February 5, 2021

The Weekly Gist: The Rooting for Showtime Edition

by Chas Roades and Lisa Bielamowicz MD

What a dilemma. Because of the pandemic, several major advertisers have decided to sit out Super Bowl LV, meaning we’re going to have to actually pay attention to the game this year, right alongside the 30,000 cardboard cutouts who’ll be in attendance at the Big Game in Tampa (so much for home field advantage). Ordinarily in any old guy/young guy matchup, we’d be behind the greybeard all the way, but…Tom Brady. The guy is already nearing a Larry King number of rings, and besides…Tom Brady. Fortunately, the decision is made simpler by the fact that one of our members is located in Chiefs territory, and another is in the Land Brady Left Behind, so you’ll find us opportunistically rooting for Showtime Mahomes this weekend. (Unless we hear from a health system executive in Florida in the next 24 hours. BayCare and Tampa General: our phone lines are open!)

THIS WEEK IN HEALTHCARE

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

Turning the tide in the battle against the virus

The national COVID indicators all continued to move in the right direction this week, with new cases down 16 percent, hospitalizations down 26 percent, and deaths (while still alarmingly high at more than 3,000 per day) down 6 percent from the week prior. More good news: both nationally and globallythe number of people vaccinated against COVID now exceeds the total number of people infected with the virus, at least according to official statistics—the actual number of coronavirus infections is likely several times higher. On the vaccine front, Johnson & Johnson filed with the Food and Drug Administration (FDA) for an Emergency Use Authorization for its single-dose COVID vaccine, which could become the third vaccine approved for use in the US following government review later this month. The J&J vaccine is reportedly 85 percent effective at preventing severe COVID disease, although it is less effective at preventing infection than the Pfizer and Moderna shots. Elsewhere, The Lancet reported interim Phase III results for Russia’s Sputnik V vaccine trials, showing it to be 91 percent effective at preventing infection, and a new study found the Oxford-AstraZeneca vaccine to be 75 percent effective against the more-contagious UK virus variant.

Amid the positive vaccine news, the Biden administration moved to accelerate the vaccination campaigninvoking the Defense Production Act to boost production and initiating shipments directly to retail pharmacies. With the House and Senate starting the budget reconciliation process that could eventually lead to as much as $1.9T in stimulus funding, including billions more for vaccines and testing, it feels as though the tide may be finally turning in the battle against coronavirus. While the key indicators are still worrisome—we’re only back to Thanksgiving-week levels of new cases—and emerging variants are cause for concern, it’s worth celebrating a week that brought more good news than bad. Best to follow Dr. Fauci’s advice for this Super Bowl weekend, however: “Just lay low and cool it.”

Humana partners with DispatchHealth for hospital at home

Humana, the nation’s second-largest Medicare Advantage (MA) insurer, is pushing further into home-based care, partnering with Denver-based startup DispatchHealth to offer its members—especially those with conditions like heart failure, chronic obstructive pulmonary disease, and chronic cellulitis—access to hospital-level care at home. The service will initially be available in the Denver and Tacoma, WA markets, with plans to expand to Arizona, Nevada, and Texas across 2021. Humana members who meet hospital admission criteria will receive daily home visits from an on-call, dedicated DispatchHealth medical team, as well as 24/7 physician coverage enabled by remote monitoring and an emergency call button. DispatchHealth will also coordinate other patient care and wraparound services in the home as needed, including pharmacy, imaging, physical therapy, durable medical equipment, and meal delivery. Dispatch’s earlier offerings centered around home-based, on-demand urgent and emergency care services, now available in at least 29 cities nationwide. Humana’s partnership with DispatchHealth could deliver a full care continuum of home-based services to its Medicare Advantage enrollees and has the potential to displace hospitals from at least a portion of acute care services. Post-COVID, it’s becoming increasingly clear that the nexus of care delivery has shifted even more rapidly to consumers’ homes—and traditional providers will need to rethink service strategies accordingly.

