Where Are We Now: Catching Up with Trends in COVID-19 & Telemedicine

In a recent podcast episode, our team of data scientists and clinicians sat down to share the trends and analysis findings that shaped the 2023 Employee Health Trends report. Catch the full conversation below.

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Listen to the full podcast episode here.

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Jennifer
‍We are now onto our fourth year dealing with COVID. Since it burst into our consciousness in early 2020, we've seen massive changes in treatments and long-term effects, including the enigmatic, long COVID and strains on mental health. To kick off season two of “Healthcare on the Rocks, Employee Benefits with a Twist,” we're going to start with a mini-series, exploring the major trends that are shaping employee healthcare. I'm Jennifer Jones, enterprise practice leader at Springbuk. 

‍Mike
And I'm Mike Pattengale, mid-market practice leader. We regularly talk with employers, benefits advisors, technology innovators, and other experts in areas like wellness, human resources, and healthcare.

Today I'm fortunate to be talking with three of the analysts and authors of Springbuk's 2023 Employee Health Trends Report. Jen, who you just met is one of them, along with Dr. Janet Young, Lead Clinical Scientist here at Springbuk. Janet has an M.D. From Yale University and has amassed more than 30 years of experience providing clinical expertise and oversight to the development of healthcare analytics.

Guiding clinical content development of new models, methods, and applications. Welcome, Janet. 

Janet
Thanks. I'm happy to be here today. 

‍Jennifer
And also with us is Chris Gagen, Senior Director of Analytic and Strategic Consulting. For more than 20 years, Chris has developed, implemented and enhanced predictive models within the employee health benefits industry.Chris has deep expertise in collaborating with business leaders, data scientists, and develop. To define and solve healthcare business problems. Chris, thanks for joining us again. 

‍Chris
Glad to be back on the show. 

Jennifer
All right, before we get into the questions, I should mention here that you can get a copy, your own copy of the Employee Health Trends report at Springbuk.com/eht23.

It's full of beautiful chart charts, data key analysis, findings, and suggestions for employers to act.

Now, Janet, let's start with you. While COVID is mostly under control here in the States, at the beginning of 2022, we were recovering from a huge increase in cases due to the Omicron variant. How did that impact employer spending related to COVID ?

‍Janet
We ended 2021 with the highest costs we'd seen related to COVID spending despite having vaccinations and tools at our disposal to reduce the severity of COVID. We also knew that many people were having breakthrough infections despite having been vaccinated, and we really didn't know what was going to happen next with COVID 19.

We had already seen the virus mutate from the delta variant that was dominant in the end of the summer of '21 to Omicron in the fall or early winter of 2021. So I think we came into 2022 was some trepidation, but 2022 appears to have been a much better year in regard to COVID -related expenses when we published the employee health Trends, this.

We noted a significant drop in spending in COVID 19, in the first half of 2022, with the second quarter having the lowest per member per month spending related to COVID. Since the pandemic began, I now have results also for '22 quarter three, which appears to show even a small decline from what we expected.

In quarter two of 2022. So I think the news is good at this point. Most of the spending we see is still on diagnosis and treatment. Not too surprisingly, the amount spent on vaccination has gone down, although it was up just a tiny bit in q3 once the bivalent boosters became available in September. 

Jennifer
And Janet, I'll ask just to see how you respond to this one. Do you have any predictions on what you think we're likely to see here in 2023? 

Janet
I think it's probably not wise to make predictions. I recently noticed that the CDC actually stopped forecasting COVID cases because they found that even combining the best models, the observed cases frequently turned out to be outside the range they've predicted.

So yeah, I think it's better. I keep away from that. I think the general agreement is that COVID is not going away, but I do think we have reason to be cautiously optimistic based on what we're seeing in the. And the fact that we have vaccinations that can decrease the risk of getting COVID and antivirals that can decrease the severity of the disease if we get COVID and that they continue to work against the circulating variants.

These are all good signs. I'm not sure what recommendations we'll have this year related to booster shots. There's been discussion around having an annual booster. But there's some differences in opinions from experts, so that's still to be determined. 

‍Mike
Let's talk a little bit about Long COVID. We hear a lot about the potentially devastating consequences of it as you wrote about COVID and last year's Employee Health Trends report that term long COVID was relatively new.

What have we learned about long COVID in the last year in regards to who might be at greatest risk, and is there any information employers can pass along to their employees about how to avoid getting long? 

Janet
That's a great question. So to date, studies suggest that people with more severe disease are more likely to get long COVID than people who have mild or asymptomatic disease.

