Wolters Kluwer Health Chief Technology Officer, Jean-Claude Sagbhini has been thinking a lot about how the pandemic will change healthcare. In this episode of the HealthBiz podcast, we discuss his predictions about scaling telehealth, accelerating evidence, predicting and preventing with AI, the changing roles of healthcare workers, and moving beyond interoperability to supra-operability.
I’ve been following Wolters Kluwer Health, and in particular its UpToDate offering for over 20 years and it’s exciting to see how the company is taking the original vision forward.
In April, with the pandemic raging, lockdowns underway in the Northeast and West, and widespread panic about what the immediate future would bring, I tried to look over the horizon to see where we were heading. My 4 predictions for the next phase of the COVID-19 pandemic and Prediction 5: The end of immigration, distilled what I was seeing in Boston plus what I was hearing from healthcare and life sciences clients and physician and scientist friends in US hotspots and around the world. I didn’t put a timeframe on when this “next phase” would be, but with the summer behind us and a new school year getting going, now seems like a good time to take stock.
Judge for yourself, but overall I think I did well. Let’s review:
#1: Treatment, not testing will be key to reopening the economy Grade: B
I was right that testing wouldn’t be our savior, but also overestimated how quickly treatment would improve.
In April, everyone was talking about the need for millions of rapid turnaround tests to get things moving again. Other countries, like Germany and Singapore had deployed testing on a massive scale. But when I looked at what was going on in the US I was unimpressed. There were lots of announcements about capacity but little follow through.
Sadly, we’re still doing poorly. Recent estimates suggest the need for 193 million tests per day; we’re only doing 21 million. In Massachusetts (one of the leaders in testing) it’s still hard to get a test if you’re not symptomatic. Test results elsewhere can take a week or even longer, if you can get tested at all. Bill Gates recently criticized the current state of US testing: too few, too slow to return results, wrong swabs.
The absence of rapid turnaround testing at scale and weak contact tracking has hampered the ability of scientists to inform policy makers and the public about what works and what doesn’t. This failure contributed to the rapid spread of disease in early hot spots. It also fed public confusion and undermined support for guidelines, which seemed vague, random and contradictory.
Remdesivir was already showing promise in April, and non-drug adjustments such as optimization of mechanical ventilation and turning patients on their sides were being tried. Intriguing stories of cardiovascular impacts and cytokine storms were emerging. I expected we’d have a bunch of drugs and other innovations that would make COVID-19 a manageable disease by now. The death rate is down, but treatment improvements have been incremental and some early hopes fizzled. Dexamethasone, an old steroid is the only drug beyond remdesivir with widespread evidence of effectiveness.
There are new possibilities ahead. Olumiant (baricitinib) appears to help patients on remdesivir recover faster and may gain emergency approval by the time you read this. And researchers are looking at new mechanisms, such as bradykinin storms to understand how COVID-19 does its damage and how to stop it. There are several other treatments under evaluation, too.
Bottom line: fatigue, denial and surrender were bigger factors in reopening decisions than I expected. The economy still isn’t fully reopened and we may need to wait for a vaccine to move back toward normalcy.
#2: Hybridization (virtual/in-person mix) will be the new reality Grade: A+
I’m proud of this prediction. At the time I made it, the consensus was that everyone would return to the office by summer and get back to school in September. That hasn’t happened. Instead, as spaces reopen, hybrid models are emerging everywhere to reduce density and decrease risk. You see it with schools, businesses, physician offices and clinical trials. Remote work and school are still happening, but work from home is no panacea.
I expect hybridization to outlive the pandemic as individuals and organizations learn that a mix of in-person and remote is best for most activities. But patients may have to assert themselves to receive the full benefits of hybrid care, because healthcare organizations have a tendency to revert to what works for them rather than what’s most convenient and affordable for patients. Telehealth was used for almost 70 percent of total visits in April before dropping to around 20 percent in the summer. Some patient-centric leaders, such as Boston Children’s Hospital have maintained rates at close to 50 percent.
#3: Public health post-COVID-19 will be like security post-9/11 Grade: B
When I started traveling again soon after 9/11, the sudden jump in security at airports, office buildings and public spaces was staggering. In the following months and years, security became a huge industry and an obsession.
In April, I wrote:
“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.”
I’ve certainly seen this in the private sector. For example, many private schools require daily health attestations, temperature checks, masks, outdoor eating, etc. Stores announce, “no mask, no service” policies in their windows. Some states and counties have good contact tracing programs, but unlike 9/11 there is no nationwide approach, and no Homeland Security equivalent.
As more venues reopen I expect that this trend will continue. What’s not yet clear is whether public health will receive additional funding and just how central it will be to our future. Much depends on how quickly and completely the current pandemic is brought under control, whether new health threats emerge soon, and who occupies the White House in 2021.
#4: Federal government will grow even more powerful relative to everything else Grade: A-
This prediction was paradoxical. Those I reviewed it with at the time found it novel and counter-intuitive. After all, the feds failed to prepare for the pandemic and threw everything onto the states. The CDC embarrassed itself with its testing approach and then was sidelined.
But the federal government has essentially unlimited spending power, which it used to prop up the economy with the $2+ Trillion CARES Act, and the stock market (via the Federal Reserve). Meanwhile, states had to come begging –quite literally—to the president for help, and our world-leading universities and colleges found themselves in desperate straits and unable to reopen.
In short, the federal government’s failures have weakened the rest of US society much more than the federal government itself has been weakened.
The reason I give myself an A- instead of an A is that I didn’t address what would happen relative to the rest of the world. The US federal government has lost international standing during the pandemic with its poor response. The country was rated as the most prepared for a pandemic –but botched things anyway. The withdrawal from the WHO weakened our hand, and our slow economic recovery means we’re losing ground on China and others.
#5: The end of immigration Grade: A
Crises present major opportunities for governments to enact policies they wouldn’t be able to get away with in normal times. The current Administration has made no secret of its disdain for immigration. It had taken some dramatic steps before the pandemic, such as curtailing the H1-B program for highly skilled workers and attempting to build a wall along the Mexican border.
In April, the president tweeted his intention to suspend all immigration. That’s about as dramatic as it gets and would have drawn much more fire even a month or two earlier. But with lockdowns and travel bans throughout the world, and a virus floating in the air, it was harder to argue against. Consider some of the additional actions taken against immigration during the pandemic, including bans on asylum seekers and refugee resettlement, a ban on international students coming to the US if their classes were not in person (rescinded after pushback), and more restrictions on H-1B lottery winners.
The pandemic has also made the US a less attractive destination for would-be immigrants, even without all of the explicit actions. That won’t be reversed quickly.
There are big questions for the next few months and years, including:
When will vaccination make a decisive difference? This includes when vaccines are approved, how quickly and rationally they are distributed, how well they work and for how long, and what the uptake is.
What will the economy of the early 2020s look like? Will travel and leisure return? Education at all levels? Office work? What new industries will emerge?
What will be the US’s role in the world? Much of this hinges on the results of the 2020 election and its aftermath.
I’ll offer my commentary on these topics as the situation continues to unfold. Check the Health Business Blog and HealthBiz podcast for updates.
In recent months, my strategy consulting firm, Health Business Group has helped our healthcare and life sciences clients factor the implications of the pandemic into their growth and M&A strategies. Would you like to discuss your own organization’s plans and how Health Business Group can help? If so, please email me: email@example.com.
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.