Interview Highlights: Understanding the Pandemic’s Spillover Effects on Non-COVID Patients With Julius Chen

Interview by: Makena Binker Cosen (CC ‘21)

Cover illustration by: Arooba Ahmed (CC '23)

---

Julius L. Chen, PhD, is an Assistant Professor of Health Policy and Management at Columbia University.

---

​The following is a heavily condensed version of the full interview. If you're interested, read more here.


What inspired your current COVID-19 research project?

During the early days of the pandemic, I felt myself wishing there was something I could do to help. Then, I started thinking, maybe there’s a way we can apply policy or economics to evaluate ongoing responses to coronavirus.

Towards the end of March, I noticed that many elective procedures and other in-person visits were being postponed or cancelled for non-COVID patients. That got me thinking about the many indirect effects the pandemic is having on healthcare. Also, people who used to get routine care were avoiding healthcare settings due to fear over potential COVID exposure. Meanwhile, people still need treatment for heart attacks, strokes, and cancer. Overall, there has been a tremendous shock to the healthcare system, for both patients and providers.


What are your current project’s research aims?

1. To identify the potential effects of delayed or forgone treatments on the short- and long-term health outcomes of non-COVID patients, such as cancer and transplant patients. How do their outcomes compare to patients who did not have their treatments delayed? 
2. To understand what is happening to in-person primary care utilization. A recent study from The Commonwealth Fund finds that in March, there was a large drop in in-person ambulatory care visits of nearly 60%, which has been followed by a gradual rebound, but volume is still about 30% lower than pre-pandemic levels. As the months progress, how much of a rebound will we see? How long will it take to return to pre-COVID levels? In the meantime, what is happening to patients that are not going to the hospital for heart attacks, strokes, or appendicitis? Are they dying at home? People should seek their clinicians for needed care. If they are waiting for their condition to become very serious, the remaining treatment options will be more complicated than they would have been had patients gone to the hospital sooner.
3. To figure out what is responsible for excess mortality that is not attributable to COVID-19. In New York City, for example, the actual number of deaths has been much higher than estimates based on seasonal projections, and roughly 80% of these “excess deaths” are attributable to confirmed or probable COVID cases. But that leaves about 20% of excess deaths that are still unaccounted for.

​

What challenges do you expect to encounter?

The first challenge is figuring out what data is available. We are fortunate to live in an era with robust data collection capabilities. Still, the pandemic and its effects are moving so quickly, and there is lag between when data is collected and when it becomes available for researchers. Also, many data sets are not publicly available, though the CDC is one source of public data that can potentially be used to quickly produce actionable findings.

​To specifically study health outcomes among non-COVID patients, we could also use electronic health record data from hospitals. The approval process to access that data can be a bit lengthy. However, once we find a willing partner to provide health record data, analyzing it and developing preliminary results should only take a month or two. 

The second challenge is methodological. Let’s say we identify some effect on health outcomes for non-COVID patients — how do we know it was caused by a delay in their treatment and not by other factors, such as sudden unemployment or the loss of health insurance? There are many confounding factors that make it tricky to isolate a particular causal relationship.
​

Moving forward, what do you think the broader impacts of the pandemic will be?
​

First, the pandemic has been a big shock to health systems’ finances. Many hospitals are heavily reliant on elective procedures for revenue; those have now been postponed or canceled. As hospital visits begin to rebound, the big question to consider is: What will hospital finances look like, and how will hospitals recover lost revenue? Will some hospitals be forced to close?

I also think that the pandemic will incentivize employers to invest more heavily in worker health. They are seeing how important it is to have a healthy workforce with stable 

insurance coverage. The possibility of another economic downturn, like what is happening now, will challenge employers to reconsider how they structure their benefit packages and their general approach to worker health. If anything, we now see the importance of innovations that employers are testing to encourage improved quality and efficiency of care, and to restructure  the way that employee healthcare is delivered and paid for.
​

All of this is going to play a very big role in the 2020 election. I’m very interested in seeing how candidates talk about U.S. healthcare reform in light of what is happening with COVID-19. It is critical for people to have adequate and stable health insurance coverage, in case something like this happens again. In the United States, we have a system where adults under the age of 65 are largely dependent on their employers for insurance coverage. With the pandemic, a lot of people who lost their jobs also lost their insurance coverage. Hopefully, this has generated more momentum towards expanding affordable health insurance coverage options for Americans.