Riding high because of the COVID-19 surge, telemedicine companies are going public and making expensive deals.

Telehealth is dialing up the dollars

Findings of a new study suggest differences exist in specialist referral patterns by race among Medicare beneficiaries.

The findings provided additional evidence that physicians may make different treatment decisions for their Black and White patients.

Bruce E. Landon, M.D., M.B.A., and colleagues examined whether differences existed between Black and White Medicare beneficiaries in the observed patterns of patient sharing between primary care physicians and physicians in the six specialties patients were most frequently referred. The team used data on 100% of traditional Medicare beneficiaries from 51 hospital referral regions for 2009-2010 to examine patient-sharing networks among physicians. They identified the hospital referral regions for which the percentage of Black patients identified in the Beneficiary Summary File was at least 10%. There were 17 markets identified and the investigators restricted the analyses to the 12 markets with the greatest total number of physicians — all had at least 750 physicians.

Physicians encounters were defined based on paid claims in the carrier file. Landon and the team excluded claims for non-direct patient care specialties or specialties where individual physicians were not typically selected by patients.

The investigators constructed networks using three approaches: one based only on encounters for White patients, one based only on encounters for Black patients, and one based on encounters for Black and White patients. The analyses were focused on shared care between primary care physicians and those from the most frequently visited specialties — cardiology, pulmonary disease, gastroenterology, orthopedic surgery, general surgery, and neurology.

Of the 12 selected markets, size ranged from Manhattan, New York (187,054 Black or White beneficiaries seen by at least two physicians within an episode of care; 9,794 total physicians) to Tallahassee, Florida (44,644 Black or White beneficiaries seen by at least two physicians within an episode of care; 847 total physicians). The percentage of Black beneficiaries ranged from 11.5% in Huntsville, Alabama to 46.8% in Chicago, Illinois.

The mean number of specialists a primary care physician shared patients with was lower for Black patients than for White patients. The mean primary care physician-cardiologist degree across all markets for White patients was 17.5 compared with 8.8 for Black patients. The degree difference narrowed after sampling White patients to equalize the numbers of patients seen, but they still were not equivalent in most markets.

Among White patients, specialist networks were much larger than those based just on Black patients (for cardiology across all markets: 135 for Black patients vs 330 for White patients), even after equalizing the numbers of patients seen per primary care physician (123 for Black patients vs 211 for White patients).

Overall, the test for differences in referral patterns was statistically significant for all six specialties examined in seven of the 12 markets and in five specialties for another three markets.

The reasons for the differences may be multifactorial and additional work is needed to better understand the associations, the investigators noted.

Assessment of Racial Disparities in Primary Care Physician Specialty Referrals

Articles

Physicians may make different treatment decisions for patients of different races.

Specialist Referral Patterns Vary Based on Race

The U.S. Food and Drug Administration today announced Theranica’s therapeutic device, Nerivio, was cleared to market for an expanded indication for acute treatment of episodic or chronic migraine in patients at least 12 years old.

Nerivio is worn on the upper arm for 45 minutes and uses Remote Electrical Neuromodulation to activate the brain’s Conditioned Pain Modulation mechanism to treat pain and associated migraine symptoms.

“Having this drug-free migraine therapy available for the adolescent migraine community could positively impact patient compliance,” Jennifer McVige, M.D., a board-certified physician in pediatric neurology, adult and pediatric headache and neuroimaging at the DENT Neurologic Institute, said in 

. “…Nerivio is an efficacious smartphone-controlled tech solution that can be worn inconspicuously and is the perfect design for teens who may unfortunately begin to experience migraine attacks.”

The clearance comes following a study published in the journal 

. Findings of the study demonstrated 71% of the adolescent participants using the device experienced pain relief after two hours while 35% were completely pain free. In 90% of the cases, pain relief and pain freedom were sustained for 24 hours. A majority of the patients (69%) experienced improvement in their functional ability, which meant they could do schoolwork and perform typical activities at two hours.

There were no adverse events related to use of the digital therapeutic.

Nerivio is available by prescription by any licensed healthcare provider and is good for 12 units before being recycled. Patients can then get the prescription refilled with a new device. It 

“This new indication is a dramatic step in our committed effort to serve the migraine community as a whole,” Theranica’s CEO and co-founder Alon Ironi said.

The approval comes following a study on the efficacy of the migraine device.

FDA Approves Digital Migraine Therapeutic

Keith Loria is a contributing writer to Medical Economics.

Eric Whitaker, M.D., is a nationally recognized authority on public health and an expert in the health issues of African American communities, and he is using his influence and knowledge to lead Zing Health, a physician-led Medicare Advantage HMO plan that helps underserved seniors.

