Experts Highlight Role of Digital Tools in Reducing COVID-19 Transmission

Like a wind-driven wildfire, the COVID-19 pandemic continues to flare and race across the U.S. and around the world, jumping firebreaks to threaten health and livelihoods and imperil long-term economic sustainability.

Short of a vaccine, digital contact tracing apps—coupled with a sustained commitment to social distancing and masks—offer the hope for arresting the virus’ spread, two health technology experts recently told Pacific Business Group on Health (PBGH) members.

Related digital tools known as health verification apps can help support and modulate community re-openings by aligning self-reported health assessments with organization-and site-specific guidelines, according to Brian McClendon and Marci Nielsen, Ph.D. co-founders of the CVKey Project. The two presented during a PBGH webinar June 26.

The success of digital apps in reducing the transmission and impact of COVID-19 will hinge on widespread, voluntary buy-in by the U.S. population, McClendon and Nielsen said. Given substantial mistrust of both government and large technology firms, developing solutions that safeguard privacy and civil liberties is paramount.

Lawrence, KS-based, non-profit CVKey Project was launched in May to pursue the goal of helping communities open responsibly without compromising personal privacy. McClendon is the founder of Google Earth and a former Google vice president; Nielsen is the former chief executive officer of the Washington, D.C.-based Patient-Centered Primary Care Collaborative.

Limitations of manual contact tracing

Traditional or manual contact tracing is designed to break the chain of exponential disease transmission by quickly working backward from known infected patients to identify and alert those with whom the individual has recently interacted. Public health workers then advise the exposed party to isolate or quarantine, depending on their condition and symptoms.

Significant barriers can undermine the efficacy of manual contact tracing, not the least of which are the labor-intensive nature of the process and the reluctance of many to accept calls from unknown numbers, Nielsen said. And if contact is established, a high level of trust must be established between the health worker and exposed individual to ensure appropriate action is taken.

Moreover, McClendon said, accelerating rates of infection in many states are making traditional contact tracing problematic. Florida, for example, has successfully traced the origins of 50% of their infected population. But with close to 9,000 new cases reported recently in one day alone, rapidly isolating the origins of each infection has become increasingly impractical.

Augmenting with digital tools

Digital solutions can serve as force multipliers that enable contact tracers to work faster and more effectively. Voluntarily downloaded apps identify whether, when and where a person has been in close proximity of an infected individual. A range of these solutions are emerging, McClendon said, though some are less effective than others. GPS-based technologies, for example, are both privacy invasive and not sufficiently accurate when it comes to identifying an individual’s location, particularly indoors, he said.

An alternative approach jointly developed by Google and Apple, known as Google/Apple Exposure Notification, mitigates the privacy and accuracy limitations of GPS-based apps by relying on Android and iPhone Bluetooth capabilities. The technology generates random number sets and then pairs with other phones that have the app installed.

The number sets are stored on the phone to assure privacy and if an individual tests positive for COVID-19, they’ll be asked to voluntarily upload their number sets to cloud storage run by a state or county agency. The process creates a mechanism for other apps to identify an exposure and notify the phone’s owner but also enables the original infected individual to remain anonymous.

The exposure notification will ask the user to alert a manual contact tracing team and a determination can be made whether isolation or quarantine is appropriate. Importantly, McClendon added, no data is shared with Google or Apple, and the random number strings prevent identification of infected and non-infected individuals by health authorities. Moreover, individuals’ whereabouts are never identifiable. Physical proximity to an infected individual is communicated to the user to inform their next steps.

Health verification apps

The CVKey project founded by McClendon and Nielsen is focused on the development of a related app that can help communities, companies and other organizations adjust economic, employment, educational and social activities based on up-to-date regional public health and community guidance. The CVKey opt-in app allows users to check their own health and potential exposure status through a series of questions to self-identify risk factors for spreading the virus.

Depending on their answers, the user is assigned one of four color-coded conditions or states. These include Blue, for no known risk factors; Yellow, for when an exposure has occurred; Orange, for both exposure and symptoms; and Red, for users that have tested positive for the virus.

McClendon said the data is stored on the individual’s phone and never uploaded to any central database. The app does, however, download policies set by specific businesses and organizations to delineate rules of entry, which are then compared with the person’s health status. Based on these comparisons, a QR code is produced and the user informed if they may enter a specific building or not and what requirements might be in place, e.g. mandatory masks or off-limit areas.

A key objective of the tool, McClendon said, is to provide both individuals and organizations with data-driven, real-time safeguards to help eliminate potential exposures. Scanning an individual’s code at a restaurant and limiting access to those with a Blue condition, for example, would help ensure both safety and peace of mind for diners and staff.

The app’s additional ability to inform users of updated company or building-specific policies based on changing conditions could provide a “dimmer switch” that would help health authorities and employers reduce transmission risk without the need for a blanket lockdown.

The CVKey app is being piloted this fall at the University of Kansas, McClendon said. The QR coded displayed by the app will provide the university’s building monitors with a simple yes or no indication as to whether the individual’s health assessment meets the criteria to enter the building that day. Anyone generating a Yellow or Orange condition will be asked to communicate with the university’s health department.

“Our message to communities is that if you can help employers choose to adopt this app, there will be less chance of going into another lockdown,” McClendon said.

Consequences of COVID-19: Experts Forecast the Future of Health Care Costs and Utilization

The unprecedented collapse in patient volume sparked by the COVID-19 pandemic could reshape health care for years to come, but whether those changes ultimately prove beneficial or destructive remains to be seen, experts say.

What is clear is that significant risks and opportunities are beginning to emerge from the chaos surrounding the pandemic. Helping large employers understand and adapt to these developments was the primary goal of an expert panel discussion hosted May 6 by the Purchaser Business Group on Health.

