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Inside Medical Liability

Second Quarter 2021

 

 

Cover Story

Transformative Changes Impact Healthcare Delivery and MPL

Will changes in telemedicine, regulation, relationships, and more survive the pandemic?

By Amy Buttell

 

As the healthcare delivery system adapted to the COVID-19 pandemic, it evolved to serve a vastly different set of patients and needs than existed before March 2020. Instead of in-person interactions oriented toward preventive, elective, and emergency care, care shifted toward telemedicine and surges of the critically ill swamping emergency rooms and intensive care facilities.

Preventive care suffered, as did the personal relationships that existed between patients and their healthcare professionals. Provider revenue declined as healthcare consolidation, a pre-pandemic trend, rose.

Trends in healthcare spending and personal consumption expenditures on health services bear out these trends. While consumption and spending dropped drastically in the second quarter of 2020, they rebounded by the end of the year in most categories. (See Figure 1.)1

“COVID-19 has had a substantial impact on healthcare delivery,” said Sarah Scher, JD, CEO, Cooperative of American Physicians. However, perhaps the most remarkable change in healthcare delivery has been the rapid advancement of telemedicine.”

The altered landscape impacted nearly all aspects of healthcare and healthcare delivery. Many providers found themselves assuming new roles and job functions while others either had too much work or not enough. Patients were either avoiding care for fear of COVID-19 and/or communicating virtually with their providers. Organizations found themselves adapting to situations without precedent.

For Sue Crook, MD, FACR, partner, Midwest Radiology in Minneapolis, MN, fractured relationships between providers and patients are the biggest change that has come from the pandemic. “I’m in a mask, which means that my patients can only see my eyes,” she said. “Experience shows us that patients only hear a fraction of what we’re saying anyway, so even more of the message will get lost due to facial coverings. As a radiologist, I view rapport between the patient and doctor as a critically important factor; unfortunately, that is crumbling, not only due to social distancing and facial coverings, but also the disconnect of telemedicine.”

There’s no doubt that the pandemic shook the foundations of medicine and healthcare delivery in negative and positive ways. What lies ahead for the MPL community?

Telemedicine thrives

Telemedicine is one of the success stories of the pandemic. Not only did healthcare organizations and healthcare professionals respond to the need for virtual care, but regulators and insurers facilitated this transformation.

“The sense that a physician has to touch a patient to know what’s happening, that has changed because of the experience that providers had during COVID,” said Mark E. Reynolds, president and CEO of the Risk Management Foundation of Harvard Medical Institutions Incorporated (CRICO).

“Telemedicine adoption will likely continue to be highest in behavioral health and primary care with selective use elsewhere for intake visits and certain assessments. A mix of virtual care services that includes video, phone calls, electronic monitoring, and so forth has become possible in a way that it wasn’t previously.”

Pre-pandemic, virtual care was a small part of overall provider-patient interactions. Post-pandemic, there’s no doubt that telemedicine is here to stay.

“Patients have become tech-savvy and comfortable ‘visiting’ their physicians virtually,” said Scher. “Some even prefer the virtual visit, as it is less time consuming.” She also noted that efforts by the Centers for Medicare and Medicaid Services, the American Medical Association, and others are pushing for more parity between inperson and telehealth visits, which makes virtual care financially viable.

Crook believes the increased acceptance of telemedicine is a definite positive, especially for rural areas that lack access to providers, especially specialized providers such as radiologists. “My only reservation is that this new norm doesn’t contribute to relationship building that is necessary between providers and patients,” she said. “How can a doctor who calls into a remote clinic to consult with a patient for 15 minutes possibly develop a relationship with that person? It’s a very difficult proposition.”

Reynolds sees continual investment by organizations, including healthcare providers and health-tech companies, that will continue to move this trend forward. “We’ll see more and more happening remotely, in terms of tracking standard vitals and indicators of chronic disease, which will arm providers with more real-time information about their patients, allowing improvement management,” he said.

Regulatory environment adapts

Pre-pandemic, regulatory and reimbursement issues were two major barriers to increased adoption of telehealth. With a speed few could have anticipated, regulators authorized increased payments and telehealth practice across state lines, facilitating a necessary shift in care delivery. This flexibility allowed many patients to continue to receive care that otherwise would not have been available.

There are still, however, many ways that regulations and the regulatory environment lag developments in both the pandemic and in healthcare. “Many nuances of pandemic regulations, whether they involve liability protections or telehealth, may not be determined for several years to come,” said Scher. “As regulation is interpreted in the judicial system, MPL carriers will gain a better understanding of the real impact of COVID regulations.”

Reynolds noted that the fragmentary system of licensure in the states, versus a national licensure system for healthcare providers, is one barrier to providing care in pandemics and postpandemic. “Our regulatory universe isn’t set up for medical care and MPL insurance to operate across state boundaries,” he said. “Will that change? Clearly, there’s going to be a demand for change. There’s also the issue of venues for cases, and currently there is no consistency in identifying those venues. In that case, some kind of interstate compact or national legislation on venues and licensure would be incredibly helpful.”

