Hospital Case Management asked Joseph J. Fifer, FHFMA, CPA, president and chief executive officer of Healthcare Financial Management Association, about his findings that failures in care coordination lead to costly waste in the healthcare industry in the following interview, which has been lightly edited for length and clarity.

HCM: According to your new paper about healthcare changes resulting from the COVID-19 pandemic, failures in care coordination create up to $78 billion in waste each year.1,2 How do these failures result in such costly waste?

Fifer: Current limitations on interoperability among healthcare providers make it hard for providers to share electronic health record information with each other. Quick example of potential savings: New York state’s health information exchange reduced unnecessary spending by up to $195 million per year by helping participating clinicians quickly access and share medical records.3

It’s not only about sharing between hospitals in different health systems — it’s also about sharing with rehab or subacute care, skilled nursing facilities, and community service agencies. Case managers who are involved in discharge planning understand these issues well.

Providers should demand greater interoperability from vendors. In some cases, providers need to reframe this issue. The benefits of sharing health information, in terms of improving quality of care and reducing unnecessary spending, outweigh any competitive advantage of keeping the information within a health system. That’s not the way to maintain patient loyalty.

‘Health Debt’ Is Growing

HCM: Would you please explain what the “health debt” of the pandemic is and how it may affect hospitals, case management, and care coordination in the next decade?

Fifer: When COVID-19 started spreading in the United States in early 2020, a lot of healthcare was put on hold. In part, that was due to hospitals being forced to cancel scheduled procedures to have all hands on deck for COVID-19 patients. Many patients were inclined to avoid healthcare settings for fear of catching COVID-19. But, of course, other healthcare issues didn’t wait for the pandemic to end. The net result: Missing out on those healthcare services will have ripple effects for years to come. That is what’s meant by the term pandemic “health debt.”

For example, fewer physician office visits for management of chronic conditions, such as diabetes and hypertension, raises the risk of complications that could occur months or years down the road. This was mitigated to some extent by the increase in telehealth and virtual visits. The acceleration of virtual health will be a lasting silver lining of the pandemic. However, despite the role of virtual health, hospitals are reporting treating patients who are much sicker than they would be if they had previously received necessary monitoring and care.

Another example: Consider the impact of missing months — and, in some cases, years — of cancer screenings, such as mammograms and colonoscopies. As a result, cancer is being diagnosed at more advanced stages. This is not just based on anecdotal accounts; about two-thirds of radiation oncologists surveyed by a medical specialty society in early 2021 reported that patients were presenting with more advanced cancers, as compared with the previous year, and that existing patients had experienced treatment interruptions.4

Not all of the health debt from the pandemic is the result of missing healthcare. Some of it is due to an increase in mental health and behavioral health issues. The stress and loss associated with the pandemic has resulted in reduced physical activity, higher alcohol consumption, and more people of all ages reporting depression and anxiety. About one-third of all U.S. adults experienced symptoms of depression in the first half of 2021, up from about 9% before the pandemic, and also higher than it was in the first year of the pandemic.5

HCM: What are your predictions for how health systems and community providers may do a better job of incorporating social determinants of health into their care? How is this tied to value-based care and payment?

Fifer: First, the background: Health status is not a function of healthcare alone. The biggest influencer — 60% — is social determinants of health, which include security of all kinds (such as food, employment, domestic relationships, and neighborhood), other environmental factors, and behavioral factors. Improving social determinants is a major undertaking that requires a high degree of collaboration. No one entity can do it alone, and it is unreasonable to assign responsibility for addressing broad societal issues solely to the provider community.6

We at the Healthcare Financial Management Association convened a meeting of thought leaders in 2019 that focused on social determinants, including who should take the lead on these initiatives. There was no consensus on that, and there still isn’t.7

Meanwhile, provider organizations that invest in addressing social determinants are typically not getting paid for doing so, under the prevailing fee-for-service payment model, and adoption of value-based payment, which is more conducive to factoring in social determinants, has been slow. Healthcare leaders who seek to pursue social determinant initiatives for the good of their communities often see their ideas wither on the vine because it’s difficult to get a return on that investment.

But the reality is that we, as a society, have to figure out how to address social determinants of health more effectively and sustainably. Value-based payment models are one route to achieving this goal. Forward-thinking healthcare organizations are taking the long view and inspiring others. That’s a start.

HCM: What other long-term effects will the pandemic have on population health/case management and care coordination in the United States?

Fifer: The pandemic has a disproportionate impact on people of color, which shined a spotlight on health inequities that existed long before COVID-19 was a known disease entity. To the extent that attention and resources shift to reducing health disparities, that will be a silver lining of the pandemic. These health disparities range from social determinants of health to access to healthcare and to health insurance. Case managers can play a very important role in improving health equity. The pandemic may be a catalyst, but the impact goes way beyond that.

Also, the future of investment in public health remains unclear. Months ago, it was conventional wisdom in some healthcare circles that public health would be an area of greater focus post-pandemic. Public health should play a prominent role in population health, by definition. However, recent rhetoric sheds doubt on the prospects for rallying around additional investment in public health. Like many other issues, public health spending has become more politicized as opposed to less so. That is disappointing because of the complex nature of population health and the previously mentioned need for engagement by multiple entities at all levels.

Overall, I believe the pandemic will shed light on many flaws in our society’s approach to population health. Improving it will necessitate strong leadership and payment reform.

HCM: Is there anything else you would like to note about new trends in healthcare?

Fifer: First, all the trends in healthcare support the importance of what case managers do. I speak for the finance professionals who make up our association’s membership when I say how much we appreciate the professionalism, expertise, and dedication case managers bring to their roles, especially during these challenging times. Case managers are valuable members of the healthcare team, as my own family’s personal experience has shown. When done well, case management is wonderful. Our healthcare system will not get simpler, but people may experience it that way if case managers play a larger role in the delivery of care.

Second, there is clearly a movement, at long last, toward more consumer-friendly processes and practices in healthcare. Granted, we still have a long way to go compared to other industries. However, there is a trend, supported within legacy healthcare organizations and by newcomers, such as those funded by private equity, venture capital, or investments by mega corporations, toward ease of use by consumers. I am encouraged by these trends, and believe the ease of use within healthcare will look much different five years from now.

REFERENCES

  1. Fifer JJ. The road to value demands a smarter approach to risk. Front Health Serv Manage 2021;38:30-36.
  2. Shrank WH, Rogstad TL, Parekh N. Waste in the US health care system: Estimated costs and potential for savings. JAMA 2019;322: 1501-1509.
  3. Leventhal R. Analysis: New York’s statewide HIE reduces healthcare spending by nearly $200M annually. Healthcare Innovation. Nov. 12, 2019.
  4. Sternberg A. ASTRO survey of radiation oncologists shows treatment delays, health disparities resulting from COVID-19 pandemic. Cancer Network. March 31, 2021.
  5. Brown University. Depression rates tripled and symptoms intensified during first year of COVID-19. Oct. 5, 2021.
  6. Graham G, Bernot J. An evidence-based path forward to advance social determinants of health data. Health Affairs Blog. Oct. 25, 2017.
  7. Fifer JJ. Social determinants of health: Pushing the boundaries of healthcare. Healthcare Financial Management Association. Oct. 22, 2019.