The public health emergency is over ... Now what?
By Greg Carey | May 11, 2023
On January 31, 2020, Secretary of Health and Human Services Alex Azar declared the COVID-19 virus a Public Health Emergency (PHE). This week, after nearly 1,200 days, that PHE declaration expires. This formal expiration will undoubtedly bring reflection and retrospectives on lessons learned; after all, while the pandemic revealed the strengths of our healthcare system, it also exposed systemic weaknesses that we must not ignore.
There are many stories of people meeting the challenge of a historic pandemic. Many doctors, nurses and other clinicians not only put their own health at risk to continue to care for their patients but also volunteered to staff ad hoc testing and vaccination sites, exemplifying the courage, bravery, and resiliency of our clinical workforce. In record time, the pharmaceutical industry developed multiple at-home tests, vaccines, and treatments for a novel virus. Federal, state and local governments largely put politics aside and took unprecedented and dramatic steps to respond.
Even with these points of light, the pandemic’s widespread effects are well documented. According to the World Health Organization, more than 100 million Americans contracted COVID, and more than 1.1 million died as a result. How can we leverage what we’ve learned from COVID to not only prevent more deaths in the next pandemic but improve healthcare operations, incentives, and outcomes on a broad scale?
Clinician burden is an existential threat
Throughout most of 2020, Americans universally rallied behind frontline healthcare workers who consistently rose to the occasion and showed their resiliency in extraordinary times. Nearly every night early on in the pandemic, windows opened ceremoniously as cheers poured out into the streets in cities across the country whenever hospital workers completed their shifts.
Yet even with such broad support of clinicians’ sacrifices, the pandemic led many healthcare workers to feel an enormous burden that continues today, even with the pandemic officially declared longer an emergency. A January 2022 study conducted by athenahealth surveyed 743 physicians and found that 92% reported feeling burned out regularly. A full 80% were facing talent shortages and 68% reported feeling rushed and not having enough time with patients. 92% said that the burden of regulatory requirements is worsening, with the majority saying that they were pessimistic about the future of healthcare in America.
Other research indicates that clinician burnout costs the U.S. healthcare system $4.6 billion per year. With numbers like these, it’s clear that clinician burden and burnout are existential threats to the American healthcare system.
The economics of healthcare are fragile
As resilient as America’s healthcare workers are, it turns out that the economics of healthcare are a bit more fragile. In fact, like many businesses across the country, the ambulatory market — which includes outpatient facilities such as doctor’s offices — was sent into disarray when faced with uncertainty. Stay-at-home orders and disruptions in care helped to keep patients safe but threatened the financial viability of many medical practices still reliant on fee-for-service payments tied to the number of patient visits.
While the rise of virtual care and emergency funding from the government ameliorated some of the pressure, a public and private reimbursement model based on the value and quality of services delivered is more important than ever. The COVID pandemic should be a tipping point driving the industry to shift from fee-for-service to value-based care because the latter is a more effective way to incentivize quality care and better patient outcomes.
Public health systems need better coordination.
It was only a matter of hours before the infectiousness of COVID-19 exposed a major vulnerability in our healthcare system – fragmented data that is often hard to transfer. Gathering, digesting and sharing meaningful population-level data was a significant challenge for the dozens of state and local health registries. At best, the local data would lag several days behind what was happening on the ground.
We need to learn from and address this vulnerability in our healthcare system. The slightest strain exposed massive shortcomings in coordination between our healthcare system and public health infrastructure. We must integrate the secure flow of data across the healthcare ecosystem, coordinating the integration in lockstep with public health agencies.
Fortunately, enthusiasm and adoption of electronic case reporting has flourished during this period. That’s partially due to CMS quality reporting requirements as well as the realized benefits that come from automatic generation and transmission of case reports between Electronic Health Records (EHR) and public health agencies. We remain optimistic that significant advancements in electronic case reporting are within reach.
Our care delivery model must be modernized
The PHE transformed how patients get healthcare. Prior to 2020, telehealth saw limited physician adoption due to lower reimbursement rates for virtual care services. When the pandemic hit, virtual care became a life raft for patients and providers alike. The PHE led to the development of appropriate reimbursement rates, increased the scope of allowable services and eliminated geographic restrictions for virtual care.
Perhaps nowhere were the effects of telehealth more obvious than in mental health. As demand increased, the use of telehealth to deliver behavioral care skyrocketed. Prior to the pandemic, 1 percent of all behavioral health visits were performed via telehealth, but as of Q2 2022, 32.8 percent of all visits were conducted through telehealth. That’s a 45-fold increase.
Beyond telehealth, we saw care delivery innovation born out of necessity and facilitated by regulatory flexibility. Pharmacies became ground zero for testing and immunization, demonstrating that pharmacists are trained to do a whole lot more than count pills and our pharmacy network is one of our least leveraged clinical assets.
Health inequity is one of America’s greatest challenges
The past three years have exposed many inequities in the healthcare system. The resulting health disparities are not new and reflect longstanding structural and systemic challenges.
A Kaiser Family Foundation study found that non-white individuals were more likely to lack a personal health care provider and Black infants had the highest risk of low birthweight. Additionally, an athenahealth survey of 2,000 respondents indicated that income level impacted whether a patient has utilized telehealth. Lower income levels were less likely to use telehealth because it was not offered to them.
During the COVID pandemic, policies such as continuous enrollment for Medicaid and the Children’s Health Insurance Program helped to narrow some gaps, but with the end of the PHE and the expiration of those policies, we risk reversing that progress and widening disparities.
Inequities are pervasive and stubborn problems to solve. Improving access is only the first step. Social determinants of health have a profound impact on access to care and the quality of that care. Technology must also be a foundational element on the road to health equity. As part of a sustainable path forward that gives everyone equal opportunity to accessing and utilizing high-quality care, technology tools must embed equity into workflows and solutions.
Artificial intelligence and machine learning hold great promise for improving the burdensome processes in healthcare. But these tools must also help eliminate bias from data sets, giving clinicians the best possible data to make informed care decisions.
Finding answers to existential healthcare questions
There will be many lessons learned from our nation’s COVID response, all of them important to making the changes necessary to deal with future pandemics. The nearly 1,200 days between the declaration and expiration of the PHE not only presented unique and novel challenges but also exposed longstanding systemic gaps and points of friction.
COVID has prompted us to reckon with fundamental questions about our healthcare system. Who delivers care? Where and how do we get care? How do we pay for it? Are health systems siloed data outposts or part of a connected ecosystem? How do we ensure equal access and outcomes for all Americans?
These are all existential questions. At stake is not only our response to the next pandemic but the future sustainability of the American healthcare system.