The Costs and Consequences of Forgone Care

In the early days of the pandemic, one of the main reasons people avoided going to the doctor was the fear of COVID-19 exposure. Now, we’re seeing some consequences of that avoidance. The personal, health, and financial costs of forgone care. In this blog post, we’ll take a closer look at the issue of forgone care through the lens of several recently published studies.

With medical visits beginning to pick up again¹, health providers are starting to see the consequences of a year of pandemic-delayed preventive and emergency care. They’re discovering more advanced cancer, rotting and damaged teeth, and other worsening ailments.

The consequences of forgone care could lead to thousands of lives lost, even after the pandemic is over. Many people have put off screenings, missed check-ups, skipped medication doses, or chosen not to seek emergency care after experiencing heart attack symptoms throughout the pandemic.

During the lockdowns of 2020, it became difficult for doctors to conduct preventive screenings for cancer. Practices started implementing mask policies and monitoring for COVID symptoms to ensure safety for routine visits, but there were still interruptions in service. Improvised telehealth visits or at-home testing kits didn’t sufficiently replace in-person procedures. Even though early detection is key in treating cancer, many patients didn’t undergo routine screenings in time, resulting in later—and therefore more progressed—cancer diagnoses.

Early consequences reported by the National Cancer Institute (NCI) showed an abrupt decrease in cancer screenings of between 60% and 80% for some procedures in the Spring of 2020.²

Exactly how many screenings were missed during the pandemic will be revealed later, when private insurers and the Centers for Medicare & Medicaid Service release all their claims data. Nevertheless, by looking at a sample of available data from 20 million patients in 2020, dramatic decreases in preventive care are apparent:

• 114,636 missed colonoscopies
• 158,717 missed mammograms
• 114,367 missed pap smears

This represents decreases of 25%, 16%, and 8% from 2019, respectively.

Using standard positivity rates, approximately 459 colorectal cancer cases, 794 breast cancer cases, and 30 cervical cancer cases went undiagnosed in 2020. According to estimations for diagnoses and average annualized treatment costs, it’s likely that patients with postponed diagnoses will pay approximately $2 million for cervical cancer, $27.5 million for breast cancer, and $35.7 million for colorectal cancer. If undiagnosed cases progress without treatment, the cost of care for patients will be even higher.

These estimates increase when looking at the total number of privately insured Americans. When the costs from sample claims data is inferred to all 220 million privately insured patients, spending projections grow 11 times, which translates to $392.7 million for colorectal cancers, $302.5 million for breast cancers, and $22 million for cervical cancers.

Officials are now warning of a looming health crisis to come. The director of the National Cancer Institute says the pandemic will likely cause at least 10,000 excess deaths from breast cancer and colorectal cancer alone over the next 10 years.

Incidence and Causes of Forgone Care

According to a recent study conducted by John Hopkins Bloomberg School of Public Health and published in JAMA Network Open,³ 41% of adults reported forgoing care from March 2020 through mid-July 2020. A total of 544 respondents out of the 1,377 people who completed the survey, representing an estimated 41% of U.S. adults, reported forgoing medical care during the initial stages of the pandemic, including 108 respondents (8%) who reported missing one or more doses of a prescription medicine, 387 respondents (29%) who reported missing a preventive care visit, 343 respondents (26%) who reported missing an outpatient general medical appointment, 105 respondents (8%) who reported missing an outpatient mental health appointment, 77 respondents (6%) who reported missing an elective surgery, and 38 respondents (3%) who reported not receiving healthcare for a new severe mental or physical health issue.

Among all respondents who reported missing any type of planned medical care, 63% attributed missing care to a medical practice being closed (either temporarily or permanently), 57% attributed missing care to fear of exposure to COVID, and 7% attributed missing care to the financial repercussions of the pandemic.

