“In seeking absolute truth, we aim at the unattainable and must be content with broken portions.”
A colleague shared an experience with me about testing one of his patients for the novel coronavirus and it left me a bit puzzled. An elderly gentleman with past medical history of severe COPD (chronic obstructive pulmonary disease) and heart failure came to the ER with shortness of breath, edema and fatigue. Chest x-day suggested pulmonary edema. He wanted to test him for SARS-CoV2 but hesitated. Eventually he was able to order it after discussions with various staff administrators. Dialogue included sentences like “why do we need testing? He has Congestive Heart Failure (CHF), not COVID-19” and “it could create panic amongst staff taking care of him”. I applauded his persistence as eventually the test was done. To not test is counter-intuitive and more like an escape from diagnosing the virus rather than escaping the virus itself.
One – the mere fact that we might hesitate before testing for a virus which is a cause of a (ongoing) pandemic should ring all the bells of concern about lack of an optimal strategy. Inadequate testing has remained the Achilles heel of our stand against COVID-19 because to have a lasting stand, we must know where to take the stand.
Two – the concern of CHF raised above is clinical and valid, but it is of grave importance to understand that CHF and COVID-19 are not mutually exclusive. We now know that even the infamous flu and COVID-19 are not mutually exclusive. Common protocols from a few months ago to test for flu in sick outpatients and not test for COVID-19 if flu was positive was like the prey closing its eyes and hoping the predator does not see it. It did defer the use of an already scarce resource at the time, testing. SARS-CoV2 is a virus and the disease caused by it is called COVID-19. Virus can be ubiquitous; disease does not have to be. A patient with CHF exacerbation can be an asymptomatic carrier of SARS-CoV2 but may not phenotypically express the disease manifestations of COVID-19. Or may be his COPD or CHF exacerbation has happened due to a milder COVID-19 inflammatory response? What we know about COVID-19 is that we don’t know enough about it and therefore we cannot rule out its presence. Especially while we are in the middle of a growing pandemic.
My practice received its first question about coronavirus from a patient on January 28, 2020. Though there were over 200 deaths reported in China by that time, no one could have imagined how drastically this would come to disrupt our lives at home.
Thankfully, I had a head start.
As a doctor at an integrated telemedicine and primary care practice in New York City, nearly two out of every three of my medical encounters that month was already virtual.
I spent much of January caring for patients who had contracted seasonal viruses, like influenza or norovirus (i.e. the stomach flu). My patients reached out nearly every day with bouts of fevers, fatigue, diarrhea, and vomiting. Our team did all we could to encourage each of these patients to stay home and avoid spreading their highly contagious virus throughout the community (sound familiar?).
We are now guiding our patients through the COVID-19 outbreak using the same tools we use to guide them through any healthcare need – real-time monitoring, proactive outreach, and team-based care.
After our first COVID-19 question, our team started compiling information about every patient who reached out with symptoms that even slightly resembled COVID-19. This soon turned into a comprehensive patient registry containing the epidemiologic risk factors, clinical risk factors, symptoms, and a follow-up plan for each patient. Based on their total risk level, we follow up with these patients every 24 to 120 hours.
Every day, one provider on the team texts or schedules a video visit with each follow-up patient, reassesses their symptoms, and re-stratifies their risk. Most patients respond with a text message letting us know that their symptoms are the same or slowly improving. But for patients at higher risk, we want more information. We help these patients acquire a thermometer or pulse oximeter to follow up on their respiratory vitals. With this data, our team can provide patients and their families with thresholds on when to seek out a higher level of care.
Our job for these patients is clear: provide treatment at home and only recommend the hospital if there is no other option. By centralizing data and establishing clear triggers for a new plan of care, a single provider can follow up with over 30 COVID-19 patients in a single day.
Health tech has suddenly found its new focus in coronavirus – but are we at risk of doing more harm than good by rushing to use unproven solutions? To avoid chaos in the aftermath, we should focus on tried-and tested tech, and only use novel solutions where need is deemed greater than the acceptable risk.
The COVID pandemic is categorically not a black swan event.
Black swans are by definition unknowable and unpredictable. In contrast, a global viral pandemic was predicted by scientists decades before, from the potential impact, right down to the source of the virus. In fact, only last year The Johns Hopkins Center for Health Security in partnership with the World Economic Forum and the Bill and Melinda Gates Foundation hosted Event 201 (video below), a high-level pandemic exercise on October 18, 2019, in New York, NY to simulate and plan for this exact scenario involving a life-threatening respiratory agent. They accurately predicted the exponential spread of disease, the sudden economic crash, and the desolation it would impose on healthcare systems. Indeed, Bill Gates himself is on record in 2015 predicting at a TED event that it would be ‘microbes, not missiles’ that would would be the next existential threat to humanity.
