March 13, 2020

The Weekly Gist: The Coronavirus Crisis Edition

by Chas Roades and Lisa Bielamowicz MD

Strange times. We’re just back from a week’s worth of travel, out on the road with our members. The mood everywhere is tense—feels very much like the calm before a storm. Most of the change is anticipatory: daily planning huddles to manage the elective procedure schedule, first steps to set up alternate triage locations, plans for surge staffing, and restrictions on non-essential travel and visitors. Elbow bumps have replaced handshakes. The coming wave of coronavirus cases has yet to hit in most places, but it’s coming—you can feel it.

As frequently as we bemoan the cost and complexity of our health system, days like these are a good reminder of just how fortunate we are to have clinical and administrative professionals working hard to make sure we get through this difficult period in good shape. A huge “thank you” in advance for all the hard work that lies ahead.


THIS WEEK IN HEALTHCARE

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

Confronting a national emergency over coronavirus

President Trump declared a national emergency today, in response to the growing spread of coronavirus across the country. The administration had come under sharp criticism for its sluggish response to the coronavirus crisis, in particular the widespread shortage of tests. Dr. Antony Fauci, director of the National Institute of Health’s infectious disease branch, told Congress on Thursday that the government’s response on testing was “not really geared to what we need right now…That’s a failing. Let’s admit it.” In response, the administration today announced a series of emergency steps to increase testing capacity, turning to private labs to support the effort. The emergency status frees up $50B in federal emergency funding. Trump also announced that the Health and Human Services (HHS) Secretary will be able to waive regulations around telemedicine licensing, critical access hospital bed requirements and length of stay, and other measures to provide hospitals with added flexibility. House Speaker Nancy Pelosi and Treasury Secretary Steven Mnuchin have negotiated a sweeping aid package that would strengthen safety net programs, and offer sick leave for American workers affected by the virus.

Meanwhile, the American economy likely entered a recession, as consumers continued to pull back on spending on airline travel, entertainment, and other discretionary areas, while financial markets experienced the worst one-day drop in more than 30 years. Many school districts and universities shut down and announced plans to convert to online instruction for the foreseeable future. Employers imposed broad travel restrictions on their employees, moved to teleworking where possible, and even began to lay off workers as demand for services cratered. Shoppers stocked up on staples, cleaning supplies, and (inexplicably) toilet paper, as shelves ran bare in many stores. Epidemiologists and disease experts urged broad adoption of “social distancing”, restricting large gatherings and reducing the ability of the virus to spread person-to-person. The objective: “flattening the curve” of transmission, so that the healthcare delivery system does not become overwhelmed as the virus spreads exponentially.

“Beyond containment”: sobering predictions for coronavirus spread

As of today, over 132K cases of coronavirus, or COVID-19, have been diagnosed worldwide, with nearly 1,300 cases confirmed in the United States. As the number of American cases begins to grow, the New York Times detailed sobering “worst case” projections from the Centers of Disease Control (CDC). CDC scientists evaluated four different scenarios of how the virus could progress, based on virus characteristics, transmissibility and severity of illness, finding that between 160M and 214M Americans could be infected, and as many as 200K to 1.7M could die. The analysis also highlighted a potentially devastating gap in needed hospital capacity, estimating that 2.4M to 21M people could require hospitalization. If these patients were to surge into emergency departments over a short period of time, the nation’s hospitals, which operate only 925,000 staffed beds, could be overwhelmed.

News from Italy, now with over 15K coronavirus patients, shows that intensive care capacity is even more important than free hospital bedsReports from the country’s epicenter in Milan and surrounding regions paint a picture of “wartime” medicine, with exhibition centers turned into ICUs and doctors, facing a shortage of ventilators, forced to decide who lives and who dies. (Read these two Twitter feeds from Italian clinicians to understand the dire situation and stress on providers in their hospitals.) As we show in the graphic below, while the US has more ICU beds per capita than Italy and many other countries, we still fall short of the number of ventilators that could be needed at peak coronavirus infection rates, or even a severe flu pandemic.

As conditions worsened in Italy, the number of new cases diagnosed in China and South Korea dropped dramatically, suggesting that both have figured out a way to stop the spread of the virus (China’s new infection rate has slowed to just a few dozen cases diagnosed daily). Both countries have mounted a similar response to contain spread. In addition to essentially shutting down all gatherings and movement of people in affected areas, both implemented widespread testing of anyone with symptoms, and aggressive tracing and screening of anyone who may have had contact with an infected patient. (This week, South Korea was testing 15,000 patients per day, while the US had performed fewer than half that number of tests in total.) China’s and South Korea’s processes of managing patients have likely been even more critical to their success in curbing spread. Both have established dedicated “fever centers” separate from hospitals to screen patients. Once patients are determined to have a fever, they are quarantined in mass units and separated from family, which continues if a patient is confirmed to have the virus. This is in stark contrast to Italy’s directive that infected patients and their contacts quarantine at home, which has been much less effective.

