The early stages of the COVID-19 pandemic have cast a bright spotlight on essential efforts to control the spread of infection and provide care for those suffering from it. This heightened focus on immediate needs, however, puts us at risk for being unprepared for what is still lurking in the shadows. Preparing to address the care needs of individuals not acutely ill with COVID-19, who are as of now not top of mind, is of utmost importance. We must anticipate and prepare for the increased healthcare demands that will present themselves after the acute COVID-19 time period has passed.
Many routine medical needs are going unaddressed
The majority of people with routine medical needs have understandably been limited in their ability or willingness to access care. This has manifested in decreases in routine visits with providers for addressing chronic conditions, such as
- getting medication refills
- having dose adjustments
- undergoing preventative services.
Nationwide there has been a halt to elective procedures; ranging from colonoscopy screening to joint replacement surgeries.
Further, the drastic shift in focus on acute and emergent care is having a significant financial impact on community physician practices and hospital systems.
Community physicians are facing unprecedented financial pressure
There has been variability in the impact of COVID-19. Some areas of the country are struggling with overwhelming numbers of inpatient and critical care demands. Others have not been as severely affected.
Despite the variation in severity of impact, there have been nationwide decreases in volumes of routine care and elective procedures. This has resulted in many community physicians facing unprecedented financial pressure. This has forced them to further limit their services and to lay off staff.
In a recent survey of physicians by the Medical Group Management Association (MGMA) recently surveyed physicians about the impact of the pandemic on their practices.1 Ninety-seven percent reported decreased revenue associated with a 60% decrease in patient volume.
Other findings include 48% of practices having furloughed staff and 22% having permanently laid off staff. All of these factors in combination set the stage for a growing number of patients with unmet chronic disease management needs during the pandemic.
These patients will most assuredly present with evidence of clinical deterioration and a need for resource-intensive care in the post-acute COVID19 period.
Learning from past experiences
Concerns around a post-acute COVID-19 increase in clinical care demand is informed by experiences from past pandemics as well as countries further along in the COVID-19 experience. For example:
- Huang and colleagues noted significant increases in hospital admissions of diabetic patients and worsening glucose control in the post-SARS outbreak period.2
- Wagenaar and associates reported on the impact of Ebola outbreaks in Liberia, observing a loss of 35-67% of essential primary care services compared to pre-outbreak services.3 They also noted significant drops in delivery of key vaccinations, institutional births, and perinatal care delivery. They went on to observe a 49% increase in malaria cases felt to be attributed to interruptions in transmission prevention interventions.
Learning from other countries
Reports from countries who have earlier experiences with COVID-19 have noted changes in the general population related to healthcare delivery interruptions. For example:
Banerjee and colleagues evaluated diabetes self-management amid COVID-19 where they noted that there are interruptions in disease management aside from direct provider care. These included:
- diet changes,
- limits of ambulation,
- medication adherence,
- access to self-monitoring supplies
- psychosocial effects.4
In another study, Xue and colleagues focused on elderly diabetic patients during the COVID-19 outbreak in China. They reviewed baseline and post-outbreak diabetic glucose levels and observed increases in fasting blood glucose levels but not Hemoglobin A1C levels.5
The spectrum of unmanaged care
Many of us in the medical community have begun to raise the alarm that a large number of people in our population have not been accessing care during the COVID-19 outbreak. We believe that they will soon generate additional stresses to our healthcare system.
The spectrum of unmanaged care secondary to the COVID-19 pandemic spans almost all clinical care delivery. Much of this care has been dramatically limited or altered during this acute period of COVID-19 response.
Chronic diseases can be anticipated to be significant drivers of demand, where they generally require ongoing management of various components of healthcare such as pharmacy, subspecialty care, and social services.
The disease burden of chronic disease and increased healthcare needs
The disease burden of chronic disease is reflected in the observation that six out of every ten Americans have at least one chronic disease. Four out of ten have two or more. The current COVID-19 pandemic will conservatively result in three to six months of disruption to the routine delivery of care for this patient population.
A recent survey noted that 48% of patients reported having to miss or cancel previously scheduled appointments during the first few weeks of April.6 Further, when services become available, the next challenge will be motivating patients to engage with care delivery out of fear of becoming infected.
From the same Evidation survey, 43% of respondents reported they were worried or very worried about going to a physician’s office or hospital to receive care unrelated to COVID-19. Another 10% indicated that they would avoid needed care out of worry.6
These fears may well persist beyond the period of restriction, lengthening the delay in care well beyond the immediate acute COVID-19 time period.
Taking care delivery financial health into consideration
The initial response may be that the physicians and healthcare services will simply be busy as they work through this backlog and anticipate sicker patients. But, there also needs to be consideration of the lingering financial and operational challenges physicians and healthcare systems will be facing in the post-acute COVID phase.
