Home-based care is on the rise. With this transition, a detailed exploration of the potential unintended consequences is necessary. This article discusses this trend and focuses on 3 effects that may be already underway:

increased informal caregiving and costs to society; and

failure to meaningfully engage clinicians.

The past century was dominated by facility-based care, but a transition to health care at home is underway. For the first time since the early 1900s, Americans are now more likely to die in their homes than in facilities.

 Medicare spending on traditional home health more than doubled between 2001 and 2017

; looking ahead, the agency projects an annual growth rate of 7% for home health, more than any other category, and it estimates that spending will reach $186 billion by 2027.

 These trends reflect not just growth but also substitution. For example, postsurgical patients who otherwise might have spent 30 days at a skilled nursing facility (SNF) are instead being discharged with home health.

 Demand for home-based services will only accelerate amid coronavirus disease 2019 imperatives to minimize patient contact and patients’ fear of entering health facilities.

The shift toward home care is often depicted as a panacea for achieving the Triple Aim of better care, improved quality, and lower costs. However, this trend may also create new challenges. As care in the United States is increasingly delivered at home, a detailed exploration of potential unintended consequences is needed. We focus on 3 that are already apparent in traditional home health services and home hospice.

First, current models of home-based care have meaningful—and sometimes unexpected—gaps in patient support. In home hospice, for instance, payment for all medications, equipment, and visits in routine home care—the most commonly used hospice service—is $200 or less daily, 10-fold lower than the $2000 cost of a hospital night. As a result, routine home hospice care offers relatively little direct support day-to-day, often with only a few in-person visits weekly. For many patients, their needs fall into the large gulf between the low-touch levels of support available at home and the high-touch care available in hospitals, SNFs, or inpatient hospice. In these cases, relying on home-based services may pose risks to patient safety. These gaps may in part explain why a 2019 Office of the Inspector General report found that 1 in 5 hospices had a situation in which the “health and safety of beneficiaries were in jeopardy.”

 Gaps in home-based care may also extend to postacute care home health. Despite saving Medicare money, discharging patients home with just a few hours of in-person paid care instead of to a SNF with around-the-clock services has been linked to a greater risk of readmission.

 Although many patients benefit, home-based services may provide insufficient access to support for some.

Second, although home hospice or home health can relieve caregiver duties for short periods, the substitution of institutional care with these services largely transfers responsibility from the health system to informal caregivers, like friends and family. The need to provide routine care at home can create new stressors for caregivers, detracting from their own work or medical needs. Respite care to provide relief for caregivers, although sorely needed, is frequently limited in duration and accessibility; one of the main programs funding support for caregivers, the Older Americans Act, appropriates less than 1% of the unpaid care informal caregivers provide. Moreover, estimates of spending reductions from home-based care compared with institutional care often do not account for informal caregiving, vastly underestimating the societal costs. With 1 in 10 adults providing long-term services assistance to a family member, the unpaid economic value of informal caregiving is enormous; informal care in 2017 amounted to $470 billion, more than the economic value of all paid long-term support services including postacute care.

 Although home hospice and home health may reduce direct health care spending, they may simultaneously reduce economic productivity by demanding unpaid labor from employable caregivers, limiting the overall benefit to society and risking harm to patients.

Third, just as families may be unfamiliar with the gaps in home health and hospice services, so too may the clinician who orders them. A recent study found that the vast majority of physicians certify plans of care for home health care services, yet nearly half spent less than 1 minute reviewing the care plan.

 This finding is consistent with earlier evidence that most primary care clinicians rarely read plans for home health carefully, suggesting that they may arrange a home-based service without understanding its scope or devoting sufficient attention to their role in it. Ideally, growth in home-based care would be accompanied by increased efforts to train clinicians about home services, each program’s features, and how to select the appropriate service for each patient—but signs that this trend is underway are lacking.

Ultimately, a greater role for home-based care is needed in the United States. Growing evidence, including a Cochrane review and subsequent randomized trial in the United States,

 shows that even hospital acuity-level care can be provided at home with at least minimal to no difference in effect on patient health outcomes. However, several measures should be taken simultaneously with this transition to address a slowly emerging crisis.

First, payers can start to align home-based services reimbursement to reward high-quality care; for example, the Medicare Home Health Value-Based Purchasing Model has shown early signs of not only reducing spending but also modestly improving quality metrics and utilization of unplanned inpatient care.

