Post-COVID-19 trend watch: Implications for practices

In its wake, the COVID-19 pandemic has left an indelible mark on the U.S. healthcare system, including shifting the healthcare needs of the population, the way healthcare is provided, and the resources necessary to conduct patient care. As we navigate these changes and emerge from this extraordinary storm, it is crucial that we maintain our focus on the future of healthcare. We believe the foresight of emerging trends can help better prepare the healthcare system for the future. Here we explore several trends in this post-COVID-19 environment and how they will reshape healthcare in years to come.

• Editor’s note: Dr. Tutty and Ms. Carlasare are employed by the American Medical Association. The opinions expressed in this article are those of the authors and should not be interpreted as American Medical Association policy.

Integration of behavioral health

The demand for behavioral and mental healthcare services continues to increase, exacerbated by the effects of the COVID-19 pandemic.1 Nearly a third of Americans exhibit depression or anxiety,2 and demand for treatment of anxiety, depression, and substance-related and addictive disorders has increased.3 College students have shown an increase in depression and alcohol use disorder;4 alarmingly, 68% of Millennial and 81% of Gen Z workers have left a job due to mental health reasons.5

Contributing to this problem is that nearly 40% of Americans live in an area designated with a mental health professional shortage.6 The lack of mental healthcare professionals means Americans are increasingly looking outside traditional care delivery models to obtain mental and behavioral healthcare, including from services provided by their schools or employers, or from more novel solutions such as mobile apps or virtual therapy.

As demand increases and the access gap widens, many universities struggle to enhance their programs to meet the growing need.7 Some universities are prioritizing changes to foster an inclusive and supportive educational environment, increasing the volume and diversity of behavioral health staff, reducing the stigma associated with seeking care, and offering mental health screenings for students.

Similarly, many employers are improving resources to support their employees’ mental and behavioral health needs — nearly 23% of workers say their employer introduced new mental health services during the pandemic,8 but a third of employees say their employer program does not go far enough.9 Employers that want to retain high-quality staff will have an increased interest in investing in their employees’ mental health, particularly in reducing absenteeism, lost productivity, increased healthcare costs, and decreased quality of work.

An influx in non-traditional mental healthcare services has occurred in recent years, particularly due to the effects of the pandemic. Year-over-year investment has more than doubled for mental health tech startups, reaching more than $5 billion in funding in 2021.10 Non-traditional mental health services, such as virtual therapy or mobile health applications such as LiveHealth Online or Talkspace, may provide more immediate access to help, but their success in sustained management of care will depend on how well they are integrated within the patient-physician relationship.

Importance to practice

While universities, employers, and virtual care options can help fill the mental healthcare gap for many individuals, a critical juncture for patients accessing mental health care is still their primary care or non-primary care specialist physician. Physicians and practices will need to be vigilant about communication and continuity of care when alternative mental and behavioral health services become part of a patient’s care. Practices that can sustainably integrate behavioral and mental healthcare with their patients’ regular care will be poised to better compete in the market and improve care for their patients.

Diversification of practice

For the first time in 2018, there were more employed physicians than those with an ownership stake in their practice.11 Historically, physicians have chosen between owning a solo practice; partnering in a group practice (single- or multi-specialty); being an independent contractor; or employment at an academic medical center, health system, or large group.12

While these options still dominate much of the practice landscape, emerging investors are shaking up these traditional models. Private equity (PE), venture capital, health plans, and employers are all investing in medical practices. PE firms usually purchase the controlling stake in the practice and then focus on increasing practice efficiency, expansion, and income growth. However, PE investors are looking for a solid financial return for their investment over the ensuing years. Venture capital invests in new businesses or delivery models (e.g., telehealth) that have the potential for innovation and rapid growth. Health plans are moving to vertical integration with the acquisition of physician practices to achieve efficiency and better patient care. Some large employers are directly contracting or employing physicians to provide better access and control costs for their employees.13 While the number of large employers with onsite clinics declined in 2021 due to COVID-19, projections show large employers will continue to provide this option for their employees.14

In addition to new investors, various new payment models are emerging as payers continue to move risk to physicians and hospitals. These alternative or value-based payment models aim to incentivize quality and value over volume.15 In response to new payment models and to meet patient needs, new care delivery models are developing. Virtual-first primary care exploded due to the pandemic and will continue; furthermore, increased virtual specialty care, asynchronous care delivery, and artificial intelligence (AI) supported care will continue to expand.16 In the coming years, organizations should be aware of the more diverse practice and payment models to stay current in the dynamic environment and meet the changing needs of their patients.