An internal medicine physician by training, Whitaker has had a carer that includes running the Illinois Department of Public Health and founding the investment firm TWG Partners. He also is a friend of former President Barack Obama. Whitaker was a student at the Harvard T.H. Chan School of Public Health when he met Obama, who was a student at the university’s law school. “I actually didn’t know his name until I saw his name in a Boston newspaper as the first Black president of the 

 and realized that though we were in Boston, we both had a connection to Chicago,” says Whitaker.

Over time, his relationship with both Barack and Michelle Obama opened his eyes to the immense possibilities in the future. Whitaker knew he wanted to do all he could to make a difference.

That was a catalyst for forming Zing Health, which he started in 2019 along with Kenneth Alleyne, M.D., FAAOS, a board-certified orthopedic surgeon. The company, which got its start in the innovation lab at the American Medical Association, markets Medicare Advantage plans to underserved communities, with a focus on Black and Latino communities. The company has branched out from its home base in Chicago and Cook County and is now marketing plans in Indiana and Michigan.

“Whereas a lot of insurance companies run away from diverse populations, we’re running toward them because we’re giving our experience to vulnerable populations,” Whitaker says. “Even with Medicare Part D, we focus on the low-income segment of that population. We feel we have a unique experience to deliver stellar health outcomes for these underserved populations.”

Whitaker, 55, was the middle of three boys raised by his mother, Charlotte, a nurse administrator and head nurse at Chicago’s Michael Reese Hospital, now closed and demolished. She graduated from the hospital’s nursing school, which at the time was one of only two nursing schools in the city that accepted Blacks. “In another age, she would have been a physician, but that path wasn’t open to her,” Whitaker says.

Whitaker grew up in Morgan Park, a neighborhood on Chicago’s South Side, and attended St. Rita of Cascia High School, taking four buses to get there each day. “I got a basketball scholarship to go there, but I tested into the top honors class, though they didn’t care,” he says. “They just wanted me to play basketball.”

Whitaker’s mother used to joke that she would whisper in her boys’ ears that they should become doctors. “I was the only one who listened to her,” he laughs. Whitaker says the experience that led to him becoming a physician occurred during his junior year in high school.

“I was enrolled in this program at the Illinois Institute of Technology called CHAMPS (Chicago Area Health and Medical Careers Program), which aimed to identify minorities who were good in sciences and expose them to the health professions,” he says. “In CHAMPS, I saw my first African American doctor — and that was an inspiration — and I learned the importance of role models. It changed my life.”

During that time, Whitaker also learned about what everyone in healthcare is now calling the social determinants of health. “There was a little clinic, and there were pregnant women lined up outside the door,” he says. “There’s this thought that poor people don’t want healthcare, and here I saw with my own eyes that folks were out in the sun waiting to be seen in what I consider inhumane conditions. That image has rested in my mind to this day and really has been a driver for how I’ve approached my career. I knew I wanted to be a physician, but I wanted to be a physician for communities and populations.”

Whitaker went on to major in chemistry at Grinnell College in Iowa and then earned his medical degree from the University of Chicago Pritzker School of Medicine and master’s in public health from the Harvard T.H. Chan School of Public Health.

While in medical school, Whitaker took a break from his studies to devote time to being president of the American Medical Student Association, a group that represents approximately 30,000 medical students around the country. That experience introduced him to the busy intersection of healthcare and politics — and to a cadre of future healthcare leaders. “I ended up testifying in front of Congress twice,” he says. “The people that I met are now running institutions, hospitals, foundations, government — they’re all over the place. It’s been a powerful network of folks that I’ve been able to collaborate and work with to improve healthcare for vulnerable populations.”

A mentor recommended that he do his residency at San Francisco General Hospital (now Zuckerberg San Francisco General Hospital and Trauma Center) because he could make a difference there during the HIV/AIDs epidemic. In the early ’90s, the epidemic’s disproportionate effect on African Americans was becoming apparent. “One of the things that I saw was that in the Black community, HIV was growing and spreading, yet a lot of the community was really ignoring it and not being proactive about preventing HIV spread,” he says.

Whitaker has spent most of his career in Chicago — and he makes a point of mentioning that he lives on the South Side today by choice. He worked first with Cook County Health’s Woodlawn Health Center, which was just a few blocks from the University of Chicago. Whitaker then started Project Brotherhood, which encouraged Black men to use community healthcare services. The project included a fatherhood and rites of passage program. “It was really about men accepting their responsibilities to go along with the rights they think they have as men,” says Whitaker. To erase the stigma associated with going to the doctor, Whitaker and his colleagues added a barbershop in the clinic.

Whitaker credits the work he did setting up Project Brotherhood with leading to his appointment as Illinois state health commissioner in 2003, a post he held for four years. “I’d say it was some of the most fun I’ve had in my life,” Whitaker says, “because it’s one thing to have a lot of ideas, (but) it’s another to be able to change a policy that impacts millions of people.” As state health commissioner, he worked on HIV prevention as well as reducing the burden of breast cancer among the state’s Black women and increasing preparedness for bioterrorism and a flu pandemic.

