It has been five years since the the World Health Organization declared COVID-19 a pandemic.
That was the start of many changes, both temporary and permanent, to the U.S. healthcare system. Some were immediate, while others took time. Many of their long-term impacts remain to be seen. Experts agree the system is still far from perfect, but it has become more nimble than it was before.
“Medicine, traditionally, is inherently very conservative,” Jonathan Grein, M.D., director of hospital epidemiology at Cedars-Sinai, told Fierce Healthcare. “We all learned how to more rapidly adopt changing clinical protocols, vaccination recommendations and infection control guidance.”
“We learned a lot more about the value of collaboration,” echoed Nancy Foster, former vice president for quality and patient safety policy at the American Hospital Association (AHA), who just retired. “We’re all in this to save people and it showed during the pandemic, and it continues in many respects.”
Fierce Healthcare talked to a dozen experts about what key changes the U.S. healthcare system has gone through since COVID. Here are their takeaways.
Public health in the spotlight, for better or worse
The pandemic’s early days were an especially scary and uncertain time. Americans turned to public officials for reassurance and clarity. Health departments were key to coordinating the COVID emergency response, working alongside trade groups and providers to keep the public informed. To succeed, they had to overcome historical silos and collaborate on an unprecedented level.
Many recognize the importance of preserving this approach for the future. More than 100 organizations have joined the Common Health Coalition, launched in 2023, with the goal of strengthening the partnership between healthcare and public health systems using the lessons learned from COVID.
“While the pandemic is over, many leading healthcare institutions are now committed to strengthening partnerships with public health, especially related to emergency preparedness, disease surveillance and detection, and data sharing,” Rishi Manchanda, M.D., CEO of HealthBegins, told Fierce Healthcare. HealthBegins, a consulting firm supporting organizations that serve Medicaid, is a member of the Common Health Coalition.
Public health in the spotlight had an unintended consequence: the politicization of science. Five years in, trust in healthcare has been severely damaged. Violence against healthcare workers is on the rise. Routine vaccine rates among kids are dropping as many Americans today approve of RFK Jr.’s Make America Healthy Again agenda.
“I don’t think any of us [in healthcare] believe vaccinations should be a political issue,” Grein of Cedars-Sinai said. Putting healthcare under a “political spotlight … is not good for anybody.”
A confluence of factors contributed to this. The severity of the pandemic toll on marginalized populations sparked crucial conversations about race and disparities. In response, healthcare, like other industries, saw a rapid rise in DEI roles and training programs, said Jeff Salvon-Harman, M.D., VP of safety at the Institute for Healthcare Improvement (IHI). These transformative roles were hailed for their potential to help achieve and sustain institutionwide health equity goals. Organizations that prized diversity were also more likely to see strong retention rates.
“That recognition of the impact on our workforce added to the value of DEI as part of our workforce well-being, our retention strategies, a way for health system leaders to demonstrate commitment to the workforce,” Salvon-Harman noted.
At the same time, the pandemic brought out a deep concern in Americans for their own health and financial well-being. Some felt that public institutions were failing them and that the U.S. was ill-equipped to deal with the crisis. “It became very clear that the general American public all of a sudden saw all the cracks in our healthcare system in a way that they didn’t before,” said Natalie Davis, co-founder and CEO of United States of Care, a self-described nonpartisan think tank. “People are waking up to systemic issues that [aren't] their personal fault.”
It wasn’t long before the public grew tired of talking about COVID and DEI. Equity became a political concept. Preventive measures like masking were seen, by some, as infringing on their rights, leading to mixed guidance along political lines. Lockdown orders were lifted much quicker in red states than in blue states. Excess COVID deaths were higher in states with Republican governors and red-leaning state legislatures, and red counties were less vaccinated.
This dynamic ultimately led to a cooling of corporate DEI initiatives. Since President Donald Trump entered his second term, some hospitals have reportedly eliminated DEI roles. Even if a few have managed to effectively integrate DEI initiatives into their daily operations, without a figurehead leader, there won’t be representational importance to the issue over time. This sends a concerning message, Salvon-Harman said.
“We didn’t resolve all of the racism issues, but they’re being relegated more so than before to the back seat,” he said. “It may give permissibility to perpetuating the inequities of the past.”
Workers gained visibility, and benefits
More than 3,600 U.S. health workers died during the first year of the pandemic. Countless more were traumatized from working on the front lines. Many resigned in droves, driven by burnout. These shortages led to increases in labor expenses, worker strikes and disruptions in patient care.
