On April 3, the Secretary of Health and Human Services, Alex Azar, announced that the federal government would pick up the tab for testing and treating all uninsured Americans for COVID-19.
Azar specifically promised that:
a) hospitals would be paid the same prices they receive for Medicare patients; and
b) hospitals which accept the funds would be barred from sending any additional bills to patients.
Did anyone notice the last detail? This is a Republican, who is promising to protect the vulnerable.
In the coming months, thousands of COVID-19 patients will be routed through a convoluted web of providers. At various points in their treatment. they will be susceptible to receiving out-of-network care — and the staggering bills that often follow.
COVID-19 patients will rarely have the luxury to choose a network hospital, or lab, or specialist. Often, they will need to be treated at any facility that is still open.
We’re not through the
COVID-19 pandemic. We’re probably not even near the end of the beginning
yet. That hasn’t stopped many pundits to start speculating about how our
society (and our healthcare system) are likely to be permanently changed as a result,
such as continued reliance on telecommuting and telemedicine.
OK, I’ll play too: I
believe we need to greatly expand the role of robots, and begin something that
resembles Universal Basic Income (UBI). They’re not the only changes that
may result, but they are two that should.
We’ve been seeing robots infiltrating the workforce for many decades, such as in manufacturing but also in many other industries.
Still, though, as our
economy pares down to “essential businesses” during the pandemic,
I’ve been alarmed at how many of the jobs remain done by humans. Not just
healthcare workers on the front lines but also all those people doing the
cleaning for essential businesses, all those people in the supply chain of food
and other vital materials, all those people making deliveries, all those first
responders, all those people all those people keeping the power on, the water
running, and the internet streaming, among others. And so on.
While President Trump mulls whether to reopen the country again in May, and as Fox & Friends host Brian Kilmeade suggests that “only” 60,000 people will die from the coronavirus, there are some warning signs that the White House COVID-19 Task Force’s prediction of 100,000-240,000 deaths may be way too low.
That isn’t surprising, considering that Administration
officials said this projection depended on us doing everything right. Of
course, it appears that large sections of the country have done many things
wrong—whether it’s Florida Governor Ron DeSantis’ reluctance to close houses of
worship or the refusal of several state governors to issue stay at home orders.
That doesn’t include Trump’s own refusal to admit the seriousness of the
COVID-19 outbreak until mid-March and the continuing failure of the federal
government to ensure an adequate supply of test kits, PPE and ventilators.
So here’s what all of this may be leading up to: a minimum
of 600,000 COVID-related deaths in the U.S. over the next two years.
We have seen and heard about the classic symptoms of
COVID-19 at UCSF Medical Center, where I work as a cardiologist. Patients keep
coming in with pulmonary distress, pneumonia, and ultimately, Acute Respiratory
Distress Syndrome (ARDS) – the life-and-death situation that requires
However, I’m beginning to learn about other symptoms that some
doctors are noticing. There are numerous reports of other complications, especially
in advanced disease.
Elevation in D-Dimer, (a biomarker of coagulation system activation) has been associated with dramatically increased risk of death from COVID-19. This has led some to speculate that empiric treatment with anticoagulants might improve outcomes in these critically ill patients. Indeed, there was this recent publication of a retrospective analysis of anticoagulation with heparin or low molecular weight heparin showing an association with improved outcomes in COVID-19 patients in China.
“I never anticipated — and no one did — the level of uptake and the level of scale.”
It says a lot that Joe DeVivo, CEO of Intouch Health, who’s worked with hospitals and health systems on standing up B2B-focused telehealth programs for years (and whose company was acquired by Teladoc Health for $600-million dollars in January) is surprised about the uptake of virtual care during the COVID-19 pandemic.
“Historically, I look at virtual care as a bell curve,” says Joe. “On one side of that small tail of the bell curve are the virtual care companies. Teladoc dominates that space for D2C. There’s millions of consultations a year, and we’re seeing a subset of that. On the opposite side of the bell curve is high-acuity, and what InTouch has been doing for critical care.”
“This crisis, and the changes in reimbursement, have opened up the middle of that bell curve. The core, everyday transaction of healthcare is now being impacted by virtual care. And the big question that everyone has is, “is this going to stick? Is this a crisis management tool and we’re going to go back to the ways of the past, or is that genie out of the bottle?”
We put Joe on-the-spot with his own question, find out what he thinks it will take to enable the permanent shift to virtual care at-scale, and dig in on how demand for telehealth within hospitals has changed as a result of the pandemic, where its not only being used to expand access to specialists, but has also been adapted into a PPE-hack to help frontline hospital workers distance themselves from infected patients.
And what of working with Teladoc? While waiting for the paperwork to finalize (all on-schedule for the end of Q2 as originally announced), the two have organized a co-selling agreement to be able to “hit the market fast” and bring their “hospital-to-home” end-to-end virtual care offering to those who need it now.
