Closing Gaps in Care for the Most Vulnerable

By RaeAnn Grossman

Telehealth services rose 11,718 percent among Medicare members in just a month and a half at the start of the pandemic. However, concerns remain regarding seniors’ ability to rely on virtual care to manage complex conditions or stay on track with preventive screenings, given that 54 percent of seniors who purchased new technologies during the pandemic need a better grasp of these technologies to connect more easily with others, while 37 percent do not feel confident using these technologies. Further, 41 percent of those ages 65 and older do not have broadband access at home.

Now, as weekly outpatient visits remain below pre-pandemic levels for certain specialties—including specialties common among senior patients, such as neurology, cardiology, and pulmonology—healthcare payers and providers must consider: “How do we proactively care for those most fragile?”

The Impact of Deferred Care During the Pandemic

Ninety-seven percent of physician practices reported a drop in patient volumes in early 2020, an MGMA analysis found. By the end of June 2020, an estimated 41 percent of American adults had delayed or avoided needed care. Most patients who deferred care during the pandemic (87 percent) cited safety reasons, according to the MGMA analysis.

While volumes began to rebound in the fall of 2020, by the end of the year, they remained 5 percent to 6 percent below the typical pattern over the prior four years, according to a Commonwealth Fund analysis. But not all populations and specialties exhibited the same degree of recovery, with pediatrics, pulmonology, otolaryngology, and physical medicine heading the list of specialties that have not yet returned to baseline level, the Commonwealth analysis found. Further, a Cotiviti analysis shows that among Medicare fee-for-service and Medicare Advantage populations in particular, care for conditions such as chronic obstructive pulmonary disease (COPD) and heart disease remains months behind schedule.

There are also significant differences in coding depth and specificity for these patients, the Cotiviti analysis found. As some states eased documentation requirements due to increased volumes, patients’ charts often reflect that a primary topic of discussion is members’ risk for COVID-19. Yet it is difficult to find evidence that providers discussed care management for existing chronic conditions such as congestive heart failure and kidney disease. In instances where Medicare members have visited their physician just once, this could reflect missed opportunities to improve member outcomes.

Meanwhile, incidence of depression among members covered by Medicare is rising, likely due to social isolation as well as the stresses of the pandemic (see Figure 1).

Figure 1: Rates of Depression Rising Among Medicare Advantage Members

Source: Cotiviti Medicare Advantage data

Preventive screenings for vulnerable populations also plummeted. One survey found 35 percent of adults missed a scheduled cancer screening  (such as a colonoscopy or mammogram) in 2020. Another analysis shows steep declines in screenings for chronic disease year over year.

These are signs that healthcare organizations could see sicker and costlier patients as the year wears on unless providers and health plans work to engage vulnerable populations in coming back for delayed care. They also could see gradual changes in risk scores that are proportional to members’ lower utilization over the past year—the impact of which could decrease reimbursement unless organizations are successful in reengaging members.

Jump-Starting Care for Vulnerable Populations

It is clear that certain populations—such as children and the elderly—need support to reestablish healthy patterns of care. But it will take creativity and a commitment to understanding the factors that hold members back from seeking care. A proactive approach to reengaging members should include the following tactics.

Pursue innovations in care policy and execution. Throughout the pandemic, some health systems and health plans boosted access to commonly missed screenings such as mammograms and bone density tests by creating mobile screening centers and taking them to the communities where they were most needed. They also brought specialized care into the home, such as dialysis treatments. These types of innovations not only are key to meeting members where they are during the pandemic, but also could prove effective in strengthening health outcomes once the pandemic is over.

Understand the barriers that prevent members from seeking care. For example, the MGMA analysis found that among the top reasons some patients have declined to seek virtual care include concerns about security and privacy, lack of understanding around what is involved in a virtual visit, and the belief that virtual visits are too impersonal. Meanwhile, some health plans are discovering that health issues, such as vision or hearing difficulties, or the need for translation services make it difficult for seniors to participate in telehealth. By digging deeper to uncover the reasons members are reluctant to seek care, providers and health plans can more effectively collaborate to reassure members or adopt new approaches that break through obstacles to care. Some health plans are sending nonmedical staff into seniors’ homes with mobile devices to facilitate telehealth visits with seniors in need of assistance.

Look for opportunities to tie together social supports and care. Barriers to care can be financial in nature: During the pandemic, one survey found that nearly half of patients say the state of the economy has affected healthcare decision-making. In creating a wraparound experience in which members are able to access social supports such as Meals on Wheels as well as primary care checkups or prescription medication assistance, the chances of reaching a city’s most vulnerable populations increase—and so do the chances of improving health outcomes.

By proactively caring for those most fragile, organizations can more effectively ensure vulnerable populations get the care they need when they need it. This helps avoid sudden spikes in demand, protecting access to care for all. It also reduces the potential for declines in risk scores and associated decreases in reimbursement, offsetting the impact of the pandemic on the organization’s financial health.

RaeAnn Grossman is the executive vice president of risk adjustment and quality for Cotiviti.

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