Forgone Care Fuels Uptick in Heart Failure Costs

According to a study published in the Journal of the American College of Cardiology (JACC) in August 2021⁴, about one in six patients with heart failure in the U.S. reported skipping their appointments, not taking their medications as directed, or otherwise forgoing care, costing the healthcare system 20% to 30% more per patient.

The study found that the average annual costs for adult heart failure patients who skipped care were $8,027 higher than for those heart failure patients who kept up with their treatment regimens. However, the costs for non-compliant heart failure patients 65 and older was $10,581 higher than compliant heart failure patients 65 and older. The differential translates into a 50% premium over average costs for heart failure patients.

New Normal Brings Bad Habits

In addition to exacerbating existing health problems, the pandemic has also created a myriad of new health concerns. Health systems are already reporting an increase in the number of patients presenting with worn teeth from grinding or clenching, back problems from slouching or sitting for extended periods in makeshift home offices, and mental health problems resulting from isolation or being too close to family members.

A recent American Dental Association survey⁵ found that more than 70% of member dentists reported an increase in patients grinding or clenching their teeth since the pandemic began. More than 60% reported an increase in other stress-related conditions, such as chipped and cracked teeth.

Patients who have transitioned to remote work are typically working with poor ergonomic setups and spending a lot more time sitting. As a result, physical therapists have reported seeing a significant increase in the number of patients presenting with back pain, neck pain, tight hips, sciatica, and other maladies consistent with poor posture and prolonged sitting.

Medicare Current Beneficiary Survey

The Medicare Current Beneficiary Survey⁶ (Summer 2020) found that one in seven (15%) adults respondents reported having one or more household members who were unable to get elective procedures or surgery for important health problems during the pandemic, with more than half (54%) reporting negative health consequences as a result.

Among Medicare beneficiaries who have forgone medical care during the pandemic:

• 43% missed dental care
• 36% missed regular checkup
• 36% missed treatment for chronic conditions
• 32% missed diagnostic or medical screening tests
• 24% missed vision care
• 17% missed surgical procedure

Health Care Cost Institute Looks at Preventive Health Services

The Health Care Cost Institute (HCCI) examined a sample of health claims clearinghouse records from 18 states containing 184 million claims from 30 million patients in 2019, and 94 million claims from 20 million patients for the first six months in 2020. More specifically, the study looked at women’s preventative health, services provided during pregnancy and delivery, childhood immunizations, and other preventive medical services such as colonoscopies and prostate-specific antigen (PSA) tests. As expected, they found that the pandemic is having a significant impact on the use of certain health services. Trends from the data showed the following:

• Childhood immunizations were down 60% in mid-April in 2020 compared to 2019.
• Mammograms and Pap smears were down nearly 80% in April 2020 compared to 2019. However, both services rebounded later in the year and eventually surpassed 2019 levels.
• Colonoscopies were down almost 90% at one point in mid-April 2020 compared to 2019, but as of December 2020 were down just 15% compared to 2019.
• PSA tests were down 70% in early April but have seen a strong recovery, with tests returning to 2019 levels by June 2020.

Forgone Care Not Forgotten

While the issue of forgone care is driven by many factors, payers and providers can make a significant difference by consistently doing one thing – proactively reaching out to high-risk patients with timely, personalized health information based on their needs, medical history, and risk factors.

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¹ https://healthcostinstitute.org/hcci-research/the-impact-of-covid-19-on-the-use-of-preventive-health-care
² https://healthcareexecintelligence.healthitanalytics.com/features/preventive-care-takes-pandemic-hit-results-in-missed-diagnoses
³ https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2775366
⁴ https://www.jacc.org/doi/full/10.1016/j.jchf.2021.05.010
⁵ https://www.ada.org/en/press-room/news-releases/2021-archives/march/new-survey-finds-stress-related-dental-conditions-continue-to-increase
⁶ https://www.cms.gov/files/document/medicare-current-beneficiary-survey-covid-19-data-snapshot-infographic-fall-2020.pdf