While the current COVID-19 pandemic and our efforts to shelter in place have had significant negative impacts on healthcare, we will learn many things about better ways to practice medicine.
With few procedures and services being performed and individuals anxious to go to clinics and hospitals to seek care, physicians need to adopt new approaches to providing clinical care. The changes we’re seeing now provide a glimpse into how medicine will be practiced in the future—and, for the most part, these changes are positive.
Medical practice before COVID-19
Before COVID-19, hospitals served as centers of care where a variety of tests, procedures, and interventions were performed at a high cost. In fact, hospital care accounts for one-third of U.S. healthcare spending.
There are many reasons for this. To a large extent, given unreimbursed care and less valuable contracts, hospitals charged high rates for all activities from performing a lab test or surgery to providing Tylenol. There are academic medical centers that offer world-class care in a variety of specialties for the high prices charged.
Many community hospitals, on the other hand, offer a wide range of procedures and services, but given the relatively low numbers of cases performed, they are unable to provide best-in-class care. Because hospitals need to be good at hundreds of different care activities, it is exceedingly difficult to excel at all of them.
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Patients cared for in hospitals are also at risk of contracting infectious disease, called nosocomial infections. With caregivers going between rooms and with multiple lines and catheters placed in patients, depending upon the required monitoring and treatment, there are many possible routes for infection. In fact, approximately 1 in 31 U.S. patients (PDF) contracts at least one infection during their hospital stay.
Most primary and specialty care before COVID-19 required patients to schedule office visits often weeks or months into the future, followed by hours to travel to the office, long wait times at the clinic and less than 15 minutes of face time with rushed, distracted physicians.
This arduous appointment process discouraged patients from seeking care. Because of limited hours and scheduling difficulties, individuals would routinely go to urgent care or the emergency room for issues better addressed elsewhere. To make matters worse, physicians ordered more tests, scheduled more visits and encouraged more activity to pay for the overhead of running a brick-and-mortar practice, many of which were not necessary to treat patients effectively.
Before COVID-19, 30% of healthcare spending was considered “waste” by researchers. According to 2018 data, 84% of Americans received health insurance from their employer or the government. There were few limits on care except in the case of high-deductible health plans or narrow networks. Physicians and hospitals could make more money by ordering more tests, services, procedures or other medical care, and payers were forced to foot the bill. Recently, the move to value-based payment contracts began to shift this dynamic, but insurance still only covered about 25 cents out of every dollar of care.
Medical practice in the post-COVID-19 era
During the current pandemic, hospitals are almost entirely focused on serving patients with emergent health needs or coronavirus symptoms. We will take our collective learning from the COVID-19 era about how we can provide hospital care for patients in non-acute hospital settings. This experience can be used to craft hospital care for the future.
We can reduce the cost of hospital care, increase patient satisfaction and reduce acquired infections with care provided in home or in an alternative, hotel-like setting. In the world after COVID-19, hospitals can continue to focus on providing care for acute illnesses, trauma, and complex procedures and surgeries. The hospital can focus on mastery of fewer services and increase quality and outcomes and let relatively less urgent care be conducted in alternative settings.
There has been robust literature written about providing hospital care in the home, pioneered by academic physicians at Johns Hopkins, and we can draw upon these studies and outcomes to design a new approach.
There would certainly be some initial challenges to address, but this should not stop us from experimenting with home hospital or hotel hospital care. Hospitals are striving to provide better customer service when hotels have already mastered this domain. With increasing use of remote monitoring devices, smartphones and telehealth, individuals presenting a set of straightforward conditions can be safely treated in one of these alternative settings. And without multiple patients in one confined setting, there would likely be a much lower rate of hospital-acquired infections.
In the future, I expect primary care will be largely conducted via telehealth visits supported with connected devices. Experts are already predicting 1 billion telehealth visits by 2021, and nearly half of all practicing physicians are now using telehealth visits. Physicians will rely less upon large offices, and patients will be able to seek medical care without taking hours of their day traveling to and from office visits. This would allow patients to seek care from the best doctors in the country for primary and second opinions, not simply the doctor that happens to have a clinic within driving distance.
This shift in practice will allow for physicians to be available during flexible hours, not just between typical weekday office hours. With sophisticated remote monitoring devices connected to a smartphone or computer, most routine exams could be conducted in a virtual manner. Today, we can collect blood pressure and pulse ox readings, heart rate, temperature, weight, views of the retina and the tympanic membrane, EKG tracings and other data to assist the physician with making diagnoses. These tools will help providers care for their patients in a more substantive manner. Studies so far are showing a rapid increase in client satisfaction with the telehealth experience and much lower costs per visit. According to a study from Jefferson Health, a telemedicine visit saves $19 to $120 per visit.
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We may learn that many visits, tests and procedures are unnecessary. To be sure, there are latent needs going unmet during COVID-19, and chronic disease progression is going untreated in many individuals.
With sheltered individuals, we are conducting a grand healthcare experiment in what healthcare is truly necessary and what is not. Is it mandatory for individuals on certain medications to visit the office every 90 days for a blood test? Do annual wellness visits really add value for patients? We should see more and more commonly accepted services and procedures come under greater scrutiny for value.
Since we’ve effectively gone without nonemergent care for months due to patient reluctance to interact with healthcare, we can better study the effectiveness of current care and treatment guidelines.
During the pandemic, clinicians are learning how to deliver care via technology that is certainly more convenient and less expensive. Whether this care provides the same or better outcomes will require longer-term study. If these changes remain in the post-COVID-19 world, they will be a great legacy of what is otherwise a deadly, terrible virus.
It will take time for providers to recover and consumers to settle into new patterns of care. But, if some of the current shifts in clinical practice—increased adoption of telemedicine, remote monitoring, focused emergency care and streamlined services for patients with certain chronic conditions—remain after COVID-19 runs its course, there will be an overall positive impact on healthcare delivery, improving the provider and patient experience in the years to come and reducing the overall cost of care.
Darren Schulte is the CEO of Apixio.