McKinsey agrees to a half billion-dollar opioid settlement

On Thursday, blue-chip consultancy McKinsey & Company entered into settlement agreements with 49 states and the District of Columbia related to advice it provided to opioid manufacturers. It agreed to pay nearly $600M to settle allegations that it helped Purdue Pharma and other drug makers drive sales of painkillers, contributing to a national epidemic of opioid addiction, even after the production and sale of high-dose opioids came under intense scrutiny by the Food and Drug Administration (FDA). States will use the money from the McKinsey settlement, along with money from an earlier $8.3B settlement with Perdue Pharma, to fund opioid recovery and treatment programs. As part of the settlement agreements, McKinsey agreed to future restrictions on its work related to narcotics, and to disclose publicly the extent and nature of its work with opioid manufacturers.

Although the consultancy admitted no legal wrongdoing, a statement from McKinsey’s global managing partner said that the firm “deeply regret[s] that we did not adequately acknowledge the tragic consequences of the epidemic unfolding in our communities.” Not that the consultants were unaware of those consequences: in one document delivered to its pharma client, for example, McKinsey estimated that nearly 2,500 CVS customers would likely overdose or develop an addiction to OxyContin in a single year alone, and in another suggested trying to “lobby Walgreen’s leaders to loosen up” on the opioid issue, despite ongoing FDA scrutiny. Companies often hire marquee firms like McKinsey to provide external validation of their business strategies, creating a moral hazard for consultancies that lack adequate internal controls and guidelines on the advice they give. This week’s half billion-dollar settlement is a stark reminder that the privilege of giving strategic advice comes with responsibility—a useful reminder for those serving clients in healthcare, where patients’ lives are often at stake.


GRAPHIC OF THE WEEK

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

Disparities may worsen as vaccine eligibility widens

Early data on vaccine distribution by race and ethnicity show a mismatch between those population groups receiving the vaccine, and those that have been hardest hit by the pandemic. As the graphic below shows, Black and Hispanic Americans have thus far been vaccinated at considerably lower rates in many states compared to their share of population as a whole—and these disparities are likely to worsen as states shift focus to senior populations for priority access, moving away from prioritizing essential workers, who tend to be more racially diverse. The White population skews older, which stands to widen disparities in the near-term. Another compounding issue: vaccine hesitancy. A recent Morning Consult poll found that, despite an overall increase in overall vaccine willingness, Black Americans remain the most hesitant, with only 48 percent willing to get the vaccine. Meanwhile, Black and Hispanic Americans continue to be disproportionately impacted by COVID, with hospitalization and death rates nearly three to four times greater than those of White Americans. Hesitancy will become an increasingly urgent problem as larger swathes of the population become eligible for vaccination, especially given that communities of color tend to be younger, as shown below.


THIS WEEK AT GIST—ON THE ROAD PHONE

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

“I got the vaccine…now what can I do?”

A family member in her 70s called with the great news that she received her first dose of the COVID vaccine this week. She mentioned that she was hoping to plan a vacation in the spring with a friend who had also been vaccinated, but her doctor told her it would still be safest to hold off booking travel for now: “I was surprised she wasn’t more positive about it. It’s the one thing I’ve been looking forward to for months, if I was lucky enough to get the shot.” It’s not easy to find concrete expert guidance for what it is safe (or safer?) to do after receiving the COVID vaccine. Of course, patients need to wait a minimum of two weeks after receiving their second shot of the Pfizer or Moderna vaccines to develop full immunity. But then what? Yes, we all need to continue to wear masks in public, since vaccines haven’t been proven to reduce or eliminate COVID transmission—and new viral variants up the risk of transmission. But should vaccinated individuals feel comfortable flying on a plane? Visiting family? Dining indoors? Finally going to the dentist?

