Health system executives surveyed early this year are optimistic about service volumes despite ongoing uncertainty linked to the coronavirus pandemic.
Although hospital service volumes decreased significantly in 2020, health system leaders expect most service volumes to rebound by 2022, a new survey found.
Particularly during the early phase of the coronavirus pandemic, healthcare providers experienced sharp declines in service utilization. The drivers of reduced utilization included state restrictions on elective surgery to accommodate coronavirus patient surges and patients deferring care because they feared exposure to the virus in healthcare settings.
The new survey, which was conducted by New York-based McKinsey & Company from Jan. 17 to Feb. 5, collected information from 30 of the largest nonprofit and for-profit health systems in the country.
A surprising finding of the survey was significant optimism about the future despite continuing uncertainty linked to the pandemic, says Kyle Gibler, MD, MBA, a partner at McKinsey & Company.
"When we talk with clients, many are concerned about a slow recovery of volumes to pre-COVID levels. But in our survey, most health systems predicted a near-return to historical levels by the middle of 2021 for most clinical areas. Even emergency department volumes, which many health systems have publicly talked about potentially never returning to pre-COVID levels, were projected to fully return by 2022," he says.
The survey includes several key data points:
Inpatient admissions: On average, hospitals surveyed experienced a more than 20% decrease in inpatient admissions from March to June 2020. Survey respondents reported that inpatient admissions rebounded by the end of 2020, ending the year at about 7% below 2019 levels. Survey respondents expected inpatient admissions to remain at 2019 baseline levels in early 2021, but they forecasted an increase of 7% to 8% in 2022 and 2023.
ED visits: Hospitals surveyed experience about a 14% decrease in ED visits in 2020, and they expected to remain below pre-pandemic levels this year. Survey respondents expected ED visits to return to baseline by 2022 and to increase about 5% over 2019 baseline levels by 2023.
Outpatient visits: Health systems surveyed experienced a more than 15% decrease in outpatient visits in 2020. They expect outpatient visits to rebound to baseline by the second quarter of this year and to increase about 7% above 2019 baseline levels by the end of this year.
Surgical volume: On average, health systems surveyed experienced about a 14% decrease in operating room procedures in 2020, and they expect surgical volume to return to baseline by the third quarter of this year. Survey respondents expect OR procedures to increase about 8% above 2019 levels by 2022.
Interpreting the data
Last year's decrease in inpatient admissions was partially offset by higher acuity among hospitalized patients, says David Bueno, PhD, a partner at McKinsey & Company.
"What we saw was that the number of patients hospitalized over that period certainly decreased, but what we also saw was an increase in acuity. So, while there were fewer patients in the hospitals, the patients who were in the hospitals were sicker. If we look more recently in the last quarterly report, we see revenue per adjusted admission up in the range of 15% year-over-year. So, there was smaller volume but sicker volume. That certainly helped hospitals sustain themselves from a financial perspective," he says.
Lower ED volumes could be a long-term trend, Gibler says.
"While ED volumes are starting to recover in the most recent quarter, many health systems expect ED volumes to remain below historical baselines for a while if not indefinitely as lower acuity patients seek other channels of care such as urgent care, primary care offices, and virtual care visits. What we expect is for hospitals to change their channel strategy. They will likely decrease the size of their ED footprint and increase in-person access points in the community such as urgent care and primary care as well as adopt digital offerings to make care more convenient," he says.
In EDs, patient acuity has had a similar effect on emergency room visits as inpatient admissions, Gibler says. "While ED volumes have been down, the average acuity has been above historical levels over the past 12 months. So, there has been some natural offset of the decreased volume by seeing sicker patients coming through the ED."
Preventive care is likely to be a primary driver of increased demand for outpatient services, Bueno says.
"We have certainly seen an outpatient visit drop-off. One of the things that we are looking for in the future is as an increasing percentage of the population becomes vaccinated for COVID hopefully health systems will see the number of preventative care visits increase, which would increase the total number of outpatient visits," he says.
Health systems are taking three approaches to the decrease in surgical volumes, Gibler says.
Some health systems are operating business as usual, with below historic volumes because they are taking whatever demand that they get. But they are not changing operations to accommodate any of the expected backlog of procedures such as knee replacements.
Some health systems are changing their bread-and-butter clinical operations and making improvements such as fixing their turnover times and making other improvements that are known levers to improve operational performance.
The bold approach is using the down time in 2020 and 2021 to completely rethink how health systems are running their ORs to accommodate volume increases after the pandemic passes, Gibler says. "They are redesigning their OR operations by using new digital tools to automate parts of the process and increase reliability. They are engaging patients in new ways to make sure that patients are not artificially deferring care longer than they need to. They are using analytics to better and more agilely match supply to demand. So, the health systems that are redesigning their OR operations will capture an outsized share of the backlog."
Historical influenza trends illuminate how to roll out coronavirus vaccines to underserved racial, ethnic, and socioeconomic groups.
Influenza vaccination trends provide valuable insight into the equitable rollout of coronavirus vaccines, a new report says.
The coronavirus pandemic has exposed inequities in the U.S. healthcare system, particularly for racial and ethnic groups, according to the Centers for Disease Control and Prevention. Research published by JAMA Network Open shows Americans with low incomes are also suffering disproportionate coronavirus infection and death burdens.
