Chad Spain is a family medicine physician who practices in an Intermountain Healthcare clinic in Salt Lake City, and during the pandemic, he treated a patient who needed more than medical care. The man is homeless, has some mental health issues, and had a series of medical problems, including a month-long hospitalization for cellulitis, a serious bacterial skin infection. “He needed close monitoring when he left the hospital,” Chad said. “But because he didn’t have a home to go to, he went to a skilled nursing facility.”
Normally that means Chad’s work would be done. But Chad’s staff reached out to a program that offers long-term housing to people with mental health or substance abuse issues, and when the patient is discharged from the nursing facility, he’ll have a place to live. “We’re improvising,” Chad said. “If the man had just been discharged from the hospital and left on his own, especially during the pandemic, he’d be right back in with Covid or another infection or something else. Lining up housing was much better for him. It’ll dramatically improve his quality of life, and it’ll probably be a lot less expensive.”
I look at that case, and I think: As bad as the pandemic is, could we end up doing better work when it’s over? Can it teach us anything about how to serve our patients better and more affordably than we did before?
Here are seven lessons we’re learning while providing care during the pandemic.
1. Harness technology more aggressively.
Telehealth may be the best example. The number of virtual doctor’s appointments has boomed since the pandemic began — fueled, in part, by higher reimbursements and an easing of restrictions. Twenty-three percent of enrollees in large-employer health plans have used telehealth during the pandemic, according to a report by the Kaiser Family Foundation, compared to 2.4% in 2018 and 0.8% in 2016.
Another survey conducted by the Harris Poll says 42% of Americans have used telehealth during the pandemic, and of those, 65% like the convenience and 63% see it as a way to avoid being exposed to other sick patients.
The lesson: Now that people are used to getting more services at home, they’re not going to want to go back to the way things used to be.
Intermountain Healthcare has pursued telehealth since 2012 on two increasingly popular platforms: We hosted 7,000 virtual visits with patients in March 2020, and that number jumped to 63,000 in April and is staying high. Our professional service connects providers in smaller facilities with medical specialists, which allows the patient to stay close to home and avoids the added risk and cost of a transfer to a bigger hospital. That means patients in, say, Intermountain’s 15-bed hospital in Garfield County in rural Utah have immediate access to specialists who staff Intermountain Medical Center, our 504-bed trauma and referral center, which is 250 miles away in Salt Lake City. They include specialists in stroke, infectious diseases, critical care, wound care, pediatrics, cancer, and mental health.
Consumers can arrange telehealth appointments through Intermountain’s new digital front door app, which helps them find, manage, and pay for their care, all in one place. Our My Health+ app was designed with input from consumers and clinicians, and it provides a simple, comprehensive tool people can use to book appointments, check their symptoms, launch online visits with their providers, access their health history, pay bills, manage prescriptions, get reminders about preventive care, and estimate their health care costs. The app includes a Covid-19 symptom checker to help people get answers and access care. Since the pandemic began, more than 230,000 people have used the symptom checker.
2. Emphasize prevention.
I’ll tell you a secret I’ve learned in 30 years as a physician: People like health a lot more than they like health care. Keeping people healthy — and keeping them out of clinics and hospitals — is the best and least expensive way to improve people’s health.
The work of Chad Spain’s team to find housing for his cellulitis patient is a great example. Connecting patients with the resources they need outside of the clinic helped them stay healthy, which keeps them in the least restrictive, most preferred, least expensive environment possible. That makes sense economically as well as socially. You see your patients as people, and you treat the whole person, not just their problem. Preventive care is the epitome of a consumer-focused priority.
But that counters how medicine is usually delivered in the United States today. Traditionally, the more services you provide, the more money you make. A patient comes into to the emergency department, gets a CAT scan for $1,800, an MRI for $3,000, inpatient care for $2,800 a day, etc. But providing all those services — all that health care — doesn’t keep her well once she leaves the hospital.
3. Eliminate racial disparities in care.
There’s a dramatic difference in Covid-19 rates among different racial groups in America: Black people comprise 13% of the population but 23% of Covid-19 deaths, according to the COVID Tracking Project. In Utah, where Intermountain is based, Hispanics account for 14% of the population but 40% of Covid-19 cases. Black people account for 2% of the population but 3% of cases.
A broader spectrum of health outcomes shows even more alarming results. A 2018 report by the Commonwealth Fund (the most recent data available) showed that Black women with breast cancer had a five-year survival rate of 80%, compared to 91% for white women. Black people in America had a heart disease mortality rate of 308.2 per 100,000 people, compared to 241.9 for white people — and the mortality rate for strokes is 74.5 per 100,000 people for Black people and 52.3 for white people.
Those disparities are disastrous to begin with, and the novel coronavirus puts that danger in high relief: If all of us aren’t safe, none of us is safe.
Some solutions at Intermountain so far have included expanding our hiring and governance practices so our team better represents our community, reaching out to connect with our patients and community members where they live, and expanding training for our staff. We’re also one of 45 systems in the Health Anchor Network, which uses the economic power of our organizations to improve long-term health and well-being at the local level, and we’re actively pursuing the American Hospital Association’s goals to increase equity of care.
Much more needs to be done, especially at points where people live and access care. A report by the Centers for Disease Control and Prevention on Covid-19 rates among different racial and ethnic groups says, “The conditions in which people live, learn, work, and play contribute to their health. These conditions, over time, lead to different levels of health risks, needs, and outcomes among some people in certain racial and ethnic minority groups.” That mirrors what my colleague Tony Iton of the School of Public Health at the University of California, Berkeley, said: Your zip code has a greater impact on your life expectancy than your genetic code.
