When COVID-19 hit, hospitals knew they would see a decline in elective surgeries and routine visits. After all, they canceled them! But the volume of patients visiting the emergency room has also dropped dramatically, and no one can seem to fully explain it. Sure, maybe we could expect fewer car crashes and skiing injuries. But heart attacks and strokes? If anything it seems like those numbers should be going up due to higher stress levels. Yet, the analyses in cardiac care during the pandemic show a sharp decline not only in elective cardiac procedures, but also in cardiac catheterizations for acute heart attacks, specifically, those with ST segment elevations – the most life threatening type.
Conventional wisdom tells us that the drop in ER visits is a bad thing. Patients must be dying at home, outcomes must be worsening, and the patients that do survive will show up as train wrecks once the pandemic subsides. Those assumptions are probably true to a certain extent, but the open question is how true? Acute conditions and complications warrant acute care. But in the routine care of behavioral health and other chronic conditions such as diabetes and hypertension, extensive overuse of the emergency room rather than other ambulatory settings has been a prime area of concern and debate for several years.
We know that ERs are overused in normal times. And we think they’re underused now during the pandemic, but to what extent should be analyzed and debated as we inform the necessary adaptation of our systems of care. We expect to see an incredible amount of variation in ER utilization as the situation unfolds, by specific patient populations, urban vs rural settings, and geography-specific COVID-19 case burden.
We are encouraged that Datavant has convened a wide variety of industry players to construct a COVID-19 Research Database, a set of de-identified data sets made freely available to enable rapid studies at scale. The new initiative fills an important gap between quick observations that are available from small sets of real world data and clinical trials, which are robust but slow.
The ER phenomenon we’re discussing is not completely unprecedented. Researchers (and ER staff) have long observed the ‘big game effect’ – where ER visits decline as people defer them to watch their favorite team. (The Health Business Blog first reported on it in 2005:Red Sox’ success eases health care crisis.) Some, but not all, of those visits are avoided entirely without negative consequences. The COVID-19 pandemic provides an opportunity for a much longer time series. Let’s use it as a chance to study what’s going on so we can apply the lessons learned as we emerge.
What could explain sustained, lower utilization of the ER? There are a few possibilities:
Many seemingly serious problems resolve on their own when people just wait. If people avoid the ER out of fear, the ‘tincture of time’ will often do the job.
Less aggressive ambulatory settings are proving effective: the physician’s office, a telehealth visit, or home remedies.
The momentum and logic of the ER setting makes matters seem more serious than they really are. Once someone appears there’s always something to find. (As a doctor colleague once told me, “Show me someone who’s perfectly healthy and I’ll give him a full workup to demonstrate otherwise.”)
The ER is the entry point for admission to the hospital. Under fee for service, hospitals need to admit patients to make money. Depending on the proportion of available beds during these uncertain times, hospitals may be even more economically motivated than usual to fill open beds. So, once a patient arrives, they may be staying.
A significant portion of ER traffic is composed of so-called ‘frequent fliers.’ Usually, they are tolerated, but in the current environment, ER staff are motivated to triage non-COVID-19 patients away from the hospital as efficiently as possible. Once this becomes evident, the ‘frequent fliers’ ground themselves.
How many times have you called your doctor’s office or pharmacy and heard the recording say, “If this is a medical emergency, hang up and dial 9-1-1”? That definitely got people used to the idea that the ER is a good place for care. Clearly people are ignoring that messaging now!
So what should we do with this unexpected information?
More finely tune financial incentives to discourage unneeded utilization while not discouraging needed care. We know from experience that bluntly requiring large patient financial contributions drive down both good and bad utilization.
Educate people about the downside of ER visits (infection risk, treatment that’s too aggressive, likelihood of admission to hospital, provider that doesn’t know you) to balance out the current bias for ER care. People will be more receptive now and won’t immediately think that health plans are only trying to ration their care.
Consider other changes in benefit design to help the decreased utilization persist, including increased access and reimbursement for home services, telehealth, and remote management tools.
Encourage physician offices and others to make better efforts to intervene quickly and prevent people from going to the ER just for convenience. This could include on-demand availability of telehealth consultations and other digital/remote management for which they would be reimbursed.
A few years back I heard that sitting is the new smoking. That concerned me, since I’m the type that tends to stay glued to my seat throughout the workday, especially when working from home. Some colleagues and clients have standing desks –or even treadmill desks!– but they never appealed to me.
