What on earth does that slide mean? You know, the Massachusetts Testing & Tracing Strategy page from the highly anticipated Reopening Massachusetts plan. We were hoping it would provide some clarity and confidence, especially since testing and tracing are the only green lights on the reopening dashboard.
Unfortunately, the graphic raises more questions than it answers. Here are a few that come to mind.
Why are we only using 1/3 of our available testing capacity now?
What good is capacity if we can’t get the tests to the people most in need (symptomatic and high-risk)?
How do we know if the actual caseload is declining if testing continues to be underutilized?
By July, testing will be available for “all symptomatic individuals, even mild symptoms.” Does that mean having symptoms now isn’t enough to justify a test? Is it really true that testing won’t be available for asymptomatic individuals even by summer?
According to the projection, we will be filling all of our available capacity at 45,000 tests per day in just 6 short weeks. However, at that level, we will still be well under the estimated capacity that public health and infectious disease experts are calling for (71,000 – 100,000 tests per day). Why is this an acceptable target?
By December, we still remain at the lower end of target capacity, and woefully under it in terms of daily tests administered. What is the plan for getting further ahead of the necessary testing for the ‘second wave’ – and to avoid making the same costly mistake twice?
Comparing the testing projections in the plan and what many of us believe is required, should we conclude that the committee doesn’t believe the need for more testing is real?
There are a variety of tests available currently – some accurate and some no better than a coin flip.
What types of tests are included in these figures at the various timepoints?
In July, is only RT-PCR with nasopharyngeal samples collected by healthcare professionals accounted for? Or are other tests and collection methods included?
Other methods are mentioned in the December description, so does this assume that there is no use of antigen or sequencing based tests until then?
If commercial entities increase the availability of at-home testing, how does this factor into the plan?
So, thinking through all of this, how can we have a green status on testing capacity now? In July? Ever?
We have heard repeatedly that adequate COVID-19 testing capacity and contact tracing would be necessary for the safe reopening of our economy. Until these questions are answered it’s hard to be confident.
We hope that everything will work out for the best, but we also know that hope is not a substitute for a strategy. Some answers to these questions would be a helpful place to start.
Today’s much anticipated Reopening Massachusetts presentation has a page entitled, “Reopening will be driven by public health data.” But look critically at the dashboard and you’ll see that some rows must be missing.
There are six indicators. Two are green (positive trend) and four are yellow (no real trend). None are red (negative trend). But even the two green ones are not that reassuring:
COVID-19 positive test rate is a reasonable indicator. All else being equal, a drop means less COVID-19 in the community. But if testing is expanded beyond people who are obviously sick, you’d expect the percent positive to drop. The metric I’d really like to see is No new cases
Testing capacity is also shown as green. But weirdly, the previous slide (which will be the subject of a subsequent post) seems to show we are only using one third of the available capacity, despite the fact that testing is not widely available.
Looking at the dashboard you’d see it’s not time to move forward. So what else is going on?
There must be considerations beyond public health, such as:
Financial stress on individuals, businesses and state and local governments
Mental health concerns
You can see some of this in the reopening plan. For example:
Supposedly there shouldn’t be gatherings of more than 9 people, and yet religious services are allowed to restart now
Hair salons are reopening despite the impossibility of social distancing. Six-foot scissors, anyone?
I think it’s ok to show the extra rows on the dashboard and take everything into account more explicitly. It’s better than pretending they aren’t there.
Healthcare analytics company Cotiviti has launched a COVID-19 tracker to predict infection outbreaks based on insurance claims data. It says its model has a high degree of accuracy and is useful for health ecosystem players and government authorities that need to decide where to allocate resources.
In this interview, I asked Cotiviti EVP, Jordan Bazinsky to explain.
What are the needs for COVID-19 tracking in the US?
To make decisions on how to best protect their citizens and employees while also limiting harm to their economies, policymakers and business leaders need accurate and timely data about how far COVID-19 has spread in their communities. But unfortunately, we’ve seen that in too many areas, COVID-19 tests are not being administered to everyone who should receive one due to lack of resources. Therefore, in the absence of this testing, we sought to develop a model that would help to forecast which geographic areas were likely to see a substantial number of COVID-19 cases using other factors such as flu testing and flu diagnoses.
How could this model impact/shift the U.S. approach to combating this health crisis (at private, federal, and state/local levels)?
We’re already seeing many states and local governments move to re-open their economies even as COVID-19 testing remains scarce. While this is understandable given the economic devastation this pandemic has caused for many, these decisions should be guided by accurate data to protect those who are most vulnerable. We hope this approach will encourage everyone to proceed with the utmost caution as they make decisions that could have far-reaching impacts.
What is the unmet need you saw at Cotiviti? And what approach are you taking to address it?
This project originated the same day the WHO declared COVID-19 a pandemic. We assembled a team to explore how Cotiviti could help respond to the outbreak by using our Caspian Insights data and analytics platform. The team began examining leading indicators such as telemedicine, rapid flu testing, and chest x-rays, that can help predict potential areas of concern before COVID-19 testing takes place.
The primary deficiency we are aiming to solve is the widespread lack of COVID-19 testing resources, which has left states unable to confirm the true impact and reach of the virus in their communities. Instead, our approach relies on other leading indicators of COVID-19, such as flu testing and diagnosis. By comparing current flu testing data seen in the CPT codes processed through our systems against confirmed flu diagnoses seen in ICD-10 codes, we can spot significant discrepancies that could indicate a “hidden outbreak” is occurring.
What are the use cases? Are people using it for purposes beyond what you originally envisioned?
Our focus is on helping all healthcare stakeholders to prepare for what’s ahead given the unpredictable nature of this virus. As healthcare organizations seek to gain more data and use that data to extract meaningful insights, we are offering this resource to supplement their existing resources.