4. Integrate mental health care and primary care.
This is another problem that was bad before and now is worse. Among 10 of the world’s highest-income countries, America has the second-highest death rate caused by substance abuse (our rate is nine per 100,000 people; only Germany’s rate of 10 is worse — and the worldwide average is three), according to the Commonwealth Fund. Another study by the group shows suicide rates in the United States are higher than other high-income countries, and our suicide rate has been increasing every year since 2000.
And again, the pandemic makes things worse. The World Health Organization reported a 60% increase in domestic violence in April. The Council on Foreign Relations says Covid-19 and domestic violence form “a double pandemic.”
In an essay in the New England Journal of Medicine, Betty Pfefferbaum of the University of Oklahoma Health Sciences Center and Carol S. North of the University of Texas Southwestern Medical Center, said, “The Covid-19 pandemic has alarming implications for individual and collective health and emotional and social functioning.” The likely results: Domestic violence, depression, anxiety, stress, irritability, insomnia, fear, confusion, anger, frustration, boredom, substance abuse, and even noncompliance with Covid-19 prevention guidelines. Who’s most at risk? Covid-19 patients, the elderly, people with previous health conditions, those who live in group settings — and health care providers.
In 2000, Intermountain Healthcare began formally integrating mental health services into its primary care clinics, so medical and mental health professionals collaborate to meet a patient’s physical and mental health needs during each patient visit. Our doctors ask screening questions that help them focus on prevention and early diagnosis, and if patients need further help, it’s easy to access mental health providers, often in the same clinic.
Our study of the outcomes, published in the Journal of the American Medical Association, showed better rates of mental health screening, more adherence to care protocols, and greater use of self-care plans, along with improved clinical outcomes, lower rates of ER visits and hospitalization, and lower costs.
5. Accelerate innovation.
Working from home is a case in point. At the start of the year, about 1,000 of Intermountain’s 41,000 employees worked at home. Today we’ve got 10,000. A survey shows 89% of our people like it, 78% want to keep it up when the pandemic is over, and a large majority say they’re more or equally productive than they were before.
Another example: When the pandemic began, our supply-chain team quickly created a new disinfection protocol to help extend the lifespan of N95 respirators and preserve our limited supply. We also collaborated with other not-for-profit organizations in a worldwide effort to enlist volunteers to produce personal protective equipment. By the end of June, more than 57,000 volunteers produced more than 5.7 million medical-grade masks, 65,000 isolation gowns, and 50,000 face shields.
6. Partner up.
The Covid-19 pandemic is too big to fight by yourself. New and nontraditional partnerships formed during the pandemic are helping providers deliver the kind of help people need, when and where they need it. Intermountain has worked closely with state and local governments and collaborated closely with University of Utah Health, traditionally a competitor, to provide testing, supplies, care, and research support. We’re a member of the national COVID-19 Healthcare Coalition, which unites health care organizations, technology firms, nonprofits, academia, and startups to help protect people across the country.
The next Covid-19 hotspot could be rural America. “Rural hospitals, already struggling financially, know the risk their organizations face if their communities suffer an outbreak,” says the Advisory Board. That’s why rural hospitals and clinics need to partner with strong and stable health systems. An example: Intermountain has forged agreements with 15 rural hospitals in Colorado, Idaho, Nevada, Wyoming, and Utah to provide telehealth consults with their physicians. In the first six months of 2020, we’ve conducted over 2,500 consults with these partners, a 51% increase over the same time period of 2019.
The need for new partnerships goes beyond the pandemic. It includes expanding access to and lowering the cost of generic drugs. To that end, in 2018 we helped forge CivicaRX, a partnership that now includes over 1,200 hospitals and 50 health systems. So far Civica has produced and shipped more than 30 medications and is continuously adding new partners and expanding the formulary.
7. High health care costs are untenable and must be addressed.
Add the economic impacts of the pandemic — a faltering economy, high unemployment, and cuts in benefits and income — to a health care model that was previously unsustainable, and providers and our patients are facing a disaster unless we can drastically improve affordability. All of the priorities I’ve listed here can help us do that.
The story of how Chad Spain and his team arranged for housing for their patient shows how working proactively costs less. Estimates indicate 60% of a person’s health is determined by lifestyle factors, around 30% is due to genetics, and only about 10% is determined by medical care. That means the best way to improve people’s health and the affordability of health care is to go upstream to improve what are called the social determinants of health. They include factors like stable housing, joblessness, hunger, unsafe neighborhoods, access to transportation, etc. Utah has a public-private consortium called the Utah Alliance for the Determinants of Health that’s dedicated to improving those influences. Intermountain Healthcare is a founding member.
I’ll repeat: That kind of care is not only better for the people we serve, it’s much cheaper. I’ve seen sobering polling data that say one of the biggest fears Americans face is medical bills. Before the pandemic 40% percent of Americans couldn’t handle an unexpected expense of $400. Now, it’s undoubtedly even higher.
Covid-19 is a wake-up call that tells us we need to change what we’re doing, do it better, and make it more affordable. Businesses across the country are getting that message. Why can’t health care?
I love what the poet Theodore Roethke said: “In a dark time, the eye begins to see.”