I recently took care of Rosaria, a cheerful 60-year-old woman who came in for chronic joint pain. She grew up in rural Mexico, but came to the US thirty years ago to work in the strawberry fields of California. After examining her, I recommended a few blood tests and x-rays as next steps. “Lo siento pero no voy a tener seguro hasta el primavera — Sorry but I won’t have insurance again until the Spring.” Rosaria, who is a seasonal farmworker, told me she only gets access to health care during the strawberry season. Her medical care will have to wait, and in the meantime, her joints continue to deteriorate.
Migrant and seasonal agricultural workers (MSAW) are people who work “temporarily or seasonally in farm fields, orchards, canneries, plant nurseries, fish/seafood packing plants, and more.” MSAW are more than temporary laborers, though— they are individuals and families who have time and time again helped the US in its greatest time of need. During WWI, Congress passed the Immigration and Nationality Act of 1917 because of the extreme shortage of US workers. This allowed farmers to bring about 73,000 Mexican workers into the US. During WWII, the US once again called upon Mexican laborers to fill the vacancies in the US workforce under the Bracero Program in 1943. Over the 23 years the Bracero Program was in place, the US employed 4.6 million Mexican laborers. Despite the US being indebted to the Mexican laborers, who helped the economy from collapsing in the gravest of times, the US deported 400,000 Mexican immigrants and Mexican-American citizens during the Great Depression.
On Episode 101 of Health in 2 Point 00, there are some scandals and competitors brewing in the health tech space! Jess and I discuss Outcome Health’s investigation and charge by the FBI for $1 billion in fraudulently obtained funds; Mint’s founder starting Vital, a new EHR company, to reinvent the overall EHR experience (even though I believe it is currently one of the toughest markets to enter into); Amazon launching Amazon Transcribe Medical which will be a tool medical professionals can use to dictate their notes and streamline them into EHR systems; and Wellframe raising $20 million to advance digital health management. If you are in Japan, catch me at Health 2.0 in Tokyo, Japan where they will be showcasing new health tech startups in the space or if you are in Vegas, go hang with Jess at the American Society of Hospital Pharmacies conference! Last but not least, Guidewell launched its Aging in Place Accelerator that is looking for startups in the senior health tech space (applications are due December 8th). — Matthew Holt
Today is Health in 2 Point 00’s 100th Episode and we are reporting from Frontiers Health in Berlin! Jess and I talk about Google & Ascension’s deal to move all of their information and data onto Google Cloud, however, they are currently facing backlash over data privacy issues and are being investigated by HHS’ Office for Civil Rights. Apple released some new research on EKGs, carrying out a clinical trial on 400,000 people, I didn’t think their results were that interesting, but their ability to reach that many people for a clinical trial was impressive and may open up new doors in research for recruiting participants using Apple products. At Frontiers Health, Noom, a nutrition startup focusing on managing chronic care conditions, announced that they are looking to do $235M in revenue by this year, which is big news considering Livongo (which IPOed this year) did $165M in revenue. We also take a moment of silence for Bernard J Tyson, CEO of Kaiser Permanente, who was an active leader for equity in health care and a leading black executive for the community. Rest in Peace – Matthew Holt
Forced absence from gun violence has created a literal and metaphorical void in schools across our country that may impact students and staff for decades to come. The students are referred to as “Parkland kids,” “Sandy Hook students,” or “Columbine survivors.” These labels are sadly reflective of a new reality for American schools, as students, teachers, and staff no longer feel safe. America’s students feel vulnerable as the facade of schools as a safe place is no longer true. The Center for American Progress recent report revealed that 57% of teenagers now fear a school shooting.
Often, perpetrators of gun violence leave a trail of “red flags” for years, as they are troubled youths. This was the case in the Parkland shooting. Tragically, multiple agencies failed to respond to the signs the troubled young man was leaving, including specifically writing online that he aspired and planned to be a school shooter.
In the aftermath of the Parkland, Florida tragedy, parents and school districts turned to security experts demanding a plan of action. Sadly, the information provided was substandard and lacked evidence to support the strategies as efficacious. Lives weigh in the balance and there is no more tolerance for guessing.
Research is needed to guide the creation of evidence-based frameworks for school communities to address prevention as well as protection. Threat assessment teams are a strategy to assess for potential threats, but more importantly is that an intrinsic safety network is woven into the fabric of the educational system. Exposing the root cause of the contagion of violence impacting our youth is key.
The system is unstable. We are already seeing the precursor waves of massive and multiple disturbances to come. Disruption at key leverage points, new entrants, shifting public awareness and serious political competition cast omens and signs of a highly changed future.
So what’s the frequency? What are the smart bets for a strategic chief financial officer at a payer or provider facing such a bumpy ride? They are radically different from today’s dominant consensus strategies. In this five-part series, Joe Flower lays out the argument, the nature of the instability, and the best-bet strategies.