MPL issues tend not to be top of mind when there’s a clamor to change telemedicine rules, for example, he added. However, as technology advances and more telemedicine capabilities are available—and providers and patients demand their adoption—more attention will need to be paid to such issues.

MPL companies offer new support, resources for insureds

Successive COVID surges stressed physicians and healthcare organizations throughout 2020 and into 2021. While vaccinations are rolling out nationwide, the pandemic is not over. As public health experts fear a spring or summer surge due to highly contagious variants and an easing of prevention measures, MPL insurers must continue to assist healthcare professionals successfully treat their patients.

“During difficult times like these, MPL carriers must partner with their insureds to improve risk management and support business transformation,” Scher said. “This means meeting provider needs through innovative virtual practice management, chat rooms, data analytics as well as old-fashioned phone calls.” CAP utilizes techniques such as monthly webinars on risk management and practice management as well as a virtual COVID-19 resource center with education and protocols on management, financial, operational, human resources, regulatory requirements, and opportunities to support providers.

An important function for MPL carriers is to offer guidance to their providers about virtual care, Reynolds noted. “Virtual care isn’t simply an office visit online,” he said. “When you walk out of a doctor’s office, you usually sign out with someone who attends to follow up care issues. With telemedicine, if you don’t think about and plan for follow up, you lose the opportunity to make sure the patient follows the care plan that was discussed.”

The adaptability of MPL carriers in cutting rates quickly to match the transformation of care, especially in the second quarter of 2020, showed MPL insurers at their best, Crook said. “This kind of action really makes a difference to providers, many of whom were struggling due to the cancellation of elective procedures and many office visits,” she continued.

Going forward, Scher stated that MPL carriers will need to demonstrate flexibility as regulations and technology evolve, requiring the development of products and services targeted to the future needs of providers. “Rapid evolution of new risk management education, training, and implementation services will be required, especially in the areas of online medicine, telehealth, and cyber risk,” she added. “Finally, carriers must be prepared to tackle the interstate telemedicine issues. Clever carriers can channel the challenges created by the pandemic into opportunities to advance the MPL marketplace.”

Other issues

Crook, Reynolds, and Scher discussed a number of other issues prompted by the pandemic, including:

  • Ongoing concentration of care: “Even large groups of providers are finding it difficult to determine whether they will have enough resources to survive through the rest of the pandemic, which is driving more consolidation into large organizations that have the resources to invest in the technology and equipment that will be necessary in the future,” Reynolds said. Consolidation of care was certainly a trend before the pandemic and it’s impossible to say right now whether the pandemic significantly accelerated that curve or not.”
  • Increased attention for long-term care facilities: “Long-term care facilities were caring for a highly vulnerable patient base. I would hope that more resources will be directed to long-term care facilities so that they can provide the standards of care that their patients and their families are entitled to,” said Crook.
  • Government support for healthcare: “The $1.9 trillion COVID-19 relief package that was recently signed by the President is evidence that legislative support of healthcare remains as robust now as at any time during the pandemic,” said Scher. “The CARES Act and other financial relief mechanisms were rapid and direct responses to needs early in the pandemic, and the American Rescue Plan is a continuation of political support throughout the pandemic.”
  • Focus on the patient experience: “Medicine expects patients to conform to where we are, when it should be the other way around,” Crook noted. “We have an obligation to meet patients where they are to ensure that they understand what is happening with their health and can work with us to be as healthy as possible. That means creating a more patient-centered experience in every aspect of healthcare delivery, from eliminating waiting to simplifying web portals and telehealth.”

Going forward, MPL insurers are committed to continued innovation and adaptability as they offer resources and support for healthcare in these changing times.

References

1. “How have health spending and utilization changed during the coronavirus pandemic?” Health System Tracker, Peterson-Kaiser Family Foundation, March 22, 2021, https://www.healthsystemtracker.org/chart-collection/how-have-healthcare-utilization- and-spending-changed-so-far-during-the-coronavirus-pandemic/#itemcovidcostsuse_ marchupdate_1.
2. “How have health spending and utilization changed during the coronavirus pandemic?” Health System Tracker, Peterson-Kaiser Family Foundation, March 22, 2021, https://www.healthsystemtracker.org/chart-collection/how-have-healthcare-utilization- and-spending-changed-so-far-during-the-coronavirus-pandemic/#itemcovidcostsuse_ marchupdate_1.
3. “Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic – United States, January-March 2020, Morbidity and Mortality Weekly Report, U.S. Centers for Disease Control and Prevention, https://www.cdc.gov/mmwr/volumes/69/wr/mm6943a3.htm.

 

   
 


Amy Buttell is the editor of Inside Medical Liability.