April 24, 2020

The Weekly Gist: The Clorox Sunrise Edition

by Chas Roades and Lisa Bielamowicz MD

Are you a Georgia resident who’s been anxiously waiting to get inked up and have your fraying fingernails tended to? Well, today’s your big day. We wouldn’t advise going out just yet, any more than we’d recommend ordering one of those Clorox Sunrise cocktails they’re serving up at the bar around the corner. But talk of opening up “essential services” did get us thinking about what’s on our retail wish lists. At the top: independent bookstores. Our fantasy outing includes some of our favorite places around the country: City Lights (San Francisco); BookSoup (Los Angeles); Powell’s (Portland); McNally Jackson (New York); Strand (also NYC); Scuppernong (Greensboro); Brazos (Houston); Interabang (Dallas); Tattered Cover (Denver); and so many more. How we miss them.

What about you? What’s on your “Independence Day” shopping list?


THIS WEEK IN HEALTHCARE

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

Tentative steps toward recovering from a deadly pandemic

The death toll from the novel coronavirus continued to mount this week, with more than 50,000 deaths reported in the US, and over 900,000 confirmed cases nationwide. Globally, the disease has infected more than 2.7M people and killed nearly 200,000. On Tuesday, public health officials in California announced that two people who died in Santa Clara County in early February were victims of COVID-19, making them the earliest known fatalities in the US, and altering experts’ understanding of how long the disease has been spreading in the country. New modeling from researchers at Northeastern University this week suggested that the virus may have been spreading widely in several cities by early February, but went undetected because of restrictions on testing. National attention has remained focused on the subject of testing, as states and localities scramble to secure enough testing supplies and equipment to allow them to understand community spread and identify new cases. President Trump signed an emergency $484B relief bill on Friday that will provide $25B to ramp up testing, give additional aid to businesses forced to shutter, and send hospitals $75B in additional emergency funding.

The new money for hospitals is in addition to $100B already approved by Congress for a “provider relief fund” as part of the CARES Act. Having already distributed $30B of the initial grant money to hospitals, the Department of Health and Human Services (HHS) was expected to pay out an additional $20B today, this time according to a formula based on the net patient revenue of each hospital, rather than the earlier approach based on Medicare billings. The shift is expected to address concerns among children’s hospitals, safety-net providers, and others who were disadvantaged by the Medicare-based approach. It is unclear how the newly approved $75B of additional funding will be allocated.

Meanwhile, states began to plan for the reopening of their economies, with most governors taking a measured approach in coordination with neighboring states. A handful of states moved to loosen stay-at-home restrictions in advance of meeting the Trump administration’s “gating” criteria, including Florida, which reopened some beaches for recreational use, Oklahoma, and Georgia, which controversially allowed gyms, bowling alleys, hair and nail salons, and tattoo parlors to reopen on Friday. Many states began to put in place plans to restart elective surgeries, which had been curtailed by a patchwork of differing state and local directives. The Centers for Medicare and Medicaid Services (CMS) released guidelines this week to help local officials decide when and how to restart surgeries. Whether for healthcare services or other types of economic activity, states will (and should) be guided by the ability to conduct widespread testing, robust contact tracing, and isolation of those infected with the virus. Ensuring that ability will likely make the next phase of the pandemic a protracted and frustrating “dance” of fits and starts, likely to last into the summer months and beyond.

What we can (and can’t) conclude from antibody testing

As we move into the next phase of the pandemic, one important group to track will be those who have recovered from coronavirus infection, hopefully carrying some level of immunity that would allow them to move confidently away from social distancing. A crop of new tests aims to measure antibodies to coronavirus, hoping to ascertain how many people may have this new Holy Grail of “seropositivity”. But there’s still much confusion about just how many Americans have been exposed, and what exactly those serology tests tell us. What does having antibodies detected in a blood sample mean for any individual patient? While experts agree that previous exposure to the virus, as detected by the presence of antibodies, probably confers some immunity, no one knows how much or for how long. A positive antibody test is not a reliable predictor of active infection; tests that look for viral genetic material, or RNA, are needed. (Dr. Bob Wachter, Chair of Medicine at UCSF, provides a great primer on antibody testing here.)

