For decades policymakers have tried to achieve what COVID-19 did in a year: improve the front lines of health care at scale.
Nearly overnight, virtual visits to hospitals and clinics — including community health centers, which serve our most vulnerable patients — surged by more than 50 percent. Between January 2020 and 2021, the number of VA telehealth appointments increased by 1,831 percent. Testing for upper respiratory viral illnesses shifted from inefficient and sometimes unsafe settings (e.g., crowded waiting rooms where viruses can be transmitted to other patients and health workers) to drive-through testing sites. Vaccination sites moved from facility-based to community locations (including football stadiums, pharmacies and local organizations) to improve access for hard-to-reach populations.
Although much of our attention to date has rightly been on the national and global tragedy that is the pandemic and efforts to mitigate it, the front lines of care have changed for the better more in the past year than perhaps at any time in recent history.
This change has a number of implications for policymakers and health care providers that apply well beyond COVID-19:
Health care can be delivered outside of a clinic or hospital. For years, health care delivery has been synonymous with clinics and hospitals. But during the COVID-19 pandemic, we realized what has long been true: Health care facilities are just one setting for the delivery of care, and often the most expensive and sometimes unsafe option. This is due to the risks of hospital-acquired infections, delirium due to sleep disruption, medical errors, and overmedication. During this public health crisis, many physician office visits were shifted to virtual visits and house calls, and COVID-19 tests moved to drive-through locations. Even some hospital-level care was delivered in the home, which decades of research has demonstrated is associated with fewer complications, and with higher patient and caregiver satisfaction, compared to hospital care. Not only are these options more convenient for patients, but they can also be more equitable. Many of our most vulnerable communities are underserved by health professionals and medical facilities. Even when they do have access to this care, some do not trust those facilities enough to set foot in them.
Virtual care is healthcare. Prior to the pandemic, virtual care — medical appointments over phone or video — was largely relegated to urgent care-type visits and was seen as a lower-quality alternative to in-person care. But during the pandemic, driven by sheltering in place and closures of clinics around the country, virtual care became the way primary care, mental health and even specialty care was routinely delivered. In fact, a patient’s first interaction with a health care professional was often online — what is increasingly being called “virtual first” care. For many patients this shift not only made accessing healthcare services more convenient, it also resulted in greater access to care. For example, anecdotally, some safety net clinics saw no-show rates dropping from between 10 and 20 percent to nearly zero with virtual visits. However, the potential of virtual visits to improve health care disparities was not uniformly realized. Although 86 percent of Americans with household income under $30,000 use the internet, we saw many Black and brown communities, rural towns and the elderly face the triple threat of the digital divide: lack of broadband connectivity, lack of mobile devices, and lack of digital literacy. Post-pandemic, digital access increasingly will equal health care access.
Trust and inclusivity are essential for health care and particularly for reducing health disparities. During the vaccine rollout, trust has been a cornerstone of effective health care delivery, without which the system fails. Consequently, strategies for building trust and equity should be explicitly considered in health policy and program development, including when expanding telehealth services. Issues of transparency, micro-targeting communications to specific population groups, and partnering with community organizations and influencers in the design and implementation of health care initiatives such as vaccination efforts are critical. Health care organizations that collaborate in trustworthy ways with communities can have far greater influence in improving the lives of people and their communities.
Social determinants of health matter. Decades of scientific research reveal that what matters most in determining a population’s health is income level, educational attainment and health behaviors, as well as the communities we call home — inclusive of transportation systems, workplaces, schools, air quality, and access to clean water and healthy food. During the pandemic, these factors meant the difference between life and death. Racial and ethnic minorities, as well as those living in poverty, have suffered the worst outcomes, with Black and Hispanic individuals dying at more than twice the rate of whites and 2.8 to 3 times more likely to be hospitalized, according to the CDC. Consequently, even seemingly simple public health guidance about quarantining in place if exposed to COVID-19 became a complex puzzle for many patients when they had to balance recommendations about staying home against forgoing income, the availability of a room to quarantine in, childcare responsibilities, and shopping for food and essential supplies. Public health communications and access to care were not enough to circumvent these barriers to medical services and directly led to the disproportionate impact of COVID-19 on underserved communities.
The front lines of care are adaptable. Perhaps most importantly, while the COVID-19 pandemic put the myriad of faults in America’s inadequate health care system — inaccessibility, unaffordability, inequity, fragility — under a magnifying glass, it also revealed just how flexible the system can be. With the right resources, payment structures and authorities, doctors, nurses and other health care professionals on the front lines of care can demonstrate remarkable ingenuity and leadership and move the system forward. These health care heroes have virtualized care, for delivering food and medicines to high-risk patients, or going door-to-door in vulnerable neighborhoods in order to educate people about the vaccine and facilitate appointments to get them immunized. COVID-19 also shone a spotlight on the need for establishing a new field of public health technology to apply the skills of computer science, engineering and design professionals to accelerate the modernization of our country’s public health infrastructure now and in the years ahead.
Over the past year, the front lines of health care changed dramatically due to the pandemic. A once-in-a-century public health emergency has ignited a once-in-a-lifetime reimagining of how medical care is delivered. Whether we seize this crisis to build a better, more modern, more affordable and more inclusive health care system is now up to us.
Shantanu Nundy, MD, MBA, practices primary care in the greater Washington, D.C., area and is the author of “Care After Covid: What the Pandemic Revealed is Broken in Healthcare and How to Reinvent It.”
Rear Adm. Susan Blumenthal (ret.), MD, MPA, and former U.S. Assistant Surgeon General, is senior medical adviser at amfAR, The Foundation for AIDS Research, director of the Health Innovations Lab at New America, and a visiting professor at the MIT Media Lab.