Both payers and providers can benefit from the same or similar high-quality data and can work together to provide the best possible services to patients with COVID-19 while avoiding overloading the healthcare system. The key is to use combined payer, clinical, and social data plus technology such as telehealth and artificial intelligence (AI).
Payer Perspective on COVID-19
The overriding concern for payers during the COVID-19 crisis is the need to support member health. During an overwhelming, unpredictable pandemic caused by a disease with many unknowns, this is a challenging task. The pandemic has played out at multiple levels of the health system, from the care of each individual patient through to understanding the needs of an entire population.
For payers, maximum access to high-quality, real-time data is a key concern. In order to support member health, payers want to know, for instance, whether they need to place more resources into enabling better testing and contact tracing. Claims take a long time to come to payers and working with a health information exchange (HIE) can help significantly. The most fundamental issue is testing for COVID-19. Unfortunately, we still have a situation where not everyone who needs a test can get one, and this impacts both payers and providers’ ability to get full control of the situation. Nevertheless, there is still useful data outside of testing that can be found and have a profound impact on care.
HIEs – The Gold Standard for Population-Level Data
COVID-19 is a disease that challenges all aspects of the health system, so it should not be surprising that managing the data is also challenging.
Initially, the focus was entirely on flattening the curve of cases, preserving hospital resources, managing demand for essential items such as intensive care unit (ICU) beds, respirators, ventilators, and personal protective equipment. Today, the situation is more complex and ever-changing. Cases are appearing across all regions of the country including rural areas that did not have a large number of cases at the outset. For payers attempting to steer a path through the pandemic, the imperative is to gather data to know as much as possible about the situation facing providers and members.
One of the best options available for payers seeking population-level health data is to support and participate in a statewide, regional, or private HIE. Real-time clinical data, along with claims data and less traditional data sources such as social determinants of health (SDOH), race and ethnicity, can all be combined in both clinically meaningful ways for the care of individual patients and to population health managers for purposes such as quality measures and predictive modeling.
Payers clearly need real-time, high-quality data, including variables such as age, gender, medications, admitting, and final diagnoses, to help determine local demand for ICUs, respirators, and ventilators. An example of the value that can come from relatively simple data points is the admission, discharge, transfer (ADT) notification. ADT notifications are a common service provided by HIEs that enable payers to work with their provider partners more effectively.
Further challenges include finding all affected patients and contact tracing. A shared HIE with payer and provider data really comes into its own here.
Accurately identifying index cases rapidly, then identifying who they’ve been in contact with is difficult to work especially when daily caseloads are very high. While contact tracing is traditionally left to public health and state health departments, it’s clear those organizations are stretched beyond their capabilities to meet the current high levels of demand. There is nothing to stop health systems and payers from playing a major role in contact tracing. Payers may also ensure that providers have the data and tools to do that work. Payers have a desire to perform contact tracing, especially for their high-risk populations. A key point is whether someone in the patient’s immediate care team has had any exposure.
It is also clear that when done manually, contact tracing requires many staff dedicated to the task. At this point, it is hard to say whether any of the various available contact tracing apps can make a difference especially given the obstacles to widespread use, such as major privacy concerns. An app can only catch interactions between people who have installed it, so public buy-in is key to success.
Value-Based Care Contracts – Hospital Financial Sustainability
The impact of COVID-19 on current and future value-based contracting is uncertain at this point, though it seems a reasonable bet that providers have exceeded their cost targets and quite possibly not achieved their clinical quality targets. This is due to the unavoidable time and effort that had to be devoted to inpatient care of COVID-19 patients.
We know that many hospitals are struggling to cope with a financial sustainability perspective. At the same time as coping with COVID-19, they have been unable to carry out elective surgeries and MRIs at anything resembling the pre-COVID-19 rate which previously provided a high percentage of their income.
Payers must do everything necessary to facilitate their providers meeting agreed quality standards captured in their HEDIS and Stars ratings – payers must provide evidence they are covering preventative care needs. Failing to achieve those basic care quality standards can cost a significant amount when payers have contracts with large employers and CMS. Unfortunately, the pandemic makes all of those measures harder to achieve.
COVID-19, Minorities and the Social Determinants of Health
Like all infectious diseases, COVID-19 does not care about the race or social class of its victim. Many White House staff members up to and including the National Security Advisor have tested positive; while Herman Caine a presidential candidate in 2012 recently died of the disease. However, it is also very clear that minorities and people with adverse social factors are more prone to contract the disease and more likely to die from it. According to one study, Black Americans died at a rate of 73.7 deaths per 100,000; Indigenous Americans at a rate of 60.5 deaths per 100,000, and White Americans at a rate of 32.4 deaths per 100,000. Adjusting for the different age distributions, the corresponding mortality numbers are 99.4 per 100,000 for Black Americans; 93.0 for Indigenous Americans, and 26.6 for White Americans.
These types of disparities were known to occur with respect to other conditions prior to COVID-19, though COVID-19 brings them to light in a very visible way. Having race, ethnicity, and language data would help payers significantly to know where to focus their efforts in monitoring, addressing, and targeting for improving clinical outcomes amongst their population.
In addition to race and ethnicity, the COVID-19 pandemic has highlighted the importance of understanding each member’s social circumstances. Unfortunately for payers, it has been quite difficult to readily access data relating to their members’ SDOH. An exciting recent development in this regard was a study showing that significant valuable information can be gained from publicly available SDOH data. In that study, it was shown possible to predict emergency department and in-patient utilization using predictive data elements or features including the Census data API and behavioral data from vendors such as TransUnion. If this approach is further validated, it opens the possibility that enriching the currently available clinical and claims data that payers should already have with publicly available SDOH data can significantly elevate a payer’s ability to understand the risk levels pertaining to their member populations.
Historically, payers have been reluctant to cover telehealth. However, COVID-19 has proven that many clinical conditions can be assessed and managed via virtual care. Funding for virtual care is a challenge if physicians are being paid via fee for service; it should be much easier in a value-based payment world.
One important question is will telehealth continue to be offered post-COVID-19? Clearly, telehealth can be used for many situations, and the major issue may be to define the boundaries of what type of visit is and is not acceptable and clinically safe. Since the pandemic, payers have invested significantly in telehealth including the necessary infrastructure. Telehealth offers the potential to manage patients across state lines, in a very convenient model. When a state of emergency was declared during the COVID-19 crisis, some states have allowed providers to manage patients outside of their state. Payers are generally prevented from operating across state lines though exceptions exist. The hope is that in a post-COVID-19 world, these types of legal restrictions will be loosened, and virtual care/telehealth could become a very significant component to healthcare in the US.
Artificial Intelligence (AI)
AI is not an unrealistic, far-in-the-future technology; it is available today and can be used in a wide range of applications. From a COVID-19/payer perspective, some of the applications include (1) predicting which patients have the greatest risk of morbidity and mortality as a result of acute respiratory illness from viruses similar to COVID-19; (2) predicting population-level trends in caseload, deaths, and costs; (3) estimating patient mortality based on a range of variables and (4) outbreak and transmission prediction.
During these unprecedented times brought on by COVID-19, payers face numerous challenges. To adapt and respond to the evolving healthcare crisis, payers need high-quality data and virtual care tools, including telehealth, AI, and HIEs, to make informed care decisions on member’s health and curb the spread of the disease.
Dr. Chris Hobson, MD, MBA is the Chief Medical Officer with Orion Health. Dr. Hobson is a primary care practitioner and internist certified in healthcare informatics. He has key areas of responsibility for the clinical direction of Orion Health products and solutions.