Acute care hospitals quickly shifted so they could respond to the acutely ill COVID-19 patients. In some cases, this means limiting services for uninfected patients when possible. In many places around the country, it led to a moratorium on elective procedures and efforts to manage patients in the outpatient setting. This resulted in sharp declines in revenue for hospitals and frequent furloughs or layoffs of non-critical staff.7
It can be anticipated that shifting back to normal operations may be a drawn-out process. The same holds true for physician practices in the community. 7 Many have experienced sharp declines in revenue and their ability to quickly begin full services is uncertain.
Physicians who are employed on a strict work relative value units (wRVU) productivity models may see significant compensation decreases. Some physicians and advanced practice providers are finding themselves furloughed or laid-off in the midst of the COVID-19 crisis.
Governmental programs are working to financially shore up the healthcare system. However, the effectiveness of quickly preparing the practices for this potential increase in demand is questionable.
Poor Payer Reimbursement and Practice Viability during COVID-19
Where do we go from here?
Independent from the financial obstacles related to dealing with the COVID-19 crisis, is the varied workflows and fragmented nature of our healthcare system.
The challenge before us is to rapidly prepare for the potential surge in demand for routine care following the acute COVID-19 time period. Advocacy for financial support for healthcare providers and care delivery systems to ensure the solvency of care delivery will be critical.
Community providers should reach out to one another to share best practices around workflows and financial insights to weather the storm. Embracing technologies such as telehealth to augment the delivery of care and reinventing the way practices work will be essential.
Strategies should include:
- Leveraging staff to proactively reach out to patients with chronic conditions to assess their status, ensure medications are refilled and appropriately adjusted
- Utilization of care coordination and care management services when available
- Ensuring that workforce training is provided to help front-line providers and practices effectively manage the complex needs of patients who have not received routine medical care, who present with significant deterioration.
The bottom line: We need to prepare for increased healthcare needs post-COVID-19
The anticipation of increased demands on the healthcare system in the post-acute COVID-19 time period needs to be incorporated into current strategic planning efforts. We need to do this while concomitantly addressing the imminent and ongoing needs of patients, providers, and the population.
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- Medical Group Management Association. April 14, 2020: MGMA survey sheds light on dire financial impact of COVID-19 on physician practices. 2020; https://www.mgma.com/advocacy/advocacy-statements-letters/advocacy-statements/april-14,-2020-mgma-survey-sheds-light-on-dire-fi. Accessed April 21, 2020.
- Huang Y-T, Lee Y-C, Hsiao C-J. Hospitalization for ambulatory-care-sensitive conditions in Taiwan following the SARS outbreak: a population-based interrupted time series study. Journal of the Formosan Medical Association. 2009;108(5):386-394.
- Wagenaar BH, Augusto O, Beste J, et al. The 2014–2015 Ebola virus disease outbreak and primary healthcare delivery in Liberia: Time-series analyses for 2010–2016. PLoS medicine. 2018;15(2):e1002508.
- Banerjee M, Chakraborty S, Pal R. Diabetes self-management amid COVID-19 pandemic. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020.
- Xue T, Li Q, Zhang Q, et al. Blood glucose levels in elderly subjects with type 2 diabetes during COVID-19 outbreak: a retrospective study in a single center. Available at SSRN 3566198. 2020.
- Evidation. COVID-19 Pulse: Delivering regular insights on the pandemic from a 150,000+ person connected cohort. 2020; https://evidation.com/news/covid-19-pulse-first-data-evidation/. Accessed April 20, 2020.
- Page L. Close Your Practice Temporarily…or Longer? Your Decision During COVID-19. 2020; https://www.medscape.com/viewarticle/927780. Accessed April 20, 2020.
Chris Windham M.D. & Ashwini Davison M.D.
Dr. Chris Windham is a Physician Executive experienced in leading high performing teams to align quality with appropriate utilization within an Accountable Care Organization (ACO) and Independent Practice Association (IPA) across the health system.
He is the Vice President and Chief Medical Officer of Catholic Health Services of Long Island Physician Partners. He is a Surgical Oncologist who is Fellowship trained at MD Anderson Cancer Center and H. Lee Moffitt Cancer Center with a Masters Degree in Healthcare Management from Harvard University.
Dr. Ashwini Davison is a Health Systems Science educator with expertise in clinical informatics, population health management, and digital health entrepreneurship.
She is the Co-Director for the Population Health Management MAS degree and certificate programs in the Johns Hopkins Bloomberg School of Public Health and the Associate Director for the Master's Degree and certificate programs in Health Informatics at the School of Medicine.
She completed her residency in Internal Medicine at Johns Hopkins and is sub-specialty board certified in Clinical Informatics