The Apple Watch has been helpful in encouraging me to stand up. While I ignore most of its other prompts (like the suggestion to Breathe) I am quite responsive to the notification I get 10 minutes before the top of the hour, imploring me to stand up at least once before the clock strikes.
Recently, FluidStance offered to let me test out its Plane balance board, billed as a product that brings “movement and happiness to your workplace.” Bottom line: I like it and you might, too.
With #COVID19 in the air, I don’t get a lot of excitement. So it’s always a highlight to receive a package on the doorstep. The balance board came in a long, thin box; when I opened it up I was impressed with the cloth backpack. I felt pretty cool carrying it up to my home office past my teenagers!
It took me a couple minutes to figure out which end was up. (I got it wrong at first.) And my initial joy was tempered when I read the label on the board.
WARNING, USE AT YOUR OWN RISK! This product creates an unstable surface. Use of this product may result in injury or death. Use at your own risk.
Injury I can live with. But death? Even if sitting is the new smoking (and that’s actually controversial) death is still the old death!
Although my balance is good, I’ve never had much luck with skateboards, wakeboards, surfboards of anything kind of board. I was particularly good with the pogo stick as a kid, however.
I need not have worried, because the FluidStance board is really easy to balance on. If you do fall off, it’s about 3 inches so no biggie! It does provide a nice stimulus –better than just standing on the floor, and it’s easy to swivel around, too, should the temptation strike you.
I didn’t want to risk messing up my hardwood floor, so I put a mat under my chair. It protects the floor but does make it a little harder to swivel. When I’m not standing (which is still most of the time) I put my feet on it and use it as a footrest.
I’ve always done audio conference calls, but the pandemic seems to be pushing what would have been in-person meetings and even many phone calls into the video realm. Since I’m not even walking from one conference room to another, I’m sitting even more and am making an effort to stand.
The balance board is good to stand on during conference calls, but it presents a couple of challenges. For audio, I’m a bit far from the speaker phone –but I’ve checked with others and my sound seems good. But for video calls my head ends up out of camera range, even if I tilt the monitor up. I could probably do something about that with a webcam or mounting my laptop on a shelf, but I haven’t. These are minor annoyances but it means I don’t use the board as much as I might like to.
I’m not sure whether there are measurable benefits from using the balance board, but in any event I do like it and plan to keep using it. The literature that came with the deck said, “We aim to blur the lines between work and play, making work a more fluid and natural part of our whole lives.” I can feel that.
The FluidStance product is very well built. It’s solid, attractive and durable. Built in California, it’s well positioned to ride the de-globalization that seems likely post-COVID.
In the final version of yesterday’s post (4 predictions for the next phase of the COVID-19 pandemic) I decided to omit prediction 5 “the end of immigration.” The piece was already too long, I was running out of steam, and didn’t want to be too political. Also, it seemed kind of obvious.
And yet, I’m now kicking myself after the President’s tweet last night announcing his plan to suspend all immigration. It didn’t surprise me because it was something the President wanted to do anyway and the timing gave him two superficially plausible rationalizations: keep the virus out and reduce competition for American jobs at a time of huge unemployment.
But it’s a bad policy, especially now. Consider how immigrants are helping the healthcare system and the broader economy respond to the crisis.
Hospitals and health systems are overwhelmed, and we are counting on our physicians and nurses to save patients from death. Immigrants make up 28 percent of doctors and 16 percent of nurses. We don’t really want to tell them they’re unwelcome, do we?
Immigrants also comprise 20 percent of healthcare support roles, including nursing, psychiatric and home health aides.
More than half of farm laborers, graders and sorters were born outside the US as are many of the people working in grocery stores, delivery, etc. They are needed to ensure a reliable food supply.
Immigrants have been a major source of innovation and job growth in the US economy throughout our history. We will need immigration going forward to create new jobs, help pay down the massive debt we are accumulating and to support the healthcare system. I’ve written plenty on this topic over the last 15 years.
If you think the Health Business Blog is the wrong place to discuss politics or you’re a fan of the current Administration, stop reading now.
Remember, you were warned…
I’m going to peer a little farther down the road to speculate about where this latest action could lead. These aren’t really predictions about what will happen, but I am pointing to where things could lead. These aren’t about healthcare.
