The coronavirus is already temporarily morphing how healthcare is delivered. However, I predict there will be huge changes in the next few years that are forced by the war against our viral foe. Much of this will center around staying away from the hospital front lines where the war against the disease is being fought. Let’s dig in.
Corona by the Numbers this Morning
New York state on a case per million inhabitants basis is now about twice as infected as Italy (NY=3059/million and Italy=1,716). Italy, despite three weeks into a country-wide shutdown and a month into a regional shutdown, is possibly beginning to come down the other side of the curve on cases per day:
What does this mean for the U.S.? The President extended our shutdown to April 30th and looking at Italy, it’s likely we’ll need to extend it again at least until May 15th.
How U.S. Healthcare Has Changed Already
In just a few short weeks, many things have changed in U.S healthcare delivery:
- Most patient visits are moving online through telemedicine
- Insurers now widely reimburse for these online visits, something that wasn’t possible previously
- Physicians used to be licensed in one state and would have to apply for a license in another, but during the COVID-19 crisis, we are permitted to work across state lines
However, there are much BIGGER changes afoot. Let’s dig in.
Staying AWAY from the Front Lines
Make no mistake, we are in a war against the coronavirus. For example, the last time the US Government spent this much money this quickly was when World War II broke out. In addition, that was also the last time the American people were asked to sacrifice at this level against a common foe. So if this is a war, where is the front line of that war? U.S. Hospitals.
No matter what you thought of the Affordable Care Act (aka Obamacare) it did one thing that dramatically changed American Healthcare delivery. It put the U.S. Hospital at the heart of the cost savings equation. That new focus and power allowed U.S. Hospitals to consolidate their powerbase by purchasing countless physician practices. Meaning, before the A.C.A. the focus was moving away from hospitals and after the ACA it moved towards hospitals. That also had the net effect of dramatically increasing healthcare costs as it created regional hospital monopolies.
However, now the hospitals are the front line of this war. While we’re all deeply grateful for those employees saving lives and want them there if we get the coronavirus and suddenly can’t breathe, we also intuitively know that if we’re not sick, we shouldn’t be close to the front lines where the viral bombs are being lobbed.
Sick vs. Well Care
Way before this crisis, I have always told all of my relatives who weren’t sick to stay away from hospitals for routine care and surgeries. Why? Hospitals are for sick care. For example, the MRSA epidemic of superbugs that were hard to treat with antibiotics centered in hospitals. That’s simple public health arithmetic. Sick people with infections get treated in hospitals. Hence, having your hospital double as a place where well people get treated has never been a good idea.
Now let’s take that concept and move it forward a few months or years. Since it’s clear that we’ll be dealing with this virus off and on for about two years (based on what happened with the 1918 pandemic), hospitals more than ever will be places where the sick go to be treated. It will be unwise to spool back up hospital operating rooms as they often share staff with the inpatient facility. For example, hospital-based physicians perform rounds on patients in the hospital and then often perform surgical cases in the operating room or outpatient surgery center.
More Non-hospital Surgeries and Less Invasive Procedures
Because the idea that hospitals are for sick care will be forever cemented in the psyche of Americans of this generation, dramatic changes will be forced on where procedures are performed. Surgeries will move off-campus and increasingly into physician clinics and less invasive procedures will be favored due to that site change.
First, surgeries that used to be performed in hospital operating rooms or at hospital ambulatory surgery centers will need to be taken off-campus and increasingly into physician clinics. This just makes common public health sense, as you need to sperate well patients without an active COVOD-19 infection from the high viral loads found in hospital-owned on-campus facilities. The best and least contaminated sites with the lowest viral loads will be physician subspecialty clinics and off-campus ambulatory surgery centers (ASCs).
However, that change of venue away from the hospital and into clinics and ASCs will have a secondary effect that will change the very nature of procedural care. For example, when procedures are performed in or close to a hospital, surgeons and physicians tend to choose more invasive procedures. Why? A hospital bed is right there if needed. However, when hospital beds are no longer close, the choice will move toward less invasive procedures.
A Concrete Example of Space Suits versus In-Office Injections
For the last several years, a small battle has been fought on whether we need to be replacing nearly as many knees as we do every year. For example, studies have shown that many people who get knee replacement procedures don’t need them (2). In addition, when large studies are performed, the procedures are not as effective as we had all thought (1). Finally, less invasive injection-based procedures can now be performed like platelet-rich plasma and bone marrow concentrate injections which look to be just as effective based on the grading of the evidence (3,4).
To learn more about how disappointing knee replacement results were in the best study performed to date, watch my video below:
However, while these less invasive procedures have gotten a toe hold in treating knee arthritis patients, they are still not being widely used. For example, our company Regenexx has gotten about 8 million Americans covered for these procedures that can be performed in a doctor’s office and away from the hospital, but that’s still a drop in the bucket when compared to the hundreds of millions of Americans with coverage for knee replacement.
For a knee replacement, this is a “spacesuit” procedure. Meaning it uses maximum Personal Protective Equipment (PPE). Why the spacesuit? Because infections are a very real problem when you’re amputating a joint and inserting a prosthesis. In addition, the vast majority of these max PPE procedures are performed in a hospital or hospital-associated ambulatory surgery center.
However, now that COVID-19 is here, is it wise to bring a middle-aged or elderly patient into the hospital? Is it wise to expose the patient to a max PPE procedure when that same PPE could be used to fight the virus? Is it wise to cut out someone’s joint in a maximally invasive procedure and have them possibly take up a needed hospital bed if something goes wrong?
As you can see, the smart move is to perform the less invasive platelet or bone marrow injection in a physician’s office away from the front lines and minimize risk, PPE use, and the need for hospital beds. In addition, when our company performed a fully loaded cost analysis of using the bone marrow stem cell approach in the office, it still saved 44%! That even when you add in the cost for knee replacement for those that fail to respond to the less invasive procedure.
The upshot? When the dust settles from round 1 of war against COVID-19, our healthcare system will have been changed forever. Not only will we see much more telemedicine and physicians who are now licensed across state lines, but also a trend away from performing hospital-based procedures. That trend will also mean that less invasive procedures in clinics and ASCs become more desirable than maximally invasive procedures performed at the hospital front lines.
(1) Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, Rasmussen S. A Randomized, Controlled Trial of Total Knee Replacement. N Engl J Med. 2015 Oct 22;373(17):1597-606. doi: 10.1056/NEJMoa1505467
(2) Riddle DL, Jiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol. 2014;66(8):2134–2143. doi: 10.1002/art.38685
(3) Xing D, Wang B, Zhang W, Yang Z, Hou Y1,2, Chen Y, Lin J. Intra-articular platelet-rich plasma injections for knee osteoarthritis: An overview of systematic reviews and risk of bias considerations. Int J Rheum Dis. 2017 Nov;20(11):1612-1630. doi: 10.1111/1756-185X.13233.
(4) Centeno C, Sheinkop M, Dodson E, et al. A specific protocol of autologous bone marrow concentrate and platelet products versus exercise therapy for symptomatic knee osteoarthritis: a randomized controlled trial with 2 year follow-up. J Transl Med. 2018;16(1):355. Published 2018 Dec 13. doi:10.1186/s12967-018-1736-8