June 5, 2020

The Weekly Gist: The Black Lives Matter Edition

by Chas Roades and Lisa Bielamowicz MD

“What is it that America has failed to hear?” asked Dr. Martin Luther King, Jr. in March of 1968, calling riots the “language of the unheard”. “It has failed to hear that the promises of freedom and justice have not been met.” Stubbornly, shamefully, we continue to turn a deaf ear: to structural racism; to institutionalized inequality; to a pandemic of police brutality and bigotry that chokes off the breath of black Americans as surely as a virus in the lungs or a boot on the neck. But the sound in the streets is thunderous.

We in healthcare must listen. We must hear that what killed George Floyd, and Breonna Taylor, and Eric Garner, and Tamir Rice, and Philando Castile, and Trayvon Martin, and Ahmaud Arbery, and countless others, as surely as the terrible actions of any single person, was the pervasive, insidious virus of racism, long since grown endemic in our country. This week’s protests are a kind of ventilator, providing emergency breath for a national body in crisis. We must work—urgently—on the therapeutics of structural change and the vaccines of education and understanding.

At Gist Healthcare we are listening, and learning. As a team, we’ve committed to each other to be attentive, invested, empathetic allies, and to dedicate our individual and collective time, talents and treasure to antiracist work, in healthcare and beyond. Our contribution may not be large, and it will never be enough, but at least we hope it will be positive. We’d like to hear your thoughts and suggestions as well. For the moment, and for our colleagues, friends, and families, we stand with the protestors.

Black Lives Matter.


THIS WEEK IN HEALTHCARE

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

Battling public health emergencies old and new

The widespread protests that swept the nation this week, coming in the midst of state-by-state reopening efforts, sparked fears of a resurgence of coronavirus cases in cities already hard hit by the virus. On Thursday, Centers for Disease Control and Prevention (CDC) director Robert Redfield told a House committee that protestors should “highly consider being evaluated and get[ting] tested” for the virus. The uneven restart of the economy has already led to a worrisome uptick in cases, as tracked by the (excellent) COVID Exit Strategy project, which showed 24 of 50 states with increasing 14-day case trends by the end of the week. Meanwhile, ICU capacity is becoming strained in several parts of the country, including, notably, Minneapolis, which has seen some of the most intense protests following the murder of George Floyd. In addition, researchers warned this week that the use by police of riot control agents like tear gas, common in several cities, could worsen the situation by amplifying the spread of virus-containing droplets, worsening infections, and undermining the ability to fight off disease.

The scenes of large numbers of protestors gathered closely together on the streets created a sharp contrast with the situation just a few weeks ago, when most Americans were sheltering indoors under stay-at-home orders. This has led some critics to highlight the conflicting advice coming from public health advocates. As the death of George Floyd once again illustrated, however, racism and police brutality are public health crises as well, and the intersection between the coronavirus pandemic and racial inequality is complicated. As reported by the COVID Racial Data Tracker—a collaboration between the well-regarded COVID Tracking Project and the Antiracist Research & Policy Center—black people account for at least 22,204 of US deaths from COVID-19, or 24 percent of deaths where the victim’s race was reported. To cite just one example, 77 percent of COVID-19 patients hospitalized in Louisiana’s largest health system were black, and 54 percent of COVID-19 fatalities statewide were black, even though blacks account for only 33 percent of the state’s population. Accuracy of data remains an issue, and this week the Trump administration ordered labs to start reporting race and ethnicity data on every person tested for the virus starting August 1st. But it is clear that black Americans and other racial and ethnic minority groups are suffering disproportionately from the pandemic, for reasons tightly bound to the broader health, income, and social inequalities faced by many. George Floyd survived COVID-19, but was not immune to the deadly impact of racism and inequality he had to navigate every day. Enough is enough. US coronavirus update: 1.91M cases, 110K+ confirmed deaths, 18.7M tests conducted.