 Along with patient outcomes, caregiver outcomes should also be assessed for such home-based services. Second, to avoid a one-size-fits-all approach, payers and providers can establish more gradations of intensity for each home service, enabling clinicians to select the appropriate level for a patient and thereby grant the benefits of receiving care at home to even those patients who need more support. Third, much like telehealth training is becoming a necessity for clinicians, more intensive clinician exposure to and education about home services can enable better coordination of a patient’s otherwise piecemeal home care.

Decades ago, clinicians providing care in homes was deemed “a vanishing practice.”

 Enabled by financial incentives and digital tools, the pendulum is now swinging from facility- to home-based care. This transition could greatly benefit patients, but only if we use these services to improve health rather than pass the buck to another setting without deeper scrutiny.

 Harvard Medical School (ALB, SG), Boston, MA; Harvard Business School (ALB, SG), Boston, MA; Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health (MLB), Boston, MA; Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital (MLB), Boston, MA.

 Mr Beckman reports receiving consulting fees from and former employment with Aledade Inc. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (ALB, SG, MLB); drafting of the manuscript (ALB, SG); critical revision of the manuscript for important intellectual content (ALB, SG, MLB); and supervision (MLB).

Michael L. Barnett, MD, MS, Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Kresge 407, Boston, MA 02115. Email: mbarnett@hsph.harvard.edu.

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2. Medicare Payment Advisory Commission. Home health care services. In: Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Medicare Payment Advisory Commission; 2019:227-248. Accessed June 24, 2020. http://www.medpac.gov/docs/default-source/reports/mar19_medpac_ch9_sec.pdf?sfvrsn=0

3. Sisko AM, Keehan SP, Poisal JA, et al. National health expenditure projections, 2018-27: economic and demographic trends drive spending and enrollment growth. 

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4. Barnett ML, Wilcock A, McWilliams JM, et al. Two-year evaluation of mandatory bundled payments for joint replacement. 

. 2019;380(3):252-262. doi:10.1056/NEJMsa1809010

5. Hospice deficiencies pose risks to Medicare beneficiaries. Office of Inspector General. July 2019. Accessed June 24, 2020. https://oig.hhs.gov/oei/reports/oei-02-17-00020.pdf

6. Werner RM, Coe NB, Qi M, Konetzka RT. Patient outcomes after hospital discharge to home with home health care vs to a skilled nursing facility. 

. 2019;179(5):617-623.doi:10.1001/jamainternmed.2018.7998

7. Reinhard SC, Feinberg LF, Houser A, Choula R, Evans M. Valuing the invaluable: 2019 update—charting a path forward. AARP. November 2019. Accessed June 24, 2020. https://www.aarp.org/content/dam/aarp/ppi/2019/11/valuing-the-invaluable-2019-update-charting-a-path-forward.doi.10.26419-2Fppi.00082.001.pdf

8. Boyd CM, Leff B, Bellantoni J, et al. Interactions between physicians and skilled home health care agencies in the certification of Medicare beneficiaries’ plans of care: results of a nationally representative survey. 

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Articles

WEB EXCLUSIVE

As home-based care utilization rises, an exploration of potential unintended consequences is necessary. The authors focus on support gaps, informal caregiving, and failure to meaningfully engage clinicians.

The Hidden Costs of Moving Care Home

In the midst of the coronavirus disease 2019 pandemic, payers must deploy policies to ensure care for individuals with opioid use disorder.

First, make it easy for patients to receive medications for opioid use disorder.

Second, increase access to care by reimbursing virtual visits.

Third, leverage data to identify and intervene when patients are at risk for recurrence or overdose.

Fourth, pay providers to maintain robust networks of addiction care.

Before the coronavirus disease 2019 (COVID-19) pandemic, care for opioid use disorder (OUD) had been steadily improving through expansion of Medicaid, widespread training of physicians, and alignment of payer policies with evidence. Today, COVID-19 threatens even these modest gains. Evidence-based policies related to physical distancing have slowed the virus but have also contributed to economic recession, social isolation, and psychological distress. These same factors, together with inappropriate prescribing of opioids and criminalization of drug use, laid the foundation for our current opioid crisis.

COVID-19 has led to a reduction in ambulatory care in parts of the United States due to physical distancing requirements, fear of transmission, lack of personal protective equipment, and staff shortages.

