Why It’s More Critical Than Ever to Support Mental Health and How Insurers Can Help
Editor’s Note: In this third post from The Council for Disability Awareness’ research files, Fred Schott reviews the trends seen around delayed or forgone medical care (due to the pandemic) during July 2020 and February 2021.
July 2020
The U.S. Census Bureau’s Household Pulse Survey revealed a great deal about the pandemic’s impact on Americans’ access to medical care.
Here are the two key questions that the Census Bureau asked regarding access to care:
- At any time in the last 4 weeks, did you DELAY getting medical care because of the coronavirus pandemic?
- At any time in the last 4 weeks, did you need medical care for something other than coronavirus, but DID NOT GET IT because of the coronavirus pandemic?
I worked with the Public Use File microdata for weeks 1 thru 12 to do an analysis of how many respondents answered “yes” to either of these questions. Overall, the percentage of U.S. adults reporting reduced access to care stayed in a fairly narrow range (43.7% to 45.7%) with no discernible upward or downward trend. I explored how the reduced-access-to-care percentage varied by various categories and noticed something interesting when I looked at differences by age band:
What the Household Pulse Survey data showed was workers (in what could be called their prime disability years) are more likely than their younger or older work colleagues to have delayed or foregone medical care as a result of the pandemic. No knee- or hip-replacement surgery, no spinal-fusion procedure, no carpal-tunnel release and no four to six weeks’ post-op recovery time that might warrant disability leave. So, if you factor out COVID-19 related claims (of which there wouldn’t have been any in prior years), you would expect to see a reduced claims incidence this year compared to previous years, right?
[Analysis note: I used these three age bands (18-44, 45-64, and 65+) based on my experience working with claims data from multiple disability insurers. I’d say age 45 is the point at which disability claims incidence really starts to shoot up. By age 65, when the vast majority of workers become eligible for Medicare, the exodus from the full-time paid labor force has begun in force (workers can start drawing limited Social Security retirement benefits at age 62 and, depending on when they were born, they can collect full benefits at age 66 or 67), and so age 65+ workers comprise a relatively smaller share of the disability-claims population.]
In early July 2020, I attended a webinar sponsored by Employee News where the presenter (affiliated with a third party claims administrator that works with large employers offering self-insured short-term disability coverage) noted a decrease in 2020 STD claims incidence over prior years. A screenshot of their data is below:
It’ll be interesting to see how things develop for the remainder of 2020. My guess is, at some point, there will be a snap-back effect for a lot of the earlier deferred/foregone care. The result will be an uptick in disability claims incidence rates. QED.
Oh, and here’s one more interesting screenshot from that same webinar. It’s not related to the current topic (reduced access to care), but most certainly is related to my other articles on mental health in times of the pandemic:
In a follow-up note, I asked the presenter if this translated into an absolute increase in mental health claims incidence rate as well (because it’s possible for a particular diagnostic category to increase as a percentage of claims, but if the overall claims incidence decreases enough, that category may not show a corresponding increase in incidence). The presenter’s answer: yes.
There you go.
February 2021
Through my news feed, I ran across this recent analysis done by healthcare consulting firm Avalere. Here’s the meat of it (I’m quoting):
“To examine the impact of COVID-19 lockdowns on healthcare utilization, Avalere assessed Medicare FFS claims volume for hospital inpatient, hospital outpatient, and professional/physician services during the first 6 months of 2020 as compared to the first 6 months of 2019.
“Avalere found healthcare utilization decreased in the first 3 months of the pandemic (March, April, and May of 2020) compared to these same months in 2019. This decrease was largest in April when there was a 51% reduction in outpatient claims and a 42% reduction in professional claims in 2020 compared to 2019.
“The impact of delayed or avoided care on the health status of Medicare beneficiaries will need to be examined over the following months and years as there could be lasting effects even as the pandemic recedes. In addition, decrease in service utilization could indicate that people missed out on preventive care and postponed care they may have needed to receive, which contributes to compounding concerns in management of chronic and acute care leading to pent up demand in future months in addition to potential healthcare costs associated with gaps in care.”
This didn’t really come as a surprise to me. I’ve been following the U.S. Census Bureau’s Household Pulse Survey since the spring of last year, and one of the things that survey has been tracking is whether or not (because of the pandemic) people have had to delay or forego necessary medical care. During the period covered by Avalere’s analysis, the percentage of U.S. adults who said they delayed or put off care was at its highest level. Forty-five (45) percent of people reported they either didn’t get or put off getting necessary care. In late January and early February 2021 that number went down, but more than a third of U.S. adults still reported they put off getting care.
