|Another brutal week in the coronavirus war
The US continued its inexorable march up the now-familiar coronavirus infection curve this week, and on Thursday the country reached the unenviable mark of having the most reported cases of the virus worldwide. New York quickly emerged as the most heavily impacted state, with hospitals in the greater New York City area reporting they had become overwhelmed with COVID-19 cases. While production and distribution of testing supplies ramped up significantly, along with the supply of personal protective equipment (PPE) for healthcare workers, widespread shortages of these critical supplies continued to plague communities across the nation. Of particular concern, hospitals in New York and elsewhere projected a coming shortage of ventilators, forcing a growing public discussion of triage and potential rationing.
The impact of the virus varied widely across geographies, with NYC one of several “hot spots”—others included Seattle, New Orleans, Chicago, Detroit, and Atlanta. Meanwhile, President Trump sparked a debate over when and where to loosen “social distancing” restrictions, floating the idea of targeting Easter (April 12th) as a potential date for “opening” the US economy, and proposing to implement county-by-county ratings of readiness to return to normal. Having largely ceded decisions about shuttering businesses and schools to governors, the administration faced questions about how much control it could exercise over loosening restrictions, and faced pushback from public health experts about the wisdom of pulling back restrictions too early. As a result of the widespread closings, new unemployment claims skyrocketed to unprecedented levels this week, leaving millions of Americans out of work and potentially without health insurance. The week ahead is likely to bring even more grim news, as the health and economic crises show no sign of slowing in the near future.
President Trump approves a $2T stimulus package
To respond to the coronavirus crisis, the US Congress passed a $2T stimulus package this week, which the President signed into law on Friday afternoon, intended to provide relief to individuals, small businesses, and large corporations impacted by the shutdown of the economy. Approved on a 96-0 vote in the Senate, and by voice vote in the House, the CARES Act includes $100B to reimburse hospitals for lost revenue and the cost of caring for COVID-19 patients, $20B to bolster veterans’ healthcare, and billions more to replenish the strategic national stockpile, provide funding for community health centers, and fund drug development and disease mitigation efforts. The bill also provides further flexibility for providers to offer telemedicine alternatives to in-person care, requirements for insurers to cover certain COVID-related diagnostic tests, and a number of “extenders” to healthcare-related programs that would have seen funding expire in the next few months. (A full summary of the healthcare measures in the CARES Act can be found here.)
Notably absent from the final version were specific measures designed to prop up independent physician practices, although they would be eligible to access the Act’s $350B in relief loans for small business operators. Rural and safety net hospitals, which typically operate with much less financial cushion than larger health systems, also expressed concern about their ability to access CARES Act funding in time to avoid running out of cash and being forced to close or lay off staff. As the crisis continues to spread across the nation, providers are likely to need more financial and regulatory relief from the federal government, but the CARES Act (already one of the most expensive pieces of legislation in American history) is an important first step toward buffering the impact of the pandemic on healthcare delivery.
The murky mess of predictive modeling
Last week the Imperial College of London’s analysis of possible COVID-19 spread predicted 2.2M US deaths if limited action was taken, which motivated leaders to quickly implement more restrictive measures and scramble to increase ventilator production. This week, news broke that Neil Ferguson, the lead researcher behind the model, had changed his guidance, when he testified to the UK Parliament that his country might only experience 20,000 deaths rather than the 500K posited in the earlier paper. Ferguson tweeted today to try to clear up the confusion, noting that his original analysis ran a number of scenarios, and the lower numbers behind his testimony were predicated on following through on the strict social distancing practices currently in place—without them, the UK could easily see the higher number of deaths. Meanwhile, amid the confusion, the Trump administration downplayed the worries about ventilator shortages in Thursday’s press conference, with White House coronavirus response coordinator Dr. Deborah Birx stating, “Please, for the reassurance of people around the world, to wake up this morning and look at people talking about creating DNR situations—do not resuscitate situations for patients—there is no situation in the United States right now that warrants that kind of discussion”—much to the consternation of doctors in hard-hit areas, who say her statement conflicts with what they’re seeing in their hospitals.
Stepping back, the whiplash highlights the limitations in making policy from predictive models, which are constantly evolving based on new data and technical refinements. Another case-in-point: health systems around the country are using on a model for surge capacity planning generously shared by Penn Medicine researchers, who are continuing to work out kinks and improve the analysis daily. It’s a reminder that no model is perfect, and must be refined over time. Any strategies based on prediction models must use them as guidelines, and when working to protect the health and safety of our communities we must always plan for the worst, even as we hope for the best.