“Healthcare was experiencing structural shortages in its workforce leading up to the pandemic. Certainly the pandemic served as an additional catalyst for those shortages,” Akin Demehin, VP of quality and safety policy at the AHA, told Fierce Healthcare.
Organizations introduced or beefed up programs to support the mental well-being of their workers. Innovative staffing models embraced virtual practice and flexible scheduling for providers. The Dr. Lorna Breen Health Care Provider Protection Act, passed in 2022, provided grants to organizations for behavioral health services for front-line healthcare workers.
“The very valuable and important work nurses do became visible during this crisis,” Michelle Mahon, director of nursing practice at National Nurses United, told Fierce Healthcare. The organization, among the largest nurse unions, is also a professional association.
Seizing on the moment, nurses unionized in record numbers and spoke out about inadequate staffing ratios and pay. “Chronic underinvestment in staffing in particular really left communities vulnerable and the workforce vulnerable,” Mahon said. Physicians, too, have leaned on unions to advocate for better working conditions.
Community-based workers were also recognized in a Biden-era initiative to put more community health workers in communities affected by COVID. “Integrating and centering community-based workers is a proven and necessary path to achieving the quadruple aim,” Manchanda of HealthBegins noted.
In 2024, doctor burnout would fall below 50% for the first time since 2020. Now is the time, experts say, to continue investing in lasting changes and support systems for providers.
“We’ve receded in terms of the record amount of burnout and attrition that was happening at the worst of COVID,” Jesse Ehrenfeld, M.D., immediate past president of the American Medical Association (AMA), said. Reducing administrative burdens and the stigma around asking for help is key “so that people can actually get the joy back in the practice of medicine.”
“Recognizing collective trauma and responding with empathy-based leadership and policies are important as ever, given other shared threats and risks to the nation's health,” Manchanda echoed.
Care moved outside the four walls of the hospital
Utilization of retail health clinics, including for things like COVID testing and immunizations, increased more than ambulatory surgical centers and emergency departments in 2020 and 2021. This was driven by outpatient services and immunizations. Though utilization dropped the following years, many alternative care sites programs are here to stay. Nontraditional providers including retailers and payers are expected to capture 30% of the primary care market by 2030.
Hospital-at-home programs also exploded during the pandemic. In 2020, the Centers for Medicare & Medicaid Services launched the Acute Hospital Care at Home program. Though quality and cost findings have been less clear-cut, clinicians and patients overwhelmingly praised their experience with the program.
Johns Hopkins went from 80 telemedicine visits a month before the pandemic, to 90,000 a month by May 2020. Today, it’s about 30,000 monthly system-wide.
The introduction of remote therapeutic monitoring codes in 2022 was a meaningful step in enabling care at home, Fierce Healthcare previously reported. And recent changes to remote patient monitoring reporting requirements are also intended to simplify reimbursement.
The pandemic also accelerated the broad recognition of social needs as well as the integration of psychosocial services into care.
“The pandemic exploited and exacerbated social and structural inequities in the U.S. and across the world, disproportionately harming people and families with lower incomes and who belonged to historically marginalized communities,” Manchanda said. “Today, the healthcare industry is closer than it's ever been to a shared recognition that the best standard of care requires effective and equitable integration of healthcare with social and behavioral health services.”
“We know that when we address [social needs] issues, it strengthens the healthcare system’s ability to address quality along all domains,” echoed Ehrenfeld. There is an opportunity for payers to design benefits to better account for social needs, he added.
The advent of telehealth changed the game for broadening access to treatment, experts agree. Telehealth can help manage chronic diseases, deliver preventive care and support people with social needs or in rural areas.
“You can’t have a conversation about the last five years and not talk about telehealth,” Ehrenfeld noted. As of late 2023, three-quarters of doctors worked at practices that offer telehealth, a 3x increase since pre-COVID, AMA data show.
Telehealth is not right for all types of care but can be especially meaningful for mental health. Johns Hopkins is seeing better show rates for psychiatry and psychology appointments as a result. “It’s been really good to help people with consistency,” Helen Hughes, M.D., medical director of the Office of Telemedicine for Johns Hopkins Medicine, told Fierce Healthcare.
Having to do things online during COVID also helped patients get accustomed to engaging with their portals. Across the board, Johns Hopkins went from about a third of patients being active on MyChart in 2019 to three-quarters of all patients having an active MyChart account today. They use it to schedule visits, check lab results or message their doctor.
Hughes knows firsthand how challenging telehealth was to stand up pre-COVID. The tech was available, but operationalizing it was not feasible. Hughes first heard about telemedicine being offered by the VA around 2016. Hughes, who practices pediatrics in the Johns Hopkins Harriet Lane Clinic, wanted to offer the option to patients, particularly for those who needed mental health or complex care follow-up.
