COVID-19 claims data shows impacts on employers and members
As a third-party administrator for the health plans of many labor unions and essential workers in the epicenter of the coronavirus outbreak – the New York tri-state metro area – we have a unique view of the impact of COVID-19 on these groups.
It’s a time period that will go down in history as among the most extraordinary any of us have ever experienced—and hope never to experience again. Individually, we have had to make major adjustments to our daily lives due to lockdowns and stay-at-home orders meant to blunt the spread of the novel coronavirus and the potentially deadly disease it causes, COVID-19.
But while some of us have had to endure disruption, many individuals have been on the front lines, working essential jobs in nursing homes, as commercial drivers, and in grocery stores. As a third-party administrator for the health plans of many labor unions and essential workers in the epicenter of the coronavirus outbreak – the New York tri-state metro area – we have a unique view of the impact of COVID-19 on these groups.
Related: Look for the good: How brokers and consultants are weathering the pandemic
Looking at these groups’ health claims in recent weeks shows drastic upheaval. They have experienced significant changes in the delivery of medical care and the types of services required, changes such as the cancellation of elective procedures, a rapid transition to virtual health care, many requests for COVID-19 diagnostic testing, and the need for sometimes lengthy hospitalizations.
These claims tell a story that may be useful as self-funded employer groups begin to understand cost/utilization trends. Right now, several of our clients are seeing significant cost impacts. We are finding that COVID-19 claims have hit employers somewhat haphazardly. Some groups have experienced very few cases while others have had a relatively high volume. This is reflected most visibly in hospital stays.
Among our findings based on 1,431 COVID-19 related claims in March and 3,921 COVID-19 related claims in April, processed through the first week of May:
- COVID-19 claims increased 174% from March to April.
- Meanwhile, overall claim volume was down 40% compared to January and February 2020.
- Diagnostic testing claim volume rose 67% from March to April, and COVID-related telehealth claims rose substantially in the same timeframe.
- 10% of all COVID-19-related hospital claims were for severe sepsis and respiratory failure, with most patients requiring an ICU and ventilator for at least part of their stay. Average costs for these cases ranged from $100,000–$300,000.
- Another 40% of cases were severe but did not require a ventilator, though a few needed the ICU. These cases ranged in average cost from $60,000–$100,000.
- The remaining 50% of cases had an average cost of around $35,000. These patients were typically cared for on the hospital floor, without a ventilator, and typically had a diagnosis of severe pneumonia.
With the caveat that these data are limited to our clients’ member population (primarily working-age individuals between the ages of 20 and 55), they provide a snapshot in time of how members have altered the way they access health care and could provide a window into how health care access may change as we move past the initial disruption caused by the pandemic.
Considering the findings
We believe overall claim volume was down 40% because of a combination of factors: elective procedures that have been postponed by the hospitals, fewer accidents, and delayed care. For providers, specialties such as ambulatory surgeries and anesthesiology have been impacted the most, which corresponds with the suspension of elective procedures in the New York-New Jersey area. In contrast, we saw that internal medicine, family practice, emergency medicine, and social work providers were less affected by the pandemic, which could be due to either their transition to telehealth or the continued need for urgent care.
Many of our self-funded groups have made special accommodations to support their members’ health and safety through COVID-19, which is their top priority. Our clients have quickly adopted to telehealth. Prior to the pandemic, some client groups did not have well defined telehealth or virtual health benefits. In the face of this emergency, many of these clients have moved quickly to add or clarify those benefits. Some have also added flexibility around prior authorization and medical management requirements. Also, a number of groups are now providing onsite antibody testing to give members better information about prior exposure as they prepare to return to work.
Even at the epicenter of the pandemic in this country, our most recent claims data are showing some early indications of recovery. Within the past couple of weeks, we have seen fewer COVID-related claims and more typical pre-authorization requests like that for routine services such as colonoscopies and for certain elective procedures such as upper GI studies. In the next few months, we will continue to monitor claims as they begin to normalize even more and share findings with our clients to aid them in reviewing the full impact of COVID-19 on their membership and on their health plans as they prepare for the future.
Michelle Zettergren is the President of MagnaCare, a division of New York-based Brighton Health Plan Solutions, which partners with self-funded health plan sponsors to build health care solutions.