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.
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!