Lancet, NEJM retract COVID treatment studies amid data questions

This week two major medical journals retracted observational studies evaluating the efficacy of drug treatments for COVID-19 patients, due to growing concerns about the integrity of the patient data undergirding both analyses. The Lancet retracted a paper published in May which reported that hydroxychloroquine increased mortality of coronavirus patients, likely due to an increase in heart arrhythmias, a well-known side effect of the drug. Just hours later, NEJM pulled a study concluding that two common classes of blood pressure medications were safe to use in COVID patients. Both studies relied on patient data aggregated by analytics firm Surgisphere Corp., which came under fire after serious questions about the dataset’s validity and accuracy surfaced; investigative work from The Guardian was crucial in bringing the flaws to lightSurgisphere has refused to provide raw data to study authors or independent auditors.

The situation has had cascading effects on ongoing research into coronavirus treatments. After the Lancet study was published, the World Health Organization (WHO) paused recruitment for an international study evaluating the efficacy of hydroxychloroquine out of safety concerns; WHO restarted recruitment again on Wednesday. The debacle highlights the challenge in balancing the desire for quick results with the need for scientific rigor amid the pressure of the pandemic. And while study retractions are nothing new, given the politicization of hydroxycholorquine in particular, the retractions could serve to undermine public trust in the validity of scientific research and provide fuel for those who wish to use it to advance their own objectives.

Physicians acquire Steward Health Care from Cerberus Capital

Private equity (PE) firm Cerberus Capital Management is selling control of Steward Health Care, a Dallas-based health system with 35 community hospitals across nine states, to a management group of Steward’s own physicians. Led by CEO Dr. Ralph de la Torre, Steward physicians will control 90 percent of the company and Medical Properties Trust will maintain its 10 percent stake. The transaction will make Steward one of the largest physician-owned and operated healthcare companies in the country, and end a decade of ownership by Cerberus, which bought Boston-based Caritas Christi Health Care system in 2010, converted it into a for-profit company renamed Steward, and pursed a path of national expansion. Steward’s financial position may have played a role in the timing of the deal—the system reported operating losses across the last three years amid a period of major expansion. We’ve long thought that PE firms are largely uninterested in being long-term owners of physician practices and other care assets, and will likely look to resell assets, pocketing the profits from aggregating smaller players and improving their performance. And we’ve heard doctors who have been unsatisfied with the outcome of other PE deals muse that they would love the chance to buy their practices back. The coronavirus pandemic is making PE firms more gun-shy about the financial outlook for care delivery businessesIf physicians can organize the necessary capital, we might see more “physician reacquisition” by doctors who sold their practices and now find themselves beset with seller’s remorse. 


GRAPHIC OF THE WEEK

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

Identifying “triple-threat” counties at higher risk of COVID outbreaks 

“Superspreader facilities”—nursing homes, correctional facilities, and meatpacking plants—have become major COVID hotspots across the US. Many counties are dealing with a large outbreak in one type of tightly-packed facility or another. Case in point: the outbreak at Cook County Jail in Chicago, which now accounts for a whopping 15.7 percent of all COVID cases in the state of Illinois. Some places, like Colorado’s Weld County, are managing outbreaks across all three types of superspreader facilities. The graphic below highlights the nearly 260 counties that we’ve termed “triple-threat counties”: those which have all three types of superspreader facilities. The counties are mapped using our Gist Healthcare COVID-19 Risk Factor Index, which identifies particularly vulnerable populations using chronic disease, demographic, and acute care access variables. The top 10 “triple-threat counties” by risk index score are all in more rural areas of the country with limited acute care access and more vulnerable populations—places where a COVID outbreak is likely to be particularly devastating. Seven of the 10 have a high percentage of African-American or Hispanic/Latino residents, groups with a an outsized burden of COVID-19 illness and death. These risk factors are intersectional; for example, food processing plants employ twice as many Hispanic workers as the national average, and a disproportionate share of long-term care workers are black.

[Click here for more information and interactive data from our analysis of the risk impact of these superspreader facilities.]


