December 18, 2020

The Weekly Gist: The Frosty Shot in the Arm Edition

by Chas Roades and Lisa Bielamowicz MD

This week brought the first big snow of the season to the East Coast, with a powerful Nor’easter dumping as much as two feet of snow from Pennsylvania to New England. Here in DC, we got our usual allotment—wet slop. But for a brief window before the snow turned to sleet, we had a lovely blanketing of the white stuff, enough to take a quick wintery walk around the neighborhood. Unfortunately, 2020 even managed to make that weird, as the absence of rosy-cheeked kids throwing snowballs and perfecting sled runs made immediately clear. Turns out the pandemic has robbed us of another tradition—snow days. With most kids still cooped up inside, staring at Zoom screens, it was little wonder that one West Virginia school superintendent made headlines for the heroic act of declaring a day off anyway. If you’re lucky enough to have snow on the ground this weekend, please, go out and build a snowman. And if you’re feeling creative, use an extra carrot to add a big, orange middle finger to this miserable virus. Or maybe, turn it into a makeshift vaccine syringe—even Frosty could use a shot in the arm right about now.

Note to readers: The Weekly Gist will be taking the next two weeks off to celebrate Christmas and New Year’s Day, but we’ll be back on Friday, January 8th with our annual recap and look-ahead edition. See you in 2021!


THIS WEEK IN HEALTHCARE

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

The vaccine offensive gets underway

On Monday, at Long Island Jewish Medical Center in New York City, critical care nurse Sandra Lindsay rolled up her sleeve and became the first American to receive Pfizer and BioNTech’s newly approved COVID vaccine, opening a new front in the nation’s battle with the coronavirus pandemic. By Friday, nearly 50,000 doses of the vaccine had been administered nationwide, with millions more expected before year’s end. Amid a complex rollout that has already raised questions  about the timely distribution of doses, the Food and Drug Administration (FDA) confirmed that it was safe to use every last drop of the Pfizer vaccine, including the excess amount used to fill the five-dose vials of the precious medicine—meaning many vials may have enough to immunize a sixth person. Based on Thursday’s recommendation from a key panel of experts, the FDA is expected to approve a similar vaccine from Moderna as soon as Friday evening, with doses of that vaccine beginning to be administered by next week. The Moderna vaccine comes in smaller packages with less-demanding storage requirements, making it suitable for a wider distribution across smaller settings and remote areas. Pharmacy chains CVS and Walgreens were set to begin administering shots to nursing home residents in Ohio, Connecticut, and Florida on Friday, as part of an agreement with the US government to vaccinate staff and residents in 75,000 long-term care facilities nationwide. In an interview this week, Secretary of Health and Human Services (HHS) Alex Azar said that the vaccine could be widely available to the general public as soon as late February or early March. While it’s surely tempting to fixate on every setback, second guess every decision about prioritization and distribution, and fret over every isolated report of an adverse vaccine reaction, it will be important in the coming weeks to keep the big picture in mind: we are on the way to beating back the coronavirus. The end is nigh.

It will be darkest before dawn

But first, we have a difficult period to get through. This week again saw record-breaking numbers of cases, hospitalizations, and deaths from COVID-19, with Thursday alone bringing more than 238,000 new cases—and a staggering 3,293 fatalities. Nearly 115,000 Americans are currently hospitalized with COVID, a rise of 16 percent from just two weeks ago, and in many places a precarious capacity situation has turned perilous. Conditions have worsened precipitously in California, with only Tennessee, Oklahoma, and Rhode Island registering more daily COVID cases per 100,000 population than the Golden State, although cases are still on the rise across 80 percent of states and territories. Intensive care availability in Southern California hit zero, with ICU volume there expected to double or triple by this time next month. The same stresses are playing out in dozens of markets across the country, leading to a staffing sustainability crisis that can’t be solved through paying overtime, cancelling vacations or looking to travel nurses to fill the gaps in a now nationwide crisis. With the Christmas and New Year’s holidays still ahead, experts predict COVID cases won’t peak until sometime in mid-January, with a peak in hospitalizations and deaths following several weeks after. Several states and cities tightened restrictions on gatherings and issued new stay-at-home orders, in an effort to keep new cases at a level that allows hospitals to manage through the next several weeks and maintain care quality and access for COVID and non-COVID patients alike. The coming weeks will require every American to take greater precautions than at any time during the course of this pandemic.