The National Center for Health Statistics (a unit of the CDC) is the agency that developed the care-related questions for the Census Bureau’s survey. On their (NCHS) website, they also provide a further breakdown of responses by age band. Because they basically do ten-year age banding from 18-29 all the way up to 80+, the display gets a bit busy:
You can see that the three oldest age bands (60-69, 70-79, and 80+) pretty much have lower rates of delayed/deferred care.
I haven’t seen a comparable analysis involving the non-Medicare (under 65) population. But based on the Household Pulse Survey data, I’m hypothesizing any such study would show a volume and extent of delayed/deferred care for under-65 insureds that’s of even greater magnitude than what Avalere found in its analysis.
An analysis of Medicare fee for service claims during the first three months of the pandemic (March thru May of 2020) showed a reduction in the number of claims per beneficiary – as much as 40 percent compared with the previous year. This wasn’t surprising given findings from the U.S. Census Bureau’s ongoing Household Pulse Survey regarding percentage of U.S. adults who reported they had to forego or delay necessary medical care as a result of the coronavirus.
During the spring of 2020, nearly half (45%) of U.S. adults reported deferring or delaying care. In February 2021, the number is down, but it’s still alarmingly high with over one-third of adults reporting they forewent or delayed necessary medical care. These rates were the lowest for older Americans — those covered by Medicare – which suggested that a similar kind of analysis of the non-Medicare population would show an even more dramatic reduction in utilization of medical care.
Fleshing out the Household Pulse Survey
For starters, let’s simplify the busy age-band display I cited above by using only three age bands: 18-44, 45-64, and 65+. Why these three?
- For starters, the 65+ more or less maps out to the Medicare-covered population (yes, I know, you can qualify for Medicare as an under-65 in certain special circumstances, especially if you’ve been on SSDI for two years, but let’s save the nitpickery for another time).
- And the split of the under-65’s at age 45 corresponds to a divide that I– and others who have been active in the disability-insurance space– have seen over the years: around that age, the number and intensity of health-related issues people have to deal with (and the likelihood those issues will keep them from working) goes up pretty noticeably.
That said, here’s what we see:
During the early months of the pandemic in the spring of 2020, the 45-64’s had a considerably higher percentage of foregone/delayed care than the 65+’s. Interestingly, since August, both the 18-44’s and the 45-64’s have had roughly similar percentages. And, from around June 2020, there’s been an especially noticeable gap between the 65+’s and their younger counterparts; it’s been the latter who are more likely to have deferred care.
Percentage of workers who’ve foregone or delayed necessary medical care by work status
The Public Use Data Files allow you to take a more fine-grained look based on whether or not, in the prior week, the survey respondent was working or not working, and if the latter, by reason (retirement, job loss, caregiving, own medical condition, etc.). I found that the “not working” segment subdivides most meaningfully into two sub-groups: retirees and people out of work for all other reasons (most noticeably job loss, caregiving, own medical condition). So, using the three categories of working, not working (retired), and not working (not retired), here’s what we saw:
A couple of observations:
- Not working (retired) are the lowest percentage. That’s consistent with what we see above for the 65+ age band.
- Not working (not retired) are the highest percentage. The Household Pulse Survey has been asking people whether or not they’ve got health insurance, and if so from what source. I haven’t looked at that dimension, which I suspect may be relevant here. It could be that lack of insurance may be the main driver. But for the sub-population here that does have coverage (which I’m guessing would most likely be Medicaid) if the percentage that have foregone/delayed care is still high, that would suggest something else (what, I’m not sure).
- The “working” group is in the middle. And it’s worth looking at it in age-band terms.
So, doing that (looking at the working population by age band):
Some helpful context: The 65+ group is relatively small (overall less than 10% of the total working population surveyed). The 18-44’s are the largest group– just over half– and then the 45-64’s, at just under 40 percent.
Looking at these numbers (especially for the two under-65 age bands) through the lens of almost 20 years in the disability-insurance business, I find myself thinking: This is like what you see prior to the approach of a tsunami, where the water retreats out of the harbor, only to come back in full force, and then some, with the big wave.
There are consequences to deferred care.
If you’re in the industry, and if you have access to actual incidence trend data (of course you do) and are willing to share insights (you probably aren’t; our industry is notoriously hesitant to share any data, even when it makes sense to do so– sigh), I’d love to hear from you.
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