May 8, 2020

The Weekly Gist: The Hitting the Century Mark Edition

by Chas Roades and Lisa Bielamowicz MD

To paraphrase the bloodthirsty, revenge-addled, farm-girl-turned-sentient-killer robot Dolores Abernathy from the HBO hit series Westworld, some people choose to see the ugliness in this world, the disarray. We choose to see the beauty. Those murder hornets? Colorful new insect friends! A polar vortex in May? One last chance to wear our wooly sweaters! Reopening Jurassic Park with velociraptors on the loose? Hm, not sure about that one.

A Weekly Gist at the end of another long week of coronavirus lockdown? Hey, it’s our 100th edition…reason to celebrate! Let’s get to it.


THIS WEEK IN HEALTHCARE

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

Reopening with a wary eye on troubling virus trends

With most states either reopening or planning to reopen shortly, the coronavirus showed few signs of loosening its grip on the US this week. Daily death totals continued to hover near 2,000, with more than 77,000 Americans having succumbed to COVID-19—a statistic that almost surely undercounts the true toll of the virus. While the situation continues to improve in “hot-spot” areas hit early like New York City and Detroit, the number of newly confirmed cases is still rising in other parts of the country, including in many of the states that have already begun to reopen. In testimony before the House appropriations subcommittee on Wednesday, a senior infectious disease researcher from the Johns Hopkins Center for Health Security said that no state now reopening meets recommended benchmarks for declining cases, sufficient testing and contact tracing, and adequate protective equipment for healthcare workers. The White House sent mixed signals this week in response to states’ efforts to reopen ahead of the gating criteria it set in its Opening Up America Again plan, delaying the release of detailed CDC guidelines designed help businesses returning to work, denying the validity of leaked internal projections showing the likelihood of increasing infections and deaths, and oscillating between sidelining, and then refocusing, its coronavirus task force.

However, there was some good news this week in the battle with coronavirus. There are now 108 candidate vaccines under investigation, with a handful in clinical trials. One, a messenger RNA-based vaccine developed by drug company Moderna, was approved by Food and Drug Administration (FDA) to enter Phase 2 trials on Thursday. Coronavirus testing, critical to the country’s ability to reopen safely, continued to ramp up as well, and the closely-watched “positivity rate” (an indicator of how widespread testing is—lower is better) fell nationwide. After last week’s FDA emergency use authorization for Gilead Sciences’ promising antiviral drug remdesivir, the company began ramping up production, although frustration mounted after only about two dozen hospitals were chosen by the government to receive scarce existing supplies. Meanwhile, the federal government began to share data on which providers have received bailout money from CARES Act funding—relief sorely needed given the massive economic hit caused by the shutdown. With the release of April unemployment numbers on Friday—showing a staggering 14.7 percent unemployment rate—the disastrous impact of the virus on the healthcare industry became more apparent. The sector lost 1.4M jobs last month, mostly on the ambulatory side. With each passing week, it becomes clearer that the recovery from the coronavirus’ assault on America will be lengthy, uneven, and difficult.

United to provide $1.5B in premium rebates

Health insurers have so far escaped unscathed from the impact of the coronavirus on the broader economy. As a result, UnitedHealthcare announced Thursday that it will provide over $1.5B in direct financial relief through premium rebates for beneficiaries in its individual and small group employer plans, and through cost-sharing waivers for its Medicare Advantage (MA) plan beneficiaries. The 8.2M employer and individual members enrolled in United’s fully-insured plans will receive a premium credit of between five and 20 percent on their June billing statement. For MA beneficiaries, all cost sharing for primary care and specialist physician visits will be waived at least through the end of September. The sudden drop in the volume of medical care being delivered—particularly for elective procedures—is more than offsetting the cost of coronavirus testing and care, for UnitedHealthcare and many other payers.

Under the Affordable Care Act, insurers are required to give consumers rebates at the end of the year if they spend less than 80 percent of premiums on medical costs for fully-insured employer plans, and less than 85 percent for individual health plans. Instead of waiting until then, UnitedHealth Group CEO David Wichmann stated the company’s desire to “get as much of this back in the hands of people as quickly as possible.” Several other national insurers are taking similar steps, all with the goal of helping maintain coverage and slow erosion of their commercial business. As the national unemployment rate continues to rise, insurance companies will likely continue to roll out incentives to prop up employer-sponsored insurance through any means possible. Beyond providing accelerated payments, it may behoove insurers to find ways to support struggling hospitals and physicians as well.

