Much of the attention surrounding COVID-19 has focused on the incidence, the risk factors, and the medical needs of COVID-19 patients as well as the profound economic impact of the pandemic. However, an increasing area of emphasis is the profound effect the pandemic has had on non-COVID related medical care. This has important impacts not only on population health but also the financial health of providers, which can be critical to ensuring ongoing access to care currently and into the future. Here I describe the potential non-COVID population health impacts of the pandemic and how those may be exacerbated by providers facing financial challenges leading to furloughs and layoffs.
As cases increased in the US, many hospitals and providers began to cancel elective surgeries and other non- emergent care. Understandably, hospitals were trying to make room for a surge of COVID-19 patients as well as protect more vulnerable patients, especially those who might become infected while recovering from elective surgery. As a result, outpatient visits declined by nearly 60% in April 2020. Although rates have begun to increase they still remain well below the levels before the pandemic hit as many patients remain unwilling or unable to return to providers. More surprisingly, even many types of emergency care that one may expect to be less likely to decline such as heart attacks , strokes, and appendicitis, are falling. The biggest concern has been that out of fear, patients delay care until symptoms worsen leading to worse outcomes. All together, spending for health care dropped by 24.3% in April with large drops across nearly all types of care.
Population Health Impact
Early evidence suggests that in addition to over 100,000 deaths directly due to COVID-19, there are numerous additional, excess deaths attributable to the pandemic . Worryingly, the current delays in care foreshadow negative, future population health consequences. Cancer providers worry that delayed surgeries may have adverse impact on patients. Longer term, the drop in cancer screenings means providers may delay diagnosis of cancers. But it is not only cancer detection and care. Providers worry how the disruptions to diabetes, hypertension, kidney disease, mental health, and a variety of chronic diseases care may impact downstream health . In fact, some of our ongoing research seeks to better understand the types of care that have been delayed as a result of providers closing as well as patient reluctance to return for care. We are examining potential declines in elective surgeries, emergency care, prevention care, and prescription drugs as well as the potential longer-term impact on care and health outcomes.
Impact on Providers and the Resulting Impact on Patients
The American Hospital Association recently estimated that the pandemic has led to economic losses of $ 202 billion for US hospitals over four months. Not only have revenue losses skyrocketed due to cancelled elective surgeries and other higher margin care, but costs of providing care have increased due to increased need for personal protective equipment (PPE), higher cost of providing COVID-19 care, and increased costs of supporting clinical and administrative staff. There is also growing concern about hospitals in rural areas, which had already faced significant financial difficulties prior to the pandemic. Since rural hospitals are often critical for chronically ill patients accessing care, the concern is that this could lead to a growing wave of closures further limiting care to an already vulnerable population.
Additionally, community practices appear particularly susceptible to the financial impact of the pandemic as they often closed, stayed closed, and saw greater drops in patient volume than hospitals. While telehealth represents a promising solution for some of these practices, many types of care may not be feasible via telehealth and provider or patients barriers may further preclude use of telehealth. It is therefore critical to maintain financial health among providers, particularly safety net hospitals and federally qualified health centers, which treat the most vulnerable patients.
Importantly, we know these effects are not likely to be distributed evenly, disproportionately affecting minority population and lower socioeconomic groups more. We have already seen the devastatingly disproportionate impact of COVID-19 on Black and Latino populations, where both incidence rates, hospitalizations, and death rates vastly exceed White populations. There is a growing public appreciation of the systemic, institutional reasons for these disparities. Just as worryingly, Black and Latino are likely to also be disproportionately affected by the non-COVID impact on care and chronic disease outcomes.
While the Coronavirus Aid, Relief, and Economic Security Act or the CARES Act provided resources for a number of hospitals and other providers, the funds were temporary and it remains to be seen whether additional support will be forthcoming. While commercial health insurers have reaped the financial benefits of reduced care, they appear to remain cautious about subsequent waves of COVID-19 so are an unlikely source of financial support for providers. As a result, providers face the difficult task of navigating the ebb and flow of COVID-19 cases in different locations throughout the US while trying to provide the usual mix of acute and chronic disease care in the midst of unprecedented reductions in revenue. It is likely incumbent on the federal government to provide continued financial assistance to ensure hospitals and other providers have the resources to weather the current financial storm in order to provide the necessary COVID-19 and non-COVID care both now and into the future.