In particular, people who are hospitalized are probably at the greatest risk. Something else that's been noted in a number of studies is that women are being diagnosed at a higher rate than men, but most of the other factors really seem to overlap with the risk of having more severe disease being older, having more comorbid conditions, being unvaccinated.

All of those appear to put people at greater risk of getting long COVID in terms of preventing long COVID. Of course, the first advice is to try not to get COVID in the first. So that brings us back to all of the strategies we've employed in the past, including hand washing, social distancing, masking, and again vaccination.

Some studies suggest that being vaccinated reduces the risk of getting long COVID, even if individuals are infected after being vaccinated. So that's another good reason to encourage vaccination. There's also evidence from a VA study that individuals who were infected but took the antiviral drug, Paxlovid, were at reduced risk of getting long COVID .

So we need to remind members about seeing if they're eligible for this drug should they get COVID because it needs to be taken within five days of acute symptoms. 

Mike
Got it. Thank you. And I'm glad to hear you pronounce Paxlovid because when I first read it I was terrified. And looking back, I know last year when we had talked with you about Long COVID you had hoped that by the end of 2022 we'd be able to understand the impact of long COVID a bit better due to a new diagnosis code coming in on the claims for this condition.

As you started preparing to do your research and analysis for this year's Employee Health Trends report, did you have any working hypotheses around what we would see and how long COVID might be impacting other healthcare costs for employers? 

Janet
Based on everything I was reading in the news and studies that reported rates of long COVID, I really expected to see a tsunami of long COVID claims and significant spending on this condition. 

Mike
So what exactly did you find? 

Janet
Surprisingly, there certainly wasn't a tsunami of claims. 16% of members hospitalized for COVID had a diagnosis of long COVID eventually, but only 1.6% of members who were not initially hospitalized for COVID received this diagnosis. 

Jennifer
And that's so interesting, Janet, because as we know, everything we were hearing out in the media and national news was showing much higher statistics.

So why do you think the rates of long COVID look lower in our data as what we're seeing reported elsewhere? 

Janet
I think the main reason is that there isn't a standard definition for long COVID. So I think physicians are underdiagnosing it or under reporting it. They're just not comfortable identifying ongoing symptoms as being long COVID.

I think there are a few other factors that might be involved, so I'll touch on a few of them. There's a possibility that some employees who are hardest hit with the symptoms of long COVID may leave the work. So we don't have their claims to know that eventually they were diagnosed with long COVID. Many of the early estimates of long COVID were before Omicron.

Some studies suggest that Omicron is associated with lower rates of long COVID, so that's a second reason. A third reason is that some of the earlier studies weren't well controlled. For instance, some were surveys, and we know that there can be a bias in who answers these. So we may have seen rates that were a bit higher than actual just due to people who were symptomatic being more likely to respond.

Mike
So if physicians aren't diagnosing or reporting long COVID, are there other ways to look at the data to see if members with COVID 19 are having ongoing issues that might impact productivity or other healthcare costs? 

Janet
I think so. The way that we've looked at this is looking for symptoms that may be related to long COVID on claims.

Since individuals who have these symptoms, if there are really interfering with their daily functioning, they are likely to seek care. We looked at five of the top symptoms. There are an awful lot of symptoms associated with long COVID, but we looked at cognitive issues like brain fog, fatigue, respiratory symptoms like shortness of breath, cardiac symptoms like an arrhythmia, and anxiety and depression.

And what we found was that in addition to the 16% of hospitalized patients, Eventually had a diagnosis of long COVID. Another 22% had at least one of these five long COVID related symptoms when we looked at claims three to six months after their initial diagnosis. Similarly, in addition to the 1.6% of non hospitalized patients who had a diagnosis of long COVID

We found another 18% who had long COVID related symptoms on claims. The increased rates we see of these symptoms, even in members without long COVID, are likely to impact productivity for employees, and it also raises some safety concerns for certain types of employ. But something that's notable that we found was that as the number of symptoms increased, so does healthcare spending regardless of whether someone has a long COVID diagnosis or not.

We also found that members with two or more symptoms who don't have a long COVID diagnosis actually had increased costs that were greater than those for members with long COVID. 

Jennifer
Now, Janet, we incorporated some of the information and statistics from the Business Group on Health's Large Employer Survey into our trends report. But can you share as far as how did that really dovetail as far as with the data that we were seeing from Springbuk? 

Janet
What I noticed in that was that only one in five employers were seeing an increase in disability claims due to long COVID. So it's definitely impacting some employers, but again, maybe not as many as we might think based on what's reported in the news.