 Concomitant disruptions in the illicit drug supply may lead to increased overdose risk and demand for comprehensive addiction treatment. In the midst of this ongoing crisis, payers, both public and private, can and must rapidly deploy policies to ensure care for individuals with OUD. We highlight specific high-value strategies that could be quickly implemented with little additional investment in infrastructure, financing, or political will.

First, make it easy for patients to receive medications for OUD (MOUD), including methadone, buprenorphine, and naltrexone. Second, increase access to care by reimbursing virtual visits. Third, leverage data to identify and intervene when patients are at risk for recurrence or overdose. Fourth, pay providers to maintain robust networks of addiction care.

Behavioral science demonstrates that choice architecture plays an important role in our decisions. Through utilization and network management techniques, payers design a system for providers and patients to navigate. Ideally, that system nudges us toward high-value care. MOUD are lifesaving, reduce health care and criminal justice system costs, reduce transmission of infectious disease, and increase engagement in primary and preventive care.

 Buprenorphine merits special attention because it is safe and effective and can be prescribed in office-based settings with fewer regulations compared with methadone. As a first step, payers can immediately remove co-pays, prior authorization, dose limits, in-network restrictions, counseling, and other requirements that are often obstacles to receiving buprenorphine.

 Some argue that these policies may lead to increased diversion and misuse. In practice, expanded access to buprenorphine reduces diversion and misuse because they occur commonly among individuals seeking relief from withdrawal.

 Compared with buprenorphine monotherapy, buprenorphine-naloxone is associated with lower rates of misuse.

 Mark et al demonstrate that among Medicare beneficiaries, removal of prior authorization for buprenorphine-naloxone doubled treatment rates and significantly reduced emergency department (ED) visits and hospitalizations.

 Ultimately, the lifesaving benefits of expanded access to buprenorphine far outweigh the associated risks.

The past few months have seen an explosion in virtual care across the country as payers, including Medicare and state Medicaid programs, have loosened restrictions on telehealth. Telehealth, including synchronous audiovisual and audio-only modalities of care, has the potential to rapidly scale addiction care to patients across the country. Pre–COVID-19 federal regulation allowed for prescribing of MOUD over audiovisual platforms only to patients with whom physicians had a preexisting relationship. Emergency federal regulations now allow for buprenorphine prescribing for new patients via audiovisual and audio-only platforms.

Limited evidence suggests that virtual OUD care is as effective as in-person care.

 Pre–COVID-19, only a minority of individuals with OUD were accessing evidence-based and lifesaving treatment. In a time of social distancing, limited personal protective equipment, and transportation barriers, payment and delivery of telehealth is imperative to ensuring access to care. Because many patients do not have reliable access to broadband connection or smartphones, audio-only visits must be reimbursed as well.

The critical and urgent need for virtual OUD care during the COVID-19 crisis has outpaced our understanding of how best to deliver this care. Important questions remain, including which patients are most appropriate for virtual OUD care, how to monitor recurrence remotely, how to ensure privacy in the home, and the cost-effectiveness of virtual care. To answer these questions, payers must work with providers and policy makers while balancing the core principles of equity, access, quality, and cost. During the COVID-19 crisis, payers should commit to reimbursing telehealth at parity with in-person visits to encourage rapid provider adoption of virtual care.

Leverage Real-time Data for Targeted Outreach at Vulnerable Moments

Advances in informatics allow payers to receive real-time data to identify individuals with OUD who are vulnerable to recurrence and overdose. For example, in Virginia Medicaid, payers leverage pharmacy data to track interruptions in MOUD receipt, particularly during the first month of treatment. Patients with a greater than 7-day interruption in MOUD are contacted, encouraged to continue MOUD, and provided with home delivery of medications if transportation is a barrier. Similarly, through the state’s health information exchange, payers receive real-time alerts if a patient presents to the emergency department (ED) with a diagnosis related to OUD, which triggers outreach from a care coordinator. Payers across the country can leverage their pharmacy and ED data to identify when individuals with OUD may be most vulnerable and provide outreach to them.

Pay Providers to Maintain Robust Networks of Addiction Care

Many addiction treatment providers operate in a fee-for-service environment with only a few weeks of financial reserves. Even short-term reductions in visits threaten practice financial viability and, ultimately, access to care. Across the country, addiction treatment providers are furloughing or laying off employees and limiting service hours. Although the federal government has implemented payment policies to support the financial viability of health care providers, including small business loans through the Paycheck Protection Program, emergency funds to hospitals through the Coronavirus Aid, Relief, and Economic Security Act, and advance payments to providers proportional to prior Medicare billing, these measures are insufficient. Medicare, for example, covers only 14% of individuals with OUD.