Colorado shelves contentious public option plan

In the midst of the coronavirus crisis, legislators in Colorado’s General Assembly announced this week that they were withdrawing a controversial bill to create a “public option” insurance plan for the state. The bill to implement the “Colorado Health Care Option”, which had drawn sharp opposition from the state’s hospitals, would have created a low-cost insurance option on the state’s individual insurance marketplace, forcing hospitals to participate in the plan’s network at rates set by the state government. Colorado hospital leaders argued that the plan, which was a marquee initiative of Democratic Gov. Jared Polis and the centerpiece of the legislative session, would have led to unsustainably low reimbursement, and caused some providers to go out of business. The bill had already passed its first committee vote in early March, just as the coronavirus was ramping up in the state.

But in the weeks since, hospitals’ financial fortunes have dramatically worsened, as non-emergency visits and surgeries were cancelled and attention turned to dealing with a spike in COVID-19 cases. Colorado hospitals are projected to lose more than $3B in revenue by year’s end. One plan sponsor said of Colorado’s provider community, “The very people we need to work with on [the public option bill] are obviously focused on other stuff. We can’t give them one more thing to do right now.” Legislators expressed optimism that they could return to the effort next year, depending on where things stand with the coronavirus. The pullback on the public option plan illustrates the difficult balance that many states will face in coming months, as they look to help healthcare providers recover economically and continue to provide access to care, while helping waves of unemployed and uninsured citizens find affordable insurance coverage, and finding solutions to keep state budgets in balance. A perfect example of the challenges presented by the pandemic for healthcare politics and policymaking.


GRAPHIC OF THE WEEK

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

Most consumers nervous about returning to care settings

As non-essential businesses begin to reopen, there’s no guarantee that merely opening the doors will make customers return. A recent Morning Consult poll provides an assessment of the impact of COVID-19 on consumer confidence: fewer than one in five US adults are currently comfortable doing (formerly) everyday activities like eating at a restaurant or going to a shopping mall. The graphic below provides similar data for healthcare. Consumers’ willingness to visit healthcare providers in person for non-COVID care is only slightly better, at 21 percent. Which providers might see patients return most quickly? Consumers say they are about twice as likely to visit their primary care doctor’s office than other healthcare facilities, including hospitals, specialists, and walk-in clinics. And when it comes to scheduling a routine in-office visit, nearly half say they will wait two to six months, with almost one in ten not comfortable going to a doctor’s office in person for a year or more. Healthcare facilities face an uphill battle in bringing back patients—many of whom have ongoing chronic diseases that necessitate care now. Reaching patients through telemedicine and providing concrete messages about how they can safely see their doctor will be critical to staving off a tide of disease exacerbations that will mount as fear delays much-needed care.


THIS WEEK AT GIST—ON THE ROAD PHONE

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

What we’ve learned from the telemedicine explosion

In our decades in healthcare, we’ve never seen a faster care transformation than the rapid growth in telemedicine sparked by COVID-19. Every system we’ve spoken with over the past two months reports its doctors are now performing thousands of “virtual visits” each week, often up from just a handful in February. As one chief digital officer told us, “We took our three-year digital strategic plan and implemented it in two weeks!” This week, we convened leaders from across our Gist Healthcare membership to share learnings and questions about their telemedicine experiences. COVID-19 brought down regulatory and payment hurdles, as well as internal cultural barriers to adoption—but leaders expressed a concern that current payment levels and physician enthusiasm could dissipate. Some insurers have hinted at pulling back on payment, although they will have a hard time doing so as long as Medicare maintains “parity” with in-person visits.

Switching to 100 percent telemedicine was easier than most doctors anticipated. But as practices now begin to ramp up office visits, new questions are emerging about how to integrate digital and physical visit workflow, requiring providers to rethink office layout and technology within the practice: is there a good physical space in the office to conduct televisits? Zoom and FaceTime have worked in a pinch, but what platform is best for long-term operational sustainability and consumer experience? Telemedicine has also raised consumer expectations: patients expect providers to be on time for a virtual appointment—setting a bar for punctuality that will likely carry over to their next in-person office visit. Across the rest of this year, health systems and physician groups will continue to push the boundaries of virtual care, establishing how far it can be extended to provide quality care in a host of specialties. But at the same time, systems must also prepare for growing complexity in 2021: what is the right balance of in-person versus virtual care? How should telemedicine integrate with urgent and emergency care offerings? How should physician compensation change? And as payers and disruptors expand their virtual care offerings, how can providers differentiate their own platforms in the eyes of consumers? We’ll continue to share learnings as our members work through the myriad challenges and opportunities of this new virtual care expansion.