Will Congress finally address surprise billing?

As Congress works toward a deadline of Friday at midnight to pass an omnibus spending bill that avoids a government shutdown—expected to include a compromise, $900B coronavirus stimulus package—the legislation is likely to include measures to address the  “surprise billing” of patients for unexpected, out-of-network care. Despite failing to agree on such a solution last year, four House and Senate committees recently reached a bipartisan compromise, which seems poised to make its way into the end-of-year spending deal. The compromise measure bans surprise billing for out-of-network emergency care, out-of-network care at in-network facilities, and out-of-network billing for air ambulance services. Resolution of claims for out-of-network care would be conducted via arbitration between hospitals and insurers, based on average in-network charges for the services billed. The deal would be the final legislative accomplishment for retiring Senator Lamar Alexander (R-TN), who chairs the Senate health committee, and is supported by House and Senate leaders of both parties, and by the White House. Still unclear is whether Senate Majority Leader Mitch McConnell (R-KY) will allow the measure to be included in the final omnibus legislation, although the fact that it would generate up to $18B in savings for the federal budget could make it an attractive offset to new stimulus spending. The American Hospital Association has expressed concerns about the legislation, and the American Medical Association has voiced its opposition. Nevertheless, we’re hopeful that the compromise legislation will pass—it’s long past time for Congress to address the terrible predicament that surprise billing poses for so many patients, particularly in the midst of the COVID pandemic. Solving this problem should not wait another year.


GRAPHIC OF THE WEEK

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

A tall order: Rolling out the COVID-19 vaccine to all

As the first Americans receive COVID vaccines, supplies remain limited even for the highest-risk populations. And with doses now in the pipeline, states are facing more intense questions about how they will prioritize vaccine delivery across demographic and at-risk groups. The graphic below shows an estimated vaccination timeline, based on the Centers for Disease Control and Prevention’s (CDC) recommended schedule. It illustrates the relative size of different populations in each allocation phase, along with the likely difficulty of targeting them and verifying eligibility. The first phase is divided into three waves (1a, 1b, 1c) for at-risk populations and essential workers, while the second phase includes the rest of the adult population, as well as children (though pediatric clinical trials are still in early stages).

Unsurprisingly, the CDC recommends that those most at risk for infection and severe disease—healthcare workers and nursing home residents—receive the 20M doses available by year’s end. While most states are generally adhering to the initial recommendations on priority groups for phase 1a set by the CDC’s Advisory Committee on Immunization Practices (ACIP), several have made adjustments. At least three are including law enforcement personnel in phase 1a, and others are further categorizing healthcare workers into high-, medium-, and low-risk groups. This weekend, ACIP will reconvene to create its official recommendations for phases 1b and 1c, which include the much larger populations of adults over age 65, and those with high-risk medical conditions. Beyond eligibility guidelines, larger questions loom. How would someone “verify” that they have a high-risk condition? Who will reach out to older Americans to let them know they are eligible, and where to access the vaccine? As vaccine rollout continues, providers should anticipate the role they will likely play in managing patients “in the queue”, documenting eligible conditions and establishing regular information channels to keep people informed about the current status of vaccine planning and access.


THIS WEEK AT GIST—ON THE ROAD PHONE

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

No more snow days in the clinic

It turns out it’s not just the kids who aren’t getting snow days this year. This week, we spoke with an executive at a health system hit hard by Wednesday’s Nor’easter, and asked how the system was faring with the expected 18 inches of snowfall. He replied that the medical group was as busy as usual. With all the work this spring to expand telemedicine capabilities, clinic staff were able to reach out to patients the day before the storm, and proactively convert a majority of scheduled in-person clinic visits to telemedicine. “Normally we would’ve been closed, and most appointments rescheduled for weeks down the road,” he told us. Instead, they were able to keep most of those visits in their scheduled time slot. “Now that we have a systemwide process for telemedicine, I don’t think we’ll have a reason for the clinic to take a snow day again.” It’s a clear win-win for the system and patients: patient care seamlessly goes on. It’s easy to see the many use cases for the ability to toggle between in-person and virtual visits. A parent is stuck at home with a sick kid, and can’t make her endocrinologist appointment? Moved to virtual! A patient has an unexpected business trip taking him out of town? Don’t cancel, let’s do that follow-up visit via telemedicine. We’ve been worried about the slowdown in progress made on telemedicine as patients switched back to in-person visits across the summer and fall. The ability to continue patient care during a record-breaking snowstorm is a perfect illustration of why it’s critical not to “backslide” with virtual care: meeting patients where they are, regardless of circumstances, is an essential part of building long-term loyalty and care continuity.

