June 19, 2020

The Weekly Gist: The Forlorn French Fathers Edition

by Chas Roades and Lisa Bielamowicz MD

Just in time for Father’s Day weekend, professional soccer has come roaring back, and now we footie fanatics are spoiled for choice as to what to watch. Between the English Premier League, Spanish La Liga, German Bundesliga, and Italian Serie A there will be something like 35 different televised matches to feast on this weekend. As long as you’re ok with empty stadiums, piped-in crowd noise, and socially distanced goal celebrations, you’re in for a treat! Only the French top division, Ligue 1, remains on the sidelines—the French prime minister declared the season fini back in April. So spare a thought for all those forlorn French fathers spending their Fête des Pères in front of darkened screens as you watch the ball sail gloriously into the back of the net. Happy Father’s Day!

Note to readers: We won’t be publishing the Weekly Gist next Friday, June 26th, due to a scheduling conflict. However, we’ll be back with a special Independence Day edition on Friday, July 3rd. See you then!


THIS WEEK IN HEALTHCARE

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

A worrisome spike in cases and hospitalizations

As states across the US continued to move forward with reopening, this week saw several places experience spikes in coronavirus cases, with Arizona, Florida, California, South Carolina and Texas all reporting record single-day increases in cases. While some of the increase was due to additional testing, spikes in hospitalizations in Texas and Arizona were particularly worrisome, leading to concern that the “first wave” of COVID cases was not yet over. Experts warned that the nation could be seeing a post-Memorial Day surge in the virus, and that more precautions were warranted. California governor Gavin Newsom issued an order for all Californians to wear masks or other face coverings in public settings, as did state and local leaders in other states. All eyes will now turn to Tulsa, OK, where President Trump plans to hold a rally Saturday that will be the largest indoor public gathering in the US since the start of the pandemic. (The President said this week that he views mask wearing as a “signal of disapproval” of himself.) Meanwhile, some hopeful news emerged from the United Kingdom, where researchers conducting a large, randomized trial of potential treatments announced that the use of dexamethasone, a widely-available, low-cost steroid, reduced deaths by one-third in ventilated patients and by one-fifth in patients hospitalized on oxygen. Full details of the study were not made available, leading some industry experts to urge caution in interpreting the results ahead of peer review. The alarming rise in coronavirus cases and related hospitalizations is a further warning that, while we may be finished with the virus, it is by no means finished with us. It’s going to be a long summer. US coronavirus update: 2.25M cases; 120K+ deaths; 25.4M tests conducted.

Two steps forward, one step back

In a sweeping 6-to-3 decision, the US Supreme Court ruled Monday that LGBTQIA+ (lesbian, gay, bisexual, transgender, queer or questioning, intersex, and asexual) Americans are protected from job discrimination under existing federal law. The court stated that discriminating against an employee on the basis of sexual orientation or gender identity inherently amounts to discriminating against them on the basis of sex, which is illegal under Title VII of the Civil Rights Act of 1964. The impact of the landmark ruling could affect the recent Trump administration rule, issued just three days prior, that would remove nondiscrimination protections for LGBTQIA+ people laid out in the Affordable Care Act (ACA). The June 12th Department of Health and Human Services (HHS) rule seeks to undo the Obama administration’s 2016 rule that expanded the scope of the ACA’s sex-based antidiscrimination provisions to specifically include healthcare protections for transgender individuals.

Under the new Trump administration rule, due to go into effect in mid-August, health plans and providers would be able to discriminate against someone on the basis of gender identity, including refusing to provide medical services. While HHS could argue that healthcare and employment are different issues, and that it has the authority to interpret what the ACA’s provisions mean, the Supreme Court ruling will make it more difficult for the administration to attempt to redefine sex discrimination to what it considers “the plain meaning of the word ‘sex.’” Most health systems and physicians feel an obligation to serve all members of their communities and to work to provide equal access and care. We must continue to be attuned to the needs of LGBTQIA+ people and other patient populations who have historically faced health disparities and reduced access to healthcare services due to discrimination. Love is love, and health is health.

