By MICHEL ACCAD
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.
By KIM BELLARD
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.
By HANS DUVEFELT, MD
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.
By KIM BELLARD
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.”
By IAN MORRISON
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”).
By ANISH KOKA, MD
The great pandemic is wreaking havoc, we are told, because the nation is not testing enough. The consensus from a diverse group that includes public health experts, economists, and silicon valley investors is that more testing will allow the country to restart the economy and do it safely.
The White House has been a mini laboratory for this testing strategy. Everyone who comes into contact with the President and Vice President is tested daily. This is supposedly what allows everyone to sit in meetings together and generally carry out the essential business of the country. But over this Mother’s Day weekend members of the White House spent their time scrambling to track down contacts of Katie Miller, the press secretary of the Vice president who tested positive. And contacts were left unclear about what exactly to do. One official started self-quarantining, while another did not.
If the White House has trouble with a mass testing, and contact tracing strategy, one wonders how this may work nationwide with thousands of new cases per day. While it would be tempting to blame administrative incompetence for the difficulties in the most important household in the land, the real difficulties lies with inherent limitations to tests that need to be understood before getting on the testing bandwagon.
By CASEY QUINLAN, HELEN HASKELL, BILL ADAMS, JOHN JAMES, ROBERT R. SCULLY, and POPPY ARFORD
Last year, the Patient Council of the Right Care Alliance conducted a survey in which over 1,000 Americans answered questions about what worried them most about their healthcare. We asked questions about access to care, concerns about misdiagnosis, and risks of treatment, which we reported on in our last THCB piece about the What Worries You Most survey.
We also asked people to rank their concerns about the costs of their care, in five questions that covered cost of care, cost of prescription drugs, cost and availability of insurance, and surprise billing. In the time since we ran the survey, everything has changed in American healthcare. The COVID19 pandemic is filling emergency rooms wherever the epidemic arrives. Bills are likely to be high, for both patients and insurers, and it is still far from clear how they will be paid. Americans are likely to continue to worry deeply about healthcare costs, with good reason, since it’s only in America that someone can go bankrupt due to seeking medical care.
By MICHEL ACCAD
It is tempting to oppose the harmful effects of COVID-related lockdown orders with arguments couched in terms of trade-offs.
We may contend that when public authorities promote the benefits of “flattening the curve,” they fail to properly take into account the actual costs of imposing business closures and of forced social distancing: The coming economic depression will lead to mass unemployment, rising poverty, suicides, domestic abuse, alcoholism, and myriad other potential causes of death and suffering which could be considerably worse than the harms of the pandemic itself, especially if we consider the spontaneous mitigation that people normally apply under the circumstances.
While I have no doubt that lockdown policies can and will have very serious negative consequences, I believe that the emphasis on trade-offs is misguided and counterproductive. It immediately invites a utilitarian calculus: How many deaths and how much suffering will be caused by lockdowns? How many deaths and how much suffering will occur without the lockdowns? How exactly are we to measure the total harm? What time frame should we consider when we ponder the costs of one option versus the other?
By KIM BELLARD
COVID-19 is changing the landscape of our healthcare system, and, indeed, of our entire society, in ways that we hadn’t been prepared for and with implications that we won’t fully grasp for some time. As we grapple with how to reshape our healthcare system and our society in the wake of the pandemic, though, I worry we’re going to focus on the wrong problems.
Take, for example, nursing homes, prisons, and the meatpacking industry.
Anyone who has been paying attention to the pandemic will recognize that each of these have been “hot spots,” and have been called “petri dishes” for coronavirus (as are cruise ships, but that’s a different article). These institutions aren’t the only places where masses of people congregate, but they seem to do so in ways that create fertile territories for COVID-19. And that’s the problem.
We knew early on that nursing homes were going to be a problem. We knew COVID-19 was a problem in Wuhan, but that was far away — until a few cases emerged in late February in a skilled nursing home in King County, Washington. We know now that these were not the first cases, nor the first deaths, but we were stunned by how quickly it spread in that facility. By mid-March experts were already calling nursing homes “ground zero,” and that has been proven right.
It is now estimated that as many as a third of all U.S. coronavirus deaths have come from nursing home residents or workers. That is (as of this writing) almost 30,000 deaths, and over 150,000 cases.
By MATTHEW HOLT
Smart Quarantine as the next step to combat COVID-19
As the nation and the world grapple with the impact of the COVID-19 pandemic, there is growing consensus among experts that we need a sustainable system of specific lockdowns, social distancing, and extreme resource provision in terms of labor, ventilators and PPE to arm hospitals and health providers as they deal with the onslaught of patients. Even while some American states start to slowly open up, we need a system that can manage COVID-19 over the coming months and years–especially if this Fall brings a second wave.
Writing in the NY Times on April 7, Harvey Fineberg and colleagues summarized an as yet overlooked issue. There are many patients who may or do have COVID-19, but are not sick enough to need hospital care, or who have been discharged from hospitals. We need to keep these patients away from hospitals but if they shelter in place in their household there is a high risk they will infect their families or housemates. This likelihood is even higher if they are homeless, incarcerated, or living in other group arrangements.
Instead of sheltering in place at home Fineberg and colleagues suggest those patients enter “smart quarantine” in temporary isolated accommodation, such as hotels or college dormitories, where they can be looked after by medical teams and tested semi-regularly. But whether they are at home or in temporary accommodation, leaving those patients with minimal support to be tested at the end of 14 days is not enough. A significant proportion of them will develop COVID-19 and some of those are going to be admitted to hospital. In addition several patients have been discharged from hospital, but still need to be monitored. We are going to need to be able to closely monitor a significant number of people even while the majority of them will need relatively limited amounts of care.
The good news is that we have had a couple of decades of development of the technologies and services required to both care for and monitor these patients, while keeping the main resources such as ventilators for those in hospitals. Pulling together available technologies and services, we will be able to quickly and accurately manage these patients, ensure their best outcomes, and spare scarce hospital resources. There are seven main components of this process, which I am calling “smart care in quarantine.”
Upon either a positive test for COVID-19 or a suspicion of those symptoms awaiting testing, patients can be admitted to isolation at home or in, say, empty hotels.
1. Monitoring equipment. Patients can be given FDA regulated monitoring devices which will work using bluetooth and WiFi (or 4G cellular). The main monitoring tools required are:
- Pulse Oximeters
- Stethoscopes (with acoustic recording)
- Weight Scales
- Video & audio via iPad, phone or computer