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June 27, 2022

Researchers react: Roe is overturned

Daily Briefing

    Radio Advisory's Rachel Woods invited Advisory Board experts to share their perspective on the biggest impact that overturning Roe v. Wade will have on providers, purchasers, and life sciences companies. Plus, experts share what they are watching for as the health care industry adapts to a post-Roe reality.

    Check out our new resource page for post-Roe implications for health care

    Below is a lightly edited transcript of the episode.

    Rachel Woods: Hey there, it's Rae. By now, you've probably seen that the news is official—Roe v. Wade has been eliminated in the United States. And since the Dobbs v. Jackson decision was leaked a couple of weeks ago, Advisory Board researchers got a head start at trying to understand the impact that, that decision would have on health care stakeholders.z

    I've said this before, and I'm going to repeat it now, regardless of your personal opinion on the ruling, we are talking about unwinding 50 years of medical precedent, and that will have huge implications for health care business.

    And frankly, our industry is just coming to terms with what that new reality might look like. So today I wanted to invite Advisory Board researchers to share their take on the biggest impact that the elimination of Roe will have on the business of health care. I'll let them take it from here.

    Don’t get distracted by volumes. The business risks are much more than cost or revenue.

    Sebastian Beckmann, Quantitative Insights

    Beckmann: My name's Sebastian. As part of our work on the reaction to the Dobbs v. Jackson ruling, I've been part of the group working on what impact this could have on health systems. I'm usually on here as the quant guy or the data nerd, so I should probably be here talking about volume and revenue shift. I'm not going to do that. My team and I think the rule is going to create important business and operational risks for health systems. And we're thinking about those in three ways.

    First, we expect more patients to show up in the ED with symptoms from medical abortion, or self-administered care that previously wouldn't have occurred in the first place or would've gone to other settings where it could have been managed more appropriately. Clinicians in the ED will need to know how to care for and support those patients.

    Second, a new legal environment means that caring for those patients will come with legal risk for those care teams. That's a big workforce challenge. Clinicians are going to feel anxiety about how to care for patients within the legal binds of the law. And at the same time have to worry about criminalizing patients, including those who could be experiencing miscarriage.

    That's also a legal risk for your organization. Hospitals will need to adhere to new laws related to abetting abortion care, but they also need to provide appropriate care for patients or risk malpractice lawsuits. Here's the scary thing about all of these, even if you don't see a lot of patients or new patients, even a single event, can unsettle your staff, carry costly legal risks, or put your hospital in the spotlight for all of the wrong reasons.

    Furthermore, any one of them could generate unexpected legal or workforce costs that you're probably not prepared for. I underscore all of that, and this is coming back to the data nerve thing, because we don't think the total number of new patients in the ED or new patients with complications in your obstetrics units will be high compared to the volumes you're already seeing in those settings.

    All of that to say that volumes are a distraction. If you over focus on that, you'll miss the much bigger business risks I just outlined. And that's to say nothing about the human impact.

    The human impact is bigger than women seeking abortion

    Tara Viviani, Women's Health and Outpatient Care

    Viviani: Hey, everyone, I'm Tara and I research Women's Health and Outpatient Care at the Advisory Board. Specifically, I work on a team that's been involved in custom market sizing assessments for the various members that we serve.

    Regardless of what side of the Supreme Court ruling you may fall on personally, we all know that overturning Roe will decrease access to abortion. My team's still working on quantifying this, but we've found that nearly 32 million people of childbearing age may be impacted by newly limited access across the 13 states with trigger bans. And out of that population, thousands of pregnant people may find themselves seeking and unable to access an abortion, but that's not all.

    You have to consider that the other states expected to ban abortion are going to add even more abortion seeking people to this population facing access barriers. And don't forget, that's on top of the hundreds of thousands of people who are already facing gestational age limits and medication abortion restrictions.

    Now this all brings us to a reality where millions of people will have limited access and that's not a point of contention. What I do think is missing from the national conversation though, is a hard look at how additional access barriers will impact health outcomes. So first let me just acknowledge that this will impact more than just abortion seeking people. We may see more live births, vasectomies, tubal ligation, use of other preventive measures and more. But for the sake of time, I just want to focus us for now on the population of people who may become pregnant and seek an abortion.