The new report, which was published by Urban Institute researchers with funding from the Robert Wood Johnson Foundation, examines historical trends for flu vaccination that indicate ways to address racial, ethnic, and economic inequities in the rollout of coronavirus vaccines. The report is based on data from the 2016 to 2018 National Health Interview Survey.
The Urban Institute report focuses on three risk groups: Nonelderly adults from 19 to 64 who are a low risk of severe COVID-19 illness, nonelderly adults from 19 to 64 who are at high risk of severe COVID-19 illness, and elderly adults 65 and over who are at high risk of severe COVID-19 illness due to their age. The report includes several key data points.
Low- and high-risk nonelderly Black and Hispanic adults had lower flu vaccination rates than their White counterparts. For example, among low-risk nonelderly adults, the flu vaccination rate for Black adults was 26.2% and the vaccination rate for White adults was 40.6%.
Risk was associated with likelihood to receive a flu vaccine among nonelderly adults with public forms of health coverage. High-risk nonelderly adults with Medicaid (34.2%) and Medicare or other public coverage (51.2%) had a higher likelihood of getting a flu vaccine than their lower risk counterparts with the same coverage (29.5% and 42.9%, respectively).
American Indians and Alaska Natives had flu vaccination rates that compared favorably with Whites. For example, among low-risk, nonelderly adults, the AI/AN vaccination rate was 45.2% and the White vaccination rate was 40.6%.
For all three COVID-19 risk groups, the presence or absence of a usual source of care was highly associated with flu vaccination rates. For example, among elderly adults, those with a usual source of care had a 69.2% flu vaccination rate compared to a 33.4% flu vaccination rate for those with no usual source of care.
Uninsured nonelderly adults had the lowest flu vaccination rates: 15.4% for low-risk nonelderly adults and 16.9% high-risk nonelderly adults.
"These findings emphasize the need to explicitly consider racial and socioeconomic equity in prioritizing rollout of the COVID‑19 vaccine. This will involve addressing access issues by expanding delivery site options and providing assistance with appointment scheduling and other logistics," the Urban Institute researchers wrote.
Four coronavirus vaccine insights from flu vaccination trends
The historical flu vaccination trends have four primary implications for the equitable rollout of coronavirus vaccines, the researchers wrote.
1. Risk has a significant impact on ethnic, racial, and socioeconomic likelihood to get vaccinated. "Among the nonelderly Black, Hispanic, Medicaid/CHIP and lower income adult populations, the higher risk group was more likely to receive their flu vaccine than their lower risk counterparts, and this pattern was particularly pronounced among lower income Black and Hispanic adults. The health conditions that put individuals at higher risk may also increase their contact with and trust in their healthcare providers and thereby increase vaccine uptake," the researchers wrote.
2. The relatively high flu vaccination rates of the American Indian and Alaskan Native populations provides insights for rolling out coronavirus vaccines to other groups that have historically experienced healthcare disparities. "Early evidence suggests that the COVID‑19 vaccine rollout among Native Americans has been very successful, with many tribes using call centers rather than online systems to schedule appointments and taking advantage of a variety of existing outreach media including newsletters, radio announcements and direct mail," the researchers wrote.
There is a lesson to be learned in avoiding reliance on the Internet to engage and enroll people for vaccination, they wrote. "Some of these strategies, especially less reliance on Internet‑based scheduling and extremely targeted outreach to the most vulnerable, could improve access for other older, less tech savvy populations."
3. It will be crucial to address low vaccination rates among uninsured adults and adults without a usual source of care. "Low vaccination rates in the South may also be related to lower rates of insurance coverage, and in the absence of progress on Medicaid or other coverage expansions, it will be important to focus on community health centers and other delivery sites that serve the uninsured," the researchers wrote.
Adults without a usual source of care would be well-served by nontraditional vaccine delivery sites, they wrote. "These may include retail pharmacies, which have also started receiving direct shipments of COVID‑19 vaccines in an effort to improve equity of vaccine distribution, and mass vaccination sites such as stadiums and convention centers."
4. Employers and community groups need to be enlisted to distribute coronavirus vaccines, the researchers wrote.
"Given that most nonelderly adults who did not receive a flu vaccine were working, employers could potentially play an important role in outreach and as delivery sites as the economy continues to reopen and vaccine supply increases. Similarly, leveraging the communication networks of places of worship, schools, sports leagues, and other trusted community organizations to promote vaccination will be critical in reaching individuals who may not regularly interact with the healthcare system."
HCCI is one of the country's leading advocacy and education organizations for home-based primary care. Julie Sacks, MSW, was recently promoted from chief operating officer of HCCI to president and chief operating officer.
Sacks joined HCCI in 2015 as vice president of operations and advancement.Previously, she was senior director of programs and services as well as director of the National Young Onset Center for the American Parkinson Disease Association.
Sacks is succeeding founder and CEO Thomas Cornwell, MD, who transitioned to executive chairman effective March 9. He also took on a new role as senior medical director of VillageMD's Village@Home.
HealthLeaders recently had a conversation with Sacks about the present status of home-based primary care and prospects for the future. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the main elements of home-based primary care?
Julie Sacks: The most basic definition of home-based primary care is that it is a way of providing primary care to the most at-risk and vulnerable people in our society. Generally, home-based primary care is provided to homebound and frail people who oftentimes are not getting primary care because it is too difficult for them to leave home.
The services you get through home-based primary care include annual wellness visits, vaccinations for patients and their caregivers, remote patient monitoring, telehealth, and care coordination. The home-based primary care doctor is often the quarterback of a patient's care team. They provide primary care, but they also know when to bring in palliative care, hospice, and home health services.