Antibody tests are more useful in determining how pervasively COVID-19 infection has spread through a population. Stanford researchers measured seropositivity rates in Santa Clara, CA, one of the earliest communities affected by COVID-19, and estimated that the number of actual cases could be 50 to 85 times higher than the number of confirmed cases; a similar study of individuals in Los Angeles posited the number of infections may be as much as 55 times higher than confirmed cases. Scientists were quick to point out flaws in these analyses, questioning the accuracy rates of testing, participant recruitment processes and rush to publish—all of which could have led to overestimation of “community seropositivity”. A state-led study in New York appears to be more credible, finding that 21 percent of tested New York City residents had exposure to the virus. That’s good news for the mortality rate in the city, which would fall to around one percent under those rates of infection—but given the outstanding questions about seropositivity, the New York City Department of Health released a statement cautioning against using antibody tests to diagnose infections or determine immunity. Further analysis, refinement of testing, and larger sample sizes are needed to truly understand how many Americans may already have been exposed to the virus. Regardless, even the most affected communities are still far from the 70 percent seropositivity needed to reach “herd immunity”—hitting that benchmark will require a widely-available vaccine, still months (or years) away.

Envision Healthcare considering bankruptcy filing

National physician staffing firm Envision Healthcare is considering filing for bankruptcy, according a report from Bloomberg. Sources say the company, backed by private equity (PE) firm KKR, which acquired Envision for $9.9B in June 2018, has hired restructuring advisors and is working with an investment bank. The abrupt halt to elective surgeries and reduction in emergency room volumes due to COVID-19 has caused Envision’s business to shrink by 65 to 75 percent in just two weeks at its 168 open ambulatory surgery centers (ASCs), compared to the same time period last year. The Nashville-based company, which employs over 25,000 physicians and advanced practitioners, has already been reducing pay for providers and executives, in addition to implementing temporary furloughs. Envision is also struggling with a debt load of more than $7B, resulting from its 2018 leveraged buyout, and has been unable to convince its bondholders to approve a debt swap.

It remains to be seen whether Envision will be a bellwether for how other PE-backed physician groups will weather the ongoing COVID crisis. While Envision’s composition of mainly hospital- and ASC-based providers, coupled with its huge debt load, leave it on especially shaky financial footing, many PE-backed physician groups will struggle this year to achieve anything close to the 20 percent annual rate of return often promised to investors. If high-profile PE-backed groups like Envision end up declaring bankruptcy, it will likely impact the calculus of the many independent practices which may have previously looked to PE firms for acquisitionand temper the enthusiasm of investors, who might see physician staffing and practice roll-ups as less attractive as volumes continue to fluctuate.


GRAPHIC OF THE WEEK

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

Which surgeries should hospitals bring back first?

Beyond the general guidelines provided by CMS for restarting elective surgeries—the need to have sufficient protective equipment for staff, the imperative to have safe and COVID-free patient care spaces, and the need to conduct thorough testing of prospective surgery patients—many health systems are grappling with decisions about which surgeries to bring back, in what order. In the graphic below, we highlight a useful framework constructed by the American College of Surgeons (ACS). Their Medically-Necessary Time-Sensitive (MeNTS) prioritization guidelines show how organizations can objectively score each potential surgical case using three different sets of factors to determine risk and required resource level: procedure, disease and patient. Each of these factors is comprised of six to eight metrics, scored using a point scale from one to five, and then summed for a final score ranging from 21 to 105. Metrics include procedure length, number of staff needed to perform the surgery, existing patient comorbidities, and the health risk in delaying the surgery. The ACS recommends institutions resume scheduling lower-scoring cases first, as higher scores represent a greater risk to the patient, higher utilization of resources, and viral exposure for the teamOther specialty organizations, such as the American Academy of Orthopedic Surgeons, have released their own sets of recommendations for reopening electives—all with similar suggestions to begin with necessary cancelled or postponed surgeries, and then proceed to ambulatory cases.


THIS WEEK AT GIST—ON THE ROAD PHONE

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

Sharing ideas on when and how to resume elective surgeries

As health systems gain confidence in their ability to manage ongoing COVID-19 infections, leaders have begun planning for “reopening”, bringing back patients in need of non-emergent procedures and in-person care. Given that health systems are navigating a host of complex decisions, we hosted a Gist Healthcare all-member convening this week, in which leaders from ten member systems assembled via Zoom (which miraculously stayed stable for the full conversation), and shared ideas around the operational processes, patient recruitment and financial impact of restarting elective surgeries. Across the country, regulatory and public health guidance is vague, and often conflicting between state and local authorities, leaving providers to decide when to begin. But with doctors reticent to further delay interventions for serious conditions like cancer and heart disease, the numbers of “elective but not optional” postponed cases are growing. All participants expressed both a rising need and sense of readiness to restart. Supplies of necessary PPE are solid, but testing supplies remained a concern. To ensure staff safety, most systems plan to test every patient for COVID-19 prior to surgery, with one system also requiring ten days of documented temperature checks, given concerns about testing accuracy.

