December 11, 2020

The Weekly Gist: The Santa Supply Chain Edition

by Chas Roades and Lisa Bielamowicz MD

People who got in line early may turn out to be the fortunate ones, as those of us who procrastinated, or decided that it was “just too soon,” may end up having to go without. Instead, we might be left to enviously watch Canadians—who’ve been spared some of the issues we’ve experienced in the US—enjoying their holidays with friends and family. No, we’re not talking about coronavirus vaccines…we’re referring to Christmas trees. Turns out there’s a nationwide shortage that’s been years in the making, thanks to the combined impact of the Great Recession and record-setting forest fires that cut into the eight-to-ten-year seed-to-harvest cycle. That means fewer trees, amid a pandemic that’s driving increased demand from housebound families. In short, if you haven’t gotten your tree yet, you might be stuck getting an artificial one instead—if you can find one. Sure, Santa is magic, but there’s a limit to the supply-chain miracles Ol’ Saint Nick and his elves can pull off. Oh, 2020.

THIS WEEK IN HEALTHCARE

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

Vaccine rollout draws closer as the pandemic worsens

Right on cue, this week the nation found itself in the grips of a post-Thanksgiving surge in coronavirus cases, hospitalizations, and deaths. Across the week, new cases have been 28 percent higher than two weeks before, and Wednesday saw a new daily record of at least 3,000 deaths from COVID-19. More than 160,000 Americans are now hospitalized with the virus, and new data released by the Department of Health and Human Services (HHS) shows that hospitals in many parts of the country are running short of ICU capacity. In remarks made Thursday, Dr. Robert Redfield, the director of the Centers for Disease Control and Prevention (CDC) made a grim prediction for the coming months: “We are in the timeframe now that probably for the next 60 to 90 days we’re going to have more deaths per day than we had at 9/11 or we had at Pearl Harbor,” Redfield said.

As Britain began inoculating the elderly and key healthcare workers this week, a panel of outside experts recommended that the US Food and Drug Administration (FDA) grant authorization for emergency use of the vaccine developed by Pfizer and its partner BioNTech. In its discussion, the expert panel raised concerns about reports that two early vaccine recipients in the United Kingdom experienced severe allergic reactions, and questioned whether the vaccine is safe for pregnant women and children under age 16. Nevertheless, FDA approval was expected by the weekend, or perhaps as early as Friday evening (given reports that the White House has threatened to fire FDA commissioner Dr. Stephen Hahn if a Friday deadline is not met). Whether real or not, the perceived politicization of the approval process likely contributed to new survey results, which show that only about half of Americans plan to get the vaccine when it becomes available. Upon approval, 2.9M doses of the Pfizer vaccine are set to be shipped to healthcare providers, out of a total of 100M doses comprising the US allotment from Pfizer. Once the initial vaccinations of high-risk recipients is done, one issue to watch will be the potential for a springtime shortage of vaccines, given that Pfizer is also committed to supplying other countries, it and AstraZeneca have faced manufacturing delays, and Sanofi suffered a major setback this week in clinical trials likely to push its vaccine rollout into the second half of 2021. Despite those concerns, it’s important to remain focused on the bigger picture: help is on the way. As soon as next week, the nation will begin its long journey of recovery from the worst public health event in its history.

Biden’s healthcare team gets a quarterback, and a key player

This week President-elect Biden named Xavier Becerra, California’s attorney general, as his choice for HHS Secretary, in a surprise choice that capped off weeks of speculation about who would get the top healthcare job in the new administration. If confirmed by the Senate, Becerra will become the first Latino to hold the position, and is expected to focus on health equity and access as he has during his tenure in California, and in his House of Representatives career before that. While Becerra is not a healthcare expert, and has not worked in a healthcare role before, he was involved in the passage of the Affordable Care Act (ACA) in Congress, and has led the legal battle to protect it from court challenges by Republican state attorneys general and the Trump administration. He will take the helm of the massive 80,000-employee department, and its $1T budget, at a critical time, overseeing the approval and rollout of coronavirus vaccines, and the shoring up of Medicare, Medicaid, and ACA insurance coverage for tens of millions of Americans amid a faltering economy. In addition to defending the ACA in court, Becerra has also been a tough critic of the hospital industrysuing the massive Sacramento, CA-based Sutter Health for anticompetitive practices that he said led to high prices for care, resulting in a half-billion-dollar settlement with the chain. While Becerra will not have direct responsibility for healthcare antitrust issues as HHS Secretary, we’d expect him to build a team and pursue regulatory approaches informed by his skeptical view of provider consolidation.

