SIGNIFICANT HEALTHCARE MILESTONES AND TRENDS IN THE PAST DECADE (2010 – 2020)

SIGNIFICANT HEALTHCARE MILESTONES AND TRENDS IN THE PAST DECADE (2010 – 2020)

By Pat Stricker, RN, MEd, Senior Vice President, TCS Healthcare Technologies

Typically I start the new year looking at the healthcare predictions and trends for the coming year. This year, I would like to change that. The past decade (2010 to 2020) experienced some dramatic healthcare challenges and accomplishments, so I would like to start the year by discussing those in this month’s article. Then next month we will focus on looking at the 2022 healthcare predictions and trends.

The following are key milestones and significant events that occurred between 2010 and 2020.    

MILESTONES AND SIGNIFICANT EVENTS

The Patient Protection and Affordable Care Act

The decade started with the historic passing of the Patient Protection and Affordable Care Act (ACA or “ObamaCare”) on March 23, 2010. This significant healthcare law fundamentally provided health insurance to millions who did not have it and transformed healthcare insurance in the United States through shared responsibility. The goals of the original act were to eliminate discriminatory practices, e.g., pre-existing conditions; provide coverage to everyone without increasing healthcare premiums; provide tax credits for individuals and families to make it affordable for everyone. It provided sweeping changes in the healthcare system, especially related to health insurance mandates and Medicaid expansion. Other examples of ACA benefits include: 135 million Americans (nearly 1 in 2 non-elderly adults) with pre-existing conditions were assured they would not be charged more or denied insurance because of their health status; women could no longer be charged higher premiums just because of their gender; young adults could now be covered on their parent's insurance until they were 26; improved access to prescription drugs were provided and at a lower cost.

Implementing the law caused significant challenges to healthcare organizations, insurance companies, large companies, federal agencies, etc. They needed to update their processes, billing, information technology applications, policies, staff training, etc. to accommodate the requirements. This took years to fully accomplish. Through the past 11 years, the ACA has faced over 70+ attempts to repeal, modify, de-authorize, de-fund, or destroy it, but it has endured. There have been changes, and it is not as strong as it was originally, but in June 2020 it was providing insurance to an additional 31 million people. ACA, while it has some issues, was certainly the most significant healthcare achievement of the last decade. 

Electronic Health Records

The electronic medical record (EHR) has been around since the 1970s; however, it was not being utilized as much as expected. Systems were installed locally, but they were not able to communicate with other systems, so they did not really meet the exact needs of the healthcare system. The idea sounded great and people wanted it, but there were too many challenges at the time to make them work interoperable and efficient. This went on for about 30 years. Just before the start of the last decade, the Health Information Technology for Economic and Clinical Health Act (HITECH), enacted as part of the American Recovery and Reinvestment Act of 2009, was signed into law on February 17, 2009. The goal of this act was to promote the adoption and meaningful use of health information technology (HIT), which included EHRs. Incentives and penalties were developed to encourage healthcare organizations to implement EHRs. The act also addressed the privacy and security concerns with the transmission of health information. These helped strengthen the civil and criminal enforcement of the Health Insurance Portability and Accountability Act (HIPAA), which was enacted in 1996, which required national standards for electronic healthcare transactions, code sets, unique identifiers, security, and privacy protections for identifiable health information. Just prior to that, in the mid-2000s, cloud computing, which had been available for years, was finally beginning to be accepted. This gave EHRs the ability to connect with other organizations and share data (interoperability) – the one big functionality that EHRs had been lacking. So with the requirements, standards, HIT structure, and connectivity in place, EHRs were able to provide the consistency, transmission, connectivity, and documentation standardization that were needed.

So by 2010, the healthcare industry was ready to get rid of paper-based systems and begin their transition to digital documentation systems that could be shared among the entire healthcare team. Electronic medical records were finally going to be a reality. While systems are still not all connected and data is not fully shared, almost all large health systems have an EHR with a patient portal that allows patients to review their records and communicate with their physician’s office. The systems still need some work, but after years of struggle, the EHRs are finally a working reality. This was a significant accomplishment!        

Value Based Care

Value based care is a model of care that has been popular in the previous decade, and it is still gaining even more momentum. Its premise is to improve quality and outcomes for patients by incentivizing providers to focus on the quality of services, not the quantity; and to be proactive, instead of reactive, by preventing problems before they start. Examples of this type of care include reducing hospital admissions, improving preventive care, and using specific kinds of health technology. The model also pays physicians and hospitals based on the quality of care provided and the patient’s outcomes. This new model is becoming more popular and is expected to become even more ingrained in the future.

