Reopening safely out of the current pandemic ought to be done via persuasion, not coercion.
It has been more than five months since the world first learned about COVID-19. Models predicted a sharp increase in the number of cases, and a seemingly high likelihood the pandemic would overwhelm our hospitals. These models were often inaccurate, and we have all come to learn about the imprecision of epidemiological prediction. Nevertheless, the infection is far worse than anyone initially accepted – becoming a staple of our generation. Fearing uncountable deaths and the possible need to prioritize resources for those affected, initial government measures were put in place to curtail the spread of the virus. Images of the Lombardic tragedy compelled all to stay in place and wait for the storm to pass, and with few exceptions most complied. Realizing the gravity of the situation, governments gradually implemented measures to prevent infections. With some vacillation, we evolved from travel restrictions, to social distancing, shelter in place and universal mask use.
As the pandemic ensued, we watched the horror stories taking place in New York City and Boston. Even while we are in the midst of the so-called first wave, with thousands of deaths per day, many have started to wonder how long society will remain isolated and locked. Politicians look to experts for recommendations regarding policies that might save lives, and for the most part they have complied. However, as the weeks ensue, we see growing jobless claims, lines for food banks, and impatience.
This brewing impatience is a response to an unknown future dictated by the vagaries of nature and the lack of a coherent strategy to resume a life with a resemblance to normal. The public searches for guidance from federal agencies, state governments, and health authorities. A lack of clear direction from these institutions has heightened this anxious impatience. Additionally, the conversation is now ideological, with an almost Manichaean division between those wanting to save lives more so than the economy, and vice versa, creating cartoons of opposing perspectives. Even for those recognized as accomplished, dissenting from orthodoxy is punished severely. In the background, the public’s patience is running thinner.
If you think the grim coronavirus death toll is causing health care workers everywhere to always wash their hands, think again.
A recent research letter published in The Journal of Hospital Infection examined whether it’s “possible to achieve 100 percent hand hygiene compliance during the Covid-19 pandemic.” The medical center involved in the research, Queen Mary Hospital in Hong Kong, had reached a pre-Covid-19 hand hygiene rate of over 75 percent.
Yet the hospital’s goal of complete compliance proved surprisingly elusive. In one pediatric ward devoted to suspected or confirmed Covid-19 patients, doctors and nurses followed hand hygiene rules 100 percent of the time, but in another ward with similar patients and staff, compliance was 83 percent, or about one-fifth less.
Given Covid-19’s risk to providers as well as patients, this was “unexpected,” the researchers admitted.
The Queen Mary study supports what infection control experts have long maintained: awareness isn’t enough. Doctors and nurses, particularly during a pandemic, understand that hand hygiene is “the most important intervention” to reduce the staggering death toll from infections, as the American Journal of Infection Controlput it.
The Smithsonian National Museum of Natural History has reported its biggest number of visitors in more than 2 ½ years. There’s a string of new Broadway musicals that are well-attended every night. It’s safe to shop in malls, eat out in restaurants and go to movie theaters again.
Of course, this has all been made possible by an effective vaccine against COVID-19 that was widely administered in the fall of 2021. Vaccinated citizens of the world are now confident that it’s safe to go out in public, albeit with appropriate precautions.
However, U.S. residents who have health problems are facing a new challenge. Five years ago, in 2017, the median wait time of new patients for doctor appointments was six days. In 2022, the wait time is six months or more.
The reason for this is no mystery. While life has started to return to what we think of as the new normal, the U.S. healthcare system has taken an enormous financial hit, and primary care practices have been especially affected. Many primary care physicians have closed their practices and have retired or gone on to other careers. Consequently, the shortage of primary care has been exacerbated, and access to doctors has plummeted. Urgent care centers, retail clinics and telehealth have not filled this gap.
