(Feb. 8, 2021) – This article highlights many of the trends your organization will likely face in the coming year as America recovers and responds to COVID-19. This strategic assessment includes questions and conclusions to guide your board's strategic thinking for 2021 and beyond.
Strong leadership from hospital and health system boards of trustees is essential to recovery from COVID-19. With the promise of wide vaccine distribution coming, leaders can start planning for a future that moves from surviving to thriving.
As with any crisis, there is an opportunity for new thinking and innovation. Boards should consider: How has COVID-19 changed the way we provide care? Have we changed how the hospital operates, how we communicate and how agile our responses are? How has COVID-19 changed the way patients access care? How can we use the changes from last year to encourage innovation and leverage employee insight?
COVID-19 Has Drastically Increased the Financial Burden. The impact of COVID-19 on hospitals and health systems is immense. According to the American Hospital Association, COVID-19 has resulted in a projected loss of $323.1 billion to hospitals and health systems in 2020. Health care leaders' top concerns include loss of revenue, overall financial stability, supply-chain risk, staff getting sick and furloughing staff.
For some hospitals, treating COVID-19 patients has been an all-consuming task. For others, the greater impact has been patients deferring medical care, a decline in health care professional services utilization and revenue, and hospital concerns ranging from financial stability to supply chain risk, as well as even greater workforce challenges.
The Focus on Value Remains. Prior to the pandemic, America's health care system was in the middle of the transition from "fee-for-service" to payment based on value and outcomes. In recent years, hospitals have engaged in a variety of new payment structures including value-based purchasing, accountable care organizations and bundled payments.
The value equation in health care hasn't changed:
Value = High Quality + Low Cost + High Patient Satisfaction
Now, more than ever, hospitals must commit to improving the components of that value equation. Quality should be infused in every board discussion. Boards should engage in continual education and conversations about understanding costs and new payment structures.
As COVID-19 recovery begins, hospital leaders have an opportunity to refocus their efforts on the areas that matter most. This requires an engaged workforce, innovative leaders, a willingness to explore non-traditional forms of care, expanding community partnerships, and addressing the social determinants of health that directly impact the populations hit hardest by the pandemic.
How is your board setting the tone for both short-term financial recovery and success in the value-based care environment?
Shortages of physicians and other caregivers has been a top challenge for hospitals and health systems for decades. Changes in how patient care is delivered, who delivers the care, and leveraging technology has helped alleviate some of the shortages, but the challenge still remains.
The Projected Shortages Continue. The number of physicians and nurses retiring, combined with the increase in demand for services, continues to widen the gap. There is a projected shortage of 21,400 - 55,200 primary care physicians by 2033. The shortage of nurses is even more concerning, with a projected need of 2,000,000 nurses by 2026 but only a projected increase in supply of 500,000.
Provider Burnout and Workplace Safety Are More Important Than Ever. Before the pandemic, hospitals worked diligently to monitor and strengthen employee and medical staff satisfaction by ensuring a strong employee-recruitment pipeline, supporting staff to the full extent of their license, and implementing a strong organizational culture. Even with these approaches, there were concerns about provider burnout and depression.
Since the start of the pandemic, half of physicians report experiencing inappropriate anger, tearfulness or anxiety due to COVID-19's effect on their practice or employment. More than 70 percent of nurses report suffering from challenges with sleep during COVID-19, half report feeling overwhelmed, and 30 percent report feelings of depression.
Now, more than ever, hospitals must be committed to creating a safe workplace that encourages emotional health and well-being. Boards are responsible for setting the tone, prioritizing employee engagement, emphasizing quality and patient safety, and creating a culture valuing all employees.
Does your senior leadership encourage and value feedback and creative solutions from all employees? What can your organization do now to reduce the mental health burden on your workforce?
Health care was already experiencing many innovative shifts prior to COVID-19, largely related to new technology, artificial intelligence, consumerism and a greater focus on population health. But COVID-19 has created a sense of urgency for organizations to pivot, refocus priorities and innovate. The pandemic initially sparked ventilator inventions and distilleries making hand sanitizer, followed by new approaches to treating both patients with and without COVID-19 and the rapid development of COVID-19 vaccines.
Employees Are Key to Creatively Solving Problems. Hospitals and health systems were forced to radically change their care delivery almost overnight, most notably finding new ways to treat patients remotely. The ability for hospitals to listen to their employees and leverage employee creativity is directly related to innovation, particularly in a crisis.
In the AHA's Futurescan, Nancy M. Schlichting, former president and CEO of Henry Ford Health System, explained this well: "Employees and the medical staff are central to the success of any hospital or health system. They frequently know of a problem that requires change before leadership does, because they are closer to it. That insider's perspective often enables them to recommend the best solution."
The COVID-19 Crisis Will Fundamentally Change Health Care. While not all the quick shifts that occurred during the early days of COVID-19 will remain, according to a recent poll, 90 percent of health care leaders agree the COVID-19 crisis will fundamentally change the way they do business over the next five years. In addition, more than 70 percent of health care leaders believe changes brought about by COVID-19 will be an opportunity for growth.