Participants included Michael Chernew, director of the Healthcare Markets and Regulations Lab at Harvard Medical School; John Bertko, chief actuary and director of research for Covered California; and Jane Jensen, senior director of the health and benefits consulting practice with Willis Towers Watson.

Utilization off a Cliff

The extent to which demand for traditional health care services would be affected by COVID-19 wasn’t immediately clear as hospitals ramped up for worst-case scenarios and a surge in COVID-19 patients in early March. But with most elective surgeries cancelled and patients fearful of contracting the virus in any care setting, the utilization drop was immediate and severe for both hospitals and physician offices.

Chernew shared data provided by Phreesia, a health care technology company, and published by the Commonwealth Fund that showed the number of ambulatory practice visits nationwide (including telemedicine visits, fell by over 50% between March 1 and March 29. Office visits for some specialists dropped even more: Ophthalmology was down 79%; ear, nose and throat, 75%; dermatology, 73%; surgical office visits by 66%; and adult primary care by 49%. The most recent data from mid-April suggests only a slight recovery off the lows.

Hospitals have likely experienced similar drops in volume, with lost admissions far surpassing COVID-19 admissions and outpatient procedures down dramatically, Chernew said. At the same time, most are experiencing rising costs due to policy changes and equipment purchases necessary to combat the virus infection threat.

“By and large, hospitals are getting creamed right now financially,” he said.

Flipped Spending Projections: What It Means for Employers and Employees

The good news from an employer standpoint is that because of the volume collapse, pandemic-related health care cost increases projected as recently as six weeks ago now seem unlikely, and though there is a wide range of uncertainty, health care spending could actually fall by 5% in 2020 and remain flat or continue to drop in 2021, according to Chernew. That should translate to lower fees and health care spend for administrative services only (ASO) plans, with the savings accruing directly to employers, and by extension, their employees.

Jensen of Willis Towers Watson projected similar reductions in employer health care costs, a reversal from the estimated increases for 2020 made in mid-March that ranged from 1% to 7%, depending on COVID-19 infection rates and hospitalization rates. With infection numbers far lower than expected, Willis Towers Watson is now predicting spend reductions ranging from 1% to 4.5% for 2020. She said her organization anticipates COVID-19 workforce infection rates of about 1% for most employers, far lower than the 10-50% range initially predicted.

Given the backdrop of a federal deficit expected to exceed $4 trillion this year and the nation’s ongoing, Depression-level economic contraction, Chernew said pressure to control health care spending will continue.

“There’s going to be less money for everything,” he said. “Going forward, everyone is going to be looking to save money on health care.”

He predicted employers will likely reduce benefit generosity and narrow networks to accomplish cost reductions. But Jensen said many employers at this point are primarily focused on ensuring that coverage remains affordable for employees. Noting that many firms have already faced “gut-wrenching” decisions about layoffs, she believes most are more likely to look for savings through limits on provider choice as opposed to benefit reductions.

“I don’t think they don’t want to nickel-and-dime [those employees that remain] by changing benefits,” she said.

How Much Comes Back?

Bertko of Covered California and the other panelists agreed that vast uncertainty surrounds the ultimate disposition of care deferred during the pandemic.

“How much will we see rescheduled in the second half of 2020? How much will be deferred until 2021? And how much will just drift away and disappear?,” Bertko said. In his view, it will take considerable time before patients feel comfortable coming back into office settings.

Jensen’s organization analyzed the volume and types of care currently being deferred. The results ranged from high levels of deferral for office visits, dental care and non-urgent procedures to lower levels with acute emergency care and cancer care. The analysis further suggested that while some of this volume would be rescheduled, the majority would not, particularly when it came to office visits and urgent care.

Noted Chernew: “You can’t have a 50-60% drop and then expect that as soon as things open back up, everybody’s going to be doing 120% until they work their way through the backlog.”

All panelist agreed a potential second wave of pandemic infection was a wild card that could extend and exacerbate the demand decline.

Risks and Opportunities

Should the volume reduction prove protracted, the implications for all providers are grim. Hardest hit will likely be already underfunded and vulnerable primary care practices. Bertko said primary care groups in California are seeing as much as a 70-80% decrease in office visits.

A survey of primary care providers in late March revealed that nearly 80% of clinicians reported their practice was facing severe or close-to-severe financial strain, and 20% said their group might need to close temporarily. If the financial pressure continues, some practices could close permanently or be acquired by large health systems, insurance companies or even venture capital firms.

Panelists said the consolidation of primary care practices could reduce carriers’ ability to negotiate better prices on behalf of employers, disrupt existing provider networks and limit progress toward pay-for-performance reimbursement models.

“We at Covered California do not want primary care practices bought up by several very large hospital systems,” Bertko said.

For employers, the current landscape presents substantial opportunities to focus on benefit designs that more effectively steer employees to high-performance providers and accelerate the transition to value-based reimbursement, Jensen said.

“Not all hospitals are created equal,” she said. “So payment reform and steerage go hand-in-hand. But at the same time, we really need to be mindful of total cost of care and not just focus on price.

“We also have to recognize that providers need to stay in business. Ultimately, we need to find ways to pay the right amount, fairly, to the right folks, and not cut off our nose to spite our face.”

The panelists agreed that determining whether the patient volume decline is temporary or marks a sea-change in how health care services are consumed represents the most important unanswered economic question surrounding recent events.

“We are in the midst of a natural experiment,” Bertko said.

Added Jensen: “What’s happening now may or may not change patterns longer term; people may or may not think differently about how they use healthcare in the future.”

While a permanent reduction in overutilized, low-value care would be a major positive for the system as a whole, finding ways to prevent it from coming back as providers scramble to recover lost revenue will likely prove “a huge challenge,” Chernew said.