The Weekly Gist: The Lightning Bugs Edition

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

As cases and deaths rise, Americans ponder a return to school

The US spent another week headed in the wrong direction, with daily new COVID-19 cases reaching nearly 60,000 on Thursday, the sixth record-setting total in the past ten days. The spike continued to be most pronounced in states that reopened early, with Texas, South Carolina, Arizona, and Florida hit particularly hard. More worryingly, several states saw daily deaths from COVID rise, with Alabama, Florida, Mississippi, South Dakota and Tennessee hitting one-day death records. Like the light from some malign star, death numbers are a lagging indicator—a reflection of new case totals from weeks earlier—leading health experts to warn of dark days ahead for the rest of the summer. In his customary understated manner, top White House health advisor Dr. Anthony Fauci said this week, “I don’t think you could say we’re doing great. I mean, we’re just not.” Responding to concerns about the availability of hospital capacity, Texas Gov. Greg Abbott expanded a ban on elective surgeries to more than 100 counties across the state, and HCA Healthcare delayed inpatient surgeries at more than a dozen of its hospitals in Florida, as did other health systems there.

School reopening emerged as a political flashpoint this week, with President Trump hosting a summit meeting on “Safely Reopening America’s Schools” on Tuesday at the White House. The President criticized reopening guidelines from the Centers for Disease Control (CDC) as being “very tough & expensive”, but on Thursday CDC director Dr. Robert Redfield told CNN that the guidelines, first published in May, would not be revised. With schools and colleges set to restart in many places next month, the influential American Academy of Pediatrics modified its earlier support for reopening schools, pushing back on the administration’s threatened funding cuts for school districts that do not reopen on time, with in-person classes. The debate over how to handle school reopening underscores how much time was lost between March and May, when a national reopening plan should have been developed. As the virus surges, with students and teachers set to return in just a few short weeks, and further economic recovery hinging on parents’ ability to send their kids safely to school, the window is rapidly closing on our ability to navigate this critical transition. US coronavirus update: 3.2M cases; 135K deaths; 38.0M tests conducted.

Democrats align around a health policy platform

Promising that “we are going to at last build the health care system the American people have always deserved”, a joint task force of health policy advisors from the Biden and Sanders campaigns this week released a unified set of proposals that will serve as part of the former Vice President’s campaign platform for the November election. While the document does not include Sanders’ signature “Medicare for All” proposal, it does support a government-run public insurance option that would be available to all Americans, at income-adjusted, subsidized rates—including free coverage for those with low incomes. It also promises to expand Medicare benefits to include dental, vision, and hearing coverage, and to extend Medicare eligibility to those age 60 and above. For those who lose their health coverage due to the COVID pandemic, the unity document endorses having the government pick up the tab for COBRA benefits and shifting enrollees into premium-free coverage on the Obamacare exchanges when their COBRA eligibility expires. It also promises greater investment in public health resources, including increased funding for the CDC, and funding to recruit 100,000 contact tracers nationwide. Other key components of the proposal include eliminating “surprise billing”, reducing drug costs, addressing racial and gender-based health inequities, and bolstering investment in scientific research.

This week’s document represents an important step in unifying the progressive and moderate wings of the Democratic party around key health policy principles. Should Biden win in November, and if Democrats gain control of the Senate, we’d expect quick action on many of these proposals. Clearly the most difficult would be the public option and Medicare expansion, which would require lengthy negotiation with various industry groups to garner sufficient political support. Similar to the 2009 process that led to the Affordable Care Act, we would likely see a year’s worth of political horse-trading, leading to passage of some compromise legislation before the midterm elections in 2022. All of that in the midst of an ongoing pandemic and likely prolonged economic downturn—both of which will probably allow for the passage of more far-reaching legislation than might otherwise be possible.

Walgreens to open primary care practices in hundreds of stores

Walgreens Boots Alliance announced Wednesday that it plans to launch physician-led clinics in 500 to 700 stores in 30 markets nationwide, in a major expansion of its partnership with VillageMD, a Chicago-based primary care startup. The companies previously partnered on a pilot of in-store clinics in five Houston-area Walgreens stores. Walgreens will acquire a 30 percent stake in VillageMD through an investment of $1B, 80 percent of which will be used to fund the launch and operations of the clinics, including the hiring of 3,600 primary care physicians. The “Village Medicine at Walgreens” clinics will also be integrated with Walgreens’ larger digital health offerings into a care management-focused model designed for Medicare beneficiaries, which could also be marketed to employers.

Other retailers, most notably CVS and Walmart, have continued to expand their care delivery offerings amid the pandemic. Walgreens’ physician-centric model is in contrast to its competitors, which more heavily rely on nurses and advanced practice providers. We visited one of Walgreens’ pilot sites on a trip to Houston last December. This VillageMD clinic was part of a larger Walgreens store renovation, but had a separate entrance, and felt distinctly less integrated with the retail store and pharmacy than CVS’ HealthHUB clinics. It will be worth watching to see if this launch, with its significantly more expensive labor model, is able to generate better outcomes and gain traction with consumers—and whether Walgreens will seek an insurer partner to create a risk model that allows the company to profit from the delivery of lower-cost care.

