There are lessons to be learned from the COVID-19 experience, and health care on a national scale is poised for big changes as a result.
By Shari Roan
In July 2020, about 300 UCLA Health primary care providers received a set of computerized data that was unlike anything they had seen before: a list of every patient in their practice who was likely to be hospitalized in the coming year. The reports were compiled by UCLA Health’s Office of Population Health using big-data computer programs that analyze patient health practices, histories and risk factors. With the ongoing COVID-19 pandemic, the idea was to alert physicians of patients who may require extra attention and support to remain healthy as the pandemic unfolds through the coming fall and winter.
“Artificial intelligence (AI) is a technique that will change all of health care. COVID-19 will accelerate that,” says Naveen Raja, DO, medical director of UCLA’s Accountable Care and Population Health. “I think AI is the way forward in helping the doctor make decisions. We said to the clinics: These are your patients who are likely to get into trouble, who didn’t get a follow-up MRI or who aren’t taking their medication. It’s a proactive care model.”
The use of AI and big-data computing to improve the health of large populations has been contemplated for years. But if the COVID-19 pandemic has taught health care professionals anything, it is that there is no better time than now to enact policies aimed at strengthening the U.S. health care system. Like a strict teacher scolding a slacking student, the pandemic has delivered some harsh lessons to the health care field that have left many of its leaders humbled and ready to embrace long-discussed changes linked to accessibility, affordability and quality.
“It is time for a reckoning, on so many fronts in the health care system, with all of the failures we have tolerated. Change is happening everywhere,” says Elizabeth Mitchell, president and CEO of the Pacific Business Group on Health, a San Francisco-based organization that advises private employers and public agencies on health care quality and delivery issues.
In his many meetings across UCLA Health’s campuses, John C. Mazziotta, MD (RES ’81, FEL ’83), PhD, vice chancellor for UCLA Health Sciences and CEO of UCLA Health, has alerted the faculty and staff that the old ways of doing business are over. “Tomorrow will be different than anything we knew before,” he says. “We now have a new world of medicine, and we need to function more efficiently, more effectively and have the end result be better for patients, trainees and scientists.”
The pandemic will elevate a practice known as a "learning health care system," says Amy P. Abernethy, MD, PhD, principal deputy commissioner of food and drugs for the U.S. Food and Drug Administration. A learning health care system is defined as one that performs ongoing assessments to learn and implement change. "The story of COVID is going to be one that acts as a catapult to move us forward to a learning health care system," Dr. Abernethy told participants at a national medical conference in June.
The suddenness and severity of the COVID-19 pandemic highlights the need for a more adaptable health care system, Dr. Raja says. Medicine has long been a field characterized by careful and ponderous introspection. New discoveries, he notes, often take a decade or more to trickle from research labs to patient care. “That is not the way to do it. We have to change that,” he says. “The learning health care system means when we do something, we learn from that and use the learning to further improve. For example, we are using AI system to learn. It’s no longer acceptable to not know how many diabetes patients are in your practice, how many are doing well and how many have diabetes that is not controlled. We need to know what is working and what is not.”
What worked quite well in the early months of the pandemic and since is the use of telehealth — video visits — that allow people to receive care from their homes. Readily available technologies like telehealth and AI will emerge as avenues to take care of large groups of people more efficiently and effectively, a concept known as population health, says Eve M. Glazier, MD, president of the UCLA Health Faculty Practice Group.
Population health is loosely defined as a focus on the health of large groups of people, such as those with a certain condition or people who live in the same geographical area. Telehealth, which soared from several hundred “visits” a month at UCLA to thousands a week by April, also could support population health by allowing patients with chronic ailments, such as high blood pressure or mental health conditions, to receive more frequent, timely visits at home from a variety of health care professionals who can help them stay well, Dr. Glazier says. “How do we stay connected to people across this huge geographic area? What are ways we can connect our patients to care teams?”
Some experts predict more health care services will shift to the home and other lower-cost and convenient settings, while physical examinations and procedures are done at in-person clinic visits, and hospitals are reserved for acute care, thus putting more control in the hands of health care consumers. “I think, in the very big picture, there will be a shift from giving care on a health care organization’s terms to giving care on the patient’s terms,” Dr. Raja says. In the traditional care model, patients make an appointment, come to an office and wait until the practitioner is free to see him or her. Consumers who embrace telehealth may begin demanding more. “Patients are asking, ‘If I can do my banking from home, why can’t I do more health care from home?’” Dr. Raja says. “I think this is on the horizon. It hasn’t bloomed yet.”
Consumers also may begin demanding more help to stay well, experts say. The pandemic has laid bare the reality of disparities in the American health care system. According to the Centers for Disease Control and Prevention, hospitalization rates for COVID-19 are five times higher for Blacks and four times higher for Hispanics compared to whites. COVID-19 patients with other health problems, such as diabetes, obesity or cancer, have suffered higher death rates and longer hospitalizations, according to several studies. U.S. Blacks have higher rates of several common medical conditions, including diabetes and cardiovascular disease.
