PUMPING IRONY: The COVID Effect

It’s common knowledge now that COVID-19 challenged our healthcare system in ways few public-health experts could’ve imagined, pushing our hospitals — and their staffs — to the brink of collapse in many cases. But the pandemic also may be remembered for the many ways it sparked new thinking throughout that sector, some of which is particularly relevant to my contemporaries here in Geezerville.

Chief among these revelations:

• Many surgeries and screening procedures may actually be unnecessary.
• In-home care may be just as effective as hospitalization — and would save everyone a lot of dough.

Researchers have long argued that certain medical procedures offer few benefits to elderly patients; a 2014 JAMA study, for instance, estimated that 42 percent of Medicare beneficiaries undergo some wasteful treatment annually. But the pandemic caused so many people to delay or cancel surgeries and screenings that scientists may be able to track their outcomes against those who underwent the procedures in pre-pandemic times — and imagine a system that focuses on “high-value” treatment.

“The COVID-19 pandemic has changed the healthcare landscape,” writes health sciences researcher Allison Oakes, PhD, in Health Affairs. “It has created a novel sense of scarcity, which has forced health systems to cut profitable services and prioritize seriously ill patients. At the same time, it has revealed a previously unseen counterfactual: a health system in which there is no low-value care.”

Earlier attempts to quantify unnecessary medical procedures, Oakes adds, have suffered from insufficient sampling. Most analyses have focused on a limited variety of treatments during a brief period of time. The pandemic offers researchers a chance to evaluate the effects in a broad population over a number of years.

“We see a unique methodological opportunity to evaluate the harms of low-value care,” Oakes explains. “Historically, it has been challenging to assess outcomes associated with low-value service use because use of observational data is susceptible to issues of selection bias and confounding; however, the COVID-19 pandemic has created a natural experiment by essentially randomizing patients to treatment or no treatment.”

A study published in Annals of Surgery earlier this year offers a glimpse at what a broader analysis may reveal. Researchers compared the outcomes of patients who canceled specific surgical procedures at Veterans Administration hospitals nationwide during the early days of the pandemic with those who underwent the same surgeries in 2018 and 2019. Tracking each set of patients over 30- and 90-day periods, researchers found those who put off the procedure were no more likely than those who went under the knife to experience an adverse outcome.

As unsurprising as such results may seem, Oakes and others may find it difficult to prevent our healthcare system from reviving its pre-pandemic menu of needless treatment offerings. Routine low-value procedures, after all, keep a regular stream of patients coming through the doors and reliably boost a hospital’s sagging bottom line.

But those financial issues — and our lengthy COVID-mandated quarantine — have convinced a number of hospitals to begin experimenting with a broad range of in-home care options that may actually deliver real benefits to the Medicare set.

As Julie Appleby reports in Kaiser Health News, about 30 percent of people currently admitted to hospitals with conditions such as pneumonia or heart failure would be eligible for round-the-clock remote monitoring and daily visits from practitioners. The concept, which has been growing gradually over the past decade, received a huge boost last month when Kaiser Permanente and the Mayo Clinic invested $100 million to help a Boston-based firm, Medically Home, expand its in-home care services.

Kaiser and Mayo are late arrivals on the in-home care scene, joining Johns Hopkins Medicine in Baltimore, Massachusetts General Hospital, Presbyterian Healthcare Services in New Mexico, and more than 20 other major players. Coming on the heels of Medicare’s announcement last November that it would pay for such care, though, their investment recognizes the opportunity awaiting the entire industry.

“In a lot of ways, this remains aspirational; this is the early innings,” says Dean Ungar, who follows the insurance and hospital industries for Moody’s Investors Service. But he sees major cost-savings opportunities for hospitals that “will increasingly be reserved for acute care [such as surgeries and ICUs].”

Bruce Leff, MD, a Johns Hopkins Medical School geriatrician who helped launch one of the first in-home healthcare programs almost 30 years ago, sees “tremendous momentum” because of the potential cost savings — as much as 30 percent according to some estimates. Hospital readmissions would drop, he notes, and the need for relentless facility expansion would ease.

For many patients, says Adventist Health’s Morre Dean, it could be a game-changer. “We see the patient in their home setting. What is in their refrigerator? What is their living situation? Can we impact that? We aren’t reliant on the family to deliver care.”

Every home is different, though, and not everyone would benefit in the same way. “It’s realistic in middle- and upper-middle-class households,” notes Gerard Anderson, PhD, a professor of health policy at Johns Hopkins University. “My concern is in impoverished areas. They may not have the infrastructure to handle it.”

And then, of course, there’s the question of Medicare’s long-term commitment to in-home care. When the pandemic is declared over, the agency will no longer reimburse these providers at the same level as it would for hospital care. That could slow the concept’s momentum considerably.

Still, it’s heartening to learn that industry leaders are taking COVID’s lessons seriously and at least considering new approaches to these and other operational issues. If a global pandemic can’t shake up a broken healthcare system, I don’t know what can.

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