HL: How does a house call add value to a patient's healthcare?
Sacks: There is a strong relationship that gets developed between the clinicians and the patients. I went on house calls when I first started working at HCCI, and there was a gentleman who told the physician that he would not be alive without his care. This patient was homebound. He was depressed. He was really struggling. Having a physician come into his home to check on him was like a life preserver.
HL: How is home-based primary care financed?
Sacks: Generally, home-based primary care is financed in the same way that office visits to primary care practices are financed. Medicare reimburses the practice based on the coding that is submitted—so it is a fee-for-service model.
Initially, home-based primary care tends to be more expensive than office-based care largely because clinicians' transportation time is not reimbursed by Medicare. And because of clinician transportation, healthcare providers cannot see as many patients as an office-based clinician can see. In the long run, though, research shows that a practice or health system will benefit significantly from creating a house call program. That is because this model of care has been shown to reduce costly emergency department visits and hospital readmissions. It also improves the quality of patient care and offers people an alternative to expensive nursing home placements.
In addition, there are ways to manage the transportation challenge. For example, assisted living facilities are considered homes because they are a residential setting. When a clinician sees multiple patients in an assisted living facility, there is obviously less travel time involved. So, by including a mix of assisted living facilities, skilled nursing facilities, and individual homes, you can address the transportation challenge.
Beyond the fee-for-service model, there are also new payment models being launched by the Centers for Medicare & Medicaid Services and the Center for Medicare & Medicaid Innovation. These models are either capitated models where clinicians get a per-member-per-month fee to take care of patients or total-cost-of-care models where a practice takes on the risk of care.
HL: Are commercial payers financing home-based primary care?
Sacks: The commercial payers are definitely contracting with home-based primary care practices. They see the value of home-based primary care for their members—particularly for members who are the most seriously ill.
Some commercial payers are contracting with practices directly to provide services, but some of them such as Humana are creating their own home-based primary care programs because they see the value of this model of care.
HL: How are home-based primary care services offered at the practice level?
Sacks: Historically, there have been more practices that only provide home-based primary care, but we are seeing it move to office-based primary care practices.
During the pandemic, one of the last places you want a frail senior is in a hospital. So, we are seeing more of the office-based practices realizing the value of treating people in the home. We see this as a big area of growth.
Historically, there have been more small- to mid-sized home-based primary care practices. But now, we are seeing both models. An office-based practice can start small by hiring a nurse practitioner and sending that clinician to patients' homes.
Another trend we have seen over the past year and half is venture capital and private equity coming into the home-based primary care space. Venture capital is seeing the value of this care model, and they can invest significant capital in home-based primary care and participate in the new payment models that often require an upfront investment. There are venture capital-backed companies that are doing strictly home-based primary care.
HL: How can health systems launch home-based primary care services?
Sacks: One thing we have found is that home-based primary care at health systems must have C-suite support. There must be buy-in from the top levels of the organization.
Health systems also must understand which patients are appropriate for home-based primary care. Not every health system patient is appropriate for this model of care—it is too expensive. You want to use home-based primary care for the right patients, so you must train your whole health system on how to identify those patients. You want to have your emergency department physicians, discharge managers, and social workers aware of a home-based primary care program. You want your office-based primary care doctors aware, so they can identify high-risk patients who have not been in for a visit in a year or two.
It takes a system-wide effort to make home-based primary care successful at a health system.
HL: After the coronavirus pandemic has passed, what is your forecast for home-based primary care?
Sacks: Not every visit has to be in-person, so telemedicine will continue to benefit home-based primary care practices. It is unlikely that we will go back to seeing as little telemedicine as we saw before the pandemic.
The increased recognition by the public that home-based primary care is needed will have an impact on the market for these services after the pandemic. What I hope will happen is that patients and caregivers will start to demand this type of care now that they know that it exists. We plan to help mobilize that grassroots pressure, so that more and more health systems will adopt home-based primary care.
Deferment of elective care and uncertainty over safety procedures were among drivers of decreased utilization, analyst says.
A recent Avalere Health report shows decreased Medicare utilization in the early phase of the coronavirus pandemic.
The early phase of the pandemic had a negative impact on healthcare utilization and healthcare provider finances. For example, a poll conducted in March 2020 found that only 33% of clinicians had confidence that their practices had enough cash on hand to function for four weeks.
The Avalere Health report, which is based on Medicare fee-for-service claims data from a random sample of 20% of Medicare FFS beneficiaries, compares claims volume during the first six months of 2020 and the first six months of 2019. The report features several key data points.
Compared to 2019, Medicare FFS claims dropped in March, April, and May 2020:
March 2020: Inpatient claims increased 4%, professional claims decreased 13%, outpatient claims decreased 18%, and overall claims decreased 14%
April 2020: Inpatient claims decreased 23%, professional claims decreased 42%, outpatient claims decreased 51%, and overall claims decreased 44%
May 2020: Inpatient claims decreased 12%, professional claims decreased 25%, outpatient claims decreased 32%, and overall claims decreased 26%
Compared to 2019, Medicare FFS claims started to rebound in June 2020:
June 2020: Inpatient claims increased 4%, professional claims increased 3%, outpatient claims decreased 1%, and overall claims increased 3%
Interpreting the data
A combination of factors drove the precipitous drop in Medicare services utilization in April 2020, says Thomas Kornfield, MPP, a senior consultant at Washington, DC-based Avalere Health. "April 2020 is when the lockdowns were most severe. At that time, there was also a lot of uncertainty about what was safe and what was not safe in healthcare facilities, which reduced utilization."