When it comes to the prevention of chronic conditions, “a lot of the outcome is not determined by medicine but by the patient’s own socioeconomic circumstances,” Dr. Raja says. While genetic factors can have a significant impact, “zip code plays a big role. The house I live in, the food I eat, the neighbor I have, the street I live on — all those have an effect on my health,” he says.
At UCLA, community liaisons work from primary care offices to help address socioeconomic problems that affect health, Dr. Raja says. “Our teams are doing that. But there is an opportunity to really expand that and do it for all populations across the health system,” he says. “We are headed in that direction.”
Employers are no longer oblivious to the social determinants of health, Mitchell says. For the first time this year, the Pacific Business Group on Health board of directors identified health equality as one of its strategic priorities. The impact of large manufacturing plants suddenly shuttered due to a COVID-19-infected workers and the lack of sufficient COVID-19 test kits has been eye-opening for business leaders. “I am seeing a level of engagement from employers and an urgency for change that I’ve never seen before,” she says. “We are hearing from large manufacturers saying we have to be much more engaged in the health of our community because one case of COVID can shut down our manufacturing plant. Staying healthy has a huge impact on the economy.”
The business side of health care is destined for transformative change in the wake of the pandemic, experts say, likely moving away from the traditional fee-for-service model toward managed care. In fee-for-service models, practitioners bill for each service or treatment they provide each individual patient. In managed care systems — also known as capitated systems — a medical practice receives a lump sum of money per patient per month. In such a system, keeping patients healthy saves money in the long run.
Managed care has already seen a boost due to the pandemic. For several months this year, Americans canceled medical appointments that were not urgent to avoid possible COVID-19 exposure. While managed care offices fared well during this period, many traditional primary care offices that operate on a fee-for-service basis have suffered severe financial losses. “The evidence is clear that providers who are in population-based payment models and who have developed the capacity to manage population health and who aren’t stuck on fee-for-service are faring much better,” Mitchell says. “A fee-for-service system incentivizes over-utilization and doesn’t support prevention and community-based care and everything that makes people healthier.”
The pandemic also has highlighted the vulnerability of a health insurance system largely dependent on employers while showcasing the value of government-sponsored health care, such as some provisions of the Affordable Care Act (ACA) passed in 2013. An estimated 20 million Americans lost their jobs in March and April, many also losing employer-based health insurance, according to the U.S. Department of Labor. But a recent report from the Kaiser Family Foundation found four-out-of-five people who lost their jobs fell into a safety net: They were eligible for coverage through expanded Medicaid programs or, if age 26 or under, rejoining their parents’ health care plans – policies authorized by the ACA.
Perhaps one of the more disheartening news stories to emerge in the early weeks of the pandemic was a report that states were competing — bidding and outbidding each other — to obtain essential personal protective equipment (masks, gloves, gowns) for their health care workers.
Viruses do not, of course, recognize state boundaries, and the folly of the situation was not lost on Americans. The pandemic has demonstrated for the public “that health care is very fragmented,” Dr. Mazziotta says. “It’s also highly competitive. It isn’t sewn together in a network that connects and adjusts. We’re going to need effective governmental input at every level, from the federal to the state to the county to the very local, in order to have an integrated system that reacts appropriately and solves problems like supply chains and managing surges.”
The failure to share data about the coronavirus outbreak also hampered the public health response, Mitchell says, noting that other countries may have managed the pandemic better because of established information-sharing networks. “We are so challenged to track and address the pandemic in part because we have such a failure in data-sharing. Hospitals don’t like to share data, and health plans don’t like to share data,” she says. “If we have a reasonable data infrastructure, we would be much better equipped to manage the pandemic.”
It is likely that America will emerge from the pandemic with a more centralized and much less vulnerable health care system, says Robert A. Cherry, MD, chief medical and quality officer for UCLA Health. He foresees the private sector seizing a business opportunity to re-establish manufacturing and supplies of personal protective equipment, pharmaceuticals and other now-scarce medical resources in the United States.
But he cautions against a complete overhaul of U.S. health care. “The U.S. health care system is, has been and continues to be one of the best health care systems in the world,” Dr. Cherry says. “There is no place other than the U.S. that I would want to get health care. The reason why we do so well in treating disease for the individual is that we have an entrepreneurial culture. A system that innovates and is focused on discovery and translating research to serve the care of patients has been with us for quite some time. That system has its advantages. But the Achilles heel is a perfectly designed virus that takes advantage of that decentralized model and rips through the country.”
The trick, Dr. Cherry says, is rethinking the balance between an entrepreneurial health care system that gives us spectacular, lifesaving treatments and a stalwart organizational structure that protects us from once-in-a-century pandemics. That balance, he says, “is going to fundamentally change.”
It is one of life’s enduring lessons, however, that change, while painful, often yields surprising benefits. That, Dr. Mazziotta says, gives him hope. “I’m actually extremely optimistic about how we come out of this,” he says. Networks focused on research and patient care, he says, have grown stronger as a result of the pandemic, while partners and competitors across Los Angeles have collaborated to endure the crisis.
“We worked together [with other large health care institutions] to prepare for a surge,” he says. “We worked together to share personal protective equipment. And we’re all going to have to continue to work together to meet the challenges that are ahead.”
Shari Roan is a freelance medical writer and frequent contributor to U Magazine.