Because of the long waiting times for primary care appointments, many more people now seek care in emergency departments (EDs). The waiting rooms of these EDs are overcrowded with people who have all types of complaints, including chronic and routine problems as well as emergencies. And this is not just a common sight in inner-city areas, as it once was; it’s now the same pretty much everywhere.
Last month marked the 400th anniversary of the birth of John Graunt, commonly regarded as the father of epidemiology. His major published work, Natural and Political Observations Made upon the Bills of Mortality, called attention to the death statistics published weekly in London beginning in the late 16th century. Graunt was skeptical of how causes of death were ascribed, especially in times of plagues. Evidently, 400 years of scientific advances have done little to lessen his doubts!
A few days ago, Fox News reported that Colorado governor Jared Polis had “pushed back against recent coronavirus death counts, including those conducted by the Centers for Disease Control and Prevention.” The Centennial State had previously reported a COVID death count of 1,150 but then revised that number down to 878. That is but one of many reports raising questions about what counts as a COVID case or a COVID death. Beyond the raw numbers, many controversies also rage about derivative statistics such as “case fatality rates” and “infection fatality rates,” not just among the general public but between academics as well.
Of course, a large part of the wrangling is due not only to our unfamiliarity with this new disease but also to profound disagreements about how epidemics should be confronted. I don’t want to get into the weeds of those disputes here. Instead, I’d like to call attention to another problem, namely, the somewhat confused way in which we think about medical diagnosis in general, not just COVID diagnoses.
The way I see it, there are two concepts at play in how physicians view diagnoses and think about them in relation to medical practice. These two concepts—one more in line with the traditional role of the physician, the other adapted to modern healthcare demands—are at odds with one another even though they both shape the cognitive framework of doctors.
Many believe that the 2020 Presidential election will be a referendum on how President Trump has handled the coronavirus pandemic. Some believe that is why the President is pushing so hard to reopen the economy, so that he can reclaim it as the focal point instead. I fear that the pandemic will, indeed, play a major role in the election, but not quite in the way we’re openly talking about.
It’s about there being fewer Democrats.
Now, let me say right from the start that I am not a conspiracy believer. I don’t believe that COVID-19 came from a Chinese lab, or that China deliberately wanted it to spread. I don’t even believe that the Administration’s various delays and bungles in dealing with the pandemic are strategic or even deliberate.
I do believe, though, that people in the Administration and in the Republican party more generally may be seeing how the pandemic is playing out, and feel less incentive to combat it to the fullest extent of their powers. Let’s start with who is dying, where.
In collaboration with the Robert Wood Johnson Foundation, Catalyst @ Health 2.0 is proud to announce funding for health care providers with limited resources and urgent needs to identify and source digital health innovation during COVID-19 through our Rapid Response Open Calls (RROC). RROCs are streamlined calls for applications that connect health care providers to digital health solutions. Deployed as part of Catalyst’s Health Tech Responds to COVID-19 platform, RROCs can be launched within days to meet the host’s needs.
Catalyst created the RROC to address an urgent need from Brigham and Women’s Hospital (BWH) Emergency Department for provider-facing, text-based platforms to help healthcare professionals self-monitor symptoms of coronavirus, report burnout, and access helpful resources. Within one day, the Brigham and Women’s Health RROC was launched. In a 7-day application period, Catalyst received an overwhelmingly positive response with more than 80 quality submissions. BWH was able to evaluate the submissions through a streamlined process and 5 innovators were selected to demo their solutions to the BWH ED team. BWH began pursuing a potential partnership with one of the semi-finalists.
If you are a healthcare provider with limited resources during COVID-19 (e.g. FQHCs, community health centers, etc.), apply for a subsidized RROC HERE!
From the vantage point of our self-quarantined shrunken universes, we cannot see even the immediate future, let alone what our personal and professional lives will look like some years from now.
Factories are closed, luxury department stores are in bankruptcy, hospitals have stopped performing elective procedures and patients are having their heart attacks at home, unattended by medical professionals. New York office workers may continue to work from home while skyscrapers stand empty and city tax revenues evaporate.
