Professor Lucy Hodder discusses how the COVID-19 pandemic has shifted the healthcare landscape for New Hampshire consumers, healthcare providers, and government policy makers. Produced and Hosted by A. J. Kierstead
Learn more about UNH Institute for Health Policy and Practice recent event on "The Shifting Health Care Landscape" at https://chhs.unh.edu/institute-health-policy-practice/focal-areas/health-law-policy
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Legal topics include pandemics, healthcare, health policy, government relations
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A. J. Kierstead (Host):
How has New Hampshire's healthcare system handled COVID-19 and what does it look like going forward? Professor Lucy Hodder joins me to discuss. This is The Legal Impact presented by the University of New Hampshire Franklin Pierce School of Law. Now accepting applications for JD graduate programs and online professional certificates. Learn more and apply at law.unh.edu. Opinions discussed are solely the opinion of the faculty or hosts, and do not constitute legal advice or necessarily represent the official views of the University of New Hampshire. So, Lucy, there was a recent event held by the University of New Hampshire Institute for Health, Policy and Practice titled The Shifting Healthcare Landscape. I think shifting is a gentle way of summarizing the situation in the last six months. How has New Hampshire's healthcare delivery system handled it?
Lucy Hodder:
So, A.J. it's a really interesting look back, and it's hard to believe how long we've been in this. I was last with you talking about the impending pandemic, back in February and how the state was going to respond. We didn't know back then, just what was about to hit us. And what's interesting about the healthcare system is we had a lot of weak points, a lot of pain points, we like to call them, before the pandemic hit. We had very high healthcare cost structure in New Hampshire. We had rising premium costs, rising out of pocket spend, consolidation of our healthcare system, a real effort by many to address some of the social determinants of health, but not a very institutionalized, systematic approach to really shifting resources to address the issues that cause poor health.
Lucy Hodder:
And so, we had a lot of pain points in New Hampshire, a lot of great bright spots too, but some real pain points. And what we tried to do two weeks ago was to figure out, where are we with those pain points? What has shifted? What have we done well, what are we really concerned about going forward? And how has this pandemic and our response to it impacted our healthcare delivery system?
A. J. Kierstead (Host):
Let's start with the consumer end of it. I mean, how are consumers in the healthcare system handling this shift?
Lucy Hodder:
Well, what's very interesting is, remember these are consumers who were paying very high out of pocket costs, if they were insured through their employer, if they were not, they may have had access to other health insurance, which as we know, is complicated and difficult to determine. So, what we had was consumers who were all of a sudden hit broadside, not just by the fear of the impact of a pandemic, but the uniform and universal response at every level of our community to that pandemic. So, we talked last time about how a state can help protect from a public safety perspective, a true public health, public safety perspective, their residents. And that's what we tried to do in New Hampshire, we lifted up an emergency response system. We issued emergency orders to stay at home, to protect people in their leases, to ensure they had utilities, to allow for telehealth visits to physicians and providers that were paid, and the same way that they could be paid in person.
Lucy Hodder:
To relieve privacy standards, so you could access a continuity of care better, to make sure insurance companies were covering what was needed for the pandemic services. So, you had this huge response to try and make sure the public could stay healthy and safe. And we actually shifted the healthcare system overnight, through a series of federal and state responses that changed the way we access care and guess what happened to the consumers? The consumers wanted it, and they responded to it, and they have woken up universally in response to this pandemic. Right now, we know that consumers of healthcare and consumers in general, prioritize efforts to keep them safe of coronavirus above economic return to stability. So, really we are prioritizing staying safe, and what that means is we have consumers who we always knew were there, concerned about the healthcare delivery system, but now we really know they're engaged.