During the next chapter of his career, Whitaker returned to the South Side where he served as executive vice president for strategic affiliations and associate dean for community-based research at the University of Chicago Medical Center.

In 2018, he helped establish the Creating Pathways and Access for Student Success (CPASS) Foundation. Like CHAMPS before it, CPASS offers students, through its SMASH Academy, a five-week experience on the Illinois Institute of Technology campus, exposing them to a STEM (science, technology, engineering and mathematics) program of study and fostering interest in both health professions and technology.

Whitaker’s wife, Cheryl, is also a physician. When they aren’t working (and before the COVID-19 pandemic), the Whitakers enjoyed eating out and traveling, often accompanying the Obamas on vacations to Martha’s Vineyard and Hawaii. They have two teenage children, Caleb and Caitlin. “Cheryl has been on a lot of the journey with me — training at the same hospitals — and did a lot of the same things,” Whitaker says.

Whitaker had been involved in several businesses prior to Zing. “I consulted with a healthcare company, and when that owner sold that business, he said he enjoyed working with me and wanted to find something we could work on together,” Whitaker says. “We looked at a lot of options and decided to get into the Medicare Part D business. It was based on our skill sets.”

The first insurance company he founded was Symphonix Health Holdings, which was sold to United Healthcare; his second was
NextLevel Health, which he co-founded with his wife, who was CEO and chair of the board. NextLevel Health sold its assets to Centene Corporation last year.

With Zing Health, Whitaker says he’s working against a health insurance system that is often complicated to navigate and access, especially for minorities in low socioeconomic communities. Zing Health uses a community-based approach oriented toward the social determinants of health to keep individuals and communities healthy. In May, Newlight Partners, a private investment firm in New York, announced that it had taken a $150 million equity position in Zing. Newlight Partners has also invested in Oak Street Health, the primary care business headquartered in Chicago that that went public in May.

Zing Health started selling coverage two years ago in Cook County and subsequently expanded to six additional counties in Illinois, three in Indiana and three in Wisconsin, and has plans for more expansion in Michigan.

“What is unique about our approach is that our company is really designed to be mindful of social determinants of health,” says Whitaker.

One of Whitaker’s hopes for Zing Health is that it becomes a training ground for African American and Latino executives in the health insurance industry so that they can move on and rise to positions of influence in the industry.

Another one of Whitaker’s goals: Have Zing reach unicorn status by crossing the $1-billion-in-value threshold that the unicorn label denotes.

“Few African Americans founders get access to venture capital, and few certainly get access to the significant capital that Zing Health has,” he says. “I want Zing to be an exemplar of what’s possible, because if someone sees us do it, then they can think they can do it themselves. So that’s a pretty lofty goal, but it’s one that I would love to reach in the next four or five years.”

®, is a freelance writer in the Washington, D.C., area.

Eric Whitaker, M.D., credits influences in high school and medical school with his success. Now he wants to turn his new Medicare Advantage plan, Zing Health, into a training ground for Black and Latino health insurance executives — and has his sights set on unicorn status. 

Eric Whitaker, M.D.- From Influences to Influencer

Despite — or maybe because of — the COVID-19 pandemic, the pace of mergers and acquisitions (M&A) in the provider healthcare sector was brisk last year, and some of the same forces may be at play this year.

While M&A activity paused briefly in the spring, it returned to historic averages by summer. According to a recent report by Kaufman Hall, M&A activity crescendoed in 2020, with a high level of activity by not-for-profit hospitals and health systems. The report shows that 19 transactions with a value of about $8 billion occurred in the third quarter, a level on par with historical averages and significantly higher than the 14 transactions in the second quarter.

Those with healthcare M&A expertise see the same pattern: a COVID-19-related pause early last year followed by an increase in dealmaking as the year went on. John Fanburg, a managing member and chair of healthcare law at Brach Eichler, a law firm in Roseland, New Jersey, says M&A activity was high in 2020 till mid-March, when COVID-19 hit and transactions either slowed dramatically or came to a complete halt. “Activity recommenced in June, and deals picked up from where they stopped,” he says.

Gay Casey, a managing director at Berkeley Research Group, a consulting firm in Philadelphia, notes that transaction activity reported through the third quarter is a leading indicator that healthcare providers are moving beyond the immediate impacts of the COVID-19 pandemic. “We are seeing a lot of M&A activity in the post-acute healthcare setting, including physician group partnerships and joint venture agreements between hospitals and home healthcare/hospice providers,” she says.

Anu Singh, a Kaufman Hall managing director, says the pandemic has, in fact, strengthened the rationale for strategic partnerships, leading to a potential uptick in M&A .