As Christians experienced Holy Week 2020, the week commemorating the trial, suffering, and death of Jesus, the somber tone such remembrances evoke took on new meaning in the midst of the COVID-19 epidemic with the catastrophic loss of life and livelihoods. Many churches remained physically closed, some already outfitted with sophisticated systems for live streaming and others scrambled, along with their congregants, to create meaningful virtual worship and fellowship opportunities. Finding ways to maintain physical distancing while still providing social and spiritual connections.
These challenges face people of other faiths as well since the current guidance regarding social distancing affected those observing Passover, April 8-16 and will likely affect Orthodox Easter, April 19 and Ramadan, which will start April 23.
Maintaining social and spiritual connections in the midst of COVID-19 are not the only challenges facing our communities of faith. For centuries if not longer, religious congregations have played critical roles in providing and supporting social services within communities. There are over 345,000 religious congregations in the US of various faiths and denominations and, despite declining rates of religious affiliation and attendance, national surveys still find a sizeable proportion – about 45% – of all adults report attending religious services at least monthly. Religious congregations play even more important roles in particular subgroups, such as low-income communities and among certain racial-ethnic minority groups and immigrants, the elderly, and other vulnerable groups, making faith-based organizations critical to the COVID-19 response in the short and long terms.
Our strategy with nursing homes in the midst
of the current pandemic is bad. Nursing
homes and other long term care facilities house some of our sickest patients in
and it is apparent we have no cogent strategy to protect them.
I attempted to reassure an anxious nursing home resident a few weeks ago. I told him that it appeared for now that the community level transmission in Philadelphia was low, and that I was optimistic we could keep residents safe with simple maneuvers like better hand hygiene, restricting visitors, as well as stricter policies with regards to keeping caregivers with symptoms home. I was worried too, but optimistic.
I figured the larger medical community would be on the same page if someone did get COVID. It made sense to me to be aggressive about testing staff and residents and quickly getting COVID-positive patients out of the nursing home. So when I heard of the first patient that was positive in the nursing home, my heart sank, but it fell even further when I found out the COVID-positive patient was sent back from the hospital because they weren’t “sick enough” to be admitted.
Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention (CDC), opened up a new front in the Coronavirus War by saying we don’t just need to treat the acute disease, we need to treat the underlying conditions that make people more susceptible to serious disease progression. He focused on heart disease, and managing mitigating risk factors such as CVD, diabetes, hypertension and smoking in order to increase people’s odds for recovery. The initial focus has been pneumonia and acute respiratory distress syndrome (ARDS), with risk factors including asthma, chronic obstructive pulmonary disease, and emphysema.
Dr. Frieden calls for better
management of people’s underlying health problems to help mitigate the impact
of COVID-19. I would take this one step further and say we need to go beyond
managing chronic diseases, and find and treat the pathogens that underlie and
fuel their pathologies. Why?
In 2001, my work as an Army
Reserve medical officer took me to Bolivia to treat 10,000 Andes Indians with
parasite medications. Not only did this resolve their parasite problems, but
many reported it helped them overcome a range of additional chronic health
problems. When I returned to St. Louis, I began to dig deeper with my chronic
disease and “mystery disease” patients and treat some of them for parasite
problems, and saw many improve. I expanded this “search and destroy” mission
with my patients to fungal and dental infections, as I learned many such
infections – often overlooked in medicine today – are overlapping, synergistic,
and can present as chronic illness.
A Conversation with Dr. Richard Isaacs, CEO of The Permanente Medical Group and the Mid Atlantic Permanente Medical Group
By AJAY KOHLI, MD
Organizations aren’t built in crises. Their mettle, their history and their leadership define how organizations adapt and succeed, particularly in difficult times. Of the three, the most important quality is leadership. In this regard, Kaiser Permanente is leading the way in healthcare delivery.
had the opportunity to speak with Dr. Richard Isaacs, CEO of The Permanente Medical Group and The MidAtlantic Permanente
Medical Group, to discuss the strategic vision and granular details of
Kaiser Permanente’s response to the global pandemic of COVID-19.
Kaiser Permanente has a strong foundation in the history of delivering care to the vulnerable. Founded in 1945 by a surgeon, Dr. Sidney Garfield, and an industrialist, Henry J. Kaiser, the organization grew from a single hospital in Oakland, California into one of the largest physician-led organizations in the world. Currently, it boasts more than 22,000 physicians responsible for the care of more than 12.5 million lives.
Many question how large healthcare organizations, like Kaiser Permanente, can adapt to a rapidly evolving problem, like the global pandemic of COVID-19, especially when cities and even countries are struggling under the burden.
Crises — like our
current COVID-19 pandemic — force people to come up with new solutions.
They slash red tape, they improvise, they innovate, they collaborate, they cut
corners. Some of these will prove inspired, others will only be temporary,
and a few will turn out to be misguided. We may not know which is which
except in hindsight.