Importance to practice

Competition in the market may come from various established and new players. The diversity and growing number of options will make it harder for patients to stay loyal to a single practice or physician. Knowing the competition and continuing to provide value for patients will be paramount. Practice leaders may also be approached by payers with new risk arrangements. Understanding these models will be essential to take on the appropriate type and amount of risk. In addition, understanding the different investment tactics will help practice leadership determine if and what models would make the most sense if a practice is approached about selling to an investor.

Changes in the physician workforce

The U.S. physician workforce is slowly evolving as new generations of students matriculate and older physicians retire. It is an understatement to say its composition will be fundamental to the future of healthcare. More women than ever are entering medical school and becoming physicians,17 contributing to a much-needed push to enhance gender diversity in medicine. In addition, more than 9% of graduating medical students identify as bisexual, gay or lesbian,18 closely reflecting the representation of these groups in the U.S. population.19 Racial and ethnic diversity lags, with persistent and significant underrepresentation of Black and Hispanic physicians.20

The physician workforce is also changing due to extrinsic factors such as the COVID-19 pandemic and relentless burdens created by administrative and other non-clinical work. Resulting burnout has persisted among physicians, contributing to one in five planning to leave their practice in the next two years.21 Similar sentiments are shared among U.S. nurses.22

Increasing healthcare needs of an aging population, coupled with retirement and non-retirement-related turnover, contribute to a growing deficiency in the physician workforce. Healthcare facilities are turning to alternatives such as locum tenens clinicians and staffing agencies to supplement their workforce, but these are often temporary and more expensive solutions. In addition, to make up for diminished or delayed access to physician care, patients may seek care from advanced practice registered nurses (APRNs) and physician assistants (PAs) or rely more frequently on urgent care or retail clinics. These alternative care solutions may provide temporary relief, but data show these will not be enough to close the impending deficit.23 The latest projections indicate the United States faces a shortage of up to 124,000 physicians by 2034,24 including a shortage of up to 48,000 primary care physicians and up to 77,100 non-primary care specialists. Moreover, research shows dependence on non-physician care may lead to higher healthcare spending. For example, a recent study found that per-member, per-month spending was $43 higher for patients whose primary care professional was a non-physician compared to a physician, translating to a potential $10.3 million more in annual spending for the clinic.25

Importance to practice

Because the healthcare workforce will continue to shift, enabling clinicians of varying generations and professional types to thrive will better position organizations for success. For example, physician-led team-based care models can ensure optimal utilization of care team members and contribute to better-coordinated care, improved resource allocation, and increased professional satisfaction.26 Forward-thinking organizations that prioritize clinician well-being and foster a culture of safety, respect, and trust will benefit in numerous ways, including better patient care, cost savings, and reduced turnover. In addition, practices and patients alike will benefit from organizational efforts to increase diversity in the clinical workforce — a critical step in reducing workforce shortages and advancing health equity in the United States.

System well-being

In 2014, the “Quadruple Aim” gained visibility, adding clinician well-being to the previous gold-standard “Triple Aim” of better outcomes, lower costs, and improved patient experience.27 This new focus cultivated an aggressive approach to understand and better address clinician well-being. Early efforts were targeted at the individual clinician, offering resources on topics such as mindfulness and resiliency. Over time, research made clear that physicians do not lack resilience;28 rather burnout is driven by system issues such as EHR usability,29 excessive workloads, inefficient processes, organizational support structures and leadership culture.30 As research contributed to a better understanding of the issues, it became clear that burnout was driven by factors unique to the healthcare system.

There is a strong business case for addressing burnout, which includes costs associated with turnover, reduced productivity, lower quality of patient care, decreased patient satisfaction, and risks to patient safety.31 Dissatisfied physicians will leave their organization at two to three times the rate of satisfied physicians.32 In addition, practices have reported the cost of recruiting a replacement physician is between $500,000 and $1,000,000.33

While many organizations started to measure the problems, commit resources (including appointing a chief wellness officer), and implement solutions, some of these efforts were paused as the COVID-19 pandemic surged. For many during COVID-19, focus and resources went to fulfilling staffing needs, finding enough personal protective equipment, and providing crisis counseling resources.

