The Weekly Gist: The Stress Baking Edition

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

The pandemic tightens its hold on the US

It was another grim week in the grips of the coronavirus pandemic, with the US death toll reaching nearly 6,600 by mid-day Friday, and over a million cases reported worldwide. In a startling press conference on Tuesday, President Trump and his top health advisors shared their forecast for the expected number of deaths from the virus, which they warn could reach between 100,000 and 240,000. That forecast, based on modeling that has since been called into question, assumes that the entire nation adheres to strict social distancing measures through the end of May—an assumption belied by the fact many states have been slow to implement “stay-at-home” orders. By week’s end, it was unclear whether the White House’s estimate might actually be too rosy, as difficult as that is to fathom.

New York continues to be the hardest-hit state, with over 2,900 deaths reported so far, over 102K cases reported statewide, and hospitals scrambling to cope with the crush of patients. New York City’s Javits Convention Center has been converted into a makeshift 2,500-bed COVID-19 hospital by the Army Corps of Engineers, and the 1,000-bed USS Comfort hospital ship docked in Manhattan to relieve pressure on city hospitals (although it remains mostly empty because it has not, as yet, been authorized to accept COVID-19 patients). Detroit, Seattle and New Orleans have also been early hotspots for the coronavirus, with several other cities warning that they expect to see surges in patient volumes in the coming week.

Although production of testing supplies has ramped up significantly, reports of test shortages are still widespread, along with delays in test turnaround, and concerns about test accuracy. The same is true of personal protective equipment (PPE), with many frontline healthcare workers forced to reuse equipment for days as they care for contagious patients. Ventilator supply continues to be a concern as well, causing the Strategic National Stockpile to run short, and leading President Trump to invoke the National Defense Production Act to require companies to increase ventilator manufacturing. The next critical area of shortage appears to be drugs, particularly those associated with managing intubated patients.

Meanwhile, the economy experienced another historic week of contraction, as 6.6M workers filed for unemployment, more than double the previous week. Medicaid programs braced for a wave of applications from the newly unemployed, and state-run health marketplaces opened “special enrollment periods” (SEP) to allow the uninsured to seek coverage. To address the coverage gap for those in states without expanded Medicaid eligibility, those whose states rely on the federal exchange (for which the Trump administration has decided not to initiate a SEP), and those who might not otherwise qualify for subsidized coverage, the Trump administration floated the possibility of devoting a portion of the CARES Act’s $100B “provider fund” to reimburse hospitals directly for caring for uninsured COVID-19 patients. Several private insurers also announced cost-sharing waivers for COVID-19 care for enrollees in their group market plans, although that does not include those who get insurance through employer self-funded (ERISA) plans.

Tragically, we’re still closer to the beginning of this pandemic than the end. Expect the coming weeks to bring even higher daily death tolls, as more areas begin to climb the now-familiar curve. There are reasons for optimism: the historic $2T stimulus package will provide needed financial relief to individuals and businesses impacted by the virus. And the heroic work of caregivers on the frontlines, and everyday acts of generosity by average Americans, will continue to provide inspiration. But as the President put it on Tuesday, we’re in for a “hell of a bad two weeks”—and more—ahead.

An especially rough week for hospital workers

Not only are doctors, nurses, and other healthcare workers putting in long hours, dealing with chaotic and sometimes dangerous working conditions, and making incredible personal sacrifices to care for coronavirus patients, they’re also having to contend with the economic impact of the pandemic on their employers. With elective surgeries—the financial lifeblood of most hospitals—being cancelled or postponed, many organizations have resorted to furloughs, pay reductions, benefits cuts, and even staff layoffs to address their sudden financial losses. Even large systems, with substantial financial resources, started cutting back on staff this week. Cincinnati, OH-based Bon Secours Mercy Health, a 7-state, 48-hospital system, which earlier this year projected it would surpass $10B in annual revenue in 2020, now expects to lose $100M per month because of the impact of COVID-19, and announced plans to freeze wages, furlough employees, and stop hiring. Intermountain Healthcare, the largest hospital system in Utah with more than $7B in annual revenue, informed some of its physicians and advanced-practice providers that their compensation would be reduced as a result of declining elective volumes. Trinity Health, a Livonia, MI-based system with 92 hospitals across 22 states—including some areas experiencing the worst of the coronavirus outbreak like Philadelphia and Detroit—planned to furlough 10 percent of its staff who “do not have work that is directly related to the most critical needs during this pandemic.” Other organizations announcing staff cutbacks and related measures included Tenet Health, Boston Medical Center, and Henry Ford Health System.

