Care Process Redesign

More than 2 years into the pandemic, the issue of deferred care continues to affect the healthcare industry

April 14, 2022 12:03 am
  • Concern about the implications of deferred care continues as healthcare organizations establish their strategies for a post-pandemic landscape.
  • Service lines where the impact of deferred care is especially significant include oncology, cardiology and behavioral health.
  • Hospitals and health systems can mitigate the effects of deferred care by making best use of their workforce and technology.

As the healthcare industry emerges from the worst of the COVID-19 pandemic, it’s struggling to gauge and address the impact of deferred care.

If nothing else, most everyone agrees the issue will have significant consequences for population health as more patients return to the fold after choosing to stay away from healthcare settings or being forced to postpone procedures over the last two years.

“Really what it’s done is create a population of people who have conditions they would never have developed in a pre-pandemic environment,” said Chris DeRienzo, MD, senior vice president and system chief medical and chief quality officer for Raleigh, N.C.-based WakeMed Health & Hospitals.

HFMA published a groundbreaking cover story that anticipated the looming issue of deferred care in late 2020. Over the ensuing months, the challenges for clinical operations have only become more daunting, said Linda Hand, CEO of the predictive analytics company Prealize Health.

That’s because there have been fewer shutdowns and operational restrictions than there were during the pandemic’s first year, meaning hospitals have been stretched to provide close to their normal array of services while also caring for COVID-19 patients. They’ve also had to expand operations to include COVID-19 vaccination programs and testing centers while coping with the pandemic’s well-documented impact on the workforce.

“And now you’ve got that deferred care trying to come back now that it’s more safe,” Hand said. “But they’re overwhelmed.”

“At one point I recall speaking with members of our inpatient team, and they said [that] as our COVID census began to come down, we’re just getting backfills with people who are just as sick with something other than COVID,” DeRienzo said.

Chris DeRienzo, MD, WakeMed Health & Hospitals

In HFMA’s quarterly Outlook Survey of members, deferred care appeared to be a fairly widespread issue for hospitals and health systems throughout 2021. In the most recent survey for which results are available, conducted in November and December, 24.4% of 688 respondents said their organization was still experiencing a deferral of nonelective care (45.6% said they were unsure).

The affirmative responses came even though the survey took place during a relatively quiet period of the pandemic. The delta surge had peaked earlier in the fall, while the omicron surge was about a month away from cresting.

Where deferred care is manifesting

The impact of deferred care is unlikely to subside even if the pandemic continues to wane as it has since the worst of the omicron wave. Top clinical areas of concern include cancer, heart disease, musculoskeletal conditions and behavioral health.

Cancer. A March study published in the journal Cancer reported monthly screening deficits in April-June 2021 at 80.6% of surveyed facilities for colorectal cancer, 69% for cervical cancer, 55.3% for breast cancer and 44.6% for lung cancer. The median drop-off in screening volume was most significant for colon cancer, at 17.7%.

Another study published in March, this one in the Canadian Medical Association Journal, analyzed the impact of cancer surgery slowdowns on patient survival.

Examining a cohort of 22,799 patients waiting for cancer surgery before the pandemic and a group of 20,177 waiting during the pandemic, the researchers found the mean wait time increased from 25 to 32 days. That delay led to 0.01-0.07 life-years lost per patient across cancer sites, translating to 843 life-years lost among patients with cancer in the province of Ontario over a six-month period, the researchers reported.

“There’s a dramatically increased burden in cancers that could have been caught at Stage 2 that are presenting at Stage 4,” DeRienzo said (not in reference to a specific study).

Heart disease. Cardiovascular disease will be a greater burden in 2022, Hand said, largely as a result of deferred care. In a published report (registration required) based on claims data from more than 2 million health plan enrollees over a four-year period ending in August 2021, Prealize predicted 2022 utilization increases of 36% for valvular disorder, 18% for cardiomyopathy and 17% for cardiac dysrhythmias.

Cardiovascular symptoms also are a hallmark of long COVID-19, Hand noted.

“Those claims are peaking in the one-to-three-month, three-to-six-month [range],” she said, referring to time elapsed after a person contracts the disease. “They start to regress to the mean maybe a year or so out, but that’s just hammering payers right now.”

