The telehealth policy changes enacted for short-term control of the coronavirus disease 2019 (COVID-19) pandemic present an opportunity to address the fundamental gap in health care underutilization.
Am J Manag Care. 2021;27(1):In Press
Despite the high and rising costs of health care in the United States, major gaps in care delivery are leading to health care underutilization, including care avoidance and care postponement, that are now being exacerbated by the coronavirus disease 2019 (COVID-19) pandemic.1 Health care underutilization, especially undertreatment of chronic disease, has negative health and economic effects. Nearly 40% of all deaths in the United States can be attributed to undermanaged chronic medical conditions such as smoking, poor diet, lack of physical activity, and excessive alcohol use.2 Moreover, chronic diseases are the leading driver of health care costs in the United States: If the economic productivity lost due to chronic disease burden is considered, the total cost is approximately $4 trillion per year, about one-fifth of the entire US economy.3 Yet chronic disease prevention efforts, such as cancer screening and influenza and pneumococcal vaccination for the elderly and at-risk populations, continue to prove to be cost-effective, suggesting that underutilization of chronic care management is contributing meaningfully to rising health care costs.4-6
Unfortunately, this underutilization of care is now being intensified by the COVID-19 pandemic. Not only are individuals dying from COVID-19 in hospitals and at home, but rates of avoiding or delaying care have increased, precipitating a 20% to 40% decrease in hospital admission rates compared with pre–COVID-19 levels.7,8 Furthermore, chronic care management is inhibited by reduced access to in-person care due to the pandemic.9 In response to this drastic mortality exacerbation and reduction of in-person health care feasibility, a plethora of interventions and policy discussions are being introduced, many of which revolve around telehealth and access to digital health communication strategies. While addressing the pandemic itself, the health care system is simultaneously presented with decisions on how to improve acute care and address the concurrent problem of health care underutilization to both enhance quality and manage costs.In this paper, we argue that the same policy changes being enacted for short-term control of the pandemic, specifically those increasing telehealth modalities, present a scope for major change to address the fundamental gap in health care underutilization and directly improve chronic care management over the long term.
A key promising opportunity that is already burgeoning is the increasing usage of innovative disease management strategies such as telehealth, which encompasses the provision of health care services over the internet.10 Numerous barriers limited the uptake of telehealth prior to the COVID-19 pandemic, including reimbursement gaps resulting from many third-party payers not covering telehealth, as well as interstate medical licensure limiting the scope of telehealth.11 However, these barriers have been directly addressed in attempts to improve health care access during the pandemic, leading to modifications in telehealth reimbursement and elimination of many restrictions on practicing telehealth across state lines.10,12-14 These changes have had drastic effects in telehealth utilization already. In 2018, only 18% of doctors practiced medicine with some component of telehealth, compared with nearly 50% now.15 To exemplify the profoundness of this point, at Mount Sinai Faculty Practice in New York, New York, more telehealth visits occurred per average day in April 2020 during the height of COVID-19 than in all of 2019.16
In light of the boom in telehealth use, current evidence suggests a cost-reduction potential for the health care system and insurance providers, not to mention the financial incentives that accompany an increased ability to care for chronic diseases.17 Furthermore, of the 4 areas of spending on chronic disease management that account for two-thirds of all health care costs, both high volume and administration would be directly affected by sustained telehealth expansion.18 The increase in telehealth as a result of the COVID-19 pandemic is a prime opportunity to improve the effectiveness of health care expenditures by filling the void in chronic disease management and increasing access to care overall. This would not only be beneficial during times of social isolation but would also continue to improve health care once the pandemic is controlled.
Remote patient monitoring (RPM) is another disease management strategy that utilizes and builds upon the expansiveness of telehealth to reach underserved populations and fill an unmet need in American health care.19 RPM is a cost-effective method of engaging patients and promoting continuity in care that can integrate care teams and target high-risk groups through multiple channels.20-22 Effective RPM can improve access to chronic care management and help reduce unnecessary admissions, thereby reducing nonessential expenditures and cost burden from more acutely sick, hospitalized patients.23 CMS has issued a number of changes that tear down prior barriers to RPM as a means of providing care during the pandemic. One such change is fundamentally redefining RPM to include care for both acute and chronic conditions, instead of only chronic conditions, which permits new patients, rather than only previously established patients, to access RPM.15,24 Moreover, through changes to reimbursement approaches, incorporation of RPM will enable medical practices to financially benefit, in addition to improving access to chronic disease management for patients.25 Given the financial stress that COVID-19 is having on medical practices, this presents a win-win opportunity.26 We recommend, along with expansion of telehealth and RPM, the concurrent expansion of paramedicine, which allows for remote, rapid evaluation and stratification of patients and has led to fewer unnecessary emergency department visits, ambulance transports, and inpatient health care services; these changes have reduced costs and achieved high patient satisfaction.27
The incorporation of community health workers (CHWs) with telehealth advancements presents an additional opportunity to advance patient care during times of reduced in-person health care contact. Prior to COVID-19, CHWs, who served their respective communities through culturally appropriate health promotion and patient education, had demonstrated vast improvements in access for patients by improving care efficiency and reducing the need for emergency and specialty services.28,29 Moreover, incorporation of CHWs—as well as, similarly, care managers and navigators—has been associated with overall cost savings in addition to improved management of chronic disease and successful outreach attempts through multimodal communication efforts such as cell phone messaging.30-33 In light of the COVID-19 pandemic, a response effort that uses established CHW networks for short-term pandemic suppression with text messaging and virtual health outreach programming will also enable long-term amelioration by strengthening established care avenues.34-36 Although national policies promoting CHW telehealth strategies to combat the pandemic have not yet occurred, some states are upregulating CHW involvement as a short-term pandemic suppression strategy. Incorporation of CHWs is a potentially inexpensive method (although not without costs given the required manpower) to help fill the massive need for additional caregivers while simultaneously addressing the rising unemployment burden in the greater economy.37
The COVID-19 pandemic is testing the American health care system and highlighting major gaps in care, such as health care underutilization. The systemic response to the pandemic presents an opportunity to address these same gaps while combating the pandemic itself. The explosion of telehealth and RPM has the potential to improve health care underutilization and strengthen established community health care networks, thereby improving chronic disease care and improving patient outcomes through established cost-effective strategies. As CMS will continue to reimburse for telehealth equally with in-person visits until the Public Health Emergency ends, it would be advantageous to streamline these methods quickly to provide additional care during the pandemic and retain these well-established systems for long-term coordination.38 The COVID-19 pandemic has removed barriers that previously inhibited the success of remote health care. Recent policy encouragement has increased patient engagement in chronic care management through telehealth, RPM, and CHWs. By fortifying these essential avenues of care, we have the ability to help patients, hospitals, and the overall American health system—an opportunity we cannot afford to ignore.
Author Affiliations: Icahn Mount Sinai Hospital (CAB, AR), New York, NY; New York University School of Medicine (MN), New York, NY.
Source of Funding: None.
Author Disclosures: 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.
Authorship Information: Concept and design (CAB, MN, AR); analysis and interpretation of data (MN); drafting of the manuscript (CAB, MN, AR); and critical revision of the manuscript for important intellectual content (CAB, MN, AR).
Address Correspondence to: Chip A. Bowman, MD, MPH, Icahn Mount Sinai Hospital, 1 Gustave L. Levy Pl, New York, NY 10029. Email: email@example.com.
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