Covid-19's Effect of 2020 Healthcare Goals & Some Hopeful Signs for the Future

 
Pat Stricker, RN, MEd
Former Senior Vice President
TCS Healthcare Technologies

Review of the 2020 Healthcare Issues, Trends, and Predictions

Let’s begin by looking at a review of healthcare articles presented at the end of 2019 and beginning of 2020 that identified the key healthcare issues, trends, and predictions that would be goals for 2020. The pandemic caused many of these goals to be put aside, but let’s look at what did get accomplished. (They are presented in random order.)   

• There was a strong resistance to the Affordable Care Act (ACA or Obamacare). There were active plans to repeal the ACA, but in November 2020, the Supreme Court rejected an attempted repeal. The pandemic and its significant economic issues left little time or desire to think about taking healthcare away from 21 million Americans in the middle of the most devastating pandemic we have ever experienced, so that was POSITIVE.

• Expanding Medicare as a public option was a key area being looked at in the beginning of 2020. The idea of Medicare-for-All or a form of Medicare Advantage-for-All was being discussed, but no decision was made. 

• New price transparency rules were expected to be rolled out in 2020, but due to the pandemic, this did not occur. However, the rule was finalized in 2020 and will become effective on January 1, 2021. The Centers for Medicare & Medicaid Services (CMS) will require all hospitals and facilities working under the hospital’s license to post the cost of 300 services on their internet site to help consumers make better healthcare decisions, so that is POSITIVE.

• Reducing drug prices was an important priority for 2020. The House passed the Elijah Cummings Lower Drug Costs Now Act (H.R. 3) in December, 2019. The bill allowed CMS to negotiate drug pricing on up to 250 of the most costly drugs. It was expected to provide savings of $500 billion over 10 years and fund the National Institutes of Health (NIH) with $10 billion for research. However, the Senate never put it on the floor for a vote.    

Senators Grassley and Wyden worked on the Prescription Drug Pricing Reduction Act, a bi-partisan bill in the Senate. Its goals were to establish a $3,100 cap on annual out-of-pocket spending for Medicare Part D beneficiaries and entice payers and pharmaceutical companies to negotiate lower, more affordable drug prices. The bill was introduced by Senator Grassley in July 2020, but it was also never put on the floor for a Senate vote. 

President Trump also issued four executive orders to: (1) allow drugs to be imported from Canada; (2) provide drug discounts to community health centers and clinics who were federally qualified; (3) disallow rebates from pharmacy benefit managers (PBMs) and require that discounts be passed along to all Medicare Part D consumers; and (4) renew a policy that would make the price Medicare pays for drugs, administered by providers, the same as those negotiated by foreign governments. The first three executive orders required lengthy rule-making processes, so they were not successful, and the fourth is still being discussed for possible alternative options. 

During 2020 the White House and Congress were not able to achieve any significant progress in reducing the cost of high-priced drugs. The use of executive orders, while seeming to be a quick way to get issues solved, proved to be ineffective. This was a DISAPPOINTMENT.

• Even before the pandemic, a Vaccine Hesitancy Plan was scheduled for 2020 to educate people about vaccines, clarify mis-information, and lessen reluctance to receive all vaccines. The 2020 National Vaccine Plan was being developed by the Department of Health and Human Services’ (HHS) Office of Infectious Disease and HIV/AIDS Policy, but little did anyone know that this plan would be needed as an essential part of the COVID-19 immunization plan. This was a POSITIVE.

• Telehealth and virtual care visits by phone or video were becoming more popular, and it was predicted that they would increase to 36 million visits in 2020. When the pandemic hit, these types of calls took the place of higher cost office, urgent care, and emergency department visits, thereby reducing healthcare costs, giving consumers an option for more convenient visits without sacrificing safety or quality, and becoming a key delivery option for visits during lockdown. Telehealth had been popular for years in rural areas but was not able to gain general acceptance as a delivery option. The pandemic made it a recognized delivery method to handle large volumes of non-complicated patients in a safe, efficient manner. HHS has since approved billing codes for Telehealth and virtual visits. This is a POSITIVE.

• Improving health disparities based on social determinants of health was also a goal for 2020. Their impact on mortality, morbidity, life expectancy, health status, and well-being were well known by health professionals prior to the pandemic, but they became much more apparent to everyone else during the pandemic. The goals were to provide access to not only physicians, but to medications, food, a place to live, transportation, and community resources for all patients, as needed. Identifying health disparities and social determinants of health has taken on a heightened sense of urgency now, due to COVID-19. This is a POSITIVE.

• Vaping and e-cigarettes were becoming a crisis, especially for teens, due to lung illnesses that had caused over 50 deaths. This goal was worked on by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA), but their main emphasis was re-directed to the needs of the pandemic. This resulted in LESS PROGRESS THAN EXPECTED.  