Lucy Hodder:
They are thinking about healthcare. They are thinking about public health. They are thinking about, as we learned two weeks ago, who is minding the store? Who is making sure that when there is a need, it turned out that this need was across all of our population, when there is a need for healthcare services and a need for a public health supports, that they are there. And that is what we've seen as a major shift from the consumer perspective. In general, we had a wonderful consumer expert from Altarum Health, her name is Lynn Quincy, and she talked about the results of a survey that they did of consumers. And we learned that consumers really care about healthcare affordability. It is their number one issue of state residents on both sides of the political aisle. They want healthcare to be affordable, and we've learned about what that means when you're somebody who's been impacted by the coronavirus or you need testing, or your family needs support, or you get coronavirus and you need healthcare.
Lucy Hodder:
Affordability is on everybody's mind. Also, trouble with paying medical bills and dealing with medical drugs and their variable costs, and their cost in general, is a huge issue for consumers. They also don't trust the system and we have had a real issues with trust at every level of our system, for all kinds of reasons. But right now, what we get back to is the people they trust for their direct care providers and that is really important. It's also really troubling when there's disruption in their care, we've had a huge impact on primary care ability to sustain their delivery system. Primary care are underpaid in our system as compared to specialty care, significantly. There's been a huge burden on them, both by the demand for primary care services, but this telehealth access and everything else has made a number of primary care offices unsustainable.
Lucy Hodder:
So, we've really seen a shift in primary care, and it is going to have a devastating impact on our public health system and our healthcare system going forward. And consumers, again, want to know, who's minding the store? Who is looking out for the fact that they are now on their fourth primary care provider since the COVID-19 crisis started, what is happening there? Why is that happening? If they are now accessing mental health services online, so that they can have the support they need during this very stressful time and their mental health provider is the same one that they were seeing in person before the crisis, and is now being paid on parity during the crisis. What happens in three weeks when that emergency order is up and the carriers are no longer reimbursing at those rates, and they lose the ability to access their mental health provider online, but they're too scared to go into the office or they have issues with transportation, et cetera? Those are the kind of things that people are concerned about and they want to make sure that we are addressing as policy makers.
A. J. Kierstead (Host):
You've touched on it a little bit, but there must have been some severe pain points for all parties of the healthcare system as a whole, with a major event like COVID-19, you mentioned telehealth, offices no longer able to be open or very limited status. What were some of the goings on with that?
Lucy Hodder:
Yes. And we talked about, me and Trish Riley from NASHP, which is the Academy of Health Policy folks, and she was talking about how states are trying to respond. One of the big question is, how are states going to distribute the COVID relief funds while they're worrying about state budget cuts? And we're seeing that play out in New Hampshire right now, we've got a lot of federal relief, who's it going to go to? Our hospitals are desperate for the resources, especially those who've had an overburden of COVID patients in their hospitals on the inpatient side. And by virtue of the fact that hospitals and other outpatient systems have lost all of their revenue from voluntary elective procedures, and they are suffering as a result. We have caregivers in the healthcare system who have stayed at work throughout this crisis while others have been out of work or receiving unemployment to support them.
Lucy Hodder:
And so, we have a very stressed system. So, distributing the COVID relief to businesses, healthcare providers, and the people who need it is a real concern. We've done a job through the GOFERR, the governor has taken control of that situation in New Hampshire, to the chagrin or not, of the state legislature and is getting the money out the door, which he has to do in a very short period of time. But at the same time, the worry about the state budget is real. How is that state budget, with the loss in revenue, going to be replenished so that it can continue to pay for the needs that the legislature has budgeted. Many to our most vulnerable citizens.
A. J. Kierstead (Host):
Yeah. I mean, specifically, what do you think the role will be for the state government going forward? Is it a lot of playing by ear and planning for the worst? Is it, we just got to get the money out the door because things are so bad right now with the economy being shut down, what do you predict?
Lucy Hodder:
Well, we could do an entire session on the civics 101 that has occurred. I would say civics, maybe, 105 that has occurred, who has the authority to do what in a crisis, given the emergency powers, et cetera? But the governor's executive branch has taken control of the federal relief dollars. They are using quasi-state agencies and charitable foundations to help distribute to nonprofit providers. They are using an oversight group to help distribute to healthcare providers. They are actually using the DRA, Department of Revenue Administration, to help to distribute to Main Street. So, there are a number of different ways they're trying to distribute the funds quickly. I think the states right now, the legislature, is dealing with how to pass legislation to implement more permanently those solutions that worked well during the crisis, but might be eliminated at the end of the emergency.
