Below is a complimentary Demography Unplugged research note written by Hedgeye Demography analyst Neil Howe. Click here to learn more and subscribe.

Doctor Appointments Plunge Amidst Pandemic   - 10 9 2020 8 00 06 AM

Since the coronavirus pandemic hit, the amount of preventive care Americans are getting has plummeted. All kinds of preventive procedures, particularly more invasive procedures such as colonoscopies and mammograms, are down, with few signs that the deferred care will be made up. (The New York Times)

NH: When the Covid-19 pandemic and lockdown first hit, most U.S. experts foresaw a large--and perhaps even overwhelming--surge in demand for healthcare services. Early on, one major goal of "transmission suppression" was to prevent hospitals from being burdened by so many Covid-19 patients (as happened for a while in Italy and Spain) that insufficient capacity would itself drive up the Covid-19's mortality rate.

Today, six months later, healthcare providers have radically revised their expectations.

Yes, the pandemic has clearly triggered an obvious growth in the demand for treatment of Covid-19 itself and its related comorbidities. This demand preoccupied large American providers in April and May during the first and worst surge in deaths. Ever since, that demand has ebbed. The decline happened in part due to a falling infection rate (which was almost certainly much steeper than the fall in the official case count since so few people were being tested early on). It happened as well due to the discovery by physicians that there are often more effective and lower-cost treatment alternatives to ICU admission and ventilators.

On balance, then, it is fair to say that the pandemic's direct burden on healthcare services--given the current infection and mortality rate--is less than what providers expected.

The even-bigger surprise, though, has been the huge drop-off in visits for provider services not related to Covid-19. After falling off a cliff in April, these visits have rebounded but remain substantially below where they were pre-Covid. In retrospect, it should have been obvious that many Americans would be avoiding contact with providers due to the risk of infections--but no one expected the fall would be this large. Overall, through Q2, the overall drop in healthcare spending has exceeded the drop in total personal spending.

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The biggest drops have been for invasive and non-essential or non-time critical services. Routine dental care is a prime example. According to Peterson-KFF, dental services show the deepest YoY decline (-34% by June 19-20, the latest data available) of all basic types of healthcare. Needless to say, the American Dental Association has "strongly objected" to the recent WHO recommendation that people put off dental cleanings and other routine visits until Covid-19 infection rates subside.

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The Commonwealth Fund, which tracks out-patient physician visits, reports that while there has been a strong recovery since April, ambulatory visits by late August are stabilizing at about 10% below the pre-Covid baseline. These visits include telemedicine visits. When you break these trends down separately, in-person visits are down by 16%. Which means that telemedicine--which is now doing very well--is making up for a good share of the in-person shortfall.

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By medical specialty, the only field that has risen since last winter is dermatology. This may be because dermatology visits are typically seasonal: rising in the summer and falling in the winter. Most of the other fields that have suffered the least decline are either noninvasive (e.g., ophthalmology) or fairly urgent (e.g., oncology). Further down the list, starting with many types of surgery, you get to care that is invasive (e.g., otolaryngology) or nonurgent (e.g., behavioral health).

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One type of visit that combines extreme invasiveness with lack of urgency is for a colonoscopy. As the NYT story notes, colonoscopy visits almost ceased entirely in April and were still down nearly 40% in July.

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Looking back at the Fund data, we notice that pediatric visits have suffered one of the biggest declines. This could be because parents regard visits for their children for such purposes as vaccines to be less-than-urgent. Indeed, according to data from the Health Care Cost Institute, vaccinations for HPV, Meningitis, and MMRV (measles, mumps, rubella, and chicken pox) are down nearly 40% through July. This fall worries healthcare experts, who note that childhood vaccination rates were already declining due to the influence of antivaxxers well before the arrival of Covid-19.

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The overall tone of the NYT story strikes me as needlessly alarmist. To be sure, the anti-vaxxers are wrong. High vaccination rates for childhood diseases clearly save lives by providing population-wide herd immunity.

But a delay of six months or a year for some kids is not the end of the world. What's more, U.S. healthcare specialists recommend levels of routine testing and monitoring which, in the opinion of many in-depth studies, exceed any useful cost-benefit threshold. Rather, they are designed to funnel more patients into further testing and procedures that generate more business. The privileged role of specialist professions in setting these levels helps make the American healthcare system the most expensive in the world by far with few if any commensurate advantages in morbidity or mortality. (For the now-classic summary of this argument, see Over-Diagnosed by Dr. Gilbert Welch, et al.)

For the time being, IMO, we can trust the common sense of most Americans to assess for themselves marginal costs and benefits of routine care during an epidemic. 

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Neil Howe is a renowned authority on generations and social change in America. An acclaimed bestselling author and speaker, he is the nation's leading thinker on today's generations—who they are, what motivates them, and how they will shape America's future.

A historian, economist, and demographer, Howe is also a recognized authority on global aging, long-term fiscal policy, and migration. He is a senior associate to the Center for Strategic and International Studies (CSIS) in Washington, D.C., where he helps direct the CSIS Global Aging Initiative.

Howe has written over a dozen books on generations, demographic change, and fiscal policy, many of them with William Strauss. Howe and Strauss' first book, Generations is a history of America told as a sequence of generational biographies. Vice President Al Gore called it "the most stimulating book on American history that I have ever read" and sent a copy to every member of Congress. Newt Gingrich called it "an intellectual tour de force." Of their book, The Fourth Turning, The Boston Globe wrote, "If Howe and Strauss are right, they will take their place among the great American prophets."

Howe and Strauss originally coined the term "Millennial Generation" in 1991, and wrote the pioneering book on this generation, Millennials Rising. His work has been featured frequently in the media, including USA Today, CNN, the New York Times, and CBS' 60 Minutes.

Previously, with Peter G. Peterson, Howe co-authored On Borrowed Time, a pioneering call for budgetary reform and The Graying of the Great Powers with Richard Jackson.

Howe received his B.A. at U.C. Berkeley and later earned graduate degrees in economics and history from Yale University.