March 20, 2020

The Weekly Gist: The Climbing the Curve Edition

by Chas Roades and Lisa Bielamowicz MD

Hello fellow COVIDians, and greetings from our basements, attics, and home offices. This was the week that everyone’s world got turned upside down, including ours. As a “virtual” firm, with team members in different locations from coast-to-coast, we’re a little more used to Zoom playing a central role in our world, but no less accustomed to the routines of daily life being reshuffled. We’ve spent most of each day this week on calls with our members, hearing how they’re responding, sharing what we’ve heard, and providing whatever support we can. Here’s what we can report: as unsettling as the news has been, we’re so inspired and encouraged by the great work being done behind the scenes and on the front lines of the nation’s healthcare system. We’re in good hands.

A bit of an appended format for today’s edition—we figured you’re already drowning in news bulletins, resource guides, consultant webinars and the like. Below, a quick roundup of where we are today, what we’ve heard that’s worth passing on, and what we’ve learned this week. You know…the “gist”.


THIS WEEK IN HEALTHCARE

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

Another week on the exponential curve

As efforts to increase testing for COVID-19 ramped up this week, the number of cases in the US rose exponentially, and the number of deaths increased sharply as well. Early but incomplete data from the Centers for Disease Control and Prevention (CDC) indicated that the virus was impacting younger people in greater numbers than had been seen in China and Italy, and concerns grew that asymptomatic but infected people could be spreading the virus to those with compromised health status. In response, many cities and states moved aggressively to put in place stricter measures to keep people in their homes to mitigate spread. Several flashpoints have emerged across the healthcare system. Supplies of personal protective equipment (PPE) are in short supply, raising concerns about putting healthcare workers at risk. Testing supplies—particularly collection swabs—are also running low in many places, forcing some newly-launched testing locations to close after just a few days. Hospitals across the country began to gear up for a wave of patients, with the number of potential cases likely to far exceed existing capacity of hospital beds, intensive care beds, and, in particular, ventilators. In response, the President invoked the Defense Production Act, which will allow the government to direct private sector production of critically needed equipment. Hospital leaders have been advised by the government to cancel elective surgeries and minimize non-emergency utilization of healthcare resources, to preserve supplies and capacity for the coming wave of cases.

The Centers for Medicare and Medicaid Services (CMS) loosened several key regulations to allow more care to be delivered virtually, in an attempt to relieve pressure on the system (more on that below). By week’s end, hospitals in several areas—including Seattle, San Francisco, New York, and New Orleans—were reporting that they were perilously close to being overwhelmed. As many have pointed out, we are faced with a decision of which curve we want to be on: one that looks like Italy, which responded late with mitigation and suppression efforts and has found their healthcare system collapsing under the volume of hospitalizations; or one that looks like South Korea, where aggressive measures to suppress spread, including extensive testing, strict social distancing, and isolation of infected people, seem to have “flattened the curve”. The next two weeks will be critical in determining what the next year looks like in America.

A flurry of regulatory changes in response to coronavirus

Government regulators have been furiously issuing a trove of new regulatory guidance in the week since President Trump’s March 13th national emergency declaration, looking to give providers proactive guidance and additional flexibility to prepare for a surge in coronavirus cases. Here are the highlights:

  • Recommendation to halt all elective surgeries. CMS issued a recommendation on March 18th that providers halt all elective medical, surgical, and dental procedures to conserve resources, including scarce PPE, for treating COVID-19 patients, and to reduce the chance of spreading the virus.
  • Expanded telehealth coverage. CMS has temporarily expanded telehealth coverage for Medicare beneficiaries—retroactive to March 6th—reimbursing providers for a wide range of telehealth services at the same rate as in-person care. The agency is also temporarily relaxing some HIPAA requirements to enable doctors to deliver telehealth services on their own phones. States are encouraged to make similar virtual care adjustments to their Medicaid programs, and will not require federal approval to do so.
  • Waivers for Medicaid requirementsCMS approved waivers from Florida and Washington State—and expects more waiver applications from other states in coming days—allowing them to curtail typical Medicaid requirements and free up resources. These waivers set aside insurer prior authorization requirements and allow states to quickly expand Medicaid payments and services related to the virus. They also make it easier for out-of-state providers to practice in each state.
  • Nursing home restrictionsFollowing guidance from the CDC, CMS announced new, temporary measures focused on nursing homes, directing them to significantly restrict both visitors and nonessential personnel, and to halt communal dining and other activities.