Lucy Hodder:
So, they're really struggling with, "All right, how are we going to continue telehealth in a way that patients have now become accustomed to, and that works? How are we going to make sure that the professionals who were freed up from certain licensing regulations to work across state lines, or otherwise, can continue to provide those services in a quasi-emergency fashion? And how are we going to make sure that our systems are sustainable going forward?" One of the things that we really learned in New Hampshire is that it's taken a number of convening entities to try and manage this crisis. We've had Crisis Standards of Care Commission. We've had a number of governor initiated commissions, looking at the overwhelmingly disproportionate impact of COVID on our underserved populations, our elderly in our nursing homes, as well as our people of color in the state of New Hampshire, and why that is.
Lucy Hodder:
So, we have a number of different ... An equity group looking at that. We have now a group looking at police brutality issues. We have a group looking at a number of different things that have arisen during the COVID-19 crisis, that really require some oversight, information and transparency. And I just cited to very different groups, so I don't mean to put them in the same basket, but what we know is that an emergency breeds a response and a need for stakeholder engagement. And we know that in our healthcare system, we have a smattering of efforts to engage in an oversight of the system itself, so we can know who is minding the store, but we haven't figured out in New Hampshire, a very good process for that. We have incredible providers. We have incredible advocates. We have now a very engaged population, but we don't have a system of minding the store that can really address these issues in a meaningful way, going forward. So, that's something that our legislature and the governor are struggling with.
A. J. Kierstead (Host):
Briefly, before we wrap, our previous episode where we talked about the state being ready for an emergency like this. How do you feel like those plans played out? Did it work out the way they predicted?
Lucy Hodder:
So, I don't know if anybody could have predicted any of this, but we do have a very strong emergency operation center and it took a while to activate, probably longer than I would have recommended, but it was activated in a really intensive way. All of our public health networks participated, safety, the new Commissioner of Health and Human Services jumped in with both feet and has just been a tremendous leader, Lori Shibinette, during this process. And really, with a lot of support throughout the agencies, worked through some really tough issues. The governor has been churning out executive orders and been on the job 24/7 since the beginning of March, when this first hit. I think we were overwhelmed by the impact on our nursing homes and our older adult population. It should not have been unpredictable given how little we have supported that community, by in terms of delivery system supports and community supports.
Lucy Hodder:
So, we really have some work to do despite some fantastic providers, really making an incredible effort to care for our older adult populations. We have also seen some significant closings, like we just saw the closing of Crotched Mountain, but I do think the state was able to respond. Our hospitals jumped in, we had a Crisis Standards of Care Commission that was looking at mental health, long-term care. What are the right care patterns in a crisis like this? The hospitals did work together. Again, some exacerbation of some of our real issues, our public health networks aren't equivalently funded, nor are they equivalently staffed or resourced, real problem in this crisis.
Lucy Hodder:
We don't have a lot of past patterns of collaboration amongst providers and transparency to patients about that collaboration. We learned that that's necessary. We're going to figure out how to do that in the future. So, a lot of weaknesses in our system were exacerbated, but at the same time, I think we learned from the pandemic that we have the tools in New Hampshire to learn from what we did and to make sure we respond in the future. I will tell you that, overall, if you look across the country, knock on wood, we have had a pretty good outcomes in New Hampshire around our infection rate. And we have a very engaged population around the social distancing and prevention, which has saved us all.
A. J. Kierstead (Host):
Thanks for listening to The Legal Impact presented by UNH Franklin Pierce School of Law. To help spread word about the show please be sure to subscribe and comment on your favorite podcast platform, including Apple Podcasts, Google Play, and Spotify.