“The reality is, COVID was a clinical impact item to a lot of organizations, but what was happening inside and outside the industry pre-COVID was a bigger story,” he says. “We’re seeing whole new ways of delivering care, whole new ways to collaborate, find value and deal with new reimbursement models. COVID has certainly accelerated these pursuits, but the most forward-thinking systems were already charting this path before the pandemic.”

Singh says providers are facing the fact that pre-pandemic revenue streams may not return. “In order to compete moving forward — whether it’s investing in telehealth or an urgent care presence in their communities — many organizations are realizing they need more capabilities and resources and are working with other organizations on a path to viability,” he says.

Four major mergers were announced in the third quarter of last year:

Cone Health, a healthcare delivery system headquartered in Greensboro, North Carolina, and Sentara Health system, headquartered in Norfolk, Virginia.

Lifespan and Care New England, both in Providence, Rhode Island, after years of on-again, off-again talks.

CHI Franciscan in Tacoma, Washington, and Virginia Mason Health System in Seattle.

Novant Health, headquartered in Winston-Salem, North Carolina, and New Hanover Regional Medical Center in Wilmington, North Carolina.

The major M&A trend, Singh notes, is large organizations thinking more strategically around partnership opportunities. “I think we’re going to see some systems who appreciate where they need to be from a geographical standpoint with facilities and now want to build out more services,” he says.

The pandemic has created an environment ripe for an increase in M&A, especially among smaller systems, rural hospitals and independent practices, says Brandon Edwards, CEO of ReviveHealth, a health communications company in Nashville, Tennessee. “While the CARES Act helped some, and elective care and routine care are picking up, many are still likely to need a partner to survive,” he says. The Coronavirus Aid, Relief and Economic Security Act, or CARES Act, is the $2.2 trillion economic stimulus bill passed in March 2020.

Edwards says M&A in the healthcare sector definitely slowed because providers have been consumed with managing through the pandemic, but as operations have trended upward, that will likely change. “We’re seeing some of the normal activity with larger systems looking to expand their geographic footprints,” he says. “But we also saw some newer dynamics like Novant and UNC (University of North Carolina) creating a partnership so they could go after New Hanover Regional Medical Center in eastern North Carolina. As the industry evolves, so will the definition of a partner.”

Edwards points to CHI Franciscan and Virginia Mason as a possible template for future pairings — an innovative system and a community hospital, respectively, joining forces.

Edwards says it’s worth noting that some deals fell apart last year. Beaumont Health in Michigan and Summa Health in Northeast Ohio called off their plans to combine in 2020. Advocate Trinity Hospital, Mercy Hospital & Medical Center, South Shore Hospital and St. Bernard Hospital, four money-losing hospitals serving a largely poor patient population on Chicago’s South Side, abandoned their plans for merging after funding from the Illinois Legislature fell through.

There are some centrigual forces at play, notes Nathan Kaufman, a healthcare consultant in San Diego. He points to Hoag Memorial Hospital Presbyterian, a two-hospital system in Newport, California, that is seeking to separate from the Providence Health system headquartered in Renton, Washington.

Kaufman says it’s difficult to make predictions for 2021 other than that it is shaping up to be a tough year for healthcare systems. “What is certain is we will have more uninsured, more Medicaid, and very tough negotiations with complicated and very greedy commercial insurance companies,” he says. According to the Kaiser Family Foundation, preliminary Medicaid data show that total enrollment had grown to 75.5 million by July 2020, an increase of 4.3 million beneficiaries from in February.

Edwards at ReviveHealth also sees tough times as the number of uninsured climbs. “Though not certain, it’s highly likely we’ll see a surge in M&A, as large systems can capitalize on this current dynamic to increase market share and geography as well as efforts to place tighter restrictions on M&A activity like we’ve seen in California,” he says, adding that payers may also see acquisition opportunities as some practices struggle.

Edwards notes that Optum, under its parent company UnitedHealth Group, is the second-largest employer of physicians behind Kaiser Permanente and one of the largest managers of surgery centers. “They are using their physician and insurance presence to cherry-pick the most profitable parts of the market, which are Medicare Advantage and ambulatory surgery, leaving everything else for the hospitals,” he says.

Casey at Berkeley Research Group notes that consolidation has been the trend among providers for the past five years; she expects that to continue this year: “We could see an increase in the number of healthcare providers exploring partnerships as a means to recover from the impacts of the pandemic .”

Fanburg at Brach Eichler sees tension between healthcare systems and their physicians. “They are seeing their doctors move in a direction that they cannot control or legally influence in the years to come,” he says. “As hospitals move more toward an outpatient strategy, controlling their medical staff members will be critical to their future strategic goals.”

Last year a lull in provider mergers and acquisitions was followed by an uptick. Experts say the disruptive effect of COVID-19 may mean plenty of deals this year.

