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Entries from October 1, 2020 - October 31, 2020

Thursday
Oct292020

How the Pandemic Impacts Physician Revenue, Visits, Well-Being and View of the Future 

By Clive Riddle, October 29, 2020

A new AMA physician survey indicates COVID-19 impact has caused a 32% average drop in physician practice revenue. Their just released results of their mid-summer survey of 3,500 physicians also found that:

  • 81% said revenue was lower and they were providing fewer in-person patient visits compared to February
  • Revenue reductions were 50% or greater for nearly 1 out of 5 physicians.
  • In-person patient visits decreased 50% or greater for more than one-third of physicians.
  • Even including telehealth visits, almost 7 out of 10 physicians were providing fewer total visits (in-person + telehealth).
  • Total patient visits decreased 50% or greater for more than 1 out of 5 physicians.
  • Spending on personal protective equipment (PPE) since February increased 50% or greater for nearly 2 out of 5 medical practice owners.
  • 36% said that acquiring PPE was very or extremely difficult

The Physicians Foundation last month released the results of part two of their national survey conducted by Merritt Hawkins of 1,270 physicians, which address physician how Covid-19 has affected physician well-being, and found:

  • 30% of physicians have been made to feel hopeless or that they have no purpose as a result of Covid-19’s effects on their practice or employment situation
  •  18% have increased use of medications, alcohol or illicit drugs as a result of Covid-19
  • 24% have sought medical attention for a physical problem
  • 18% have sought mental healthcare
  • 8% have considered self-harm
  • 22% report they know a physician who has committed suicide

The Foundation last week released the results of part three of their national physician survey conducted by Merritt Hawkins, with this component addressing future of the health care system, which also found that:

  • 44% of physicians indicate that 26% of their patients delay or decline care due to costs
  • 42% strongly agree that conditions worsened by the pandemic induced delays will place a high demand on our health care system in 2021

Regarding the central focus of part three of their survey - on the future - the Foundation found this:

"While physicians' overall preference is for a hybrid approach, their opinions on other options for organizing our system yielded significant insights. Most surprisingly, maintaining or improving the current Affordable Care Act (ACA) influenced program did not initially rank high, with only 19% selecting this as number one on the one to four scale. Instead, 30% of physicians (the second highest percentage) chose moving to a market-driven system with Health Savings Accounts (HSAs) and catastrophic policies as number one. It wasn't until the next levels (two to four) were added that improving the current ACA system became more highly ranked (49%) than transitioning to a market-driven/HSA model (45%). The survey found significant polarity in support for HSAs: thirty percent of physicians rated it a number one, but 42% also rated it a four.  Support for a "single payer/Medicare for All" type of system consistently scored last with physicians, who rated the option either one through three. The only time it was not the least preferred option was among level four ratings, in which it was surpassed by HSAs 42% to 38%."

Thursday
Oct222020

Not Just Faxes

By Kim Bellard, October 21, 2020

I missed it when it was first announced in Japan, but fortunately the U.S. mainstream media has finally picked up on the story, with articles in both The Washington Post and The Wall Street Journal: Japan’s new Administrative Reform Minister Taro Kono has “declared war” on fax machines, among other paper-based traditions.

Wait, what? “Administrative Reform Minister?” The U.S., or at least the U.S. healthcare system, has to hear about this.

Mr. Kono set up a hotline for people to report government red tape, which was quickly overwhelmed with thousands of examples. It soon reopened.

It didn’t take long for Mr. Kono to start calling for significant changes. “To be honest, I don’t think there are many administrative procedures that actually need printing out paper and faxing,” he said in a press conference in late September. “

Part of the problem in Japan is the hanko, a personal stamp that is routinely used for authentication (and which thus requires paper.)

If you’ve ever envied Japan for its bullet trains, its early adoption of robots, or its broad use of consumer electronics, you may be surprised to hear that more than 95% of Japanese businesses still use faxes, and 34% of Japanese households have a fax. Mr. Kawaguchi admitted: “It may be 1970s technology, but it is extremely secure and very difficult for someone on the outside to hack…Digitisation may make things more efficient, but there is clearly a trade-off when it comes to security.”

Not surprisingly, the COVID-19 pandemic has been a big driver in the anti-fax initiative. Health care professionals were overwhelmed by the amount of reports that had to be prepared by hand and then faxed. “Come on, let’s stop this already,” one physician tweeted. “Even with corona, we’re handwriting and faxing.” Mr. Kono quickly retweeted it, even though he was still in his former position as Defense Minister — and within a week the health ministry announced a system of online filing (which, not surprisingly, has not entirely succeeded).

