While most of us are thankful this year is coming to a close, it’s important to look back at all we have learned. This year has been the most challenging in so many ways – COVID-19, the divide in America, both political and racial, jobs lost, lives lost, social distancing, social isolation, and the list goes on and on. One thing this year has taught us is that we all need to have an advance care plan should the unexpected happen. With over close to 18M COVID-19 cases and more than 300,000 deaths (at the time this was written) we as a country were unprepared in so many ways.
We as individuals were unprepared as well. As COVID-19 initially ran rampant through nursing homes, senior living environments, and those with chronic illness, it soon hit people of all ages. It continues to threaten the younger, arguably healthier populations, making no one immune. Whether it be through personal stories or watching the evening news, the last 9 months has forced us all to stare death in the face.
With the vaccine still months away for the general public, the death rate will continue to rise in the foreseeable future. We are living the post-Thanksgiving rise in cases, and will see this trend continue as we approach the Christmas holiday into the new year.
Advance Care Planning Is More Important Than Ever
COVID-19 has showcased that advance care planning conversations are not broadly conducted by healthcare providers and many do not know the end-of-life wishes of their loved ones. If these conversations have happened, and a document, such as an advance directive was completed, it’s often locked up somewhere, unavailable when and where needed. Without knowing these end-of-life wishes, heroic, life-saving measures are taken. The result: many people ending up on ventilators who most likely will not make it off the ventilator, and if they do, their life may be of much lower quality, especially if they are elderly and/or suffer from chronic illness.
Now is a great time to think about, discuss, and document your end-of-life wishes. Request an advance care planning conversation with your healthcare provider and ask them to document your wishes. Your providers can be reimbursed for these conversations through ACP CPT codes 99497 and 99498, so there is no excuse for them to not have these conversations. Make sure to include your loved ones in these conversations or express your wishes to them after. And make sure your advance care planning documents are available when needed, ideally digitally, through a system like Vynca.
Palliative Care Is Having Its Moment
Palliative care came to the rescue of many hospitals this year because many onsite clinicians were not trained or able to keep up with the demand for these important and uncomfortable advance care planning conversations. Some hospitals have responded to the demand by embedding palliative care physicians in the ED to conduct goals of care conversations, while others have leveraged additional palliative care support through telehealth. Moving forward, palliative care will continue to be in high demand during the pandemic and beyond. We also expect that virtual palliative care and organizations who offer it will continue an upward trend in the coming years.
There Is Inequality in Healthcare in America
Earlier this year, we focused on the racial divide of healthcare in our country. We looked at the life expectancy gap between black and white populations. We saw the largest gap in some of our largest cities: Chicago – 31.7 years, Washington, DC – 27.5 years, New York City – 27.4 years.
As we mentioned back in June, the COVID-19 infection and death rate among minorities was higher than those who were white. At of the end of November, this continues to be true. Cases, hospitalizations and death rates continue to be higher than those among whites:
1.8x – American Indian/Alaskan American
.6x – Asian
1.4x – Black
1.7x – Hispanic/Latino
4.0x – American Indian/Alaskan American
1.2x – Asian
3.7x – Black
4.1x – Hispanic/Latino
2.6x – American Indian/Alaskan American
1.1x – Asian
2.8x – Black
2.8x – Hispanic/Latino
There Was a High Demand for Resources, But Not Enough Resources
Healthcare was unprepared for COVID-19 in so many ways. The pandemic not only uncovered the issues in the healthcare supply chain, but also the realization of bed and staff shortages when the masses are being admitted to hospitals and requiring medical care. In the beginning of the pandemic, there was much focus and unimaginable stories around the lack of PPE and ventilators. Healthcare organizations were, and continue, to run out of beds. Tents and convention centers were set up to serve as overflow treatment centers.
The shortage of healthcare providers, especially as many became infected with COVID-19, was highlighted. Some parts of the country allowed those providers who tested positive but were asymptomatic to continue treating COVID-19 patients. Many were calling healthcare providers to come out of retirement to treat patients. All of these are signs of desperation to keep up with the demand hospitals were and continue seeing.
The True Barrier to Telehealth Was Reimbursement
Technology proved to not be the barrier to telehealth. Once restrictions were loosened around reimbursement, there was an uptick in telehealth consults. The 1135 waiver allowed Medicare to pay for more types of telehealth visits, including home telehealth consults across the country and not just limited to those who live in designated rural areas. We also saw a loosening on the reimbursement for audio-only advance care planning conversations, eliminating any technological barrier that may have existed.
Telehealth proved to be the only safe way for many to see their healthcare providers, especially those with chronic illness. It also ensured that this vulnerable population did not cancel their visits, which would have increased the likelihood of them being admitted to the hospital. An April 2020 report from Evidation showed that 50% of patients with chronic illness worried about visiting their provider in-person, with 10% saying they would skip their visits due to COVID-19.
Telehealth also saw one of the biggest and most talked about health technology M&A transaction in 2020: Teladoc and Livongo. Teladoc acquired Livongo for $18.5B, making Teladoc the largest virtual care company. This merger further proves the future of delivering care (in many cases) will be virtual.
While we could probably never be prepared for the magnitude of this pandemic, it’s important to recognize how we reacted and how we move forward. While it exposed the vulnerabilities we have in healthcare, it also forced us to make much needed changes that arguably happened way too late. Recognizing the importance of advance care planning and palliative care highlighted that we actually have a say in how we die. We need to focus on the inequality in healthcare, as it is not acceptable that access to healthcare and outcomes are based largely on where we live, our ethnicity or the color of our skin. The shortage of clinicians to treat COVID-19 patients gave us a glimpse the future anticipated physicians shortages. And telehealth is here to stay and is expected to gain adoption in the years to come.