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Administration’s new pandemic adviser pushes controversial ‘herd immunity’ strategy, worrying public health officials
The administration has already begun to implement some policies along these lines, according to current and former officials as well as experts, particularly with regard to testing.
The approach’s chief proponent is Scott Atlas, a neuroradiologist from Stanford’s conservative Hoover Institution, who joined the White House earlier this month as a pandemic adviser. He has advocated that the United States adopt the model Sweden has used to respond to the virus outbreak, according to these officials, which relies on lifting restrictions so the healthy can build up immunity to the disease rather than limiting social and business interactions to prevent the virus from spreading.
Sweden’s handling of the pandemic has been heavily criticized by public health officials and infectious-disease experts as reckless — the country has among the highest infection and death rates in the world. It also hasn’t escaped the deep economic problems resulting from the pandemic.
But Sweden’s approach has gained support among some conservatives who argue that social distancing restrictions are crushing the economy and infringing on people’s liberties.
That this approach is even being discussed inside the White House is drawing concern from experts inside and outside the government who note that a herd immunity strategy could lead to the country suffering hundreds of thousands, if not millions, of lost lives.
“The administration faces some pretty serious hurdles in making this argument. One is a lot of people will die, even if you can protect people in nursing homes,” said Paul Romer, a professor at New York University who won the Nobel Prize in economics in 2018. “Once it’s out in the community, we’ve seen over and over again, it ends up spreading everywhere.”
Atlas, who does not have a background in infectious diseases or epidemiology, has expanded his influence inside the White House by advocating policies that appeal to Trump’s desire to move past the pandemic and get the economy going, distressing health officials on the White House coronavirus task force and throughout the administration who worry that their advice is being followed less and less.
Atlas declined several interview requests in recent days. After the publication of this story, he released a statement through the White House: “There is no policy of the President or this administration of achieving herd immunity. There never has been any such policy recommended to the President or to anyone else from me.”
White House communications director Alyssa Farah said there is no change in the White House’s approach toward combatting the pandemic.
“President Trump is fully focused on defeating the virus through therapeutics and ultimately a vaccine. There is no discussion about changing our strategy,” she said in a statement. “We have initiated an unprecedented effort under Operation Warp Speed to safely bring a vaccine to market in record time — ending this virus through medicine is our top focus.”
White House officials said Trump has asked questions about herd immunity but has not formally embraced the strategy. The president, however, has made public comments that advocate a similar approach.
“We are aggressively sheltering those at highest risk, especially the elderly, while allowing lower-risk Americans to safely return to work and to school, and we want to see so many of those great states be open,” he said during his address to the Republican National Convention Thursday night. “We want them to be open. They have to be open. They have to get back to work.”
Atlas has fashioned himself as the “anti-Dr. Fauci,” one senior administration official said, referring to Anthony S. Fauci, the nation’s top infectious-disease official, who has repeatedly been at odds with the president over his public comments about the threat posed by the virus. He has clashed with Fauci as well as Deborah Birx, the White House coronavirus response coordinator, over the administration’s pandemic response.
Atlas has argued both internally and in public that an increased case count will move the nation more quickly to herd immunity and won’t lead to more deaths if the vulnerable are protected. But infectious-disease experts strongly dispute that, noting that more than 25,000 people younger than 65 have died of the virus in the United States. In addition, the United States has a higher number of vulnerable people of all ages because of high rates of heart and lung disease and obesity, and millions of vulnerable people live outside nursing homes — many in the same households with children, whom Atlas believes should return to school.
“When younger, healthier people get the disease, they don’t have a problem with the disease. I’m not sure why that’s so difficult for everyone to acknowledge,” Atlas said in an interview with Fox News’s Brian Kilmeade in July. “These people getting the infection is not really a problem and in fact, as we said months ago, when you isolate everyone, including all the healthy people, you’re prolonging the problem because you’re preventing population immunity. Low-risk groups getting the infection is not a problem.”
Atlas has said that lockdowns and social distancing restrictions during the pandemic have had a health cost as well, noting the problems associated with unemployment and people forgoing health care because they are afraid to visit a doctor.