 If there is no further action, more addiction treatment providers will have to close their doors. The reduction in billed visits means that payers now have a substantial amount of dollars to direct to and support an adequate network of addiction treatment providers. They can deploy advance or retainer payments on a per-member-per-month basis and tie those payments to basic quality indicators, such as receipt of MOUD and retention in care. Without a more resilient health care financing model, our already limited network of addiction treatment providers will be further devastated, resulting in significant harm just when those with OUD need care the most.


The most important question for us to ask is what happens if we do nothing. Empirical and observational evidence suggests that economic and psychological distress combined with social isolation and reduced health care access can have deadly consequences for individuals with OUD. The strategies outlined in this article can be implemented rapidly by all payers to ensure that the COVID-19 crisis does not worsen the opioid crisis. We failed to act early enough to forestall the opioid crisis. Today, we have the opportunity to apply lessons from the past to limit damage in the future. The lives of our patients, families, and communities depend on it.

 Virginia Department of Medical Assistance Services (CB, MT), Richmond, VA; Virginia Commonwealth University (CB), Richmond, VA; Leonard Davis Institute of Health Economics, University of Pennsylvania (CB), Philadelphia, PA; Friends Research Institute (MT), Baltimore, MD.

 Dr Terplan is employed as the Addiction Medicine Specialist for Virginia Medicaid. Dr Bachireddy reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (CB, MT); drafting of the manuscript (CB, MT); and critical revision of the manuscript for important intellectual content (CB, MT).

 Chethan Bachireddy, MD, MSc, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, 1101 E Marshall St, Richmond, VA 23298. Email: chethan.bachireddy@vcuhealth.org.

1. Mehrotra A, Chernew M, Linetsky D, Hatch H, Cutler D. The impact of the COVID-19 pandemic on outpatient visits: a rebound emerges. The Commonwealth Fund. May 19, 2020. Accessed May 27, 2020. https://www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits

2. National Academies of Sciences, Engineering, and Medicine. 

Medications for Opioid Use Disorder Save Lives

3. Martin SA, Chiodo LM, Bosse JD, Wilson A. The next stage of buprenorphine care for opioid use disorder. 

. 2019;170(11):821-822. doi:10.7326/L19-0145

4. Mark TL, Parish WJ, Zarkin GA. Association of formulary prior authorization policies with buprenorphine-naloxone prescriptions and hospital and emergency department use among Medicare beneficiaries. 

. 2020;3(4):e203132. doi:10.1001/jamanetworkopen.2020.3132

5. FAQs: provision of methadone and buprenorphine for the treatment of opioid use disorder in the COVID-19 emergency. Substance Abuse and Mental Health Services Administration. Updated April 21, 2020. Accessed May 9, 2020. https://www.samhsa.gov/sites/default/files/faqs-for-oud-prescribing-and-dispensing.pdf

6. Lin AL, Casteel D, Shigekawa E, Weyrich MS, Roby DH, McMenamin SB. Telemedicine-delivered treatment interventions for substance use disorders: a systematic review. 

. 2019;101:38-49. doi:10.1016/j.jsat.2019.03.007

7. Harris SJ, Abraham AJ, Andrews CM, Yarbrough CR. Gaps in access to opioid use disorder treatment for Medicare beneficiaries. 

. 2020;39(2):233-237. doi:10.1377/hlthaff.2019.00309

COMMENTARY

As the coronavirus disease 2019 (COVID-19) pandemic threatens to worsen the opioid crisis, payers must rapidly deploy policies to ensure care for individuals with opioid use disorder.

Payer Strategies to Ensure Access to Care for Individuals With Opioid Use Disorder During COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed how health care systems deliver services and revealed the tenuousness of care delivery based on face-to-face office visits and fee-for-service reimbursement models. Robust population health management, fostered by value-based contract participation, integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic. Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization. Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm.

Robust population health management integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises.

The coronavirus disease 2019 pandemic revealed the tenuousness of care delivery based on fee-for-service reimbursement models.

Population-level data and care management facilitate identification of demographic-based disparities and community outreach.

Telemedicine and integrated behavioral health have ensured primary care and specialty access, and mobile health and postacute interventions shifted site of care and optimized hospital utilization.

