Feeling forced to choose between avoiding essential healthcare during the pandemic and possibly being exposed to COVID-19, many Americans opted for the former, seeing it as the “safer” option. However, delaying or deferring your care can have a significant impact on the entire healthcare system – from patients to payers and providers.
“The biggest disruption in healthcare delivery in modern history”
William Shrank, MD, chief medical officer of Humana, blamed the pandemic for “the biggest disruption in healthcare delivery in modern history.” The pandemic has resulted in reduced cancer screening and immunizations, as well as a decline in follow-up appointments for patients who had experienced heart attack, stroke, heart failure and other chronic conditions.
Fewer than 1.5 million total Medicare Advantage (MA) claims were filed in April 2020, a 66% drop from nearly 4 million in April 2019, according to a report in Healthpayer Intelligence News, which warned of the possibility of “a sicker population and lower payments” in 2021. Less than half of the beneficiaries who filed a claim in April 2019 did so a year later, with telehealth the main factor preventing an even steeper drop. Although the number of claims crept up as the summer approached, the June numbers remained 34% lower than a year earlier.
“Delayed or avoided medical care might increase morbidity and mortality associated with both chronic and acute health conditions,” according to a report on the Centers for Disease Control and Prevention (CDC) website, which estimated that 41% of American adults had delayed or avoided medical care because of COVID-19 concerns. That included urgent or emergency care (12%) and routine care (32%).
Healthpayer Intelligence News echoed the CDC warning: “Patients who do not access chronic disease management support due to the coronavirus pandemic could require acute care later on and contribute to higher costs overall. Meanwhile, payers will receive less payment from CMS (the Centers for Medicare & Medicaid Services) to cover these higher costs.”
The impact of delayed care won’t just be a one-time moment either, as it may take years, if ever, to reconnect with some patients who may have “fallen through the cracks.” Gina Bruno, the vice president of value-based care at naviHealth, believes a significant challenge that primary care providers (PCPs) will face is the need to reassess and re-baseline a patient’s needs after a lengthy gap in care. This may require additional assessments and medication reviews, as well as referrals for tests and screenings that may be overdue, which may extend the amount of time each provider must spend with each patient.
In fact, Bruno believes that providers may need to even consider the patients’ first office visit to be similar to a “new patient” visit in order to establish those post-pandemic baselines to address physical and psychosocial issues that may have emerged during COVID-19.
What that means for Medicare Advantage
From a payer and provider perspective, the sharp decline in utilization is expected to hit MA plans hard in a couple of ways. In addition to the increased costs related to potentially sicker patients, MA risk scores could be affected.
Because diagnoses from 2020 claims are used as an input to determine 2021 risk scores, fewer claims in 2020 could mean lower risk scores, even though the health status of enrollees has not changed. Consequently, risk scores may not fully reflect the cost of care.
As of July 2020, more than 26 million Americans—over a third of Medicare beneficiaries—were enrolled in MA which the Better Medicare Alliance (BMA) has praised for “boasting a higher quality of care at lower consumer costs” and “quickly edging out traditional fee-for-service Medicare.”
Former U.S. Rep. Allyson W. Schwartz, BMA president and CEO, in 2020 reported a “record-setting 99% satisfaction rate” for MA, to go with an average $1,598 in cost savings when compared with traditional Medicare.
As we previously noted, the coverage of supplemental MA benefits such as vision and hearing has become increasingly important during the pandemic. Meanwhile, MA beneficiaries had lower rates of potentially avoidable hospitalizations than traditional Medicare beneficiaries, and MA beneficiaries with multiple chronic conditions experienced fewer inpatient hospital stays and emergency room visits than their traditional Medicare counterparts.
The return of patients to the office
As some semblance of normalcy begins to return to our way of life, projections show a significant increase across the board in patients returning for care. Providers must communicate to patients the importance of resuming their care plan while also preparing for the likely influx, particularly of those whose illnesses may be more advanced as a result of their delayed or deferred care.
First things first – providers need to put their patients’ minds at ease by openly communicating about their vaccination plan for their staff. The only way to get patients through the front door again is to address the most significant hurdle, which is to create a safe environment for patients, especially for the frail seniors or for those who have compromised immune systems.
“While many health systems are marketing preventative and elective procedures in an effort to draw patients back to the hospital, PCPs and specialists play a unique role, as they have a trusted relationship with their patients,” said Bruno. “They should contact patients directly, in multiple ways, to directly communicate how they are keeping patients safe and why it’s important to come in for a visit.”
Here are three ways providers can address patients’ reluctance to return:
- Try to understand their reasons – “Understanding factors associated with medical care avoidance can inform targeted care delivery approaches and communication efforts encouraging persons to safely seek timely routine, urgent and emergency care,” the CDC report says.
- Communicate – By both listening to patients’ concerns and sharing the medical facts with them, providers can allay fears about returning to a care setting. Individual patients and specific demographics may need to be targeted. For example, the CDC report found that people with underlying medical conditions, Black and Hispanic adults, young adults, and people with disabilities were more likely than others to avoid urgent or emergency care. Social media advertising, virtual town halls and Facebook Live events are among the outreach methods being used to reach out to patients who have or are at risk of chronic disease.
- Expand care options – Nationwide polls show that recent delays in medical care are mostly not related to insurance coverage or other financial reasons and are instead because of “nonfinancial, clinician-side barriers,” according to a study published in the JAMA Health Forum. Most households that delayed care contained people with chronic illness, “underscoring the importance (of) expanding care options for patients with long-term health issues during this time,” the study concluded.
Telehealth visits are one way to achieve this, and some providers are sending caregivers to the homes of high-risk patients with chronic disease. One study showed that CMS COVID-19 waivers “significantly improved Medicaid Advantage plan telehealth access,” Healthcare Financial News reported. “Nine in ten seniors who leveraged telehealth during the shutdown reported a positive experience.”
Meanwhile, healthcare professionals and policymakers “should focus on improving capacity and infection control to accommodate patients with serious medical needs other than COVID-19,” the JAMA study advised.
The entire healthcare industry may feel the significant impact of the COVID-19 pandemic for many years to come. For those who are entrusted with the care of seniors, they must continue doing the good things they were doing before the pandemic, while applying the lessons learned during it. And that includes overcoming any issues caused by delayed or deferred care.
As we begin to take tentative steps toward lives in which COVID-19 is a less daunting factor in nursing homes, payers and providers can have an impact on how best to help seniors reconnect with family and friends. Click below to read how payers and providers can make this happen.