October 23, 2020

The Weekly Gist: The Cats Versus Birds Edition

by Chas Roades and Lisa Bielamowicz MD

Last night, in what will become known to history as the “Mute Button Debate”, the pressing issue of wind turbines and their impact on birds again became, literally, a topic of national interest. As he has many times before, the President inveighed against electricity-generating windmills, telling his opponent, “I know more about wind than you do…Kills all the birds.” Not quite. As a helpful infographic points out, if you’re really interested in the plight of our feathered friends, you shouldn’t ban wind turbines. You should ban cats. According to the US Fish and Wildlife Service, only 234,012 birds lose their lives every year to windmills (a startlingly precise statistic). Cats murder 2.4B. Turns out feral felines are our most powerful line of defense against the only surviving descendents of dinosaurs. Where you come out on the cats versus birds issue? That’s a whole other debate.


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

Heading into a “third wave” of the pandemic

In Thursday’s second and final Presidential debate, former Vice President Joe Biden warned that a “dark winter” lies ahead in the coronavirus pandemic, and with cases, hospitalizations, and deaths on the rise across the country, it now appears that we are headed into a “third wave” of infections that may prove worse than both the initial onset of COVID on the coasts and the summertime spike in the Sun Belt. Yesterday more than 71,600 new cases were reported nationwide, nearing a late-July record. Thirteen states hit record-high hospitalizations this week, measured by weekly averages, most in the Midwest and Mountain West. Several Northeastern states, which had previously brought the spread of the virus under control, also experienced substantial increases in infections, leading schools in Boston to suspend all in-person instruction. Of particular concern is hospital capacity, which is already being strained in the more rural areas now being hit by COVID cases. With infection spikes more geographically widespread than in earlier waves, fewer medical workers are available to lend support to hospitals in other states, leading to concerns about hospital staffing as admissions rise.

As hospitalizations increase, so too will demand for therapeutics to help shorten the course and moderate the impact of COVID. This week, Gilead Sciences’ antiviral drug remdesivir, previously available under an Emergency Use Authorization (EUA) from the federal government, became the first drug to win full approval from the Food and Drug Administration (FDA) to treat patients hospitalized with COVID-19. The approval was based on clinical studies that showed that remdesivir can reduce recovery time, and also includes use for pediatric COVID patients under the age of 11. Meanwhile, the FDA cleared AstraZeneca to resume US clinical trials of its coronavirus vaccine, which had been suspended for a month following an adverse patient event. It’s widely expected that one or more drug companies will submit their vaccine candidates for EUA sometime next month, although new polling data released this week indicates that the American public is growing more skeptical in their willingness to take an early vaccine against the virus, with only 58 percent of respondents saying they would get the shot when it first becomes available, down from 69 percent in August. (Only 43 percent of Black respondents say they would get the vaccine, compared to 59 percent of Whites—a racial divide that reveals deep distrust based on the history of inequities in the US healthcare system.) In many respects, the coming month will surely prove to be a pandemic turning point, revealing the magnitude of the next wave of COVID, the direction of US public health policy, the prospects for reliable therapeutics, and the timing of a safe and effective vaccine. We’ll soon know whether we are, indeed, headed for a winter of darkness.

A guilty plea from Purdue Pharma for its role in the opioid epidemic

In the most significant move to date to hold drug companies accountable for their role in encouraging the epidemic of opioid addiction that has claimed over 470,000 lives in the US, the Department of Justice announced an $8.3B settlement with Purdue Pharma, which produces the powerful drug OxyContin. Purdue will plead guilty to three felony criminal charges, including conspiracy to defraud the government and violating federal anti-kickback laws. The ultra-wealthy Sackler family will lose all control of the company, which will become a “public benefit company” accountable to a governing board that will balance company and public health interests. Although the Sackler family pledged separately to pay billions of dollars to settle the range of civil actions against its members, no company executive or owner was criminally charged, leading to vociferous objections from state attorneys general and others involved in bringing legal suits against the company. Massachusetts Attorney General Maura Healy criticized the settlement as an election-season stunt. She said, “I am not done with Purdue and the Sacklers, and I will never sell out the families who have been calling for justice for so long.” In the midst of a new public health crisis that has claimed nearly a quarter-million American lives, it’s worth noting that the opioid epidemic’s tragic toll was avoidable as well—corporate greed and the malign influence of the “health-industrial complex” combined to create a market for painkillers and then benefit from their overuse. Perhaps the 2020s can be a decade of reinvestment in public health, to help ensure we avoid the next epidemic, man-made or otherwise.