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

Consumer confidence declines as COVID surges

Just as consumer confidence was approaching pre-COVID levels in early June, cases began surging in many parts of the country. The graphic below shares highlights from a recent Morning Consult poll, which found reduced consumer confidence in participating in a range of activities, like dining out or going to a mall. The poll also showed a significant consumer divide based on political affiliation, with Republicans’ confidence levels for many activities being twice that of Democrats. It remains to be seen whether the current surge will result in consumers pulling back on healthcare utilization the way they are beginning to for other activities. A coalition of healthcare organizations is urging consumers to continue social distancing but “stop medical distancing”—in hopes that the new surge will not lead patients to avoid needed medical care. While cell tower data at thousands of hospital facilities suggest volumes may be stalling again, we anxiously await the latest national data on outpatient visit and elective procedure volumes. We’d predict the surge will exacerbate consumer discomfort with “waiting” in healthcare settings—urgent care clinics, emergency departments and the like—though we’d expect the reduction in utilization to be less severe and more regionally varied this time around. Let us know what you’re seeing!

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

A lifeline for independent doctors may have worked—for now

“We’ve been thinking through how quickly we would be able to bring doctors into our employed group,” a health system chief clinical officer told us this week. “Given how hard independent practices have been hit, especially primary care, it seemed like a good time to strategically grow the group.” But she has been surprised how few knocks on the door they’ve received from doctors: “We expected a flood, but it’s been a trickle.” Looking through the list of federal Paycheck Protection Program (PPP) loan recipients released this week, the system saw a number of the independent physician practices in their market received substantial loans, which surely helped to stabilize finances as volumes cratered. We’ve heard similar stories around the country, with another system CEO telling us, “Only a few practices have come asking about employment so far, and those are the ones who were struggling before COVID. The stronger ones seem to be doing okay.” The healthcare sector was the largest recipient of PPP loans, and tens of thousands of physician practices received much-needed support. But this one-time cash infusion is unlikely to be enough to see many practices through months of depressed volumes and increased expenses, ever more likely given recent COVID surges. Absent another wave of federal funding, it’s likely that many more practices will see their finances deteriorate across the second half of this year—setting up 2021 as a potential “land grab” for physician partners, with health systems, insurance companies and investors battling to acquire the most strategically attractive practices. It will be a busy year for those who negotiate physician deals.

Facing another round of elective surgery shutdowns

With elective surgery shutdowns hitting health systems in Florida and Texas, providers across the country are thinking through the odds of a second round coming to their markets. While shutting down nonemergent cases in areas truly overwhelmed by the virus may be a necessity, we have been struck by how much better prepared systems are to deal with a second surge.  According to one of our member COOs, the enormous amount that hospitals and doctors have learned about COVID across the past six months, and the operational changes they’ve made to ensure safety (which now feel routine) make systems much better equipped to manage elective cases even if COVID admissions begin to rise. “We created designated non-COVID facilities, supported by rigorous safety procedures. And we now have a few months of evidence that these changes allow us to manage electives without putting patients or staff at risk,” he said. “Just like none of us are wiping down our groceries with bleach anymore, we’ve learned what is and isn’t essential to create a safe environment in a surgery center.” But he cautioned that, in their market, supply shortages will likely threaten electives before a local surge of COVID cases. The system recently postponed some procedures when the turnaround time for COVID test results suddenly jumped, and they are once again worried about shortages of PPE. As we look toward fall, when more surges are likely as kids return to school and the flu season sets in, hospitals must have the resources to manage COVID spikes without shutting down the rest of the system. Many patients with ongoing health needs put their care on hold for much of the spring. If much of healthcare is forced into a second months-long shutdown, the toll from untreated conditions could be enormous.

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

Note to listeners: Our podcast was on a much-deserved holiday hiatus this week. Make sure to tune in on Monday, as we feature a week of “best of” interviews—a collection of our favorite recent conversations with healthcare innovators. The regular daily podcast will return with all new episodes on July 20th.

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

What we’ve been writing about this week on the Gist Blog.

Three things COVID-19 has taught us about the healthcare workforce

This week, our Gist colleague Jenn Stewart shares her thoughts on what we’ve learned about the healthcare workforce in the course of the COVID pandemic. In a nutshell, she believes it has shown itself to be too brittle and costly, and that healthcare workers are at risk of becoming angry and disengaged. Even in the throes of the pandemic, leaders must act now to increase workforce flexibility, radically restructure labor costs, and seize a rapidly closing window to engage early-career providers. Click here to read more, and let us know if you’d like to discuss it further with our team!

