Looking back, social scientists have seen the silver linings of the influenza epidemic of 1918, the cholera epidemic of the early 1830s, and the Black Death of the 14th century — the most fatal pandemic recorded in human history. Fast forward, COVID-19 has exacted suffering and loss of epic proportions, and we’re not yet out of the woods. While the number of new cases and hospitalizations are coming down, the death toll climbs, new variants emerge, unemployment remains high, and food lines are long. Payers are acutely aware of this suffering and are quite concerned about the potential for negative outcomes associated with avoidance of necessary care. Yet payers already see potential silver linings of the COVID-19 pandemic.
Fewer unnecessary emergency visits
Emergency department (ED) visits are down. The potential downside is that some emergent visits were avoided; the potential upside, some non-emergent visits were avoided. ED visits for mild illnesses and less-severe injuries are down, and this decrease is desirable. Curiously, ED visits associated with chest pain are down, but, thankfully, payers do not see a commensurate uptick in negative outcomes. Some of this suppressed utilization may have been simply avoidance due to fear, and some may have been facilitated by payers through access to and reimbursement of telehealth visits. Payers will gladly pay for a $200 telehealth visit that avoids an unnecessary $2,000 ED visit.
More telehealth visits
Telehealth visits are up. In particular, telebehavioral health visits are way up, and this is largely due to the good fit — a physical exam is not necessary. COVID-19 has ushered in broader acceptance of telehealth among patients and providers alike. Enhanced reimbursement of telehealth visits at or near parity with in-person visits has been the primary driver of provider acceptance. Not surprisingly, if you reimburse it, they will come.
Increased home care
Home care is up. Payers have been encouraging site-of-care shifts from inpatient to the most cost-effective outpatient settings, including the home, for quite some time; COVID-19 has accelerated this shift. Home care services are often more convenient, private, socially supportive (if the patient is not home alone) — and safer because of a lower risk of nosocomial infections. During the COVID-19 crisis, many payers have actively promoted Cologuard or FIT screening tests as alternatives to colonoscopies, which were down.
Hospital-at-home programs designed to improve outcomes and lower costs were slowly gaining traction for years. To help ensure hospitals and health systems had the capacity to absorb and manage potential surges of COVID-19 patients, CMS rolled out its Hospitals Without Walls program in March 2020. Several months later, CMS’s Acute Hospital Care at Home program built on this in the belief that more than 60 acute conditions can be treated appropriately and safely in home settings with proper monitoring and treatment protocols. Reimbursement could sustain this trend.
A shift to self-administered drugs
Use of provider-administered drugs is down. In part, this is because economic hardship or loss of health coverage have made cost sharing requirements unaffordable, and in part because use of patient-administered drugs, which are typically more convenient, is up. For example, there has been a shift from Remicade to Humira and Stelara, and COVID-19 has accelerated this shift. Patient-administered drugs eliminate office visits, helping payers to avoid an administration fee and patients to avoid potential exposure to the virus. Prior to COVID-19, payers did not want to pay for convenience. But this is a new era, and payers may soften their stance on more convenient products and accept some higher costs as a trade-off for reducing members’ exposure to the virus. Further, payers may realize larger rebates and deeper discounts by growing the market share for preferred patient-administered products. So, what appears on the surface to be more expensive may be less expensive.
A similar shift is occurring from infused chemotherapies to more targeted products. While these targeted products are more expensive, they are also more effective, safer, and better tolerated — and an oral pill without the risk of virus exposure. Utilization of Revlimid, a top-10 drug in terms of spend, was increasing and COVID-19 accelerated that growth. Payers do not celebrate higher costs, but welcome opportunities to move away from buy and bill — a long-term play with potential savings.
Better awareness of racial and ethnic disparities
Awareness of disparities is up. People of color are disproportionately affected by COVID-19 cases, hospitalizations, and deaths in the United States, and this is shining new light on longstanding disparities in health status and access to care. Some payers — particularly those serving low-income members — hope greater awareness of racial and ethnic disparities may lead to greater societal investments that narrow the gap. Expanding Medicare eligibility, enriching Medicaid benefits, and investing in other programs that address social determinants of health (e.g., food, housing, transportation) would bring relief to millions.
Evidence generation
Some utilization is down. As previously mentioned, colonoscopies are down. So are mammograms. To evaluate periodicity of screening recommendations in a rigorous way, patients would be randomly assigned to a delayed-screening group, though in practice this would be unethical and funding a large study may not be feasible. COVID-19 is not a natural experiment randomly assigning patients to treatment and control groups, but it lays the foundation for a large-scale observational study of the impact of delayed or missed screenings. Over time, these insights will emerge and inform United States Preventive Services Task Force recommendations. It wasn’t long ago when routine chest X-rays were recommended until evidence emerged that they did not save lives! Payers welcome evidence-based coverage policies.
Greater uncertainty
Back to the future: Will unnecessary visits remain suppressed while necessary visits fully rebound? Will telehealth continue to gain traction? Will shifts to home care and self-administered drugs continue and ultimately lower costs and/or improve outcomes? Will awareness of disparities lead to societal investments, programs and policies that address social determinants of health and more equitable access to care? Will the evidence that will surely emerge from the answers to these questions be put to good use? None of us, payers included, know for sure.
Forrest Gump, the lead character in the Forrest Gump movie stated a simple truth — “My momma always said life was like a box of chocolates. You never know what you’re gonna get.” While payers already see potential silver linings of COVID-19, they are not yet sure what they’re going to get.
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