On immigration itself, the administration will be happy with the debate, which will further pit the base against the urban elites. American universities will be further weakened by this policy (a follow on from my prediction 4 yesterday: “The federal government will grow even more powerful relative to everything else”). Others can come begging for temporary relief, e.g., farmers looking for migrant laborers.
The next logical steps on immigration are deportation of people with green cards and the stripping of citizenship of Americans who were born elsewhere. The threats and hints will come first, and that may be enough to achieve the objectives. Remember, in late February the Justice Department created a Denaturalization Section to do this very thing. Whether it goes further depends on how people react to the upcoming Executive Order and whether officials think it will help politically.
It’s quite possible that this latest, bold step will embolden the President to take further actions, including:
Postponing the November election –in the name of protecting the safety of the population
Ruling by decree — since it’s an emergency and Congress is too slow
Closing down newspapers and others critical of him –since they are interfering with his message and the ‘enemy of the people’
Yes, all of these are outlandish. But, how can you argue convincingly that they won’t happen?
We’ve already seen elections canceled, postponed or reinstated this year. At a minimum, expect strategic suppression of voting
Congress has put itself on the sidelines by not meeting and by not changing the rules that require it to meet in person. Rule by decree has already come to Hungary
The disdain for newspapers and desire for tougher libel laws has been made abundantly. Don’t the ‘enemy of the people’ deserve some kind of punishment, especially during a crisis they’ve whipped up by writing ‘fake news’?
The President says his “authority is total.”
I’ll leave it there for now, except to note that what I’ve listed above is not all that could happen and not even the most extreme. The President wants to control the news cycle. That means doing something bigger than the pandemic to make it happen.
COVID-19’s impact on the United States and its healthcare system is unprecedented. In this piece, I make four predictions for what the next phase will bring. Each has important strategic implications for healthcare companies and investors.
Here’s what I expect:
Treatment, not testing will be key to reopening the economy
Hybridization (virtual/in-person mix) will be the new reality
Public health post-COVID-19 will be like security post-9/11
The federal government will grow even more powerful relative to everything else
Treatment, not testing will be key to reopening the economy
It is accepted wisdom among public health experts and many others that the widespread availability of COVID-19 testing is a necessary condition to reopen the economy. It says so on the roadmaps of California, Massachusetts, the federal government, and many companies and institutions. It makes great sense: once we can see the problem clearly we can prevent infections from spreading. Other countries that are reopening –like Germany and Singapore—make extensive use of testing and contact tracing. This, we’re told, is the way things will be until a vaccine is introduced in a year or so.
Here’s the problem: progress on ramping up testing has been slow, even in Massachusetts where I assumed it would go fast. Despite lots of announcements of new capacity coming online I haven’t seen anything that makes me think there will be a breakthrough. Consider, also that effective testing for COVID-19 can’t be a one-time phenomenon. People will need to be tested over and over.
Meanwhile, with the worldwide deluge of patients, doctors are figuring out how to treat them. We might not have a vaccine in a year –or ever (unfortunately), but treatments are improving now, through experimentation, physician insight, and good luck. There is early promise from Gilead’s remdesivir; other drugs will be useful, too. But it’s not just drugs, it’s also non-drug adjustments such as how to optimize use of mechanical ventilation for these patients and even when to turn them onto their stomachs. As another example, I received firsthand reports from frontline Italian physicians who hypothesize that the coronavirus attacks the cardiovascular system first, and that is where to focus to address the root cause in a straightforward way. These are just things I’ve been privy to; certainly there are thousands of other investigations going on around the world. Some will work, and soon. These innovations can be additive or multiplicative, even if they’re not a miracle cure.
Bottom line, I think it’s likely that COVID-19 will become a manageable disease within a few months or even a few weeks, and that’s what will enable us to start to go back to work and school and to start flying again with an acceptable level of risk. For better or worse, it’s also more consistent with how the American healthcare system works: treat the sick.
It would be so much better to have ample testing in place before trying to reopen. Until we get there the US will suffer from higher disease burden, greater cost, higher inequities, and more skittishness about public gatherings compared to other countries. Yet as a whole we will figure out how to make do without the testing capacity that everyone wants.