Pandemic Takes M&A Activity on a Roller-Coaster Ride

Jessani is head of healthcare, higher rducation & not-for-profit, middle market & specialized industries, commercial banking at J.P. Morgan

The rapid onset of COVID-19 forced many healthcare organizations to implement virtual care essentially overnight. Nearly one year later, the benefits of telemedicine have continued to become increasingly clear to both patients and organizations. It has the potential to expand communities’ access to specialized care, enable higher connectivity for at-risk patients and offer greater independence for individuals facing health challenges that require frequent monitoring.

While restrictions around payer reimbursements were previously a barrier to entry for some healthcare organizations, key policies have been temporarily 

 to meet the increased need for virtual care during the pandemic. But as telemedicine continues solidify itself as an important pillar of healthcare delivery post-pandemic, it will be imperative that organizations and providers closely collaborate with payers to ensure the long-term sustainability of the model.

The importance of centralized payment systems

To optimize telemedicine reimbursement in the long-term, organizations should implement a centralized technology system that connects healthcare providers, insurance payers and patients through a singular platform. A centralized system can help solve for a number of challenges related to telemedicine reimbursements and offer benefits including reducing paper processing, improving transparency for patients and lowering costs incurred from payment collections.

 platform can streamline the online collections process, eliminating manual processes for organizations and providing patients with greater transparency and convenience. While legacy approaches to bill pay, claims processing, payment collection and reconciliation have been slow to modernize—particularly in light of recent disruptions—centralized billing and payments solutions will be key to the long-term feasibility of virtual care.

Building on early successes to better serve patients

Telemedicine has already demonstrated its ability to bridge the gap between people, physicians and health systems in the short-term by enabling patients to communicate with physicians from home and ultimately reduce the virus’ spread. It has also uncovered longer-term opportunities to better-support vulnerable populations by delivering quality care to the safety of their homes.

Looking ahead, many healthcare leaders are turning their focus to developing more permanent infrastructure for telemedicine deployment, anticipating continued demand after the pandemic wanes. The next frontier of telemedicine delivery will be for hospitals to curate their offerings for a more personalized, transparent patient experience. Health systems with easy-to-use technology and interfaces will be more attractive to patients expecting retail-like healthcare delivery.

The rapid rise of telemedicine has also underscored an opportunity to build a centralized feedback loop between all areas of patients’ care—from their doctor, pharmacist and even through data from wearable technologies—so that providers can make data-driven adjustments in real-time. By combining telemedicine with interconnectivity and the integration of data from remote monitoring tools, providers will be able to deliver increasingly sophisticated virtual care.

Building a bright future for telemedicine, together

As society treks toward a new normal, it will be important for all stakeholders in the healthcare ecosystem — including healthcare providers, policymakers, insurance payers and a number of others—to ensure the strides in virtual care delivery that have been made over the past several months will ultimately lead to sustained access for patients in a post-pandemic care model.

While certain policies have been recently amended to enable greater reimbursements in the short-term, healthcare providers must continue to closely track and quantify the benefits of telemedicine to inform longer-term policies that will ensure its sustainability for years to come.

It’s no question that COVID-19 will have long-term impacts on healthcare delivery. Technologies that were initially popularized as short-term solutions have demonstrated their efficacy in driving operational improvements, increased patient access and more positive health outcomes. As the benefits become increasingly clear, it will be critical for healthcare organizations to forge forward in collaboration with industry stakeholders and use lessons learned as a catalyst for the future.

is head of healthcare, higher education, and not-for-profit, middle market & specialized industries, commercial banking at J.P. Morgan.

Centralized technology that connects payers, providers and patients are needed to optimize telemedicine reimbursement, argues J.P. Morgan's Kerry Jessani. 

Telemedicine and Reimbursements: Preparing for Virtual Care in a Post-Pandemic World 

The U.S. Food and Drug Administration (FDA) has approved VERQUVO to reduce the risk of cardiovascular death and heart failure hospitalization in adults with symptomatic chronic heart failure and ejection fraction less than 45%.

The FDA approval comes following the results of the phase 3 VICTORIA trial of more than 5,000 adults. The goal of the VICTORIA trial was to determine whether VERQUVO was superior to placebo in combination with other heart failure therapies, in reducing the risk of cardiovascular death, or heart failure hospitalization in adults with symptomatic chronic heart failure and ejection fraction less than 45% following a worsening heart failure event.

Participants received up to the target maintenance dose of VERQUVO 10 mg once daily or matching placebo. The therapy started at 2.5 mg once daily and was increased in two-week intervals to 5 mg once daily and then 10 mg once daily. Placebo doses were adjusted the same way.

Investigators found the drug met the primary efficacy objective (HR, .9; 95% CI, .82-.98; 

 = .019). Overall, there was a 4.2% reduction in annualized absolute risk with VERQUVO compared to placebo.