Nebraska gets the nod for Medicaid work requirements

This week Nebraska became the latest state to receive waiver authority from the Trump administration to implement work requirements as part of its Medicaid expansion program. The program, called “Heritage Health Adult”, will be a two-tiered system, with expansion-eligible adults choosing between “Basic” and “Prime” coverage levels. The lower tier will provide coverage for physical and behavioral health services, with a prescription drug benefit, and is open to adults not eligible for traditional Medicaid with incomes under 138 percent of the federal poverty line. “Prime” enrollees will get additional dental, vision, and over-the-counter drug benefits, in exchange for agreeing to 80 hours per month of work, volunteering, or active job seeking, which must be reported to the state. Nebraska voters approved the Medicaid expansion two years ago, although enrollment only began this August, and the work-linked demonstration project is slated to start next year. An estimated 90,000 additional Nebraskans are expected to enroll in Medicaid under the expanded program.

The approval of Nebraska’s Medicaid work requirement comes a week after the Trump administration approved a partial expansion of Medicaid in Georgia, called “Pathways to Coverage”, which is also tied to a requirement to seek or engage in employment or education activities. The Georgia program also requires premium payments by eligible adults who make between 50 and 100 percent of the federal poverty line. Court challenges will inevitably ensue for both the Nebraska and Georgia programs—only Utah has successfully implemented Medicaid work requirements, with 16 other state programs either pending approval, held up in court, or awaiting implementation. We continue to be deeply skeptical of Medicaid work requirements, and believe they only serve to deter those who would otherwise qualify for coverage from enrolling, and that the expense of their implementation and ongoing operation often outweighs any savings to the state. The argument that “work encourages health”, often advanced by proponents of work requirements, gets it exactly backwards—rather, health security encourages work, a reality that has become ever more urgent as the COVID pandemic has drawn on. As the economy continues to falter, Medicaid’s importance as a safety net program grows ever greater, and work requirements create an unhelpful obstacle to basic healthcare access.


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

COVID response leads voters’ healthcare concerns

The upcoming election has huge implications for healthcare, far beyond how COVID is managed, ranging from how care is covered to how it’s delivered. The graphic below shows a continuum of potential policy outcomes of the November 3rd vote. If President Trump wins a second term and Republicans control at least one house of Congress, there will likely be more attempts to dismantle the ACA, as well as continued privatization of Medicare coverage. If Democrats win the presidency and sweep Congress, actions to expand the Affordable Care Act (ACA), or even create a national public option, are on the table—although major healthcare reform seems unlikely to occur until the second half of a Biden term. In the short term, we’d expect to see more policy activity in areas of bipartisan agreement, like improving price transparency, ending surprise billing and lowering the cost of prescription drugs, regardless of who lands in the White House.

While healthcare emerged as the most important issue for voters in the 2018 midterm elections, the COVID pandemic has overshadowed the broader healthcare reform platforms of both Presidential candidates heading into the election. As shown in the gray box, many Americans view the election as a referendum on the Trump administration’s COVID response. Managing the pandemic is one of the most important issues for voters, especially Democrats, who now rank the issue above reducing the cost of healthcare or lowering the cost of drugs. In many aspects, the COVID policies of Biden and Trump are almost diametrically opposed, especially concerning the role of the federal government in organizing the nation’s pandemic response. The next administration’s actions to prevent future COVID-19 surges, ensure safe a return to work and school, accelerate therapies, and coordinate vaccine delivery will remain the most important aspect of healthcare policy well into 2021.


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

Are health systems ready for “work from home forever”? 

Over the past few weeks we’ve fielded a spate of questions from health system executives wondering about their peers’ plans for employees to return to the office. Some who have set a January 1st target for employees to return to their physical workspaces are now reconsidering. “The first of the year sounded good back in the summer, but now it seems kind of arbitrary,” one system COO told us. “And if we really are entering a winter ‘third wave’ of COVID, it may not be a sound decision for health reasons, either.” Many have been positively surprised by the levels of communication and productivity since many employees began telecommuting full-time back in the spring. “It would be one thing to tell people they had to come back if the work wasn’t getting done. But for many, productivity has actually been better,” one executive shared.

