August 21, 2020

The Weekly Gist: The World on Fire Edition

by Chas Roades and Lisa Bielamowicz MD

Enough already, 2020! As if we needed more evidence that our world is on fire, now our world is literally on fire. It’s hard to think of a more 2020 storyline than this: the climate crisis has produced a grinding heat wave and storms in California that resulted in over 20,000 lightning strikes, causing nearly three-quarters of a million acres to burn. The heat wave is forcing power blackouts around the state, while the fires are jeopardizing homes and forcing evacuations. On top of that, the resulting smoke and ash are worsening air conditions for residents in the midst of the worst respiratory virus pandemic in a century. The coronavirus is also impacting the operation of emergency shelters, as well as the availability of prison work crews, which California typically relies on to fight fires.

While you let that too-on-the-nose-for-Hollywood plot sink in, join us in offering our deepest sympathies to those impacted, and gratitude to those providing assistance on the ground. Please consider a donation to the Red Cross to help support the relief efforts.


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

The future of the ACA takes center stage yet again

Across four nights of a national convention that was anything but conventional, with the nominating process, acceptance speeches, and traditional pomp and circumstance forced into a virtual format due to the coronavirus pandemic, Democrats returned to the healthcare playbook widely viewed as successful in the 2018 midterm elections. In addition to promising a more robust and concerted response to the COVID crisis gripping the nation, party leaders vowed to protect and expand the Affordable Care Act (ACA), rather than aiming to replace it with the more aggressive “Medicare for All” (M4A) approach that dominated much of the discussion during the primary campaign. In his acceptance speech on Thursday, Democratic nominee Joseph R. Biden, Jr. promised “a healthcare system that lowers premiums, deductibles, and drug prices by building on the Affordable Care Act he’s trying to rip away,” referring to President Trump’s continued support for the full repeal of the 2010 healthcare reform law. Earlier, progressive runner-up and vocal M4A advocate Sen. Bernie Sanders signaled a closing of the party’s ranks around Biden’s more moderate approach: “While Joe and I disagree on the best path to get to universal coverage, he has a plan that will greatly expand healthcare and cut the cost of prescription drugs. Further, he will lower the eligibility age of Medicare from 65 to 60.” Several other speakers highlighted the need to protect the ACA’s guarantee of affordable insurance to those with preexisting conditions, most powerfully the prominent M4A crusader Ady Barkan, who suffers from amyotrophic lateral sclerosis (ALS). “Even during this terrible crisis,” Barkan said, “Donald Trump and Republican politicians are trying to take away millions of people’s health insurance.”

In the Democrats’ successful campaign to retake the House in 2018, voters cited concerns about healthcare as their number one issue, so it was no surprise that it featured so prominently in this week’s convention. It will likely be a key rallying issue as Democrats try to win back the Senate as well; the Supreme Court announced this week that it will hear oral arguments in the Trump administration-backed lawsuit to overturn the ACA on November 10th, just a week after Election Day. Whether Republicans also choose to highlight healthcare during their nominating convention next week remains to be seen, with President Trump considering issuing an executive order to protect those with preexisting conditions, and promising to release an ACA replacement plan of his own. Either way, it seems certain that the future of the ACA will feature prominently in yet another national election cycle, as it has each time voters have gone to the ballot box in the decade since its passage. With pandemic response also on voters’ minds this year, healthcare is as polarizing a political issue in this country as it has ever been.

Pharmacists authorized to deliver childhood vaccinations

On Wednesday, the Department of Health and Human Services (HHS) issued a directive allowing pharmacists to administer childhood vaccinations, in an effort to address falling vaccination rates during the pandemic. The directive temporarily overrides restrictions in 22 states that limit pharmacists’ ability to deliver childhood immunizations for the duration of the COVID-19 emergency declaration, and enables pharmacists to deliver any FDA-approved vaccine to children age three or older, meaning infants and toddlers receiving their frequent early rounds of shots will still need to visit a doctor. Public health officials worry the pandemic has depressed vaccination rates—immunizations in children older than two fell 91 percent in the first two months of the pandemic in New York City—leaving the population exposed to outbreaks of measles and other preventable diseases. The American Academy of Pediatrics responded that the directive was “incredibly misguided” and will have little impact on vaccine hesitancy, and that pediatricians’ offices are open, safe and able to meet patients’ vaccine needs, which include reassurance and guidance from their doctor. Among specialties, pediatric office visits have been the slowest to rebound, with visits among school-age children seeing the sharpest declines. While receiving vaccines in the context of a well-child visit with a pediatrician is clearly ideal, enabling pharmacists to deliver immunizations opens another important channel for patients, and could help stave off a “crisis within a crisis” of outbreaks of preventable diseases.