The results of that survey were also a reminder that the pandemic has had impacts that go well beyond the direct costs of COVID and long COVID. A high percentage of employers reported seeing the impact of delayed care on chronic conditions. And also the impact of the pandemic on mental health issues. 

Mike
Got it. Okay, Janet, so before we give you a break and turn to Chris, what are some of the main takeaways for employers related to long COVID and just COVID 19 In general?

Jennifer
I am cautiously optimistic about what we'll see in 2023. We need to remember that some of what happens in the future is actually in our hands.

We have tools to prevent or at least decrease the severity of COVID and decrease the risk of long COVID, but we need to use them. So we know that includes, everything that we've talked about here: vaccination, the use of antivirals like Paxlovid, and then social distancing, hand washing, masks.

In regard to long COVID, I think our takeaway here is that it's likely that it's being under-reported or undiagnosed. So even if you don't see a lot of members reported with the condition on claims, don't underestimate the impact it may be having on members. You can help members who have ongoing symptoms navigate to in-network multidisciplinary clinics that are more adept at treating long COVID patients.

I think a lot of physicians, as I mentioned, this is a new diagnosis and perhaps are not as adept at how to deal with all of the symptoms that long COVID patients. 

Mike
Okay, Chris, Janet set the bar pretty high. Are you ready to raise it? 

Chris
Indeed she did. Per usual. I'm just here trying to hold the bar up.

Mike
Classic, Chris. Before we go too deep into your analysis around mental health and telemedicine, why don't we back up and start by just having you explain to us what those two terms mean and what they cover?

Chris
Sure. Both of those are broad terms and they're often thrown around, so it's a good idea to clarify that upfront.

So first, when we get into mental health, we're talking about three categories, depression, anxiety, and behavioral health. Of these three, the broadest category is the last one. Behavioral health, this includes but is not really limited to conditions such as ADD, bipolar disorder, autism spectrum disorder, and substance abuse type conditions.

As far as telemedicine goes, people will use telemedicine and telehealth interchangeably. Generally, telehealth is a broader definition than telemedicine, and we are interpreting the term telemedicine to be more specific to using technology to support the delivery of medical care to patients. For example, remote monitoring consultations and online evaluations and visits.

And these are defined by combinations of codes including revenue, place of service, CPT, HCPCS, and modifier codes. 

Mike
Thank you for that. I think that'll be really helpful for our listeners. So here's a similar question to one we asked Janet, did you have any working hypotheses around what you'd find specific to telemedicine and mental health services?

Chris
When we looked at this a year ago, it seemed like telemedicine might be one of the silver lining trends coming outta the pandemic. At least for some conditions, people were forced into an action in early '20. Adapt to a new technology or else it was the only option? So I thought it was interesting.

According to CMS, the percent of Medicare users with a telehealth service went from 7% in the first quarter of 2020 to 47% in the second quarter, and that's the Medicare population. So my hypothesis coming in was that the barrier had been broken, especially with mental health, where the demand has only increased. Therefore I expected to see these two things find each other and stabilize over the last year. I was hopeful because if that was the case, it would be an example of evolving efficiency in the healthcare marketplace, which is positive news. 

Jennifer
Yeah. And Chris in the report you wrote, telemedicine has claimed a permanent seat at the benefits table. Can you explain, what you mean by that and what that permanent seat looks like? 

Chris
Sure. According to the 2023 National Business Group on Health's large employer survey, 74% of employers believe virtual health will have a significant impact on how care is delivered in the future. So there is acknowledgement and belief that technology like this will be a big part of employer benefit strategy going forward.

It's interesting to note that a year ago that percent was 85. So even though 74 was high, it was even higher a year ago. So now a big reason for this decrease is that employers are concerned about siloed care and the lack of coordination. So a permanent seat is going to look like a benefit design and strategy that optimizes integration between virtual and community-based providers, as well as virtual point solution vendors.

Jennifer
Great. That's helpful. So take us through. What you have studied over the past few years. So walk us through what that journey has been like for telemedicine encounters going back to 2019. 

Chris
Yeah, so we generally look back to 2019 as the baseline for the old normal when comparing to this new normal and after a huge initial spike in April of 2020.

Telemedicine utilization rates overall experienced a steady decline, although still much higher adoption rate than in 2019. But this regression was somewhat expected. Last year, we found pockets of care where telemedicine was finding its place. This was mostly around mental health conditions.

