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Transcription:

Angel: Hello and welcome to Avalere’s tenth episode in a series of podcasts focused on COVID-19 pandemic. Today’s episode will focus on the impacts on healthcare provider performance. My name is Angel Valladares, a consultant in the Center for Healthcare Transformation at Avalere, and I will be discussing these notable impacts to providers with two my colleagues. My background is in population health research, measure development, and data infrastructure and strategy. I am joined by Sura Edmonds and Penelope Solis, two of my colleagues who are also in the Center for Healthcare Transformation. Sura is an obstetrician/gynecologist (OB/GYN) by training and Penelope has a legal background but has spent more than 15 years working with specialty provider practices in cardiovascular disease (CVD) and diabetes care on the development of their clinical registries and quality measures. In today’s episode we will provide highlights and takeaways from a more detailed conversation that we subsequently publish on this topic at a later date. To get us started, I will first provide an overview on today’s conversation. If you work in any sector of healthcare, you have likely been impacted by the outbreak of the SARS-COV-2 virus that has caused a global pandemic.

The COVID-19 outbreak in the United States (US) has had demonstrable impacts on providers and patients. These impacts have interfered with providers ability to compile with performance reporting and payment programs that often require them to have unobstructed access to resources and their own patients. We will discuss the reported impacts that the COVID-19 pandemic and the repercussions it has had on: provider participation in quality reporting and pay for performance program, as well as the potential relief policy the Centers for Medicare & Medicaid Services (CMS) may implement in the near future. For this discussion we pay specific attention to specialists in CVD and diabetes care, which will be led by Penelope, obstetrics, and gynecology care, will be led by Sura, and primary care, which I will lead. So, why don’t we get started. Which major obstacles are providers encountering due to impacts of the COVID-19 outbreak, that will impact their performance on key metrics and participation in value-based programs and clinical registries. Penelope, why don’t you get us started by giving us a picture of the CVD and diabetes space?

Penelope: Thank you, Angel. To answer your question the COVID-19 outbreak will impact a number of metrics that are used by value-based programs and registries in the CVD and diabetes space. For example, commonly used measures for the Merit-based Incentive Payment System (MIPS) are process based measures that are focused directly and rely on the use of laboratory diagnostic test data to determine, for example, if the patient is “in control” or “not in control”. The clinician then uses this to determine if a treatment plan change is needed for that patient. However, due to the pandemic, some patients that were previously scheduled for a routine visit and would have had these test conducted, are now unable to go into their doctor’s offices. So, this data cannot be generated. While much has been done via this pandemic to facilitate the use of telemedicine to ensure patients get care, unfortunately there are certain measures that seek to gauge control or not control, that are not feasible. Moreover, it is uncertain as to how quickly these patients will be able to get in and see their physicians once the COVID-19 pandemic has removed those barriers to in-person patient visits. This is particularly evident for patients with diabetes, who are being monitored for poor glycemic control or for patients who are at risk for arthroscopic CVD and may need to be placed on statins as part of the medication regimen.

Angel: Great, those are great examples. And as I mentioned earlier in the introduction, each of us will cover this question with various lenses and our knowledge backgrounds. Sura, can you describe the obstacles that are particularly impacting OB/GYN clinicians?

Sura: Thank you, Angel. From an OB/GYN perspective, it is a very hands on field. However, telehealth can be an option to provide certain aspects of care. This may be limited due to lack of office infrastructure, or patient limitation to internet access/service or even lack of tools like iPads and computers to access their providers, unfortunately. Another aspect being affected involves elective GYN surgeries. Some of these include tubal ligations and things of that nature, where physicians depend on these elective procedures to generate income – which has been affected. Another aspect is the follow up treatment after abnormal results. For instance, abnormal Pap test results are supposed to be followed up in a timely manner based on certain guidelines that we all follow, however, with the inability to properly see patients in the office, some of these procedures may be ineffectively delayed. Finally, there are certain obstetric performance measures that may be affected from the maternity care performance set. This is something as basic as establishing the proper gestational age, looking at the Body Mass Index (BMI) assessment and recommended weight gain during pregnancy, and there are also various labor and delivery, and post-partum measures as well.