Uber launches home prescription delivery service

Ride-share heavyweight Uber announced it will enter the prescription delivery business through a partnership with on-demand, digital-prescription startup NimbleRxUber will utilize its Uber Direct platform to deliver prescriptions directly to consumers’ homes, starting in the Seattle and Dallas markets. The company plans to expand into other cities in the coming months, building on NimbleRX’s relationships with over 700 pharmacies, mainly smaller to midsize chains, across 34 states. Uber’s entry into prescription delivery comes as national drugstore chains CVS and Walgreens have seen an exponential increase in home deliveries during the pandemic, a service they began expanding in the wake of Amazon’s acquisition of online pharmacy PillPack two years ago. In this new partnership, Uber could find demand among COVID-cautious consumers, who want to avoid unnecessary in-person visits to pharmacies and physician offices, as well as aging Baby Boomers who have growing prescription needs. And with the cost cutting fracas at the US Postal Service already delaying prescription deliveries, Uber’s offering may provide an appealing alternative for the one in five Americans who receive their medications through the mail.


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

The kids are not all right

Many children heading back to school—in whichever form that that may take this fall—have skipped their annual visit to the pediatrician. The graphic below highlights the sluggish rebound in pediatric ambulatory volume. While adult primary care visits have mostly bounced back, pediatric visits are still 26 percent below pre-COVID levels. The drop in visits early in the pandemic also impacted immunizations, with 2.5M regular childhood vaccinations missed in the US during the first quarter of 2020—and early data suggests those seem to be rebounding at a similarly anemic rate. This lack of pediatric routine care is particularly worrisome as COVID-19 cases in children are climbing, with a 90 percent increase from July to August. Though most of the nation’s largest public school districts have opted to begin the school year with online learning, some districts have already returned to in-person classes, and, unsurprisingly, new cases are already being reported. While COVID-19 is normally neither severe nor fatal in children, infections among school-age kids put others at risk. According to the Kaiser Family Foundation, nearly a quarter of teachers (1.5M) are considered high-risk and almost six percent of seniors (3.3M) live with school-aged children. Without the traditional back-to-school push for well-child visits, sports physicals, and immunization updates, healthcare providers must think creatively about how to give children with the care they need, whether through personalized communication from pediatricians that assuages parental concerns about office safety, or through more innovative means such as drive-thru vaccination services.


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

You probably don’t need a Chief Telemedicine Officer

This week a chief strategy officer asked to discuss telehealth leadership structures, and specifically, whether his health system should establish a “Chief Telemedicine Officer” position. With the explosion in virtual visits across the past six months, it’s not surprising that systems would look to dedicate leaders to growing and scaling their virtual platforms. However, we cautioned against a quick decision to recruit a new “chief”, which is often healthcare’s approach to tackling any business challenge outside of the organization’s core expertise. Some other recent examples: the rush to appoint Chief Experience Officers with hospitality industry experience as systems looked to address “consumerism” coming to healthcare. Or the many Chief Population Health Officers hired to launch accountable care organizations. These roles are often doomed to fail from the start. It can be a frustrating job for a new leader charged with working across established clinical and operational domains, but vested with little decision-making authority or ability to direct resources. And it speaks to the industry’s knee-jerk tendency to add more administrative overhead, which can negate cost savings and productivity gains. To be sure, we have seen effective leaders in these kinds of roles. We’ve seen a handful of Chief Digital Officers charged with building a broader digital consumer and virtual care platform, who bring expertise that is significantly different from most Chief Information Officers. To be successful, they require dedicated resources, direct involvement in system strategy, and a mandate from the CEO. And at best they view their roles as transient: “Hopefully in a few years, we won’t need a Chief Digital Officer. My goal is to make my role obsolete. I’ll know I’ve succeeded when ‘digital’ is not viewed as something separate, but just the way we do things across the system.”

Does lean management stifle innovation?

We’ve been picking up on growing interest among health system leaders in accelerating innovation, following the COVID-era explosion in virtual care. As they look to meet the demands of a rapidly changing market, and contend with competition from new disruptors, many now recognize the urgent need to invest in processes and partnerships that allow them to quickly deploy new approaches to care delivery. In our work with members on this topic, an interesting question has emerged—is the imperative to innovate incompatible with an orientation toward lean management? “Lean” has been a helpful lens for inherently conservative organizations that have needed to make steady improvements in quality, and reductions in cost and waste. But the discipline’s rigidity, and focus on “standard work”, has not been as useful in generating creative new ways to deliver care. Indeed, the orientation toward continuous, incremental improvement seems ill-suited to produce the breakthrough thinking needed to keep pace with market disruption. On the other hand, lean methods can be very helpful in implementing innovations once they’ve been identified and tested—the “plan, do, check, act” framework might even turn out to be an advantage for those looking to scale new innovations. There seems to be a lively debate around the tension between lean management and innovation, and we’re no experts in the field. Before you put on your black belts and deliver a roundhouse kick to our midsections, we’d love to hear your perspectives on this issue—what’s working, and where are the challenges in your organization?