Hybridization (virtual/in-person mix) will be the new reality
When COVID-19 hit, telemedicine made more progress in one week than it had in the past 10 years. Suddenly patients were scared to come to the office or hospital (and doctors/nurses/staff were afraid of the patients), reimbursement with in-person visits was equalized, and cross-state licensing restrictions were eased. People are getting accustomed to online meetings, online socializing, online schooling, and online shopping. Some of it –like convenience, immediacy—they like. Other parts –such as the difficulty building new, trusting relationships and absence of physical contact, and difficulty interacting with groups or teams—they don’t.
The pandemic will be with us for a while, which means people will have plenty of time to get used to being remote, understand better how to make it work, and won’t always default to the old ways. This is true even for some older Americans who thought they’d be able to ride out their careers or lives without jumping into the digital waters.
There has been a gradual shift to online over the past couple of decades, but the pandemic changes things. Now, we realize that we may have to suddenly revert to a remote world at any time, so we had better be ready for it. Social distancing is likely to be required to some degree over the next couple years, which means offices, factories, schools and entertainment venues won’t be able to return to their previous density. We can expect to see a rotation of remote and in-person staff and students –instead of total shutdowns. And kids may not like it, but there will be no excuse for another snow day!
Health status and age will play important roles in how hybridization is realized. Older people and those with conditions making them vulnerable may find that they have to spend more time in the digital world than their younger and healthier peers, because it’s not safe for them to show up in person. Ageism and discrimination against people with disabilities is already a major problem. It will become much more so in a COVID-19 influenced economy, especially during a recession where the job market favors employers.
For healthcare delivery and clinical trials, it is likely that more routine interactions will be conducted online rather than the office, and that the home will become even more attractive for recovery, aging and research. Providers will make greater use of nurse practitioners and physician assistants as front-line representatives, for triage, follow up and care coordination. It’s more straightforward to standardize protocols and supervise staff in the digital realm, plus it’s cheaper. We will also see a rise in asynchronous interactions, which are often more effective and efficient than as live video call. With the right leadership, these changes can also facilitate an increase in value based and evidence based cared.
The current situation has very negative consequences for the health of people with chronic and even acute conditions, who are avoiding the doctor and hospital at all costs. Meanwhile, providers face financial ruin as patients stay away. It has to be addressed, and hybridization is the way to do it.
Public health post-COVID-19 will be like security post-9/11
After 9/11, security came to the fore. Suddenly there was visible security at airports, in office buildings, and throughout public spaces. New physical and digital surveillance technologies and practices were introduced and there was massive hiring of security guards, analysts, etc.
Now that COVID-19 has struck, we can expect public health to be similarly elevated. It will become a pervasive part of our economy and society. Expect temperature –and maybe face mask and hand washing– checks at the office, school, and any public venue. Contact tracers may call or visit our homes or scrutinize our cellphone records. Event managers and employers will need to hire a health team and devise a health/safety plan to prevent outbreaks and provide confidence.
New products and tools will be needed to sanitize surfaces, detect pathogens in the environment, and monitor outbreaks. Sick leave policies will need to be revised and enforced. New cultural norms will be established –for example on the wearing of masks, shaking hands, what personal space means. Mental health needs must also be recognized and addressed in the adult and pediatric populations.
It won’t be enough to pursue these approaches privately. Local, state, and federal agencies will have to invest in order to deploy a comprehensive strategy to protect and reassure the public.
The new public health approach will dovetail with existing post 9/11 security measures and infrastructure. For example, the Red/Orange/Yellow/Blue/Green threat level developed for terrorism is actually more suitable to viral dangers. There will also be opportunities to redefine and expand the corporate wellness industry, which at last will be able to demonstrate a robust return on investment.
Federal government will grow even more powerful relative to everything else
The federal response to the pandemic has been problematic. The US had time to prepare after observing China and Europe, but largely failed to do so. States complain that there’s been little federal response or coordination and that they have been left to fend for themselves. The underlying reasons and political elements can be debated elsewhere.