An independent report on Japan’s response to the pandemic found that their system “made it difficult to grasp the spread of infection in real time nationwide, and exhausted health center staff. The new coronavirus crisis was also Japan’s ‘digital defeat.’”

We don’t have hankos in the U.S., and we’re not as reliant on faxes as Japan is, even in our healthcare system. But red tape, inefficiencies, and antiquated technology? Yeah, we’ve got all that, especially in healthcare. But where’s our Secretary of Administrative Reform? Where are our Chief Administrative Reform Officers?

Heck, where are our hotlines to report red tape?

Even now, well over six months into our pandemic response, we have a slapdash, state-by-state (or even county-by-county) system of reporting, with hospitals and HHS still struggling to figure out what and how to report.

Yoshimitsu Kobayashi, chairman of Mitsubishi Chemical Holdings, sees the pandemic as an opportunity: “The very negative damage it has inflicted on Japan has in turn served as a powerful accelerator. If we miss this chance, we won’t be able to do it next time.”

Economist Paul Romer is usually credited with the quote, “A crisis is a terrible thing to waste.” Well, we certainly have a crisis, and I’m worried we’re going to waste it. Using it to just get rid of faxes would be a waste. We’re already using it to streamline development of therapeutics and vaccines, although not without problems. But will we use it to solve fundamental problems in our healthcare system, such as inequities, inefficiencies, and infrastructure?

Maybe we could recruit Mr. Kono to do the job.


This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Monday
Oct122020

Management and Rehabilitation of Long-Term Effects of COVID-19

By Dr. Seleem R. Choudhury, October 12, 2020

As a society, we have been enduring life in a pandemic for over half a year. Though we have been feeling the effects of COVID-19 for a long time, medically speaking the disease is still very new to us. It is important to remember that our knowledge is still developing regarding the virus and much remains unknown—specifically the long-term effects of the disease.

There is a common misconception that once a patient infected with COVID has a negative test, the issue is resolved.  It is often repeated that according to the World Health Organization, about 80% of COVID-19 infections are mild or asymptomatic, and patients typically recover after two weeks (Carfì, Bernabei, & Landi, 2020). 

Yet there are tens of thousands of people who have joined support groups on Slack and Facebook, who call themselves “long-termers” or “long-haulers” who are wrestling with serious COVID-19 symptoms a month or more after being infected with the disease (Yong, 2020). 

There are essentially two types of COVID patients experiencing who appear to be experiencing long-term effects of the virus—those who were ventilated due to critical symptoms and those who have residual symptoms despite having “mild” symptoms while infected with the disease (Liu, Yan, Wan, Xiang, Le, & Liu, 2020).

Critical care teams know that the longer patients remain in the intensive care unit (ICU), the more likely they are to suffer “long-term physical, cognitive and emotional effects of being sedated” (Edwards, 2020). In fact, those effects have a name: "post-intensive care syndrome (PICS)," also referred to as post-ICU delirium. PICS is an ongoing challenge even in non-pandemic conditions. An article in 2019 described PICS resulting in cognitive impairment in 30–80% of ICU survivors, the severity may vary and often lasts for years (Colbenson, Johnson, & Wilson, 2019).

As a hypothesis based upon 2019 post-ICU delirium numbers together with an increased number of patients on ventilators due to COVID, and then combined with non-hospitalized virus survivors who are experiencing long-term symptoms, our current circumstances potentially present a public health crisis (Vittori, Lerman, Cascella, Gomez-Morad, Marchetti, Marinangeli, & Picardo, 2020).  This presents hospitals, community practices, and mental health support agencies with an opportunity to expand their care services to meet a growing—and likely lasting—need.

Long-term effects of COVID-19

Four-fifths of those diagnosed with COVID experience mild symptoms.  A “mild” case is defined as two weeks or more of symptoms such as fever, cough, sore throat, malaise, and myalgias.  Beyond these flu-like symptoms, some patients have gastrointestinal issues, including anorexia, nausea, and diarrhea (Gandhi, Lynch, & del Rio, 2020). 

But experts are finding that patients who had mild symptoms can experience more than just a decline in physical health. Between 30% and 50% of people infected with COVID that have clinical manifestations will face some form of mental health issues, according to an estimate from Dr. Teodor Postolache, a professor of psychiatry at the University of Maryland School of Medicine (Goldberg, 2020; Advisory Board, 2020).  Those affected may experience anxiety or depression but also “nonspecific symptoms that include fatigue, sleep, and waking abnormalities, a general sense of not being at your best, not being fully recovered in terms of the abilities of performing academically, occupationally, [and] potentially physically” (Cooney, 2020).