HCA Healthcare, the nation’s largest hospital operator, said it planned to avoid layoffs, instead redeploying clinical staff at reduced pay and cutting executive salaries, among other measures. Meanwhile, one system at the epicenter of the pandemic, NewYork-Presbyterian, announced plans to pay a $1,250 spot bonus for all workers involved in COVID-19 care in March. And executives at another, Mount Sinai Health System, said senior executives would take a 50 percent pay cut to allow funds to be redirected to frontline care. Hospitals are in an unenviable position—with revenue from profitable elective procedures evaporating, beds and facilities emptying, and the “wave” of COVID-19 cases still several weeks away for many. Those with the financial reserves and wherewithal to do so should resist the temptation to make big staff cuts now; rather, staff should be redeployed and quickly retrained to assist in the difficult weeks that lie ahead.

Coronavirus testing accuracy called into question

Amid a scramble to ramp up testing, reports this week suggested that as many as one in three individuals who test negative for the novel coronavirus may actually have it. This high rate of false negatives calls into question the accuracy of case counts and raises concerns about asymptomatic people unwittingly spreading the virus. False-negative results could leave individuals with unwarranted confidence they can return to business as usual—an especially risky proposition for frontline healthcare workers. While health experts caution that this assertion is based on limited data and their own experience, it nonetheless casts doubt on the reliability of a rash of new tests being developed by multiple companies operating with minimal regulatory oversight, and little time for quality control. The Food and Drug Administration (FDA) said in a statement it is balancing the need for more testing with the imperative to ensure tests are accurate.

Current COVID-19 testing relies on the polymerase chain reaction (PCR) method, which amplifies a small portion of viral RNA to detect the virus. Reasons for the false-negative results could include testing a patient too early, before they have any symptoms, as well as the administration of the test itself—clinicians may not be swabbing high enough in a person’s nose to collect a good sample. And given the large volume of tests, some may have been handled poorly. (Any of these explanations would be better than a fundamental flaw in the test itself.) Regardless, until testing accuracy is improved, or a serological test is developed (confirming antibodies in the blood that signal exposure to the virus), providers must treat anyone with symptoms as coronavirus-positive and follow proper isolation and protective gear protocols as well as self-distancing guidelines. And until accurate tests are widely available, the country will not be able to loosen today’s strict social distancing requirements and begin the process of reopening schools and businesses.

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

A COVID-era field guide to postacute care options

As health systems look to increase capacity for COVID-19 patients, they must broaden their current focus on inpatient and intensive care unit (ICU) settings to also include the postacute care (PAC) space, in order to both alleviate inpatient pressure as well as deliver post-discharge care for the estimated 50 percent of discharged COVID-19 patients who may require it. The graphic below shows the main PAC sites and services available—each with its own set of requirements and considerations for this complex patient population. The most critically ill patients will likely require recovery care at traditional PAC sites, including long-term acute care hospitals (LTACHs), skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs). These sites are equipped with the clinicians and equipment, including ventilators, needed to manage more complex patients.

To avoid a massive spread of infection, all of these facilities must create a separate COVID-only unit and adopt stricter infection control protocols, which will require increased supplies of scarce personal protective equipment (PPE). The Centers for Medicare and Medicaid Services (CMS) has temporarily relaxed the PAC regulatory environment, including waiving the three-day hospital stay requirement for SNF coverage and approving payment for additional capabilities like telehealth to increase PAC utilization. Beyond traditional PAC sites, many hospitals will need to incorporate both the temporary “field hospital” facilities being stood up in many cities, and expand in-home care options. Nursing homes have arisen as a flashpoint issue for discharging COVID-positive patients, with many refusing to accept these patients after hospitalization. This week, New Jersey joined New York in requiring nursing homes to accept all patients, regardless of whether they are positive for COVID-19; as volumes grow nationwide, more states will likely follow suit. Health systems will need to work closely with PAC providers, temporary healthcare facilities, and state health departments to align admission and transfer procedures, so patients can move along the post-discharge care continuum safely and expeditiously as they recover, freeing precious inpatient capacity for the most acutely ill.