To plan for capacity needs, systems are trying to estimate how much demand will return, and how quickly. There was consensus that not all cancelled patients will return: a likely best-case scenario is that 80 to 90 percent will come back. But concerns remain about the financial impact of rising rates of unemployment on coverage and patients’ ability to pay: “If 90 percent of the cases return, we’ll be lucky if they bring 80 percent of the margin,” shared one chief strategy officer. Systems are planning for extended hours, with operating rooms running evenings and weekends to account for slower throughput, given enhanced safety procedures and changes in staffing. But leaders hope that the reboot will provide the opportunity for a broader examination of block scheduling processes, and a chance to reset relationships with surgeons, leading to improved operations in the long-term. We were reminded of the power of sharing ideas as systems navigate completely uncharted waters, and we were humbled by the effort and care all were taking in ensuring the safety of patients and staff as they resume this critical and complicated work.

“I’ll take my chances with breast cancer”

It’s entirely understandable that consumers would be reticent to visit in-person care settings right now. Given that doctors’ offices and urgent care facilities are where sick people congregate, a patient might well assume their chances of contracting COVID-19 would be higher there than in almost any other public space. But a story we heard this week from a health system chief strategy officer (CSO) reveals just how frightened patients may be to return. Last week the system began to reach out to patients who had positive screening mammograms in February, before elective procedures and tests were cancelled, and who now needed to return for more detailed diagnostic images. A full 75 percent of these patients were unwilling to schedule a diagnostic mammogram within the next month, with one patient even saying, “I’ll take my chances with breast cancer over COVID!”.

Women with a concerning mammogram finding are typically among the most motivated patients in seeking follow-up care. If a majority of them are unwilling to pursue in-person follow-up, the same will likely be true of scores of patients with other possible cancers, heart disease, and other serious conditions. As fear delays needed care, patients are likely to end up much sicker, with more advanced disease, when they do return. With rigorous attention to symptom and temperature screening, visiting a doctor’s office should be less risky than going to the grocery store—but providers will have to publicly communicate the steps they are taking to keep patients safe before many will be willing to come in the door.


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, Dr. Charles Dennis, Chief Medical Officer at the Carle Foundation, told us that engineers and medical professionals there have been collaborating to develop an emergency ventilator. Dennis expects the RapidVent, which costs around $100 to produce and requires minimal infrastructure, could be useful for medically underserved communities across the world.

Coming up on next Monday’s episode, we’ll hear from Dr. David Carsten about how the dental field is being impacted by COVID-19. As a dental commissioner in Washington State, he’s investigating reports of dentists performing elective procedures in violation of the governor’s order to shut down. The pandemic has also upended dentistry’s live-patient licensure requirement, which is now being rapidly transitioned to an exam. Tune in to learn more!

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


ON THE GIST TURNTABLE

Give this a spin—you might like it.

“Ladies, ladies, ladies, ladies,” says Fiona Apple on her new album Fetch the Bolt Cutters, leaving no doubt who she’s addressing in her first full-length release in eight years. Remember Fiona Apple? Before Billie Eilish, before Lana del Rey, before Lorde, there was Fiona, who dropped her debut album on the world in 1996, delivering smoldering, angry breakup songs she’d been writing since she was a young teen, and earning critical acclaim and comparisons to the likes of Patti Smith and Nina Simone. Twenty-four years and three albums later (each as good as the first), she’s back with a stunning fifth collection that takes the advice she gave MTV viewers back in 1997 to heart: “The world is bullshit…Go with yourself.” On track after track, she turns what once were heartbroken laments into a powerful call to arms, urging women to unshackle themselves (with those bolt cutters), right the wrongs, and declare that enough is enough. It’s a breakup album inside of a protest album inside of an arthouse soundtrack. The urgency of the lyrics (“Kick me under the table all you want/I won’t shut up.”) is matched by Apple’s stripped-down, readymade musicianship—recorded in her California home, she takes social-distancing practicality to the extreme, creating a makeshift studio in her living room filled with noisy objects, barking dogs, and her own raw vocals. She stretches from whispered lyrics to full-on shouts, over awkward time signatures, off-kilter harmonies, and a cacophony of sounds. There’s not a weak moment on the album—each song is an epiphany. Undoubtedly the album of the year, give out the awards now. Best tracks: “Heavy Balloon”; “Shameika”; “Under the Table”.


GIST IN THE NEWS

We said it, they quoted it.