“Patients with symptomatic chronic heart failure and reduced ejection fraction have a high risk for hospitalization after experiencing symptoms of heart failure requiring outpatient IV diuretic treatment or hospitalization. By some estimates, more than half of these patients are rehospitalized within a month of discharge due to a worsening event and approximately one in five die within two years,” Paul W. Armstrong, M.D., cardiologist and university professor of medicine at the Canadian VIGOUR Centre, University of Alberta, and study chair of the VICTORIA trial, said. “The approval of VERQUVO provides doctors, health care professionals, and patients with a welcome new option to current available therapies.”

The box label indicates VERQUVO should not be used by pregnant females as it may cause fetal harm.

The approval come following the results of a phase 3 trial.

FDA Approves VERQUVO for Patients With Chronic Heart Failure

When the COVID-19 pandemic spread to the U.S. last spring and the country went into lockdown, the utilization of healthcare services came to a screeching stop. Many experts are concerned that this “hiatus” will lead to greater illness — and healthcare costs — this year because care, especially for chronic conditions, was deferred or canceled.

Another unintended consequence of COVID-19’s hitting the pause button may be the elimination or attenuation of “low value” care: the wasteful tests, prescriptions and procedures that result in little, if any, improvement in outcomes. By some estimates between about $75 billion and
$100 billion is spent on low-value care and overtreatment each year, a relatively small fraction of the $3.6 trillion in annual healthcare spreading but, nevertheless, a great deal of money. Some experts see the pandemic and the resumption of healthcare as a rare opportunity to reset U.S. healthcare without so much low-value care.

Low-value care takes many forms. Walt Ellenberger, a senior director of healthcare business development and innovation at SAP, a software company, lists a few classic examples: overprescribing brand-name drugs when generics are available, prescribing antibiotics for viral infections and moving too quickly to surgical procedures for conditions such as back pain that can be managed with medications or physical therapy. The Choosing Wisely campaign launched by 

 and the ABIM Foundation in 2012 is aimed at rooting out low-value care. The publication and the foundation have worked with the specialty societies to develop lists of tests and procedures for physicians and patients.

Low-value care has ripple effects beyond the direct cost of care that doesn’t improve health. Low-value services may have harmful adverse effects. And they can trigger a cascade of follow-up tests or services that can lead to anxiety; the risk of still more adverse effects; and, of course, more higher healthcare costs.

Some experts see low-value care commanding resources that might otherwise go to more healthful interventions. “This unnecessary spending crowds out resources available to pay for high-value care or other important priorities outside of healthcare, such as education and transportation,” says Corinna Sorenson, Ph.D., M.H.S.A., M.P.H., an assistant professor of population health sciences at Duke University School of Medicine in Durham, North Carolina.

Says Ellenberger: “Many clinicians are already overburdened. Removing unnecessary testing and procedures frees them up for work they really need to do. It also frees up resources in the laboratory and diagnostic departments, which helps move patients through the health system more efficiently.”

Patient demand is one of the causes of low-value care. People are swayed by advertisements or believe that a low-value intervention is effective — the antibiotic prescription for a viral upper respiratory infection, for example. But, as Ellenberger notes, unnecessary services can backfire, lowering patient satisfaction and eroding trust in providers. “That can manifest itself in distrust in a specific provider or distrust in the entire healthcare system,” he says. “Either way, it can lead to poor outcomes and higher costs later.”

Physicians and other providers order low-value tests, treatments or procedures for a wide variety of reasons, says Sorenson, ranging from the inertia around established clinical practices and workflows to the volume incentives inherent in fee-for-service payment to fear of malpractice.

When the pandemic first hit in March/April 2020, many hospitals and other providers pivoted to tests and procedures that were needed most and postponed elective procedures (although how “elective” they really are is open to debate). Furthermore, many people avoided going to the hospital or doctor for nonemergency health issues because they didn’t think it was worth the risk of infection. “Although this likely prevented them from receiving tests and scans they didn’t need, on the flip side, many people likely suffered because they didn’t get necessary care,” says Vikas Saini, M.D., president of Lown Institute, a healthcare think tank in Brookline, Massachusetts, that focuses on low-value care.

Sorenson says that some people may never seek out low-value care that was postponed. She also notes that the pandemic may shift perspectives on what care is truly necessary and whether there are better ways of delivering care that lowers costs and improves, or at least maintains, health outcomes. That said, Sorenson says the industry is at high risk of reverting back to “business as usual” given the pervasiveness of low-value care in American healthcare, partly because many providers are under financial strain.

But there’s an opposing point of view that disruption wrought by the pandemic is likely to mean less low-value care. David Nickelson, Psy.D., J.D., vice president of client growth-healthcare for Nerdery, a digital business consulting firm, believes healthcare won’t return to the way it was before COVID-19. “There has been an immense growth for digital health services as well as an emphasis on using data to improve the patient experience that will reduce the use of low-value services,” he says. “Many more people are now willing to receive services via telehealth or virtual care platforms, which can free up healthcare providers to focus on more pressing challenges or critical patients.”

