COVID-19 testing in grocery store parking lots. Clinicians crossing state lines to practice in hard-hit hospitals miles away from their health system. ICU doctors made to shore up shortages of ventilators by adapting medical equipment from its intended purpose. Are these just medical malpractice suits waiting to happen?
Margaret Nekic, CEO of Inspirien, a hospital-and-physician-owned medical malpractice and worker’s comp insurance company, reveals what’s happening behind-the-scenes as professional liability carriers hurry to adapt to the changing circumstances of a healthcare system thrown into crisis-mode.
While new legislation is emerging to somewhat safeguard healthcare workers from bearing the risk of some of the pandemic’s unprecedented circumstances, what happens when the immediate surge has passed? Will costs for medmal insurance go up? And, what happens from a worker’s comp standpoint if a healthcare worker becomes infected with COVID-19?
As healthcare delivery in hospitals continues to change — and, at the same time, more and more care extends outside the traditional doctor’s office by way of an uptick in use of digital health and telehealth options among non-COVID patients — it seems the pandemic might ultimately also accelerate changes in the way healthcare organizations think about risk management and their insurance coverage for it.
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.
I
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.
I covered some of these
in a previous article, but let me highlight a few:
Hospitals: We’re building new hospitals, such as in convention centers, to address the expected shortage of beds. Hospitals are also coordinating where to send which types of patients.
Due to the rapid escalation of the COVID-19
pandemic, America’s health care system is at immediate risk of reaching a level
of over-capacity. While most hospitals have emergency plans for pandemics, the
COVID-19 pandemic has quickly highlighted critical gaps in the nation’s health
care crisis-management infrastructure.
To assist health care workers on the frontlines, GuideWell has launched the COVID-19 Health Innovation Collaborative. The initiative seeks to connect diverse innovative health technology companies across the U.S., in response to the coronavirus. This Collaborative is focused on addressing critical risk areas facing health care professionals and staff, homebound COVID-19 patients/families, and the larger social issues arising from the social distancing mandates across the nation.
As hospitals focus on taking care of COVID-19 patients, the American Hospital Association is stepping up its advocacy for hospitals, fighting on their behalf for everything from PPE to reimbursement for uninsured patients. AHA’s Policy Director, Akin Demehin, dives into the top issues facing U.S. hospital administrators as they scramble to adjust their businesses to meet the unprecedented demands of the pandemic.
Besides the obvious concerns related to the direct delivery of care to a surge of very sick patients, hospitals are worried about cash flow, having enough personal protective equipment (PPE) for front-line clinicians, and the challenges of rolling out massive telehealth and remote monitoring programs to care for non-COVID patients at-home.
As the pandemic wears on, and the evolution of hospitals continues, the way these institutions function as part of the U.S. healthcare system will likely be forever changed. We learn what’s important to the AHA — and its 5,000 hospitals and healthcare system members — as they redefine their role in the healthcare system of the future in real-time.
Governors like Andrew Cuomo of New York have discovered the price for inefficiency and conflicts of interest in the face of the COVID-19 epidemic. As he said last week, “No one hospital has the resources to handle this. There has to be a totally different operating paradigm where all those different hospitals operate as one system.”
Our system is marked by extreme variability: a nation of health care haves and have-nots. Yet even when we Americans acknowledge the absurdity of our convoluted system of third-party payers and the pretzel positions our politicians weave in and out of as they try to justify it, reform it, then un-reform it, many still find solace in telling themselves, “Well, we still have the best health care in the world.”
This
crisis in a matter of weeks has revealed the limitations of a conflicted
network built on short-term profiteering and entrepreneurial adventurism. Here
are a few early learnings:
COVID is here. A little strand of RNA that
used to live in bats has a new host. And
that strand is clearly not the flu. New
York is overrun, with more than half of the nation’s new cases per day, and
refrigerated 18-wheelers parked outside hospitals serve as makeshift
morgues. Detroit, New Orleans, Miami,
and Philadelphia await an inevitable surge of their own with bated breath. America’s health care workers are scrambling
to hold the line against a deluge of sick patients arriving hourly at a rate
that’s hard to fathom.