Two factors were likely responsible for the steep decline in Medicare outpatient services during the early phase of the pandemic, he says. "My theory is that these decreased outpatient services were likely elective activities that Medicare beneficiaries felt could be delayed. In addition, many elective procedures were not being provided in the early phase of the pandemic."
There were a pair of primary drivers for the rebound in Medicare services, Kornfield says.
"In June 2020, that is when states started to relax lockdown restrictions. There was also less uncertainty about safety measures such as wearing masks. Healthcare providers had been able to figure out how to treat patients in a way that was safe. So, it was a combination of understanding ways in which services can be provided in a safe environment as well as more states moving toward reopening."
Healthcare providers and researchers should try to monitor and address the impact of deferred care, he says. "It is going to be important to look at what the deferred care means in terms of higher healthcare costs down the road. At this point, the impact of the deferred care is unknown."
The membership of the coalition includes many organizations that are focused on other complex chronic illnesses.
More than 50 organizations have formed the Long COVID Alliance to use their collective knowledge and resources to educate policymakers, accelerate research, and empower patients.
There are coronavirus "long haulers" among COVID-19 patients who have experience mild, moderate, and severe infections. In a recent study of COVID-19 patients hospitalized with severe acute respiratory infection, functional impairment was found in 53.8% of patients four months after hospital discharge. Long COVID symptoms include cough, shortness of breath, anxiety and depression, cardiac issues, fatigue, deconditioning, and hair loss.
The formation of the Long COVID Alliance was announced on Feb. 25. "At this point, we are more of a coalition than an organization. We are composed of both organizations and individuals. We see the need for the Long COVID Alliance as being three-fold: education, research, and advocacy," says Emily Taylor, MA, director of advocacy and community relations at The Solve ME/CFS Initiative in Glendale, California.
The Solve ME/CFS Initiative is one of the founders of the Long COVID Alliance. The organization is dedicated to research, advocacy, and patient support for myalgic encephalomyelitis, which was previously called chronic fatigue syndrome.
In addition to The Solve ME/CFS Initiative, several complex chronic illness organizations are participating in the Long COVID Alliance.
"Many patients who have complex chronic illnesses such as ME/CFS have not been taken seriously by the health system. All of a sudden, the long COVID patients have validity. COVID is real and the medical community is treating it like it is real. There are many COVID patients getting the same long-haul symptoms at the same time, and long COVID is legitimizing illnesses like ME/CFS that have fought for legitimacy for years," Taylor says.
Long COVID Alliance goals
The Long COVID Alliance wants to promote public-private partnerships, Taylor says.
"For complex chronic diseases, the most successful initiatives are public-private partnerships. For example, the National Institutes of Health has established partnerships with nonprofits and for-profit entities such as collaborative research centers. There are three collaborative research centers that the NIH has funded for ME/CFS in the past couple of years. This was a perfect example of academia, private partners such as Solve ME, other advocacy organizations, and public research centers with public dollars coming together to identify the primary research barriers and design studies that can address those barriers."
The Long COVID Alliance wants to confront systemic bias and racism in the response to long COVID, she says.
"The Long COVID Alliance can help drive health equity by being a bridge between healthcare providers, federal policy makers and funders, insurers, and the patient community. Long COVID patients mirror the disparities and systemic inadequacies that already existed before the pandemic. People of color are getting COVID and long COVID at a higher rate than other Americans. We are hoping that the Long COVID Alliance can bring issues of health equity to the forefront by being a conduit for patient voices and being a source of good peer-reviewed science."
Time is of the essence in finding effective treatments for long COVID, Taylor says.
"There is a sense of urgency to get this work started. Public-private partnerships in cancer, Alzheimer's, and autism took years to generate results. We do not have that kind of time with the long COVID patients. What we have learned from ME/CFS and other post-viral illnesses is that you have a treatment window at early onset that is usually two to three years. If patients do not receive treatment in that time, their illness can last the rest of their lives," she says.
The endgame is getting bench-to-bedside science fast enough so that coronavirus long haulers do not stay disabled for years, Taylor says. "We do not want the long haulers to become part of the permanent chronic illness community. That is why we are pushing this initiative so soon."
Hopeful for the future
The Long COVID Alliance is off to a good start, Taylor says.
"It is a lot of work to build an effective coalition or alliance. In my 15 years of working in this field, I have never seen a coalition come together so quickly and so organically. That reflects the urgency of treating long haulers and the decades of experience that our coalition partners have with similar post-viral chronic illnesses. We see the writing on the wall, and everyone is on the same page—we need to get these patients well as soon as possible. We all have this single-minded goal, and we are all working as hard as we can to get there."
Case managers are a pivotal element of a new program designed to improve care for behavioral health patients up to three months after hospital discharge.
A collaboration in Rhode Island between a behavioral health hospital and a payer seeks to reduce hospital readmissions and improve quality of care.
Readmissions are a significant issue in hospitalizations for behavioral health conditions. A research article published by the Agency for Healthcare Research and Quality examined data from more than 840,000 hospital stays for mood disorders and more than 380,000 hospital stays for schizophrenia. The 30-day readmission rate for mood disorders was 9.0%, and the 30-day readmission rate for schizophrenia was 15.7%.