But from reimbursement limitations to logistics, the pilot her clinic ran did not go far. In six months, they offered 10 telehealth visits. “It’s very hard to make it part of your standard practice when you can only do it for a narrow sliver of patients,” Hughes explained.
During COVID, Hughes got to see in real time how quickly telehealth could be adopted when used at scale. Because of special flexibilities, all previous barriers melted away, she recalled. Johns Hopkins went from 80 telemedicine visits a month before the pandemic to 90,000 a month by May 2020. Today, it’s about 30,000 monthly systemwide.
Johns Hopkins has also been able to offer more hybrid work options since COVID. In 2022, it launched a virtual care center staffed with providers working from home. “It’s been a great access tool,” Hughes noted. Recently, the health system started working with telehealth company Caregility to roll out a virtual nursing program.
“Patients continue to use telehealth because it provides convenient access to high-quality care and helps prevent delays in getting care,” Desiree Gandrup-Dupre, SVP for care delivery technology services at Kaiser Permanente, said in an emailed statement. Today, nearly a third of Kaiser’s ambulatory care visits are virtual.
Overall, the pandemic also accelerated the transition to omnichannel care, Gandrup-Dupre added, giving patients a range of options from in-person to video to phone to chat. “This omnichannel approach yields improved patient outcomes and higher patient satisfaction,” she said. “We routinely assess member satisfaction with telehealth by tracking follow-up care and consistently find comparable rates for in-person visits and telehealth services.”
All care interactions are integrated with Kaiser’s EHR for a coordinated and personalized patient experience. “The integrated omnichannel approach will continue to evolve and improve as new applications are developed and more health systems adopt this approach,” Gandrup-Dupre said.
The future of tech use remains uncertain
At the start of COVID, providers rushed to deploy telehealth and later artificial intelligence, often without clear long-term strategies. Challenges with reimbursement, workflow integration and clinical concerns led organizations to eventually pull back from these efforts, Andrew Rebhan, senior consulting director of intelligence at Sg2, a Vizient company, told Fierce Healthcare in an emailed comment.
“You’re seeing many organizations that were caught off guard by a rapid need to adopt technology due to shifting market conditions. A more sustainable path would be for stakeholders to have a proactive, intentional and measured approach to digital transformation that has a long-term orientation,” Rebhan said.
That entails considering current and future needs when determining where digital tools can have the biggest impact and seeking cross-discipline input. It could also look like establishing a culture of ongoing experimentation and upskilling one’s workforce with tech literacy.
“This is all about having a solid foundation that fosters sustainable innovation versus always needing to take big reactionary swings,” Rebhan said.
For home care to succeed, organizations need to thoughtfully select the right patients, conditions, staff and tech to support them, Patricia McGaffigan, senior advisor on patient and workforce safety at the IHI, said. “COVID has really given us and reaffirmed the blueprint for what’s necessary to ensure that care is safe,” McGaffigan said.
With tech, she added, “it’s important for us to proceed with a reasonable level of enthusiasm, but also a clear degree of caution to be sure that adoption doesn’t outpace our understanding of the technology.”
AI has arguably brought with it more questions than answers, particularly around privacy and ethics. General-purpose large language models not intended for the healthcare setting are being used by some doctors to make clinical decisions, Fierce Healthcare previously reported. Regulators are playing catch-up, while industry efforts to create standards around responsible AI use, like the Coalition for Health AI, are progressing slowly.
Still, some AI tools have undoubtedly freed up valuable provider time or facilitated smoother care delivery. In late 2024, Johns Hopkins deployed Abridge’s ambient AI platform to help with clinical note-taking. The tech has been “transformative,” per Hughes. AI scribes have been found to save doctors an hour or more a day. Meanwhile, chatbots can help collect data and support patient triage, respond to basic patient questions and facilitate care navigation. They may even be more empathetic than doctors.
“AI is coming into practice in a way that is really exciting,” Ehrenfeld of the AMA said. Two in 3 docs used health AI in 2024—a stark 78% increase from 2023. “If we’re going to expand capacity across the workforce, we’re going to have to lean into digital health and AI,” Ehrenfeld said.
Still, there is work to be done. Congress continues to delay making a decision on permanent Medicare telehealth policies as COVID-era flexibilities were yet again recently extended through September. The American Telemedicine Association’s advocacy arm recently called for an end to the “telehealth rollercoaster” of waivers that confuses patients and providers.
“We would like those changes to be permanent,” Ehrenfeld said. “We’re optimistic.”