Quarantined and furloughed families are planting gardens and cooking at home. Affluent families are doing their own house cleaning and older retirees are turning their future planning away from aggregated senior housing and assisted living facilities.
In healthcare, procedure performing providers who were at the pinnacle of the pecking order sit idle while previously less-valued cognitive clinicians are continuing to serve their patients remotely, bringing in revenues that prop up hospitals and group practices.
As the coronavirus pandemic overtook the tail end of the Democratic primary season, attention rapidly shifted from examining the nuances of the differences between the candidates’ healthcare platforms to simply demanding a response to the pandemic. Beyond addressing the immediate crisis, however, lie many questions about the weaknesses of our current healthcare system, and how we will address them in the long run. These questions should be at the forefront of voters’ minds as we head into the election this fall.
One of the major weaknesses in our system is that we do not have universal healthcare. Importantly, virtually all of the Democratic candidates called for making healthcare a right in the U.S. This is a key first step toward universal healthcare. Their approaches to achieving this varied, however. Bernie Sanders and Elizabeth Warren called for “Medicare for All,” but most of the other candidates, including Joe Biden, have pushed for some kind of public option. The public option has faced criticism that it will simply maintain the status quo. This criticism inspired me to write this blog, because a large-scale public option program could actually help to reshape the US healthcare system and result in improvements in access to care in this country, ultimately getting us to universal healthcare.
If you’re lucky, you’ve been working from home these past couple months. That is, you’re lucky you’re not one of the 30+ million people who have lost their jobs due to the pandemic. That is, you’re lucky you’re not an essential worker whose job has required you to risk exposure to COVID-19 by continuing to go into your workplace.
What’s interesting is that many of the stay-at-home workers, and the companies they work for, are finding it a surprisingly suitable arrangement. And that has potentially major implications for our society, and, not coincidentally, for our healthcare system.
Twitter was one of the first to announce that it wouldn’t care if workers continued to work from home. “Opening offices will be our decision, when and if our employees come back, will be theirs,” a company spokesperson wrote in a blog post. “So if our employees are in a role and situation that enables them to work from home and they want to continue to do so forever, we will make that happen.”
Other tech companies are also letting the work-from-home experiment continue. According to The Washington Post, Amazon and Microsoft have told such workers they can keep working from home until at least October, while Facebook and Google say at least until 2021. Microsoft president Brad Smith observed: “We found that we can sustain productivity to a very high degree with people working from home.”
Back in the early 2000s I was on the board of the California Health Care Foundation and one day the German Minister of Health paid CHCF a visit as part of a learning tour of American healthcare. Mark Smith MD CHCF’s CEO invited me to join the meeting with the minister. She was a delightful person who didn’t speak much English, but because she was accompanied by her handler/translator we managed to communicate just fine. Mark and I tried to explain to the Minister how the American healthcare system worked, and we got to the point in the conversation about the money. The essence of the “game” we described was that commercial insurers (particularly self-insured employers) paid a significant multiple of cost (sometimes in excess of 300% of costs) in order to make the math work for providers. We explained that the game works only if these purchasers paid much higher prices. I don’t speak German, but I think she said: “What The F**k?!”. Exactly.
As we enter the Post COVID world, a key question is: Will healthcare simply restart this game? Or make it even more extreme, in fact, by providers turning to those commercial insurers and self-insured employers to make up the difference for the COVID “Elective Collapse Recession” that has so traumatized provider’s finances including hospitals, specialists, primary care, and dentists leading to job cuts, furloughs, salary reductions and bankruptcies of providers.
A number of recent articles have pointed to how the game works. In particular, the always superb New York Time’s columnist Sarah Kliff’s review of the Mayo Clinic and the other highflying institutions whose excellence is rewarded not by value based reimbursement but by high prices for commercial activity under a relatively benign payor mix (industry code for “don’t see a lot of poor people, uninsured or on Medicaid”).