According to infectious disease and public health experts, the United States is at a turning point in working to stop the virus, with the country now past the hope of containing the virus, and the goal shifting to slowing spread. The US has been very slow to increase availability to testing, due to a host of reasons ranging from regulatory red tape and political indecision, to supply chain challenges. Efforts announced by the Trump administration today to ramp up testing, and establish dedicated testing centers separate from doctors’ offices and hospitals, are a step in the right direction. So are moves this week to cancel large gatherings, close schools, and encourage telework. While government-enforced quarantine measures of the level proven effective in China and South Korea are unlikely to be palatable here, we must all embrace the difficult work of strict social distancing and changing how we work and interact with each other. This may be the key to ensuring we can control spread and slow the rate of infection so we can continue to provide the best care to all severely ill patients.


GRAPHIC OF THE WEEK

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

Taking a look at the Biden healthcare plan

Now that the Democratic primary campaign has produced a clear front runner, it’s worth examining Joe Biden’s healthcare plan, which aims to expand the Affordable Care Act (ACA) by increasing access and affordability. As the graphic below highlights, former Vice President Biden has a broad—if at this point, still fairly high-level—proposal that includes a Medicare-like public option along with a variety of other ACA tweaks that aim to offer consumers more options and lower their healthcare costs. These include allowing individuals in states without Medicaid expansion to join the pubic option premium-free, providing unlimited subsidy eligibility, and limiting drug price increases to the level of consumer inflation. An independent analysis projects Biden’s plan would cost $2.25T and add an additional $800B to the deficit over 10 years. While large at first blush, these costs pale in comparison to Sen. Bernie Sanders’ Medicare for All plan, which would add a projected $12.95T to the deficit over the same period. Of course, there are still many unanswered questions in Biden’s proposal, including how much consumers would pay under the public option, how much the public option plan would reimburse providers as a percentage of Medicare, and how the public option would impact competition among private insurers. A public option offered at a significant discount has the potential to drive private plans out of business, which some project could eventually result in Medicare for All as an ultimate consequence. The devil will, as always, be in the details.


THIS WEEK AT GIST—ON THE ROAD

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

A source of balanced—and local—guidance in a crisis

Lisa:
Spending time onsite with our members is my greatest joy in the all of the work we do. As meetings cancel and most health systems restrict travel, our time this week with the board and leadership of a regional health system might be our last face-to-face meeting with a member for a while. Like all recent board meetings, this one included an update on the system’s coronavirus response. The first two local cases were just diagnosed in the prior 24 hours, but this system had already put in place a comprehensive plan to prepare for affected patients. In addition to plans to free up hospital capacity as needed, a number of care sites and physician practices were being taken offline and repurposed as COVID-19 testing and triage sites. They contacted hundreds of thousands of patients via email and through their patient portal to share information about what symptoms would trigger the need for a test or a visit to the emergency department—and provided specific instructions about where to go for care. The system’s chief strategy officer said these messages had a huge rate of “opens” and “clicks”, and that internet searches for the health system had spiked. Specifically, tens of thousands of people in the area were searching for “coronavirus” and the system’s name. Amid all of the conflicting messages they received from the media and political leaders, citizens were looking to their local health system to understand the local impact and guidance for what to do. It’s an important reminder of the trust that communities place in their doctors and health systems, to both take care of them in a time of need, and be a source of truth and advice in a very chaotic time.

Seeking standards, not standardization

Chas:
We’ve been working with a number of our members on the topic of “systemness”: helping think through how health systems can (finally) make progress on creating value from consolidation, moving from being a holding company of assets to a true, functioning system of care. One critical aspect of that work is standardization—making sure that, where appropriate, operational and clinical processes are uniform across different clinics, hospitals and markets. That’s one of the core sources of corporate value for any company—it would be crazy for GE to make refrigerators differently in Hyderabad, India than in Louisville, KY, for instance. Of course, delivering healthcare is more complex than making refrigerators, and (as we point out in our work on systemness) there needs to be a certain zone of allowable variability in many operational and clinical areas. Along these lines, a phrase that one physician executive used in a meeting recently caught my attention: he said what he tries to achieve are “standards, not standardization”. In other words, setting clinical and operational standards (for example, how much a knee implant should cost) rather than fully standardizing elements of care (what knee implant must our surgeons use). Of course, there are lots of things that should be completely standardized across the system—especially in “back office” areas like marketing, HR, revenue cycle, and legal. And some clinical work can be standardized as well: care protocols and agreed-upon pathways for treatment. But allowing variability in clinical practice requires a more flexible approach—one built on standards that clinicians can build consensus around—rather than on rigid standardization. We’ll have more to share about our systemness work in weeks to come—it’s a critical topic for executives as cost pressures mount, and questions about the value of health system scale abound.


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 Aneesh Chopra, Co-Founder of healthcare analytics company CareJourney and former US Chief Technology Officer (CTO) during the Obama administration. Chopra said the push to make patient health information more accessible is one of the few remaining areas of bipartisan agreement.