This more optimistic take on the pandemic is that it has served as a kind of seminar of teachable moments about low-value care and a host of other festering issues. “It exposed the vulnerabilities of a healthcare system designed to be reactive in treating patients,” Ellenberger says. “A fragmented industry used to working independently had to collaborate with other stakeholders to effectively combat a common enemy in order to survive.”

Sorenson says the pandemic exposed long-standing flaws in the healthcare system, such as its fragmentation, inefficiencies and glaring disparities, as well as how susceptible these flaws leave the system and economy to crisis. But she also sees some positive developments: The pandemic has showcased that, with sufficient will and collective action, the healthcare system can make innovative payment and care delivery changes swiftly as long as there are sufficient will and collective action. Sorenson points to telehealth and coverage for its use: “Coupled together, there seems to be a growing awareness that we don’t want and can’t afford to return to our pre-pandemic health system.”

Sorenson says that the pandemic has created a natural experiment to better understand the short- and long-term impacts of eliminating low-value care on health outcomes, quality of care and costs. Rather than just springing back thoughtlessly to prior practices, she says steps should be taken to sideline low-value care. “If a service is truly low-value care (and its absence will have) minimal or no negative effects on health or quality of care ... steps should be taken to ensure it’s not reintroduced into the system or, at minimum, its use should be reduced,” she says.

NEJM Catalyst Innovations in Care Delivery

 in August, Sorenson and three of her colleagues at the Duke-Margolis Center for Health Policy suggest the development of “do not restart” lists to educate providers and patients about low-value care services that should not be reinstated. Other possibilities include low-value services and reminders in electronic health records and clinical decision support tools that steer providers away from ordering or using low-value care services. Low-value care can also be discouraged by upping patient cost sharing while decreasing cost sharing for high-value care, notes Sorenson.

One of the truisms of the COVID-19 pandemic is that it accelerated the shift from in-person care to digital platforms. That switch, many believe, can help rid the system of some low-value care. “Relying on data-driven systems that transfer information more quickly to healthcare professionals and prioritizing patients’ needs will improve the overall quality of care in the healthcare system and reduce unnecessary or low-value services,” Nickelson says.

Nathan Ray, director of healthcare and life sciences at West Monroe, a management and technology consulting firm headquartered in Chicago, says that COVID-19 highlighted the possibility for sustained virtual care. “It has allowed for the reduction of volume, meaning not less interaction but, rather, more timely interaction with physicians,” he says. “Consequently, more patients can get the drug or therapy they need faster than booking multiple in-person appointments.”

Farzad Mostashari, M.D., Sc.M., is co-founder and CEO of Aledade, a company that operates accountable care organizations with and for primary care practices. He says that the value-based care that his company implements is built “to support virtual care tools in a responsible, high-value way.”

The pandemic, in Saini’s view, may also speed the move away from fee- for-service to value-based payment: “I foresee a greater openness and interest in capitated payment models in which providers are paid a flat fee per patient per month.”

Sorenson says that the COVID-19 pandemic has shown that value-based care and reducing low-value may go hand in hand. “Providers practicing within these models have been more successful in responding to the pandemic and weathering the ongoing economic uncertainties as a result of more predictable financial structures and associated investments in infrastructure, staff, programs and data systems to improve population health and care delivery,” she says. “These same capabilities are needed to reduce low-value care in the long term.”

Karen Appold is a medical writer in the Lehigh Valley region of Pennsylvania.

Some see the decline in healthcare utilization as an opportunity to eliminate ineffective, sometimes harmful healthcare.  


Will COVID-19 Wring Low-Value Healthcare out of the System? 

In a study of women in low- and middle-income countries, findings demonstrate there are low levels and large gaps in knowledge of HIV/AIDS between groups.

The findings suggested future HIV-prevention campaigns should emphasize providing easily accessible information to socioeconomically disadvantaged groups.

Chunling Lu, Ph.D., and colleagues assessed the levels of and changes in knowledge of HIV/AIDS and the associations with socioeconomic disparity among young women in low- and middle-income countries. They used nationally representative Demographic and Health Surveys (DHSs) from 51 low- and middle-income countries with available data on knowledge of HIV/AIDS from 2003 to 2018. The surveys were used to collect information on sociodemographic characteristics, child and maternal health, and awareness and behaviors associated with HIV/AIDS. The analysis was limited to young women aged 15 to 24 years old.

DHS constructed a survey module to measure a country’s level of knowledge of HIV/AIDS. The module was based on the definition of and knowledge about HIV prevention, including identifying the two major ways of preventing the sexual transmission of HIV, rejecting the two most common local misconceptions about HIV transmission, and knowing that a healthy-looking person can transmit HIV. If a woman answered yes to whether they ever heard of an illness called AIDS, they were asked to make yes, no, or do not know selections for five statements: “people can reduce the risk of contracting HIV by using condoms consistently,” “people can reduce the risk of contracting HIV by only having sex with 1 faithful uninfected partner,” “HIV cannot be transmitted by sharing food with people who have HIV,” “a person cannot contract HIV from mosquito bites,” and “healthy-looking people can have HIV.”

