April 16, 2021

The Weekly Gist: The Fully Vaccinated Edition

by Chas Roades and Lisa Bielamowicz MD

Well, we did it! Our turn came, we rolled up our sleeves, and lo and behold—we’re fully vaccinated! As many of you already know, and (we hope) the rest of you will soon find out, there’s a palpable feeling of relief when the moment comes, the feeling of a heavy weight being removed. Not gonna lie—it was an emotional experience for both of us. A moment we’ll never forget. We’re so grateful for the incredible work of the scientists and researchers that developed these miraculous vaccines, and the inspirational work of the healthcare professionals that have cared for the sick under such difficult circumstances, and continue to do so. Quite literally, we owe them our lives.

THIS WEEK IN HEALTHCARE

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

Two steps forward, one step back on vaccinations

As states rush to fully reopen businesses, and Americans leave their masks at home in greater numbers, it appears that the feared “fourth surge” of COVID is now underway in many parts of the countryCoronavirus cases are up in half of all states, and up nationally by 9 percent compared to last week. While the latest wave appears to be much less deadly—largely targeting younger people who haven’t yet been vaccinated—it adds urgency to the effort to get shots in arms as quickly as possible. The good news: that’s happening. Today the US surpassed the milestone of 200M vaccinations given, with nearly a quarter of the population now fully vaccinated (including nearly two-thirds of those over age 65). The progress on vaccines comes as the Johnson & Johnson COVID jab is sidelined, over safety concerns stemming from a small number of rare blood-clotting cases in younger women that caused the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) to urge states to pause the use of the shot. Wednesday’s inconclusive meeting of the FDA’s Advisory Committee on Immunization Practices meant an additional 7 to 10 days of limbo for the J&J vaccine, drawing criticism from experts who warned that the negative publicity could undermine confidence in vaccines among the general population, both in the US and around the world.

Count us among those skeptical of the decision to pull back on the J&J vaccine, which plays a pivotal role in the campaign against COVID, given that it’s a single-dose vaccine that can be stored at normal refrigerator temperatures, making it more easily distributed than the two-dose mRNA vaccines. While the blood clotting cases are serious, and merit investigation, the odds of suffering a vaccine-related blood clot are far outweighed by an individual’s risk of death or severe complications from COVID itself, let alone the chances of getting a blood clot from other medications (such as oral contraceptives). It was a big week for innumeracy, unfortunately: headlines abounded about the CDC’s discovery of 5,800 “breakthrough” COVID cases, in which fully vaccinated people still contracted the disease. Unsurprisingly, the numerator got the headlines, not the denominator—the 80M people who’ve been fully vaccinated. Your chances of hitting a hole-in-one as an amateur golfer are better than the chances of getting COVID after being fully vaccinated. Furthermore, of those 5,800 people infected after being fully vaccinated, only 7 percent were hospitalized, and 74 died. Each a tragedy, to be sure—but we’ll take those odds any day. Get vaccinated as soon as you can.

Microsoft announces acquisition of Nuance Communications

Microsoft announced Monday that it plans to acquire speech recognition company Nuance Communications in a $19.7B cash transaction, marking a significant push by the tech giant into the healthcare space. Nuance was an early leader in voice recognition technology, and provided a fundamental component to the development of Apple’s Siri voice assistant. The company gained a strong foothold across healthcare, and its products are used by more than three quarters of hospitals and half of the country’s physicians today. Microsoft plans to integrate Nuance’s artificial intelligence (AI) and speech recognition platforms into its Cloud for Healthcare suite, providing a tested interface layer with the front lines of care delivery. Some industry observers believe that the deal will trigger a looming battle between tech giants for the healthcare space. However, we think Microsoft’s approach is fundamentally different from that of Amazon and other consumer-focused tech companiesNuance’s portfolio fits with Microsoft’s longstanding focus on business solutions, looking to integrate into provider operations rather than aiming to replace or upend the traditional healthcare business model.

Bright Health adds Zipnosis to its portfolio as it aims to go public

Health insurance start-up Bright Health announced that it has acquired telehealth company Zipnosis, which provides virtual triage and diagnosis solutions to almost 60 health systems nationwide. Zipnosis was an early developer of asynchronous diagnostic tools, which allow patients to be evaluated and treated without directly interacting with a clinician. (Over the years, we’ve largely heard positive reviews from doctors about Zipnosis’ capabilities—when applied to the right clinical conditions.) The deal follows other recent payer acquisitions of virtual care capabilities. Zipnosis, which treated more than 2M patients across 2020, could give Bright the ability to provide telemedicine services directly to its 500K members nationwide, likely in concert with its health system partners. Earlier this month, Bloomberg reported that Bright plans to go public in 2021. As investors weigh Bright’s future, Zipnosis not only brings attractive technology, but a portfolio of health system relationships that could lay the foundation for future network partnerships for the insurer’s core business.


