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?
Imagine this: You and your colleagues know there are problems to be solved. You have resources to offer, such as funding, access to experts, and publicity.
You are pretty sure there are people with great ideas out there, asking questions, defining the scope of the problems you care about, seeing things that you can’t see. Some people are even forging ahead, developing solutions on their own, but you don’t know how to connect with them.
You need an intake valve for new ideas, a honeypot to attract problem-solvers. So you launch a prize competition.
If you have escaped all the buzz around prize competitions and grand challenges over the last decade or so, don’t worry. KidneyX has a wonderful FAQ, including:
What is a prize competition?
A prize competition is a method of problem-solving that describes a problem (usually to the general public) and offers a prize or prizes to whoever comes up with the best solution(s). Prize competitions are a good way to attract ideas and skills from a wide range of fields.
I served as a volunteer judge for the KidneyX Patient Innovator challenge and was bowled over by the creativity of the submissions, both those who won and those who did not. It reminded me to welcome people into the health innovation conversation who may not think of themselves as inventors, but who deeply understand the community at the center of a crisis. The “need-knowers” as Tikkun Olam Makers call them.
Episode 9 of “The THCB Gang” was live-streamed on Wednesday (instead of our normal Thursday slot) on May 13th at 1pm PT- 4pm ET! Watch it below! Next week we’ll be back to Thursday
Joining me were health “IT” girl Jessica DaMassa (@jessdamassa), health futurist Ian Morrison (@seccurve), health economist Jane Sarasohn-Kahn (@healthythinker), patient safety expert Michael Millenson (MLMillenson), and MD & hospital system exec Rajesh Aggarwal (@docaggarwal). The conversation looked at the likelihod of big picture change, Medicare Advantage expansion, whether the move to remote care is real and sustainable, and at one point got us to war with China!
If you’d rather listen, the “audio only” version is preserved as a weekly podcast available on our iTunes & Spotify channels from Thursday onwards— Matthew Holt
Today on Health in 2 Point 00, Jess and I cover all the big comings and goings of digital health. But first, what happened with Atul Gawande departing Haven Health as CEO? Moving to a whopping 7 deals in this episode, Jess asks me about Wellth raising $10 million in an A round using behavioral economics to drive medication adherence; Vynca, an end-of-life startup, raising $10.3 million, Carbon Health getting a $26 million add-on investment expanding its telehealth offerings, Nanit raising $21 million for its machine learning baby monitor, Stellar Health raising $10 million in an A round to improve physician incentives to address gaps in care, Lucid Lane raising $4 million in seed funding for its substance use disorder program, and Limbix raising $9 million for its digital therapeutic for teens with depression. —Matthew Holt
In any economic disaster, the largest, best-financed organizations have a natural advantage over smaller, cash-strapped organizations. The bigger entities have a greater ability to withstand economic downturns, while the small ones can quickly go out of business because they lack the financial reserves needed to tide them over.
In the roughly 2 ½ months since the COVID-19 pandemic began sinking its hooks into America, the pertinence of this business axiom has been amply illustrated. Small companies across the country are desperate to reopen so they can survive, while many large corporations are seeing their stock prices soar. Most healthcare systems are not for profit, so they don’t issue stock; yet bigger hospitals are not suffering as much financially as smaller and rural hospitals are. Even though the large hospitals’ losses from elective surgery bans have been higher, they have much deeper reserves and greater access to bank lines of credit.
Physician practices have been hit disproportionately by the pandemic. Most practices have switched to telemedicine visits as patients have shunned in-person encounters and the offices have tried to protect their staffs. But the revenue from virtual encounters has not come close to making up for the loss of revenues from office visits that, in many cases, include lab tests and/or minor procedures.
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.
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:
The COVID crisis has shown us clearly that major portions of the American care system are extremely dysfunctional and some are now badly broken. We need to put in place a cash flow for American health care that can help our care sites survive and ultimately thrive, and we need to put that approach to save the sites in place now because a vast majority of hospitals and medical practices are badly damaged and some are financially crippled and even destroyed by their response to the crisis.
We have learned a lot in the COVID crisis that we need to use now in building our next steps and our collective response to the crisis.
The COVID crisis has shown us all that our care sites do not have good patient data, do not have good patient linkages, usually do not have team care of any kind in place, and most are so dependent on current piecework fee volumes from patients that they quickly collapse financially when that volume is interrupted.
We should be on the cusp of a golden age of care delivery that uses all of the best patient support tools to deliver continuously improved care — and we now know that the piecework way we buy almost all of our care today will keep that golden age from happening for the vast majority of American patients for the foreseeable future until we change the way we buy care.
We need to buy care in a way that both requires the use of those tools and rewards caregivers and care teams when they use them.
We need a dependable cash flow for care to anchor that process.
We are unlike most of the rest of the industrialized world in not having a dependable cash flow now to buy care. We rely on a hodgepodge and mishmash of unlinked, unaligned and uncoordinated payment sources now and that lack of coordination in payment creates a vast and damaging lack of coordination in the delivery of care.
We can make a huge improvement in that entire process and we can give our health care system a stable and functionally useful future cash flow by becoming a much more highly skilled purchaser of coverage and care. We need a flow of money to make that happen.
We actually can create that flow relatively quickly and fairly easily by imposing a payroll tax on every employee that exactly copies the approach we use now for our Social Security payroll tax process and then using that money in a health care purchasing pool to buy health coverage for every person who is not on Medicaid.
Is the beginning of the end in sight? Perhaps. After much stress and strain, many experts believe we’re seeing early signs of a COVID-19 plateau in some states and cities. Everything could change tomorrow, but healthcare leaders should be preparing now to reopen their shuttered operating rooms and get back to business.
When restrictions loosen, lost days and weeks could have dire implications for health systems already weakened by months of deferred and canceled elective procedures. These surgeries — joint replacements, tumor biopsies, gallbladder removals, and cosmetic procedures, for instance — underpin the economics of hospitals and physician groups. Delay some of these surgeries for too long and patient care can also suffer. Essential? Absolutely.
Unfortunately, healthcare leaders will be reopening their doors to a world unlike anything they’ve seen before. Aren’t we all seeing our personal health through a new lens?
Today on Episode 122 of Health in 2 Point 00, Jess asks me about LetsGetChecked raising $71M for at-home testing, Vida Health raising $25M for virtual chronic-conditions-management programs, Medable securing $25M for clinical trials, and Livongo publishing their Q1 earnings report (and their stock rising 10% days before the report was released!). I am excited to see their CFO, Lee Shapiro, go on a buying spree in the space now — Matthew Holt