“From personal communications with neurosurgery colleagues, about half of their patients have not appeared for treatment of disease which, left untreated, risks brain hemorrhage, paralysis or death,” he wrote in The Hill newspaper in May
The White House has left many of the day-to-day decisions regarding the pandemic to governors and local officials, many of whom have disregarded Trump’s advice, making it unclear how many states would embrace the Swedish model, or elements of it, if Trump begins to aggressively push for it to be adopted.
But two senior administration officials and one former official, as well as medical experts, noted that the administration is already taking steps to move the country in this direction.
The Department of Health and Human Services, for instance, invoked the Defense Production Act earlier this month to expedite the shipment of tests to nursing homes — but the administration has not significantly ramped up spending on testing elsewhere, despite persistent shortages. Trump and top White House aides, including Atlas, have also repeatedly pushed to reopen schools and lift lockdown orders, despite outbreaks in several schools that attempted to resume in-person classes.
The Centers for Disease Control and Prevention also updated its testing guidance last week to say that those who are asymptomatic do not necessarily have to be tested. That prompted an outcry from medical groups, infectious-disease experts and local health officials, who said the change meant that asymptomatic people who had contact with an infected person would not be tested. The CDC estimates that about 40 percent of people infected with covid-19, the disease caused by the coronavirus, are asymptomatic, and experts said much of the summer surge in infections was due to asymptomatic spread among young, healthy people.
Trump has previously floated “going herd” before being convinced by Fauci and others that it was not a good idea, according to one official.
The discussions come as at least 5.9 million infections have been reported and at least 179,000 have died from the virus this year and as public opinion polls show that Trump’s biggest liability with voters in his contest against Democratic nominee Joe Biden is his handling of the pandemic. The United States leads the world in coronavirus cases and deaths, with far more casualties and infections than any other developed nation.
The nations that have most successfully managed the coronavirus outbreak imposed stringent lockdown measures that a vast majority of the country abided by, quickly ramped up testing and contact tracing, and imposed mask mandates.
Atlas meets with Trump almost every day, far more than any other health official, and inside the White House is viewed as aligned with the president and White House Chief of Staff Mark Meadows on how to handle the outbreak, according to three senior administration officials.
In meetings, Atlas has argued that metropolitan areas such as New York, Chicago and New Orleans have already reached herd immunity, according to two senior administration officials. But Birx and Fauci have disputed that, arguing that even cities that peaked to potential herd immunity levels experience similar levels of infection if they reopen too quickly, the officials said.
Trump asked Birx in a meeting last month whether New York and New Jersey had reached herd immunity, according to a senior administration official. Birx told the president there was not enough data to support that conclusion.
Atlas has supporters who argue that his presence in the White House is a good thing and that he brings a new perspective.
“Epidemiology is not the only discipline that matters for public policy here. That is a fundamentally wrong way to think about this whole situation,” said Avik Roy, president of the Foundation for Research on Equal Opportunity, a think tank that researches market-based solutions to help low-income Americans. “You have to think about what are the costs of lockdowns, what are the trade-offs, and those are fundamentally subjective judgments policymakers have to make.”
It remains unclear how large a percentage of the population must become infected to achieve “herd immunity,” which is when enough people become immune to a disease that it slows its spread, even among those who have not been infected. That can occur either through mass vaccination efforts, or when enough people in the population become infected with coronavirus and develop antibodies that protect them against future infection.
Estimates have ranged from 20 percent to 70 percent for how much of a population would need to be infected. Soumya Swaminathan, the World Health Organization’s chief scientist, said given the transmissibility of the novel coronavirus, it is likely that about 65 to 70 percent of the population would need to become infected for there to be herd immunity.
With a population of 328 million in the United States, it may require 2.13 million deaths to reach a 65 percent threshold of herd immunity, assuming the virus has a 1 percent fatality rate, according to an analysis by The Washington Post.
It also remains unclear whether people who recover from covid-19 have long-term immunity to the virus or can become reinfected, and scientists are still learning who is vulnerable to the disease. From a practical standpoint, it is also nearly impossible to sufficiently isolate people at most risk of dying due to the virus from the younger, healthier population, according to public health experts.
Atlas has argued that the country should only be testing people with symptoms, despite the fact that asymptomatic carriers spread the virus. He has also repeatedly pushed to reopen schools and advocated for college sports to resume. Atlas has said, without evidence, that children do not spread the virus and do not have any real risk from covid-19, arguing that more children die of influenza — an argument he has made in television and radio interviews.