Eight months into the work-from-home experiment (and with a handful of high-profile companies like Twitter saying employees can work from home forever), some leaders are now wondering whether they too should allow some staff to work from home permanently. The opportunities are obvious: real estate and overhead cost savings, and a potential boost to employee engagement and retention. But contemplating a long-term shift raises big questions. As remote workers in expensive markets look to move to lower-cost cities, or even to states with lower tax rates, does a geographic connection to the area matter? As new staff who have never met in person are added, can culture and teambuilding be sustained? And how to blend operations and communication across remote staff and those who work in the office, by choice or necessity? (“In-person meetings are great, Zoom meetings have gotten better, but the ones where half of us are in a conference room and the other half are dialing in feel like a death knell,” one physician leader told us.) The pandemic has likely launched a lasting shift toward “work anywhere”. But in order to capture the benefits of remote or flexible work, leaders must invest time and resources to rethink and transform the way they onboard, manage, operate, and communicate with the hybrid teams of the future.

What can Whole Foods tell us about integrating telemedicine?

A quick stop at the local Whole Foods Market recently yielded surprising insights into the dilemma faced by physician practices in the COVID-era telemedicine boom. The store location opened just last year, part of a brand-new residential and shopping complex designed for busy professionals. It’s larger than the old-style, pre-Amazon era stores, and was designed to integrate Amazon’s online grocery operations into the bricks-and-mortar retail setting. There’s a portion of the store set aside for Amazon “shoppers” to receive and pack online orders for pickup and delivery, along with an expanded array of convenience-food offerings for the app-powered consumer to scan and purchase. But when COVID hit, the volume of online orders went through the roof, and the store hired a small army of Amazon shoppers (including one of our own adult children who’s on a “gap year”) to keep up with demand. The result has been barely controlled chaos—easily 70 percent of the shoppers in the aisles last weekend were young Amazon employees “shopping” on behalf of online customers. They’re all held to an Amazon-level productivity standard, which makes the pace of their cart-pushing somewhat frantic and erratic. And the discreet area at the front of the store for managing the Amazon orders has become a noisy hub, making entering and exiting the store problematic. Even the “regular” store employees at Whole Foods have begun to complain about the disruption caused by the Amazon fulfillment operation.

It’s a cautionary tale for traditional physician practices and other care delivery organizations looking to “integrate” telemedicine into normal operations. Integration sounds great in theory, but in practice raises important questions: what physical space should be set aside for delivering virtual care? Should telemedicine work be done in a separate, centralized location, or in existing clinic space? How does the staffing of clinics need to change to meet the demand for virtual care? How can we flex staffing up and down based on demand for telemedicine? If new staff are required, how will they be incorporated into the existing team—or should they be managed separately? What operational metrics will they be held accountable for, and what impact will those metrics have on other operational goals? If Amazon, a worldwide leader online, renowned for running tight, precision, productivity-driven operations, is having trouble figuring out physical-virtual integration at the front end of their business, imagine how difficult these challenges will be for healthcare providers. The sooner we start to dig into these issues and find sustainable solutions, the better.


What we’ve been writing about lately on the Gist Blog.

Should Your Health System Centralize Innovation?

This week, our Teresa Breen and Michael Cuello share insights from recent work with health system members to address the pressing topic of innovation. Many health systems found themselves forced to change quickly as the COVID crisis took hold, and are now faced with the challenge of sustaining momentum and building lasting approaches to innovation. Teresa and Michael argue that a centralized innovation function can accelerate innovation efforts, supporting both incremental, business unit-driven innovation, as well as spearheading more disruptive innovations that result in new business or delivery models.

Check out their post on the Gist Blog, and let us know your thoughts!


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

On last Monday’s episode, Gist’s Senior Governance Advisor and former CEO of Jacksonville, FL based Baptist Health Hugh Greene shared insights and lessons he learned from leading a health system board for almost two decades.

Coming up on Monday, we’ll have a special report from the Walmart Health Centers springing up outside of Atlanta, GA. You’ll hear from patients who love the affordable and comprehensive primary care, and local providers who are surprisingly welcoming of the new offering. Make sure to tune in, you won’t want to miss it!

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We would’ve worked harder, but we watched this instead.