THIS WEEK AT GIST—ON THE ROAD PHONE

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

Getting back on the road again

After eleven weeks of Zoom meetings, we ventured out from our basements last week for our first face-to-face meeting with senior executives at a member health system since before the pandemic. It was fantastic to be “on the road”—and completely surreal. Fortunately, this system was close enough to avoid a flight. Even the two-hour drive felt different: no traffic, and people on the highway were driving alarmingly fast. We discovered, however, that everything else with travel will take longer than before. The hotel was empty (only 14 of 500 rooms in the hotel were booked). During the stay, we saw just two hotel employees, and never crossed paths with another guest. The hotel seemed safe and clean (that didn’t stop us from taking our Clorox wipes and Lysol to every surface). But with hotel dining limited, every meal required masking up and heading out to find a restaurant open for takeout in an unfamiliar town. The stay made us more confident in the safety of travel, even though many of the small pleasures of being on the road—discovering new restaurants, visiting local businesses—have disappeared.

Visiting the health system confirmed our predictions that going into a care facility is safer than shopping at your local grocery. Everyone wore masks, and our health status was screened and temperatures checked upon entry. We met with three executives in the hospital board room, each of us spaced more than six feet apart around the table. We’ll be honest: business meetings with masks take some getting used to. It’s harder to read reactions, and you really do have to talk louder. Expect every meeting to start with a long, cathartic catch-up of the events of the past three months, both professional and personal. This system has fared well through the pandemic. They’ve been able to avoid furloughs so far, and elective volumes are returning faster than anticipated. Located a few hours from a hard-hit metro area, they’ve had a moderate number of COVID-19 cases. And while they now feel very capable of managing affected patients (“The amount we’re learning and the pace at which clinical management has advanced is astonishing”), the CEO was concerned about a looming resurgence. COVID admissions had jumped 25 percent in the prior week, which was attributed to a possible “Mother’s Day spike”, leaving us concerned that Memorial Day could bring an even larger resurgence. From there, we got down to the business of discussing future strategy, and a growth decision that is on the table. Over the past three months we’ve all become comfortable with meeting over Zoom, and many meetings that used to be done face-to-face will likely be conducted via videoconference for the foreseeable future. But getting back on the road reminded us of the power of human connection—and we hope to be back out “on the road” soon. 

An optimistic view from health system workforce leaders

Continuing our series of Gist member convenings to discuss the “Brave New World” that awaits in the post-pandemic era, we brought together a group of senior human resources and nursing executives this week for a Zoom roundtable. Several themes emerged from the discussion. First, there was general consensus that the COVID crisis exposed a workforce that had become over-specialized and inflexible. Said one chief nursing officer, “Our workforce is much more brittle than we thought.” A key lesson learned is the need for increased cross-training—especially for nurses, and especially in critical care. Systems should work now to increase the supply of nurses comfortable in an ICU environment to enable hospitals to flex staff across settings and roles to deal with future waves of the virus.

Not surprisingly, layoffs were top-of-mind for many. Executives were of one mind on the need to safeguard clinical staff as much as possible, and many systems are now considering deep cuts to management and administrative ranks: “It’s easier to stand in front of your clinical staff and be able to say you’ve stripped millions from administration before turning to clinical cuts.” There was broad consensus for the potential for artificial intelligence and robotic process automation to enable greater reliability and productivity at lower cost in areas such as billing, coding, and even some clinical functions—and that the pandemic will accelerate plans to implement these solutions.

On a more optimistic note, one executive shared that “relationships between clinicians and administrators have never been stronger. The pandemic has forced us to have difficult and constructive conversations we would have never had the courage to have before.” Another noted the pandemic has spotlighted new leadership talent who might otherwise have been overlooked, and plans are now in place to formally recognize and retain newly crisis-tested talent for the work of restructuring the system. On the whole, the discussion was far more upbeat that we had expected—as difficult as the crisis has been for many teams, the opportunity to rethink old ways of doing business seems to have created renewed enthusiasm even in the face of daunting financial and operational challenges ahead.