It struck us that the tone of much of the available guidance speaks to public health implications, rather than individual decision-making. Take this tweet from CDC director Dr. Rochelle Walensky. A person over 65 asked her if she could drive to visit her grandchildren, whom she hasn’t seen for a year, two months after receiving her second shot. Walensky replied, “Even if you’ve been vaccinated, we still recommend against traveling until we have more data to suggest vaccination limits the spread of COVID-19.” From a public health perspective, this may be correct, but for an individual, it falls flat. This senior has followed all the rules—if the vaccine doesn’t enable her to safely see her grandchild, what will? It’s easy to see how the expert guidance could be interpreted as “nothing will change, even after you’ve been vaccinated.” Debates about masking showed us that in our individualistic society, public health messaging about slowing transmission and protecting others sadly failed to make many mask up. The same goes for vaccines: most Americans are motivated to get their vaccine so that they personally don’t die, and so they can resume a more normal life, not by the altruistic desire to slow the spread of COVID in the community and achieve “herd immunity”. In addition to focusing on continued risk, educating Americans on how the vaccinated can make smart decisions will motivate as many people as possible to get their shots.

In need of more nuanced consumer segmentation

As “consumerism” becomes an ever-greater focus of health system strategy, we’ve begun to field a number of questions from leaders looking to develop a better understanding of consumers in their market. In particular, there’s a growing desire for more sophistication around consumer segmentation—understanding how preferences and behavior differ among various kinds of patients. Traditional segmentation has largely been marketing-driven, helping to target advertising and patient recruitment messages to key groups. For that, the old-school marketing segments were good enough: busy professionals, the worried well, the growing family, and so forth. But as systems begin to develop product offerings (telemedicine or home-based services, for example) for target populations, those advertising-based segments need to be supplemented with a more advanced understanding of care consumption patterns over time. Segmentation needs to be dynamic, not static—how does a person move through life stages, and across care events, over time? A single consumer might be in different segments depending on the type of care they need: if I have a new cancer diagnosis, that matters more than whether I’m a “busy professional”, and my relevant segment might be different still if I’m just looking for a quick virtual visit. Layered on top of demographic and clinical segments is the additional complexity of payer category—am I a Medicare Advantage enrollee or do I have a high-deductible exchange plan? With consumers exercising ever greater choice over where, when, and how much care to receive, understanding the interplay of these different kinds of segments is fast becoming a key skill for health systems—one that many don’t currently have.


THIS WEEK AT GIST—ON THE PODCAST

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

Last Monday, we shared an episode from our friends at health policy podcast Tradeoffs. Their team reported on how nursing homes are trying to encourage hesitant employees to take the COVID-19 vaccine.

Coming up on this Monday’s episode, we’ll hear from Dr. Mark Prather, CEO and co-founder of Denver-based DispatchHealth. As reported above, the company is expanding from its roots in on-demand urgent care home visits to provide home-based services across the full continuum of care, including hospital-level care through a new partnership with Humana. Make sure to tune in, you won’t want to miss it!

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


ON THE GIST TURNTABLE

Give this a spin—you might like it.

This week brings another eagerly anticipated debut album from the febrile South London music scene that’s currently producing some of the most interesting young bands of the UK’s post-punk revival. Black Country, New Road are a seven-piece outfit from the stable of new acts signed to the white-hot Speedy Wunderground label, which includes the likes of Fontaines D.C., Squid, black midi, and Goat Girl—all pushing the edges of post-rock, post-punk music and garnering serious critical attention. BCNR’s first long player, aptly titled For the First Time, is a daring (if slender) collection of the group’s experimental ideas, sounding less like a studio album and more like a documentary recording of performance art. Front man Isaac Wood’s nervously intoned, mostly spoken vocals recall Mark E. Smith, Nick Cave, and even Scott Walker, as he delivers edgily ironic lyrics full of (as he says on one track) “references, references, references”. Distorted bass and guitar lines, and klezmer-tinged sax and violin surround his vocals and fill in the awkward pauses. The group is clearly aware of the yardstick they’re being measured by—at one point Wood mentions being “the world’s second-best Slint tribute act,” namechecking one of the ur-indie bands of the late 80s. But that’s belied by the musical nous of the band, which kicks off the album with an impressive new-jazz number showcasing their instrumental chops. The sky’s the limit for Black Country, New Road, with enough flashes of genius on this debut outing to promise a fascinating career ahead. Best tracks: “Science Fair”; “Track X”; “Opus”.


