Have you ever been bothered by an annoying sound only to find that it blends into the background after a while? Or put on a scratchy sweater, forgotten about the discomfort while sitting still, then resumed itching when you moved again? These are examples of a phenomenon called neural adaptation, a curious process by which unvarying stimuli disappear from our awareness until something happens to refocus our attention on them. A particularly interesting example of neural adaptation is a visual illusion known as the Troxler Effect. First identified in 1804 by Ignay Troxler, a Swiss physician practicing in Vienna at the time, the illusion involves our peripheral vision. If you fix your gaze on a specific point and keep it there for a short time, an unchanging stimulus in a peripheral field fades and disappears.
Pilots are made aware of the Troxler Effect during their training. A section of the Federal Aviation Administration’s handbook is devoted to a very specific process called visual scanning, which involves a series of short, regularly-spaced eye movements that bring successive areas of the sky into the central visual field. Most mid-air collisions and near misses occur in clear weather during daylight hours. A pilot is five times as likely to have a mid-air collision with another plane flying in the same direction as with one flying in the opposite direction. It’s perilously easy to set your sights on the horizon and inadvertently lose your peripheral vision. The danger is not limited to pilots. Our most vulnerable patients can easily disappear from view, with adverse consequences.
Much has been written about the uneven impact of the COVID-19 pandemic—in particular, on the disproportionate toll that the virus has taken on patients with poor social determinants of health (SDOH). That disproportionate toll is indisputable and merits every effort we put into its eradication. There is another manifestation of the pandemic, however, that appears to be going under-detected, like an unmoving spot in our peripheral vision that has all but disappeared as we focus on the horizon, on a return to normalcy. It’s the patients whose social determinants of health regressed materially as a direct consequence of the economic fallout associated with the pandemic. Unlike the segment of the population whose SDOH were poor heading into the pandemic (and who bore a disproportionate brunt of the COVID-19 burden of illness), the latter cohort would not have been on their providers’ SDOH radar prior to the pandemic. Unless we turn our heads, we may miss them.
It's a sign of the times that the quickest estimate of the number of small businesses lost to the pandemic comes from Yelp, an online local business rating service, which estimates that over 100,000 firms have closed their doors for good. Moody’s projects that as many as one million “micro firms”—those with fewer than 10 employees—will fail to survive, and cautions that it may take four years to recover the 22 million jobs lost to the pandemic. Perhaps the most counterintuitive statistic to come out of 2020 was the fact that average per capita disposable income increased, largely due to the enormous federal stimulus outlays. With fewer places to spend money, personal consumption decreased, resulting in net savings going up. An economic gaze fixed on that specific spot would miss the fact that the bottom fell out for millions of people, and some of them will get sick.
Health systems saw a rebound in demand during the second half of 2020; by late in the year, clinical volumes were approaching (but not quite reaching) pre-COVID levels. Given the high fixed costs in health care, there was an understandable sigh of relief among health systems when operations returned closer to “normal.” There is no clear consensus among providers as to exactly what accounts for the gap between current volumes and pre-pandemic demand. It is widely assumed that at least part of the shortfall arises from persistent patient reticence to re-engage, mainly out of fear of exposure to the virus. Another contributing factor could be the repercussions of the jobs lost to the economic shutdown. Folks whose employers—or family businesses—closed during the pandemic will be slow to pursue anything but emergent health care. Providers scanning their own records will see what appear to be employed (and perhaps insured) patients based on their status when last encountered. We have no way of knowing whether the SDOH circumstances for patients changed…unless we ask.
We have long known that poor SDOH are associated with increased medical utilization. More recently, we have realized that proactive intervention in complex and chronic episodes of care among our Medicaid and underinsured patients can improve their wellbeing while reducing the uncompensated costs to the health system. But do we have mechanisms in place to monitor those patients when the alarm signals might come from outside of our system? Do we know when a congestive heart failure patient with a low ejection fraction does not fill their prescription at the local pharmacy? Or if an advanced rheumatoid arthritis patient fails to appear for their infusion at a standalone facility? Do we know why? If a family member alone on a long drive failed to check in, we would check on them. We wouldn’t just assume that they were OK or that they had called someone else.
Patients with chronic illness and compromised SDOH are like family members alone on a long drive. If they miss an expected milepost, we should check in with them. Our research over recent years has made the case for proactive intervention in chronic episodes where social determinants are a known risk factor. Hidden from view, however, are the chronically ill patients whose economic conditions worsened as a result of the pandemic. Whose SDOH looked quite different the last time we saw them. Who may be accounting for some of the unrecovered demand. And who we will not see unless we turn our heads, expanding our field of view.
It’s natural to focus on the horizon—eyes forward—as our clinical volumes return to something approaching normal, but like the pilot engaged in visual scanning, we need to keep our eyes moving to find those patients who should be returning but aren’t...not only including, but especially, when they can’t afford to. They are not our customers, they are our patients. Their well-being is more than our business, it’s our reason for being.
About the author: As executive director of the Vizient Research Institute, Tom Robertson and his team have conducted strategic research on clinical enterprise challenges for 20 years. The groundbreaking work at the Vizient Research Institute drives exceptional member value using a systematic, integrated approach. The investigations quickly uncover practical, tested results that lead to measurable improvement in clinical and economic performance.