Make (surgery) hay while the sun is shining

As we talk this week with leaders of health systems that have restarted non-emergent surgeries, they report that volume has been slower to return than anticipated. A typical data point: a Midwestern system opened up half of its outpatient surgery capacity two weeks ago, but by the end of this week saw just 15 percent of that capacity being utilized. Most surgeons are ready to operate, but patients are still reticent to come into a healthcare setting. Many providers are facing more sobering forecasts and expecting that volume may not return to pre-COVID levels until 2021. They’re also anticipating challenges in filling the summer surgery schedule. Patients expecting to have procedures in June or July should be seeing their doctor now, and undergoing screening exams and other diagnostic testing—the months-long surgery “pipeline” has almost evaporated. And looming over everything are worries about a COVID-19 resurgence forcing another shutdown. Taken together, the outlook seems grim, but one chief strategy officer told us it’s motivation to act quickly: “We have to do as much as we can, as fast as we can, until we can’t.” With a future resurgence and shutdown likely, hospitals and doctors must quickly recruit patients and make them feel comfortable, while finding ways to expedite diagnostics and testing amid operational challenges. And they must deliver as much care as they can while it’s safe to do so. That’s critical for providers’ finances, but even more important for the thousands of patients facing delayed diagnoses, postponed treatments, and prolonged pain as the pandemic continues.


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 former Cigna executive-turned-industry-observer Wendell Potter. He shared his concerns that the coronavirus pandemic could exacerbate the power imbalance between payers and providers. Coming up next Monday, we’ll talk to John Gorman, chairman of the newly-formed, social determinants of health-focused investment firm Nightingale Partners. Gorman expects the poor economy to drive higher enrollment in Medicare Advantage plans among seniors looking for protection from high out-of-pocket medical expenses. 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.

We’ll get back to our regular rotation of rock, R&B, and jazz later, but for this Mothers’ Day we’re cueing up a lovely new classical piano collection from the Icelandic wunderkind Vikingur Ólafsson. The 36-year old just released his third recording on Deutsche Grammophon, Debussy-Rameu, to follow his widely acclaimed collections of works by Glass and Bach. On the new album, Ólafsson juxtaposes the works of two Frenchmen writing centuries apart: Jean-Philippe Rameau (1683-1764) and Claude Debussy (1862-1918). At first blush the two could not be more different, Rameau the Baroque-era harpsichord virtuoso and father of French musical theory, and Debussy the turn-of-the-century Symbolist, known for his impressionistic compositions often inspired by avant-garde poetry and Eastern musical traditions. By creating what he calls a “playlist” of interwoven short pieces from the two composers, Ólafsson at once makes Rameau sound modern, and Debussy sound firmly connected to 18th century roots. Throughout, the playing is bright, precise, and playful, with Ólafsson showing off his toccata chops and his unique interpretive skill. (A synaesthetic, Ólafsson “sees” music as colors, and the ordering of the pieces here reveals the power of that vision.) The well-worn 1910 Debussy prelude “La fille aux chevaux du lin” is warm and melodic, but more interesting are Ólafsson’s takes on some of the shorter sketches by both composers. Rameau’s “La poule” brings the pecking of the titular fowl to life, while you can nearly catch the flakes on your tongue in Debussy’s “The Snow is Dancing”. The collection bears repeated listening and will make a perfect Sunday soundscape for your Mothers’ Day-at-home brunch (or a welcome link to share virtually with your favorite mom). Gorgeous. Best tracks: “The Arts and the Hours” (Rameau); “La fille aux chevaux du lin” (Debussy); “Le Rappel des oiseaux” (Rameau).


GIST IN THE NEWS

We said it, they quoted it.

Doctors Without Patients: ‘Our Waiting Rooms are Like Ghost Towns’
New York Times; May 5, 2020

“While Congress has rushed to send tens of billions of dollars to the hospitals reporting large losses and passed legislation to send even more, small physician practices in medicine’s least profitable fields like primary care and pediatrics are struggling to stay afloat. ‘They don’t have any wiggle room,’ said Dr. Lisa Bielamowicz, a co-founder of Gist Healthcare, a consulting firm.”


WHAT WE’RE READING

Stuff we read this week that made us think.