    Studies show a moderate increase in total maternal mortality in states with greater abortion restrictions. But to understand the full impact of access changes on health outcomes, you really have to consider how decreased access creates three precedented alternatives for these patients.

    The first is they can travel for abortion services. The second is attempting a self-induced abortion. The third option is carrying an unintended pregnancy to term. And each of those pathways is associated with adverse health outcomes for these pregnant people.

    So first, traveling for abortion services—and I think it's really important to note that this is going to include people who need to travel for medication abortions that may now be banned in their state. Traveling farther for abortions is associated with delayed care, additional ED, follow up care and negative mental health outcomes. We also see that patients who travel farther for abortions have higher odds of visiting an ED in general or lower acuity outpatient sites that aren't even tracked as well in the data that we have available.

    The second—attempting self-induced abortion. We have to remember that self-induced abortion is actually one of the leading preventable causes of maternal deaths and morbidity globally, but in the United States in particular, we've seen that there is slightly higher ED visits related to self-induced abortion in Southern states with more restrictions.

    But that third pathway—carrying an unintended pregnancy to term. Unintended pregnancies are related to delayed prenatal care, higher risks of miscarriage, low birth weight infants, and severe postpartum depression, as well as down the line, higher instances of depression rates, suicidal thoughts, and physical and psychological violence too.

    For the low birth weight piece in particular, that's linked to several other downstream health impacts for infants. But studies show that states with greater restrictions have greater odds of infant mortality as well. Clearly there's strong evidence on all of these points and that these are outcomes we can expect, but we don't know yet what proportion of pregnant people are going to proceed down each of these three pathways.

    And you have to remember too, that provider, payer and other stakeholder responses will influence those choices. The scale of adverse outcomes is going to be dependent on how that shakes out.

    So my team's hard at work, sizing these impacts, but regardless of the final numbers we may arrive at, we already know that there will be negative health impacts for some pregnant people. Even if the total increase in these negative outcomes and in complex and adverse births is small relative to total volumes. It is still tragic.

    And remember where I started—it won't just be abortion seeking patients and their children who will be impacted by these outcomes. There will be a shift in downstream community care needs, and there will be a shift in care utilization patterns that is going to have an effect on all of women's health and on the health care industry more broadly.

    Autonomy over clinical decisions is in question—and it will have ripple effects across the clinical workforce

    Sarah Hostetter, Physician and Ambulatory

    Hostetter: I'm Sarah. I lead our research team dedicated to physicians and to ambulatory providers, so I spend a lot of time thinking about the physician workforce and the clinical workforce more broadly.

    My immediate reaction to the Supreme Court decision was thinking about the impact that this has on provider autonomy. We know that physicians and all types of clinicians really value their autonomy and want to be able to make the choices that they need to for their patients.

    The legal field for providers just got so much more complex. Imagine being a provider and seeing a patient and having to ask yourself the question, will I get sued for performing this procedure? Or will I get sued for not performing this procedure that might be medically necessary? It adds a whole other level to already complex decision-making processes. And I can't emphasize enough that a legal decision was just made that impacts the autonomy physicians have for their own care decisions and that we expect there may be more legal ramifications and decisions to come as a result of this—that will impact clinical care.

    The second thing that I've been thinking a lot about in the last two years, honestly, is the supply and demand for clinicians across the country. This ruling has the potential to shift where clinicians are willing to practice. And we've already seen that similar rulings or state level rulings have impacted where and how physicians are trained. Some physicians just can't be taught to do abortions in medical school because of where they are practicing or where they're training. We've seen some states that actually have to send their physicians to another state to learn how to do abortions in the course of their training.

    So we're already seeing this major impact to how physicians are trained that will be even more widespread. The other supply and demand question that I have is will we see any movement of clinicians in terms of where they are willing to practice and where they're not willing to practice?

    Before, in many states, you might have had the autonomy to decide where I want to practice within this state, if it aligns with my belief. So, I do want to be able to perform abortion, so I will work at somewhere that I can, or I don't want to perform an abortion,  so I'm going to choose a provider in my state that doesn't do that.