Emerging from COVID-19, organizations need to maintain a commitment to clinician well-being by refocusing their efforts to address system drivers of burnout and continuing improvements to the system in which care is delivered. Practice leadership should build consensus within the organization, get buy-in, create a wellness team dedicated to making improvements, and implement interventions.34 The National Academy of Medicine (NAM) consensus report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-being, provides a road map to address burnout and advance professional well-being for clinicians.35

Importance to practice

With clinician shortages projected into the coming decade, competition for top talent will intensify. Organizations that commit to system well-being will be better positioned to retain and recruit in a competitive environment. Large organizations should have a dedicated well-being office led by a chief wellness officer (CWO), and smaller organizations should assign a dedicated individual or team to lead organizational efforts to address physician and care team burdens. This dedicated individual or team should assess the current environment within the practice, develop and share a vision for the organization, design and implement systematic and sustainable changes, and document and share progress.36 Physician and care team burnout is a serious problem, but when practices address the issue with a systems-driven approach, the practice and patients benefit.

Digitally enabled care

In March 2020, demand for telemedicine services skyrocketed with the onset of the COVID-19 pandemic. Almost overnight, the adoption of telemedicine grew to what would have otherwise taken years to develop. After an initial spike in telemedicine use in the first months of the pandemic, utilization has since sustained at approximately 13% to 17% of office and outpatient visits.37

Despite this ebb, the seismic shift to the global use of digital health technologies to advance the delivery of high-quality patient care has only just begun. Investment in the digital health space continues, with more than $29 billion invested in 2021, almost double the investment from 2020.38 Telehealth provided a safe, digital form of the traditional office visit. As telehealth and other forms of digital health advance, they will inevitably alter current forms of healthcare delivery. Look for technology to help address chronic disease, improve health equity, and create practice efficiencies.

Medical devices and treatments will contain software, sensors, and other technologies that enable advances in remote patient monitoring and provide real-time insights for patients and physicians. Despite the challenges of clinical integration, the use of wearable technologies will continue to increase.39 Challenges in using these devices and their resulting data may emerge, particularly in integration within physicians’ workflow.

Digitally enabled startups will compete with practices for patients, moving from basic primary care to more complex chronic care management. Digital, direct-to-consumer companies are attractive for companies, as they bypass many regulatory and payer barriers.40 Other digital companies will partner with practices, hospitals, payers, and employers.41 Regardless of the approach, patients will have more options to receive care integrating technology by traditional and new market entrants.

Importance to practice

Practices will need to stay current on new digital health tools and offer those that support their clinical practice, remaining vigilant in protecting data in the use of tools that extend care outside the clinic. When assessing new technologies, answering four questions is critical:

1. Does it work?
2. Will I receive payment?
3. What is the practice liability?
4. Will it work in my practice (workflow)?42

Practices that can assess and select technologies that will advance their practice, and integrate them into physician workflows, will set themselves apart from competitors. In addition, practices will also need to consider that competition includes nearby practices as well as nationwide and global tech startups looking to acquire patients. Integrating digitally enabled patient care will bolster a practice’s market competitiveness and significantly improve the practice’s ability to meet patient needs and expand access to care.

Looking ahead

Healthcare in the United States is susceptible to influence by external forces. Much like nature, the healthcare system adapts and evolves, revealing new opportunities and solutions. As we recover from the COVID-19 pandemic and navigate the challenges ahead, maintaining sight of emerging trends and how they will impact the practice of medicine will be paramount to carve our way toward the future.

Notes:

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3. American Psychological Association. 2021 COVID-19 Practitioner Survey. Oct. 19, 2021. Available from: bit.ly/3RFB2oG.
4. Kim H, Rackoff GN, Fitzsimmons-Craft EE, et al. “College Mental Health Before and During the COVID-19 Pandemic: Results From a Nationwide Survey.” Cognitive Therapy and Research. 2022;46(1):1-10. Available from: bit.ly/3odtlZf.
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18. Ibid.
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24. American Association of Medical Colleges. The Complexities of Physician Supply and Demand: Projections From 2019 to 2034. June 2021. Available from: bit.ly/3B3Rl8T.
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