A new wave of mergers kicks off

This week brought the first two major merger announcements of the post-COVID era. Illinois- and Wisconsin-based Advocate Aurora Health and Michigan-based Beaumont Health announced Wednesday they are “exploring a potential partnership” that would create a $17B health system across three Midwestern states. (Last month Beaumont called off a planned acquisition of Akron, OH-based Summa Health.) Given the lack of market overlap between the systems, this merger is less likely to face the kind of antitrust scrutiny that stalled Advocate’s previous merger plans with Evanston, IL-based NorthShore University HealthSystem. The combination bears watching to see if the merger of two like-minded, integrated regional health systems is able to deliver strategic value despite being geographically dispersed, and what kinds of synergies it can find.

On the payer side of the industry, two Blue Cross Blue Shield health plans also announced an affiliation agreement. Under the agreement, Pittsburgh-based Highmark, Inc. will become the licensee for Buffalo-based HealthNow New York, Inc.’s 21-county service area across the state. We’d expect to see more consolidation of this kind among state-level Blues plans as they look to compete with well-funded and diversified national insurers like UnitedHealth Group and CVS Health. These two deals are likely to be the first of many across the rest of this year and next, as health system finances experience continued pressure, and well-positioned payers and providers look to pursue growth opportunities by bulking up. As always, the key metric to watch is what happens to pricing in the wake of mergers—the historical evidence is not promising.


GRAPHIC OF THE WEEK

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

Comparing COVID-19 to past pandemics

Although the coronavirus is easily the most disruptive disease event of our lifetimes, pandemics have ravaged humanity over history, leaving devastating death tolls in their tracks. This graphic compares lives lost in some of the worst worldwide pandemics on record. While a staggering 450,000 people have died from COVID-19 worldwide, the current pandemic represents a mere 0.2 percent of the deadliest plague in recorded human history, the Black Death. Caused by the bubonic plague, the Black Death took an estimated 200 million lives over just a five-year span during the Middle Ages, killing an estimated 30 to 50 percent of Europe’s population. Arguably, the entire course of history was altered by the Black Death—will the same be true for COVID-19?

The 1918 Spanish Flu, the deadliest pandemic in modern history, claimed 40-50 million lives worldwide across 15 months. Unlike COVID-19, the Spanish Flu—caused by the H1N1 virus—was notable for being atypically fatal in otherwise healthy people, including in children younger than five and especially in adults between the ages of 20 and 40. The Spanish Flu ebbed and flowed over three very distinct waves across two years, killing 675,000 Americans in total. That’s more than five-and-a-half times the current US COVID-19 death toll, but today we’re less than six months into the coronavirus pandemic. The vast majority of Spanish Flu deaths occurred in the illness’s second wave, beginning in the fall of 1918—if history repeats itself, the worst of our current pandemic could still be in front of us. One stark difference between 1918 and today: the advancement of medical science in the last century has allowed a swift, global effort to create a COVID-19 vaccine—over 125 vaccines are currently in development and 18 have progressed to human trials.


THIS WEEK AT GIST—ON THE ROAD PHONE

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

My telemedicine visit was a little too “normal”

Needing a quick prescription refill, I logged on to my first post-COVID telemedicine visit with my primary care physician this week—and while I appreciated being able to meet with my doctor from my living room, the experience revealed the kinks in the way many practices are delivering virtual care. To schedule, I filled out a form on the website, which triggered a follow-up call from practice staff the next morning. Straightforward, but far from an “Open Table” level of simplicity. The technology worked just fine: a single click on an emailed link launched Microsoft Teams (which happened to already be installed on my laptop), and I was met by a medical assistant dialing in from an exam room in the practice. She took my information, said the doctor would be joining shortly, and left. So I waited. And waited. The camera was on, and I was left looking at the blood pressure cuff, otoscope and ophthalmoscope hanging on the wall—literally the same view I would’ve had sitting on the exam table (I just needed to don a paper gown and turn the thermostat down ten degrees to completely replicate the experience of being there in person). I waited some more—22 minutes to be precise, as the webinar screen had a count-up clock recording just how long I was looking at the wall.