    That decision-making isn't there anymore, because we're going to see states where you have to choose, can I practice in this whole state or not? Do I feel comfortable performing medicine in this state or not? And I think that's going to exacerbate a workforce that already has supply challenges.

    And then the last thing that I've been thinking about is the fact that we already have an incredibly burned-out workforce. After the last two years of a pandemic, the workforce is tired. We're still in the middle of a pandemic. We're still seeing skyrocketing rates of provider burnout. And then we are going to make it even more complicated for a clinician to do their job.

    So, I'm a burned-out physician, I want to do something for my patient and I have to add the level of, can I do this or not? Am I going to get sued for this or not? Is this allowed in my state or not? So providing care to pregnant people just became even more complex and challenging for a burnt-out workforce.

    And the other layer of that is the potential for moral distress. When you have a provider that can, or can't, perform a service mandated by the government; that they may disagree with the mandate in their state. That adds a level of moral distress around, "can I give my patient the care that I think they need? Are my personal beliefs being taken into account? Are my personal beliefs being cast aside is my clinical training being cast aside and what I think the patient needs by lawmakers?"

    And that adds a whole other level of moral distress on this already burned-out workforce. So I have concerns for the implications on the physician workforce and the provider workforce more broadly in the months to come.

    Employers must be ready to discuss abortion access in the workplace

    Alex Polyak, Workforce and International Research

    Polyak: My name is Alex and I'm one of Advisory Board's Workforce Whisperers, and when we talk about the impacts that Dobbs v. Jackson will have on our health care workforce, I'm reminded actually of something my mother said to me on my very first day of work. She said, "No matter what, you never talk about religion or politics in the workplace."

    I'm sure many of you will likely have heard similar advice during the course of your career. But I mentioned that because it absolutely makes sense why for so long health care leaders have avoided talking about abortion access, particularly in the workplace. It's an exceptionally intensely human topic, volatile, complex, and it's the type of thing precisely that we want to avoid.

    If we want to have a peaceful stable workforce, or at least that's what we thought. But the fact of the matter is that Dobbs v. Jackson has changed the moment and you are going to have a lot of deeply human questions from your workforce. Questions about operations. What does this mean for me as a clinician, but also questions about, what is my organization's position on abortion access? And you can't avoid answering these questions—not if you want to effectively engage, recruit, and retain your workforce.

    Now think about it, for example, if the law is changing in your state. And moreover, there are hundreds upon hundreds of bills currently making their way from state legislatures. So, this is a time of great legal flux, meaning clinicians, employees of all stripes are going to be asking, what is my organization providing for me in terms of tools and support to manage a different and kind patient population? Particularly patients who now aren't able to terminate pregnancy and who will present with higher risk pregnancies, for example. Do I have the tools that I need as a clinician to deliver safe and effective care?

    From a legal perspective, we know that health care is litigious at the best of times, so it makes sense that health care workers are going to be asking, will you have my back if I'm sued? Particularly in a time of great legal uncertainty and flux.

    And then there's an entire element that I encourage you to think about across 2022 and into 2023, which is, how do we help our employees needs? Particularly when they become pregnant—like so many corporations are currently considering—do I now offer medical benefits for out of state care, including transportation costs? Do I offer expanded childcare benefits? Do I offer expanded leave benefits?

    I want to end on this note though—this is part and parcel of a much larger trend, namely that people don't just view their employer anymore as a pay stub. Rather, they increasingly want to work for an organization that aligns with their values, indeed promotes their values. And that goes for all sides of this debate on abortion access.

    In fact, it raises a lot of long-term questions about how Dobbs v. Jackson is going to impact your organization's long term recruitment and retention, but more than anything, it means that my mother, as strange as it is to say was wrong. You cannot avoid discussing this issue in the workplace now. You have to stake out a position.

    Purchasers and plans will struggle to predict their costs and decide what services to cover – which could affect where they ultimately operate

    Natalie Trebes, State of the Health Care Industry

    Trebes: I'm Natalie. I spend a lot of time covering how the different industry players intersect with each other strategically, but I've spent most of my career focused on the health plan and purchaser space.