We expect more actions in the coming days and weeks, including guidance allowing clinicians to practice across state lines, which Vice President Pence has promised is on its way soon. This CMS guidance comes amid a sea of other legal and regulatory changes designed to offer more resources and maximum flexibility to providers, including a law signed Wednesday that allows N95 construction masks to be sold to hospitals without fear of liability. While the above measures have been taken temporarily, some—particularly the expansion of telehealth—may spur changes in care that will become ingrained in practice and persist once the crisis is over.


Expanding critical care staffing for COVID-19

As concerns about the limited number of ventilators mount, hospitals leaders know it’s not just the machines that are in short supply—they must also focus attention on the limited number of clinicians available to operate the ventilators needed for the surge of COVID-19 patients. A recent projection from the American Hospital Association estimates that 960,000 COVID-19 patients will require mechanical ventilation. According to the Society of Critical Care Medicine (SCCM), even if that many ventilators could possibly be procured, there are nowhere near the number of intensive care-trained clinicians needed to safely operate them. The graphic below lays out SCCM’s tiered intensive care unit (ICU) pandemic staffing guidance, which includes the addition of some staff not typically deployed in the ICU (shown in yellow) to help cover these critically ill patients. Anesthesiologists and nurse anesthetists, who have experience with ventilator operation in surgery, play a key role. In order to implement this kind of staffing model, hospitals must cancel all elective surgeries, including those in ambulatory surgery centers, and reallocate all clinicians who can operate ventilators to critical care units.


THIS WEEK AT GIST—ON THE ROAD PHONE

What we learned this week from our work with members.

“We’re looking at a tsunami”

Yesterday we spoke with a senior healthcare executive leading the COVID-19 response for a regional health system on the West Coast. Their area is now experiencing exponential growth of new cases, with the number of local diagnoses doubling every couple of days. In all likelihood, they’re less than two weeks from having the number of cases seen in harder-hit areas like San Francisco, Seattle and New York City. She said the “anticipation of what is about to happen” is the scariest part of the around-the-clock work they are doing to prepare.

But that two-week lead time has given them precious time to organize, and she generously shared key elements of their action plan. Their preparation work—surely similar to what hundreds of health systems around the country are doing—impressed us not only with its breadth, depth and comprehensiveness, but also the level of energy and confidence conveyed by the hundreds of actions and decisions, large and small, the system is making every day. Here are some of their important learnings so far:

  1. Even though the surge of patients has yet to begin, staff are “worried and scared”. They are concerned about PPE shortages and personal safety and stressed at home with schools and daycare closed. Detailed and regular communication is more critical than ever—and they’re trying to answer every inbound concern or question from associates directly. They are funding and expanding childcare options for staff, through partnerships with community organizations and daily stipends for home-based care.
  2. As the system works through worst-case scenario planning, they anticipate the need for critical care nurses, respiratory therapists, and emergency physicians will be the worst bottlenecks, and they are working to cross-train adjacent clinicians and build new staffing models to increase capacity. While most providers are deeply dedicated to providing care for COVID-19 patients, a small number have already “called off” and refused to report—creating unanticipated questions around how to manage these difficult situations.
  1. As they prepare to implement new surge staffing models, the system is now navigating through a period of downtime. With elective procedures cancelled and some ambulatory sites closed, they currently need fewer nurses and clinical staff than a month ago, and are creating policies, like allowing staff to go negative into PTO, to maintain income while they wait for the surge. Staff who must work in-person are working variable shifts to reduce crowding. They are also working to credential nurses and staff furloughed from local ambulatory surgery centers, so they have them ready to deploy when needed.
  1. IT staff are working nonstop to quickly make it possible for all eligible employees to work remotely, and to enable staff to safely gain access to the system’s intranet while guarding against new cybersecurity threats. The system is training and enabling hundreds of doctors to deliver care virtually, including affiliated independents.
  1. Guidelines for coronavirus patient management and recommended PPE practices change daily; it’s a full-time job for clinical leaders to keep up. Doctors are eager to try novel and creative treatments for very sick patients. (For instance, one doctor is developing a 3-D printed device that will allow one ventilator to be used for four patients simultaneously.) This eagerness to “do something” is understandable but creates a bit of chaos as leaders work to create policies around how to best manage patients.
  1. While leaders communicate with other health systems and local and state authorities daily, the vast majority of decisions are made internally, on the fly. For instance, the system is connecting with now-empty local hotels and universities to provide options for low-acuity patient capacity, but leaders hope that parallel efforts at other organizations can be brought together into a more unified regional response. For now, however, coordination would likely create unacceptable delays.
  1. Long-term health and stamina of staff is top among the system’s concerns. “If I borrow worry from the future”, this leader said, “I am worried that we are facing years-long trauma, both emotional and financial, and I’m not sure how we will sort it out”. For now, efforts to support staff and provide moments of relief and joy, are critical, and very appreciated by front-line team members.