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

Where are all the heart attacks?

Even in advance of a surge of COVID-19 patients, the vast majority of hospitals have cancelled elective procedures and shifted outpatient office visits to telemedicine. And as expected, emergency room visits for low-acuity conditions have nearly ceased, but many hospitals have been perplexed by a steep decline in ED visits for serious problems. As one COO told us, “We expected—and we are glad—that people aren’t coming to the ED for sore throats and sprained ankles. But this week we’ve found ourselves asking, where are all the heart attacks?” Conversations from around the country suggest that health systems are seeing a 25 to 30 percent drop in ED visits for patients seeking care for serious conditions, including heart disease, stroke and even appendicitis. Data from England’s National Health Service show similar trends: “emergency attendances” are down 50 percent over the past three weeks, including a similar decline in emergent cardiac cases. The causes are still opaque. Drops in trauma visits are likely due to more people staying at home. And perhaps patients are using telemedicine to redirect care. But many doctors are concerned that patients will only be able to delay care so long, and ED avoidance, coupled with missed outpatient visits, may set us up for a flood of patients experiencing serious exacerbations of chronic disease in coming weeks.

Anticipating a “search for the guilty”

Conversations with health system leaders suggest that acute shortages of PPE may have abated slightly over the past week, although every system remains worried about running out in coming weeks, as the number of COVID-19 patients continues to surge. A physician leader we spoke with this week said the worry among doctors and nurses about becoming infected, and the feeling that the healthcare system was unprepared to protect them, will create lasting scars in the workforce. A recently retired health system CEO shared his concern that “once the dust settles, healthcare will become consumed with a search for the guilty”, looking to place blame for systemic failures that placed frontline workers at risk. The ramifications could be far-reaching. After working through the crisis, older nurses and doctors may decide they’re done, precipitating a flood of Baby Boomers leaving the workforce (provided retirement savings hold). And a resurgence of unions is almost guaranteed, as staff look for support to ensure better protection in the next crisis. These factors will have a huge impact on the post-COVID healthcare workforce, both on the kind of talent we need, and the flexibility hospitals will have in redesigning traditional roles.

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 Dr. Bertie Bregman, co-owner of Westside Family Medicine  in New York City. He’s been treating COVID-19 patients, trying to keep them out of overburdened emergency departments. He shared his concern that lower patient volumes will drive more primary care practices to join health systems. On Tuesday’s episode, we heard from Carrie Kozlowski, COO and co-founder of Upfront Healthcare. She told us that their patient care navigation platform has been adapted to the needs of health systems and physician practices during the pandemic. freeing providers to focus on treating the sickest patients. On Wednesday’s episode, we heard from Dr. Jeff Olgin, Chief of Cardiology at the University of California, San Francisco. He talked about how his new COVID-19 Citizen Science study is tracking early symptoms, trying to identify risk factors and using geo-location to track community spread. Olgin said he hopes to get 1M people from around the world to participate in his mobile research study.

Coming up on next Monday’s episode, we’ll hear from Rosemarie Day, CEO of healthcare consulting firm Day Health Strategies. She helped lead Massachusetts’ health insurance reform under then-Governor Mitt Romney. In her new book Marching Toward Coverage, she calls on women to engage more actively in the debate over universal coverage.

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Give this a spin—you might like it.

