With healthcare utilization for preventive care, chronic care, and emergent care significantly decreasing in 2020 due to the COVID-19 pandemic, a new report explores key medical conditions payers and providers should proactively address in 2021. One key finding is that the year ahead will see an influx of newly diagnosed and later-stage conditions.
The report, from Prealize, an artificial intelligence (AI)-enabled predictive analytics company, identifies the top at-risk conditions based on Prealize’s claims analysis and predictive analytics capabilities. For the study, Prealize accessed claims data for more than 581,000 patients between March and August 2020. These patients represent a wide range of ages across commercial, Medicare, and Medicaid coverage, and the data was compared to claims from the same time period and patient population in 2019. Prealize then applied over 50 machine-learning (ML) models built into its platform to project diagnostic and utilization trends for 2021. These ML models assess over 30 clinical drivers of future healthcare utilization to predict a patient’s risk for being diagnosed with a clinical condition or needing a clinical procedure, up to 18 months before a claim is filed, according to company officials.
The research unsurprisingly noted that many procedures and diagnoses fell significantly in 2020, with several dropping nearly 50 percent below 2019 levels between March and June. What’s more, total healthcare utilization fell 23 percent between March and August 2020, compared to the same time period in 2019.
An analysis of this data at the procedure and diagnosis level using Prealize’s machine learning algorithms projected significant increases in several serious conditions, including heart disease, next year. The report’s predictions for 2021 include:
Cardiac diagnoses will increase by 18 percent for ischemic heart disease and 14 percent for congestive heart failure
• These increases will be driven by 2020 healthcare utilization declines; for example, patients deferring family medicine and internal medicine visits. These visits, which help flag cardiac problems and prevent them from escalating, declined 24 percent between March and August of 2020.
• “Cardiac illnesses are some of the most serious and potentially fatal, so delays in diagnosis can lead to significant adverse outcomes,” said Gordon Norman, M.D., Prealize’s chief medical officer. “Without early recognition and appropriate intervention, rates of patient hospitalization and death are likely to increase, as will associated costs of care.”
Cancer diagnoses will increase by 23 percent.
• Similar to cardiac screening trends, significant declines in 2020 cancer screenings will be a key driver of this increase, with 46 percent fewer colonoscopies and 32 percent fewer mammograms performed between March and August 2020 than during that same time period in 2019.
• “Cancer doesn’t stop developing or progressing because there’s a pandemic,” said Ronald A. Paulus, M.D., president and CEO at RAPMD Strategic Advisors, immediate past president and CEO of Mission Health, and one of the medical experts interviewed for the report. “In 2021, when patients who deferred care ultimately receive their diagnoses, their cancer sadly may be more advanced. In addition, an increase in newly diagnosed patients may make it harder for some patients to access care and specialists—particularly for those patients who are insured by Medicaid or lack insurance altogether.”
Fractures will increase by 112 percent.
• This finding, based on combined analysis of osteoporosis risk and fall risk, is particularly troubling for the elderly patient population.
• A key driver of increased fractures in 2021 is the number of postponed elective orthopedic procedures in 2020, such as hip and knee replacements. These procedural delays are likely to decrease mobility, and therefore, increase risk of fractures from falls.
• “In elderly patients, fractures are very serious events that too often lead to decreased overall mobility and quality of life,” said Norman. “As a result, patients may suffer from physical follow-on events like pulmonary embolisms, and behavioral health concerns like increased social isolation.”
“Several factors contributed to these utilization declines, including patients’ fear of COVID-19 infection and healthcare providers’ decisions to delay certain procedures and appointments,” said Mark Smith, M.D., professor of clinical medicine at the University of California at San Francisco, another medical expert who was interviewed for the report. “We will continue to face unusual utilization patterns throughout 2021. It’s a tumultuous time for providers and payers, unlike anything we have ever faced.”
Prealize CEO Linda T. Hand, added, “The COVID-19 pandemic has challenged every aspect of our healthcare system, but the way to get ahead of these challenges in 2021 will be to proactively identify and address patients most at risk. We’re going to see proactive care become an important driver for success next year, as providers and payers seek to mitigate unnecessary and expensive procedures that result from 2020’s decreased medical utilization…”
