Health debt – the post-pandemic trauma

by TheEditor

Categories: Medicine, Mental Health

The delay or disruption of healthcare services due to the COVID-19 pandemic has created what some have referred to as a “healthcare backlog.” This refers to the accumulation of health needs that were unmet or postponed during the pandemic, which now need to be addressed. See also pandemic lash.

This backlog includes everything from delayed or cancelled elective surgeries to missed routine screenings and vaccinations, postponed mental health treatments, and disruptions in chronic disease management. These delays can have serious impacts on patient health, leading to more severe disease outcomes and even increased mortality in some cases. The COVID-19 pandemic has had a profound impact on healthcare systems around the world, leading to substantial backlogs in various types of medical care. This has been caused by the need to prioritise the treatment of COVID-19 patients, coupled with cancellations and postponements of non-emergency procedures to prevent further spread of the virus.

Health service systems faced the challenge of addressing the long-term health impacts of COVID-19 itself, including what’s been referred to as “long COVID” or post-acute sequelae of SARS-CoV-2 infection (PASC). [AC_PRO id=913]

Health-debt

The concept of health-debt is not recognised elsewhere as a term. I therefore coin the term. Internet searches refer to ‘health backlogs’. Such terminology misses the non-linear and often irreversible impact of missed interventional and maintenance treatments. Backlogs are a simple numbers ‘game’ – health is not. Waiting lists which are about numbers, exist somewhere on spreadsheets. But think; spreadsheet numbers do not – cannot – give any insight into the loss of life-expectancy or the scale of suffering.

In a rough and ready somewhat inaccurate analogy, if we compare an individual’s health to a financial loan, the estimated life-expectancy can be considered as the repayment period of the loan, and the health service interventions or treatments can be likened to the scheduled payments. The ‘loan’ in this case is the initial health and life expectancy that an individual is born with, and the ‘interest’ that accumulates represents health issues and diseases that may develop over time. Health service interventions or treatments (the payments) are designed to ‘pay down’ these health issues (the accumulated interest). If these ‘payments’ are missed or delayed, the ‘interest’ could compound, leading to increased health losses or decreased life expectancy. Therefore, consistent and timely health interventions are crucial for managing health issues and maintaining the estimated life-expectancy (from birth).

In servicing a financial debt with interest, one can catch up by just making good on payments missed, perhaps with some penalties. The loan does not simply multiply five or ten-fold. However, with health problems, loss of service can lead to rapid acceleration of illness pathology. Having three shots of intramuscular Vitamin B12 to catch up on missed doses, does not mean that the effects of pernicious anaemia on the spinal cord would reverse to where it was left off. The situation would remain dramatically worse, even if you had ten injections in of B12 in short succession. In the case of treatments for heart conditions, a person could be dead by the time a slot arrives for them on a waiting list. With some mental disorders, like untreated or under-treated depression, suicide could have happened before health services return to help.

With health issues – missing out on treatments allows ‘escape’ of pathological processes, which then accelerate the course of illnesses. So – a heart problem could be five times worsened for someone after a year of ‘missed care and treatment’, compared to if they did not miss at all.

It should be noted that the above is a simplification. The actual dynamics of health care and life expectancy are influenced by a variety of other factors such as genetics, environment, lifestyle, and socioeconomic status.

But let me bring this home by way of another analogy. Your hypothetical car (with an internal combustion engine) needs a service every year or at 10,000 miles whichever comes first. If ‘you’ regularly miss services then you could expect trouble ahead because lack of oil changes will lead to sandpaper-like  and sludge effects on moving parts in the engine. Your car might have a good life-expectancy of say 100,000 miles, when serviced regularly. Missing half of the recommended annual services, does not mean that you’d get a minimum of 50,000 miles. Your car’s engine could well seize up and die at 30,000 miles. The cost of repairing engine damage will be far worse than the total cost of services you missed. Catching up by having three services in one year for the three you missed over the previous three years, does not help. Why? The damage has been accumulating on a path towards catastrophic failure. Three services in one year just does not reverse the cumulative damage.

Impacts

Health impact

The healthcare backlog created by the COVID-19 pandemic is not just about the immediate financial costs, but about the ongoing and potentially irreversible impacts on people’s health.

The  health-debt that accumulated during the pandemic isn’t just a matter of restoring funding levels to pre-pandemic norms. The pandemic has created a situation where many illnesses and conditions have been left untreated or inadequately managed for extended periods of time. This means that the disease burden in the population may have increased, and people’s health may have deteriorated beyond the point that would have been the case had they received timely care.

For many health conditions, early intervention is crucial to prevent progression of the disease and to minimise the impact on the individual’s quality of life. The delay in care may have allowed conditions to worsen, leading to more complex and costly treatments needed when care is finally provided. For example, cancers may have progressed to more advanced stages, chronic conditions like diabetes or cardiovascular disease may have worsened due to lack of management, and mental health issues may have escalated without timely intervention.

From a human perspective, the impact could be even more profound. People may experience decreased quality of life, increased disability, and higher mortality rates. Mental health impacts could also be significant, with increases in conditions such as depression, anxiety, and post-traumatic stress disorder and/or worsening of those pre-exiting conditions. The social and economic consequences of these health impacts could be far-reaching, affecting productivity, social stability, and overall well-being.