THIS WEEK AT GIST—ON THE PODCAST

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

On last Monday’s episode we heard from Teke Drummond, the executive director of corporate partnerships for Penn Medicine HealthWorks at Lancaster General Hospital. He described how employers are turning to the health system for advice on how to bring employees safely back to work. And on today’s episode, we talked with Dr. David Asch, behavioral economist and executive director at the Penn Medicine Center for Health Care Innovation. He told us there’s a fine line that hospitals need to walk between taking visible safety precautions and not making the hospital feel more dangerous than it is.

Coming up on Monday’s episode, we’ll hear from Keith Figlioli, general partner at venture capital firm LRV Health. He believes the pace and shape of change will increasingly be driven by the course of the pandemic. Figlioli is watching to see which regulations the Centers for Medicare and Medicaid Services (CMS) reinstates, such as restrictions on telemedicine, as that will have a big impact on future innovations. Make sure to tune in!

[Subscribe on Apple, Spotify, Google, or wherever fine podcasts are available.]


ON THE GIST TURNTABLE

Give this a spin—you might like it.

Maybe this week was the first time you ever heard of Killer Mike, when you saw the Atlanta-based rapper speak passionately at a press conference with Mayor Keisha Lance Bottoms. On Friday night, he urged citizens to “plot, plan, strategize, organize, and mobilize” in response to police brutality and structural racism. This week, Killer Mike and his partner El-P (Michael Render and Jamie Meline), better known as the rap superduo Run the Jewels, are back in the spotlight with the release of their fourth album, RTJ4. Now seven years into their collaboration, the pair’s combination of in-your-face beats and intricate lyricism have earned them a growing audience and glowing reviews from critics. Rightly so—their work is as brutally authentic and beautifully poetic as anything on the rap scene today. With help from Greg Nice, 2 Chainz, Pharrell Williams, Zack de la Rocha, Josh Homme, and the legendary Mavis Staples, RTJ have assembled another gut punch of truth-talking about racism and hate. Their message could not be more relevant. Several tracks speak directly to the issues raised by George Floyd’s murder at the hands of police, and the Black Lives Matter protests that continue into this weekend. El-P has assured fans the album was fully written and recorded in 2019, but it certainly feels as though it were written yesterday—partly because, as he tweeted recently, “…unfortunately this week is last week is last year is 50 years etc etc etc”. Truth. This Killer Mike lyric, squarely at the album’s center, is worth quoting in its entirety:

“The way I see it, you’re probably freest from the ages one to four
Around the age of five you’re shipped away for your body to be stored
They promise education, but really they give you tests and scores
And they predictin’ prison population by who scoring the lowest
And usually the lowest scores the poorest and they look like me
And every day on the evening news they feed you fear for free
And you so numb you watch the cops choke out a man like me
And ’til my voice goes from a shriek to whisper, “I can’t breathe”
And you sit there in the house on a couch and watch it on TV
The most you give’s a Twitter rant and call it a tragedy
But truly the travesty, you’ve been robbed of your empathy
Replaced it with apathy, I wish I could magically
Fast forward the future so then you can face it
And see how fucked up it’ll be
I promise I’m honest, they coming for you
The day after they comin’ for me.”

Best Tracks: “walking in the snow”; “JU$T (featuring Pharrell Williams and Zack de la Rocha)”; “pulling the pin (featuring Josh Homme and Mavis Staples)”.


GIST IN THE NEWS

We said it, they quoted it.

Hospitals Emptied Out by Pandemic Push for Patients to Return
Bloomberg; June 4, 2020

“‘Hospitals and doctors are going to have to do as much as they can as fast as they can until they can’t anymore,’ said Lisa Bielamowicz, co-founder of consultancy Gist Healthcare.

Many patients, on the other hand, are in no rush. ‘They’re waiting and watching rather than pulling the trigger and going to see the doctor like they would have in the past,’ Bielamowicz said.

