“If COVID-19 has taught the healthcare industry anything, it is this: Our revenue cycle and our financial operations are wrapped around the care we provide,” said Virginia Gleason, nThrive senior manager, Advisory Services, during the recent Keeping up with COVID-19 webinar, “Re-opening healthcare during the public health emergency.”
Gleason recounted the early pandemic timeline, noting that it officially began on January 31 with the declaration of a public health emergency and hit a crescendo on March 18, when the Centers for Medicare and Medicaid Services (CMS) recommended shutting down all non-essential services. “While CMS asked us to limit non-essential services, they did give us the mechanism to provide care via telehealth,” however she emphasized that this shift not only challenged the norms of clinical care but also resulted in significant financial impact across the hospital and healthcare organization revenue cycle landscape, begging such questions as: “How do we change our operations in the midst of a pandemic and respond to the financial impact? How do we battle COVID-19 on the front line and still treat patients who need non-COVID-related care?”
With sheltering in place, Gleason also pointed out that most areas of the country did not see a large surge in cases on the scale of New York. “Since the overwhelming majority of patients who contract COVID-19 don’t need to be hospitalized, when we shut down our operations, we had empty hospitals,” resulting in unprecedented financial loss across the continuum of care.
Deconstructing the impact with healthcare analytics
Looking back retrospectively, Gleason gave her audience a compelling look into the early impact of the COVID-19 shutdown, drawing from nThrive Chargemaster data derived from de-identified nThrive claims. Giving a nod to the nThrive Data Insights team, she noted that, in many cases, the de-identified claims data provides much deeper detail than publicly reported data from the Center for Disease Control (CDC), with a caveat that the nThrive information is based on smaller numbers of cases.
“The nThrive database looks at 175,043 cases, while the CDC database includes 1.2 million,” Gleason said.
What did the medical claims data reveal?
“We can see pre-existing conditions, not just whether a patient was admitted to the ICU. We can see how many days they were in the ICU and what happened to them while they were there,” she explained.
Clinically, this paints the following picture:
- Of the 175,043 cases in the database, 29 percent were admitted to the hospital
- 17 percent were treated with targeted COVID-related drugs
- 10 percent were treated in the ICU (2.4 percent were treated with a respirator)
- 3.5 percent expired
“In this population, we can also see that 64 percent were treated with Azithromycin and steroids, which is very interesting as steroid treatment impacts immune response, while just 24 percent of patients were treated with hydroxychloroquine and these cases were early on in the pandemic. We can also look at the number of patients treated with plasma and report on the impact.”
In addition, 84 percent of the patients who were treated in the ICU stayed from 10 to 19 days.
“What happened when they were in the ICU? Did they get discharged and come back? That’s the level of analysis that can be done by looking at claims data,” she explained.
Of the 3.5 percent mortality rate, she added that 75 percent of patients were above 65 years of age, with 52.4 percent being over 75. 57 percent of the patients had co-existing hypertension and almost 34 percent had diabetes.
She noted that medical claims data can also be flexed to look at specific categories of patients.
“How many patients who were hospitalized also had cancer? Among the population of 175,043, it was 6 percent. What is the risk associated with treating cancer patients during the public health emergency?
“The 6 percent of cancer patients had a 27.9 percent fatality rate compared to 14 percent for other COVID cases, with the highest risk being lung cancer patients (55 percent fatality rate), which makes sense given the nature of COVID-19 as a respiratory disease. In hematologic cancers, the fatality rate was 37 percent; with solid tumors, 25 percent.”
“Should we treat cancer during a pandemic? Our normal response would be, ‘of course we should treat it,’ versus delaying treatment. However, during the pandemic, this became part of the risk-benefit analysis by the National Institutes of Health.”
Analyzing the revenue cycle impact with healthcare analytics
“The resulting financial impact on organizations due to canceled elective procedures and screening tests has been staggering,” said Gleason, adding that “there’s both a clinical and a financial argument” in favor of getting services back up and running.
“We had a higher acuity in our patients that ended up hospitalized, and we also experienced a decrease in volume, both resulting in significant financial impact. Providing care was harder on the healthcare providers, too, especially with the use of personal protective equipment (another added expense).”
In addition, Emergency Department visits declined 42 percent, with patients delaying care during the height of the pandemic. “From March 29 to April 25, we saw an all-time low in ER visits, with a 72 percent decline in the zero- to 10-year-old group. Our 11- to 14-year-old group declined at a 71 percent rate.”
The largest decrease in ER visits – 66,000 visits per week – was for abdominal pain, with musculoskeletal pain cases down by 52,150 per week.
Predictably, ED traffic increased by 18,000 visits per week for exposure to infectious disease. “Patients were coming to the ED with signs and symptoms of COVID-19 pneumonia. However, in cases of respiratory disease, patients weren’t coming in until they had respiratory failure. We also weren’t seeing patients coming in for chest pain, but cardiac arrest increased.” Gleason also noted an increase of about 350 per week for psychosocial factors, because “sheltering in place is not easy.”
Sadly, she emphasized that “more people are dying and not just from COVID-19, with 35 percent of the 87,001 excess deaths in the United States attributed to other causes. To quote Eric Valazquez, MD, chief of cardiovascular medicine at Yale University, “If the hundreds and thousands of people who die each year from heart disease are avoiding healthcare, this is going to be a double whammy.” Long term, to quote Mitchel Elkind, professor of neurology and epidemiology at Columbia University, “There is no question the risk of untreated heart attack or stroke is higher than the risk of COVID-19.”
Safely re-opening healthcare for revenue cycle success
Because COVID-19 is still with us and a vaccine is arguably months away, hospitals and healthcare organizations across the country cannot just flip a switch and resume normal operations. Since June, Gleason says the focus has been on prioritizing the backlog, identifying capacity and creating a cadence for growth.
“Over the next 12-18 months we are going to have to be able to provide non-emergent care. We expect ‘hotspots,’ and that is something we need to watch to ensure surge capacity.” As part of this, she noted that maximizing telehealth should continue to be a priority, along with patient solutions that cannot be provided virtually.
Gleason also emphasized that it is critical to partner with post-acute care for hospitalized patients following discharge to ensure safe continuity of care. Continued testing both of patients and staff remains the new normal to ensure asymptomatic individuals don’t inadvertently expose others.
“As healthcare organizations re-open, there is the need to go back and re-evaluate non-emergent cases, prioritizing and pacing your re-opening plan. Make sure you can defend non-emergent, non-COVID care that you chose to provide for both the clinical acuity of the patient and the medical need during the pandemic. And, don’t assume that pre-COVID-19 financial clearance still stands. Go back, make sure you have financial clearance.” Establishing patient trust is also a key factor. “The fact that there is a backlog of cases previously cancelled doesn’t mean that we have patients ready to receive care. Organizations must ensure they have re-established trust with their patients and that patients feel safe seeking care,” she added.