My doctor is a great clinician, and surely was running behind because she was spending time with a patient who needed her attention. Once she came into the room, the visit was efficient—and we talked about the challenges of transitioning to virtual care. I was happy to cut the practice some slack since I know them, but it would have been really underwhelming if I were a new patient—honestly, I probably wouldn’t be a repeat user. And it fell far short of what is needed to create a differentiated virtual care offering. Like everything else “digital” in our lives, we want telemedicine to be easy, integrated, efficient and on time—and our expectations for experience are set outside of healthcare. One thing was made painfully obvious: providers need to make sure not to replicate the frustrating parts of traditional office visits, as they look to create a lasting, sustainable virtual care platform.

Thinking through the new continuum of urgent care

We’ve both received care from of Portland, OR-based Zoom+Care when traveling, and are big fans of its highly efficient, consumer-centric clinic design and urgent care model. We’ve heard reports from across the country that urgent care visits have been slow to rebound as in-person healthcare services have reopened (no surprise that people are reticent to return to a care setting where sitting in a waiting room next to a coughing patient is often part of the experience). We wondered if Zoom+Care, with scheduled appointments and operations that largely eliminate the wait, had fared any better, and recently we caught up with Torben Nielsen, the company’s CEO, to hear about his experiences across the past three months. As COVID-19 hit in March, Zoom+Care quickly eliminated self-scheduled visits and took many of its 50 clinics offline, requiring all patients to be triaged virtually before any in-person care. The company had a robust chat visit function already in place, and like most health systems, quickly brought video and phone visits online in the first weeks of the pandemic. They’ve now delivered more than 30,000 virtual visits. With 34 percent of virtual visits coming from patients in markets where Zoom+Care does not have clinics, telehealth has driven rapid expansion into new markets, presenting both opportunities (virtual demand highlights where to site new clinics) and challenges (the need to quickly develop referral relationships for the 10-20 percent of telemedicine patients who would benefit from in-person follow-up).

Telemedicine visits have continued to grow even as self-scheduling was turned back on and in-person volume returned. Nielsen thinks centralization will be a big part of their ongoing virtual care strategy. Over the years Zoom+Care learned that chat visits required a different provider skill set, necessitating a dedicated team—and the same is true of phone and video visits. They’re also exploring what specialty care can be managed virtually, and the best modes to deliver it. Case in point: it’s no surprise that a visually-oriented specialty like dermatology is well-suited for virtual. But with the grainy images of videoconferencing software, telemedicine falls far short of chat-based care, where a patient can send a high-resolution image and text back and forth with the provider. Given that payment for chat visits falls fall short of video visits, Zoom+Care is now exploring new relationships and economic models to support a multimodal, multispecialty care model. A fascinating conversation, and confirmation that creating the ideal access platform will require not just layering telemedicine on top of the existing “physical” clinic footprint, but redesigning the entire care journey to create a seamless and connected access experience.


THIS WEEK AT GIST—ON THE PODCAST

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

In a two-part series on last Monday’s and Tuesday’s episodes, we heard about the increasingly popular hospital-at-home care model. Co-founder of Medically Home Raphael Rakowski and Chief Medical Officer Dr. Pippa Shulman said COVID-19 has spurred interest from health systems and patients who don’t want to be separated from their loved ones.

Coming up on next Monday’s episode, we hear from Jennifer Stewart, Gist’s Senior Vice President, Development. about the challenges COVID-19 has brought to the healthcare workforce. She tells us the pandemic has uncovered ways the workforce has grown brittle, and created revenue losses that will force health system leaders to reconsider labor costs, workforce flexibility and automation. Make sure to tune in!

