What are the potential impacts of COVID-19 on health care utilization? How will changes in healthcare use impact quality measures? Researchers are asking many key questions to understand the impacts of COVID-19. It is clear that trends in healthcare use are changing. These changes will likely affect quality measure scores in the future. This is especially true for healthcare value-based purchasing and quality improvement programs that adopt health care utilization “outcomes” measures to assess quality of care. Assessing changes in health care data and health care use will be critical to address pre- and post-COVID differences and to ensure the effectiveness of quality measures.
As of August 10, the US Centers for Disease Control and Prevention (CDC), reported over 5 million cases of COVID-19 and over 161,000 deaths. The CDC also reported that people over age 65 are hospitalized at higher rates (378.8 per 100,000) than people in lower age groups. At the same time, high-risk patients are delaying care to protect themselves from the virus.
The Centers for Medicare & Medicaid Services (CMS) took swift action to improve the US health care system’s capacity to respond to the pandemic. CMS issued a public health emergency and passed blanket waivers to relax or suspend certain care requirements. CMS also published an interim final rule (IFC) that laid out the pandemic response for federal programs. Through the waivers and the IFC, the CMS removed barriers to help the healthcare system meet heightened medical needs. However, the waivers, IFC, and shifts in healthcare use bring up concerns about the accuracy of data down the line and how we use it. The following are shifts we expect to see in health care data and the likely impact on quality measures.
Potential effects of COVID-19 on unplanned hospital admissions and readmissions
Older adults and adults with multiple chronic conditions have a higher risk of getting COVID-19 and of suffering complications. The more serious cases often need hospital care.
As high-risk patients avoid seeking medical care or cancel routine visits, the volume of delayed care continues to grow. These delays in care may worsen the health of patients, especially for those who need chronic care. As a result, patients who delay care to protect their health may require hospital care later on.
We expect unplanned hospital admissions and readmissions for high-risk patients with COVID-19 and worsened health issues to increase in 2020. If COVID-19 cases spike in late 2020, hospital admissions and readmissions could also increase in the first half of 2021.
Relaxed place-of-care requirements and waivers that allow the quick movement of patients could increase readmissions
Several CMS waivers relaxed place-of-care requirements to expand the spaces available for patient care. For example:
- Skilled nursing facilities (SNFs) may use buildings and spaces approved by the state as patient care and quarantine sites.
- Critical access hospitals (CAHs), rural health clinics (RHCs), and federally qualified health clinics (FQHCs) may set up temporary sites of care.
- CMS eased patient length of stay requirements for long term care hospitals (LTCHs) and for extended cancer care hospitals. This allows LTCHs and cancer care hospital to use their space to treat patients in response to the pandemic, and still qualify to get paid at the adjusted rates for these special hospital types.
Several CMS waivers also allow facilities to quickly move patients to better manage medical care needs. For instance:
- Acute-care hospitals can house acute-care patients in special-care units, such as inpatient rehabilitation facilities (IRFs). IRFs or inpatient psychiatric units may move patients to acute-care beds.
- CMS waived requirements for long-term resident transfer and discharge procedures.
- CMS also relaxed discharge planning and waived many requirements that might delay access to post-acute care services. Now, hospital staff do not have to provide detailed follow-up care information to patients or to the care setting receiving them.
These changes help facilities to isolate COVID-19 patients from the general patient population and to treat them as needed. However, pressed to serve many more patients, facilities might use the waivers to move, release, or transfer patients sooner than otherwise recommended. Premature transfers or discharges could worsen patients’ health and increase their readmission risk.
Potential Impacts of COVID-19 and Relaxed CMS Requirements on Quality Measures
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Changes in healthcare utilization might alter measure rates and disrupt trending and benchmarking efforts.
Higher rates of unplanned hospital admissions might inflate the number of claims that should be included in calculations of measures that use claims data. This would reflect health service use patterns that differ from the health care use assumptions used to develop instructions for calculating measures. Therefore, applying these instructions to data spanning the pandemic may not be adequate and could produce inaccurate measure rates. It could also skew results for measures that are trended over time or assessed against pre-pandemic benchmarks.
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Relaxed CMS requirements may increase the risk of data errors and inaccurate measure estimates.
CMS may have increased the risk of data errors by relaxing data reporting requirements. Relaxed data reporting requirements could drive up rates of missing data and data errors. Data entry errors could also occur if transfer exceptions are applied incorrectly. Such errors may make it difficult to correctly select claims that should be used in measure calculations. The temporary expansion of providers and care locations may also add to the problem. This in turn could result in inaccurate measure estimates.
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Delays in care may result in misleading risk estimates
When patients delay medical care, the true severity of conditions may not be captured in patient data. The lack of care history will obscure the true risk for some patients. Reductions in certain types of hospitalizations, such as planned procedures, may make some patients superficially appear at lower risk. A reduction in the frequency of conditions or procedures used as risk factors could make the current risk adjustment strategy less effective.
Health services researchers will need to think on how to handle these changes and risks. We will also need determine how to manage differences in the data once the public health emergency ends.
In summary, we expect the COVID-19 pandemic to increase acute and unplanned hospital admissions and readmissions. While the CMS waivers may help the health care system better respond to the pandemic, they may lead to unintended consequences for quality measures down the line. Shifting patterns in healthcare use may also skew measure results. Similarly, shifts in rates of medical conditions may make it difficult to accurately assess risk and risk adjust measures. The varied impact of COVID-19 in the US will likely result in very different patterns of health care use across regions. Researchers will need to closely assess these patterns and come up with ways to address differences.
Amarilys Bernacet
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