Category: Policy and politics

Opening up schools –or not

published date
August 21st, 2020 by

Some schools are opening up but then quickly shutting down again. Others aren’t even going to try. After the spring’s failed experiment with virtual school are we really here again? CareCentrix CEO John Driscoll and I argue it out.

 

COVID-19 contact tracing. The 7 keys to success

published date
August 14th, 2020 by

This is a guest post by summer intern, Marina Zapesochny.

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Mask wearing, social distancing and testing are helping bend the COVID curve in the US.  Increasingly, local communities and states are adding contact tracing –one of the oldest tools in epidemiology– to break the back of the outbreak. Contact tracing is highly effective for limiting COVID-19, but only if done well. Here are the 7 tips for getting it right.

  1. Recruit “people persons” as contact tracers

Contact tracers need to have difficult conversations with people all day long. Training helps, but too often the focus is on the technical aspects of the job.

The real emphasis should be on hiring people with the right personalities. That means “people persons.” You know, the folks who like to strike up conversations with strangers at the supermarket or bus stop and ask all sorts of questions about personal matters.

People persons will have a much easier time talking to others than those that lack those skills. CDC training instructions for contact tracers focus only on how to get in touch with people, and how to trace who they have been in contact with. Nowhere does it address how to schmooze with people, how to build trust with them or how to really empathize with them.

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  1. Follow the “Paterson Principle” by building trust at the community level

Building trust is essential in a community where contact tracing is implemented to protect public health while also respecting people’s privacy. People can’t feel stigmatized when they are called about COVID. Spreading awareness that a contact tracer might reach out, and normalizing it by communicating about the program in local forums can make people feel less targeted.

Paterson, NJ is handling contact tracing particularly well. It is the second most densely populated place in the US after New York City. As soon as the pandemic began, Paterson expanded its contact tracing team in preparation. The mayor, Andre Sayegh had the coronavirus and beat it. Following his recovery, he said “I survived coronavirus and so will Paterson.” The mayor himself was contact traced and strongly endorsed the program. The mayor was prepared and open with his citizens. If more cities treated contact tracing this way, trust would grow.

Who answers calls from unknown numbers? With so many spam calls nowadays, most people don’t. That makes it extra tough for tracers. Portland, OR  is one of many places struggling with this challenge. People don’t answer the phone and only about one in five are willing to share their contacts.

If local media explained contact tracing  better and let people know what to expect and why,  people would be less hesitant to pick up and cooperate. Building trust in contact tracers and the security of it in a community is what produces the best results

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  1. Remember: Less is more

Contact tracing only works when cases are rare. The US was caught flat footed in early 2020 with a lack of testing capacity and federal leadership; cases exploded and contact tracing was no longer practical. Now that cases are declining in some parts of the US, contact tracers can be reasonably expected to find all the people the infected few were in contact with and warn them relatively quickly of their exposure. But the only way to get to a low number of cases is for the whole community to take  precautions such as social distancing and wearing masks. This makes it possible for contact tracers to do their work. The tracers can then accelerate a virtuous cycle to crush the curve.

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  1. Help COVID apps go viral

Several companies have created apps to assist in contact tracing. However, almost no one is using them. A good way to improve the quality of contact tracing would be to make these apps more mainstream and attractive to users –in other words, help them go viral.

The potential for many of these apps is amazing. If enough people used them the apps could provide alerts when a COVID-positive individual is nearby. But unfortunately, such apps need at least 60% of the population to use them. So, the questions stands, how do you get people to want to download the app? According to Harvard Business Review, the best way to get people to actually use the apps is to follow the Facebook and Uber models: start in a small area, expand it one city at a time and then launch globally.

The current approach to having people download these apps depends on the country. In China it is mandatory and in Iceland in is voluntary, but newsflash, neither is generating enough use of their app!. The Uber/Facebook model sets an exmple for the use of these apps. One of the apps with potential is Contact Tracing by Piusworks LLC. It is a free app with easy to understand instructions. However, the reviews on the Apple App Store lean to the negative side with many of them saying it was “not ready for release.” This is because they released to the general public all at once instead of following the Uber/Facebook approach. If they rebranded and relaunched to just one city at a time the results and reviews would be much more positive.

Uber, itself has played a part in sharing contact tracing information. Uber started sharing information with health departments on both passengers and drivers. The health departments can then track who used Uber services and encourage them to get tested and quarantine. Privacy remains an issue. Such a big company sharing the information of others seems like a violation, but it is covered in the Uber user agreement.

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  1. Keep up the good work!

One call is not enough. It is necessary to follow up with people to get their contacts and sometimes to connect them with support resources. This was especially relevant during the AIDS epidemic. These practices are helpful, but more could be done. Contact tracers should check in with patients, not just for information but also to have a conversation about how the person is doing over time. Even a short conversation goes a long way.