To measure disparities, the team used the absolute differences in the percentage of young women with the knowledge of HIV/AIDS in three socioeconomic domains — residential area, wealth, and education. Women were divided into two groups: those who received primary education or less and those who received more than primary education.

Of the more than 280,000 women from 51 low- and middle-income countries, 29.3% (95% CI, 24.1-34.5) reported having knowledge of HIV/AIDS in the latest years. In 2015, Afghanistan reported 1% knowledge (95% CI, .7-1.3), while from 2014-2015 Rwanda reported 64.9% knowledge (95% CI, 63.3-66.5).

Living in rural areas, in households in the lowest income quintile, or with low levels of education reported less knowledge about HIV/AIDS than others (−12.8 [95% CI, −10.6 to −14.9] percentage points; −21.8 [95% CI, −18.3 to −25.3] percentage points; and −19.4 [95% CI, −16.6 to −22.2] percentage points, respectively).

Among the 40 countries that took at least two surveys, the surveys demonstrated a significant increase in knowledge of HIV/AIDS among young women in 24 countries (60%) and a significant decrease in 10 countries (25%). It was reported less than halfa of countries experienced significant reductions in disparities linked to residential area (20%), wealth (12.5%), or education (42.5%).

“Future HIV-prevention campaigns or programs should continue to emphasize the needs of young people with socioeconomic disadvantage and to provide more support for effective interventions, such as public campaigns through mass or social media,” the investigators concluded.

Assessment of Knowledge of HIV/AIDS and Association With Socioeconomic Disparities Among Young Women in Low- and Middle-Income Countries, 2003 to 2018

There needs to be more support for those at a socioeconomic disadvantage.

Study Emphasizes Knowledge Disparity for HIV and AIDS

Findings of a new poll of more than 1,200 seniors on Medicare demonstrate near-universal satisfaction with Medicare Advantage’s coverage (98%), provider networks (97%), and handling of the current health crisis (98%).

“This poll, fielded more than seven months into the COVID-19 pandemic, shows that when crisis struck, Medicare Advantage was ready,” Allyson Y. Schwartz, president and CEO of the Better Medicare Alliance said. “In a global healthcare emergency that has laid bare deep, persisting challenges in healthcare, we saw beneficiaries’ satisfaction with Medicare Advantage reach new heights.”

Still, nearly one-third of seniors on Medicare felt they did not have enough information about the option of Medicare Advantage and 57% were not familiar with the ‘Star Ratings’ system used by the government to grade Medicare Advantage plans on quality. And the 67% of seniors on Medicare Advantage familiar with the ‘Star Ratings’ system did not refer to it when selecting a plan.

With the increased use of telehealth services during the pandemic, the poll showed the percentage of seniors who use such platforms rose from 24% in May 2020 to 40% in December 2020. A majority of seniors (91%) had a favorable experience.

Most respondents (71%) on Medicare found the process of enrolling in coverage simple, but 29% still found it confusing. Additionally, 79% of seniors on Medicare were aware of differences between traditional Medicare, Medicare Advantage, and Medigap coverage. A majority of respondents (95%) said it was important to have a choice of plans other than traditional Medicare, including 64% who believed it was very important.

“The results of this poll depict a rapidly growing beneficiary population that is highly pleased with their health coverage and ready to take action to ensure it is protected,” Schwartz said.

Seniors still need additional information about Medicare Advantage and Star Ratings.

Poll Demonstrates Satisfaction with Medicare Advantage 

Although virtual visits as a whole have dropped off since their peak last spring, visits for behavioral health issues are still going strong, a reflection, in part, of the toll the COVID-19 pandemic has taken on the mental health of Americans. 

A survey by the CDC found that by late June 2020, 40% of Americans were struggling with mental health or substance abuse issues. More than 10% of those surveyed said they had seriously considered committing suicide during the previous 30 days. With COVID-19 cases and deaths increasing this winter, the mental health consequences of the pandemic are likely to continue.

Providing mental health services virtually can increase access to providers who, even before the pandemic, were in great demand, as well as reduce the stigma that can surround mental health care. Rather than going to a therapist’s office, patients can access care from their mobile phone or home computer.

MDLive reported its behavioral health business grew by nearly 50% during the first months of the pandemic, and the company expanded its network of board-certified psychiatrists and licensed therapists by 50% to meet the surging demand.

Teladoc Health reported in its third-quarter earnings call that virtual visits for anxiety and depression, along with hypertension and back pain, represented more than half of its volume, compared to a third of visits in 2019. “Demand for dermatology and behavioral health services continues to significantly outpace overall volume growth,” the company reported.