Gorgeous new music this week from bass guitar virtuoso Stephen Lee Bruner, better known to fans as Thundercat. A vital part of the LA jazz renaissance, and a Grammy-winning session musician who’s contributed to work by Kendrick Lamar, Erykah Badu, Flying Lotus, and Kamasi Washington, Thundercat is the merry prankster of the bunch. His playful songwriting, gentle falsetto voice, and rapid-fire bass playing give him a manic energy that feels just barely contained by the prodigious quantities of weed he ingests (judging by many of his lyrics). The focus of his latest album, It Is What It Is, undercuts that goofy persona, drawing on the experience of losing his close friend Mac Miller, a rap artist who died in 2018 from an accidental overdose. Across fifteen wistful, moving tracks, Thundercat works his way through grief, settling on the stoicism of the album’s title, which repeats as a lyric in four different songs—most poignantly on “Fair Chance” (“So hard to get over it/I’ve tried to get under it/Stuck in-between/It is what it is”). There are still plenty of light moments on the record, along with a bunch of great featured artists (Ty Dolla $ign, Childish Gambino, BADBADNOTGOOD, Lil B), and loads of Thundercat’s signature bass riffs (the intro to “Unrequited Love” is a gem). And there’s solace for these difficult times in the album’s title refrain, appropriately delivered in a track called “Existential Dread”—“It is what it is/I’m not sure of what’s coming next/But I’ll be all right as long as I keep breathing/I know I’ll be all right.” Amen. Best tracks: “Dragonball Durag”; “Fair Chance”; “Black Qualls”.

We said it, they quoted it.

“Hospitals, Doctors Feel Financial Squeeze as Coronavirus Sweeps U.S.”
Wall Street Journal; April 1, 2020

“‘There’s this waiting period for the wave to hit that a lot of hospitals aren’t prepared to weather,’ said Chas Roades, chief executive of Gist Healthcare, a consulting firm. ‘Because the revenue has gone way down, they’re having to cut expenses in a way that might make them less prepared when the wave does hit.’”

Stuff we read this week that made us think.

A data-driven plan to reopen America

President Trump’s brief flirtation with the goal of easing social distancing guidelines by Easter sparked the very real question of how the country would approach a return to business as usual. A report out this week from the American Enterprise Institute (AEI) provides a framework for a path to “reopen America” with clear goals and “triggers” to move forward. The AEI team, led by former FDA Commissioner Scott Gottlieb, outlines four phases of response and recovery, beginning with the work we are doing now in “Phase I” to slow the spread of the virus, extending to the final phase, focused on rebuilding the country’s pandemic readiness. Unfortunately we seem to be a long way from meeting the triggers that would indicate it’s safe to move to Phase II, state-by-state reopening of schools and businesses: a sustained reduction of new cases for 14 days; hospitals able to manage all acutely ill patients; and the ability to test all people with possible COVID-19 symptoms and actively monitor confirmed cases and their contacts. The report is well worth a read and will help you begin to get your head around what a clear, concrete plan, based on data and science rather than reactive impulses, could look like. A much-needed roadmap toward a “new normal”: different from, but closer to, the way our lives looked just a month ago.

Should all Americans be wearing a mask?

The debate about whether all of us should wear masks to prevent COVID-19 heated up this week, with the Centers for Disease Control and Prevention (CDC) announcing new guidance on Friday that Americans should wear “non-medical cloth-based face coverings” when going out in public. An article in The Atlantic turns to experts to explain the science and research behind mask use. Changes in the CDC guidelines seem to be based on research suggesting that the coronavirus may be “airborne”—a term with little meaning to scientists. It’s the specifics that matter to researchers—and they increasingly think that the distinction being drawn between “droplet” or “aerosol” spread is irrelevant, as sneezes and coughs have been shown to consist of both. What matters is how far away a virus can spread in the air, how long it lingers, and at what concentration. Viral particles and RNA have been found in the air and on surfaces many feet away from patients—but it’s unclear if these levels of concentration can cause infection, and in the words of one expert, “To say that after three months we know for sure that this [new] virus is not airborne is … expletive deleted”. Also unknown are the social implications of wearing a mask in the US. In contrast to Asia, where mask-wearing is common and a sign of social responsibility, will masks embolden Americans to venture out more? General consensus seems to be that wearing a mask may confer some protection—and may be useful in keeping asymptomatic, COVID-positive patients from spreading infection. (But beware: some experts say novice mask-wearers may be more inclined to touch their faces.) Regardless, any guidance may be moot, given the short supply of masks of all kinds. And public health experts can agree on one thing: available masks must go to healthcare workers first, before the general public is asked to wear them.

Most of all, thank you for the important work that you’re doing. Please let us know how we can be of assistance. 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