The past two months of claimsdata tell a dramatic and sometimes heartbreaking story.

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It's a time period that will go down in history as among themost extraordinary any of us have ever experienced—and hope neverto experience again. Individually, we have had to make majoradjustments to our daily lives due to lockdowns and stay-at-homeorders meant to blunt the spread of the novel coronavirus and thepotentially deadly disease it causes, COVID-19.

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But while some of us have had to endure disruption, manyindividuals have been on the front lines, working essential jobs innursing homes, as commercial drivers, and in grocery stores. As athird-party administrator for the health plans of many labor unionsand essential workers in the epicenter of the coronavirus outbreak– the New York tri-state metro area – we have a unique view of theimpact of COVID-19 on these groups.

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Related: Look for the good: How brokers and consultants areweathering the pandemic

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Looking at these groups' health claims in recent weeks showsdrastic upheaval. They have experienced significant changes in thedelivery of medical care and the types of services required,changes such as the cancellation of elective procedures, a rapidtransition to virtual health care, many requests for COVID-19diagnostic testing, and the need for sometimes lengthyhospitalizations.

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These claims tell a story that may be useful as self-funded employer groups begin to understandcost/utilization trends. Right now, several of our clients areseeing significant cost impacts. We are finding that COVID-19claims have hit employers somewhat haphazardly. Some groups haveexperienced very few cases while others have had a relatively highvolume. This is reflected most visibly in hospital stays.

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Among our findings based on 1,431 COVID-19 related claims inMarch and 3,921 COVID-19 related claims in April, processed throughthe first week of May:

  • COVID-19 claims increased 174% from March to April.
  • Meanwhile, overall claim volume was down 40% compared toJanuary and February 2020.
  • Diagnostic testing claim volume rose 67% from March to April,and COVID-related telehealth claims rose substantially in thesame timeframe.
  • 10% of all COVID-19-related hospital claims were for severesepsis and respiratory failure, with most patients requiring an ICUand ventilator for at least part of their stay. Average costs forthese cases ranged from $100,000–$300,000.
  • Another 40% of cases were severe but did not require aventilator, though a few needed the ICU. These cases ranged inaverage 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 hospitalfloor, without a ventilator, and typically had a diagnosis ofsevere pneumonia.

With the caveat that these data are limited to our clients'member population (primarily working-age individuals between theages of 20 and 55), they provide a snapshot in time of how membershave altered the way they access health care and could provide awindow into how health care access may change as we move past theinitial disruption caused by the pandemic.

Considering thefindings 

We believe overall claim volume was down 40% because of a combination of factors: elective proceduresthat have been postponed by the hospitals, fewer accidents, anddelayed care. For providers, specialties such as ambulatorysurgeries and anesthesiology have been impacted the most, whichcorresponds with the suspension of elective procedures in the NewYork-New Jersey area. In contrast, we saw that internal medicine,family practice, emergency medicine, and social work providers wereless affected by the pandemic, which could be due to either theirtransition to telehealth or the continued need for urgent care.

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Many of our self-funded groups have made special accommodationsto support their members' health and safety through COVID-19, whichis their top priority. Our clients have quickly adopted totelehealth. Prior to the pandemic, some client groups did not havewell defined telehealth or virtual health benefits. In the face ofthis emergency, many of these clients have moved quickly to add orclarify those benefits. Some have also added flexibility aroundprior authorization and medical management requirements. Also, anumber of groups are now providing onsite antibody testing to givemembers better information about prior exposure as they prepare toreturn to work.

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Even at the epicenter of the pandemic in this country, our mostrecent claims data are showing some early indications of recovery.Within the past couple of weeks, we have seen fewer COVID-relatedclaims and more typical pre-authorization requests like that forroutine services such as colonoscopies and for certain electiveprocedures such as upper GI studies. In the next few months, wewill continue to monitor claims as they begin to normalize evenmore and share findings with our clients to aid them in reviewingthe full impact of COVID-19 on their membership and on their healthplans as they prepare for the future.

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Michelle Zettergren is the President of MagnaCare, adivision of New York-based Brighton Health Plan Solutions,which partners with self-funded health plan sponsors to buildhealth care solutions.

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