|THIS WEEK IN HEALTHCARE
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.