In December, Butler Hospital in Providence, Rhode Island, launched its pilot Transitional Outpatient Program for patients who have insurance coverage from Blue Cross & Blue Shield of Rhode Island.
"The program is targeted from one month to three months after hospital discharge—that is the time that problems are more likely to develop and people need extra support. What we offer is a collection of different services depending on the needs of the patient. Those services include case management, which is what we have teamed up with Blue Cross to provide. It is short-term case management for those initial months after hospital discharge. In addition, patients often benefit from getting additional counseling, therapy, and medication management," says Brandon Gaudiano, PhD, clinical director of the Transitional Outpatient Program.
Butler Hospital can provide outpatient services on a timely basis after hospital discharge if those services cannot be set up in the community, he says. "If patients need new healthcare providers or need to be seen sooner than they can be in the community, Butler Hospital has providers who can provide those services to make sure that the time between hospital discharge and being seen by a provider is shortened."
Many patients who have a behavioral health inpatient stays are at risk of rehospitalization, Gaudiano says. "With the types of diagnoses that patients are dealing with, such as substance use disorders, risk of relapse can be very high. There are also diagnoses such as mood disorders—bipolar disorder and severe depression—where patients need a lot of extra assistance and help. There are also patients with schizophrenia and other psychotic spectrum disorders who often are dealing with chronic conditions, where even if the acute episode is over there are still many things they need assistance with."
The Transitional Outpatient Program is designed to make sure that patients receive care after their hospital discharge, he says. "We want to make sure the treatment that patients get continues after they leave the hospital. Patients go from very intensive, 24-hour monitoring and support to typical outpatient treatment, which might be meeting once per week with a clinician."
With the new program, patients get support from a team of professionals who work together to monitor the patients' situations, help them to problem-solve, and identify if there are certain needs that are not being met that can be addressed with services, Gaudiano says.
"Our approach prevents things like nonadherence to treatment—we can make sure that we are supporting the patient, make sure that they can continue with their medication, and make sure that they can continue to get to their appointments. We can make sure that patients are being followed up, monitored, and reassessed for any kind of risk factors that might be developing. It is nonadherence problems and not being able to manage stressors effectively that trigger relapse and rehospitalization."
How the Transitional Outpatient Program was implemented
The most innovative element of the new program is case management, Gaudiano says.
"Adding in case management provides an extra level of support and care that otherwise is not typical of care when patients leave the hospital. We feel that if patients have short-term case management, that extra support that patients need in a limited time can help to reduce rehospitalizations. Often, patients need help with a variety of different issues that they are dealing with in the community. There might be several social determinants of health issues that a case manager can address and help the patient problem-solve. The case manager can help the patient access services for housing, financial issues, or other problems that they might be having," he says.
Two part-time case managers are the only new hires for the Transitional Outpatient Program, Gaudiano says. "We also have the outpatient therapists and prescribers, which include psychiatrists. They are basically devoting some of their time for this new program, but they were already employed at the hospital. So, this program does not require completely new staff because we can repurpose some staff or expand their duties to include this new program."
Therapy is individualized for the patients based on their mental health needs, he says. "Typically, it is a short-term model of care that identifies the patient's goals after hospital discharge. We want to make sure patients are supported in achieving those goals. Often, there is cognitive-behavioral treatment and short-term counseling that is provided. We also make sure our therapists provide safety planning to reduce suicide risk."
Medication management is another key element of the Transitional Outpatient Program, Gaudiano says. "Patients often have medication changes done when they are in the hospital. In seeing a provider after patients leave the hospital, sometimes there are further medication adjustments as their symptoms improve or as they adapt to the medications. So, a medication provider will assess that and adjust medications as needed to make sure that medications are continuing to work for the patient."
Measuring effectiveness of the program
Readmissions are the primary metric being used to gauge the effectiveness of the Transitional Outpatient Program, says Sarah Fleury, LICSW, manager of behavioral health at Blue Cross & Blue Shield of Rhode Island.
"The main quality metric that we are looking at is readmissions—we are hoping to lower 30-day readmissions for members who go through this program by 5%. If we can achieve a 5% reduction in readmissions—taking into account the costs of the case managers—we expect to have about $118,000 worth of net savings per year. That would be about 14 fewer readmissions per year," she says.
The Transitional Outpatient Program should be a good example of a behavioral health initiative that generates a return on investment and improved clinical outcomes, Fleury says. "The cost of the case managers, which is the component that we are adding, should ultimately result in a net savings from reduced readmissions. So, the program should generate a return on investment, and it ensures that our members have access to high quality care."
An Ohio medical center's chief diversity officer discusses the origins of mistrust and strategies to overcome vaccine hesitancy.
As the coronavirus pandemic enters its second year, reaching the Black community has emerged as one of the daunting challenges of vaccinating as many Americans as possible.
Survey data indicate that COVID-19 vaccination hesitancy is high among Black Americans. A survey commissioned by the National Foundation for Infectious Disease found 51% of Black adults were not planning to be vaccinated for COVID-19. A survey conducted by the Urban Institute found 49% of Black adults said they were unlikely to get vaccinated, with 28% who said they probably would not get vaccinated and 21% who said they definitely would not get vaccinated.
HealthLeaders recently spoke with Leon McDougle, MD, MPH, chief diversity officer at The Ohio State University Wexner Medical Center in Columbus, Ohio, to get his perspectives on vaccination hesitancy among Black Americans. McDougle is president of the National Medical Association, the country's largest and oldest national organization representing African American physicians and their patients. He is also past chair for the Association of American Medical Colleges' Group on Diversity and Inclusion.