Patients should also be checked on to make sure that they are getting the care that they need (are they in the hospital? did they get tested? are they quarantining?). These steps will reduce the doubt that the public may have had in contact tracers before. But the contact tracers can’t do it all. Partnering with other organizations so that people could get their support quickly and easily would be a fantastic idea for contact tracers. Local organizations already have connections and a reputation in the community. They could help contact tracing organizations develop a reputation with the community as well.

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  1. Leverage the data, lose the bias

Analyzing patterns in the population of infected individuals can yield helpful insights. If people of a certain neighborhood, religious group, ethnic group, etc. are getting COVID more often, that can guide allocation of resources for intervention. Perhaps some people from a certain neighborhood are continuing to get together despite social distancing guidelines, or a religious organization isn’t requiring facial coverings. The important thing to remember when looking into this is to not input any bias or stereotypes, but let the data do all the talking. Singling out groups is a very taboo subject, but finding patterns and using them well can be effective. Another important part of it is making sure that people don’t feel targeted. Targeting people rather than just discussing patterns with them is harmful, because they won’t trust contact tracing anymore. Finding patterns, investigating them, and then informing the groups that are continuing to get sick could greatly reduce the amount of COVID positive cases. It also helps to warn members of those groups that they had a possibility of exposure before they even show symptoms.

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  1. Testing, testing, 1-2-3

Quick turnaround time for test result is vital in contact tracing. The average person comes in to contact with roughly 16 other people each day. If it takes 2 weeks for results to come back and for contact tracers to start reaching out, that number goes way up. Sure, some of the 16 people a day are easily recalled repeats like family or coworkers, but what about the cashier at the local grocery store? Or a friend who met for coffee? The longer it takes for test results to come back, the more  people can get infected unnecessarily. Calling this many people would take a lot of time, possibly days, so they wouldn’t be alerted immediately.

Another related challenge is asking people to quarantine until their test result come back. It is reasonable to ask people to quarantine for a day or two until their results are reported, but making people quarantine for 2 weeks with a possible case is outrageous. COVID testing and contact tracing need to work hand in hand to effectively reduce cases. This is what makes partnerships between contact tracers, community organizations and the healthcare system so important.

Growing our contact tracing tools now will also benefit us in the future. When another wave of COVID or a new pandemic appears, American cities and towns will be far better equipped.

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Colleges adapt porn industry policies for safe reopening

published date
July 2nd, 2020 by
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Giving it the old college try

Top colleges are taking a page from the adult film industry’s playbook to ensure that they can reopen this fall and stay open, despite the COVID-19 pandemic. I applaud them for it.

As I wrote in early April (Let the porn industry reopen the economy):

Donald Trump, the CDC and much of the rest of the federal government have demonstrated sustained incompetence on getting testing going…

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.

I went on to describe the PASS system that had operated successfully for a decade, with frequent testing and follow-up. I encouraged employers to do something similar.

Employers haven’t really taken this on, but one sector of the economy is not only adopting this approach but taking it to the next level. Some high-end private colleges and universities are determined to return to campus this fall. Online classes are ok but they are a very poor substitute for the in-person experience and are frankly not worth the tuition.

Unlike some of our red state governors, certain college presidents are taking a cold, hard look at what it will take to make it happen. They aren’t relying on science and public health experts, not wishful thinking. And they have come to the same conclusions that the porn kings did.

Here’s what Colby College is doing (emphasis mine). They expect to spend $10 million this year.

Colby’s testing program… will require the participation of all members of the campus community—students, faculty, and staff. Students will be tested prior to arrival with test kits provided by Colby, and all community members will be tested three times during the opening weeks of the semester. Thereafter, everyone will be tested twice per week, a rate that scientific models have demonstrated will greatly limit the spread of the virus by detecting infections in individuals prior to them becoming contagious. To put this in perspective, we expect to administer roughly 85,000 tests in the first semester alone, a number that almost equals the total number of tests administered in the entire state of Maine since the start of the pandemic.

…Test results will be returned to the individual and the College within 24 hours, allowing for any required mitigation efforts to be instituted quickly. We have leased additional housing for quarantine and isolation of students, who will be provided with a range of support services, including facilitating their coursework, attention to medical and mental health, and food delivery.

And Brandeis?

Brandeis will provide high-frequency, mandatory COVID-19 testing to all on-campus community members…All students living in campus residence halls will be tested upon their arrival to campus, and students living off-campus will be tested at a designated time before the start of the fall term. There will also be mandatory testing multiple times per month for all students, faculty, and staff who either live on campus or who come to campus several times per week, whether or not they are symptomatic. This will enable us to quickly identify and contain any instances of infection on our campus. Those coming to campus less frequently will also be tested, though not as frequently.

Testing is part of broader plans, but it is the core and let’s us know they are dead serious. Both of these schools are working with the Broad Institute for testing.

Interestingly, some other colleges are wavering on testing or throwing in the towel with a move to online only. Good luck with that.