The importance of seeking advice from a peer

Given all the turbulence in the industry, it can be difficult for health system leaders to keep perspective. A recent conversation with a health system CEO reminded us of something we’ve seen a handful of successful executives do—seek counsel from peers in other markets. Our contact shared how useful it’s been to have an out-of-market system CEO on his board, if only to help board members understand which problems are unique to his organization and market, and which are playing out more universally. As helpful as that is, it’s been even more important for him to have an external sounding-board, someone who’s sat in the same seat, and been faced with the same kinds of decisions, even if in a different market context. The dialogue provides a needed reality check, and comparing notes on how each leader handled similar situations—ranging from dealing with a difficult team member to evaluating a potential merger—brings an extra set of (experienced) eyes to decisions. Building such a relationship isn’t easy; it requires the humility to recognize that you don’t have all the answers, and that, even as the top executive, you still have more to learn. It’s an even bigger step to let another CEO into your board room, and we’ve heard some leaders express concern about being overshadowed by external, “celebrity” CEOs, who board members might use as a measuring stick to identify shortcomings in their own leadership. We’d argue that humility of that sort is critical for a CEO, and that looking beyond the four walls of one’s own organization is often the best way to ensure sound decision-making and effective leadership. It may sound like an obvious insight, but given how rarely we see this kind of cross-pollination in practice, it’s one that we wish more system CEOs would embrace.


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, Buffy White, Group President of staffing firm Cross Country Healthcare discussed how rising COVID hospitalizations are driving up travel nurses’ rates and shortening their contracts.

Coming up next Monday, Dr. Jeffrey Stalnaker, Chief Clinical Officer of Rockledge, FL-based Health First, discusses monoclonal antibody treatments for COVID patients, and why uptake has been disappointingly low. Stalnaker also shares his thoughts on vaccine rollout and adoption by health system employees. Make sure to tune in!

Note to listeners: The Gist Healthcare Daily podcast will be taking a break from Wednesday, December 23rd through Monday, January 4th. During this break, Alex will be sharing some of our favorite episodes from the past year. Regular episodes will return on Tuesday, January 5th. Happy holidays!

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


BINGE WATCH ALERT

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

Stayin’ Alive” might just be the theme song of 2020, a year when we can “feel the city breakin’ and everybody shakin’”, as we cope with grim daily headlines that force us to “try to understand the New York Times effect on man”. Thanks to an outstanding new HBO documentary, that 1977 disco earworm is now back in the air. Bee Gees: How Can You Mend a Broken Heart, from producer/director Frank Marshall, is a worthy retelling of one of the most remarkable musical careers of the 20th century. Following the England-born, Australia-raised trio from their days as a skiffle band in the late 1950s to their meteoric rise in as a British Invasion act in the 1960s, and on through their disco superstardom, the film makes clear just how good these guys were at, well, staying alive. After a stunning run of hit singles in the Beatlemania era—“I Started a Joke”, “New York Mining Disaster 1941”, “To Love Somebody” (the latter written for Otis Redding just before his death)—the band acrimoniously dissolved in 1969, but came back together to record “How Can You Mend a Broken Heart”, only to fade again by 1974. That’s when Eric Clapton—Slowhand, himself—stepped in and suggested the Bee Gees move to his studio in Miami, where disco music was just starting to take off. Hit after hit ensued, supercharged by the soundtrack to Saturday Night Fever, which became one of the bestselling records of all time.

By the early 1980s, the “disco sucks” backlash (a racist and homophobic “book burning”, according to the documentary) turned the Bee Gees into public enemy #1 nearly overnight. Forced to recast themselves as songwriters, the Gibbs spent the Eighties writing hits for a host of other acts—Dionne Warwick, Dolly Parton, Kenny Rogers, and Barbara Streisand, among others. After their younger brother Andy’s untimely death at the end of the decade, the Bee Gees made a yet another comeback in the 1990s, recording several chart-topping albums, but never fully recapturing the magic of their disco heyday. Only the oldest brother, Barry, survives, and his reflections on the Bee Gees’ tumultuous history lend a bittersweet dimension to Marshall’s documentary. (It’s Barry’s crystalline falsetto everyone remembers most clearly from those monster disco hits, and he’s still got the pipes, as a recent appearance at the Glastonbury Festival proved.) The Bee Gees were the third most successful band in Billboard history, after the Beatles and the Supremes—don’t miss this chance to rediscover why.