Now is the time for boards to leverage the creativity and innovation sparked by the pandemic. For a robust set of resources, data and analytics, case examples and more, go to the AHA's Center for Health Innovation at www.aha.org/center.
How did your organization adapt to COVID-19, and how can that momentum continue after the crisis ends?Are you maximizing employee and physician engagement to encourage innovation?
Emerging Competitive Challenges
Consumer Loyalty Is Declining. Before COVID-19 was widespread in the United States, a 2019 survey reported the majority (67 percent) of consumers preferred to receive health care services from their own doctor or hospital. The pandemic has shifted consumer mindsets. For many, concerns about COVID-19 symptoms, the shortage of COVID-19 testing, or simply a desire to see a provider—any provider—has led to a shift in where patients are getting care. For some, a virtual appointment with anyone was a "win." For others, the loss of health insurance led to a shift in where they could access or afford care.
According to a September 2020 PBS NewsHour-Marist poll, 35 percent of those polled said they think America's health care system is below average compared to the rest of the world. In addition, two-thirds are now willing to use telemedicine for future health care needs.
Retail Health Is Expanding. In September 2019, Walmart opened its first Walmart Health center, which its website describes as a commitment to "making health care more affordable and accessible for customers in the communities we serve." Walmart Health currently has 12 locations and plans to open more soon. Similarly, CVS is expected to expand from its 50 HealthHubs locations in 2019 to 1,500 locations by the end of 2021.
The rise in retail clinics may be accelerated by the pandemic, providing an easy and safe way for consumers to access much-needed care. At the same time, retail clinics are leveraging their existing market share to support increased demand for telehealth.
In May 2020, CVS reported a 600 percent increase in virtual visits and a more than 1,000 percent increase in prescription home delivery. Many retail clinics were swift to respond in offering COVID-19 testing, including Walmart, Target, Walgreens and CVS Health. Between their already growing presence during the pandemic and the promise of partnerships between the U.S. Department of Health and Human Services and retail providers to provide COVID-19 vaccines to the public, expect further willingness and interest to use these providers.
Virtual Solutions Are Growing. Amazon Care is a great example of a virtual platform well-poised to meet this growing demand for telemedicine. Amazon launched Amazon Care in 2019 as a health care benefit for its own employees. It is currently available to all Amazon employees and their families in the state of Washington. The pilot program allows beneficiaries to chat with clinicians and launch video appointments through the app, with in-person follow-up care and prescription delivery in the Greater Seattle area.
According to Business Insider, Amazon may be looking to expand Amazon Care to other employers using a similar concept, offering both primary and in-person care. Particularly in the wake of COVID-19, consumers are increasingly open to this kind of "outside" and "non-traditional" care. In fact, these non-traditional providers are now what many consumers want instead. It's immediate, easy and often you don't even have to leave your home.
How does your organization meet the needs of consumers looking for fast, easy affordable health care? Have you considered partnerships with organizations like Walmart, Amazon or Walgreens offering alternative options for care?
Cyber Attacks Are on the Rise. As telehealth has increased during the pandemic, the risk of cybersecurity attacks has also increased. Not only are patients engaging in more telehealth visits, but providers are increasingly working and accessing medical data remotely. According to Check Point Research, ransomware attacks increased 50 percent in the third quarter of 2020 compared to the first half of 2020. In addition, health care is the number one most targeted industry for cyberattacks in the U.S.
Hospitals Can Take Preventive Measures. The American Hospital Association recommends hospitals defend themselves by acknowledging the risk levels they face, updating cybersecurity and enterprise risk-management practices to correlate to the elevated threat level, and communicating ransomware threats to all stakeholders. For more on cybersecurity, go to www.aha.org/cybersecurity.
Has your board acknowledged the increasing risk of cyber-attacks? How have you ramped up your cybersecurity?
Partnerships and Care Coordination
New Collaboration. One exciting outcome of the COVID-19 pandemic response is hearing the stories of organizations and individuals working together to develop solutions. Sharing best practices and peer networking is nothing new, but the rapid evolvement of COVID-19 treatment and response has invited new forms of collaboration. In the beginning, it was finding people in the community to sew masks and donate supplies. As the complexity grew, so did the partnerships.
National Platform and Case Examples. On a national scale, the American Hospital Association launched the AHA Living Learning Network, a platform that helps health care professionals share pressing COVID-related needs and tools and resources for learning and training. Locally, stories tell of hospitals partnering with cultural organizations to address COVID-19 disparities, establishing new communication structures between hospitals and community organizations to rapidly respond to community needs and continued growth in partnerships to meet both community health needs and social needs in the midst of the pandemic. For case examples highlighting hospital community partnerships and care coordination, go to www.aha.org/type/case-studies and www.aha.org/topics/community-partnerships.
How have your organization's community partnerships and efforts to improve care coordination changed as a result of COVID-19? What should continue, and what lessons can you take away to move forward with?