Biden also announced his choice for one of Becerra’s key deputies, naming Massachusetts General Hospital infectious disease chief Dr. Rochelle Walensky to be the new CDC director. The Walensky pick was widely hailed by the medical community, among whom she is well-respected as a brilliant physician and public health expert. Walensky faces the challenge of rebuilding the reputation of the CDC, which has been diminished by the politics of the coronavirus pandemic, even as she deals with the most significant public health crisis of the past century. Expect an early focus on more forceful, consistent public communication on masking, social distancing, and other protective measures, and a greater role for the CDC in addressing the COVID crisis. Biden has named a strong team of leaders to drive the healthcare agenda in the new administration—with one key position yet to be filled. Look for Biden’s choice of administrator of the Centers for Medicare and Medicaid Services (CMS) in the weeks to come, which will tell us a lot about future plans to address another ongoing crisis: the high and rising cost of care in the US.

Sanford, Intermountain call off merger after CEO’s departure

This week Sioux Falls, SD-based Sanford Health announced that it would suspend merger discussions with Salt Lake City, UT-based Intermountain Healthcare. Discussions around the planned combination, which was announced in late October and would have created a combined $15B, 70-hospital system, are on hold indefinitely. The news comes in the wake of the abrupt departure of Sanford’s longtime president and CEO Kelby Krabbenhoft following a controversy about mask use. A quick summary of the drama: Krabbenhoft made national headlines after sending an email to Sanford employees stating that he refused to wear a mask after contracting COVID-19, as doing so would be a “symbolic gesture” that sends an “untruthful message that I am susceptible to infection or could transmit it”. Several Sanford senior leaders responded with a joint message to staff disavowing Krabbenhoft’s position; Krabbenhoft and the Sanford board “mutually agreed to part ways” less than a week later. Bill Gassen, formerly Sanford’s Chief Administrative Officer, was installed as CEO. In discussing the reasoning behind pausing the merger, Gassen stated, “With this leadership change, it’s an important time to refocus our efforts internally as we assess the future direction of our organization.” We were intrigued by the combination of these two innovative systems, which would have brought not only their care delivery assets but also two large health plans to the deal, with the promise of creating value for patients and consumers. The abrupt halt is a reminder that any successful merger is built on a foundation of cultural and leadership compatibility, which may be even more important than the more tangible assets the parties bring to the table.


GRAPHIC OF THE WEEK

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

Measuring healthcare worker burnout during the pandemic

Healthcare workers are becoming the scarce resource in caring for COVID-19 patients, and clinician burnout threatens to further exacerbate staff shortages. New studies quantify what has been anecdotally reported for weeks: clinicians are experiencing high rates of burnout. As shown on the left in the graphic below, an American Nurses Foundation survey of more than 1,000 critical care nurses found 57 percent had experienced depression, and 54 percent had experienced anxiety (within two weeks of being surveyed in the spring of 2020). Moreover, 19 percent of critical care nurses felt betrayed and 14 percent felt like a failure. This is noteworthy because only seven percent of nurses routinely work in critical care and just 8 percent routinely work in emergency or trauma care; most RNs work in lower-acuity specialties and need significant cross-training to be ready to work in the ICU.

As shown on the right, physicians report comparable rates of burnout. A Physicians Foundation survey in September found that 58 percent of physicians often feel burnout. This was an increase of 18 percentage points from just two years ago. Neither specialists nor primary care physicians were insulated: 61 percent of PCPs reported burnout, compared to 57 percent of specialists. Unlike ventilators and PPE, clinical workers can’t be stockpiled, or produced under the Defense Production Act. Currently, at least 25 states are experiencing a workforce shortage. Burnout and shortage create a downward spiral—burnout decreases the number of available workers, and stress and overwork of the remaining staff can intensify feelings of burnout. It’s a situation that bears close monitoring in the months ahead.


