While we’re still in the thick of the coronavirus (COVID-19) crisis, it can be difficult to look to the future. But as the months go by, it’s becoming clear that the COVID-19 pandemic will likely have lasting effects on U.S. healthcare. What will those effects be, and how can we prepare for what’s to come? Read on for a Q&A with four DispatchHealth leaders.
DispatchHealth Leaders Weighing In
Phil Mitchell. MD, Chief Medical Officer. With experience as an emergency physician, Dr. Phil Mitchell provides leadership and oversight of all clinical programs and bridges operational and clinical initiatives across the organization. His focus is on patient safety and the delivery of quality, evidence-based medicine.
Stefen Ammon. MD, Medical Director and Implementation Physician. A practicing emergency physician in addition to our Medical Director and Implementation Physician, Dr. Stefen Ammon manages two careers on the front lines of the pandemic and leads the DispatchHealth COVID-19 Task Force to develop safety and treatment protocols.
Caren Misky. MSN, APRN, FNP-BC, Senior Vice President of Advanced Practice. A member of the American Academy of Nurse Practitioners and the Specialty Practice Group of Emergency Medicine, Caren Misky has been instrumental in the foundation and development of DispatchHealth’s mobile acute care EMS pilot and ED Diversion Program. A champion of nursing and clinical excellence, Caren has also been honored for her innovation in nursing with the the prestigious Nightingale Award
Kevin Riddleberger. MBA, MS, PA-C, Chief Strategy Officer. An active leader and advisor in Colorado’s healthcare start-up community, Kevin Riddleberger has nearly 20 years’ experience as a board-certified physician assistant, redefining healthcare delivery through technology, process, and quality improvement along the way. Additionally, he serves on the board of trustees at 9Health Fair and Project Angel Heart.
What are your predictions for the short-term and long-term effects that the COVID-19 pandemic will have on U.S. healthcare?
PM: Short term, I see healthcare systems struggling to deal with how to keep patients, providers, employees, and associates safe in an environment with a novel infection. There will be new information related to the virus that will require new processes, new testing, and new techniques to protect healthcare workers. Systems will have to address safety concerns before planning routine procedures and practices, which will directly affect budgets.
Long term, the systems will right themselves through either better understanding of the illnesses related to COVID-19, adaptations to new normals, or a state of normalcy related to herd immunity or vaccination (if successful). All areas of healthcare will be different due to the disruption caused by COVID-19. The question remains as to how different.
SA: The immediate, short-term effects of the COVID-19 pandemic on the U.S. healthcare system include the expansion of alternative health services (including novel healthcare delivery services and telehealth options) as well as the relaxation of regulations to allow for these alternative care options.
The long term effects will likely include probable contraction in a number of health systems and hospitals and looking into in-home care alternatives.
CM: In terms of short-term effects, the swift outbreak of the pandemic had healthcare system leaders pivoting rapidly, spurring innovation, teamwork, collaboration, and communication. There are new technologies and an acceptance of virtual medicine and meetings.
There was also a worldwide show of love and support for our front line workers—reverence and understanding and awe for their selflessness at what they do every day. I am hopeful that this will influence our younger generations to consider healthcare careers.
Another short-term impact that I see now is that our interactions with patients are very different. Either virtual visits or in person with full PPE (masks, gowns, face shield, and distance), there is less human connection, which is a patient and provider dissatisfier.
A positive effect is that, as the pandemic continues, there is now a focus on readiness and stockpiling of PPE supplies to protect front line workers and patients. There is also research being fast tracked for immunization creation.
A truly unfortunate effect of COVID-19 is the downstream impact to budgets and resources, and there will be significant repercussions. Most states will be financially strapped, which will lead to a lack of resources for schools, social programs, mental health, primary care, and basic state infrastructures. Hospital systems have lost millions, and in turn, medical staff has been furloughed. And less clinical staff equates to a lessened ability to properly care for patients.
Long term, there will continue to be more and more healthcare disparities. As the crisis drags on and social isolation and other stressors continue, there will be an explosion of depression, suicide, and addiction—and there is already a severe lack of funding for mental health. People are losing their jobs and their health insurance. Undertreated or untreated disease and lack of primary care will cause people not to seek treatment until later in their disease process, which is the most costly care to provide.
KR: The way consumers interact with their medical providers and access to their medical care will fundamentally change in the short term and long term. Healthcare consumers will not be going back to the inconvenience of medicine. Lost productivity will go away by eliminating the drive to the appointment, the waiting in the office, and the driving back home or to work. Healthcare will be more consumer-centric moving forward.
Healthcare providers will shift more of their patient panel to manage virtually or with tele-presentation capabilities from home. When a video isn’t enough, further technology advancements will enable providers to extend their practice into the home and senior living community to treat more medically complex issues with hands-on support and tele-presented exams. It will deliver a higher level of virtual care for patients who are homebound, are memory-impaired, or need proximate ancillary studies.