WHAT WE’RE READING

Stuff we read this week that made us think.

An unprecedented chance to examine the effects of “watch and wait”

It’s hard to forget the haunting question emanating from emergency departments early in the pandemic: “Where have all the heart attacks gone?” Undoubtedly, thousands of patients experienced worse outcomes as a result of delaying care, amid fears of contracting COVID. But a piece in the New York Times looks at a possible opportunity presented by the pandemic: what if many of the patients who avoided care experienced no adverse effects whatsoever? At the start of the pandemic, office visits declined by as much as 70 percent, and screening studies like colonoscopies and pap smears by as much as 90 percent, during the deepest lockdowns. Anecdotes abound regarding patients who cancelled appointments with orthopedists that would have certainly led to surgeries, who ended up getting better on their own. Or about others scheduled for steroid injections who saw their pain largely resolve without treatment. Evaluating care during the pandemic may even provide an opportunity to reexamine cancer diagnosis and treatment, assessing whether patients with disease found on a screening study or “incidentally” during a scan for another reason actually fare better than those whose care is found at a later time. According to one expert, “We’ve never been able to argue to stop screening for a period, because the standard of care is regular screening.” Taking a data-driven approach to examine the recent abrupt, deep changes in care patterns could provide a once-in-a-lifetime opportunity to better define the boundaries of “low-value care” that provides little benefit for patients.

But it’s her wedding day!

We’ve read many stories across the year about how weddings have turned into super-spreader events. We were intrigued by a recent Texas Monthly piece that looks at the COVID-era wedding from the perspective of people whose livelihoods depend on it: wedding photographers. According to the profiled photographers, who are just “one of the many cogs in the wedding machine”, some big Texas weddings didn’t change much during the pandemic. It’s understandable that brides and grooms are reluctant to delay, and likely face lost deposits from cancellations. Friends and family, coming from far and wide, don’t want to disappoint the lucky couple. But a wedding provides the opportunity for a multi-generational, often alcohol-infused, mixing of close relatives—the perfect scenario to cause people to let their guard down. Thus, a COVID outbreak is born.

The profiled photographers describe events with hundreds of attendees eating and dancing in close contact, not a mask in sight. Anyone who has attended a traditional Texas wedding may have participated in the “grand march”. Guests form a tunnel, with people running through, slapping and high-fiving each other to the music—creating one super-spreader event inside another. Worst of all, photographers and other staff are derided for speaking up and taking precautions. Case in point: a photographer was thanked for working a wedding despite “everything that was going on with the groom”, who had apparently tested positive for COVID the day before the ceremony. The photographer, who hadn’t been told prior to the event and suffered from asthma, told a bridesmaid, “I have children. What if my children die?” The bridesmaid responded, “I understand, but this is her wedding day.” (The photographer tested positive for COVID a few days later.) Wavering guidance from officials has created a lack of clarity about what kinds of interactions and events are “safe”. But these stories highlight the importance of personal responsibility, especially for hosts, in keeping guests, and those who work any party or gathering, healthy. With the promise of a vaccine just a few months away for all Americans, the stakes for avoiding COVID infection have never been higher, even amid a holiday season that finds us starved for close contact with those we love and miss.


That’s it! The last Weekly Gist of 2020, a year we’d all like to forget. It has meant so much to us to be able to share our thoughts across this year, and to have the opportunity to engage with many of you, even if only via email or Zoom. Thanks for sharing your feedback and suggestions, and for letting us be a small part of each week. Let’s do it again next year—minus the pandemic! In the meantime, please remember to share this with a friend or colleague, and encourage them to subscribe, and to listen to our daily podcast. We’ve got lots of great things planned for next year!

Most importantly, please let us know if there’s anything we can do to assist in your work, now or in the year to come. You’re making healthcare better—we want to help!

Best regards, and Merry Christmas,

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

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