THIS WEEK AT GIST—ON THE ROAD PHONE

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

Tensions arise along the “last mile” of vaccine distribution

As hospitals finalize preparations for the arrival of the first doses of Pfizer’s vaccine next week, we’re beginning to hear anecdotes from around the country about tensions arising on the ground. With state and local health departments in charge of distributing the shipments of vaccines to healthcare facilities, there are disagreements about how many doses each hospital will get to administer vaccinations to critical frontline staff. In theory, the distribution should be based on staffing numbers, but as in so many parts of healthcare, the datasets to support that distribution are turning out to be a problem. Data available to health departments are often incorrect or out of date, and we’ve heard of instances of favoritism and political motivation playing a role in some places—for example, the “big bad” health system getting far fewer doses than needed, while smaller, “friendly” hospitals are getting more than required. It’s hard to tell how much of this is real, or just old animosities playing out in a new context. But the range of stories we’ve heard make one thing clear—the further down the chain of distribution from manufacturer to patient’s arm, the more variability and confusion there will be, and the greater the potential for chaos. That will matter less once there’s plenty of vaccine to go around, but during the period of short supply we’ll be dealing with for several weeks (or months), it’ll be critical to iron out these details and make sure the distribution system is transparent and rational, all the way to the “last mile”. A task made all the more complicated, given our fragmented, underfunded, and (largely) uncoordinated public health infrastructure.

The danger of “breezing through the upfront” with doctors

In our decades of speaking to physician audiences, we commonly get the guidance from health system leaders to “breeze through the upfront” part of the discussion and get on to the “meat” of the presentation. Translation: you only have an hour, so don’t spend too much time on the policy, payment or disruptive forces affecting the larger healthcare industry, because we really need you to tell our docs they need to standardize care, accept a new compensation model, or make other important changes to the way they practice. Well, we’ve yet to meet a physician who isn’t interested in how the election could impact their patients and livelihoods, or the ways Walmart is expanding their healthcare offerings, despite being told that “Our doctors aren’t really that interested in politics”, or “We don’t have many CVS stores in our market, so you can delete that slide”. It’s undoubtedly important to devote ample time to the mechanics and success stories of practice change, but it’s a mistake to cut short discussion of the larger forces necessitating those changes. One physician leader recently told us, “It seems like we keep having the same conversation over and over with our docs, and we never really get anywhere.” Perhaps it’s time for a change in the conversation. Jumping straight into the things doctors need to do differently, without ample discussion of the “why” behind the change, can easily be interpreted as the system telling its physicians how they need to practice. If leaders truly believe doctors are partners in setting strategy, they must build a common understanding of how the environment is changing, and then come up with solutions together.


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 yesterday’s episode, we featured a piece from Seattle, WA-based health reporter Will Stone. While covering the pandemic for NPR, Stone reported on hospitals at the brink, developing crisis standards of care. Although most state leaders are relying on bed capacity as an indicator of hospital COVID readiness, Stone learned that sufficient staffing is just as important.

Coming up on Monday, Buffy White, Group President of healthcare staffing firm Cross Country Healthcare, will discuss how volatile demand for healthcare workers, especially travel nurses, across the past year has exacerbated staffing shortages. She says that going forward, the industry needs to focus on cultivating a robust staff pipeline. 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.

Twenty years ago, a trio of Australian musicians calling themselves The Avalanches released their debut album Since I Left You, setting the tone for 21st century music as a perpetual, nostalgic remix of everything that came before. Constructed entirely of over 3,700 samples from previously released recordings, assembled in a collage of danceable electronica, the album was a groundbreaking example of “plunderphonics”—the act of crate-digging to produce something entirely new from everything old. It took the group sixteen years to produce their next record, during which time their iconic debut worked its magic on a generation of electronic artists. And now, to close out 2020, The Avalanches are back with their latest album, We Will Always Love You. They’ve dialed back the quantity of samples in favor of a tighter, more cohesive trip-hop collection, and added live guest vocals from a mouth-watering range of artists: Blood Orange, Leon Bridges, MGMT, Johnny Marr, Kurt Vile, Tricky, Jamie xx, Mick Jones (from the Clash and Big Audio Dynamite), Karen O (from Yeah Yeah Yeahs), and Rivers Cuomo (from Weezer), among many others.