HealthLeaders asked McDougle about the origins of COVID-19 vaccination hesitancy among Black Americans and how healthcare providers can address vaccination hesitancy in this population. The following is a lightly edited transcript of that conversation.
HealthLeaders: Why is there vaccine hesitancy among Black Americans?
Leon McDougle: When it comes to vaccine hesitancy, we need to be careful not to place the blame on Black Americans themselves. We must acknowledge the history of the medical establishment's treatment of Black patients and the trauma that has caused. A revealing example is the Tuskegee syphilis study, in which public health officials worked with the Tuskegee Institute to study impoverished Black men who had syphilis, leaving them without treatment for the disease so that researchers could study its progression in the body over 40 years.
Even today, we know that many of the health disparities among people of color are a direct result of unconscious bias and racism. A 2019 study, for example, shows that Black women are considerably less likely to receive standard treatment for heart attacks than white women. When you or members of your community have experienced this kind of unequal treatment, it's understandably difficult to take the word of strangers in white coats who want you to try a vaccine that has been developed unusually quickly.
HL:What can physicians do to address vaccine hesitancy among their Black patients?
McDougle: Physicians need to earn the trust of their Black patients in the spirit of mutuality by having conversations with patients that are not dominated by the healthcare provider—understanding the perspective of the patient is key. Those in the Black community can be assured by knowing that they were adequately represented in the COVID-19 vaccine trials. Independent groups of scientists and physicians, such as the National Medical Association COVID-19 task force on vaccines, are providing extra vaccine reviews on their behalf.
Importantly, transparent communication must include listening to individual concerns and acknowledging that vaccine hesitancy, especially in the Black community, is valid. This pandemic and the COVID-19 vaccine are unprecedented, and it is reasonable and understandable to have questions.
Safe, convenient, accessible vaccination sites must be established to ensure that certain communities of color are also able to get the vaccine easily when they are ready.
Leon McDougal, MD, MPH, chief diversity officer at The Ohio State University Wexner Medical Center in Columbus, Ohio
HL: What steps has Ohio State Wexner Medical Center taken to address vaccine hesitancy among Black people?
McDougal: Among Ohio State's many health equity and anti-racism initiatives are efforts specifically designed to address COVID-19 vaccine availability, accessibility, and misinformation. Our Anti-Racism Action Plan includes periodic Roundtables On Actions Against Racism (ROAAR)—public panels that bring together institutional and community leaders and are led by the Ohio State Wexner Medical Center's Health Equity Steering Committee. Our most recent ROAAR addressed these health disparities and other race-specific issues laid bare by COVID-19.
A multifaceted COVID-19 Vaccine External Education Committee at the Ohio State Wexner Medical Center develops consistent, educational, accessible messaging targeted specifically to our most vulnerable communities, while providing transportation to vaccine sites and assisting with neighborhood-based, mobile vaccine distribution. Recent examples are public service announcements that aired during the Super Bowl, featuring a diverse group of Ohio State Wexner Medical Center staff who shared their personal reasons for getting vaccinated.
Recently, we also opened a dedicated vaccination site on Columbus' Near East Side, central to the city's neighborhoods that typically have the fewest resources available to them. Patients and community members in targeted ZIP codes can receive their COVID-19 vaccine at a closer, more convenient site at Ohio State's East Hospital, in addition to the option of traveling to Ohio State's mass vaccination site at the Jerome Schottenstein Center.
Digital tools can increase the capability to communicate with patients and boost the efficiency and safety of intake processes.
Digital tools for intake processes and patient engagement boost efficiency for hospitals, physician practices, and patients.
During the coronavirus pandemic, hospitals and physician practices have adopted new intake processes and patient engagement tools to increase safety and ease staffing shortages. For example, hospitals and physician practices have adopted new processes to limit the number of patients in waiting rooms.
Family Practice Associates of Lexington, which is based in Lexington, Kentucky, adopted digital intake processes and new patient engagement tools in April 2020. "Most healthcare providers who utilize these kinds of tools would implement gradually over months. We implemented these tools in four days because of the pandemic. It was difficult but very beneficial in the long run," says Virginia Burberry, director of clinical education at Family Practice Associates of Lexington.
The physician practice implemented several elements of Phreesia's suite of digital intake workflows and patient engagement tools. Phreesia is a software-as-a-service platform that integrates with practice management and electronic health record systems.
In addition to a telehealth scheduling feature built into Family Practice Associates of Lexington's website, Burberry says the practice uses five of Phreesia's tools:
1. Enhanced mobile: The practice uses this tool to send check-in forms to the patient's mobile device. "In the past, the patient would have to stand in line and wait for a pad that someone else had used before them. Now, having that registration form sent to the patient's personal device allows them to fill out the registration form remotely. It gives the patient peace of mind," she says.
2. Self-scheduling: "The self-scheduling allows patients to avoid standing in line to make follow-up appointments or waiting in line to schedule the bone density assessment their doctor said they needed. The self-scheduling is online, and it is easy for them to use," Burberry says.
Self-scheduling has been particularly beneficial during the pandemic, she says. "We often have been operating with skeleton crews. We have had a lot of staff that were either sick or had to quarantine because family members had been exposed."