Angel: Great, thank you Sura. Those are great examples in that specialty area. I think what is different for primary care is that we are seeing major impacts unlike any other area due to the nature of primary care in the US. It can be fragmented, and there already shortages across the country. Primary care physicians are reporting significant reductions in terms of patient visits, which are important for these primary care offices – like you said in your example Sura – to keep the doors open.

Many primary care facilities are highly dependent on patient services to keep their doors open and have small margins to implement innovation. As the discussion pivots towards innovation to go around the restrictions implemented due to the COVID-19 pandemic, we will likely see some of these impacts exacerbated. What is interesting about performance measurement and the programs in which performance measures are a major component, there are specific minimal qualifications. For participation in a program, such as the MIPS program, there are both limitations to patient volume and total charge minimums. This means that if you do not see a minimal number of patients and/or charge a minimal number of dollars to the payer, you do not qualify for participation into the program, and the provider would then have to opt in. What will likely happen due to these major reductions is that there will be a much larger group of providers who will not meet the requirement for participation. In terms of trying to stop this reduction, CMS has recently announced expanded coverage for telehealth. However, Medicare is now a large proportion of revenue for primary care practices. While CMS is making it easier for providers to offer telehealth as an option for their patients and covering it at a level that is almost equivalent to an in-person visit, individuals who require more care in the primary setting are predominantly not in the Medicare population. So, what we are seeing is a large group of patients that will not be experiencing those benefits, unless their private payer coverage is offering similar flexibilities. In terms of patients that require coordination of care that includes primary care, especially those with comorbidities, many may remain uncomfortable venturing out. Measures for preventive care like screening for age-related conditions that occur in the Medicare population, will likely see reductions in those services because there are less patients seeking preventive care to reduce risk of exposure to COVID-19. Measure wise, long-term follow-up measures for patients that require monitoring of functional status could be another potential area where performance is impacted, specifically for those who require monitoring of functional status issues associated with chronic pain and mobility. There will likely be irregular performance due to the lack of follow-up from obstacles like transportation, access to clinics, and additional patient factors. When we think about the issues associated with coordination of care for both chronic patients that are in the primary care and those with long-term needs – specific to the Medicare population, we are very likely to see performance impacts across preventive care measures, long-term follow-up measures around functional status, and patient reported outcomes.

Let’s transition to the impact on patients and how changes in patient day to day behaviors translates to provider performance impacts. How do we think patient obstacles to healthcare access may impact performance on quality measures? Penelope, with emphasis on CVD and diabetes patient care, what are some of those impacts from your perspective?

Penelope: I think that obstacles and impacts fall into 4 over-arching buckets:

• First, patients during a pandemic, may know if their disease management activities that they identified with their clinician are proving to be successful or not successful. Again, a lot of the success rate markers that relate to CVD and diabetes heavily rely on tests that are performed prior to the patient coming into the office or during that visit. There is a disruption in proper cadence that would normally happen between the patient and the clinician team, where the patient is able to see how they are doing in their disease management at their current visit as it compares to their last visit, where they would be able to ask their clinician a series of questions about things they can be doing better or areas of improvement, and discuss any additional changes to their treatment plan to better manage their disease. Patients need this active feedback and dialogue with their physicians – and while telehealth has helped bridge the gap in many areas during the pandemic – because there is a lack of data generated through diagnostic and lab testing, in some cases this will only provide a partial picture into what the patient’s journey looks like from their last visit to their current telemedicine visit.
• Another area that emerges due to this pandemic is that not all patients will have access to telemedicine, as Sura mentioned.
• Additionally, even when leveraging telehealth, some patients may not be willing to share any new symptoms or raise any concerns during a telemedicine visit with their clinician. This may occur because the way they may interact with the clinician team is very different than when they go in for an in-person office visit. In the office they will speak with the nurses, cardiologists, and in the case of a diabetes patient they will also speak to their endocrinologist, and this different layered team component is missing.
• And finally, a major component is patients with comorbidities, such as CVD and diabetes, are afraid – with good reason – of going to hospitals or seeking urgent care because they are at a higher risk for developing infection and may want to delay necessary care. There is a huge fundamental problem with this. In some cases, it is important for that patient to seek immediate care. A lot of the medical societies that relate to CVD and diabetes have urged their patients to get the appropriate care as needed. However, there is some anecdotal data that does show, in the case of myocardial infarction, that the number of cases occurring pre-COVID pandemic compared to those occurring during the COVID-19 pandemic are dramatically different. There may be people who are delaying care, which may result in a significant fall out that cannot yet be quantified.