Atlas’s appointment comes after Trump earlier this summer encouraged his White House advisers to find a new doctor who would argue an alternative point of view from Birx and Fauci, whom the president has grown increasingly annoyed with for public comments that he believes contradict his own assertions that the threat of the virus is receding. Advisers sought a doctor with Ivy League or top university credentials who could make the case on television that the virus is a receding threat.
Atlas caught Trump’s attention with a spate of Fox News appearances in recent months, and the president has found a more simpatico figure in the Stanford doctor for his push to reopen the country so he can focus on his reelection. Atlas now often sits in the briefing room with Trump during his coronavirus news conferences, even as other doctors do not. He has given the president somewhat of a medical imprimatur for his statements and regularly helps draft the administration’s coronavirus talking points from his West Wing office as well as the slides that Trump often relies on for his argument of a diminishing threat.
Atlas has also said he is unsure “scientifically” whether masks make sense, despite broad consensus among scientists that they are effective. He has selectively presented research and findings that support his argument for herd immunity and his other ideas, two senior administration officials said.
Fauci and Birx have both said the virus is a threat in every part of the country. They have also put forward policy recommendations that the president views as too draconian, including mask mandates and partial lockdowns in areas experiencing surges of the virus.
Birx has been at odds with Atlas on several occasions, with one disagreement growing so heated at a coronavirus meeting earlier this month that other administration officials grew uncomfortable, according to a senior administration official.
One of the main points of tension between the two is over school reopenings. Atlas has pushed to reopen schools and Birx is more cautious.
“This is really unfortunate to have this fellow Scott Atlas, who was basically recruited to crowd out Tony Fauci and the voice of reason,” said Eric Topol, a cardiologist and head of the Scripps Research Translational Institute in San Diego. “Not only do we not embrace the science, but we repudiate the science by our president, and that has extended by bringing in another unreliable misinformation vector.”
Hospital revenue at risk in CMS’ proposal to move joint replacement to outpatient care
The Centers for Medicare and Medicaid Services’ push to move procedures from inpatient to less expensive outpatient care continues, with revenue at risk for lucrative joint replacement starting in 2021.
CMS’s continued push to the outpatient setting has been going on for some time, but the agency has found its sea legs in the recent hospital outpatient prospective payment system proposed rule, according to Stuart Clark, a managing director for The Advisory Board Company, in an August 27 presentation on payment updates.
CMS is slowly phasing out the inpatient only list over the next three years and is adding more services to the ambulatory surgical center list. There’s around 1,400 total codes on the list right now which are expected to be phased out by 2024.
AUG 29MORE ON REIMBURSEMENT
Hospital revenue at risk in CMS’ proposal to move joint replacement to outpatient care
At stake is $3.2 billion in revenue for a one-day length of stay as 80% of revenue for all services is in joint replacement.
, Managing Editor
The Centers for Medicare and Medicaid Services’ push to move procedures from inpatient to less expensive outpatient care continues, with revenue at risk for lucrative joint replacement starting in 2021.
CMS’s continued push to the outpatient setting has been going on for some time, but the agency has found its sea legs in the recent hospital outpatient prospective payment system proposed rule, according to Stuart Clark, a managing director for The Advisory Board Company, in an August 27 presentation on payment updates.
CMS is slowly phasing out the inpatient only list over the next three years and is adding more services to the ambulatory surgical center list.
There’s around 1,400 total codes on the list right now which are expected to be phased out by 2024.
For 2021, CMS has added 11 new procedures to the ASC list, including musculoskeletal services and total hip replacement.
WHY THIS MATTERS
Eighty percent of hospital revenue for all services is in joint replacement. At stake is $3.2 billion in revenue for a one-day length of stay.
Per hospital, 12-15 procedures may shift from a one-day stay to outpatient, according to Clark and Shay Pratt, vice president of Strategy and Service Line Research for the Advisory Board.
Hospitals may not see a huge amount of revenue at risk if they can continue to keep the services in-house, but in an outpatient setting.
However, there is less revenue to be made from the move to a lower cost care setting. And an estimated 83% of ambulatory surgical centers are physician-owned.
There is still debate on the efficacy of total hip replacement done as an outpatient service. Commercial payers say ASCs can provide total hip replacement, while opponents say they are not equipped for the service, according to the Advisory Board.