The Opioid Crisis

The decade has been plagued with several public health issues. One of the most pressing issues has been the large number of deaths from overdoses of opioids and other prescription drugs. In 2010, there were 38,329 deaths from all drug overdoses, and by 2021 the annual number rose to 100,306. The majority of these deaths were from opioids (natural and semi-synthetic, methadone, and fentanyl). In 2010, 21,089 opioid overdose deaths occurred, but by 2021 the annual opioid had risen to 75,673.  These are overwhelming, catastrophic increases over a short 10-year span. A great deal of focus has been placed on trying to manage these overdoses, but it is obviously not making enough progress. It is essential that even more directive actions be taken to manage this crisis.   

COVID-19

Of course, as we all know, the most urgent and significant public health event of the decade is COVID-19. This pandemic started in the U.S. in December 2019, and to date, there have been 65,159,554 cases and 847,577 deaths. Worldwide, COVID-19 has caused 328 million cases and 5.54 million deaths. These are staggering numbers. COVID-19 has been a catastrophic incident like no other. All healthcare resources have been focused on this for the past 2 years, and it is still not letting up. It has consumed all areas of healthcare, and many projects and plans in the entire healthcare sector have been postponed due to the need to focus totally on trying to manage this pandemic. Effective vaccines were developed quickly and have made a significant difference in the number of cases and deaths, but there is still lingering vaccine hesitancy and refusal, which has allowed the virus to continue to infect the unvaccinated and mutate to additional strains. Hopefully, we will be able to get control of this pandemic soon. It is undoubtedly the most significant healthcare event in our lifetime.

Now we will take a look at the significant healthcare trends that occurred in the last decade.

HEALTHCARE TRENDS

Healthcare Spending

The cost of healthcare spending in the U.S. is always an issue and one that needs to be continually re-evaluated and re-addressed. In 2010, healthcare spending was $2.6 trillion or $8,402 per person. In 2020, the cost increased to $4.1 trillion or $12,530 per person. The spending for 2020 accounted for a 9.7% growth, the fastest rate of growth since 2002. However, this increase was due in large part to the amount of healthcare spending needed for the COVID-19 pandemic. The growth rate had been about 4% to 6% for the prior years. With the costs of COVID-19 removed, the rate of growth would have only been 1.9%. This lower than usual number was the result of less overall healthcare spending on procedures and services that were being postponed or canceled during the pandemic.

Healthcare spending in the U.S. is higher than in other countries. In 2019 it was $10,966 per person, while the next country, Switzerland, was only $7,732 per person. Healthcare organizations have been trying to decrease costs over the past decade, and the good news is that there has been a gradual drop in the percentage increase of U.S. healthcare in the last decade. Another factor in healthcare spending is the cost of prescription drugs. Prescription drug costs accounted for $348.4 billion in 2019, which was 10.1% of the total healthcare spending. Prescription drug costs are a hotly debated and often talked about topic in Congress. Hopefully, they will be able to find a way to reduce these costs, rather than just debating or talking about them. If healthcare spending is not curtailed, it will be one of the top threats in the next decade. We must find a way to reduce costs, while still maintaining quality healthcare.     

Vaping

Vaping is a public health issue that is a big problem, primarily in the teen and young adult age group. Vaping has caused 68 deaths as of February 18, 2020, and 2,807 hospitalizations. Most of these serious lung injuries are caused by vaping THC, the substance in marijuana, and vitamin E acetate, an ingredient in vaping products. Vaping other flavored e-cigarettes does not seem to be as harmful, but these are still being studied. These lung illnesses have even been given a name — EVALI (e-cigarette, vaping, product use-associated lung injury.”  Attention needs to be given to this now before it becomes a larger issue among young adults.

Health Information Technology (HIT)

Healthcare technology grew exponentially from 2010 to 2020. The ability for technology to help with issues related to ACA, HIPAA, EHRs, COVID-19, and cloud computing were the main drivers of the growth. The ACA and HIPAA initiatives in 2010 opened the doors to a myriad of technology companies with products that would help with these transitions. HIT companies have raised more than $7.65 billion since then from venture capital firms. Likewise, companies also created numerous software products that would help with the EHR transitions. Other HIT products like wearable devices, wellness APPs, remote monitoring, analytic programs, wireless communications, and research into artificial intelligence and virtual reality tools are all helping to fuel that growth. Another area that needs to be improved is the ability to have one platform perform multiple functions, rather than having multiple platforms working together to accomplish that goal. If multiple platforms are needed, they should be interoperable, so they can work seamlessly with each other to share data and functions.