Healthcare in the home is not a new idea. But moving forward, we will see an actual system of care being delivered in the home, from remote patient monitoring leveraging a connected home to virtual care, home health, home-based primary care, ER care, and even hospital-level care in the home, disrupting our brick-and-mortar healthcare delivery model.
How do we take advantage of the crisis to initiate change?
PM: One important change would be to have a more universal method of immediate licensing in states within the U.S. Currently, the licensing system varies for physicians and other providers in every state. There must be an expedited, central method of doing this in order to avoid delays in obtaining assistance in areas where needed. If providers knew that they could be granted a license (even temporary) to help that did not require 2-3 days of work, significant cost, and frustration, more would be likely to contribute.
SA: The U.S. Healthcare system is a behemoth—a gigantic creature of habit that is incredibly slow to move and adapt. The COVID-19 pandemic, in all its terror, has helped to bring to light the inadequacies and shortcoming of our current health system… and has forced the hand of change. To quote an insightful fellow emergency physician, Dr. Maia Dorsett from the University of Rochester Medical Center School of Medicine:
“The coronavirus (COVID-19) pandemic has amplified pre-existing deficiencies and inequities of our healthcare system. U.S. healthcare is incentivized to react to sickness rather than proactively focus on health maintenance. As an emergency physician, I witness the impact of this approach daily. Far more money and effort are expended on minimally impactful interventions than addressing social determinants of health such as housing, food security, and safety from violence. Collectively, these have a greater impact on healthcare outcomes than any pill. Procedures to manage illness are well compensated, but public health systems to improve population health are underfunded and understaffed.” (Dorsett M. Point of no return: COVID-19 and the US Healthcare System: An emergency physician’s perspective. Sci. Adv. 26 June 2020.)
If we are wise, we will use this opportunity to not only identify our shortcomings, but to identify real world solutions to overcome these inadequacies as well.
KR: The pandemic has accelerated the pace of healthcare transformation for the betterment of the consumer and provider. We must continue to lean into this transformation in order to push healthcare forward with improvements to the experience and the quality of care delivered, translating into increased value to the system of care.
Is virtual care here to stay?
PM: Some degree of virtual care is here to stay. For low acuity issues or basic follow-up on those with chronic conditions, it is appropriate and necessary to expand the reach of care teams. For higher-level care (ICU) where intensivists are in high demand but low supply, we have shown that this method of care delivery can be well adapted.
For new patients, patients with acute care issues, or significant social determinants of health concerns, a person-to-person evaluation cannot be replaced.
SA: Yes, I think telehealth and virtual visits are here to stay. Prior to the pandemic, various sectors within the U.S. healthcare system had been working toward making services more available using various forms of technology, including telehealth. The COVID-19 pandemic helped shift this process into overdrive. In fact, some healthcare experts claim that the COVID-19 pandemic accelerated telemedicine by a decade or more.
Now that telemedicine capacity has grown to meet increasing demands imposed by the COVID-19 pandemic, and countless skeptics (both providers and patients) have experienced the firsthand convenience and ease with which telemedicine and other non-traditional methods of care delivery can be deployed, these forms of care are likely to remain a part of the healthcare landscape indefinitely.
That being said, I think the large forced experiment imposed by the pandemic has also helped to identify the limits of telemedicine. Though it is a great tool for visual diagnosis (e.g., rashes and diabetic foot checks) and continuity visits, telehealth cannot supplant many aspects of the physical exam. In many instances, nothing can take the place of an in-person patient assessment. In addition, there are important elements of human contact associated with in-person healthcare delivery.
My unfounded suspicion is that the preference for human contact will follow a generational divide—that older patients will prefer an in-person visit while younger patients, who are more comfortable with virtual interactions, will be equally satisfied with a telehealth visit.
CM: Yes, I believe telehealth and innovative models such as tele-presentation are here to stay and can dramatically offer improved access to care and decrease the burden on taxed traditional models and overwhelmed emergency departments.
KR: Yes, virtual care is here to stay. Virtual health can come in many flavors moving forward based on the patient, the provider, and care plan needs, such as:
- Traditional video-based visits
- Remote patient monitoring or a smart connected home
- AI-driven chatbots with virtual assistants supplementing the engine
- Virtual reality medicine/therapy/training will become more advanced and adopted
The technology has not been lagging over the years—it has been the incentives aligned to drive further adoption of this technology. I believe we will see continued payment models to support this model of care, which will be a critical factor in the utilization of these surfaces. The ship has already sailed on this new healthcare service with considerable consumer and provider adoption to support continued growth.
Do you think there will be a rise in home health and mobile care services even after the pandemic is over?
PM: Care in the home was on the rise prior to COVID-19. The pandemic has brought to light the importance of being able to provide a high level of care in the home in order to help lessen the burden on emergency departments, hospital wards, and clinics that are not prepared to protect themselves from a spreading infection. The ED and hospital in the home will only continue to grow and demonstrate value.