The comment period for the proposed rule is set to close on October 5.
Next year, CMS is expected to add cardiovascular services to the outpatient list, but the volume and revenue is not on as large a scale as joint replacement.
THE LARGER TREND IN TELEHEALTH
In telehealth, CMS is implementing incremental change as its use has increased dramatically during the coronavirus pandemic.
For Medicare reimbursement, 22 services have been added to the telehealth list. Of these, nine codes have been added permanently and 13 are approved through the end of the year in which the public health emergency ends.
Audio-only services are eligible under the public health emergency, but CMS is inviting input on how long they should remain eligible. The agency has said it’s uncertain about the value of an audio-only visit.
US surpasses 6 million coronavirus cases nationwide
The United States has passed six million confirmed cases of the coronavirus since the beginning of the pandemic, according to Johns Hopkins University.
The country has also passed 183,000 deaths nationwide.
President Trump and his 2020 Democratic opponent, former Vice President Joe Biden, have battled for months over the U.S.’s coronavirus response, with allies of the Democratic nominee hammering the administration over the U.S.’s status as the country with the most confirmed COVID-19 cases in the world.
In July, Biden accused Trump of giving up on the U.S.’s efforts to control the disease’s spread, claiming that the president “raised the white flag.”
“He has no idea what to do. It’s zero. It’s only one thing he has in mind — how does he win reelection? And it doesn’t matter how many people get COVID and or die from COVID because he fears that if the economy is strapped as badly as it is today that, in fact, he is going to be in trouble,” the former vice president told MSNBC.
Trump, meanwhile, has struck an optimistic tone on the virus when addressing it in recent months and claimed that he believes a vaccine could be available before the election. He also claimed in a recent Axios interview that the virus is “under control as much as you can control it” in the U.S.
“They are dying, that’s true. And you have — it is what it is,” Trump said earlier in August. “But that doesn’t mean we aren’t doing everything we can. It’s under control as much as you can control it. This is a horrible plague.”
Massachusetts health system lays off 118 furloughed workers, extends exec pay cuts
Citing financial hardships due to the COVID-19 pandemic, Barnstable, Mass.-based Cape Cod Healthcare will lay off 118 employees and extend salary reductions for executives, according to The Cape Cod Times.
In May, Cape Cod Healthcare furloughed 595 employees due to low patient volume and revenue declines amid the pandemic. Of the workers furloughed, 477 have returned to work, and 118 will be laid off.
Employees affected by the layoffs include eight vice presidents, a nurse, lab workers, environmental service workers and dietary employees.
In addition to the personnel reduction, Cape Cod Healthcare is extending a 10 percent salary cut for its senior executives, according to the report.
Cape Cod Healthcare CEO Michael Lauf told the Times that the layoffs were “an extremely difficult decision to make, as Cape Cod Healthcare values each and every one of our employees.”
Read the full report here.
Northwell records $329M loss in first half of 2020
Northwell Health, a 19-hospital system based in New Hyde Park, N.Y., ended the first half of 2020 with an operating loss despite a revenue increase year-over-year, according to recently released financial documents.
In the six months ended June 30, the health system recorded revenue of $6.3 billion, up from $6.1 billion reported in the same period in 2019.
The health system saw its patient revenue drop 9.7 percent in the first half of the year to $5.1 billion, compared to the same period in 2019. The patient revenue drop was attributed to the COVID-19 pandemic.
Northwell’s expenses climbed in the first six months of this year to $6.6 billion, an increase of about 9.5 percent from the same period in 2019.
The health system recorded an operating loss of $249.6 million.
After accounting for nonoperating gains and losses, the system ended the first half of 2020 with a $329 million net loss. This compares to a net income of $393 million in the first half of 2019.
Northwell Health estimated that the negative financial hit from the COVID-19 pandemic in the six months ended June 30 was about $1.2 billion and attributed most of the financial impact to lower patient volume.
Through Aug. 28, Northwell has received $1.2 billion in grants from the Coronavirus Aid Relief and Economic Security Act. In the six months ended June 30, the health system recorded $754 million of this relief aid as “other operating revenue.”
“While the financial impact estimates noted above have been made using the best available information at the time, the ultimate net impact of the pandemic to Northwell and its financial condition is uncertain,” Northwell Health stated.
HENRY KOTULA 