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

Over two episodes last Monday and Tuesday, we heard from Travis Messina, CEO of hospital-at-home company Contessa. He told us that the greatest hurdle to scaling the model is a lack of reimbursement, but he’s confident Medicare is close to paying for the model.

On next Monday’s episode Lisa and Chas will be invading Alex’s studio to talk with her about how COVID-19 is accelerating consolidation, payer-provider integration and digital health innovation. They’ll also share their thoughts on how demand for healthcare is likely to change in the wake of the pandemic. Make sure to tune in for a fun discussion!

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Give this a spin, you might like it.

Another stellar release from the burgeoning London jazz renaissance this week: this time from saxophonist and 2019 UK Jazz Act of the Year Nubya Garcia. She’s been an integral part of the scene since her appearance on the landmark 2018 compilation We Out Here, and a key member of the female-led collective Nerija, whose album Blume was one of the best of last year. Garcia is back with her solo debut LP Source, confidently showcasing the diversity of musical traditions that have come together to make this new vanguard of jazz artists so exciting to listen to. The title track is a 12-minute odyssey through dub, soul-jazz, freeform, and calypso sounds, with Garcia’s horn providing the through-line and propulsion. Having played sidewoman to other superstars of the new-jazz firmament—Shabaka Hutchings, Moses Boyd, the Ezra Collective—Garcia shines at the helm of her own work, even as she brings in a range of collaborators from Bogota’s all-female cumbia trio La Perla to Chicago’s neo-soul artist Akenya. Something incredible is happening in London right now—the rebirth of a musical style, with a newfound determination to address issues of diversity, justice, and equality through collaboration and fusion. Don’t miss this latest revelation. Best tracks: “Source”; “La cumbia me está llamando”; “Pace”.


Stuff we read this week that made us think.

When COVID infection becomes a chronic disease

The minimal evidence of serious impact of COVID infection on young healthy individuals has been one of the bright spots of this pandemic. Overall, only a small percentage of those infected, mostly the elderly or those with pre-existing conditions, get very sick, and an even smaller number die. But a new piece in The Atlantic lays out mounting evidence that many younger patients don’t spring back to good health after a few weeks, as common wisdom suggests; instead, they experience debilitating long-term effects, months after infection. The profile of the average patient with “Long-COVID” is just 44 years old, and previously fit and healthy. She (the condition is much more common in women) likely suffered a mild initial infection. But now, months later, she still faces a wide range of symptoms. Some patients have significant chronic pulmonary or cardiac function abnormalities (like Georgia State’s star freshman quarterback recruit, sidelined for the year with post-COVID myocarditis). But others are dealing with a different, but just as debilitating, set of symptoms resembling chronic fatigue syndrome (CFS). And like CFS patients, many COVID “long-haulers” find their symptoms minimized by their doctors. Early studies show that large numbers of patients may be affected: in a series of 270 non-hospitalized patients, the CDC found a full third hadn’t returned to their usual health after two weeks (as compared to just 10 percent of influenza patients). A handful of centers have taken the first step toward better understanding “Long-COVID”, establishing dedicated clinics to study and treat the growing number of patients for whom COVID-19 is turning out to be a chronic disease, leaving a wave of people with long-term disabilities in its wake.

Contact tracing stopped at the country club gates

From downtown New Orleans to the tony suburbs of New York, post-graduation parties and summer gatherings drawing dozens of teens have become loci of COVID infections around the country. Taking a look inside one prep-school-party COVID cluster, an article in the New Yorker recounts the reverberations from graduation parties turned superspreader events at an exclusive Atlanta private school. Spurred by a false sense of security (“We don’t live in New York,” one dad said) and Georgia’s early reopening orders, several families at the Lovett School held graduation parties, some with as many as 50 attendees. The school received its first report of a student testing positive four days after attending the graduation festivities. A growing cluster of infections became evident as more cases came to light, including among students who posted TikTok videos to announce their positive test results. Lovett’s school nurse began ad-hoc contact tracing, finding 23 positive cases on her first day of searching. But Fulton County contact tracers were met with fierce resistance from parents, with the vast majority of those contacted declining to talk. The school provided students’ contact information, but said it couldn’t cooperate with tracers further due to privacy regulations. There are many reasons that individuals might be reticent to participate in contact tracing, such as fear of losing a job, or worries about immigration status. But the resistance of wealthy, highly educated “prep school parents” to contact tracing is shocking. Public health efforts will continue to be stymied as long as the instinct to protect individual and school reputations from the perceived stigma of infection outweighs the greater good—the health of the community.

Thanks for reading this week’s edition of the Weekly Gist. We truly appreciate your time and attention, and we’re grateful for your feedback and suggestions. If you have a moment, we’d love for you to forward this to a friend or colleague, and encourage them to subscribe, and to check out our daily podcast.

Once again, please consider donating to support relief efforts for the California wildfires, or for any of the other disasters currently facing our nation. And on a more personal note, please 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

Lisa Bielamowicz, MD
Co-Founder and President