The calculation for the health-care industry is different than for many other service businesses resuming operations. A hospital procedure or even a check-up is more intimate than a meal out.

For procedures that require in-patient rehab stints for recovery, the havoc Covid-19 has brought to nursing homes adds another layer of concern. ‘Those places seem like deathtraps now, so it’s much harder to bring back those patients because you need to find an alternative way for them to rehab,’ Bielamowicz said.”

E.R. Visits Drop Sharply During Pandemic
New York Times; June 3, 2020

“‘Where are all the heart attacks and strokes?’ asked Chas Roades, the co-founder and chief executive of Gist Healthcare, which advises health systems. He said that many patients were returning for rescheduled surgeries, but that hospital executives were reporting that people, worried about possible infection, continued to avoid their emergency rooms and urgent care clinics.”


WHAT WE’RE READING

Stuff we read this week that made us think.

The patients stayed away—will they come back?

new analysis from the CDC this week confirmed what we have been hearing anecdotally from health systems for several weeks—as the coronavirus lockdown took hold, there was a precipitous drop in visits to hospital emergency departments. According to the study, visits were down by 42 percent in the month of April compared to the previous year, and despite a rebound in May, were still 26 percent lower than a year ago. Visits in the Northeast dropped the most, as did those among women, and children under 14. Although visits for minor ailments and symptoms declined the most, even more disconcerting was the drop in visits for chest pain, echoing the concern we’ve heard in many parts of the country that many patients may have suffered minor heart attacks without being treated, or may have waited to be seen until significant damage had been done.

As non-emergent visits have begun to return to many facilities, we continue to hear that emergency department and urgent care volume remains relatively lowSurvey data indicate that patients are fearful of becoming infected with coronavirus if they visit healthcare facilities—especially, it seems, ones where they’ll be forced to wait. While many providers are investing in messaging campaigns to assure patients it’s safe to return, this nightmarish first-person account by one healthcare insider provides a useful cautionary tale. Visiting a surgeon for a pre-op consult, she found the experience of visiting a COVID-era hospital downright dystopian. Simply touting safety precautions by itself won’t make patients more comfortable—they’ll need to see and feel that measures are in place to make time spent in a care setting as efficient and reassuring as possible. Otherwise, like the insider in question, they’ll take their business elsewhere. There’s work to be done.

How the CDC “missed its moment”

If, like us, you’ve been wondering exactly why the CDC always seems to be a step behind in responding to the pandemic, a new, in-depth New York Times piece helps elucidate the myriad challenges—structural, cultural and political—that led to the agency’s flawed response. Given the CDC’s history, it should have been the world’s “undisputed leader” in the pandemic response. But its early reticence to absorb lessons from other countries, combined with flawed testing, slowed down responses across the nation. While much has been made of political machinations within the Trump administration, a deep-rooted bureaucratic and exacting culture left the CDC ill-suited to respond to a crisis of this scale, requiring improvisation and rapid adaptation. Career scientists and epidemiologists clashed with CDC leader Dr. Robert Redfield, who was eclipsed by Drs. Tony Fauci and Deborah Birx in public communication. But even if it were firing on all cylinders, the CDC is only one of the many parts of government at the table for what should have been a coordinated, all-government response. Whether led by the CDC or another entity, the pandemic response has highlighted the need for a massive overhaul of the nation’s public health system, so that future challenges—both COVID-related and beyond—are met with a rapid and coordinated response.


That’s all for this week. It’s been a difficult one, and the hardest work is still ahead. Thanks for taking the time to read the Weekly Gist, and for sharing your thoughts and feedback with us. We’d be so grateful if you’d consider sending this to a friend or colleague, and encouraging them to subscribe, and to check out our daily podcast.

As always, we hope you’ll let us know if there’s anything we can to do assist in your work as well. You’re making healthcare better—we want to help!

Best regards,

Chas Roades
Co-Founder and CEO
chas@gisthealthcare.com

Lisa Bielamowicz, MD
Co-Founder and President
lisa@gisthealthcare.com