In the AHA's letter to President-Elect Joe Biden outlining policy priorities in December 2020, the association highlighted the impact of COVID-19 on the already strained behavioral health resources in America: "The stress from unemployment, isolation due to quarantine, and grief over loved ones lost to the pandemic are likely to manifest in increases in already high rates of deaths of despair (i.e., suicides and substance use)."
The Mental Health Epidemic Has Worsened During COVID-19. Before the pandemic, the Kaiser Family Foundation reported deaths due to drug overdoses increased more than threefold from 1999 to 2018. But the pandemic has taken an even greater toll on this major health challenge in America. In 2019, approximately one in ten (11 percent) of adults reported symptoms of anxiety or depressive disorder. But during the COVID-19 pandemic, more than one in three adults reported the same symptoms. In addition, 13 percent of adults reported new or increased substance use as a way to manage stress during the pandemic, and more than ten percent of adults reported thoughts of suicide.
New data from the Centers for Disease Control and Prevention confirm what many experts have warned: 2020 recorded the highest number of drug overdose deaths ever recorded in a single year. For the 12 months ending in May 2020, more than 81,000 drug overdose fatalities occurred, and many believe the first few months of the pandemic played a key role.
Compared to 2019, synthetic opioid-linked deaths rose by 38 percent, cocaine-related deaths rose by 26 percent and deaths from psychostimulants, including methamphetamine, increased by nearly 35 percent.
Like many other health challenges, the increased mental health toll of COVID-19 has hit Black/African American and Hispanic/Latino communities the hardest. And, while they experience proportionally lower rates of mental health challenges, white Americans are more likely to get treatment for mental illness.
CDC Director Robert Redfield recently described the challenge facing communities across America: "The disruption to daily life due to the COVID-19 pandemic has hit those with substance use disorder hard. As we continue the fight to end this pandemic, it's important to not lose sight of different groups being affected in other ways. We need to take care of people suffering from unintended consequences."
Consumers Are More Willing to Engage Online. One benefit of the forced shift toward telehealth during the pandemic has been an increased willingness to engage in telepsychiatry, with more adults using the services during the pandemic and reporting an interest in continuing telepsychiatry after the pandemic. This willingness for virtual visits has the potential to expand access to services for areas without behavioral health providers, and investments are supporting the trend.
By the third quarter of 2020, venture capital funding for U.S. mental health start-ups had already surpassed investments in 2019. Examples of recent mental health start-ups include Talkspace, BetterHelp and Brightside offering online therapy, counseling and medication plans. Other services such as Headspace and Calm focus on mindfulness, meditation, sleep stories and relaxing music. Calm has also partnered with Kaiser Permanente to offer qualifying members free access to Calm's content. According to AHA, first-time downloads of the top 20 mental wellness apps increased by nearly 30 percent from January 2020 to April 2020.
Is mental health a central component of your hospital or health system's vision for the future? What opportunities are there to partner with other organizations to better meet future community mental health needs?
Social Determinants of Health
Every year in the U.S., millions of people face food insecurity, homelessness or an inability to access medical care, sometimes simply due to the lack of transportation. Experts estimate medical care accounts for only 20 percent of "modifiable contributors" to keeping a population healthy. The remaining majority of factors are impacted by Social Determinants of Health such as housing, healthy food, income, family and social support, and community safety.
Pre-Pandemic Challenges. A Kaiser survey conducted before the COVID-19 pandemic found 68 percent of people living in the U.S. experienced at least one unmet social need. Further, 25 percent of those surveyed reported concern over an unmet social need as a barrier to health. In that same survey before the pandemic, Kaiser patients who expressed a desire for food assistance were 3.8 times higher among Black members and 4.6 times higher among Hispanic members when compared to white respondents.
According to Bechara Coucair, MD, senior vice president and chief health officer at Kaiser Permanente, "The connection between unmet social needs and poor health outcomes is clear. Social needs must be addressed at the same level of importance as physical and mental health. Access to safe and secure housing, nutritious food, reliable transportation and meaningful interpersonal connections are essential for well-being."
The Pandemic Has Exacerbated Disparities. The sobering fact of health inequity has been spotlighted through the experience of COVID-19 infections in the U.S. Just three months into the pandemic, data from the CDC revealed that Black and Latino people were disproportionately affected, often having three times the rates of infection as their white neighbors. This disparity was demonstrated in a widespread manner that spans the country, throughout hundreds of counties in urban, suburban and rural areas, and across all age groups.
It's Worth the Investment. Most hospital and health system missions are centered on meeting community needs. This can't be done without addressing social needs, and payment shifts like accountable care models and Medicare shared savings are reflecting this shift. According to AHA's Futurescan report, it is projected $230 billion could be saved if health equity improved in the United States. A 2020 study found that every $1 invested in community health worker interventions addressing unmet social needs results in a $2.47 return to the average Medicaid payer.
Has your board and senior leadership prioritized social health? Do you know what your community's greatest social health needs are? How does your organization prioritize meeting social health needs when compared to meeting physical and mental wellness needs in the community?
Special thanks to The Walker Company and governWell™ for use of: Board Leadership is Essential to COVID-19 Recovery and Success. Additional trustee resources are available in Kansas governWell and in the Trustee section of the KHA website.