The new interoperability and information sharing rules are out, and next Monday, health policy veteran Julie Barnes, founder of Maverick Health Policy tells us that implementation is just around the corner. In short order hospitals will need to start sending electronic notifications about patient admissions, discharges and transfers. Listen in!

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


ON THE GIST GAMING TABLE

Bored? Game!

So, you’re stuck at home for an extended period of “social distancing”, and you’re facing a house full of antsy people with nowhere to go. Need a break from TV? How about a good, old-fashioned board game? If you haven’t played tabletop games in years, you’re in luck! There’s a whole universe of games beyond the dull assortment of Milton Bradley snoozers you grew up with. Among the best of them, and perfect for our times, is Pandemic—a 2-4 player “cooperative” game that pits you and your fellow players against the creeping, worldwide spread of a dangerous infection. Round by round, your team of scientists and disease-fighters travel the globe, assembling response teams and research facilities to contain and cure the virus. It takes about an hour to play, and there’s a bit of a learning curve, particularly if you’re not used to the collaborative play style the game requires. Be warned: you’re not guaranteed to beat the virus—the deck is (literally) stacked against you.

First launched in 2007, Pandemic has become a beloved board-game classic over the years and has since spawned a series of spin-offs and sequels. Best among these, and highly recommended, is 2016’s Pandemic: Legacy Season 1, which takes the core concept of the original but structures it around a 12- to 24-session “campaign”, with new twists and turns revealed each time you play. The downside is that once your group has worked its way through the campaign, you’re done—you’ve “completed” the board game. But this “season” structure adds an element of drama and suspense that delivers gameplay loaded with the same kind of tension you’d find in the best TV action shows. So, switch off Netflix, clear off the kitchen table, and gather your stir-crazy group around the game board. Your quarantine will fly by!

(Pro tip: For more great gaming ideas, head over to Board Game Geek—an incredible collection of reviews of thousands of games.)


WHAT WE’RE READING

Stuff we read this week that made us think.

Will coronavirus be the turning point for telemedicine?

Given concerns about overwhelmed emergency departments becoming transmission belts for infection spread, telemedicine is poised to play a crucial role in providing triage and care across coming months—and you can count on digital innovators to never waste a crisis to get their brand out in the market. Anyone who has taken a recent ride on the New York City subway has probably been introduced to Roman, the “digital health clinic” for men which has papered trains and stations with risqué ads for erectile dysfunction treatments. Starting last week, Ro, the parent company of Roman, announced they will offer free telemedicine assessments for coronavirus infection. Ro joins a host of telemedicine providers, including American Well, MD-VIP and Teladoc, to provide free online telemedicine triage for patients worried they might have the virus. Amazon Care, the company’s virtual clinic for employees, is reportedly teaming up with the Bill & Melinda Gates foundation to provide home delivery of rapid testing kits to Seattle residents.

Now many health systems are looking to quickly expand their telemedicine programs to accommodate the surge of patients seeking care, seeing new value in the ability to triage patients remotely, and keep healthy patients away from clinical care settings. Some tell us they will waive fees in order to encourage patients to use the service. Because of payment and regulatory challenges, and wary of destroying demand for reimbursed in-person services, health systems have been slow to scale telemedicine services. Many of those hurdles may be falling, as the $8B coronavirus funding bill passed by Congress last week expands Medicare payment for telemedicine, and today’s emergency declaration loosens regulatory restrictions around provider licensing for virtual care delivery. The COVID-19 pandemic may finally provide long-overdue motivation for providers to expand telemedicine access, and for patients to learn how to seek treatment online—creating new patterns of care likely to become permanent even after the crisis has passed.

HHS releases its long-awaited interoperability rules

HHS released the much-anticipated federal interoperability and information-blocking rules, which President Trump had been slated to announce at the recently cancelled HIMSS conference. The rules make for light weekend reading, at more than 1,700 pages combined. A provision of the 21st Century Cures Act designed to make it easier for providers, insurers, and patients to exchange health data, the new regulations require insurers and providers to adopt standardized application programming interfaces (APIs), protocols that connect electronic health records with third-party apps, by next year. Patients will soon be able to authorize which types of data they want to receive through smartphone apps of their choice, and app developers must have their privacy policies written in plain language and address how they plan to share clinical data. The rules also build on the Trump administration’s ongoing price transparency efforts, requiring insurers to provide cost-sharing information to beneficiaries through third-party apps—though the rules do not go as far as requiring hospitals to disclose how much patients would be charged for services. Hospitals participating in Medicare or Medicaid will also be required to electronically notify other healthcare facilities or community providers when a shared patient is admitted, transferred or discharged. As significant to the healthcare system as the introduction of ATMs was for banking, these rules lay the groundwork for a future in which consumers play a much larger role in managing their own health information and can use it to drive care decisions.


That’s all for now. Stay safe, be well, and take good care of those around you—even if it just means washing your hands and avoiding crowds. Thanks so much for taking the time to read our work—we really appreciate your feedback and suggestions. Don’t forget to pass this along to a friend or colleague and encourage them to subscribe, and to listen to our daily podcast.

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
chas@gisthealthcare.com

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

.