Category: Research

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.

COVID-19 outbreak tracker. Interview with Cotiviti’s Jordan Bazinsky

published date
May 18th, 2020 by
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Cotiviti EVP, Jordan Bazinsky

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.

  1. 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.

  1. 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.

  1. 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. 

  1. 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.

  1. 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.

  1. 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.

  1. 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.


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

Where did all the emergencies go?

published date
April 30th, 2020 by
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Do you need me?

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:

  1. 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.
  2. Less aggressive ambulatory settings are proving effective: the physician’s office, a telehealth visit, or home remedies.
  3. 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.”)
  4. 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.
  5. 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.
  6. 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?

  1. 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.
  2. 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. 
  3. 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.
  4. 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.

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By healthcare business consultant David E. Williams, president of Health Business Group and Surya Singh MD, president of Singh Healthcare Advisors.

Coronavirus: We are all in this together

published date
March 20th, 2020 by

In this edition of #CareTalk, Carecentrix CEO John Driscoll and I discuss the impact of COVID-19 in the US and around the world.  John retracts his earlier claim that the feds are doing a good job, and we go on to discuss the fact that we’re all in this together, universal coverage is a sensible policy, science matters, and government can help.

We agree with Tony Fauci, who said, “If it looks like you’re overreacting, you’re probably doing the right thing,” and we also look for signs of hope on the horizon (or just over it).


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

Health disparities: You ain’t seen nothing yet

published date
January 22nd, 2020 by
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Welcome to the machine

A survey in the UK showed that the gap in health between rich and poor is widening. From the US perspective that comes as a bit of a surprise. After all, don’t the Brits have universal healthcare through the NHS?

But of course, social determinants of health such as diet, exercise, stress, access to transportation, and education play a bigger role in health than the healthcare system. With socioeconomic disparities widening, it serves to reason that health disparities will grow, too.

So where do things go from here? They probably get worse –that’s my guess. Current political and economic forces in the US, UK and elsewhere point toward an exacerbation of current gaps. And as climate change makes the world a generally harsher environment it’s the poor who will be more adversely affected by floods, fires, air pollution, etc.

But in a decade or two that will be nothing compared with the haves and have nots wrought by the advancement of medical technology. Expect the well off to increasingly invest in tools that let them get further ahead: for example cyborg inventions that augment intelligence, strength, vision, hearing and more. Not to mention artificial organs and genetic interventions to greatly extend life.

Will such modifications make people happy? Maybe not. But it will enable them to lord it over the rest of society to an increasingly greater degree.

Enjoy!