WHAT WE’RE READING

Stuff we read this week that made us think.

Glitches in the vaccine distribution software

After the miracle moonshot that delivered several highly effective coronavirus vaccines in less than a year, the nation’s progress in distributing and administering those vaccines has been underwhelming, to say the least. In dissecting the operational challenges, two federal IT systems have come under scrutiny for creating logjams for states, providers and patients. A new piece in Politico looks into the shortfalls of vaccine distribution software developed by data-mining company Palantir. Called Tiberius, the Palantir software was designed to track shipments of vaccines from factory to states, and on to their final administration sites. Tiberius does a good job in tracking when the vaccines are shipped but falls down from there. State and public health officials report difficulties uploading data, leading to gaps in information across the supply chain. And dashboards are only updated twice weekly, making it difficult for states or the federal government to understand how much vaccine is available real-time.

A second federal IT solution to centralize patient vaccine registration has fallen even further short, according to a MIT Technology Review report. The CDC contracted with consulting firm Deloitte last spring to build a web-based vaccine scheduling, inventory and reporting solution that would be offered to states at no cost. The resulting Vaccine Administration Management System, or VAMS, has been responsible for slowing down vaccine distribution, according to several states who have used the software. The scheduling interface, which only works on Google Chrome, is far from user-friendly, especially for older adults who are less tech-savvy. Many have experienced cancelled appointments, only to find that they can’t reschedule because there’s already an appointment “in progress”. Providers report that the software is clunky, from sign-in to updating records after patients have been immunized. Several states have already abandoned VAMS for other solutions—in the words of one South Carolina official, “VAMS has become a cuss word”. Experts point to bureaucracy and contracting issues as root causes of these software shortfalls. Tiberius was developed prior to COVID, to manage routine vaccines like mumps and measles, and wasn’t able to scale as the pandemic grew. And Deloitte was awarded a $40B+ no-bid contract for VAMS, in a contracting system that prizes previous work and relationships over fit and innovation. COVID has shown the challenges of managing public health initiatives across myriad state and local entities—but the experiences of VAMS and Tiberius show that “federalizing” the process is no panacea.

What happens after a year without the flu?

Doctors and scientists have been relieved that the dreaded “twindemic”—the usual winter spike of seasonal influenza superimposed on the COVID pandemic—did not materialize. In fact, flu cases are at one of the lowest levels ever recorded, with just 155 flu-related hospitalizations this season (compared to over 490K in 2019). A new piece in the Atlantic looks at the long-term ramifications of a year without the flu. Public health measures like masking and handwashing have surely lowered flu transmission, but scientists remain uncertain why flu cases have flatlined as COVID-19, which spreads via the same mechanisms, surged. Children are a much greater vector for influenza, and reduced mingling in schools and childcare likely slowed spread. Perhaps the shutdown in travel slowed the viruses’ ability to hop a ride from continent to continent, and the cancellation of gatherings further dampened transmission. Nor are scientists sure what to expect next year. Optimists hope that record-low levels of flu could take a strain out of circulation. But others warn that flu could return with a vengeance, as the virus continues to mutate while population immunity declines. Researchers developing next year’s vaccines, meanwhile, face a lack of data on what strains and mutations to target—although many hope the mRNA technologies that proved effective for COVID will enable more agile flu vaccine development in the future. Regardless, renewed vigilance in flu prevention and vaccination next fall will be essential, as a COVID-fatigued population will be inclined to breathe a sigh of relief as the current pandemic comes under control.


Let the weekend begin! Best of luck to fans of Tampa Bay and Kansas City—may the best (young) man win! Thanks so much for taking the time to read our thoughts this week, and for sharing your perspectives with us. We love to hear from you! And if you have a moment, don’t forget to share this with your friends and colleagues and encourage them to subscribe, and to listen to our daily podcast.

Most of all, please do 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!

Best regards,

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

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