SA: Yes. Some healthcare experts believe that the numerous deaths in nursing homes and long-term care facilities will forever sour public opinion toward such facilities and will lead to a shift toward in-home care alternatives. In addition, the impending rise in the number of individuals in need of such services will invariably increase as baby boomers come of age.
These pressures are sure to lead to an increased demand for healthcare services in the home, where people will be allowed to age in place for as long as possible.
CM: Yes. Hospital systems have lost millions of dollars during the pandemic related to the inability to perform money-making elective surgeries. The financial impact will force systems to reimagine healthcare in order to use their dollars efficiently, and many have recognized that traditional brick-and-mortar hospitals and clinics require huge amounts of overhead. A clinic or hospital without walls, the continuation of virtual care, and the addition of mobile services is a much more cost-effective model that has improved outcomes and patient satisfaction as DispatchHealth has proved with our EMS and acute- and advanced-care service lines.
KR: The home is set up for success particularly relevant during this crisis and as we move forward. From coast to coast, we will continue to see the shift of the site of care into the home because of patient preference, safety (i.e., from COVID-19 and other nosocomial infections), improved clinical efficacy, and decreased cost to our healthcare system. Our typical facility-based care model can and should be turned on its head. For years, we’ve had ample medical literature to support the conclusion that care in the home is more efficacious in many instances. With the emergence of value-based care, healthcare consumerism, and the COVID-19 pandemic, the transition to the home appears to have reached a tipping point. We spend $4 trillion annually on a healthcare system that produces inferior outcomes compared to other western countries. A third of our spending comes from facility-based care delivery: emergency department visits, hospitalizations, and post-acute interventions. Imagine if we could cut that spend in half with a lower-cost care model that is preferred and produces better outcomes. The answer is staring us right in the face: To push more care safely in the home setting.
Any other thoughts on COVID-19’s impact on the healthcare economy?
PM: This pandemic is another contributing factor for hospitals to one day be comprised of three areas: an emergency department, an operating suite, and an ICU. All other care will be done in other venues.
SA: The adverse economic impact of COVID-19 on the U.S. healthcare system cannot be overstated. This is particularly true for hospitals and health systems.
As the pandemic began to spread in the U.S., many hospital systems closed primary care and specialty clinics and canceled elective outpatient surgeries in order to: 1) limit unnecessary exposure to patients and healthcare providers, 2) ration PPE and critical equipment (ventilators), and 3) create hospital bed capacity to accommodate a possible surge in volume due to patients sick with COVID-19.
During this same period, many potential emergency department patients responded by staying home in order to avoid potential exposure at the hospital, resulting in a drop in U.S. emergency department volumes of more than 40%.
The net result was a significant loss in revenue for hospital and health systems. Per the American Hospital Association (AHA), the net effect of these losses for U.S. hospitals and health systems between March 1 and June 30, 2020, amounted to $202.6 billion.
When you consider that 1) many physicians and hospital systems live on fee-for-service reimbursement models, 2) many hospital systems have already seen declining profits over the past few years, and 3) hospital systems function at a narrow profit margin (the mean hospital profit margin in 2016 was 2.7%), it becomes obvious that many hospital and health systems in the U.S. are in trouble. The likely result will be that some hospital systems will not survive.
The United States is destined to need a mobile, nimble solution to address growing healthcare needs with fewer access points and bricks-and-mortar facilities.
CM: I am afraid the strain on the healthcare economy will have further downstream effects. Hospitals are delaying expansion and growth, which in turn will limit staffing and hiring. An unintended consequence may be higher patient-to-staff ratios, which can be dangerous for patients. Small hospitals will go under, which will limit access to care, especially in rural communities.
Elective and primary care and transplant services may be cut—something has to give, since there are only so many resources to go around. Overall, this is not good for healthcare or patient care.
KR: The healthcare economy is not only driven by traditional ways of accessing our medical community, but also rooted in our communities in which we live, work, and socialize. Prior to COVID-19, medical literature strongly supported the importance of social factors in the health and wellbeing of our lives, such as food access, housing stability, and education. COVID-19 has only stressed the importance of this even more. We must make sure we are addressing these needs for those most vulnerable in order to avoid a rapidly widening gap in disparities. We must make sure we are investing in our communities with not only traditional services, but also new and emerging services, such as widely available internet access, technology, public service announcements around infection control measures, and educational material. Our communities across the country will be further impacted heading into fall and winter without the proper attention and investment from all of us.
The COVID-19 pandemic has a lot to teach us about our current healthcare system, where it falls short, and what we can do to improve it in the future. Although it’s tough to see the forest for the trees while we’re still in the midst of the COVID-19 crisis, taking a step back to assess how we can improve will be essential as we move forward into a healthcare industry made over.
Feel free to get in touch with DispatchHealth with any questions!