We left this conversation emotionally overwhelmed ourselves, and with a huge sense of gratitude for clinicians and health system leaders. Americans can take comfort in the amount of work that is taking place even before critical patients begin to appear—and that doctors, nurses and hospitals are truly dedicated to providing us the best possible care under circumstances they have never faced before. If you know about creative approaches or new ideas organizations are putting in place to contend with the current situation, please let us know. We’re eager to share great ideas!


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 Thursday’s episode we heard from Dr. Asaf Bitton, Executive Director of Boston-based Ariadne Labs, which is working to put out pandemic guidance for healthcare workers about safe surgical systems, obstetrics pathways and social distancing. Bitton told us that clinicians and health system leaders need to take “decisive, courageous action” now.

And on Tuesday, we heard from Dr. Erik Vanderlip, Chief Medical Officer at Zoom+Care. He told us that to respond to the COVID-19 pandemic, the urgent care chain, with clinics in Oregon and Washington, launched its text-to-provider tool weeks ahead of schedule. Vanderlip said Zoom+Care has been reevaluating what care really needs to be in person.

On next Monday’s episode, we’ll hear from David Kerwar, Chief Product Officer at Mount Sinai Health System. The New York City-based system has adapted its digital flu screening tool for COVID-19 to direct patients to the right level of care. Mount Sinai is utilizing medical students, who are now out of school, to help remotely answer patient questions through the digital platform.

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


ON THE GIST TURNTABLE

Give this a spin—you might like it.

We’ll return to our regular rotation of music, movie, and TV reviews next week, but this week we decided to deliver some groovin’ tunes—stat. Look, we’ll be honest—others have already had this same jive idea, but that didn’t stop us. To keep you entertained as you self-quarantine, shop for emergency groceries, or huddle around a conference room table trying to figure out staffing and supply chain contingencies, we’ve assembled an official Weekly Gist COVID-19 Playlist on Spotify. Here’s the twist: we want your suggestions too! Once you’ve grown weary of our roster of virus-related songs, send your recommendations along and we’ll add them to the playlist. Check back frequently to see what your fellow readers have queued up—don’t stop the music! We’ll get through this together.


WHAT WE’RE READING

Stuff we read this week that made us think.

Turning to Twitter for news and analysis

Not sure how you’re managing the overwhelming torrent of breaking news and analysis of the COVID-19 crisis, but we’re relying heavily on Twitter these days. Sure, there’s a lot of noise on the platform, but we’ve curated our own lists of key academics, policymakers, clinicians, and journalists over the years, and we’ve come to rely on a handful of their feeds to keep our thinking current. In case you’re not a veteran Twittizen, here are a few suggested “follows”:

Nicholas Bagley (@nicholas_bagley)—Professor of Law at University of Michigan. Analysis of legal issues surrounding health policy.

Dan Diamond (@ddiamond)—POLITICO health policy and politics reporter; former editor-in-chief of Advisory Board Daily Briefing. Investigative reporting and inside-the-Beltway insights on health policy.

Austin Frakt (@afrakt)—Health economist at the Dept. of Veterans Affairs and Boston University; frequent contributor to the New York Times Upshot blog. Microeconomic analysis of policy and public health issues.

Scott Gottlieb, MD (@ScottGottliebMD)—Resident Fellow at the American Enterprise Institute, former Commissioner of the US Food and Drug Administration. Insights on pharmaceutical business and policy; informal “coronavirus czar”.

