Conversations that dominated the health policy discourse only a few weeks ago have been suspended as we scramble to contain Covid-19. The overall cost of health care in the United States was a first-order concern before the virus struck. Now, most people are focused on the critically important but narrower issue of the price tag of Covid-19 testing and treatment.
While we absolutely must reorganize our collective efforts to secure the health of our communities, the issue of ballooning health care costs will not only persist but get worse as we grapple with Covid-19.
In theory, a coronavirus funding package and state-level emergency dollars will defray added costs. But everyone so far seems to be glossing over an expensive piece of the virus-management puzzle whose cost will be borne by the system. Calculating the cost of Covid-19 using the formula of testing plus treatment leaves out the huge price tag associated with merely walking through the door to be evaluated, especially if that door leads to an emergency department.
For the last several years, policymakers and health services researchers like me have studied or implemented programs to keep patients with non-urgent health issues out of emergency departments as a way to control costs. These programs range from small pilot studies to Medicaid expansion. Their success so far is mixed, though some were able to reduce unnecessary visits.
Yet for all the forward-thinking ingenuity I witnessed while doing this work, my colleagues and I never imagined, much less prepared for, something that now seems obvious: a highly contagious virus that is extremely dangerous for a subset of the population but that most people will recover from with self-care, if they experience symptoms at all. This virus continues to spread while we are unprepared to determine whether every person with a cough or fever has contracted the disease and what level of care the person needs.
In this scenario, which is now very real, unnecessary use of the emergency department seems inevitable and the price tag will be hefty.
What kind of cost am I talking about? It’s impossible to know, given our current state of uncertainty, but data on the H1N1 influenza pandemic from the federal Agency for Healthcare Research and Quality offers a hint.
In 2008, before the emergence of H1N1, there were 491,100 emergency department visits for influenza-like illnesses. In 2009, there were 1,281,700 visits. In 2008, 86.8% of those patients were treated and released, compared to 90.4% in 2009. In other words, 87% of emergency department visits were probably avoidable in 2008, compared to 90% in 2009.
Notice two changes with significant cost implications during the pandemic year: the total number of emergency department visits went up, and so did the percentage that were probably unnecessary.
UnitedHealthcare put a price tag of $2,032 on an emergency department visit for a health issue that could have been addressed in a less expensive setting, like urgent or primary care. Multiplying that by the potentially avoidable visits in 2009 equals almost $1.5 billion in unnecessary costs. Assuming that we will be experiencing a similar upward trend from a non-pandemic year to a pandemic year, and that the Covid-19 pandemic will be worse than H1N1, we will potentially add billions of dollars of unexpected unnecessary costs to the health care system, something we simply can’t afford.
Granted, the CDC estimated that more than 60 million Americans were infected with H1N1, while as of March 12, the actual number of Covid-19 cases is unknown. The number of confirmed cases in the United States is still relatively small. It’s possible that the total number of people visiting emergency departments for Covid-19 will ultimately be lower than in 2009. Experts have also cautioned against using influenza as a proxy for understanding any aspect of the Covid-19 outbreak.
That said, it isn’t unreasonable to assume that Covid-19 will result in more people heading to emergency departments for evaluation and treatment and that many of these visits will be unnecessary. New York City has been issuing alerts to local residents about this:
Do your part NYC, stay home! Visit the ER only if you are severely ill, otherwise you jeopardize the lives of others who are ill.
— NYCEM – Notify NYC (@NotifyNYC) March 17, 2020
The city has a point: Far more concerning than cost is the life-threatening consequences of emergency department and hospital overcrowding and stretching health care resources too thin. Stories from Italy and China provide alarming examples of what happens when hospitals and other health care resources are overwhelmed by this pandemic.
I understand the impulse to be seen in an emergency department when one is experiencing symptoms and is scared. Research shows that patients often prefer emergency departments because they are more accessible and convenient than more appropriate primary care settings.
One readily implementable solution proposed by medical experts is triage via telemedicine, the field I work in. Direct-to-consumer (DTC) telemedicine platforms already have the infrastructure in place to rapidly design and launch a virtual system that takes advantage of evidence-based algorithms for triage, such as the one published by the CDC.
My company, Ro, built and piloted such a platform in a single weekend. Here’s how it works:
Individuals who think they may be experiencing signs or symptoms of the novel coronavirus can complete Ro’s online assessment — developed with guidance from infectious disease specialists using guidelines from the CDC, the World Health Organization, and state and local public health departments — to determine if they are at risk for Covid-19. If a patient is at risk for Covid-19, Ro will connect him or her with a with a U.S. licensed provider, who will follow up via secure messaging, phone, or video call.
During that consultation, the provider will collect additional information about the patient’s symptoms and concerns, recommend the proper course of action (which may include self-quarantine), and, if needed, instruct him or her to follow up with a local provider for testing and diagnosis. Patients who would benefit from in-person care are given resources to find a local provider so they can get the help they need.
The platform also reports suspected cases to the pertinent public health authorities, as required, to help inform local and national response efforts.
Individuals deemed to be at low risk for Covid-19 are encouraged to continue monitoring their symptoms and are directed to a resource hub, which is updated regularly.
There are limits to this model. Telemedicine currently can’t test for or provide actual treatment for Covid-19, and it cannot continuously monitor patients whose symptoms may worsen after the visit. But it’s a powerful triage tool that can help keep patients unlikely to have Covid-19 out of the emergency department, which will keep costs down and prevent overcrowding.
As a free service, this isn’t likely to be scalable across the system. UnitedHealthcare estimates that a telemedicine visit costs payers less than $50 dollars, a far cry from its $2,000-plus estimate for an unnecessary in-person emergency department visit. Applied to the H1N1 example, redoing the math using $50 dollars a visit instead of $2,032, the cost is just over $50 million, or about 2.5% of the cost of unnecessary H1N1 visits in 2009.
One study found that access to direct-to-consumer telemedicine visits to treat acute respiratory infections were so convenient they increased utilization by people who would otherwise not have seen a doctor in person. While this means that there is more work to be done to maximize telemedicine’s ability to help control costs, it also suggests it is more than capable of competing with the emergency department as far as convenience and access. This makes it a more viable solution than trying to redirect people who prefer the emergency department to go to primary care instead.
While we might be unprepared for Covid-19, we are not without tools that can be leveraged as real solutions. Government leaders, including President Trump, now see telemedicine as a crucial intervention in Covid-19 response efforts. Government agencies are partnering with industry leaders in virtual care. Ro is now a part of the White House’s Tech Task Force for coronavirus as a representative of the telehealth industry.
The telehealth approach to Covid-19 triage can save lives and billions of dollars — a win for everyone.
Lauren Broffman, Ph.D. is a research scientist at Ro, a telehealth company.