Give this a spin, you might like it.

It’s no small feat to pull off a three-year, two-continent, 25+ artist collaboration, but if anyone could do it, it’d be Coldcut. The UK duo, godfathers of electronic dance music and pioneers of sampling who founded the venerable Ninja Tune label, first ventured to Soweto in South Africa in 2017, and they’ve spent the past three years assembling Keleketla! Released this month, the album is a genre-spanning exploration of what happens when the grassroots sounds of Afrobeat, highlife, jazz, and gqom music merge with the slick studio production of electronica. The word “keleketla” means “response” in the Sepedi language of South Africa, as in “call and response”—a community-driven musical approach that provides the heartbeat of the project. Capturing local artist recordings in a performance space in Johannesburg, Coldcut returned to the studio in London and mixed in a number of other Western and West African sounds, including (brilliantly) the drumming of the late Tony Allen, who passed away earlier this year. Allen was the percussionist and mastermind of Fela Kuti’s 1960s and 1970s Afrobeat work, and the Nigerian sound pervades several of the album’s nine tracks. Other standouts include the vocal work of Nono Nkoane, a jazz vocalist from Cape Town, and the saxophone work of Tamar Osborn, a London-based musician. But the star of the show is the sound of collaboration itself—there’s a magic to what came together in a storefront Soweto music studio (check out this documentary footage of the sessions). Best tracks: “Future Toyi Toyi”; “Crystallise”; “Papua Merdeka”.

Stuff we read this week that made us think.

Dispirited, demoralized, and “facing the wrath of a nation on edge”

Take a read through this recent article in The Atlantic and imagine yourself in the shoes of America’s public health leaders: you’re working 18-hour days, your phone rings off the hook. Your department is chronically understaffed and underfunded, and has been running at an unsustainable pace since the first signs of COVID-19 in January. You’ve been giving the same (scientifically-sound, evidence-based) guidance on how to slow the spread of the virus over and over, every day, for months, only to have it ignored by politicians that “every public-health person [you] know disagreed with”. These experts have been watching and warning that early reopening and resistance to masks and social distancing would lead to spikes in cases, and now they’re being proven correct. And many public health leaders—especially women—are facing harassment and threats, leading some to resign. We entered the pandemic with a public health infrastructure that faced not only a lack of resources but a “drought of expertise”. The best leaders we have in the field are now at risk of burning out at the moment we need them the most. It’s imperative for our country’s leaders—providers and politicians—to support them, follow their guidance, and make investments to bolster our public health infrastructure for future crises.

A closer look at the unequal impact of coronavirus

While it has been known for some time that racial and ethnic minorities make up a disproportionate share of COVID cases and fatalities, an analysis of new federal data by the New York Times provides the most comprehensive look to date at the extent to which Black and Latino residents are being impacted by the virus. According to the new data, Black and Latino people have been three times as likely to become infected as whites, and are almost twice as likely to die from COVID. (When the data is normalized for age, the disparities are even more extreme, given the younger average age for minority populations.) The analysis also reveals similar disparities impacting Native Americans. For people of Asian descent, the inequities are not as pronounced, although they are still 1.3 times as likely to become infected than white people. While these data—only made available after the New York Times sued the CDC for access—provide the most up-to-date racial picture of the pandemic in the US, they are far from complete. Race and ethnicity data is missing from more than half the records, because state and local health agencies do not collect detailed information about every person who tests positive. While the release of this information is a step in the right direction, full and ongoing data transparency is essential, so public health officials and other healthcare leaders can make informed decisions to protect vulnerable populations, ranging from locating testing centers to targeting prevention strategies.  

Beyond the simplistic connection between “underlying health conditions” and COVID mortality, it’s clear that larger structural factors play a huge role in making Black and Latino people especially vulnerable to the virus. In addition to having lower levels of healthcare access and insurance coverage, these groups are more likely to work in low-income service and production jobs that cannot be done remotely, are more reliant on public transportation where it’s difficult to control the spread of the disease, and more frequently live in multigenerational homes with increased risk of household transmission. African-Americans in particular are more likely to die from cancer or in childbirth, suffer from chronic diseases at higher rates, and are less likely to receive timely and compassionate treatment in healthcare settings. In short, COVID-19 has exposed the impact of structural racism that has long pervaded our healthcare system.

Our small team at Gist is committed to doing our (admittedly small) part to help address the impact of racial disparity in healthcare. As our team members look to devote their personal time and financial resources, we’re also looking for opportunities to partner more closely as a firm with a small number of organizations whose work we can support through hands-on advising and thought partnership—bringing the skills we use at Gist to the work of nonprofits who are committed to making an impact in this area. We’d love your suggestions for potential partners—let us know of any organizations you think could benefit from our assistance. We’ll keep you posted as our work in this area develops.

Most importantly, if there’s anything we can do to be of assistance in your work, please let us know. 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