In fact, in 2019, the top conditions being treated by telemedicine were mild, moderate infections, signs and symptoms, prevention and wellness type conditions, and mental health was hardly on the radar. Today, each of the three mental health categories are at the top: depression followed by behavioral health and then anxiety have been the top three for the past two years. 

Jennifer
So to recap that when we looked initially as far, or when we looked back to 2019, mental health conditions were not in the top three for telemedicine encounters. But over the past few years, that has shot up to more than 50% in 2020. And how does that look? 

Chris
So back in 2019, those mental health conditions represented only 19% of all telemedicine encounters. And in 2020 it shot up to 50%, like you mentioned. And since then, it's been hovering around 60% for the last two years.

And this is due to a couple of factors. One, the barriers were broken and the setting made sense to continue. And two, the need for mental health care has increased since the pandemic started as Janet had mentioned. And we found that roughly one in four members are now suffering from some sort of mental health condition.

Mike
This is really powerful stuff. So curious, Chris, what do employers and benefits advisors need to know now and plan for throughout this year and into the next? 

Chris
So the statistic that really hit home for me, for advisors was that in 2019, only 1% of mental health encounters were done virtually – just 1% – and now it's nearly 30%.

This is a really positive trend for a number of reasons. Telemedicine is great for these high frequency, low intensity care visits. It's convenient for members and for employers. It improves access providers like, And finally, it's a lower cost setting. So I would say that employers and benefit advisors should continue to steer members in this direction. Let's drive that 30% even higher. 

There are solutions embedded within medical carriers. There are carve out solutions where you pay per member per month, and there are highly engaged EAP programs as well. So evaluating these options for what is best for you is I. And at the end of the day, finding ways to engage members with frequent and convenient mental health care pays dividends with more productive employees, better chronic care management, and less risk for high cost episodes in the future.

Mike
Awesome. Thank you, Chris. All right, Jen, you are not getting away that easily. You're not just asking questions today. 

Jennifer
Sure I am!

Mike
Janet and Chris … no!, Janet and Chris gave us some of their top recommendations, but being the third internal author here at Springbuk, again, not bitter that for the third year in a row, I am stiff armed to the side, but that's all right. With your population health expertise what would you add?

Jennifer
I'd say in relation to the two topics that we've discussed today as we think about COVID in general I think Janet covered all the key points as we think about long COVID impacts along COVID and how to ideally prevent the one piece I would add there, as really we highlighted back in 2020 in thinking about some of the underlying conditions that put individuals at a greater risk as far as having severe COVID type of symptoms. And in this situation, even potentially long COVID , so individuals with specific heart conditions: those with diabetes, those that are overweight smokers, like any of those underlying chronic conditions.

I would say continuing to advocate and really educate on how individuals can further control and manage those conditions. So if they do contract the virus hopefully they'll be in a better position to not go into a long COVID scenario and be trying to battle both types of conditions and really from, more of a telemedicine mental health perspective, I think what Chris shared, those key last points there are all dead on. 

One thing that we have talked about in each report for the past three years is really about ensuring you're communicating all of those options to your members and to your employees with with any type of mental health service over-communication seems to be the right way to do it because you never know when someone is going to need those types of services. So always making sure that they know who or where to turn to in an emergency. And having, telemedicine type of virtual options for those types of visits are great alternatives.

I think we really have crossed over to where many more services will now be available from a virtual perspective, and that will save time. It'll save energy of employees and members and get people into the right care faster. The one piece that Chris also goes into in the report that we didn't necessarily touch on today is still the ongoing impact of telemedicine on low acuity ER visits.

It is definitely an area I highly recommend that you do delve into and read through bec ause we're still seeing some positive numbers where those visits from an ER perspective have not necessarily risen back to the pre pandemic levels, and we're hoping and assuming that a lot of those numbers are attributed to the virtual options as far as understanding and knowing the right type of care to access to first before you would end up in the ER.

Mike
Got it. Yeah. Thank you for that. I think this is a great way to wrap up the episode. And I know all jokes and passive aggressive jabs aside the Employee Health Trends is just an awesome report. And speaking more from a Springbuk employee and coworker perspective, for all of us that just get to watch you all glean these insights from the data to share with our clients, prospects and just folks out there in the market, it really is something to be proud of to see, how you all are using your expertise to share that back with our industry and the greater world beyond that.

Janet, Chris, Jen, thanks again for joining us, and we really look forward to having you back soon to look at some of the other significant trends employers should plan for this. 

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Download the full 2023 Employee Health Trends Report here.

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