    There are two big things to generally pay attention to here for the payer world, it breaks down into health care costs and the benefits that they actually cover. In the realm of costs, I think this introduces a number of uncertainties and anyone who knows the health plan business knows that is a very scary word—accurate predictions of spending are what the business turns on.

    And so we've got questions about, will there be higher health care costs from increased pre-, peri-, post-natal care, more births, more complications from high risk pregnancies and self-induced abortions. There are a lot of questions and that's going to be really hard to predict accurately in the first few years.

    In the realm of the benefits that you actually cover, this is where we really need to differentiate between health plans and their purchasers. For the most part, health plans are pretty constrained by what their purchasers and regulators allow, so most states limit the majority of Medicaid and individual marketplace plans in covering abortions. That really won't change.

    The real place to pay attention to is with employers, especially self-funded national employers who have a lot of flexibility about what they pay for and how they pay for it. And they also have to think about how they're going to offer fair, equal benefits to employees across a wide range of geographies and states.

    My biggest question here is actually in the long term—the five-to-10-year horizon—this is ultimately such a highly charged, highly public environment that employers can't really hide from this. They're going to have to contend with legal challenges from states, especially if they're thinking about covering travel for abortion care.

    I think a big question on the horizon is whether we are ultimately going to see two very different types of national employers—some of which cover abortion care and some of which don't and are very public about that. Or are we actually going to see a geographic redistribution where some employers won't operate in certain states and other employers will operate in the opposite states?

    So potentially what's at stake here is, what is the nature of business in general and where do we all work? The reason I think that can happen is the decisions that employers are making right now about what that coverage will look like. So providers for example—they can't assume that employees are going to find safe ways of accessing reproductive health care through free clinics. They have to make active choices there, that can have those ramifications for how do they recruit and retain productive employees? Are there products appealing to their customer base? Even what locations are they able to operate in?

    So, the national employers have to take a stance here, which is something they don't want to have to do. This is a scary place for them to be operating. On the one hand, they can actively embrace abortion care support—and we're certainly hearing stories of companies like Starbucks, Citi, Apple, Amazon, all saying they're going to pay for employee travel costs related to seeking medical care, that's not available near their home, including abortion care. Some are even saying they're going to pay for rapid medevacs if complications arise during pregnancy while an employee is traveling to restrictive states.

    On the other hand, not taking action might be appealing to some employee and customer segments. We might see headlines from some employers that really want to run at that because they're openly politically supportive of this ruling and they want to explain their benefit strategy as a way to appeal to those segments.

    Others will probably stay silent and fly under the radar there, but ultimately all of these positions and stances are going to reflect where the company sees its future and where they see their customer base and their employee base coming from

    It's not just providers. Life sciences companies must deal with the change in demand and patient journeys for the products that they make

    Solomon Banjo, Life Sciences Research

    Banjo: Hi everyone. My name is Solomon Banjo and I work with Life Science Organizations here at the Advisory Board.

    Now, when we think about abortion access, abortion rights, it's easy to think about how the overturning of them impacts patients and impacts physicians and clinicians more broadly. What I don't think is as obvious is the implications that has on my clients—the pharma device and other manufacturers who create products and services that those patients will end up using to manage their health. And so there are few things that come to mind for me.

    One is that, in all likelihood, this is going to change the demand for the services and the products that my clients make. Whether that be medication assisted abortions, or even just contraceptive care or other resources unrelated to maternal health. The other thing that I think this will impact is the support needed to provide to clinicians in order to make sure that they feel more comfortable navigating this complex environment.

    Now, on the one hand, I would say from an interaction perspective, life science leaders need to be thinking about how they're equipping their commercial and medical teams to have the conversations, to provide the resources for clinicians. I would also say that we need to be keeping in mind the pharmacists who are often the people actually interacting with patients in these relevant situations, whether it be around contraception, Plan B, etc.

    Now, what I don't know that I do believe will have an impact on the health care ecosystem and especially from the perspective of my clients is the way in which the removal of a bedrock assumption we have had about maternal and female health. The right to abortion will impact our understanding of the health needs, the consumption patterns of patients.

