Jeffrey Levin-Scherz is an assistant professor at the Harvard University T.H. Chan School of Public Health and population health leader at Willis Towers Watson. Inside Medical Liability spoke with Dr. Levin-Scherz about how healthcare delivery, medicine, and MPL are evolving in response to the pandemic.
IML: How has the pandemic changed healthcare delivery?
Levin-Scherz: Three of the more obvious changes were the dramatic increase in the number of telehealth visits, the COVID-19 surges that filled intensive care units (ICUs), and the cancellation of the elective surgeries and procedures that are the foundation of hospital profitability.
This combination of overwhelmed ICUs and a lack of elective procedures affected the balance sheets of providers and provider organizations, forcing some out of business and others to consolidate.
IML: Is pandemic-related consolidation likely to continue among providers?
Levin-Scherz: The pandemic isn’t over yet and even once it is over the impacts will linger. Provider consolidations usually increase prices and decrease competition. Consolidation has already been a trend in healthcare for some time, and the pandemic intensified that trend, at
least for a while.
IML: Do you have any other concerns about the potential impact of consolidation?
Levin-Scherz: I worry especially about pediatrics. While adult practices can be acquired by hospitals if they can’t pay their bills, pediatric practices generate little ancillary or downstream revenue. These types of practices aren’t real profit centers and also aren’t easily acquired by other groups outside of hospitals. If hospitals decide that they don’t want more primary care, family medicine, and pediatrics practices, there’s nowhere for these doctors to go and practice if they can’t make it on their own. And COVID has made it very, very difficult for doctors in these types of practices to stay solvent. If we let too many practices in these areas go out of business, kids won’t receive the care they need or their necessary vaccines. Adults will also then lack access to that primary care internist or family doctor who they can build a relationship with and who can coordinate their care.
Unfortunately, the economics of this situation involved pandemic-related stoppages of elective procedures that created more barriers for even large group practices to stay independent. With the increasing use of telehealth and other technologies, all practices are finding it difficult to support the costs involved in these kinds of upgrades. It gets to the point where they decide that it’s more effective and efficient to affiliate with a larger organization that can spread costs over a wider group of providers and facilities.
IML: Will telehealth continue to be such a large part of healthcare delivery post-pandemic?
Levin-Scherz: That’s at least somewhat dependent upon regulation and policy. Patients and providers seem to have embraced it. It’s hard to know, however, what’s a good balance between in-person and telehealth visits. During the pandemic, we swung way toward telehealth because it was the best option to delivering healthcare without endangering patients or providers. However, there are types of healthcare that don’t lend themselves as much to telemedicine as other types of
healthcare. I think it’s going to take some time for the system, providers, patients, and regulators to work out which types of care are best delivered through telehealth and which in person.
IML: How can telehealth fill some of the gaps in American healthcare?
Levin-Scherz: We have a crisis of lack of access to healthcare in rural America that telehealth
can definitely help address. There are more and more small communities with populations that are more than 30 miles away from hospitals—these communities can benefit from an increase in
telehealth. In fact, in many rural areas, patients are already receiving care via telehealth at a local clinic or hospital from a specialist in another locale.
While telehealth is poised to continue to help ameliorate the access problem in rural America, the financial problems caused by the pandemic are further weakening rural health systems that were already on the financial brink before COVID-19. Communities can really experience a death spiral when a hospital closes because not only is there a lack of healthcare, but all the jobs associated with that organization go away. Many communities are in a tough, tough spot. Also, telehealth can’t take care of everything. Pregnant women have to deliver with a real doctor, not a virtual one, and many are having to drive hours to get prenatal care and deliver their babies.
IML: How has the pandemic impacted medical professional liability?
Levin-Scherz: To the extent that providers are practicing medicine differently, there’s been an impact. Most MPL insurance does include virtual visits, but there are definitely different risks for in-person visits and virtual visits. In virtual visits, even with video, there is a lot of care that can’t be done as effectively.
We might see more failure to diagnose. There also might continue to be the tendency for patients to wait before they get care. Whether late diagnosis is the provider’s fault or not, we still don’t know. A virtual visit can’t include a rectal or abdominal exam or a probe with the fingers for lumps. Essentially, virtual care brings different MPL challenges while patients expect the same level of care.
IML: How might the trend toward consolidation that the pandemic accelerated impact the MPL space?
Levin-Scherz: More providers consolidating into larger organizations will likely sweep more providers into captives that self-insure. Hospitals with captives that are acquiring outside medical practices will see a cost savings that they can realize by moving these newly acquired providers into their captive networks. That will reduce the number of providers needing insurance through traditional MPL insurers, whether those companies are for-profit or mutual organizations.
IML: What can the MPL industry do in response to this potential trend?
Levin-Scherz: The traditional MPL industry has been exceptionally good at promoting incident prevention and provider education around patient safety. MPL insurers may need to move toward captives and consider how they might collaborate with them. Continued consolidation in healthcare will create market pressure for the traditional MPL industry to deliver value-added products and services.
IML: How has the regulatory environment dealt with these pandemic-related changes in healthcare delivery?
Levin-Scherz: The regulatory environment has been surprisingly nimble. At the beginning
of the pandemic, regulators quickly increased reimbursement rates for virtual visits to the
same levels as in-person visits. Another big, welcome change was permitting providers to
practice via telemedicine across state lines in areas where those providers might not be licensed.
IML: What will the post-pandemic landscape look like from the patient point of view?
Levin-Scherz: I think that people are going to want more control over their care. Going forward, I think we’ll see more care that patients can manage themselves, such as more ways for self-testing. For example, if a patient is on blood thinners, instead of having to go to a lab and wait for a test and the results, the patient instead will be able to do their own testing via a monitor at home. We may see more care delivered at home, with providers going to patients’ homes instead of patients going to see doctors at their offices.