Beyond the pandemic, population health is a cornerstone of a resilient health system and can improve public health while mitigating risk in a value-based paradigm.

Prior to the coronavirus disease 2019 (COVID-19) pandemic, the US health care system was in the midst of major transformation—shifting away from the inefficiencies of fee-for-service toward value and patient-centeredness. The pandemic has highlighted the fragility of a volume-driven health care industry and illustrated how mature population health infrastructure can promote public health, strengthen health system resiliency, and support financial recovery.

Historically, large health care systems focused their population health efforts on optimizing performance in risk-based insurance contracts.

 However, the COVID-19 pandemic has caused priorities to shift rapidly. With a dramatic decrease in procedures and in-person visits, population health stands to become increasingly vital in health care delivery to improve outcomes and reduce costs.

 By utilizing the technology, governance, and infrastructure of existing population health programs, organizations can adapt care delivery to meet emerging patient needs. In this article, we examine how strategic population-based efforts can combat COVID-19, highlighting our experience within Partners Healthcare System (PHS), a large integrated health system based in Massachusetts (summarized in the 

). We detail the programs that have had the highest impact at PHS and other health systems in potentially stemming the impact of COVID-19, and we explore the fundamental role of population health in revitalizing health systems beyond the pandemic.

Population-Level Data: Identifying High-risk Patients and Potential Gaps in Care

During COVID-19, PHS utilized established population health information systems to identify high-risk patients, including data from clinical sources, claims reports, and risk capture efforts. We developed real-time dashboards to merge geography, demographics, and clinical characteristics of patients with COVID-19 to better understand disease incidence, drive service delivery decisions, and identify “hot spots” among vulnerable communities (

). For example, understanding that more than 6000 non–English-speaking patients were tested and 56% tested positive allowed rapid deployment of testing, food delivery, and kits with masks and disinfectant to high-prevalence neighborhoods using interpreter support.

 In addition, dashboards enabled leadership to review a defined set of COVID-19 key performance metrics on a daily basis, driving coordination and communication across a dispersed network.

Other population health programs have similarly adapted existing data and analytics infrastructure to support pandemic response efforts. For example, the University of California San Francisco Office of Population Health and Health Equity created an interactive map curating publicly available community data including COVID-19 cases, deaths, social determinants, and health outcomes.

 As a result, providers, payers, and industry partners could identify and address drivers of poor health outcomes, such as food insecurity. After the pandemic, these dashboards will be able to identify ongoing health inequities and monitor for COVID-19 recurrence (Table).

The COVID-19 pandemic has also had a collateral impact on chronic disease management.

 Existing risk capture efforts were used to identify complex patients at risk for adverse outcomes and to facilitate direct outreach. For example, registries for hypertension, diabetes, and chronic kidney disease identified the highest-risk patients to receive laboratory monitoring or medical procedures, prioritizing those who were likely to need dialysis in the near future.

 Similarly, a registry of patients with frailty, defined by the Johns Hopkins ACG System, was used to identify patients for augmented home-based care and goals of care outreach.

Care Management: Delivering Public Health to High-risk Patients and Addressing Disparities

For the last decade, the integrated care management program (iCMP) has been an essential component of PHS population health to coordinate care, improve outcomes, and reduce cost for high-risk patients by leveraging a dedicated nurse, social worker, or community health worker.

 This team was utilized as a public health workforce to provide outreach to patients at increased risk for adverse outcomes, including elderly patients, frail patients, and those with complex health conditions. They performed wellness checks, provided COVID-19 education, and conducted serious illness conversations clarifying goals of care before patients presented to a hospital.

 During the COVID-19 surge, iCMP reached out to 98% of its 15,000 adult and pediatric patients with an average of 14 contacts per patient and called more than 5000 non-iCMP patients at high risk for COVID-19.

The PHS ED Navigator program, which serves as an emergency department (ED) resource to link patients to primary care and social services, adapted its work to be telephonic and to identify isolation resources for patients who are homeless, housing insecure, or living in crowded conditions. ED navigators increased their work from 400 to 528 encounters monthly across the network to connect high-risk patients with critical resources.

Population health teams from other organizations, such as the Public Health Institute (PHI), have similarly adapted operations to meet public health needs exacerbated by the pandemic.