GRAPHIC OF THE WEEK

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

Examining the economic pressures facing healthcare workers

As health systems look to address the “social determinants of health”, one obvious but often overlooked place to start is with their own employees. The left side of the graphic below shows forecasted employment growth and salaries across a range of healthcare occupations. Many of the fastest-growing healthcare jobs—including home health and personal aides, medical assistants, and phlebotomists—are among the lowest-paid. Case in point: home health and personal care aides are among the top 20 fastest-growing occupations in the US, and median wage for these jobs is only about $12 per hour, or around 200 percent of the federal poverty level—well below the living wage in many parts of the nation. (Note that this analysis does not include support staff who are not healthcare specific, like custodial or dietary workers, so the number of low-wage workers at health systems is likely higher.)

Among of the many struggles lower-income healthcare employees face is finding affordable housing. Using fair market rent data from the US Department of Housing and Urban Development, the right side of the graphic shows that healthcare support workers, even at the 90th percentile salary level, struggle to afford rent in the majority of the 50 largest US metros areas. In particular, home health aides in the top decile of earners can only afford rent in 14 percent of major cities. These disparities have caught the attention of lawmakers. The $400B in President Biden’s proposed infrastructure plan devoted to home healthcare for seniors includes tactics to increase the wages and quality of life for these caregivers. But as we await policy solutions, health systems should pay careful attention to issues of housing insecurity and other structural challenges facing their workers and look to increase wages and provide targeted support to these critical team members.


THIS WEEK AT GIST—ON THE ROAD PHONE

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

Taking time for post-pandemic catharsis

We’ve reached the point in the pandemic when many health systems, including those we work with, are beginning to talk seriously about “demobilization”: standing down from the crisis footing they’ve been on through the surges in COVID cases, and the all-hands-on-deck efforts they’ve mustered to support the rollout of vaccines. There is still work to be done on both fronts, but leaders are planning now for a return to more normal operations by late spring or early summer. As groups of executives and leaders meet to plan for the transition, often together in person for the first time, we’ve noticed a strong desire on the part of all involved to spend dedicated time reflecting on the year gone by, sharing war stories about the COVID response, and discussing lessons learned. It’s a healthy process, and a necessary one—taking time to process the experience and the impact that the pandemic has had on caregivers and administrators. There’s something cathartic about the dialogue, and it strikes us as a critical step in moving forward. Whether in employee town hall meetings, leadership retreats, or even board meetings, we’d urge health system executives to set aside ample time to have these reflective moments, both to celebrate and grieve, but most importantly to acknowledge the magnitude of the events we’ve all just lived through. Frontline workers in particular will need that time. One system we work with is looking to create a video “oral history” of the past year, to allow caregivers to record and share their experiences with others. It’s a terrific idea, and one we’d love to see others emulate. Now, more than ever, healthcare workers need to be lifted up, and have their stories heard—before we just return to business as usual and aim to put the pandemic squarely in the rearview mirror.

Maintaining positive communication after the pandemic

Several health system leaders have told us recently that they’ve been surprised how positive relationships have been with physicians lately. One chief clinical officer told us, “For the past year, I can’t remember a single doctor complaining about communication, or that they were ‘out of the loop’. We used to get those grumbles every week.” As another leader noted, doctors were starved for information: “We were communicating to our medical staff about COVID daily for most of last year. And nearly all of our doctors, employed or independent, read those emails.” She raised the question, is there a way to maintain that hunger for information as the focus shifts past the pandemic to other areas of strategy and operations? In fighting the pandemic, health systems and clinicians have been united by a singularity of purpose, making critical decisions quickly. All parties put self-interest aside in service of a higher goal. Across this year health systems will exit crisis mode, and by necessity, return to the “forever work” of quality, growth and operations. But they should guard against the tendency to slip back into bureaucratic habits of communicating and working with doctors, and fight to maintain the agility and collaboration that allowed them to manage through the most significant health crisis of our lifetimes.


THIS WEEK AT GIST—ON THE PODCAST

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

This week we wrapped up our two-part conversation with healthcare futurists Ian Morrison and Jeff Goldsmith. Given the vital role health systems played in the country’s pandemic response, the two health policy experts say it’s time to reconsider the value of scale, and reimagine health systems’ place in the country’s public health infrastructure. Take a listen to parts one and two!