About halfway through American Utopia, the Spike Lee-directed film adaptation of David Byrne’s acclaimed 2019 Broadway show, you suddenly realize that you’re not just watching a follow up, 36 years later, to the best concert movie ever made—Jonathan Demme’s Stop Making Sense, which captured the Talking Heads at their mid-80s peak. You’re watching a musical reimagining of Mister Rogers’ Neighborhood, with the angular, twitchy, but somehow kindly Byrne delivering a feel-good message of connection and community, updated for our anxious times. At once a greatest hits compilation (including “Once in a Lifetime,” “This Must Be the Place,” and “Burning Down the House,” among many other favorites), and a coda to the weirdness of Demme’s earlier interpretation (boxy grey suits, stark staging, deconstructed compositions), the new Spike Lee “joint” debuted this month on HBO, after Byrne’s Broadway production was cut short by the coronavirus pandemic. (The show was part of Byrne’s ongoing multimedia project, “Reasons to Be Cheerful”.) Lee’s camera brings us right onstage, amid the diverse and joyful musicians, dancing, marching, and (yes) twitching along with Byrne, who intersperses the songs with brief homilies on kindness and inclusion. The show includes more than 20 musical numbers, combining classic Talking Heads music with cuts from his 2018 album of the same name. But the most powerful moments come from others—a stirring cover of Janelle Monáe’s anti-racist anthem “Hell You Talmbout”, and a cover of Byrne’s own “Everybody’s Coming to My House” by students from the Detroit School of the Arts. All these years later, American Utopia shows us, the well-trod “Road to Nowhere” finally leads us to Mr. Byrne’s Neighborhood.


Stuff we read this week that made us think.

The mounting mental health crisis among millennials

Last year we were stunned by data from a Blue Cross Blue Shield (BCBS) study showing that millennials are less healthy than previous generations, exhibiting a higher prevalence of chronic disease and mental health disorders, at a younger age, than their Gen-X counterparts. This month, BCBS is out with a new update on the mental health of millennials. Analyzing claims data, the report finds that a full third of millennials have a diagnosed behavioral health condition. Even more concerning is the sharp growth in incidence, with depression increasing 43 percent between 2014 and 2018; ADHD diagnoses grew 38 percent over the same time. Incidence rates were lower among minority populations, with Blacks and Hispanics showing 30-60 percent lower rates of major depression and ADHD, although this likely reflects significant under-diagnosis in these communities. Undoubtedly the incidence of mental health conditions has skyrocketed during the pandemic from these already high rates. In a September BCBS Association survey, 92 percent of millennials said that COVID-19 has had a negative impact on their mental health, and 34 percent report an increase in alcohol use. With the oldest millennials turning 40 next year, those with chronic disease could soon be experiencing complications requiring costly treatment. As the healthcare system struggles with managing the cost of care for aging Baby Boomers, preventing serious, long-term chronic disease and mental health conditions among their children is emerging as a critical priority.

An early pardon for overweight turkeys?

Overweight patients infected with COVID-19 have a higher risk of severe disease—but it turns out the pandemic may have brought a reprieve for overweight turkeys. According to a recent Washington Post piece, turkey farmers are facing a glut of, ahem, larger birds, as social distancing and reduced travel are expected to result in fewer people around the Thanksgiving dinner table, and fewer families springing for a 20-pound bird. Farmers commit to their chicks as early as January, making a bet on the ratio of larger (male) toms versus smaller (female) hens to meet holiday demand, so many were locked into their plans before the pandemic hit. Demand for larger birds has also been hit by fewer orders for piece parts: with fall Renaissance festivals canceled, demand for turkey legs cratered. (Spare a thought for mead brewers as well.) Sadly, these soon-to-be-spared holiday heavyweights are unlikely to spend the winter roaming free—look for a rise in ground turkey supply a few months down the road. Smaller birds for smaller gatherings: just another way our “Pandemic Thanksgiving” will look like none we’ve experienced before.

That’s it for another edition of the Weekly Gist. Thank you so much for taking time to read our work—we really appreciate it, and we’re so grateful to hear your feedback and suggestions each week. We’d love it if you’d take a moment to share this edition with a friend or colleague, and encourage them to subscribe, and to listen to our daily podcast.

Most of all, we hope you’ll let us know if there’s anything we can do to 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