Sachin Jain, MD (@sacjai)—CEO of CareMore Health. Insights on population health and care management from a leader in the field.

Ashish Jha, MD (@ashishkjha)—Faculty director at Harvard Global Health Institute; moving this fall to become Dean of Brown University’s School of Public Health. One of the nation’s leaders in public health, thoughtful analysis and guidance.

Farzad Mostashari, MD (@Farzad_MD)—Founder, Aledade; former National Coordinator for Health IT. Voice of independent physician practice, unique insights on population health and health IT issues.

Charles Ornstein (@charlesornstein)—Deputy managing editor at ProPublica; past president of the Assoc. of Health Care Journalists. In-depth, investigative reporting on the healthcare industry and related issues.

Eric Topol, MD (@erictopol)—Director of the Scripps Research Translational Institute; EVP of Scripps Research. Cutting-edge thinking on digital and personalized medicine, and implications for healthcare delivery.

Bob Wachter, MD (@bob_wachter)—Chair, UCSF Department of Medicine. View from the world of academic medicine from the “father” of the hospitalist movement.

In addition to these outstanding individual feeds, we also follow a number of organizational and news outlet feeds, and recommend that you do, too. Among them: Kaiser Health News (@KHNews); Health Affairs (@Health_Affairs); Kaiser Family Foundation (@KFF); New England Journal of Medicine (@NEJM); and New York Times Health (@NYTHealth).

Got your own favorite Twitter feeds? Let us know who we should be following. Happy tweeting!

The five best articles we read this week

It felt like there was an ocean of relevant information to absorb this week, and we’re guessing your reading list might be as long as ours. Amid all the studies and analyses that came across our screens this week, here are five that we think merit your attention.

  1. A study showing just how bad things could get. paper published this week by the Imperial College of London COVID-19 Response Team left a number ringing in our ears: 2.2 million—the number of Americans who could die from coronavirus if no control measures were put in place. The data was also reportedly responsible for jarring members of the Trump administration and Boris Johnson’s team into a new level of action.
  2. A measured perspective on how we beat coronavirus. Global health expert Ashish Jha and physician Aaron Carroll remind us that the alternatives aren’t only an 18-month lockdown or unmitigated spread. Their proposal for decisive short-term social distancing, coupled with long-term extensive testing, provides a helpful counterpoint to the Imperial College doomsday scenario, and a practical vision for a sustainable path forward.
  3. The data showing young people will suffer too. Americans were conditioned by China’s experience into thinking that nearly all serious illness and deaths from COVID-19 occur in the elderly. A new CDC report shows that young people may be much more vulnerable than we thought, showing that nearly 40 percent of US adults hospitalized for the virus were aged 20 to 54. While a deeper look reveals inconsistencies and holes in the data—many driven by the distributed and inconsistent processes of our public health system—it’s increasingly clear that young people will not emerge unscathed. Hopefully the broad coverage of this news will spur “invincible” twenty-somethings off the beaches and into action.
  1. Something that explains all of the options. If your head is spinning trying to understand the difference between mitigation and suppression, discern which social distancing measures provide greatest benefits, or comprehend how virus mutation could affect spread, this piece is the best we’ve seen to provide context and answers to all of these questions. Supported by data and analysis, it’s written in a way that a non-scientist can easily understand. Yes, it’s long, but delivers a fantastic grounding in the science and policy around COVID-19. Well worth the read.
  1. A (cheesy) moment of coronavirus-related levity. We’re still chuckling over an article that first appeared in the Irish Post, recounting the story of a woman in Washington State who was trying really, really hard to follow those handwashing guidelines we’ve all heard about. For some reason, it just wasn’t working. Might want to check the label next time.

That’s all for this week. We’ll end with a personal appeal: this weekend, take whatever time you can spare and spend it doing something enjoyable. Play a game, cook a meal, take a walk, FaceTime a friend, share a memory. The more things fall apart, the more we need to focus the things that bring us together with those we care about.

Thanks for reading our work, don’t forget to subscribe and encourage others to do the same. And if you have a chance, check out our daily podcast, too. Most of all, please let us know how we can support your work. 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