On next Monday’s episode, we’ll hear from Medically Home oncology division president Patricia Brown on how the hospital-at-home trailblazer is now treating cancer patients at home. As the popularity of “care anywhere” grows in the wake of the pandemic, disruptors are expanding the breadth of conditions that can be treated at home. Make sure to tune in!

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


ON THE GIST TURNTABLE

Give this a spin—you might like it.

It doesn’t sound that compelling at first: yet another post-punk band from South London, borrowing angular guitar lines and spare bass riffs from the likes of Joy Division and Sonic Youth, fronted by a visual artist who delivers all of her lyrics in a monotone speaking voice. But there’s something electrifying in how those elements come together on the debut album from Dry Cleaning, New Long Leg. Florence Shaw’s sprechgesang lyrics turn out to capture perfectly the bewildered boredom of the present moment, framed in the stream-of-consciousness narration of—in her words—“an emo dead stuff collector”. The band’s 2020 breakthrough single “Scratchcard Lanyard” was a tantalizing promise of things to come from the band, all 80s drums and whammy bars and stabbing bass, and the mission statement of the year: “Do everything and feel nothing.” (The video was even better, with Shaw’s face sandwiched inside a tiny toy cocktail lounge in her own head, inventing an interior social scene to replace the one we’d all been cut off from.) The album delivers on that promising start, with ten sharp tracks, each an intriguingly bleak vignette of modern life with wry observations tossed off in rapid succession (“They’ve really changed the pace of The Antiques Roadshow”… “Would you choose a dentist with a messy back garden like that?”… “I’ve been thinking about eating that hot dog for hours.”) Like Talking Heads at their David Byrne-iest: you wouldn’t necessarily want to spend time with these people, but they sure do make interesting music. Worth a listen. Best tracks: “Scratchcard Lanyard”; “Strong Feelings”; “Unsmart Lady”.


GIST IN THE NEWS

We said it, they quoted it.

The Big Tech of Health Care
The American Prospect; April 5, 2021

“On a recent podcast, Chas Roades and Dr. Lisa Bielamowicz of Gist Healthcare described Optum in a way that sounds eerily similar to a single-payer health care system. ‘If you think about what Optum is assembling, they are pulling together now the nation’s largest employers of docs, owners of one of the country’s largest ambulatory surgery center chains, the nation’s largest operator of urgent care clinics,’ said Bielamowicz. With 98 million customers in 2020, OptumHealth, just one branch of Optum’s services, had eyes on roughly 30 percent of the U.S. population. Optum is, Roades noted, ‘increasingly the thing that ate American health care.’”


WHAT WE’RE READING

Stuff we read this week that made us think.

Could Dollar General help dramatically expand vaccine access?

For some time, we’ve been focused on the efforts of Walmart to launch and grow a care delivery business, especially as it has piloted an expanded primary care clinic offering in a handful of states. We’ve long thought that access to basic care at the scale that Walmart brings could be transformative, given that more than half of Americans visit a Walmart store every week. Along those same lines, we’ve always wondered why Dollar General and Dollar Tree—each with around four times as many retail locations as Walmart—haven’t gotten into the retail clinic or pharmacy businesses. (Part of the answer is ultra-lean staffing—this piece gives a good sense of the basic, and troubling, economics of dollar stores.) Now, as the federal government ramps up its efforts to widely distribute the COVID vaccines, it turns out that the CDC is actively discussing a partnership with Dollar General to administer the shots. A fascinating new paper (still in preprint) from researchers at Yale shows why this could be a true gamechanger. The Biden administration, through its partnership with national and independent pharmacy providers, aims to have a vaccination site within five miles of 90 percent of the US population by next week. Compared to those pharmacy partners, researchers found, Dollar General stores are disproportionately located in areas of high “social vulnerability”, with lower income residents and high concentrations of disadvantaged groups. Particularly in the Southeast, a partnership with Dollar General would vastly increase access for low-income Black and Latino residents, allowing vaccine access within one mile for many, many more people. And the partnership could form the basis for future expansions of basic healthcare services to vulnerable and rural communities, particularly if some of the $7.5B in funding for COVID vaccine distribution went to helping dollar store locations bolster staffing and equipment to deliver basic health services. We’ll be watching with interest to see if the potential Dollar General partnership comes to fruition.


That’s all for this week. It’s good to be back—we’re excited to make use of our newfound superpowers of COVID immunity to get back on the road, and we hope to see some of you in person soon! In the meantime, thanks for taking the time to read the Weekly Gist, and for sharing your feedback and suggestions—we love hearing from you. If you can, please take a moment to share this with a friend or colleague and encourage them to subscribe, and to listen to our daily podcast.

Most importantly, please let us know if there’s anything we can do to be of assistance with 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