Anecdotally, this matches what healthcare professionals are hearing from “long-haulers.” In addition to widely-reported fatigue reported by those healing post-COVID, these patients are experiencing neuropsychological problems ranging from headache, dizziness, and lingering loss of smell or taste to mood disorders and deeper cognitive impairment. Early reports from clinicians in China and Europe describe those infected with the disease suffering from lingering depression and anxiety, and in some cases muscle weakness and nerve damage preventing the ability to walk (Cooney, 2020).

Some COVID patients experiencing critical symptoms such as difficulty breathing were admitted to an Intensive Care Unit and placed on a ventilator.  On average in the U.S., approximately 0.8 million people every year receive this treatment in critical care; it can be reasonably assumed that this number will drastically increase in 2020 with the spread of COVID (Jaffri, 2020).

There are years of substantial data indicating that people requiring mechanical ventilation experience adverse effects after they are discharged from care (Wunsch, Linde-Zwirble, Angus, Hartman, Milbrandt, & Kahn, 2010).  People who survive up to two years after discharge from critical care are readmitted to nursing care, a rehabilitation facility, or to an ICU at up to a rate of 80%. Patients who have similarities to morbidities and the acute respiratory distress experienced by COVID-19 survivors are readmitted into these types of care at a higher rate (Jaffri, 2020). 

Additionally, a study published by the American Thoracic Society found that other issues such as physical impairment, physical deconditioning, and muscle weakness can affect those who required mechanical ventilation for up to a year after their removal from the ventilator (Ruhl, Lord, Panek, Colantuoni, Sepulveda, & Chong, 2014). Some also report difficulties returning to work or maintaining financial stability.  According to a 2018 study, 33% of individuals placed on a ventilator are unable to drive, limiting their mobility and social responsibilities, even up to a year after being discharged from critical care (Ohtake, Lee, Scott, Hinman, & Ali, 2018).

Solutions and opportunities

There is growing consensus that COVID-19 has potentially serious long-term physical and mental effects for survivors, regardless of whether symptoms at the time of infection were mild or critical.  Simple analytics should be able to ascertain the need. This review is important as It is the responsibility and opportunity of the healthcare community to respond to this potential health crisis within its community. 

The European Respiratory Society and American Thoracic Society-coordinated International Task Force recommends that clinicians follow up with all COVID-19 patients who were hospitalized because of the infection 6 to 8 weeks after their discharge from care (Spruit, Holland, Singh, Tonia, Wilson, & Troosters, 2020).

In response, COVID-19 rehabilitation clinics are being formed to focus on assessing patients’ cognitive ability, mental health, mobility, and ability to perform daily activities. These clinics offer mental health, physical therapy, and occupational therapy services, as well as pediatric rehabilitation medicine to address the needs of those dealing with long-term effects of the virus (Spruit, Holland, Singh, Tonia, Wilson, & Troosters, 2020).

The Spaulding Rehabilitation Network has engaged a multidisciplinary physician-led team of physiatrists, physical therapists, occupational therapists, speech language pathologists, and case managers to establish a dedicated outpatient clinic for those who are recovering or were hospitalized for COVID-19.  The Kennedy Krieger Institute is introducing a rehabilitation clinic for those children and adolescents under age 21 who have “recovered from the virus but need additional support to regain lost neurological and physical function as a result of the illness.”  The Shirley Ryan Ability Lab has been offering rehabilitation services for decades, and has already opened their services to those dealing with impairments as a result of COVID-19.

“Long-haulers” are experiencing the effects of a debilitating illness, and it will be vitally important for them to receive rehabilitation care, whether in person or via telehealth, to return to full health and quality of life (Urban, 2020).  As was stated in the European Respiratory Journal: “Considering the expected high burden of respiratory, physical and psychological impairment following the acute phase of COVID-19, a huge number of patients should be referred early to a rehabilitation program” (Polastri, Nava, Clini, Vitacca, & Gosselink, 2020).

Early data from health authorities in the United Kingdom and Italy, two countries hit hard with COVID-19, has shown that a structured rehabilitation program in-clinic, in the home, or virtually can mitigate post-ICU symptoms for those treated for COVID-19, thus resulting in improvements in daily function and independence. This success can also be extended to those with milder symptoms and reduce alienation that victims of the disease have reported experiencing, and ensure physical, emotional and cognitive functioning and recovery.

In the U.S. hospitals have been so focused on the present crisis, that they have not developed the capacity to deal with patients and their post-COVID needs. This could create a potential health crisis down the road. It is time to transition out of crisis-mode and begin to form a strategy to serve the needs of patients who are experiencing long-term effects of COVID-19.