Linda Hand, Prealize Health

Diabetes is a separate yet related issue in cardiometabolic health. Analyzing 2021 claims, Prealize found that patients with diabetes were presenting to the emergency department with higher A1C levels relative to pre-pandemic cases. The company predicts a 17.6% increase in healthcare utilization stemming from diabetes this year.

Musculoskeletal (MSK) conditions. Prealize foresees significant issues with deferred care involving MSK conditions after a long stretch in which people struggled to stay active. Data show U.S. residents have gained an average of 29 pounds during the pandemic, Hand said.

In addition, many of the postponed elective surgeries involve MSK-related services such as joint replacement. The predicted 2022 increase in healthcare utilization for MSK issues, according to Prealize, is 22% — the most of any diagnosis.

Behavioral health. Citing Kaiser Family Foundation data, Prealize noted in its report that more than 20% of adults with symptoms of anxiety or depression reported needing but not receiving mental healthcare during the pandemic. The analytics company said that statistic “portends dizzying ramifications for care in 2022.”

“Treating the whole person is going to be really important,” Hand said. “I’ve seen a lot of [organizations] move to that team care where they’ve included mental health to reduce No. 1, the stigma — this is a part of your care.”

She noted a recent report from the U.S. Surgeon General highlighting a crisis in mental health among kids younger than 18. If that trend goes unchecked, it will escalate across the healthcare system in the years to come.

“We will feel the burden of the pandemic’s impact on behavioral health for an entire generation,” DeRienzo said.

How organizations are responding

Based on late-2021 data from HFMA’s Outlook Survey, key areas in which deferred care is affecting the deployment of resources include clinical staffing (27.3%) and operational staffing (24%), according to a question in which respondents were asked to select any of seven areas (also including space utilization, revenue cycle tactics and management, collections, decision support/technology and human resources).

More broadly, organizations are looking at workforce solutions and technology to try to mitigate the impact of deferred care.

Workforce. Organizations need to consider how to make optimal use of a workforce that has been besieged during the pandemic and could look different coming out of it, DeRienzo said.

“We can expect to need to position our workforce to manage that [higher acuity] for the foreseeable future,” he said. Organizations should be preparing to “serve a population who we know is likely going to be sicker [for] longer.”

A rethinking of care processes to better emphasize home-based care and remote patient monitoring is advisable, said Mark Smith, MD, MBA, professor of clinical medicine at the University of California, San Francisco.

“The normal, default general provider network is not well-organized or engineered to take intensive outpatient care of people that you want to keep as outpatients,” Smith said. “You can do an awful lot of intensive work with outpatients for less than the cost of an ER visit, let alone a hospitalization.”

Mark Smith, MD, University of California, San Francisco

In the revenue cycle, any opportunity to automate processes can help a potentially depleted workforce process surges of returning patients, said Rick Heise, CPA, senior vice president with CommerceHealthcare.

“If you think about all the junk that comes in from insurance companies and patients that is paper-based, and then having to reconcile all that, get a clean reconciliation and posting to the revenue system and to the finance system — if you’re relying on a lot of manual effort to do that, these surges in volumes coming back make it very difficult and expensive,” Heise said.

Technology. The ability to deliver care virtually can help providers reach larger numbers of patients who otherwise might slip through the cracks and put themselves at risk of worsening health.

Smith maintains a clinical practice for patients with AIDS at Zuckerberg San Francisco General Hospital. In that capacity, he typically sees individuals who have Medicaid coverage or are uninsured.

“They’re not a particularly wired population,” said Smith, who also serves on the board of directors for Teladoc Health. “They have not generally been early adopters of technology.

“And yet we found that a lot of them prefer to receive at least some of their care in virtual ways. Doctors, patients and institutions like hospitals recognized how much of what they were doing in person really wasn’t necessary to do in person.”

However, he added, value-based payment needs to become more widespread for the full benefits of telehealth and remote care to be realized.

“Doctors don’t get paid to talk to patients on Zoom. They get paid when they come into the office,” Smith said. “They’re not really anxious to adopt that way of doing things unless they’re paid to keep their patients healthy in the least expensive way.”


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