CalOptima, a Medicaid insurer, pivoted care during the pandemic to focus on the home within its Program of All-Inclusive Care for the Elderly, or PACE, in Orange County, Calif.
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Written by: Steven Ross Johnson
Will COVID-19 be the catalyst for creating a more sustainable healthcare system?
It was not long after COVID-19 hit the U.S. that Dr. Ari Robicsek, chief analytics officer for Renton, Wash.-based Providence, began seeing patients reporting symptoms tied to the virus.
A year ago, the virus was largely a mystery, making it hard to pinpoint a diagnosis. Testing was scarce, and shortness of breath and tightness in the chest weren’t immediate red flags for COVID.
When his sister showed symptoms, Robicsek began to think about the years it normally takes to collect and analyze enough patient data to inform patient care. While that process is thorough and there for a reason, it makes it hard for clinicians like him to adapt quickly—something that is necessary to contain spread and fight mortality.
“It was frustrating both as her brother and as an infectious-disease specialist that we knew so little about this disease,” Robicsek said.
So like many others in healthcare over the past year, Robicsek worked quickly to develop a clinical project to collect and analyze information based on the first-person accounts of COVID-19 patients.
“One of the things I think this teaches us is that we need to re-think our model about how we learn about disease,” Robicsek said. “We need to ask ourselves as a medical community how do we engage in more participatory research.”
The pandemic, despite being tragic and widespread, created models that taught providers, payers and their affiliated partners to create more efficient methods and improve care.
The pandemic, despite being tragic and widespread, created models that taught providers, payers and their affiliated partners to create more efficient methods and improve care. Chief among them is going directly to the patient, whether to care for them in their homes or simply for their opinions and stories.
“A recurring theme I think you will see throughout the healthcare industry is how the pandemic forced providers to go places where they otherwise would not have been and how that’s going to change consumption patterns,” said Andrew Sorenson, chief analytics officer at Castell, a firm owned by Salt Lake City-based Intermountain Healthcare that provides support to help stakeholders transition to value-based pay models.
Renton, Wash.-based Providence used a mobile platform to directly engage with COVID-19 patients and document their care experience.
More than 38,000 patients have been contacted through Providence’s platform since August and more than 5,200 agreed to document their experience. Robicsek said over the first eight weeks, patients wrote an average of 12 journal entries.
Among the more common traits was an intense burning sensation in their nose, something Robicsek had not previously seen documented in COVID-19 patients. Also, most journal entries reported cognitive impairments lasting several weeks following recovery.
Robicsek said Providence did not yet have information on what kinds of cost savings have been generated using the platform, but felt that the patient information collected will help Providence deliver better treatment. They found other information useful as well, specifically how COVID-19 has affected patients financially.
The program began screening for social needs after patients with essential jobs reported how being sick put a strain on their finances. Now Providence ensures COVID-19 patients receive better social services. The system is also using the data to inform its investments in community resources.
"If we can characterize what the economic impact is for individuals who have COVID, that’s going to give us powerful information about the economic impact this disease can have on the entire country," Robicsek said.
“If we can characterize what the economic impact is for individuals who have COVID, that’s going to give us powerful information about the economic impact this disease can have on the entire country,” Robicsek said.
Since the U.S. reported its first case of COVID-19 more than a year ago, more than 482,000 Americans have died and more than 27 million COVID cases have been reported to the Centers for Disease Control and Prevention as of Feb. 16. The unemployment rate jumped from record lows of under 3.5% in February 2020 to nearly 15% by April, according to a January 2021 Congressional Research Service report.
While the pandemic was a catalyst that pushed the industry to find ways to meet the health needs of patients where they live, economics also played a large part in motivating providers to transform their delivery models. The pandemic cost an average of more than $50 billion for the nation’s hospitals collectively every month, due largely to a massive slowdown in revenue-generating non-emergency procedures and steep declines in patient volume.
“One of the things the pandemic did was expose a pretty major overhead problem on the part of large health systems,” said Dr. Robert Fields, senior vice president and chief medical officer for population health at Mount Sinai Health System in New York.
Some of the best lessons hospitals have learned during the COVID-19 pandemic that will influence their care delivery approaches moving forward:
- Conduct a review of current care delivery practices to identify areas where efficiencies in clinical workflows can be made, and processes streamlined. Hospitals that remained flexible were able to more quickly develop care models that met their changing needs during the pandemic.
- Leverage virtual tools like telehealth and remote patient monitoring to expand capacity.
- Design care models that target reducing health and access disparities that are more scalable and less expensive than expanding traditional brick-and-mortar care sites.
- Identify and address challenges patients may experience obtaining or maintaining access to internet service.
- Convert patient transportation services into a mobile health program to provide at-home preventive health services and delivery support for patients living in food-insecure households.
Fields said providers were reliant on patients coming to their facilities. The pandemic has highlighted the vulnerabilities of hospital-centric care.
Drops in demand for non-COVID healthcare services led to a 32% decline in spending last April, according to the Kaiser Family Foundation, resulting in a 2% decrease for the entire year compared with 2019.
Those losses are compounded by the high costs of treating COVID-19. A March Kaiser Family Foundation analysis estimated the average cost per patient ranged from more than $20,000 to over $88,000 for those who required ventilator support.
Getting to patients sooner and preventing them from getting ill in the first place was a key strategy in combating the impact of COVID.
