The pandemic has done what no legislator could have dreamed of:
force sudden major changes to the nation’s health care system.
By Julie Rovner, Kaiser Health News | June 08, 2020 at 11:13 AM
The U.S. health care system is famously
resistant to government-imposed change. It took decades to create Medicare and
Medicaid, mostly due to opposition from the medical-industrial complex. Then it
was nearly another half-century before the passage of the Affordable Care Act.
But the COVID-19 pandemic has done what no
president or social movement or venture capitalist could have dreamed of: It
forced sudden major changes to the nation’s health care system that are
unlikely to be reversed.
“Health care is never going back to the way it
was before,” said Gail Wilensky, a health economist who ran the Medicare and
Medicaid programs for President George H.W. Bush in the early 1990s.
Wilensky is far from the only longtime
observer of the American health care system to marvel at the speed of some
long-sought changes. But experts warn that the breakthroughs may not all make
the health system work better, or make it less expensive.
That said, here are three trends that seem
likely to continue.
Telehealth for all
Telehealth is not new; medical professionals
have used it to reach patients in rural or remote settings since the late 1980s.
But even while technology has made video
visits easier, it has failed to reach critical mass, largely because of
political fights. Licensing has been one main obstacle – determining how a
doctor in one state can legally treat a patient in a state where the doctor is
not licensed.
The other obstacle, not surprisingly, is
payment. Should a video visit be reimbursed at the same rate as an in-person
visit? Will making it easier for doctors and other medical professionals to use
telehealth encourage unnecessary care, thus driving up the nation’s $3.6
trillion health tab even more? Or could it replace care once provided free by
phone?
Still, the pandemic has pushed aside those
sticking points. Almost overnight, by necessity, every health care provider who
can is delivering telemedicine. A new survey from
Gallup found the number of patients reporting “virtual” medical
visits more than doubled, from 12% to 27%, from late March to mid-May. That is
due, at least in part, to Medicare having
made it easier for doctors to bill for virtual visits.
It’s easy to see why many patients like video
visits ― there’s no parking to find and pay for, and it takes far less time out
of a workday than going to an office.
Doctors and other practitioners seem more
ambivalent. On one hand, it can be harder to examine a patient over video and
some services just can’t be done via a digital connection. On the other hand,
they can see more patients in the same amount of time and may need less support
staff and possibly smaller offices if more visits are conducted virtually.
Of course, telemedicine doesn’t work for
everyone. Many areas and patients don’t have reliable or robust broadband
connections that make video visits work. And some patients, particularly the
oldest seniors, lack the technological skills needed to connect.
Primary care doctors
in peril
Another trend that has suddenly accelerated is
worry over the nation’s dwindling supply of primary care doctors. The exodus of
practitioners performing primary care has been a concern over the past several
years, as baby boomer doctors retire and others have grown weary of more and
more bureaucracy from government and private payers. Having faced a difficult
financial crisis during the pandemic, more family physicians may move into retirement
or seek other professional options.
At the same time, fewer current
medical students are choosing specialties in primary care.
“I’ve been trying to raise the alarm about the
kind of perilous future of primary care,” said Farzad Mostashari, a top Health
and Human Services Department official in the Obama administration. Mostashari
runs Aledade, a company that helps primary care doctors make the transition
from fee-for-service medicine to new payment models.
The American Academy
of Family Physicians reports that 70% of primary care
physicians are reporting declines in patient volume of 50% or more since March,
and 40% have laid off or furloughed staff. The AAFP has joined other primary
care and insurance groups in asking HHS
for an infusion of cash.
“This is absolutely essential to effectively
treat patients today and to maintain their ongoing operations until we overcome
this public health emergency,” the groups wrote.
One easy way to help keep primary care doctors
afloat would be to pay them not according to what they do, but in a lump sum to
keep patients healthy. This move from fee-for-service to what’s known as
capitation or value-based care has unfolded gradually and was championed in the
Affordable Care Act.
But some experts argue it needs to happen more
quickly and they predict that the coronavirus pandemic could finally mark the
beginning of the end for doctors who still charge for each service
individually. Mostashari, who spends his time helping doctors make the
transition, said in times like these, it would make more sense for primary care
doctors to have “a steady monthly revenue stream, and [the doctor] can decide
the best way to deliver that care. Unlimited texts, phone calls, video calls.
The goal is to give you satisfactory outcomes and a great patient experience.”
Still, many physicians, particularly those in
solo or small practices, worry about the potential financial risk ―
particularly the possibility of getting paid less if they don’t meet certain
benchmarks that the doctors may not be able to directly control.
But with many practices now ground to a halt,
or just starting to reopen, those physicians who get paid per patient rather
than per service are in a much better position to stay afloat. That model may
be gain traction as doctors ponder the next pandemic, or the next wave of this
one.
Hospitals on the
decline?
The pandemic also might lead to less emphasis
on hospital-based care. While hospitals in many parts of the country have
obviously been full of very sick COVID patients, they have closed down other
nonemergency services to preserve supplies and resources to fight the pandemic.
People with other ailments have stayed away in droves even when services were
available, for fear of catching something worse than what they already have.
Many experts predict that care won’t just snap
back when the current emergency wanes. Dr. Mark Smith, former president of the
California Health Care Foundation, said among consumers, a switch has been
flipped. “Overnight it seems we’ve gone from high-touch to no-touch.”
Which is not great for hospitals that have
spent millions trying to attract patients to their labor-and-delivery units,
orthopedic centers and other parts of the facility that once generated lots of
income.
Even more concerning is that hospitals’
ability to weather the current financial shock varies widely. Those most in danger
of closing are in rural and underserved areas, where
patients could wind up with even less access to care that is scarce already.
All of which underscores the point that not
all these changes will necessarily be good for the health system or society.
Financial pressures could end up driving more consolidation, which could push
up prices as large groups of hospitals and doctors gain more bargaining clout.
But the changes are definitely happening at a
pace few have ever seen. Said Wilensky, “When you’re forced to find different
ways of doing things and you find out they are easier and more efficient, it’s
going to be hard to go back to the old way.”
Kaiser Health
News is a nonprofit news service covering health issues. It
is an editorially independent program of the Kaiser Family Foundation, which is
not affiliated with Kaiser Permanente.
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