3. Health campaigns: Health campaigns enable Family Practice Associates of Lexington to send targeted text messages or emails to update patients on important information or prompt them to schedule appointments. "We can ask patients whether they are due for their well visit, due for their Pap smear, or due for six-month follow-up to get lab work. We also use health campaigns for general education such as where we are at in getting COVID-19 vaccine, our safety precautions for patients, and how we are doing our no-waiting-room policy," she says.
"The health campaign tool was important for sending information out to the patients about the new digital features. Within seconds, we could send out emails to 38,000 patients."
4. Patient chat: "This feature allows us to communicate with patients via text. We can direct patients to their exam room and communicate with patients when they arrive and when they leave," Burberry says.
The patient chat tool plays a key role in operating the practice's no-waiting-room policy, she says. "We can work off a dashboard and broadcast to several patients at the same time. They are told that when they arrive for their appointment, they should text us that they have arrived and that we will send further instructions. That allows our waiting room to be completely empty and gives the patients the confidence that when they come in, they are not going to be exposed to other people."
5. Broadcast messaging: This feature allows the practice to communicate with specific segments of patients or all patients. "We recently had to close on a Tuesday and were able to click on the dashboard and broadcast to more than 400 patients within seconds that we were closed due to inclement weather. We included the self-schedule link to allow them to reschedule their appointments later in the week," she says.
RWJBarnabas Health moved forward quickly in treating COVID-19 patients with monoclonal antibody therapy, giving the medication to patients within 10 days of emergency use authorization.
RWJBarnabas Health has embraced monoclonal antibody therapy for high-risk COVID-19 patients, providing the medication at all 11 of the health system's hospitals.
On Nov. 9, bamlanivimab became the first monoclonal antibody to receive an emergency use authorization (EUA) for the treatment of COVID-19 patients. The EUA for bamlanivimab marked a milestone in the coronavirus pandemic because the monoclonal antibody became the first medication that could be administered to COVID-19 patients on an outpatient basis.
"On the outpatient side, we really did not have anything to manage COVID-19 before monoclonal antibodies. People were just doing supportive care at home. Now we have a therapy that can be used to prevent the progression of COVID-19 in an outpatient setting," says Indu Lew, PharmD, senior vice president and chief pharmacy officer at RWJBarnabas Health.
The West Orange, New Jersey-based health system moved quickly to treat eligible patients with bamlanivimab, she says. "The EUA for bamlanivimab came out on Nov. 9; and within 10 days of the EUA being approved, we were treating our first patients. Ten days is extraordinarily quick from EUA approval to actual implementation."
Monoclonal antibodies mimic the body's immune response, and they have been approved to treat COVID-19 patients who are at high risk of developing severe illness, according to an article published recently in the Journal of the American Medical Association. "An antibody is a protein that is naturally produced by the immune system in response to an infection. A monoclonal antibody is a molecule developed in a laboratory that is designed to mimic or enhance the body's natural immune system response against an invader, such as cancer or an infection," the article says.
Monoclonal antibodies limit the ability of the coronavirus to bind to human cells and replicate, Lew says. "It binds to the receptor binding part of the spiked protein of the COVID-19 virus. What it does is it prevents the attachment of the spiked protein with the human receptor cells. So, if you cannot have the spiked protein attach to the human receptor cells, it prevents the virus from replicating and going into the severe symptoms that you see with COVID-19."
Under the EUA, there are four primary eligibility criteria for COVID-19 patients to receive monoclonal antibody treatment. A patient must:
Test positive for coronavirus
Present for treatment within 10 days of COVID-19 symptom onset
Not be sick enough to require oxygen or hospitalization
Be at high risk for progression to severe illness such as being over age 65
Model of care
RWJBarnabas Health is administering monoclonal antibody therapy at emergency departments in all 11 of the health system's hospitals.
There are two pathways for patients to receive the treatment, according to Christopher Freer, DO, senior vice president for emergency and hospitalist medicine at the health system.
1. Referrals: "We can get referrals from our doctors in the community. They are calling us and having a conversation between the emergency department doctor and primary care doctor to see whether a patient is a candidate. If the patient is a candidate, they are sent into the emergency department for the therapy," he says.
2. Presenting at the emergency department: If an ill patient tests positive for the coronavirus in the ED, the patient is assessed for whether hospital admission is necessary. If hospitalization is not necessary and the patient meets the other criteria for monoclonal antibody therapy, the patient receives an infusion of the medication that takes about an hour. Then the patient is observed for at least an hour for any side effects such as an allergic reaction.
After the monoclonal antibody therapy has been administered, the patient is discharged from the ED with a pulse oximeter and is monitored via telemedicine, Freer says. "We do telehealth visits on day 1 and day 3. We have a core group of doctors who have become outpatient specialists in the three regions served by our 11 hospitals. They call these patients and know what to ask and what to look for to see whether patients are progressing in the right direction or are taking a turn for the worse."
Promising data
As of Feb. 11, the health system had administered monoclonal antibody therapy to about 3,200 patients. Among these patients, there was one fatality. "When you have 3,200 high-risk patients and you only have one death, that is a good number," Freer says.
For monoclonal antibody patients, the primary metric the health system has been following is whether any of the patients have required hospitalization. Out of the 3,200 patients, more than 95% have not required hospitalization.
The positive outcomes are good news for patients and the health system, he says. "Keeping people out of the hospital keeps our beds open for people who need it. Our supplies, our ventilators, our personal protective equipment, and our medications for the patients are conserved. It has been a welcomed change compared to early in the pandemic when we did not have this type of therapy."