There are a number of ongoing obstacles in terms of care for CVD and diabetes patients, so the long-term impact is yet to be known for those who delayed necessary care.

Angel: I think the last point you made is very important. I read an article highlighting a significant spike for those seeking care after things have settled down and we work to return to “normal” again. Much of that is due to some of the delays in seeking necessary care. In primary care, aligned to what you had shared Penelope, is relevant to the patient population given the significant overlap. Many of the patients who are seeking care-coordination for CVD, diabetes, or both, and have any comorbidities are seeking primary care and we have to consider that many of those obstacles will have an impact on their long-term impact on outcomes. An interesting population, that we will cover a bit later, is the Medicaid population.

The Medicaid population is impacted with higher morbidities like the Medicare population but for different reasons. In Medicare we are looking at patients who are older and more likely to have diseases that come with the aging process. In Medicaid we have patients who may have lower socioeconomic status, less access and more burden associated with factors that are impacting social determinants of health which can prevent a healthy life and healthy outcomes. In the Medicaid population many would also need to seek primary care and that is also being impacted due to the pandemic.

Lastly, the limited access to routine primary care is an issue even before the COVID-19 pandemic. The data we are seeing shows that a number of ambulatory practices have seen nearly a 60% decline in visits since April, which has no historical comparison to the modern era of our healthcare system. Although there is substantial increase in telehealth visits, they have only partially offset the drop for in-person visits. For many patients, the obstacles, as Penelope mentioned, have to be taken into consideration on top of additional factors – whether they are cultural or technology-oriented – and primary care routine screenings or breast cancer screenings and influenza vaccinations will see impacts. We will also likely see an issue in influenza cases in the fall as it resurges, as this current season tapers off. It is pretty uncertain how soon after states reopen for when patients will feel comfortable going back to their clinician’s office.

In terms of overall measurement, the trend continues that primary care will see reduction in volume and there will be issues with minimal thresholds, we have preventive measures and care coordination measures that will be impacted. And as Penelope mentioned, patients who are experiencing comorbid conditions will likely have the biggest impact which will translate to impacts on outcomes. Very important outcomes of returning to the hospital with an emergency issue from an exacerbation of the condition due to lack of follow-up. Transitioning to Sura, could you talk about what is unique in your specialty area and how patients and their behaviors are impacting providers? And any impacts to OB/GYN provider abilities to perform according to quality measures and programs that they participate in?

Sura: Sure, as you and Penelope stated earlier, patients are not going to the hospital to seek care for emerging issues like heart attack or stroke. This unfortunately is extending into women who need OB/GYN care because they are refusing to go to the hospital to deliver their babies in fear of contracting COVID-19. In addition, labor and delivery has also been affected because most hospitals have limited the number of visitors allowed in the delivery room during birth. This is a time when a woman needs a lot of support from her family, partner, or spouse. And what is normally a happy occasion is affected. So, many women are choosing to have a homebirth, and we know that homebirths are unfortunately associated with two-fold risk of perinatal death. American College of Obstetricians and Gynecologists (ACOG) released a statement earlier this year before the COVID-19 pandemic was starting to impact labor and delivery, noting that hospitals and accredited birthing centers were still the safest place to give birth despite the virus. Additionally, since women are choosing to have homebirths instead of having physicians involved there are midwives and doulas involved, where their licenses and training are not as standardized as an OB/GYN physician and may lack affiliation with local hospitals thus creating some safety issues. If there is a chance of an emergency during the delivery, there can be unfortunate outcomes. As Penelope mentioned earlier, it is hard to quantify these unfortunate incidences that may happen in a homebirth.

Angel: Very interesting indeed. I am curious to hear about the other national statistics, especially those around health disparities and maternal health outcomes – whether it be mortality or overall health of the mother and baby – which we can touch upon in a further episode. It would be interesting to hear your perspective on how this area may be impacted by COVID-19.

Sura: Yes absolutely.

Angel: Great. Thank you, Penelope and Sura for your insights, it is invaluable to our listeners. Thank you all for tuning in today to Avalere Health Essential Voice. Stay tuned for part 2 of this episode, where we will discuss provider exemptions and waivers. If you would like to learn more please visit to our COVID-19 Intel Center. Have a great day!