Value-based care has been having a transformative impact on health care in recent years. COVID-19 is accelerating and amplifying changes that will have a long-lasting effect on the delivery of care. Adjustments are urgently needed.
A discerning and prophetic article in the Journal of Critical Pathways, explaining how COVID-19 will change the patient journey, reimbursement, and care delivery, described the situation as follows:
“COVID-19, with its stay-at-home requirements and restrictions on face-to-face interactions, has changed how care is delivered, and these changes will remain beyond this crisis. Indeed, actions by and learnings for all stakeholders (eg, patients, payers, providers, policymakers) from the COVID-19 crisis will have long-term effects. These include changes to the entire patients’ journey from awareness to diagnosis to treatment and follow up—every aspect of care will be impacted. Clinical pathways are a fitting tool to accompany the new focus and collaborative mindset stakeholders have had (and must continue) to curate. Given how clinical pathways have evolved from simple treatment regimen guides to comprehensive guides for best practices along the entire patient journey, these shifts change everything, opening new opportunities with greater urgency.”
In short, the changes are dynamic, sweeping, and long term, and they involve the entire patient journey, including:
- Increased governmental control of health care
- Expansion of telemedicine
- Growth of nonphysician providers
- Increase in “payviders” (payers who acquire providers)
Increased Government Involvement
The insurance industry has transitioned to employer-based commercial insurance from individuals paying for their own health insurance. Dependence on employer-based commercial insurance has created a vulnerability that the high unemployment caused by COVID-19 has exposed. Changes are very likely on the way, including a reduction of the Medicare age and an increase in the number of people receiving Medicaid coverage. These adjustments fall short of the government-controlled health care payments proposed under a Medicare for All (M4A) system. The changes would mean a measurable movement toward significantly more government control of health care payments.
The M4A movement has lost momentum due to leadership changes, but proposals are being floated that include expanding Medicare coverage by reducing the entrance age to 60 years. The option is for early retirees or workers losing their jobs before the age of 65 years. Americans between the ages of 60 and 64 years would be presented with the choice to buy into Medicare. An additional 20 million Americans would be eligible for Medicare. Some of these new Medicare recipients would retire, thus opening up job opportunities for others, which is especially important with the current high unemployment rate. How many of these jobs would be eliminated altogether is unknown. The number of people stepping up to fill the new job openings is also a matter for speculation.
The author, Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD, brings to light a resultant downward shift in private premium rates and Medicare Advantage premium rates should the Medicare age be reduced to 60 years. “In addition, this shift from private commercial insurance would likely decrease private insurance rates as well as decrease Medicare Advantage premiums, as this group represents both relative higher utilizers for commercial plans and lower utilizers for Medicare.”
Government coverage through Medicare will also expand. The uninsured could rise from 27 million to 40 million people, many of whom will rely upon Medicaid for health care. Medicaid enrollment could realize an expansion of five million regardless of the number of job losses.
What are the implications of this expansion in the government’s responsibility for an ever-increasing portion of health care payments? Governmental regulations will dictate every facet of the restrictions that limit access to health care. Any and every clinical pathway would have to address these factors and account for them to ensure the best patient and provider outcomes, especially in instances of potential inappropriate restrictions.
Expansion of Telehealth Services
COVID-19 restrictions are giving telemedicine a much-needed boost. Limitations of face-to-face care and positive actions to remove restrictions hindering the greater use of telehealth to deliver care in the home are key factors. The lifting of cumbersome restrictions and the approval for risk-adjusted payments from Medicare Advantage for telehealth have opened the way for robust telemedicine moving forward from COVID-19. These, along with other changes and modifications, are long past due and will go a long way to making treatment more affordable and accessible.
Telemedicine, if not already, will become mainstream. Patients will have immediate access to doctors for diagnosis and treatment. Many obstacles to reimbursement have been removed. All four dimensions of the Quadruple Aim will benefit from the growing use of telemedicine.
The Growth of Nonphysician Providers
The COVID-19 pandemic has highlighted the shortage of primary care physicians. In response to the pandemic, CMS is allowing for the expanded use of nonphysician providers. Physicians are empowered to delegate tasks, including physician visits, to physician assistants, nurse practitioners, and clinical nurse specialists. Licensed pharmacists can order and perform COVID-19 tests, including serology tests that have been granted an emergency use authorization (EUA).
Increased availability of care creates more opportunities for earlier diagnosis, treatment, and referral to a specialist. This advantage must be viewed in a positive light despite the COVID-19 pandemic.
Increase in “Payviders”
COVID-19 is accelerating the growth in the number of “payviders.” A payvider is the combination of payer and provider. In some cases, traditional payers may acquire providers. In other cases, health systems become payers. Many private practitioners are struggling to survive independently and are having to adjust. Despite government and private aid, many private providers are still having to move to operating under payers or health systems rather than remaining private. Expectations are that more consolidations will occur as a result of COVID-19.
COVID-19 has forced changes in four critical areas:
- Increased government involvement in reimbursements for Medicare and Medicaid
- Expanded use of telemedicine
- Growth of nonphysician providers
- Increase in payviders
As the pandemic ebbs and flows and as the healthcare industry adjusts and adapts, stakeholders must seek out guidance from industry leaders who possess the knowledge, experience, and fortitude to turn the challenges presented by the COVID-19 pandemic into opportunities. These opportunities will enhance the patient journey, improve population health, reduce costs while strengthening the bottom line. Through it all, stakeholders must also remember the doctors, nurses, and support staff who work on the frontlines at the peril of their own lives.