Employers have long sought programs and practices that can help workers be proactive in managing their health. But a pandemic disrupted that work in many ways.
COVID-19's spread — a health risk by itself — coincided with a decline in healthcare participation. In one study conducted by healthcare navigation company Castlight Health, researchers found "dramatic reductions" in the use of healthcare during the first two months of the pandemic. Musculoskeletal surgery, for example, declined about 47% compared to the same time frame in 2019, while MRIs declined 45%.
Some of the biggest plummets came at the expense of preventative care, a broad category that can include check-ups, immunizations, screenings and other procedures undertaken for disease prevention purposes. According to data from the nonprofit Health Care Cost Institute (HCCI), submitted health claims for mammograms and pap smears were down nearly 80% in April 2020 year-over-year, and those for colonoscopies were down "almost 90%" in mid-April 2020 year-over-year.
Percentage change of selected preventative care procedures during COVID-19 pandemic
|Preventative care type||YOY trend (as of April 14, 2020)||YOY trend (as of Oct 1. 2020)|
|Childhood vaccinations (aggregate)||-57%||-8%|
SOURCE: Health Care Cost Institute
Those declines reversed by fall, HCCI data show, but preventative care procedures generally have not returned to pre-pandemic levels, said Daniel Kurowski, senior researcher at HCCI. While Kurowski noted that there are limitations to the type of claim-based analysis used by HCCI in its study, he confirmed that the organization's data suggest the U.S. healthcare system has not made up for the loss of services that occurred since the pandemic's onset.
What can employers derive from these findings? Healthcare industry sources who spoke to HR Dive expressed some concern that deferred care could have an impact on disease prevention down the line, but the complete picture is far from clear. What's more, the scramble to respond to such challenges could yield some positive lessons.
Dr. Mark Cunningham-Hill remembers the initial months of the pandemic well. As the medical director for the Northeast Business Group on Health, a regional coalition of employers and healthcare stakeholders, Cunningham-Hill observed closures on a wide scale. "Everything stopped for a month or two," he told HR Dive, "and gradually, telemedicine started coming online."
An executive at insurer Aetna shared a similar view. "We have seen declines in every aspect of care within our populations, specifically within preventative services," said Julie Bietsch, the company's senior vice president, clinical operations. But by August, Aetna began to see preventative care utilization trends rebound to the point that, by October 2020, those trends were close to 2019 levels, Bietsch noted.
Virtual care has helped to fill in some of the gaps caused by COVID-19 and may even have helped to offset some declines in care utilization, said Magda Rusinowski, vice president of Business Group on Health. While such care was initially delivered via providers that specifically focus on virtual care, the format "has emerged as a way to see your brick-and-mortar provider" as well, Rusinowski said.
Cunningham-Hill said telehealth and similar technologies can allow care providers to review patients' health and direct them to book appointments for in-person procedures, such as a mammogram, when available. For other specialties, such as mental healthcare, telehealth "possibly works better" than it did even before the pandemic, he added.
Even for procedures such as colonoscopies that typically require an in-person visit, alternatives are available. The pandemic has caused providers and other members of the healthcare system to "think outside the box" when it comes to preventative care, Bietsch said. Examples include HbA1c test kits that can evaluate blood glucose levels and Cologuard, a Food and Drug Administration-approved, at-home testing kit that helps screen for colon cancer.
'A matter of enormous concern'
Still, the impact of deferred care may be a puzzling development for employers, one with potentially devastating consequences for some patients.
Early detection of serious conditions is a primary concern. In a June 2020 article published in Science Magazine, Norman E. Sharpless, director of the U.S. National Cancer Institute, described a statistical model for excess deaths from colorectal and breast cancers between 2020 to 2030. Due to delayed diagnosis and care issues caused by COVID-19, Sharpless said the model suggests almost 10,000 excess deaths from both types of cancer over the next decade, or about a 1% increase.
"This analysis is conservative," Sharpless wrote, "as it does not consider other cancer types, it does not account for the additional nonlethal morbidity from upstaging, and it assumes a moderate disruption in care that completely resolves after 6 months. It also does not account for regional variations in the response to the pandemic, and these effects may be less severe in parts of the country with shorter or less severe lockdowns."