Hospitals Aim to Resume Procedures Postponed by Coronavirus
Wall Street Journal; April 22, 2020

“Federal health officials followed Sunday with recommendations for reopening operating rooms, while urging hospitals to keep up efforts to conserve protective gear. The Centers for Medicare and Medicaid Services also said patients should be tested before treatment as soon as hospitals can do so. Until then, hospitals should screen patients by symptoms, CMS said.

Protective equipment and testing capacity remain limited in many U.S. communities, said Lisa Bielamowicz, president of consultants Gist Healthcare. ‘In most places, both of those things are very uncertain,’ said Dr. Bielamowicz.”


WHAT WE’RE READING

Stuff we read this week that made us think.

A more detailed plan for reopening the economy

On the heels of last week’s release of the White House’s “Opening Up America Again” plan, which contained broad guidelines for restarting activities based on a phased approach with “gating” criteria, the National Governors Association (NGA) released its own roadmap for reopening this week. Developed in conjunction with the Association of State and Territorial Health Officials, it gives a much more detailed and practical set of suggestions for state and local officials to consider as they put in place the measures needed to safely reopen their economies. It lays out a 10-step process for building public health infrastructure and planning for a gradual reopening, detailing evaluation criteria, metrics to monitor, and resources for building key capabilities. The report describes how states can build testing capacity (including the critical ability to conduct antibody tests), put in place public surveillance methods to track disease spread, and scale up the ability to identify, isolate, and quarantine those who become infected. It addresses the need to develop detailed criteria for which businesses to open when, and to implement a clear and comprehensive approach for communicating with the public. In short, it’s a much-needed complement to the high-level guidelines set out by the White House, and well worth reading for a sense of just what lies ahead. Kudos to the team at NGA and their public health colleagues for creating this important resource.

Learning from the largest US study of coronavirus patients

study published this week in JAMA provides a look at the largest series of COVID-19 hospitalized patients studied to date in the US, reporting that almost all patients treated had at least one underlying condition. Physicians from Northwell Health evaluated the outcomes, comorbidities and clinical course of 5,700 confirmed coronavirus patients hospitalized between March 1st and April 4th across the New York City area. Hospitalized patients, 60 percent of whom were men, had a high burden of chronic disease. Similar to other reports, older patients, and those with a higher chronic disease burden (especially diabetes) were both more likely to require mechanical ventilation, and more likely to die. Only nine of the 436 patients under age 50 who had no significant cormorbidities (as measured by the Charlson Comorbidity Index) had died. One number received the most press coverage: as reported in the abstract, 88 percent of patients who received mechanical ventilation died. Digging into the details of the series, this may end up being an overestimation, as the statistic is based on a subset of 320 ventilated patients who either died or were discharged by April 4th. At that time, 831 patients remained in the hospital on ventilators, with outcomes still to be determined. Ultimately, the mortality rate of full cohort of ventilated patients could fall nearer to the 50-60 percent range seen in other studies.

Regardless, the rich dataset of the Northwell report adds to the body of evidence that severe COVID-19 infections and deaths involve several organ systems. This Science article provides a thorough (and comprehensible to the non-clinician) review of how the virus invades the body. While the lungs remain “ground zero” for infection, critically ill patients may experience serious kidney, cardiac, or even nervous system involvement. A host of chronic diseases predispose patients for worse outcomes—yet doctors remain puzzled that they aren’t seeing “a huge number of asthmatics” in ICUs. Patients are presenting with dangerously low oxygen levels but less distress than expected, likely because they are able to still “blow off” carbon dioxide, limiting the body’s ability to sense the seriousness of their condition. Many dying patients are overwhelmed by a “cytokine storm”—an overreaction of the immune system that compounds organ failure. And new evidence suggests that large numbers of critically ill patients may experience abnormal blood clotting, contributing to the high mortality rates of the disease. The more doctors and scientists learn about coronavirus, the more complex the disease process seems—leaving doctors with work to do to understand, manage, and treat the tens of thousands of these seriously ill patients.


Another week marked off the calendar. We’re staying optimistic—we’ll be back out and about soon, and we can’t wait to get back on the road! Until then, we really appreciate you taking the time to read our basement scribblings, and we’d be so grateful if you’d share this with a friend or colleague and encourage them to subscribe, and to check out our daily podcast.

Most importantly, please let us know if there’s anything we can do to be of assistance in your work, especially at this critical time. You’re making healthcare better—we want to help!

To those observing the Holy Month, Ramadan Mubarak, and to all, our best regards,

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

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