Inviting patients to “c’mon back”

Providers looking to engage wary patients face a trust gap. According to a recent consumer surveyhospitals, doctors and nurses are the most trusted source of information on critical healthcare issues, yet a majority of consumers surveyed do not feel safe entering a healthcare facility. And beyond a drop in local COVID-19 cases, consumers say that what would make them feel most secure in returning would be having infectious cases isolated in designated facilities, seeing new sterilization and cleanliness procedures, and hearing their doctor tell them it’s safe. We were intrigued by a profile of Dallas-based Baylor Scott & White Health (BSWH), where leaders are working to educate their patients about the steps the system is taking to make facilities the safest possible place to receive care. Data is central to Baylor’s “C’mon Back” message, demonstrating that the reality inside the hospital is likely far better than patients fear. COVID-19 patients never accounted for more than 10 percent of Baylor’s admissions, and only two of the system’s 52 facilities even approached that level. Baylor facilities are safe for staff and patients, with only one percent of COVID-exposed healthcare workers testing positive. Clinical leaders are providing patients detailed information about new infection control and social distancing measures. BSWH was one of the first to develop its own coronavirus testing, and patients scheduled for surgery there will first be tested at a drive-by testing site. It’s a good example of how providers can reach out to the market with data and detailed information about how they’re working to make the care experience safe—and making sure patients know that the risks of exposure are much lower when going to the doctor than when they make their weekly trip to the grocery store.

What researchers are discovering about COVID-19

Thanks to the work of scientists around the world, our knowledge of the novel coronavirus that causes COVID-19 has blossomed over just a few months. For an overview of what we know now (and what we don’t), we’d highly recommend this fascinating summary in Nature. The article pieces together how the virus may have reached humans: the virus likely started in bats, which are essentially flying coronavirus petri dishes, carrying 61 strains known to infect man. But genetic mapping shows there was probably an intermediary animal vector between bats and humans (civet cats, sold live in Chinese markets, are high on the list of suspects). It’s a large virus that uses our cells’ own enzymes to enter, similar to other deadly viruses like HIV and Ebola. And the new virus is hardy: it may mutate less frequently than influenza, but is able to recombine with other coronaviruses, exchanging chunks of RNA, with an uncanny ability to repair itself. Comparing how this new virus invades its host with its coronavirus cousins shows how it has been able to both spread quickly and kill frequently. Mild coronaviruses, like those that cause common colds, invade the upper respiratory tract, and are able to spread widely but cause only mild illness. Lethal ones like SARS-CoV (the cause of SARS) and MERS (Middle East Respiratory Syndrome) invade the lower respiratory tract, which limits their ability to spread. The new virus, SARS-COV-2, invades both the upper and lower respiratory tracts, making it both highly contagious and highly lethal.

This week also saw the publication of the most comprehensive study of hospital patients to assess factors associated with death from COVID-19. Researchers evaluated medical records from nearly 17.5M patients admitted to hospitals in Britain’s National Health System (NHS) from February 1st to April 25th, finding 5,683 deaths attributable to COVID-19. Patients who were male, older, or suffering from uncontrolled diabetes or severe asthma were at higher risk of death, confirming the results of earlier studies. More significant was the finding that patients of Black and Asian ethnicities had substantially higher death rates—and that this increased risk was independent of poverty and clinical risk factors. The study also sparked headlines by suggesting that patients who smoke may paradoxically be at lower risk of death from COVID-19. But before you light up, read this outstanding Twitter thread, in which a Boston University epidemiologist debunks that theory by showing how misinterpreting confounding relationships between risk factors can lead to an incorrect interpretation of causation.

Researchers and clinicians are not only learning how COVID-19 kills, but are also making great strides in understanding how to successfully rehabilitate critically ill patients. Our attention was captured yesterday by this extraordinary tweet from a physical therapist at the University of Iowa, sharing the progress made by the hospital’s first COVID patient, an expectant mother who received ECMO, or extracorporeal membrane oxygenation. The video shows the woman walking with the aid of therapists—while intubated and connected to the large catheters which carry her full blood volume to the ECMO system. While ambulation during ECMO has been done before, this patient may be the first pregnant woman to undergo the process. No better way to mark Mother’s Day than to wish her a safe recovery and a healthy delivery!


That’s it! Our 100th Weekly Gist in the bag. We look forward to sitting down to write to you each week, and we’re so grateful for your readership, and your generous feedback and suggestions. Don’t forget to share this with a friend or colleague, and encourage them to subscribe, and to check out our daily podcast.

And finally, as Mom says, if we’ve told you once, we’ve told you a hundred times…please let us know if there’s anything we can do to be of assistance in your work. You’re making healthcare better—we want to help!

Wishing you a Happy Mothers’ Day,

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

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