The decrease in in-person healthcare this year because of the COVID-19 pandemic could be a good thing for telehealth and programs that deliver hospital-level care at home.
At certain times and in certain parts of the country, the COVID-19 pandemic stretched hospitals and other sorts of providers to the limit this year. But the pandemic has also had the opposite effect. Concern about receiving in-person healthcare, along with worry about the country’s economic future despite the bull stock market, means that millions of Americans have put off healthcare. The follow-up visit, the screening test, the annual checkup — the pandemic has had a chilling effect on all of them. “We’re going to have a population health issue on our hands” as a result of deferred care, undetected diseases such as cancer and an increase in chronic conditions, predicts Arielle Trzcinski, a senior analyst with Forrester Research and co-author of the research firm’s “Predictions 2021: Healthcare” report.
One of the questions facing American healthcare going into 2021 is how much telehealth and other forms of remote care delivery can replace what now seems almost old-fashioned: going to see the doctor in person instead of seeing them on your phone, tablet or laptop. There’s still plenty of apprehension about remote care, but it is ebbing — and some small studies have been producing evidence that it could have certain decided advantages over the pre-pandemic ways of delivering healthcare.
According to research reported in Morbidity and Mortality Weekly Report, by the end of June, about 40% of American adults had delayed or avoided medical care, and a sizable proportion — 12% — had put off urgent or emergency care. Those most likely to avoid urgent care had underlying health conditions, were Black or Hispanic, were young, had disabilities, or served as unpaid caregivers.
As the number of COVID-19 cases and deaths decreased in many parts of the country during the summer months, the provision of medical services bounced back to a certain extent. It is too soon to tell what impact the escalating number of cases and deaths in November will have.
Although the economic indicators this year are a mixed bag, the economic disruptions caused by the pandemic have factored into many people’s decision to skip medical care, observes Trzcinski: “Many can’t afford an unexpected medical bill.” And millions of people have lost their jobs, along with their health insurance, as a result of the pandemic. “People are making hard decisions — paying for health insurance or paying for rent,” she says.
Can telehealth step in?
Of course, the decline in in-person care has been accompanied by the much-talked-about surge in telehealth, especially for behavioral health problems. The Forrester researchers estimate that American consumers will make roughly
480 million telehealth visits this year, with almost 40% of those visits for behavioral health care. The research firm predicts a slight drop next year to about 440 million visits.
But the evidence of the shift to telehealth is overwhelming. Research results reported in JAMA Network Open in October showed that in 2018 and 2019, between
122 million and 130 million primary care visits occurred each quarter and that only 1% of those visits were conducted virtually. During the second quarter of this year, the number of primary care visits dipped to fewer than 100 million, but 35% of those visits were conducted virtually.
“It’s anybody’s guess how long the pandemic will significantly pressure patients and clinicians to use telemedicine in settings where they might otherwise engage face- to-face,” says lead author G. Caleb Alexander, M.D., M.S., a professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health. Alexander believes that telehealth can be used successfully when patients have an ongoing relationship with a primary care provider. He has qualms, though, about depending on a telehealth visit when a clinician is seeing a patient for the first time or dealing with a new complaint. It can be “very hard to evaluate them properly using telemedicine,” says Alexander.
During a recent webinar on 2021 healthcare predictions, Sam Glick, an Oliver Wyman partner and leader of the consulting firm’s innovation center, said telehealth usage represented 70% to 80% of care during the height of the pandemic and is expected to account for 30% to 50% of care going forward. Primary care physicians are using telehealth to improve the continuity of care, Glick observed, but he said the change was in its infancy. Glick’s prediction: Virtual visits that are not integrated into someone’s healthcare record, such as care provided through Teladoc or a similar service, “will be commoditized and compete with urgent care.”
Primary care underutilized
Andrew J. P. Carroll, M.D., FAAFP, a family physician in Chandler, Arizona, and member of the board of directors of the American Academy of Family Physicians, says his office pivoted to virtual care “really out of necessity” and as a way to maintain continuity care for patients with chronic conditions and for those with COVID-19. Carroll says that in some cases, patients who have skipped routine care during the pandemic ended up having to receive costly emergency care.
Even before the pandemic began, consumers were forgoing visits to primary care physicians, according to Forrester’s research. A study published in the Annals of Internal Medicine in February found that from 2008 to 2016, visits to primary care physicians dropped by about 25% for adults under the age of 65, and the proportion of adults making no visits to their primary care provider in a year jumped from 38% to 46%. “I don’t think telemedicine is going to solve our historic problem of underutilization of primary care,” says Alexander. And as primary care visits fell, visits to urgent care clinics, retail clinics and emergency departments climbed 47%. Trzcinski at Forrester says that healthcare clinics at retail locations such as Walmart and CVS have benefited because of their price transparency and convenience.
The primary care visit isn’t the only type of care that has declined since the pandemic began. A drop in hospital usage is projected to cost health systems $350 billion this year, according to Forrester. According the research firm’s predictions report, emergency department visits have fallen by 42%, outpatient visits by 35%, and in-patient care by 22%.
Hospitals have responded, in part, by providing hospital-level care to patients in their homes. Results of what appears to be the first randomized controlled trial looking at the effectiveness of hospital-at-home care were reported last year in the Annals of Internal Medicine. Lead author David M. Levine, M.D., M.P.H., M.A., of Brigham and Women’s Hospital in Boston, and his colleagues found that the average cost of an acute care episode was almost 40% lower for patients receiving hospital-at-home care compared with those who were traditional inpatients. The hospital-at-home patients had fewer lab tests, imaging studies and consultations. They were less sedentary, and their 30-day readmission rate was 7% compared with 23% for those receiving care in the hospital.
Levine says that hospital-at-home care is common in many industrialized countries: “We are pretty far behind.” Levine is doing his part to change that and expects to have two more studies published in the next month or so. One challenge has been the number of patients who declined to receive care at home. “We’ve spent 100 years telling people the best care is at the hospital,” Levine says. “We need to prove they can get high-quality, safe care at home.” Another one has been reimbursement, says Levine. “There is no easy payment mechanism,” he notes. “That’s one of the reasons why it hasn’t taken off in the U.S.”
Susan Ladika is a health and business writer in Tampa, Florida.