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


FROM THE GIST BOOKSHELF

Feed your head—read this.

The coronavirus lockdown seemed like an opportune time to reach for hefty volumes from the stack of unread books to pass the time. How unexpectedly fitting that as protests erupted against the brutal murder of George Floyd and people took to the streets to call for an end to violent policing and systemic racism, I found myself in the middle of the first volume of Taylor Branch’s magisterial 1988 trilogy on the history of the civil rights movement. Parting the Waters: America in the King Years 1954-63 could not be a better guide to understanding where we are now. Branch devoted 24 years of his life to collecting the oral histories of those involved in the pivotal events of the late 1960s and shaping them into a sweeping narrative of the movement and Martin Luther King, Jr.’s leadership role in it. The first volume, for which he won a Pulitzer Prize, follows King from his formative years as Baptist preacher through the Montgomery bus boycott, the Freedom Rides, the Birmingham campaign, and the March on Washington. It’s a gripping read, often a minute-by-minute account of some of the most critical moments in our nation’s history. There are fascinating anecdotes about the turbulent relationship between the Kennedy administration and the movement, the nefarious role of Hoover’s FBI, the internecine conflict among leaders of the Black church, and the strategic use of nonviolent protest to force the system to change.

But most striking to a reader today is how resonant the conditions of 1960s segregation-era America seem. Structural inequalities, limitations on free and fair voting, brutal police tactics, craven politicians more interested in optics than progress—all as vexing today as on the streets of Birmingham in 1963. But this, too: we witness quiet, courageous, and often anonymous leaders willing to take a stand and put their lives on the line to make positive change. One of the joys of Branch’s account is becoming reacquainted with figures like Bob Moses, Septima Clark, James Bevel, Diane Nash, and James Forman—unknowns at the time, who dared to imagine that their efforts could make a difference. At a moment when we’re called to look forward and work toward a better future, there’s real value in reaching for historical accounts like Branch’s—they allow us to lift up and see the broader sweep of events in context. We have to know our history.


GIST IN THE NEWS

We said it, they quoted it.

Why People are Still Avoiding the Doctor (It’s Not the Virus)
New York Times; June 16, 2020

“The inability to afford care is ‘going to be a bigger and bigger issue moving forward,’ said Chas Roades, the co-founder of Gist Healthcare, which advises hospitals and doctors. Hospital executives say their patient volumes will remain at about 20 percent lower than before the pandemic.”

Navigating a Post-Covid Path to the New Normal
Healthcare is Hard: A Podcast for Insiders; June 11, 2020

“Almost overnight, Chas went from in-depth sessions about long-term five-year strategy, to discussions about how health systems will make it through the next six weeks and after that, adapt to the new normal. He spoke to Keith Figlioli about many of the issues impacting these discussions including:

  • Corporate Governance. The decisions health systems will be forced to make over the next two to five years are staggeringly big, according to Chas. As a result, Gist is spending a lot of time thinking about governance right now and how to help health systems supercharge governance processes to lay a foundation for the making these difficult choices.
  • Health Systems Acting Like Systems. As health systems struggle to maintain revenue and margins, they’ll be forced to streamline operations in a way that finally takes advantage of system value. As providers consolidated in recent years, they successfully met the goal of gaining size and negotiating leverage, but paid much less attention to the harder part – controlling cost and creating value. That’s about to change. It will be a lasting impact of Covid-19, and an opportunity for innovators.
  • The Telehealth Land Grab. Providers have quickly ramped-up telehealth services as a necessity to survive during lockdowns. But as telehealth plays a larger role in the new standard of care, payers will not sit idly by and are preparing to double-down on their own virtual care capabilities. They’re looking to take over the virtual space and own the digital front door in an effort to gain coveted customer loyalty. Chas talks about how it would be foolish for providers to expect that payers will continue reimburse at high rates or at parity for physical visits.
  • The Battleground Over Physicians. This is the other area to watch as payers and providers clash over the hearts and minds of consumers. The years-long trend of physician practices being acquired and rolled-up into larger organizations will significantly accelerate due to Covid-19. The financial pain the pandemic has caused will force some practices out of business and many others looking for an exit. And as health systems deal with their own financial hardships, payers with deep pockets are the more likely suitor.”