Getting to patients sooner and preventing them from getting ill in the first place was a key strategy in combating the impact of COVID. “Systems that were more heavily invested in population health processes and contracts tended to do better (during the pandemic),” Fields said. “I think that was an eye-opening experience.”
Dr. Imran Andrabi, CEO of Appleton, Wis.-based ThedaCare, said the system has spent two years transforming its care delivery processes with the goal of becoming a leader in population health management strategies.
ThedaCare has relied largely on community partnerships with organizations like Feeding America and United Way that during the pandemic have delivered food and prescription drugs to older and more vulnerable patients with chronic health conditions.
Other programs have included collaborating with local hotels to provide temporary housing and medical respite care services for discharged patients diagnosed with COVID-19 who either did not have stable housing or wanted a place to quarantine before going home to reduce the risk of spreading the virus to their families.
In turn, ThedaCare’s community partners provided free day care to the health system’s front-line healthcare workers.
“Everything that we have learned over the past year is applicable to our work going forward,” Andrabi said.
Elizabeth Lee, director of the Program of All-Inclusive Care for the Elderly at CalOptima, the public health insurance provider for Orange County, Calif., said much of the program’s on-site wellness and support services has been converted to an at-home model. That happened rapidly last March after it became clear that keeping its center open posed too much of a health risk for patients.
Lee said the capitated contract CalOptima operates under for its clients easily translated to a home-based care delivery model. Reimbursement has been based on how well they keep patients from going back into the hospital rather than how many patients visited their health centers.
CalOptima and others like it benefit from a number of federal rule changes during the pandemic, including how home-based healthcare services are reimbursed. In October, CMS made permanent its home health payment rule that was initially created as an emergency measure during the pandemic that increased the pay rate for such services by 1.9%.
To help with care coordination, Lee’s clinical care team members consulted with seniors through telehealth. Vans delivered meals, medical equipment and supplies to seniors. Mobile phlebotomists conducted blood drives while mobile radiologists performed ultrasounds and X-rays at patient homes.
Lee said the changes made to PACE in response to the pandemic have led to the program’s growth. More patients can now take advantage of the mobile care delivery offerings created due to COVID, making it easier to provide care to patients too sick to leave their homes even after their day centers re-open.
“It’s pretty amazing to look back and see how far we’ve come knowing that it’s probably never going to look the same again for us,” Lee said.
Community-based care largely grew as a result of an explosion in the use of digital health. Telehealth visits increased by more than 50% during the first quarter of 2020 compared with the prior-year period, according to the Centers for Disease Control and Prevention. Between mid-March and mid-August 2020, more than 12 million Medicare beneficiaries received a telemedicine service, according to CMS. Nearly 35 million people covered by either Medicaid or the Children’s Health Insurance Program received telehealth services between March and June of 2020, a more than 2,600% increase in use over the same time in 2019.
Telehealth was not the only technology to gain ground as a result of COVID. Since the start of the pandemic, Mount Sinai in New York has used predictive analytics to flag patients most at risk of dying from COVID. Patients get a text with a questionnaire to screen them for potential clinical and social needs. Healthcare professionals then text or video chat with the patients to help them manage their conditions remotely.
But the efficiencies haven’t stopped at care delivery.
Geisinger Health battled steep declines in patient volume. Even during December, the Pennsylvania-based health system saw a 24% drop in monthly surgeries compared with December 2019.
“If you look at what happened back in March, we like every other healthcare system, really brought the delivery system as we know it to a screeching halt,” said Karen Murphy, Geisinger’s executive vice president and chief innovation officer.
The health system took many of the steps to curb transmission for patient-facing staff. But it also identified opportunities for administrative staff to stay safe. Geisinger took its live call center to a series of automated platforms that allowed patients to get reliable answers about COVID-19, receive health screenings, and schedule appointments to get tested for the virus.
“A year ago in terms of digital strategies it would have taken us a while to educate doctors,” Murphy said. “I think now when we have a problem, instead of asking how many people do we need to solve it, we’ll be thinking digital first.”
Kate Sommerfeld, president of social determinants of health at ProMedica, said the Toledo, Ohio-based health system has been analyzing data for years to better identify social risk factors among patients. That contributed to industry-leading efforts like the opening of a grocery store in Toledo in 2015 to combat food insecurity, as well as nutritional education, job training and financial coaching programs.
But safety concerns during the pandemic temporarily shut down many of those in-person programs. So Sommerfeld and her team conceived new ways to address those logistical challenges.
Toledo, Ohio-based ProMedica opened a grocery story in 2015 after years of data analysis showed food insecurity was an issue in its community. The pandemic forced some changes in how food was distributed.
Like other grocers, ProMedica’s store began providing online food delivery services as the pandemic progressed. By spring, the health system converted all of its financial wellness education and counseling programs from in-person classes to remote learning. Sommerfeld said the switch to online has unexpectedly led to a 15% increase in participation. The growth has come from insurance plan members across the country.
“It’s really been an interesting experiment in pushing innovation,” Sommerfeld said. “Out of this, I think one of the things that does become apparent is the need for those remote and virtual services not only in the traditional clinical sense, but even as we provide social determinant interventions and supports.”
Geisinger’s Murphy hopes the industry will embrace what was learned over the past year. She envisions a more flexible industry that innovates and responds to patient needs faster than before and that good ideas are scaled quickly.
“We’re going to have to be disciplined to hold on to those lessons, “ Murphy said. “Shame on us if we slide back to where we were before.”
Learn more about Dr. Ari Robicsek's research contributions.
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