Samples still abound—you’ll catch a smorgasboard of soulful snippets from Karen Carpenter, The Alan Parsons Project, Smokey Robinson, and on and on. But the focus here is on a concept inspired by humankind’s most significant mixtape: the “Golden Records”, sent into the cosmos in 1977 aboard Voyager 1. Assembled by a committee chaired by Carl Sagan, and now more than 14B miles out in space, the golden discs include hallmarks of human civilization, from music by Bach, Beethoven, and Chuck Berry to sounds and pictures of animals, examples of human speech, a depiction of human DNA, and mathematical and chemical formulae. Along with all of that, and an inspiration to The Avalanches as they put together their latest, was a recording of the brain waves of Sagan’s partner Ann Druyan, just after he proposed to her—intended to show the human impact of love and joy. Imagine an accretion of all that matters in human experience, hurtling endlessly through time and space, and you’ve got the idea behind The Avalanche’s latest, and their larger oeuvre. Well worth a listen. Best tracks: “Interstellar Love”; “Take Care In Your Dreaming”; “Wherever You Go”.


WHAT WE’RE READING

Stuff we read this week that made us think.

A slipshod process erodes confidence in a vaccine frontrunner

As the healthcare community bemoans the federal government’s decision to pass on securing an additional springtime tranche of the Pfizer vaccine, another vaccine candidate faces mounting questions. A fascinating (and frankly, alarming) New York Times piece details the many blunders plaguing the AstraZeneca-Oxford University vaccine candidate. The AstraZeneca vaccine was considered the frontrunner early in the development process, as it was built on an approach tested by Oxford scientists for decades, utilizing an adenovirus, a harmless cold virus, to deliver genetic material to human cells. With little experience in vaccine development, AstraZeneca wasn’t the Oxford team’s first choice of a corporate pharmaceutical partner, and challenges surfaced almost from the beginning. The company has been criticized for lack of transparency in the design of clinical trials, and about the adverse events that developed in two patients. The FDA was not proactively notified of the events, which led to the halting of Phase 2 trials, and only learned of them through media reports. Problems in the manufacturing chain created uncertainty about the dose strength of the product, leading some patients to receive what was likely half the dose outlined in the study design. Interim clinical results showing that the half dose was far more effective than a full dose of the vaccine remain a mystery for which scientists still have no explanation.

All of these issues have slowed clinical trials, with the company only halfway through enrollment in its US trial. The United States bet strongly with AstraZeneca-Oxford, agreeing to pay $1B for 300M doses, accounting for as much as 60 percent of the nation’s supply—which will surely be impacted in the short-term if the vaccine is not approved. It’s unclear whether the company’s many missteps were the result of intentional obfuscation, or merely incompetence and poor decision-making. Regardless, the slipshod process has eroded confidence in the AstraZeneca-Oxford product—especially as two other highly-effective vaccine candidates near approval.

Mourning the loss of the break room

Whether you work in a hospital ICU or meatpacking plant, it turns out the most dangerous room in the workplace for the spread of COVID-19 is the break room. The Wall Street Journal cataloged a series of workplace super-spreader events with a common theme: all resulted from numbers of employees spending time in a common lunchroom or break room. It makes sense, as break rooms combine two significant risk factors for spread. Masks are removed to eat and drink, making the break room similar to any other indoor dining venue. And especially in healthcare, employees may even feel comfortable congregating with close colleagues, who they believe to be maintaining strict precautions outside work. (That’s the same instinct that makes us think we’re safe spending time indoors with friends and family—as we heard recently, the virus “hitchhikes on our trust of each other”.) Obvious solutions, like staggered break times and Plexiglas shielding, or eating lunch outside or in your car, can mitigate break room spread. But break rooms serve another important function for staff: providing a place to blow off steam. Losing their “water cooler” time is even more of a blow for hospital workers facing high levels of stress—creating an imperative for leaders to find other venues to allow colleagues to relax and vent their frustrations as a daunting holiday season approaches.


That brings us to the end of another Weekly Gist. Thanks so much for taking the time to read our work—writing it gives us a way to make sense of the crazy world of healthcare, and we hope you find it worthwhile as well. If you do, we hope you’ll share it with a friend or colleague, and encourage them to subscribe, and to listen to our daily podcast. And don’t forget to let us hear your feedback and suggestions, we’d love to know what you thought!

Most important, please let us know if we can be of assistance in your work. You’re making healthcare better—we want to help!

Best regards, and Happy Hanukkah,

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

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