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By healthcare business consultant David E. Williams, president of Health Business Group.

How does COVID-19 change Medicare Advantage?

published date
June 29th, 2020 by

Medicare eligible Americans have borne the brunt of coronavirus. Some of the immediate impact on Medicare Advantage plans is obvious. They are covering telehealth and paying for acute hospital stays.

But there are longer term implications, too. Their risk adjustment scores are thrown off by the lack of visits. Certain supplemental benefits (think gym membership!) no longer sound so healthy, while others (meal delivery) become super valuable.

In this episode of #CareTalk, CareCentrix CEO John Driscoll and I lay it all out,

Massachusetts school reopening plan gets an A from me

published date
June 26th, 2020 by
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See you in the fall

There’s much to like about the new Massachusetts Initial Fall School Reopening Guidance document. It is:

  • Purposeful –aiming to meet the objective of educating children in person while keeping them and staff members safe
  • Timely –coming at the end of the school year, with updates promised over the summer
  • Evidence based –relying on the latest medical and public health guidance and the experience of schools abroad
  • Appropriately detailed –with enough specifics to  guide decisions that need to be made now without being overly prescriptive
  • Circumscribed –acknowledging and accounting for issues of racism and disparities without purporting to solve every problem
  • Balanced –recognizing that we are living in the real world (such as it is!) and that COVID-19 is part of it. None of the measures (hand washing, masks, staying home when sick, social distancing) on their own will prevent the spread, but taken together they have and will

I’m not an easy grader, so my A for this assignment is real. I have publicly criticized Massachusetts’ reopening plan and its testing plan for being vague, non-evidenced based, and irrational. Privately, I’ve admonished the local school system for its defeatist attitude toward COVID-19.

Predictably, the Boston Globe (School guidelines feel unsafe to some) used today’s lead article to find fault with a wide variety of plan elements. Here are the ones I see mentioned:

  • The plan doesn’t set a cap on the number of students in classrooms
  • COVID-19 testing is not mandated
  • Daily temperature checks are not required
  • It mandates only 3 feet of social distancing even though officials have been telling us 6 feet
  • Superintendents need to develop 3 sets of plans (in person, hybrid, virtual)
  • No clear guidance on whether state should go back to in-person classes when school reopens
  • Doesn’t adequately address  challenges of urban schools that serve children from disadvantaged backgrounds and have limited space
  • Racism is not connected to students’ mental health in the plan
  • It doesn’t say how many students can ride the bus
  • People don’t like the idea of wearing masks all day

The report itself anticipates and addresses these criticisms. The Globe notes  some but not all. Here is the reasoning

  • Number of students isn’t capped because the relevant constraints are adequate space between desks and proper behavior. If a room is larger it can accommodate more students. The report encourages use of new spaces like libraries and cafeterias
  • No one in the country (or world?) is seriously suggesting testing all school age kids. It’s expensive, slow, unpleasant, impractical and unnecessary. Maybe there will be cheap, spit tests at some point. They can be used if the need is real
  • Daily temperature checks produce too many false negatives and false positives, offering a false sense of security and causing students to miss school when they don’t need to. These checks are good for other illnesses, like the flu where fever is a good indication of active infection, but it’s of limited use for COVID-19
  • There’s no magic in 6 feet. Three feet seems to work fine in other countries’ schools, especially in combination with other measures, like wearing masks. Schools with 3 feet of distance abroad have not had outbreaks. Kids aren’t going to be safer out of school
  • Superintendents need to develop plans for different scenarios. Of course they do! If they just developed one plan it would have to be for remote instruction only. Is that what we want?
  • Of course the guidelines can’t be definitive in June about whether students can go back in September. But the goal is to get as many back as possible. To make that happen requires everyone to behave well over the summer (adults, especially!)
  • Although the plan isn’t going to eliminate disparities or solve racism, there are extra funds to help all schools and especially those with extra needs. And the best way to reduce disparities is with kids in school. Disparities widen (as I’m sure they did this spring) when normal routines are thrown off. For extra space, the guidelines suggest working with local community centers, libraries, etc.
  • Kids will need to wear masks on the bus. If the bus is crowded then buses will need to be added or kids will need to get to school in other ways. They can keep windows open, too.
  • It’s true that people don’t like wearing masks all day. The guidelines call for mask breaks and make special mention of how to work with people with breathing or communication problems. If we all behave there’s a good chance we can take our masks off sooner rather than later.

Notably, these guidelines are endorsed by people who know what they’re talking about and have children’s interests at heart. The healthy approach is to work within the guidelines to plan a return to in-person classes this fall. We should continue to challenge the guidelines and expect them to be updated as we learn more and as the situation on the ground evolves.

Meanwhile, we can all contribute to a safer back-to-school scenario by continuing to follow public health guidelines that are knocking the virus down in Massachusetts. The lower the level of community spread, the safer any reopening plan will be.


By healthcare business consultant David E. Williams, president of Health Business Group.