As of Feb. 25, RWJBarnabas Health had provided monoclonal antibody therapy to 3,800 patients.
Successful program
Patients do not have to pay the cost of the medication, Lew says.
"Right now, the therapy we are using is provided by the federal Department of Health and Human Services. The monoclonal antibodies go from Health and Human Services, come to our state, then our Department of Health allocates the monoclonal antibodies to our facilities. So, there is no cost to the patient for the therapy because we are receiving it for free. There is a cost that goes through insurance for the actual administration of the therapy and the ED visit," she says.
All eligible patients can get the therapy, Lew says. "At the end of the day, regardless of insurance or not, if someone comes to our facility and they are a candidate for monoclonal antibodies, we will treat them."
RWJBarnabas Health is a national leader in monoclonal antibody treatment for COVID-19 patients, Freer says. "We are way ahead of other health systems. I am getting calls from other health systems to discuss how we rolled out this therapy."
Among vaccine-hesitant adults, most were concerned about side effects and vaccine effectiveness.
A significant number of Americans say they are unlikely to get vaccinated for COVID-19, a survey report from the Urban Institute says.
Vaccination is widely viewed as an end-game stage in the coronavirus pandemic. One of the primary goals of vaccination is to achieve herd immunity—a point at which enough of the country's population will have immunity to the coronavirus that community spread is unlikely. In December, leading infectious disease expert Anthony Fauci, MD, said herd immunity for the coronavirus will require 70% to 75% of the population having immunity.
The Urban Institute survey report, which was funded by the Robert Wood Johnson Foundation, features data collected from more than 7,500 adults ages 18 to 64. The survey report has several key findings:
35% of survey respondents said they were unlikely to get vaccinated, with 19% who said they would probably not get vaccinated and 16% who said they would definitely not get vaccinated
49% of Black adults said they were unlikely to get vaccinated, with 28% who said they would probably not get vaccinated and 21% who said they would definitely not get vaccinated
47% of Republicans said they would probably not or definitely not get vaccinated
25% of Democrats said they would probably not or definitely not get vaccinated
Among vaccine-hesitant adults, most were concerned about side effects and vaccine effectiveness
Among vaccine-hesitant adults, 57% said they did not need the vaccine
Among vaccine-hesitant adults who were Republicans, 63% said they did not need the vaccine
Among vaccine-hesitant adults, 51% said they trust their healthcare providers about the vaccine
Addressing concerns about safety and effectiveness of vaccines
When it comes to the safety and efficacy of vaccines, a primary concern is the speedy development and production processes, says Julie Morita, MD, executive vice president of the Robert Wood Johnson Foundation.
"The survey done by Urban Institute made it clear that there were some people who had concerns about the short timeframe in which the vaccines were developed and produced as well as concerns about the safety of the vaccines and how effective they could be given that the vaccines were produced so quickly," she says.
"You can address those kinds of concerns by talking through the manufacturing process. The reason that these vaccines were developed so quickly was because billions of dollars were pumped into the development and manufacturing. There was incredible coordination between the manufacturers, government agencies, and academic institutions to have these vaccines produced," Morita says.
Concerns about safety and efficacy also can be addressed by highlighting the review process, she says.
"The process for reviewing the vaccines was comprehensive and rigorous. The Food and Drug Administration has a process and an external body for reviewing the safety and efficacy of vaccines before they authorize them. The Centers for Disease Control and Prevention has a process and an external body that reviews the vaccines before making recommendations about them. So, the vaccines that are currently available have been demonstrated to have strong clinical trial data that supports the vaccine safety and efficacy."
Addressing concerns among Black Americans
To address vaccination hesitancy among Black Americans, the reasons for the hesitancy should be recognized, Morita says.
"It goes to the deep-seated distrust of the healthcare system and government based on historic and ongoing mistreatment and lack of access to services. There also has been a poor history of experimentation in the past. Those kinds of things are things that we need to confront and acknowledge when we are working with the African American community," she says.
"We need to say, 'We know that there have been reasons in the past for mistrust. You may not have gotten the services you needed. You may have mistrust because of historic or ongoing discrimination that you faced.' Then you need to listen to them and engage with them."
Building trust among Black Americans will take effort, Morita says. "Earning trust after years of discrimination and years of mistreatment cannot be done overnight. You need to work with the community and get information into the hands of people they do trust, so they can have confidence and faith in the vaccines."
Addressing concerns of Republicans
Skepticism about the severity of COVID-19 is a root cause of vaccination hesitancy among Republicans, she says.
"A high proportion of Republicans reported that they did not feel they needed to get the vaccine. That would suggest that they do not necessarily recognize the benefits of the vaccine versus the risk of the disease. That is where healthcare providers can play an important role in terms of making it clear that what we know about COVID-19 is that it can cause serious infections and it can cause long-term illness."
How healthcare providers can address vaccination hesitancy
Healthcare providers need to be good communicators to address vaccination hesitancy among their patients, Morita says.
"It is important for healthcare providers to listen. Healthcare providers are trained to listen to their patients in terms of understanding what their symptoms are, what they are experiencing, and why they are in for a visit. Healthcare providers need to ask questions. If you are offering the vaccine, and people refuse the vaccine, then you need to ask why. You need to spend the time to understand what the questions or the concerns are. You need to spend the time to find out what information is needed to reduce the vaccine hesitancy."