 PHI created guides about telephonic asthma management, provided opioid use support, and addressed health-related social inequities as part of its remote care management. Such care management programs will be critical after the pandemic to follow patients affected by COVID-19 and to identify those at risk of poor outcomes due to deferred care (Table). By proactively addressing chronic health conditions and the social determinants underlying them, care management can stem the impacts of a future pandemic.

Home Hospital and Postacute Collaborative: Providing Flexibility When Site of Care Matters Most

PHS site of care and postacute programs have been rapidly scaled to offer remote care options for patients with COVID-19. The Home Hospital program provides inpatient level of care to low-acuity patients in their homes, and the Mobile Integrated Health (MIH) program uses paramedics to further support home-based care delivery.

 During the pandemic, these programs expanded capacity to prevent potential COVID-19 exposure in patients requiring hospital care and to monitor patients with COVID-19 who were recovering at home, reducing inpatient utilization and preserving higher-acuity resources.

 Within the first 46 days of MIH expansion, teams evaluated 102 patients with confirmed or suspected COVID-19, with 92.2% of patients able to continue care at home. During April to June 2020, 96 additional patients without COVID-19 symptoms were admitted to Home Hospital for an average of 4.8 days, resulting in approximately 480 inpatient bed days saved.

Postacute care is critical to identify safe locations for patients with and without COVID-19 to recover and to maintain inpatient hospital capacity.

 PHS mobilized an existing collaborative of long-term acute care hospitals and skilled nursing facilities (SNFs) to address the surge in postacute capacity by creating unified admission plans, creating COVID-19–specific SNFs, and supporting personal protective equipment (PPE) provision to facilities.

 This team’s expertise was extended to support the creation of a 1000-bed field facility called Boston Hope Medical Center, with a dual focus on respite care for homeless populations and postacute care for those recovering from COVID-19.

The University of Washington also collaborated with postacute partners to develop a comprehensive strategy for COVID-19, which included establishing clear criteria for facility admission, providing PPE training, equipping testing supplies, and developing isolation plans.

 Population-based postacute strategies during the pandemic helped prevent delays in discharge, spread of infection, and overwhelmed facilities to mitigate the effects of the public health crisis.

Behavioral Health: Providing Psychological Support at a Time of Great Need

COVID-19 has brought numerous mental health challenges due to elevated stress, financial insecurity, and exposure to traumatic events.

 To address these needs, we adapted existing programs in behavioral health management, substance use disorders, and digital health. We identified patients at high risk of mental health complications and used primary care–based resources to intervene on acute anxiety and stress. We also adapted substance use disorder programs to include virtual recovery coaching, resulting in 10 virtual recovery groups weekly, and supported medication-assisted treatment when new regulations allowed prescribing without an initial face-to-face visit.

Across Massachusetts, organizations leveraged the rapid reforms in insurance and Health Insurance Portability and Accountability Act waivers to increase access to telehealth psychiatric care and to enhance support for residential and group home settings.

 At PHS, digital health pilots expanded capacity for internet-based cognitive behavioral therapy (iCBT) and mindfulness tools and to offer a Spanish-language iCBT platform. PHS also increased access to telehealth programs and psychiatric care for employees and their families. In the first 3 months of the COVID-19 pandemic, 148 patients and employees were provided iCBT.

In New York, the New York City branch of the National Alliance on Mental Illness embraced population-level telephonic mental health services and expanded digital platforms for anxiety, depression, and peer support, particularly for New York City health care workers.

 Behavioral health programs developed during COVID-19 will be increasingly needed to “flatten the behavioral health curve” of subsequent trauma, grief, and unhealthy coping, and they will be vital in the future to offer more flexible and rapid access to mental health resources (Table).

Telemedicine: Ensuring Access While Maintaining Social Distancing

Early in COVID-19, CMS eased telemedicine regulations to promote telehealth services and enable social distancing.

 This rapid shift facilitated the development and scaling of telehealth in essential ambulatory care and new COVID-19 programs.

 Nationally, more than 50 health systems leveraged existing telemedicine programs to provide virtual care during the pandemic.

 At PHS, we rapidly transitioned established virtual visit platforms to enable chronic disease management and urgent care access, addressing conditions that may otherwise lead to hospitalizations. In April to May 2020, virtual visits accounted for nearly 60% of total visit volume, with 330,000 completed visits. Similarly, an existing e-consult program was expanded to increase access to specialty care without an in-person visit. One of our academic medical centers has seen the proportion of e-consults among total referrals increase from 8.5% to 19.6% since March 2020.