Somewhat paradoxically, the pandemic has strengthened the federal hand relative to others. Consider:
With interest rates near zero, the federal government is easily able to borrow $2+ Trillion for the CARES Act
The Federal Reserve has propped up the stock and bond market with its promise to buy essentially anything, including non-investment grade securities
States are facing huge drops in revenues thanks to the shutdown of the economy. They need to balance their budgets and don’t have the borrowing powers of the feds. They also have to beg the federal government for assistance with the current crisis
The completely unprecedented surge in unemployment is leading to dependency on programs such as SNAP and Medicaid that are primarily funded at the federal level
Many industries –think travel, tourism, restaurants—are essentially shut down and need a bailout to restart
Colleges and universities, are hamstrung by having to close their campuses -possibly through the fall semester as well—and the question of whether domestic and especially international students will return
The healthcare delivery system is suffering from a huge disruption as essentially all resources are diverted to COVID-19 or idled
The broad implications of this sudden swing will play out over time and will be affected by the November elections (assuming they occur on schedule). The pandemic really does place the country at a crossroads. The conditions are ripe for further dividing the nation along various fault lines (rural/urban, nationalist/globalist, etc.) or for bringing us together. We may also see blocs of states ally more formally to coordinate with one another and attempt to shift the balance of power. Meanwhile, it is notable that this federal power expansion, involvement in the economy and massive increase of borrowing are occurring under ostensibly conservative leadership.
One near-term result is that the country has jumped much closer to the left-wing policies of Bernie Sanders and Andrew Yang than would have seemed imaginable in February. Everyone will be covered for COVID-19, whether directly through their insurance plans or through federal subsidies to providers, and the $1200 stimulus checks with the president’s signature are like Yang’s Universal Basic Income.
Massive unemployment will shift millions of people to Medicaid, so we may have Medicaid for All rather than Medicare for All. (This is actually a better idea, in my view.) I think we’ll see the holdout states finally accept the Affordable Care Act’s Medicaid expansion now that their backs are to the wall. And I also expect the COVID-19 experience means the Supreme Court will decline to strike down the Affordable Care Act, even though that won’t be the explicit rationale.
The situation is fluid and each of these predictions is subject to change. But I wanted to get some thoughts down while they were fresh, with the goal of spurring conversation and debate. In addition, I hope that clients will find this thinking useful as they determine what to do next and make longer term strategic and investment plans.
We’ve heard it over and over again. We can’t reopen the economy until we have a robust testing process in place for #coronavirus. Employees need to be tested frequently so they can return to work and stay on the job without infecting others and causing the whole worksite to have to close down and stay shut.
Meanwhile, Donald Trump, the CDC and much of the rest of the federal government have demonstrated sustained incompetence on getting testing going. Countries like Germany and China are organizing testing programs and restarting their economies.
Obviously we aren’t Asia or Europe. We need an American solution! And we need an adult in the room.
The obvious answer is to enlist the adult film industry in returning the economy to normalcy. The industry has operated a testing system successfully for years to stave off threats of infections from HIV and other sexually transmitted diseases.
The [Free Speech Coalition] took over managing sexual health protocols for the mainstream, straight porn world in 2011. It has since developed a set of testing guidelines known as the Performer Availability Screening Services (PASS) system. The guidelines have shifted over the years, but as of today, performers in the system test every two weeks for HIV, chlamydia, gonorrhea, syphilis, Hepatitis B and C, and trichomoniasis at a handful of clinics that partner with the FSC. If performers test positive for any non-HIV infection, a central database visible to agents, studios, and other performers automatically flags them as unavailable for work until they test negative. It also flags them if they have gone more than two weeks without being tested…
Unlike old systems of bringing copies of a recent test to a set, this database system protects performers’ real identities and medical information—and prevents test doctoring to hide results, an issue that has led to outbreaks of STIs like syphilis in the past.
Here is some background from the PASS website. Forgot about the titillating nature of the work for a moment. Replace “performer” with employee and there you have it. Why wouldn’t we want the same thing for other workplaces?
Performer Availability Scheduling Services provides guidelines and services for the adult production industry designed to ensure a safe and healthy work environment of performers and adult film professionals. The program includes:
A series of nationwide testing sites providing low cost, high-quality testing in a timely manner
2. Performers have electronic access to testing results directly from labs
3. Variety of medical providers for treatment of performers in need of medical follow-up
4. Consistent standards and guidelines for testing and treatment of adult performers
5. A secure database that ensures performer privacy and protects producer liability
6. Protocol for performer support in the event of a positive HIV test result, including funding for testing of 1st and 2nd generation partners
It’s time for Dr. Fauci to team up with stars of the adult film industry to replace the President’s daily briefing with a more informative, entertaining and productive replacement.
Strange times make for strange bedfellows. So be it!