Our research team breaks down this week’s top healthcare news.
In an age of unprecedented change, staying current has never been more important. Our team at Chartis is curating news most relevant to the healthcare industry and tracking the topics that are trending on seven key issues: clinical quality and risk, digital and advanced technology, financial sustainability, health disparities, the health ecosystem of the future, partnerships, and the provider enterprise. Each week, we break down what’s happening and why it matters.
The pediatric population represents a growing proportion of COVID-19 cases in recent months. In April children made up only 2 percent of COVID diagnoses, but by the end of September, they represented 10.5 percent of all cases cumulatively. While cases in children have typically presented with milder symptoms than adults (approximately 2 percent of children have required hospitalization, compared with roughly 9 percent of adult cases), a JAMA Pediatrics study analyzed nasal swabs and found children have similar viral loads to adults, indicating that they can transmit COVID. High rates of asymptomatic pediatric cases combined with varying degrees of mask adherence depending on age and enforcement makes detection and spread prevention in children even more difficult. It is not surprising, then, that a JAMA study in May 2020 found that communities with school closures were associated with lower COVID incidence and mortality.
While lower infection rates are an obvious advantage of school closures, the drawbacks to the health of many children should not be understated. For many students, school provides much more than daily education — it is the source of healthy meals, mental and preventative care and health screening, special needs education and therapy, and a safe space for movement and exercise. Shuttering in-person schooling has clear benefits but at a cost to one of the largest pediatric safety nets.
Millions of children rely on school as a safety net, and without school in the pandemic, families are scrambling to find replacement health and social services. Many public schools were already struggling with funding, and the pandemic has only exacerbated that. Families of color and low-income families are hurt disproportionately more by these service losses. Childhood obesity, an already growing problem, is expected to see a rapid increase without the safe, scheduled recess time schooling provides. Nearly 30 million children received free meals through the National School Lunch Program last year, and while some communities have continued to provide meal distribution or funds for purchasing food, many children have likely slipped through the cracks. Families of children with special needs have faced the difficult decision to pay out of pocket for virtual therapy or home health or to forgo therapy all together. Schools cannot simply re-open and risk increasing community spread without the right precautions and procedures in place. But without in-person schooling, there is an urgent need to fill the role schools play in health and social services.
Investment in digital health solutions, including telehealth, slowed in the second quarter of 2020 as uncertainties grew about the pandemic and its impact on healthcare and the general economy. However, a spike of $4.0 billion in venture capital funding in the third quarter pushed total investment in digital health solutions for the first nine months of 2020 ($9.4 billion altogether) past the total for all of 2019 ($8.2 billion). The growth in digital health start-ups and investment began years ago, but the pandemic introduced an immediate need to minimize direct human-to-human interaction at all levels of clinical care and follow-up. Development of digital solutions for that type of care delivery accelerated. The digital health category that has received the most interest from fund investors the third quarter is “on-demand” services, including telehealth, prescription delivery, and at-home urgent care. To add to the growing landscape, large tech companies like Apple and Alphabet (the parent company of Google) are launching their own telemedicine and other digital health platforms to compete with both giants like Teledoc and smaller start-ups.
Despite the proliferation and success of many digital health solutions, technology has not replaced human capabilities perfectly. For example, total primary care visits during the initial surge of COVID-19 (in the second quarter of 2020) fell below levels in the same quarter in previous years, despite the spike in telehealth. In addition, some key components of primary care, such as blood pressure and cholesterol checks, are not as easily performed virtually without special equipment that most patients do not have and many providers’ tech platforms can’t support. In addition, a key requirement for telehealth and virtual care — a secure, reliable internet connection — by definition excludes some already at-risk populations, such as those who cannot afford wireless and those in rural areas where it isn’t available.
The development and adoption of digital health solutions and virtual care have accelerated due to the pandemic, and these solutions will likely remain and evolve, helping to shape the future of healthcare delivery. However, telehealth and virtual care solutions are more applicable to certain services than others (e.g., behavioral health vs. orthopedics), and some specialties may substantially reduce telehealth use once it is safe to do so. In addition, since most digital health solutions currently cannot perform remote versions of many tests and procedures (or require expensive add-ons to do so), those with chronic conditions are not being managed well through virtual primary care. Adverse events, such as heart attacks and strokes, may rise as a result. If telehealth is to continue at high volume in specialties like primary care, we will need to find a way to advance the capability and adoption of at-home testing and monitoring solutions and increase affordability and insurance coverage.
A potentially detrimental impact of the largely positive growth in telehealth is the exacerbation of health disparities in poorer or isolated communities due to lack of internet access — again, a key requirement of digital health solutions. As we wait for broader internet coverage to be built across all areas of the country, and potentially some subsidies for lower-income families to afford internet, an idea has emerged to help reduce these disparities and increase access to telehealth: use community libraries’ internet services for virtual care. This is an interesting approach and would certainly increase access, though ethical and privacy issues would need to be addressed.
As we look ahead, we will need to find the right balance of in-person care and virtual care, by specialty and locale, and consider the potential shortcomings of virtual care alongside the touted benefits, mitigating the former where possible.
The care of the president this week, as well as other high-profile individuals throughout the pandemic, highlights the impact of privilege in healthcare. The president was given daily testing, and once positive, had immediate access to expert hospital care and experimental drugs like Regeneron’s monoclonal antibody treatment, not available elsewhere outside of clinical trials. Even for those who do not contract COVID-19, its impacts on health disparities may be felt in other ways. Many have lost their jobs, resulting in loss of employer-sponsored health insurance and soaring out-of-pocket care costs. For people with diabetes who do not have insurance — a population that is disproportionately more likely to be Black, Hispanic, or Native American — the cost of insulin can become prohibitively expensive. As a result, during the pandemic, insulin sharing (using another patient’s excess prescribed medication) has skyrocketed. While the practice is illegal, it is the only financially viable option for many.
Prior to the pandemic, insulin costs for patients with diabetes was already a concern. A survey by the National Center for Health Statistics, as reported by the CDC, found that among adults who were prescribed a diabetes medication in a recent 12-month period, 13.2 percent skipped doses, took fewer doses, or requested a lower-cost medication. In June of this year, the unemployment rate among patients with diabetes had risen to 18 percent. Chronic conditions like diabetes (which can be well-managed through preventative care, monitoring, and medication adherence) can quickly escalate to life-threatening crises for those without insurance who cannot afford their care or medication. Those with insurance are also more likely to have access to technology and replace their in-person care with telehealth. But for more vulnerable populations, limited infrastructure excludes this option. In order to protect vulnerable populations, we should consider investing in smart technology and monitoring for safety net patients, prioritizing broadband access so that telehealth does not further widen the health inequity gap, and ensuring a quick and seamless process for drug assistance programs, so that no one has to make the decision of whether to pay for food, housing, or life-saving medicine.
For children's hospitals, COVID-19 has been materially disruptive — impacting both the health of pediatric populations as well as the health system bottom line. Children’s hospitals must continue to lead throughout this crisis, focusing on the health of children and the long-term sustainability of the child health ecosystem while at the same time taking immediate action to reopen services and close the budget gap created by the pandemic.
For months, CIOs and their teams have supported their health systems in preparing for and combating the COVID-19 pandemic. As many look beyond the initial surge, CIOs face a new stage of challenges as they consider how to best leverage technology to help their organizations survive and ultimately thrive in the “new normal.”
In this new analysis, The Chartis Center for Rural Health explores key factors in assessing the potential impact of the COVID-19 pandemic on the rural health safety net, including access to intensive care unit beds, the reliance on outpatient service revenues and rural provider days cash on hand.