    A huge amount of the work that my clients do is just understanding their respective patient populations. What do they need? What are the unmet needs and taking away something that has been so foundational that has been a bedrock for decades and decades is likely to have second and third order impact we can foresee. But I think that we need to be actively listening and observing for those areas where our assumptions need to be updated.

    A boost to telehealth volumes, but a dangerous moment for patient (and provider) privacy

    Ty Adherhold, Digital Health

    Aderhold: My name is Ty Aderhold. I'm the director of Digital Health Research here at Advisory Board.

    You might have heard me on past podcasts speaking about digital health equity, and as I consider the implications of Roe being overturned here for digital health companies, there are two major ones that come to mind. First, what will happen, what does this mean for telehealth volumes? And then second, what is going to be the impact on patient privacy?

    Let's start with the first one Telehealth volumes. We expect telehealth abortion volumes to go up, and this is because it's one of the simplest ways for women in states where abortion has been restricted to maintain access. It is hard to know, however, how exactly volumes will shift, which providers they will shift towards, and where those numbers are going to go overall.

    We expect patients will, first and foremost, be willing to drive across state lines, take their telehealth appointment in the car, and then receive abortion pills either at their home, or even set up a P.O. Box in another state to receive those pills.

    So that's the simplest way we expect this to go. We've also seen some states pass laws that will protect providers if they provide out-of-state abortions. Connecticut is one example here. This will be very important for providers as there's some legal murkiness around if they need to check the IP address of the patients who are dialing in for telehealth. So, we'll certainly see an increase in telehealth abortions in those states that pass these laws, protecting providers.

    A final note here is there's also international organizations that are planning to continue to provide telehealth abortions to all 50 states, as there's little legal recourse that states could take towards these international organizations. So, all in all, we're certainly going to see volumes go up. But between these international organizations and organizations across states, where they might have protections, it's really hard to know exactly where these volumes are going to end up.

    Certainly, I would expect that states that do allow telehealth abortions and that provide protections to providers for providing out-of-state abortions. We will see significant volume increases in access issues in those states likely because of those volume increases.

    Now to the second implication here, which is around patient privacy. We've seen women use data and tools for their own health care purposes, digital health tools, stuff like period tracker apps, or asynchronous telehealth tools to communicate with providers.

    I think there's immediately going to be quite a lot of patient fear around continuing to use these tools. There have already been reports of states who have been able to identify women who have received abortions based on some of the data in these app and I think this will immediately bring fear to a lot of women who may want to avoid using this because of potential legal ramifications that they could face.

    Also, I want to note, there very well could be legal ramifications for providers as well. I expect clinics will be more concerned about their cyber security, their data privacy, their patient data privacy than they ever have been.

    And these are both immediate impact implications, I think there's also a longer-term implication here, especially when it comes to the patient data piece around, how is this going to impact digital health growth in general five years from now, 10 years from now? If so many women are concerned about their patient data, it could really stymie a lot of the growth we've seen across all types of telehealth, whether it is signing in for a virtual visit, communicating with a provider over messaging or using a digital health app that tracks their data.

    All of this is to say, digital health may not be the space you first think of when it comes to abortion rights and implications of Roe being overturned, but this is something that our team will certainly be watching as we expect telehealth to become a key access point for women who are seeking abortions.

    Opting out of the abortion conversation is no longer an option

    Rachel Woods, Host of Radio Advisory Podcast

    Woods: The biggest impact for you, our listeners is that you are going to have to take a stand on what the elimination of Roe means in your market, because the truth is health leaders used to be able to kind of opt out of dealing with abortion care because in most markets, there was an alternative that pregnant people could use, even if accessing it wasn't necessarily easy.

    The elimination of Roe marks a change in the way that providers, payers, and life sciences companies intersect with women's health. It means that leaders like you are going to have to address whether or not you continue to offer abortion services. It means you'll have to question the types of protections you offer your staff. You'll need to assess how you're dealing with your employees, the benefits that they get and the protections they have.

    This also marks a change in the kinds of research you are going to hear from Advisory Board. In the show notes, I've added a link to a new landing page that will house Advisory Board's latest guidance as it develops, including some of the materials that my colleagues talked about in this episode. Because remember, as always, we are here to help.

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