WHAT WE’RE READING

Stuff we read this week that made us think.

Masks may be the key to safely reopening

Widespread use of facial coverings is proving to be one of the most effective public health measures to slow the spread of the coronavirus—and may have accounted for the dramatic difference in infection rates in countries like Japan compared to the United States. But mask-wearing has emerged as a politically charged issue, and amid mixed messaging, millions of Americans are reticent to wear them. A new study in Health Affairs aims to understand the impact of mask-wearing policies, modeling rates of spread and transmission in the fifteen states and District of Columbia that enacted policies mandating masks when in public, versus those states that didn’t. The estimates are striking: as many as 230,000–450,000 COVID-19 cases may have been averted through mid-May based on the passage of mask mandates. (Researchers also compared these broader public mandates with states that issued employee-only mask requirements, finding no evidence that the narrower policies slowed case growth rates.)

Anecdotal stories of the effectiveness of masks are also emerging. When two stylists tested positive for COVID-19 shortly after a Missouri hair salon reopened, public health officials feared a huge outbreak. But none of the 100+ employees and customers exposed contracted the virus, which experts attribute to the strict mask policy adopted by the salon (we have found this story particularly helpful in changing the minds of mask-reticent friends and family). As more evidence emerges, masks may ultimately be the key to safely reopening the economy and preventing future spikes of the virus, especially when coupled with widespread testing. But getting a majority of Americans to regularly wear them will require a cultural shift, to make mask wearing feel “normal”, and treated as a sign of social responsibility—as has happened in other countries that have managed to quickly bend the curve of new infections.

Can porn teach us how to keep safe from coronavirus?

As businesses look to reopen, and Americans everywhere are forced to make daily, personal calculations about their own exposure to the coronavirus, some experts are pointing out that one industry in particular has already implemented a successful, sophisticated solution for workplace safety—the porn industry. As reported in a fascinating piece in the New York Times this week (and an earlier article in STAT), workers in the adult film industry are routinely tested for HIV and other sexually-transmitted diseases every 14 days, and the results are reported to a nationwide registry called Performer Availability Screening Services (PASS). Most film sets require actors to participate in the testing system, and if a performer tests positive, sets are shut down, the individual receives treatment, and their partners are tested before work can resume. The PASS system has been in place for 20 years, and thousands of performers and studios participate in what amounts to an industry-wide test and trace regimen. According to Dr. Ashish Jha, head of Harvard’s Global Health Institute, “In many ways, what [the adult film industry is] doing is a model for what we are trying to do with COVID.” He proposes a voluntary, nonprofit-run testing database that employers and employees can use to monitor workplace infection risk. Of course, experts caution, containing the spread of coronavirus will be more complicated, because the disease is much more infectious, and less is known about how to effectively stop the spread. There will be legitimate questions about payment, privacy, and the practicality of testing a large number of American workers. But we shouldn’t let our reservations about the porn industry cloud our ability to borrow proven practices and techniques to make workplaces safer. Maybe there’s something to learn from porn after all.


That brings us to the end of another Weekly Gist. Thanks for taking the time to read our work—let us know what you thought! We love hearing your feedback and suggestions, and we hope you’ll share this with a friend or colleague and encourage them to subscribe too, and to listen to our daily podcast.

And as the nation continues to confront its many challenges, we wish you a Happy Juneteenth—may it soon be a national holiday celebrating Emancipation Day, reminding us of one momentous step forward our country took, even as we have so many more mountains to climb ahead.

Best regards,

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

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

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