There is increasing recognition that telemedicine helped mitigate the consequences of delayed care due to COVID-19 and could replace aspects of in-person care.

 However, the proliferation of telehealth also requires a deliberate focus on health equity. Within our system, equity programs collaborated to reduce the “digital divide” by increasing patient portal enrollment, distributing educational materials in multiple languages, and using SMS text messaging applications for virtual health. After the pandemic, further efforts will be needed to evaluate telemedicine and to ensure that all populations have access to its benefits.

Population Health as the Foundation of Care Delivery in the Post–COVID-19 World

In the near term, health care systems may understandably focus on volume to recover lost revenue and may worry that participation in accountable care organizations could increase financial risk due to the unknown impact of COVID-19 on contract performance.

 However, population health management will have an essential role after COVID-19 to support financial recovery and to lead the transformation of health care delivery.

Financially, capitated contracts and shared savings payments can allow continued cash flow during the pandemic. Risk coding can ensure adequate reimbursement and federal stimulus funding by identifying the complexity of COVID-19 cases. Network management programs can help recover referral volume as nonessential procedures are resumed. In the long term, population-based payment models, like capitated or subcapitated contracts, can enable health systems to flexibly deploy clinical programs to meet evolving patient needs and slow the growth of health care spending.

After the pandemic, population health programs can lead the development of a resilient health system (Table). The analytics, proactive outreach, and program innovation that drove success during the initial COVID-19 surge can help prevent a resurgence by delivering tailored services. Clinical registries and risk prediction models can identify patients at highest risk of poor outcomes, and high-risk care management should expand to flexibly respond to medical and social needs. Telemedicine should be recognized as an essential tool to minimize low-value care while improving efficiency and patient experience. Robust postacute and behavioral health programs will be needed to manage future capacity for convalescing patients and to address the ongoing mental health challenges of COVID-19. Interventions to identify health inequities and support digital access should continue to address the disparities highlighted by the pandemic.

 By creating efficiency and improving outcomes, population health can both advance our system of health care delivery and support the changing needs of providers, payers, and patients.

Effective population health management is vital to enable rapid adaptation to public health crises and to promote long-term financial sustainability. Population health should lead as a suite of programmatic initiatives and as a learning system of delivery science to support the evolution of the health care system to be more patient-centered, efficient, and resilient.

Salina Bakshi, MD, MPH, and Katherine H. Schiavoni, MD, MPP, contributed equally to this work and are listed as co–first authors.

The authors would like to thank Michael Esters and Janet O’Malley for their leadership and contributions to the population health management programs described in the article.

 Population Health Management (SB, KHS, LCC, TEC, AOF, BPF, FRK, CTP, JSR, DFT, JHW, GSM, MLM), Department of Quality and Patient Experience (TEC, BPF, TDS), and Data and Analytics Organization (DFT), Partners Healthcare, Boston, MA; Division of Cardiology (JHW), Department of Medicine (SB, KHS, FRK, CTP, JSR, SJB, GSM), and Department of Psychiatry, Depression Clinical and Research Program (TEC), Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Emergency Medicine (LCC), Division of Nephrology (MLM), and Department of Medicine (AOF, TDS, GSM, MLM), Brigham and Women’s Hospital, Boston, MA; Division of Geriatric Psychiatry, McLean Hospital (BPF), Belmont, MA; The Mongan Institute, Massachusetts General Hospital (SJB), Boston, MA.

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (SB, KHS, LCC, TEC, AOF, BPF, FRK, CTP, JSR, DFT, JHW, SJB, TDS, GSM, MLM); acquisition of data (SB, KHS, LCC, TEC, AOF, BPF, FRK, CTP, JSR, DFT, JHW, SJB, TDS, GSM, MLM); drafting of the manuscript (SB, KHS, LCC, TEC, AOF, BPF, FRK, CTP, JSR, DFT, JHW, SJB, TDS, GSM, MLM); and administrative, technical, or logistic support (SB, KHS, LCC, MLM).

 Mallika L. Mendu, MD, MBA, Department of Quality and Safety, Brigham and Women’s Hospital, One Brigham Circle, Boston, MA 02115. Email: mmendu@partners.org.

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The authors detail how population health management enables health systems to promote public health, strengthen health system resiliency, and support financial recovery during and beyond coronavirus disease 2019 (COVID-19).

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