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How the pandemic changed health care, one year later

System’s shortcomings were made painfully obvious as virus spread, though slim silver linings did emerge

The World Health Organization officially declared the COVID-19 outbreak a pandemic on March 11, 2020. More than 500,000 American deaths and trillions of taxpayer dollars later, the virus has reshaped the health care landscape for years to come.

That system’s shortcomings became painfully obvious as the virus spread, exposing glaring gaps in care for rural and low-income communities, as well as people of color. The lack of domestic manufacturing capacity for critical supplies like protective equipment forced nurses to reuse masks and dress in garbage bags. Patient care unrelated to COVD-19 suffered.

Mental health crises and substance abuse skyrocketed. Patients skipped preventive appointments, making diseases they contracted during the pandemic harder to treat.

Slim silver linings emerged in the form of increased access to telehealth and better payment systems. And there are lessons learned that should help combat future epidemics.

Deferred care

Health care spending fell sharply in March and April of last year before rebounding closer to regular levels. All those missed appointments could mean higher spending in the future if long-term outcomes worsen, said Cynthia Cox, vice president at the Kaiser Family Foundation.

“You can imagine that, in theory, if people delay or forego needed medical care and their conditions worsen, that could mean that not only are we having to pay for all of this missed care but it may become more expensive to make up for that,” she said.

It may be important to launch a messaging campaign urging people to get regular health screenings, such as for cancers, that they may not have received last year.

Ada Stewart, president of the American Academy of Family Physicians and a physician at a community health center in Columbia, S.C., said her practice called patients to explain the safety precautions the office adopted to make patients more comfortable coming in.

While telehealth has helped doctors there stay in touch with patients throughout the pandemic and made it possible to address mental health problems, some screenings or blood work require an in-person visit.

Patients with chronic diseases are facing complications that could affect their health for years. Patients with diabetes or hypertension could be more likely to develop heart disease later. Delayed colonoscopies and other screenings may mean doctors aren’t catching cancers as early as they would have.

“Not having the access and not having people come in for regular visits, not having those preventative things taken care of really created a huge amount of devastation,” Stewart said. “It’s going to cost our system as we move forward.”

Mental health

The pandemic exacerbated mental health and substance use challenges for many people. Dawn Brown, the National Alliance on Mental Illness director of HelpLine Services, said the amount of calls over the last year ebbed and flowed, but that at the height of the pandemic, calls shot up as much as 75 percent. Calls about anxiety and depression replaced schizophrenia and bipolar disorder as the hotline’s top illnesses.

The expansion of telehealth made it easier for some people to keep up with mental health care. Still, patients with severe mental illness often rely on community support services that weren’t always available.

Stewart said primary care providers are taking on a greater focus on mental health care, but that it’s important they are reimbursed properly for that care.

Lawmakers could weigh in on these challenges later this year. Sen. Tim Kaine told reporters last week that expanding the mental health care workforce would be an important focus for the Health, Education, Labor and Pensions Committee.

“We were short on that before COVID. We’re really going to be short now,” the Virginia Democrat said.

Telehealth

Once the pandemic shuttered their doors, doctors scrambled to get online as the Department of Health and Human Services lifted a number of telehealth restrictions. But telehealth visits dropped as states began reopening, and many of the HHS waivers will eventually expire.

Congress must grapple with familiar questions about cost and quality before making broader changes under Medicare, where some of the toughest obstacles remain.

Should doctors be paid the same rates for in-person appointments as video or audio visits? What safeguards should exist to prevent fraud and ensure patient safety? When are audio calls or texts acceptable? How do you avoid worsening disparities for patients who struggle to access or navigate technology?

The pros and cons were captured in a House Energy and Commerce Health Subcommittee hearing this month. Oklahoma Republican Markwayne Mullin recounted a video visit with doctors from multiple states for his son’s traumatic brain injury. Meanwhile, California Democrat Nanette Barragán detailed how her mother still struggles to answer her flip phone.

The series of COVID-19 relief laws Congress enacted in 2020 contained myriad measures aimed at boosting telehealth, from expanding its use for mental health services to funding broadband infrastructure.

Energy and Commerce Health Chairwoman Anna G. Eshoo is now working on a bill to chart a path forward. One key provision lawmakers want to eliminate is a restriction preventing most Medicare patients from using virtual visits outside of rural areas or inside their own homes.

“I would like to see one bill, one bill that is comprehensive,” Eshoo, a California Democrat, said at the hearing, adding that it will hopefully be “so durable that it will really speak to the future beyond — God willing — this pandemic.”

New payment systems

A broad expansion of telehealth would only intensify the need to overhaul the health care payment system, which largely pays for the quantity of services rather than quality of care.

The current structure incentivizes unnecessary services, and federal budget analysts project the ease of a telehealth visit will only increase overall spending. With costs projected to outpace revenue in Medicare’s hospital fund as soon as 2024, the spending issue is a serious concern.

Doctors in Medicare payment pilots already have broader access to telehealth waivers. But the pandemic’s shutdown fueled a separate interest in alternative payment models and their guaranteed revenue streams.

Many alternative models provide steady payments, coupled with penalties or bonuses depending on whether doctors hit spending and quality thresholds. The approach partially shielded participating doctors when the pandemic effectively shut their practices down.

Melissa Cohen, vice president of payment innovation strategy at insurer Anthem and a former Center for Medicare and Medicaid Innovation official, said her team expected physician interest in value-based arrangements to drop as they focused on the virus. But interest increased instead.

“There is a real opportunity to think through how we can integrate some of these features into our value-based models and that’s another area that we are exploring with our partners,” she said.

Mark Fendrick, director of the University of Michigan’s Value-Based Insurance Design Center, hopes insurance companies will also embrace improving coverage for their patients by reducing cost-sharing for necessary preventive care.

“It adds to the idea that Americans should not have to have a bake sale to afford their essential clinical services, whether it be the COVID vaccine, their insulin or their physical therapy,” he said.

Lessons learned

The successes and failures of the U.S. response on testing, treatments and vaccines during the COVID-19 crisis will set the agenda in preparing for future health emergencies.

The Food and Drug Administration is evaluating which emergency measures could benefit the agency after the pandemic wanes. The Operation Warp Speed vaccine development effort is likely to spur lasting changes to clinical trials and some experts hope the unprecedented interest in once-obscure FDA processes could prompt more transparency and racial diversity in drug trials.

Drug companies are also pushing to loosen FDA policies on “decentralized” trials that require less data. Those became more common during the pandemic to reduce potential spread. But critics also worry that COVID-19 booster shots, which only require small studies for emergency use, could be evaluated under relaxed standards for years.

On testing, early stumbles from the FDA and the Centers for Disease Control and Prevention undercut the ability of labs to test for active infections. The FDA initially blocked labs from developing their own tests without an emergency authorization, which compounded delays brought on by a flawed CDC test.

But the agency’s decision to allow antibody tests on the market without prior review unleashed a number of unreliable products, further confusing medical providers and the public.

In October, FDA officials reflected in the New England Journal of Medicine that partnering with a limited number of companies that could scale up a small number of reliable tests might be a better approach.

The strategy could also help address competition among ongoing supply shortages, which range from chemicals to pipette tips. Shortages of protective equipment were more severe and spurred interest in changes to domestic manufacturing and the Strategic National Stockpile.

“A year ago I didn’t even say the word supply chain in my day-to-day,” said Romney Humphries, medical director of the clinical microbiology laboratory at Vanderbilt University Medical Center. “And now I’m spending — even today — the majority of my time ensuring that we have enough supplies to perform the testing.”

Emily Kopp contributed to this report.

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