September 10, 2021

The Weekly Gist: The Always Remembering Edition

by Chas Roades and Lisa Bielamowicz MD

Four Presidents, two wars, a Great Recession, a global pandemic. Kids born, and grown, and off to college and work. Parents and grandparents lost. Houses bought and sold; careers advanced and businesses launched. And yet here we are, twenty years later, on a crisp and clear September day—just like the weather on that day—and it comes back to us as if it were yesterday. Hearing the awful news, then seeing the awful footage. Eyeing the sky nervously, bracing for another blow, reeling from the enormity of the loss. What would happen next? What could the future possibly be like after such a day? Slowly the answer has come: the same joys and sorrows, the same celebrations and mourning, the same excitement and tedium. But through it all, remembering. Still, remembering. Even today, remembering. Twenty years.


What happened in healthcare this week—and what we think about it.

Implementing a long overdue vaccine mandate

Declaring that “our patience is wearing thin” with Americans who refuse to be vaccinated against COVID-19, President Biden announced sweeping new plans to implement vaccine mandates on Thursday. Businesses that employ more than 100 people must require their employees to get vaccinated or face weekly COVID testing, federal workers and contractors must be vaccinated or face disciplinary measures, and all healthcare organizations that receive Medicare or Medicaid funds must ensure 100 percent employee vaccination as a condition of continued participation in those federal payment programs. The healthcare component of the mandate will impact about 17 million workers, including those at hospitals, surgery centers, dialysis facilities, and home health agencies. The Centers for Medicare & Medicaid Services (CMS) already requires nursing home workers to be vaccinated, and yesterday announced plans to release a new regulation by October 1st, implementing the expanded mandate. According to Fierce Healthcare, at least 172 hospital systems have already announced some form of vaccine mandate, but others have expressed concerns that forcing workers to get vaccinated might exacerbate labor shortages and result in employees seeking work elsewhere.

Responding to President Biden’s announcement, the American Hospital Association (AHA) echoed those concerns, citing “the critical challenges that we are facing in maintaining the resiliency of our workforce.” In our view, that concern pales in comparison to the imperative to protect patients by reducing the potential for exposure by unvaccinated caregivers. If anything, the national healthcare mandate should provide cover for those hospitals and care providers that have shied away from mandates, letting other organizations take the lead. Once universal healthcare mandates are implemented, vaccine resistant workers will find few employment alternatives left, significantly dampening the risk of widespread resignations. If you don’t want to take the necessary precautions to keep patients safe, you shouldn’t be working in healthcare in the first place. Yesterday’s mandate announcement, while aggressive, is overdue.

Mobilizing for the intensifying COVID battle

In addition to announcing a broad vaccine mandate, the Biden administration unveiled other steps intended to bolster the fight against the resurgent COVID pandemic. The President reiterated his intention to provide booster shots to targeted populations starting on September 20th, subject to approval by the Food and Drug Administration (FDA), and promised that those boosters would be free and widely available. He further committed to ensuring the FDA had the resources needed to quickly review and approve vaccines for children under the age of 12 and called for a number of measures to enhance COVID safety in school settings. With the goal of significantly increasing the availability of COVID tests—a longstanding problem which has worsened as the Delta variant has taken hold—the President mobilized the Defense Production Act to procure over $2B worth of rapid and over-the-counter test kits, and announced partnerships with key retailers and care providers to make those tests easily available, at cost. Addressing the shortfall of frontline clinical workers, the President vowed to double the number of Department of Defense teams deployed to COVID-impacted hospitals, along with “monoclonal antibody strike teams” to provide onsite technical assistance in administering COVID therapies. Shipments of monoclonal antibody drugs to hospitals will also be increased by 50 percent.

Finally, responding to pressure from the hospital lobby and members of Congress, the Biden administration now plans to distribute more than $25B of the remaining provider relief funds approved as part of the CARES Act and American Rescue Plan. The Department of Health and Human Services (HHS) had been criticized for dragging its feet on the release of the funds, while citing a desire to ensure the money was distributed equitably. With the resurgence of COVID hospitalizations, and many hospitals being forced to again cancel or postpone non-emergent procedures, the funding has become increasingly critical for providers. On the whole, it appears the Biden administration has finally moved past the hopeful but premature optimism of the “summer of joy”, and is now steeling itself for a difficult autumn and winter of COVID—as should we all.