Resources:

Read more from Dr. Seleem Choudhury at seleemchoudhury.com.

Thursday
Oct082020

15 Things to Know From Three New TeleHealth Studies

by Clive Riddle, October 8, 2020

July results from Fair Health's Monthly Telehealth Regional Tracker tells us that telehealth use continues to increase significantly during this COVID -19 year compared to last year, use has decreased somewhat from the previous month, and mental health conditions continue to be the number one telehealth diagnosis. The data represent the privately insured population, excluding Medicare and Medicaid. Launched in May as a free service, the Monthly Telehealth Regional Tracker uses FAIR Health data to track how telehealth is evolving from month to month.

Here's four things to know from their just released July data:

  1. Telehealth claim lines (an individual service or procedure listed on an insurance claim) increased 3,806 percent nationally from July 2019 to July 2020, rising from 0.15 percent of medical claim lines in July 2019 to 6.00 percent in July 2020
  2. While increasing greatly from 2019 to 2020, telehealth claim lines fell 12 percent nationally on a month-to-month basis, from 6.85 percent of medical claim lines in June 2020 to 6.00 percent in July 2020.
  3. In July, mental health conditions continued to be the number one telehealth diagnosis nationally and in every region, as they had been since March 2020. Nationally, mental health conditions represented 45 percent of telehealth claim lines in July 2020, compared to 37 percent in July 2019.
  4. Trends in the four US census regions (Midwest, Northeast, South and West) were similar to those in the nation as a whole. The Northeast had the greatest percent increase in volume of any region from July 2019 to July 2020: 8,987 percent. From June to July 2020, it also had the greatest percent decrease: 16 percent.

Last week J.D. Power released findings from its 2020 U.S. Telehealth Satisfaction Study, their second annual examination of patient satisfaction with telehealth services, measuring consumer telehealth service experience based on four factors (in order of importance): customer service (42%); consultation (28%); enrollment (19%); and billing and payment (11%). Here’s six things to know from their findings:

  1. The overall customer satisfaction score for telehealth services is 860 (on a 1,000-point scale), which is among the highest of all healthcare, insurance and financial services industry studies conducted by J.D. Power.
  2. 52% of telehealth users say they encountered at least one barrier that made it difficult to use telehealth. The most common hurdles are limited services (24%); confusing technology requirements (17%); and lack of awareness of cost (15%). Additionally, 35% of telehealth users indicate they experienced a problem during a visit. Tech audio issues (26%) are the most common problem.
  3. Overall satisfaction is 117 points lower among patients with the lowest self-reported health status than among patients who consider themselves to be in excellent health.
  4. Among patients who used a telehealth offering this year, 46% say their top reason for choosing telehealth was safety. That compares with just 13% in 2019.
  5. Cigna ranks highest among payers of health plan-provided telehealth services with a score of 874. Kaiser Foundation Health Plan (867) ranks second and UnitedHealthcare (865) ranks third.
  6. Amwell ranks highest in telehealth satisfaction among direct-to-consumer brands, with a score of 885. Doctor on Demand (879) ranks second.

Speaking of Amwell, they have just released findings from their 2020 Physician and Consumer Survey. Here’s five telehealth things to know from their study:

  1. The shift toward scheduled visits and specialty care is one of the most pronounced trends in telehealth usage during COVID-19. During the pandemic, patients were far more likely to use telehealth for scheduled visits, especially with providers they already knew. Just 21% of consumers who reported having a virtual visit had an on-demand urgent care visit in 2020. By contrast, 54% had a scheduled visit with their primary care physician.
  2. In 2020, 42% of consumers who reported having a virtual visit had a scheduled visit with a specialist they already knew, and another 13% had a virtual visit with a new specialist.
  3. The number of consumers who’ve had a virtual visit has nearly tripled since last year. What’s more, 59% of consumers who’ve had a video visit had their first one during the pandemic, and 91% of patients reported being “very” or “somewhat” satisfied with the visit.
  4. Among providers, the percentage of those who have used telehealth nearly quadrupled since last year, and 84% said they were “very” or “somewhat” satisfied with one or more telehealth platforms. 96% of physicians said they were willing to use telehealth, with a sizable majority saying they’d be willing to use it for prescription renewals (94%), regular chronic care management check-ins (93%), and follow-up visits after surgery or hospital stays (71%).
  5. During COVID-19, physicians most frequently cited technology challenges as a barrier to telehealth adoption at their organization (72%), followed by uncertainty around reimbursement (64%) and questions about clinical appropriateness (58%).