Financial impact

From a financial perspective, for services, this could mean significantly higher healthcare costs in the future. These increased costs could stem from several factors:

  1. Higher complexity of care:  conditions that have progressed may require more intensive and costly treatments.
  2. Increased demand for services: The backlog of care needs to be addressed, which means healthcare providers will need to serve not only their usual patient load but also the backlog of cases. This could necessitate increased hours, hiring more staff, or investing in new infrastructure.
  3. Long-term care needs: Individuals whose conditions have worsened may require long-term care or support, adding to the ongoing costs.
  4. Prevention and management: There may be a need for increased investment in preventive and management measures to try to mitigate the impact of the backlog and prevent further deterioration of public health.

Addressing these issues will require strategic planning and considerable investment, not only to deal with the immediate backlog but also strengthening healthcare systems to be more resilient in the face of future challenges. The situation underscores the importance of continuous and comprehensive healthcare, and the risks associated with disruptions to care.

Catching up –  not easy

Hospitals are facing unique challenges, including workforce instability. These challenges are expected to impact procedural capacity and add incremental operating expenses. The combination of backlogs and reduced effective hospital capacity could impact both providers and patients for years to come​1​.

In terms of backlog resolution, it is estimated that around 80 percent of deferred procedural care will ultimately result in cases. For the United States to work through the excess surgical demand, it would require hospitals to operate at 120 percent of historical volumes for ten straight months, but this is unlikely due to limited provider capacity. A more realistic scenario is if health systems were to operate at an average 10 percent increase above baseline volumes, in which case, around 20 months would be required to work through the pent-up demand from 2020​1​.

The McKinsey report emphasised the importance of proactive measures to address the backlog, including engaging patients and providers to instill confidence, optimizing the use of existing capacity, and reimagining clinical operations to become significantly more efficient​1​. Some suggested actions include:

  1. Proactively engaging patients and providers to reduce unnecessary deferral of care. This could involve identifying patients who have delayed care, communicating with them about enhanced safety measures and protocols, and engaging them via virtual care channels​1​.
  2. Increasing effective capacity to optimize the use of existing resources. This could involve extending operating room hours, scheduling cases on the weekend, and optimizing operating room block time allocation​​.
  3. Utilizing advanced analytics to forecast potential patient demand and manage real-time system capacity, enabling more agility in the response to fluctuating volumes​​.

Specific data on the current status of healthcare backlogs, including exact numbers and types of delayed procedures, as well as the time expected to clear these backlogs, were not readily available. An insightful long read is Review of mental health crisis services in Northern Ireland.

Real world experience

As the pandemic took hold from around March 2020, I witnessed how patients suffered with increased anxiety and other forms of social stress. This led to worsening of mental conditions such as anxiety disorders, depression, and schizophrenia (among others). Many people were unable to have proper reviews of their progress. Services were unable to respond to the needs of patients in a timely way. Psychiatrists seemed to rely more on pills, as face-to-face support/counselling became more difficult. Many resorted to polypharmacy. Some of the worst kinds of polypharmacy and excessive use of medications is seen in disorders of intellectual development (aka learning disabilities).

I am told that ‘in defence’ psychiatrists had to do their best with medications as ‘counselling’ and hands-on support were in short supply. Statements ‘in defence’ seems to mean that lesser standards of care became more acceptable. The General Medical Council said, “We recognise that in highly challenging circumstances, professionals may need to depart from established procedures in order to care for patients and people using health and social care services. Our regulatory standards are designed to be flexible and to provide a framework for decision-making in a wide range of situations.

Telephone and video conferencing support did not work well, according to reports I received from patients.

Now in the post-pandemic period, I am witnessing patients who have not had medication/treatment reviews for between 9 months and 3 years, with an approximate mean of around 14 to 18 months. Some have remained stable but many have become far worse. It is now difficult to address the degrees of mental health problems I am seeing.

WHO

The World Health Organisation (WHO) conducted three pulse surveys between February 2020 and November 2021, which revealed that 92% of countries reported some form of healthcare disruption during this period. Initially, disruptions were mainly observed in hospital services, dental care, and mental health services. However, as the pandemic progressed, backlogs primarily affected primary care and emergency care. The surveys also revealed that the average disruption of services was still at 26%, indicating ongoing challenges in healthcare delivery​1​.

The WHO has suggested several key policies to address these backlogs, including:

  1. Hiring more health workers and health staff, improving working conditions, and providing mental health support and better pay.
  2. Managing capacity and productivity by extending hours of care, introducing financial incentives to clear backlogs, and expanding access to telehealth services.
  3. Upgrading health facilities and investing in primary and community care, while expanding home care and rehabilitation services​1​.

Many countries have been lagging in the above.

Concluding remarks

Health-debt is not a widely recognised concept at this time. Most systems recognise only ‘backlog’; a term that does not address impacts on individuals’ health or service provision.

Debts in service provision can expectedly lead to acceleration of pathologies among those suffering with health conditions. Health services may also have suffered irreversible or difficult to reverse structural issues.

Health-debt can lead to  serious loss of life-expectancy and exponential costs for health services.

Psychiatrists – being medical doctors – have no real defence for polypharmacy in the pandemic period. There is an idea that ‘morally’ they could not just let people suffer. However, the harvest of doing what was morally right is coming home. Polypharmacy is wrong – it was always wrong. The scale of suffering from polypharmacy – often involving unlicensed use of medications – will probably never be known. No one seems to have the will to evaluate the harm that may have been done.


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