And while declines for procedures such as colonoscopies and mammograms pose a challenge for health plans, another item — childhood vaccinations — can be just as worrisome, multiple sources told HR Dive. HCCI found that childhood immunization rates varied by type. Meningococcal and HPV vaccines saw year-over-year declines of 75% in mid-April 2020, while those for Rotavirus saw a 33% decline.
This area is "a matter of enormous concern" for employers, said Jeff Levin-Scherz, national co-leader of Willis Towers Watson's health management practice, because vaccinations save lives and prevent families from incurring substantial medical costs.
Childhood vaccinations have not only been impacted by closure of care centers, in which such vaccines are often given, but also by the closure of school systems, which often provide reminders to families about receiving vaccines, Bietsch said. Lack of access in certain geographic areas can also play a role in vaccine disparities, she added.
There also are concerns about the management of chronic conditions such as diabetes and asthma. Bietsch said Aetna has messaged plan members after, for example, a trend of diabetic patients who would receive a lab test but not a foot or eye exam.
What employers can do
Providing coverage is the most important thing employers can do to encourage employees to use preventative care, Levin-Scherz said; "No one should miss preventative care because they didn't think it was covered." Employers have several opportunities to improve their healthcare offerings as a result of the pandemic, including the chance to work closely with health plans that are proactive about reminding employees about the importance of such care, he added.
COVID-19 also may prompt healthcare providers, payers and even employers to re-examine what constitutes high-value or low-value care, Cunningham-Hill said. He referred specifically to procedures such as colonoscopies that are performed on patients over the age of 75, as well as false positives that lead to lengthy investigations that do not turn up problems. But there are also items proven to be valuable, such as asthma medications and diabetes management tools. "How do we come out of this doing more of the high-value stuff?," Cunningham-Hill said.
That points to another actionable item for employers: access. It is one thing to provide coverage for a given form of preventative care, but associated copays may discourage workers from actually taking part in that care. Even if the plan provides 80% coverage for a procedure with a $25 copay for the worker, "that copay is a fortune for someone earning $25,000 a year," Cunningham-Hill said. Such examples point to the need for greater healthcare equity, he added.
Employees may have alternatives when it comes to things like ensuring their children have access to important vaccinations. "It doesn't have to be a physician's office," Bietsch said, adding that pharmacies and other qualified health centers can provide such vaccines.
Communication also emerged as a common theme in conversations with sources. Kurowski said his takeaway for employers is to encourage employees to take control of their health and remind them of the access that employers provide to chronic care management, preventative care and even fringe wellness programs, like fitness benefits.
This can be particularly important for workers with chronic conditions. "You can't tell people enough about looking at their diabetes in different ways," Bietsch said. Plans and employers might decide to mix up communications around preventative health by sharing stories about how a plan member managed their diabetes successfully, she noted. Rusinowski said organizational leaders, especially those whom employees trust, can also play a part in communications strategy.
Healthcare industry observers have noted for months that COVID-19 spurred the growth of the virtual healthcare space, but that growth also could yield positive results for preventative care. Telehealth can allow care providers to monitor patient health, recommend follow-ups and help patients manage their chronic conditions. "Many of the telemedicine companies have been doing substantially more primary care," Levin-Scherz said. "As they do that, they become educated on preventative care and they become advocates of preventative care."
There are still hurdles to the adoption of telehealth and similar services and, importantly, not all visits can be replaced by virtual care. But Rusinowski sees the space "not as a replacement, but as a way to enhance" care specialties and improve the overall patient experience.
As employers seek to communicate to employees the importance of continuing their care routines and seeking preventative care, businesses should not focus solely on costs. "I just want to make sure that when we talk about it, we emphasize the well-being component and the desire to create an environment where employees can have the best health outcomes possible," Rusinowski said. "The pandemic has shown us more than anything else that you can't have a productive workforce where health is an issue, but this is not anything new for [employers]."
Correction: An earlier version of this story misspelled Rusinowski's name. HR Dive regrets the error.