A key insight or teaching point from our work with clients, illustrated in infographic form.

A bidding war for critical nursing talent

As the pandemic rages on, hospitals across the country are experiencing significant labor shortages for critical clinical roles. In the graphic below, we highlight the shortage of nursing talent, perhaps the most sought-after role for which health systems are struggling to hire. Even before the current COVID surge, many nurses reported feeling dissatisfied or feeling burned out. In a May 2021 survey, more than one in five nurses said they were considering leaving their current jobs, citing insufficient staffing, workload, and the emotional toll of the work. Many health systems are offering lucrative incentives, such as five-figure signing bonuses, to fill immediate critical care needs, and to address the growing backlog of patients returning for delayed care. As more nurses quit or retire from their permanent positions, health systems are being forced to fill workforce gaps by luring temporary talent at much higher costs (now cresting $8K a week to fund a single travel nurse in some parts of the country). Travel nurse demand reached an all-time high in August, up almost 40 percent from the previous peak in December 2020. As they struggle to fill essential openings, hospital leaders must also focus on keeping the current nursing staff engaged—a challenge that only gets harder as staff nurses compare their salaries to those paid to the temporary colleagues working alongside them.


What we learned this week from our work in the real world.

Shortage extends beyond nursing, beyond hospitals

The typical media coverage of the healthcare workforce crisis often focuses on the acute shortage of hospital-based nurses. For instance, the hospital forced to close a unit as nurses, burned out after 18 months of extra shifts taking care of COVID patients, leave for lower-stress, more predictable jobs in outpatient facilities or doctors’ offices. But we’re hearing about a reverse trend in recent conversations with health system leaders. Instead of outpatient settings benefiting from an influx of nursing talent, ambulatory leaders report that nurses are now leaving for hospital or travel nursing positions that offer higher salaries and large sign-on bonuses. That’s forcing non-hospital settings to reduce operating room and endoscopy capacity. Nor are shortages just in the nursing workforce. One system executive lamented that they had to cancel several non-emergent cardiac surgeries, not due to nurse staffing challenges; rather, they were short on surgical technicians. “Surgical techs aren’t leaving because of COVID,” the executive shared, “they’re leaving because the labor market is so strong, and they can make the same money doing something entirely different.” For lower-wage workers in particular, the old value proposition of working for a health system, centered around good benefits, continuing education, and a long-term career path, isn’t providing the boost it used to. Workers are willing to trade those for improved work-life balance, predictability, and the perception of a “safer” workplace. Stabilizing the healthcare workforce will ultimately require providers to rethink job design, the allocation of talent across settings of care, and the integration of technology in workflow. And it will require re-anchoring the work in the mission of serving the community. But in the short term, many health systems will find themselves having to pay more to retain key workers, including but not limited to hospital nurses, to maintain patient access to care.

Is price transparency a “To Err is Human” moment?

Recently we heard a refreshing perspective from a health system executive we work with, on the hot topic of price transparency. As we reported earlier this summer, a study from Patient Rights Advocate indicated that as of July, 94 percent of hospitals were not in compliance with Medicare’s requirement to post their negotiated prices online for patients to view. Subsequently, the Centers for Medicare & Medicaid Services announced that it planned to substantially toughen penalties for noncompliance, to up to $2M per hospital. But in the opinion of the executive we spoke with, systems shouldn’t have to be goaded into transparency, they should embrace it. “We should view this as similar to the IOM report,” she said, referring to the landmark 1999 study from the Institute of Medicine that shed light on the thousands of deaths each year caused by preventable errors in hospitals. “That report was a wake-up call for the industry,” she said, “and rather than point fingers and take punitive measures, we all rallied together to address the problem.” Similar to the issue of avoidable medical errors, the root cause of distorted hospital pricing is system structure, not individual bad actors. Public scrutiny of high and widely variable pricing is an opportunity to address structural issues around how reimbursement works, rather than a moment to punish individual organizations for acting rationally in the context of a broken payment system. We’d agree—don’t hate the players, hate the game, as the saying goes. We must address the complex tangle of cross-subsidies, cost shifting, pricing leverage, and misaligned incentives, all of which are exposed by transparency.