Telemedicine

Telemedicine is the use of technology and electronic communications to provide remote clinical services to a patient. Video and phone appointments are conducted between a patient and their provider, instead of routine face-to-face visits. Other examples include text messaging, emails, video chats, remote medical diagnosis and evaluations, and video consultations with specialists. This concept has been around since the 1980s. [NOTE: As the manager of a large emergency department, I remember setting up a remote telemedicine urgent care on a small island in Lake Erie that was a popular “party island” for boaters on evenings and weekends. It was staffed by a nurse practitioner and an orderly. Our emergency department physicians would communicate with them and the patient by phone and video camera. It was quite crude compared to today’s technology (the video was black and white and a little “grainy”), but it worked quite well. Most of the visits were cuts, bruises, or simple fractures, so this was a good way to provide basic services for a low cost to the island. And it was quite successful. Thanks for allowing me to digress.] 

However, the telemedicine concept never really caught on to become a main healthcare service. It was beginning to gain more momentum in the last decade as remote ICU units used this type of concept, but again, it has not been able to break away into a solid program and obtain reimbursement for services. However, telemedicine took on a big role in providing a way to communicate and evaluate patients by video and phone sessions during the COVID-19 pandemic. In-person office visits were canceled or reduced, yet patients were still sick and needed to be seen. The skeleton for implementing a telehealth visit was already there, and it was relatively quick and easy to implement. It has always faced difficulties in getting approval for reimbursement of services, but these were quickly solved, as this type of service was badly needed. It cannot be used for every visit, but it is an easy, convenient way to evaluate and diagnose simple situations, and it works well for older patients or those in rural settings who have a difficult time getting to an in-person office visit. Telemedicine visits make sense since they provide increased access at reduced costs. The COVID-19 pandemic transformed telemedicine from an obscure practice to a new care delivery model. It is predicted (and hoped) that telemedicine will become a permanent addition to healthcare services.     

Closing of Rural Hospitals

Over the past decade, an alarming situation has arisen. According to a report by the American Hospital Association, 120 rural hospitals have closed due to low patient volumes, high numbers of uncompensated care, the shift from inpatient to outpatient care, and heavy reliance on government payers. Thirty-one states have had at least one rural hospital close since 2010, and 101 closures occurred in just 14 states. These are occurring now in increasing numbers, as evidenced by a record of 19 closures that occurred in 2020 alone. These closures have left about 60 million people (1 in 5 Americans) without hospitals in their rural towns. Closures result in worsened patient outcomes and increased patient mortality rates by 5.9%. It also creates difficulties in obtaining care, increases transportation costs to travel to other healthcare facilities, eliminates numerous healthcare jobs in the community, and leads to higher unemployment rates. In addition, cost-cutting measures before the closure usually include closing obstetric units. A study in Minnesota showed that counties lacking obstetric units jumped from 45% to 54% in the past ten years. These closures are occurring more often in the past 2-3 years and are devastating to patients, healthcare workers, and the community as a whole. Hopefully, we will be able to find a way in the coming decade to reverse this trend.    

Analytic Programs

Emphasis on having meaningful analytic programs has been an increasing need expressed over the past decade. Analytics are needed to analyze population health management (PHM) programs to target specific needs and identify specific situations, diagnoses, potential risks, etc. Many analytic programs are designed for smaller, specific programs and can be adapted to work in larger PHM programs, but they do not work that well with larger data sets consisting of events with interactions and inter-dependencies that need a longitudinal view. Smaller analytic programs are too linear and are unable to correctly analyze the data into meaningful output. Analytics are a necessity for being able to customize programs and identify the key data needed for each population.  

CONCLUSION

The decade from 2010 to 2020 was certainly memorable! It included three extremely significant milestones: the passage and implementation of the Affordable Care Act in 2010; the implementation of electronic health records in record numbers thanks to the HITECH Act (2009); and the COVID-19 pandemic from December 2019 through 2020.  

This was an exciting, and at times frustrating, timeframe to live through, but it was also a very productive time. The milestones and trends were mostly very positive or hopeful, except for the excessive number of small rural hospitals that were closed. This is a sad and alarming trend. I hope we will be able to turn this around and re-open some of them.

We live in a very exciting time. Things are changing so quickly it is hard to keep up. Advances in information technology, communication tools, AI, and medical advances are overwhelming at times, yet they are helping us provide better care and outcomes in a more efficient manner. Who would have thought 10 years ago that we would have progressed so far? I am certainly looking forward to the next 10 years. In the article next month, we will look ahead to see what the predictions and trends hold in store for the next decade.