• The rise of consumerism was one of the factors involved in the move toward price transparency, drug pricing, and quality of care. The consumers’ highest priorities were expected to be front and center in 2020. Again, these items were worked on, but COVID-19 became the main priority. This resulted in LESS PROGRESS THAN EXPECTED.     

• The move to an Outpatient (OP) Model from a hospital-focused model was to take on an intensified interest in 2020. Consumers had already identified in the 2019 Definitive Healthcare Outpatient Trends Survey that cost and home care were most important to them, so this OP model fit what consumers wanted. CMS approved more OP surgery and procedure codes that helped lessen the need for hospitalized patients in the midst of the pandemic, thereby lowering the risk of hospital-acquired conditions and COVID-19 exposures. These will remain in use and increase the outpatient model even more.This was a POSITIVE.

Many of the issues and trends were not worked on as originally planned, but most of them showed progress or a positive outcome, even though intense emphasis and resources were placed on dealing with the COVID-19 pandemic. In some cases, COVID-19 actually helped to highlight the need for and value of some of the goals.       

Opportunities for Improvement

The pandemic may actually result in healthcare making some meaningful incremental changes, especially in the public health area where deficiencies were so obvious. These are examples of areas that should be looked at, based on issues that occurred during the pandemic. These are just a few of the issues and solutions that should be discussed to determine how to proceed.  

It seems obvious that the pandemic proved that all Americans need healthcare. COVID-19 left more than 50 million people uninsured, along with the 40 million who were under-insured before the pandemic. Expanding healthcare to provide it to all American has been a goal for many for a long time, but it as progressed slowly. The ACA was a big success in making this a reality, but it didn’t go far enough to include everyone. But is this the time it will finally get accomplished? If so, here are some of the questions we should ask: 

• What will healthcare-for-all look like?  Will it be public insurance or expanded Medicaid?  
• Should Medicare or Medicare Advantage be provided for everyone?
• Should employers continue to pay for healthcare? 
• Should the government provide subsidies for the ACA? 

The U.S. needs to find a way to preserve essential healthcare services even when there is a serious economic disruption. Providers experienced significant financial problems during the pandemic when they were unable to maintain office hours or provide revenue paying services. These are some of the financial payment questions we should ask:

• Should the healthcare system move to capitation, where providers would receive a monthly payment, rather that stay on the volume-based system? Which is better in a financial lockdown?
• Should a prospective annual budget be provided to hospitals to provide necessary services instead of the fee-for-service system we have today?
• How can quality and efficiency be incorporated into these new payment options? 
• How can essential services that have experienced issues in the past be included, e.g., primary care, behavioral health, rural health, etc.?   
• Racial and ethnic disparities were very obvious during this pandemic. People of color are especially vulnerable to COVID-19 and experienced increased numbers of cases and deaths.
• How can these disparities be lessened? 
• How can access to care and services be improved? 
• Should a system be developed to monitor and track the care given to patients of different races and ethnic groups? If so, how can the data be analyzed to identify and lessen the disparities? 
• How can safety-net facilities be provided?    

 Lessons Learned

There have been many lessons learned from this pandemic, but the most important thing is – what should be done with that information?  Winston Churchill once said “One should never let a crisis go to waste.”  For this situation, the lessons learned during the crisis should be used to proactively fix what was wrong, so it does not happen again. The lessons should be thoroughly analyzed to determine  what worked, what did not work, and what changes need to be made for the future. A detailed written plan should be developed and updated routinely, so it is always ready for any crisis. These steps are critical and essential.  

These are some of the “lessons learned”: 

• Federal leadership, support, guidance, coordination, and national direction is essential, and it needs to work closely and collaboratively with state and local governments.

• Critical measures need to be taken quickly. Time cannot be wasted, otherwise the disease will grow exponentially before we can start to combat it, as it did in this pandemic. 

• A federal public health information system should be established that connects the federal public health agencies with all state and local health departments and private healthcare providers. It should provide real-time data on the illness incidence, disease prevalence, and availability of critical treatment resources. Other healthcare organizations and facilities, as well as laboratories and medical companies should also be involved and provide available resources.  

• Federal funds should be made available immediately, without the need for time-consuming congressional approval. This would allow emergency development and distribution of needed procedures and items, e.g., PPE, basic testing, isolation and quarantine procedures, hiring and training of contact tracers, etc.  

• Legislation should provide the federal government with the ability to force states and local agencies to comply with mandated, critical measures, e.g., mask wearing, social distancing, closing of businesses, restricting large gatherings, and implementation of isolation and quarantine actions.  

• Basic prevention measures should be practiced immediately: Wear a mask when with others indoors and outdoors, wash your hands frequently, practice social distancing (stay at least 6 feet away from others), avoid large gatherings, limit gatherings to family in same home, and limit indoor gatherings.

• Treatment options and medications were identified and are now used that did not exist when the pandemic started. Trends seem to suggest that more people are beginning to survive critical care situations as a result of the improved knowledge-base in how to treat COVID-19, but definitive studies still need to be done. However, this is very positive and promising.