I pause here to attest to the heroic response
of the medical community and the countless more working to support them. At the
time of this writing, despite 368,000 confirmed cases in the United States,
11,000 deaths have been reported. A
horrid number, but still a far cry from Italy with 130,000 cases, and 16,523
deaths, and Spain with 14,000 deaths amidst 140,000 cases. Italy and Spain may be a few weeks ahead of
the United States, but at the moment, Italy and Spain have case fatality rates
(12.5%, 10%) that are multiples of the United States (2.5%). If this rate does
stand, it will be a testament to the tenacity of medical workers toiling under
extenuating circumstances.
With the scale of the tragedy now obvious, the
take from some very smart people is that the people who should have been paying
attention were asleep at the wheel. The
easy target is the bombastic New York real estate developer and current
President of the United States who repeatedly assured raucous campaign crowds
and the nation that the virus was under control before it wasn’t.
The charge is made that the President ignored
warnings and painted a rosy picture of an unfolding crisis in a short-sighted
attempt to preserve the economy and a beloved stock market. He may be guilty of the latter charge, but
the real question relates to ignored warnings.
Where were the warnings? Who was sounding the alarm that was ultimately
ignored?
Indu & I have been talking about Flipping the Stack in health care for about 3 years. 2 years ago we wrote an article for a general hospital audience which appeared in the 2019 AHA SHSMD Futurescan magazine. I was talking about the changes in home monitoring that might come about due to COVID-19 and remembered this article. The one that got published went through a staid editing process. This is the original version that I wrote before which was rather more fun and hasn’t seen the light of day. Until now. Take a look and remember it is 2 years old–Matthew Holt
Over the past twenty-five
years most businesses have been revolutionized by the easy availability of
cloud and mobile-based computing systems. These technologies have placed power
and access into the hands of employees and customers, which in turn has created
huge shifts in how transactions get done. Now the companies with the highest
market value are both the drivers of and
beneficiaries of this transition, notably Apple, Facebook, Amazon and Alphabet
(Google), as well as their international rivals like Samsung, Baidu, Tencent
and Alibaba. Everyone uses their products every day, and the impact on our
lives have been remarkable. Of course, this also impacts how businesses of all
types are organized.
Underpinning
this transformation has been a change from enterprise-specific software to
generic cloud-based services—sometimes called SMAC
(Social/Sensors/Mobile/Analytics/Cloud). Applications such as data storage,
sales management, email and the hardware they ran on were put into enterprises
during the 80s and 90s in the client-server era (dominated by Intel and
Microsoft). These have now migrated to cloud-based, on-demand services.
Twenty
years ago the web was still a curiosity for most organizations. But consumers
flocked to these online services and in recent years businesses followed, using
GSuite, AWS (Amazon Web Services), Salesforce, Slack and countless other
services. Those technologies in turn enabled the growth of whole new types of
businesses changing sectors like transportation (Uber), entertainment (Netflix),
lodging (AirBnB) and more.
Figure 1. Growth in use of cloud data v s traditional data centers
What about the hospital?
Hospitals and health
systems were late comers to the enterprise technology game, even to
client-server. In the 2000’s and 2010’s, mostly in response to the HITECH Act,
hospitals added electronic medical records to their other information systems.
The majority of these were client-server based and enterprise-specific. Even if
they are cloud-based, they tend to be hosted in the private cloud environment
of the dominant vendors like Epic and Cerner. Of the major EMR vendors only
Athenahealth had an explicit cloud-only strategy, and its influence has been
largely limited to revenue cycle management on the outpatient side.
However, the hospital sector is likely to move towards the trend of using the cloud seen in other businesses.