All the headlines in healthcare policy, business, and more, in ten minutes or less every weekday morning.

“We think telemedicine is a commodity,” Chief Business Officer of London-based Babylon Health, Paul-Henri Ferrand, told us on last Wednesday’s episode. The digital-first, value-based care company has expanded rapidly beyond its roots as a UK virtual care company, and is now partnering with health plans and providers in the US to take full risk for the total cost of care. Take a listen!

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Give this a spin, you might like it.

Attention has (rightly) been focused this week on the release of star-crossed, the excellent new album from Kacey Musgraves, who’s continuing to remake the template for 21st century country music stardom. Give it a listen for sure, but also take a few minutes to check out the recent debut record from Sierra Ferrell, another Nashville sensation who seems poised to be the Next Big Thing from Music City. Hailing from coal-mining country in West Virginia, Ferrell spent several years busking her way across the US, eventually alighting in Nashville and gaining the attention of record producers. Her new album, aptly titled Long Time Coming, is an expansive combination of traditional country waltzes, 70s-style balladry, and a peppering of interesting influences from French chanson to Mexican conjunto. What brings it together is Ferrell’s incredible vocal talent, with all the simplicity of Loretta Lynn and the punch of Dolly Parton. Make no mistake, Ferrell is charting new country music ground here, just like the better-known Musgraves—this is songwriting for a new generation of Nashville aficionados. Her years on the road have given her a seasoned sound and a fully developed musical persona, along with the ability to stage a killer live show. Catch her if she visits a venue near you, but in the meantime, enjoy this brilliant record, and the emergence of an important new voice on the country scene. Best tracks: “The Sea”; “In Dreams”; “West Virginia Waltz”.


Stuff we read this week that made us think.

The shoddy science that led to the ivermectin craze

If you, like us, have been wondering how ivermectin, a relatively obscure drug used to treat parasitic infections like intestinal worms, scabies and lice, became an in-demand for treatment of COVID-19, we’d highly recommend this well-researched Buzzfeed article, which traces how sketchy research, published in an obscure journal, amplified by a handful of physicians given a big media platform, has led to thousands of Americans taking a horse medication in the hopes of curing or preventing COVID infection. The first connection between ivermectin and COVID traces back to an April 2020 report from Australian scientists, who claimed that the drug reduced the amount of virus in lab-cultured cells. But the momentum behind the ivermectin claims being made today comes from research published by an Argentine endocrinologist who insists that his studies have shown that ivermectin (given alongside carrageenan, a thickening agent derived from algae, used in ice cream and other foods) was 100 percent effective in preventing COVID infection in healthcare workers. His work was published last November in the Journal of Biomedical Research and Clinical Investigation, an obscure online journal launched in 2019, which has published fewer than 10 articles to date (and is happy to include your research for a fee of $1,200). The study has been criticized for discrepancies in timelines, enrollment numbers, patient demographics and methodology, leading one respected researcher to call it “one of the worst studies I’ve ever come across”. Some hospitals listed as trial sites state they never participated, nor had their ethics boards approved the research.

Despite the shoddy science, the paper was picked up by groups such as the Frontline COVID-19 Critical Care Alliance, whose physician leader promoted the study to 11M daily listeners during an appearance on podcast celebrity Joe Rogan’s show. (Rogan has also reported taking ivermectin to treat his own recent COVID infection.) Now individuals desperate for a COVID cure are buying out veterinary supplies of ivermectin, and taking legal action to force hospitals to administer the drug against policies. Like the debates last year around hydroxychloroquine, the ivermectin controversy is a prime example of the intersection of partisan politics and science, likely a lasting ramification of the pandemic, undermining trust in medicine—and putting all of us at greater risk.

That’s all for this week! Thanks for taking time to read the Weekly Gist, even when the title is more aspirational than real—no matter how often we manage to produce an edition, we’re delighted to have the privilege of your company. We’d love to hear from you! Let us know your feedback, and don’t forget to share this with a friend of colleague. Encourage them to subscribe, and to listen to our daily podcast—it means the world to us.

Most of all, please let us know how we can be of assistance in your work. You’re making healthcare better—we want to help!

Best regards,

Chas Roades
Co-Founder and CEO

Lisa Bielamowicz, MD
Co-Founder and President