§  Much has been learned about treatment options in the past 11 months. Placing a patient in the prone position was found to improve lung function. Initially, patients were placed on ventilators when they were having serious shortness of breath as a deterrent to becoming critical, but it was later identified that once on the ventilator it was difficult to wean them off. Ventilators are now typically only used when patients have a critical respiratory problem that necessitates its use.

§  Medications are now available to treat COVID-19. Initially there were no known medications to treat COVID-19, so this is very positive and promising. Now there are several medications that are given to hospitalized patients to help lessen the symptoms and reduce the length of the illness. Remdesivir is the only medication that is FDA approved for the treatment of COVID-19. Dexamethasone, a common corticosteroid, is also being used for those needing extra oxygen or those on a ventilator. Emergency Use Authorizations have been given to other medications, e.g., convalescent plasma, monoclonal antibodies, Bamlanivimab, an “antibody cocktail” of Casirivimab and  Imdevimab. Other drugs that are not recommended by the NIH include: Hydroxychloroquine, Chloroquine, Azithromycin, Tocilizumab, and Kevzara.      

• The first vaccine was just approved for use by the FDA, with several others ready to be approved within a few weeks. It is amazing how quickly they were developed and the trials show over 90% efficacy. The first vaccines are scheduled to be given this week. The goal now will be to manufacture as much vaccine as possible so everyone can get vaccinated as quickly as possible. However, given the number of people in the U.S., it will take us until late spring or early summer to get everyone vaccinated.

• Patients with acute medical conditions need to be assured that they can get treatment during a time of crisis. This did not happen at the beginning of the pandemic. Some patients experienced poor outcomes or death because of a delay or lack of care for strokes or cardiac symptoms during the pandemic. Others included patients with severe conditions, e.g., cancer, trauma, emergency surgeries, etc.

• Patients can be cared for at home, if the respiratory symptoms are not severe enough for hospitalization. Guidelines need to be developed o indicate what the parameters are for admission. This will keep them away from other COVID-19 patients, free up hospital beds, provide them with more comfortable surroundings, and assure they are able to see and communicate with their family members.  

Next Steps

A major rollout of the vaccines is now underway. Vaccines will be given, as determined by a panel of experts, to individuals in Phase I: high-risk healthcare workers, first responders, individuals of all ages with co-morbid and underlying issues that put them at significant risk, and older adults living in congregate or overcrowded conditions.  Phases 2, 3, and 4 will follow over the next months. There is an online calculator that asks you to enter basic information and then tells you how many people are ahead of you for the vaccine in your state and in the nation.    

A defined plan is in place for the distribution to sites across the entire nation. The military is responsible for planning and executing the rollout, but once the vaccine is at the site, local personnel will be responsible for giving the vaccines.

A plan to educate the public about the vaccines is a key, critical action that is needed immediately to make sure everyone knows that the vaccine in safe and reliable. It should include: how the vaccines were developed, how they protect a person from getting COVID-19, their safety, and that fact that a person cannot get COVID-19 from the vaccine. Of the people who were asked if they would take the vaccine, more than half said they would not. Some are afraid of vaccines in general and others do not feel this one is safe. It is essential that more than 70% of people in the U.S. receive the vaccine in order to ensure herd immunity to slow or stop the spread. There is a lot that is still unknown about the vaccine, e.g., how long the protection will last, so continued preventive measures will still be needed for another 6 months or so after receiving the vaccine. These measures include: mask wearing, social distancing, hand washing, avoiding large gatherings, limiting gatherings to the family in the same home, and limiting indoor gatherings.

Conclusion

A lot has been learned about the novel coronavirus in the last 11 months: what prevention measures should be used and how important they are; how the disease is transmitted and that it can be transmitted by non-symptomatic patients, the best treatments for hospitalized patients, which medications can be taken to reduce symptoms and lessen the length of the illness, and which medications should be avoided. We now know so much more than we did during the previous high peaks of the pandemic. That is a big positive and gives us optimism and hope for the future.

When will we be back to normal?  That is the big question. No one knows for sure, but we could gain some sense of normalcy by summer. However, it may never get back to the normal that we were used to before. This pandemic has changed a lot about how our world works day to day. We may never get everyone back in offices, instead of working from home. Travel may take a long time to get back to “normal,” but we should be able to get our children back in school by next fall and we should be able to move around more freely.

This has definitely not been easy. It has gone on for 11 months, but we now may have only 6-9 months left. So we are more than halfway finished. YAY!  But the next month or two are going to be the hardest, especially over the holidays. However, it is imperative that we do not attend large gatherings or visit families over the holidays, no matter how much we want to. This is the height of the pandemic, and we do not want to get sick now. Our goal is to avoid getting COVID-19 and  stay healthy until we can get the vaccine. Staying home for this one holiday will be hard, but it is important so we can enjoy all of our future holidays. It should get better after January, and by then we will only have 5-8 months to go. Hang in there. We can do this!

Have a wonderful, safe, and healthy holiday season!