We have fielded questions recently regarding how this data may support contact tracing. We have also had inquiries from retailers wanting to use this data to inform decisions about when to open stores in various parts of the country. While neither of these were uses we initially envisioned, they reflect the need from all stakeholders to have access to reliable, timely COVID-19 data.
Now that states are looking at loosening their social distancing mandates and re-opening previously shuttered businesses, Cotiviti has unveiled a second map that shows which states have seen a downward trend of influenza-like illness and COVID-like syndromic cases to aid in decision making. It will be critical to maintain active surveillance of any early spikes that may be predictive of COVID-19 resurgence.
How does it compare with other initiatives, like the Johns Hopkins model?
While Johns Hopkins has assembled an excellent, informative COVID-19 dashboard that aggregates data to track cases around the world and show trends over time, it specifically focuses on confirmed cases, which can only be identified through COVID-19 testing. Similar dashboards and tracking tools released by other organizations are also limited to tracking confirmed cases. Our approach looks at where there are a significant population of unconfirmed but likely cases to help forecast the hidden impact of this outbreak.
What are the data sources? How did Cotiviti ensure data quality and accuracy?
Our data source is Cotiviti’s Caspian Insights data and analytics platform—the engine behind our healthcare analytics solutions—which processes millions of claims per day and comprises longitudinal data for more than 130 million Americans. It combines financial and clinical information alongside a multitude of other healthcare data types, such as social determinants of health, medical records, pharmacy, dental, and lab information to give health plans and providers actionable information at their fingertips.
We have both automated data quality standards and rigorous processes to ensure data quality and accuracy at all levels. For example, healthcare data is known to be inconsistent across disparate systems—the same individual might be listed by different names in the different data feeds we receive. To overcome this challenge, we leverage a unique combination of probabilistic and deterministic models to establish linkages between data sources, while also ensuring the data is de-identified. Finally, we have a strong organizational commitment to quality at all levels of Cotiviti.
How accurate are the predictions? How is that changing?
We made our first forecast on March 12, and 80 percent of our predictions were realized by March 22. We have continued to maintain this level of accuracy while refining our data and algorithms, and we continue to see indications of potential hidden outbreak in certain states. However, as COVID-19 testing becomes more available, we know that hidden outbreaks will diminish and transition to confirmed outbreaks. Therefore, our team is preparing to shift to a more sophisticated modeling approach that identifies “COVID-like illness” based on the unique care pattern of COVID-19 that can be seen in the claim, clinical, prescription, and lab data for a patient. This approach will allow continued monitoring of the virus until a vaccine is available.
It’s no surprise why auto insurers like State Farm and Geico are sending rebates to customers this spring and summer. No one’s driving, so accident claims are way down and insurers are paying out very little. No one expects drivers to make up for lost time by crashing their cars more often once they return to the roads. That means a dollar saved now on claims is a dollar saved forever. Insurance companies and state insurance commissioners realize this, too and that’s why the rebates are coming.
But you might be surprised that health insurers, starting with UnitedHealth are beginning to do the same thing. United is offering a 5 to 20 percent credit on June billing statements, which is the same order of magnitude as the auto insurers.
So the questions are:
Aren’t insurers spending a fortune on the surge of COVID-19 patients as they overwhelm the medical system?
What about the coming surge of deferred elective surgeries and the ‘train wrecks’ with acute or chronic conditions that have stayed away from the emergency room and doctor’s office? Won’t insurers need the money to pay for those when they return?
And the answers?
Insurers are spending a lot on some COVID-19 patients. Big bills are rolling in for hospitalized patients, especially those that land in the ICU and are on ventilators for weeks. But even though a lot of people are sick, it’s only the hospitalized patients that incur expenses. With no costly outpatient or drug treatments, overall COVID-19 costs are not so high. Also, many of these patients are older (Medicare) or poorer (Medicaid), not in United’s commercial markets, where the rebates are focused.
Other than COVID-19, the medical system is eerily quiet. Essentially the only other bills are for telemedicine, some cancer treatments, and medications for chronic illness.
We do hear about a coming ‘second wave’ of non-COVID-19 patients later this year as hospitals reschedule elective surgeries, people who have been avoiding the emergency room come back in worse shape, and chronic care patients incur more intensive treatments after declining.
These assumptions are driven by a combination of what seems like common sense, clinician desires to help patients, and wishful thinking by hospital financial chiefs.
But UnitedHealth knows something that others don’t: utilization and costs are not going to rise as fast as people assume. So insurers are getting out ahead of it before regulators, the ACA medical loss ratio requirements, and public opinion force their hand.
They will be in for a rude surprise, however, because many people will continue to stay away. Instead patients will use telemedicine, pursue less aggressive treatments, or just wait for time to heal what ails them. For years, healthcare experts and insurers have known that hospital care is over-utilized and sometimes dangerous. Now COVID-19 has done what co-pays, deductibles and hospital safety reports never could –keep patients away.
It’s no surprise that elective procedures and routine visits have plummeted. After all, hospitals canceled them. Surprisingly, the use of emergency rooms in Boston for strokes, heart attacks and appendicitis has also dropped by half during the emergency. Many emergency patients will return, but those with common issues like back pain and rashes will think twice or three times before coming in. Patients who are due for colonoscopies or mammograms will put them off even longer than usual.
In the latest episode of #CareTalk, CareCentrix CEO John Driscoll and I talk about whether it’s right to make meat plants reopen. We also ponder whether public health after #COVID19 will look like security after 9/11. As if that wasn’t enough for one episode, we tacked on a debate on why emergency room use has plummeted and whether telehealth is here to stay.