy. We’ve witnessed a growing preference for home-based care that will likely continue to grow for the foreseeable future. In a 2020 Kaufmann Hall survey, 54% of respondents cited fear of contracting COVID-19 as the primary reason for delaying care; 43% of commercial members and 35% of Medicare members stated that they were likely to avoid hospital care for the same reason.[3]

The cost benefit of homecare is impressive. CMS estimated that home healthcare saved Medicare $378 million in hospital costs. The most successful home-healthcare organizations use a team-based approach. Physicians, nurse practitioners, and nurses form the foundation of these organizations, with a support staff of pharmacists, behavioral health specialists, medical assistants, and social workers.

Leverage Health supports wholistic home healthcare for seniors through our innovative portfolio company WellBe Senior Medical. RecoveryOne, another company in our portfolio, treats patients for musculoskeletal conditions using home-based physical therapy.

The pandemic has also fueled the growth of ambulatory surgery centers (ASCs). Hospitals, with limited resources and overwhelmed by the volume of COVID-19 cases, are pushing for elective procedures to be done in ASCs. This helps to reserve operating rooms, ICUs, and post-op units for COVID-19 cases and other emergencies. Medicare’s latest outpatient payment ruling added 267 surgical procedures to the number eligible for reimbursement, starting this year.

Also, as surgeons learn how to better integrate virtual visits into their workflow, more pre-op and post-op care will take place in patients’ homes rather than in healthcare settings.

There are other benefits. The cost of outpatient surgeries can be 45% to 60% less than those performed in hospitals. Surgical site infections (SSIs) are 4.84 per 1,000 patients at ASCs versus 8.95 per 1,000 patients in hospitals. Scheduling a procedure in an ASC is easier and more predictable than inpatient scheduling, since an emergency surgery can bump an elective case off the schedule. The time a patient spends in an ASC can be 26% less than what that patient would spend in a hospital for the same procedure.[4]

All of this allows me to predict that the trend toward ambulatory surgeries will continue over the next several years, and that more elective procedures will be done in ASCs instead of hospitals.

The shift in care from hospitals to outpatient settings, however, began long before the pandemic. Many illnesses once treated in the hospital, such as pneumonia, can be and are being treated in the doctor’s office or in the home. Primary care physicians who used to treat patients in their offices as well as in the hospital no longer do hospital care. The rise of hospitalists, about 20 years ago, and the sophistication of treatment in the hospital setting, have made it such that primary care physicians in urban and suburban settings no longer admit patients to hospitals.

The U.S. has approximately 6,000 hospitals, with 1 million hospital beds and only 100,000 ICU beds. COVID-19 has overwhelmed our hospitals, and ICU and critical-care beds can be scarce, so more and more regular hospital wards are being converted to critical-care units. As this trend continues, physicians and other clinicians will continue to shift cases to outpatient settings, be they ambulatory surgery centers or home-based care. As homecare becomes even more sophisticated, certain conditions will no longer need to be treated in an inpatient setting, and hospitals may become giant ICUs.

However, this major shift from inpatient to outpatient settings will not happen overnight. It might take several years, and during this transitional period, patients will still be admitted for non–COVID-19 illnesses. Resources, including the number of attending physicians, will remain limited.

A few clinicians, whose work for years has been exclusively outpatient care, have told me that they are being asked to staff hospital wards. ICU doctors, critical-care physicians, and hospitalists are all busy caring for COVID-19 and other critical-care patients­, leaving regular hospital wards understaffed. Primary care physicians who’ve not done hospital care since completing their residencies expressed some reluctance to reenter the hospital environment—in the interim, medical technologies and pharmaceutical agents have changed to the point that these PCPs are uncomfortable about working in unfamiliar conditions, and feel they can’t keep up with the rapid changes. However, the majority of practicing PCPs won’t have to, as this trend is unlikely to continue. It seems probable that current residency programs will once again offer improved inpatient curricula, and that doctors of the future, being well trained in inpatient care, can more effectively divide their time between inpatient and outpatient care.

With the continued shift to value-based contracting, digital quality measurement becomes even more important. More and more, provider performance will be evaluated with measures of quality, efficiency, and patient experience. With accurate and timely quality measures, physicians and other providers can close potential gaps in care, thereby improving quality of life and chronic disease management for their patients. The use of artificial intelligence, natural language processing (NLP), and year-round Healthcare Effectiveness Data and Information Set (HEDIS) measurement will only make this easier, with reminders to providers and/or directly to patients to get the appropriate testing and medical care.

Another Leverage Health portfolio company, Astrata, uses NLP, machine learning, and advanced analytics built specifically to support digital quality measurement. Astrata’s application helps HEDIS^® medical-record review teams move from sample measurements to total population measurement, ensuring that providers have access to gaps in care for their entire patient populations, rather than just a small segment.

Innovation in healthcare is complex, and disruptive innovation even more so. The COVID-19 pandemic has forced the U.S. healthcare system to suddenly start thinking and acting differently. More collaboration among providers, health plans, patients, and a variety of healthcare vendors is taking place. And as mobile apps and vendor solutions are more widely adopted, providers and patients are sure to see numerous benefits. Certainly, what these new technologies offer to fill the gaps between doctor visits are a plus, but this is only the low-hanging fruit. The myriad changes and innovations spurred by the pandemic may be embraced only gradually, but to my mind, they set up healthcare for a far better future.

1. “How COVID-19 Has Changed the Way Consumers Think About Healthcare,” McKinsey & Company, June 4, 2021. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/how-covid-19-has-changed-the-way-us-consumers-think-about-healthcare
2. “Psychiatrists Use of Telepsychiatry During COVID-19 Pandemic Public Health Emergency,” American Psychiatry Association PDF.
3. “Consumer Attitudes Inform Post-COVID Recovery,” KaufmanHall eBook. https://www.kaufmanhall.com/insights/ebook/consumer-attitudes-inform-post-covid-recovery
4. “COVID-19 Accelerates Trend of Hospitals Acquiring Ambulatory Surgery Centers,” Fierce Healthcare, April 5, 2021. https://www.fiercehealthcare.com/hospitals/covid-19-accelerates-trend-hospitals-acquiring-ambulatory-surgery-centers