Cost. Get serious control of your costs. Most providers I talk to are dismissive. “Yeah, yeah, you’ve been saying that for 10 years. We’re on it, believe me.” But I don’t believe them. Observation of the industry makes it clear that most healthcare providers have not gone after costs with nearly the ferocity of other industries. Some providers that I have worked with and interviewed over recent years have gotten their full cost of ownership down to a level where they can survive on Medicaid rates (that’s not a typo, I mean Medicaid) and build bigger, stronger systems at the same time. They have proven it can be done. But this is far from the industry norm. In the new competition, getting your costs seriously down is not the way to win. It’s just the price of admission. In the new competition, any entity that can deliver any particular service at a lower price will steal that business from you. You need to be that entity.
Overtreatment and waste. Do a deep and honest analysis of how much of your book of business is actually not effective, not necessary, does not deliver value or satisfaction to the customer—because that book of business is likely to wither away under alternative financing arrangements. Keep in mind that among various studies, the low estimate of how much of healthcare delivers no real value to the customer (an estimate by doctors about their own specialties) is 20%. The high end (in a PricewaterhouseCoopers study) is 54.5%. Most studies and estimates cluster around 35%.
Abandon monopolistic practices. An “all system” fee-for-service contract hidden from public scrutiny is smart, but not wise. It may help this year, maybe next year, but in the longer run it creates vulnerability to political attack, legislation, and lawsuits, and also to shifts in the market. A semi-monopoly position allows you to charge a premium for your products, but it locks you into that ability to charge a premium. As the market shifts and finds ways around paying high prices, you will find that you will be forced to compete at the lower prices, but you will not have developed the partnerships, the strategies, and the product lines to do that. If there is no competition in your area, then compete with yourself to forestall lower-cost competition developing.
Birth your competition. The growth area in the new healthcare competition will be: “How to cut into the hospital’s bottom line by keeping people out of the hospital.” The most competitive business models in healthcare will be in the business of cutting off hospitals’ revenue streams upstream. Get into this business model, even if you are a hospital. Especially if you are a hospital. Get into this business and get better at it than any potential competition. Create high-performance bundled programs with deeply managed costs well below the industry median. Get into contracts with large buyers for particular niches in which you give financial and quality performance guarantees. If you can’t guarantee that you can drop the cost and improve the quality, you will lose that business to someone else who can show that track record and give that guarantee.
Put yourself into all the business models that are disrupting you, such as outpatient clinics, community clinics, mobile vans, mini-hospitals, stand-alone emergency departments, onsite clinics, personalized management of complex cases, direct-pay primary care and others. Make these businesses able to compete for market share by unshackling them from hospital pricing and facilities fees.
Risky? Sure, but you do not want to end up being just the super-expensive job shop at the end of the line that every single customer and buyer is making every effort to avoid.
In 1807, in an effort to spite the British and French for shipping interference (and forced recruitment of American citizens into military service), the United States Congress passed an Embargo Act, effectively shutting down trade with these two countries. Britain and France quickly found other trading partners; the US, then limited in our capacity to sell products outside our borders, was left with a devastated economy and a gaping hole in our face. It took only weeks before Congress passed a loophole; they repealed the act within 15 months of its passing. It was a great lesson in unintended consequences.
Today, ignoring history, both Republicans and Democrats seem to spar continuously around healthcare: whether the message is about tearing down the Affordable Care Act or about some version of Medicare (For-All, For Whoever Wants It, For America, or For Better or Worse), both parties are terribly wrong.
Assuming the social imperative for healthcare is to eliminate preventable morbidity and disability (and associated costs) and improve (or sustain) quality of health of all our citizens (in order to help as many of them as possible remain productive, contributing members of society), another approach to ‘universal care” would be to flip the figure/ground relationship for our current efforts: instead of developing better payment systems, let’s develop and commit to a universal clinical operating framework that ensures that every member of society has the same opportunity to optimize their health status.
“Centralizing” the methodology around a universal model for how we plan for care, and allocate resources to ensure care plan goal achievement, would be far more valuable to society than centralizing the sources of funds to pay for care, because then we’d know what we’re paying for.
We Need Legal Assaults On The Greediest Providers!
When a patient is hospitalized, or diagnosed with a deadly disease, they often have no choice about the cost of their treatment.
They are legally helpless, and vulnerable to price gouging.
We need more legal protection of patients. In some cases we need price controls.
Next in this three-part series, I discuss how we could challenge Big Pharma by lessening regulation of generic drugs, having the government take over production and establishing price review boards.
Assault Phase Three – Challenge Big Pharma
Step One – Less Regulation of Generic Drugs
If an off-patent drug has been approved by other first-world nations, this would
constitute automatic approval by the FDA.
The price gouging around Epipen would have ended quickly,
if new versions of genetic drugs did not require an FDA approval process. We
should let reputable drug companies produce whatever generic drugs they want.