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Industry Voices—6 ways the pandemic will remake health systems

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Industry Voices—6 ways the pandemic will remake health systems ...

Provider executives already know America’s hospitals and health systems are seeing rapidly deteriorating finances as a result of the coronavirus pandemic. They’re just not yet sure of the extent of the damage.

By the end of June, COVID-19 will have delivered an estimated $200 billion blow to these institutions with the bulk of losses stemming from cancelled elective and nonelective surgeries, according to the American Hospital Association. 

A recent Healthcare Financial Management Association (HFMA)/Guidehouse COVID-19 survey suggests these patient volumes will be slow to return, with half of provider executive respondents anticipating it will take through the end of the year or longer to return to pre-COVID levels. Moreover, one-in-three provider executives expect to close the year with revenues at 15 percent or more below pre-pandemic levels. One-in-five of them believe those decreases will soar to 30 percent or beyond. 

Available cash is also in short supply. A Guidehouse analysis of 350 hospitals nationwide found that cash on hand is projected to drop by 50 days on average by the end of the year — a 26% plunge — assuming that hospitals must repay accelerated and/or advanced Medicare payments.

While the government is providing much needed aid, just 11% of the COVID survey respondents expect emergency funding to cover their COVID-related costs.

The figures illustrate how the virus has hurled American medicine into unparalleled volatility. No one knows how long patients will continue to avoid getting elective care, or how state restrictions and climbing unemployment will affect their decision making once they have the option.

All of which leaves one thing for certain: Healthcare’s delivery, operations, and competitive dynamics are poised to undergo a fundamental and likely sustained transformation. 

Here are six changes coming sooner rather than later.

 

1. Payer-provider complexity on the rise; patients will struggle.

The pandemic has been a painful reminder that margins are driven by elective services. While insurers show strong earnings — with some offering rebates due to lower reimbursements — the same cannot be said for patients. As businesses struggle, insured patients will labor under higher deductibles, leaving them reluctant to embrace elective procedures. Such reluctance will be further exacerbated by the resurgence of case prevalence, government responses, reopening rollbacks, and inconsistencies in how the newly uninsured receive coverage.

Furthermore, the upholding of the hospital price transparency ruling will add additional scrutiny and significance for how services are priced and where providers are able to make positive margins. The end result: The payer-provider relationship is about to get even more complicated. 

 

2. Best-in-class technology will be a necessity, not a luxury. 

COVID has been a boon for telehealth and digital health usage and investments. Two-thirds of survey respondents anticipate using telehealth five times more than they did pre-pandemic. Yet, only one-third believe their organizations are fully equipped to handle the hike.

If healthcare is to meet the shift from in-person appointments to video, it will require rapid investment in things like speech recognition software, patient information pop-up screens, increased automation, and infrastructure to smooth workflows.

Historically, digital technology was viewed as a disruption that increased costs but didn’t always make life easier for providers. Now, caregiver technologies are focused on just that.

The new necessities of the digital world will require investments that are patient-centered and improve access and ease of use, all the while giving providers the platform to better engage, manage, and deliver quality care.

After all, the competition at the door already holds a distinct technological advantage.

 

3. The tech giants are coming.

Some of America’s biggest companies are indicating they believe they can offer more convenient, more affordable care than traditional payers and providers. 

Begin with Amazon, which has launched clinics for its Seattle employees, created the PillPack online pharmacy, and is entering the insurance market with Haven Healthcare, a partnership that includes Berkshire Hathaway and JPMorgan Chase. Walmart, which already operates pharmacies and retail clinics, is now opening Walmart Health Centers, and just recently announced it is getting into the Medicare Advantage business.

Meanwhile, Walgreens has announced it is partnering with VillageMD to provide primary care within its stores.

The intent of these organizations clear: Large employees see real business opportunities, which represents new competition to the traditional provider models.

It isn’t just the magnitude of these companies that poses a threat. They also have much more experience in providing integrated, digitally advanced services. 

 

4. Work locations changes mean construction cost reductions. 

If there’s one thing COVID has taught American industry – and healthcare in particular – it’s the importance of being nimble.

Many back-office corporate functions have moved to a virtual environment as a result of the pandemic, leaving executives wondering whether they need as much real estate. According to the survey, just one-in-five executives expect to return to the same onsite work arrangements they had before the pandemic. 

Not surprisingly, capital expenditures, including new and existing construction, leads the list of targets for cost reductions.

Such savings will be critical now that investment income can no longer be relied upon to sustain organizations — or even buy a little time. Though previous disruptions spawned only marginal change, the unprecedented nature of COVID will lead to some uncomfortable decisions, including the need for a quicker return on investments. 

 

5. Consolidation is coming.

Consolidation can be interpreted as a negative concept, particularly as healthcare is mostly delivered at a local level. But the pandemic has only magnified the differences between the “resilients” and the “non-resilients.” 

All will be focused on rebuilding patient volume, reducing expenses, and addressing new payment models within a tumultuous economy. Yet with near-term cash pressures and liquidity concerns varying by system, the winners and losers will quickly emerge. Those with at least a 6% to 8% operating margin to innovate with delivery and reimagine healthcare post-COVID will be the strongest. Those who face an eroding financial position and market share will struggle to stay independent..

 

6. Policy will get more thoughtful and data-driven.

The initial coronavirus outbreak and ensuing responses by both the private and public sectors created negative economic repercussions in an accelerated timeframe. A major component of that response was the mandated suspension of elective procedures.

While essential, the impact on states’ economies, people’s health, and the employment market have been severe. For example, many states are currently facing inverse financial pressures with the combination of reductions in tax revenue and the expansion of Medicaid due to increases in unemployment. What’s more, providers will be subject to the ongoing reckonings of outbreak volatility, underscoring the importance of agile policy that engages stakeholders at all levels.

As states have implemented reopening plans, public leaders agree that alternative responses must be developed. Policymakers are in search of more thoughtful, data-driven approaches, which will likely require coordination with health system leaders to develop flexible preparation plans that facilitate scalable responses. The coordination will be difficult, yet necessary to implement resource and operational responses that keeps healthcare open and functioning while managing various levels of COVID outbreaks, as well as future pandemics.

Healthcare has largely been insulated from previous economic disruptions, with capital spending more acutely affected than operations. But the COVID-19 pandemic will very likely be different. Through the pandemic, providers are facing a long-term decrease in commercial payment, coupled with a need to boost caregiver- and consumer-facing engagement, all during a significant economic downturn.

While situations may differ by market, it’s clear that the pre-pandemic status quo won’t work for most hospitals or health systems.

 

 

 

The Future of Hospitals in Post-COVID America (Part 1): The Market Response

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Click to access CBC_72_08052020_Final.pdf

 

[Readers’ Note: This is the first of two articles on the Future of Hospitals in Post-COVID America. This article
examines how market forces are consolidating, rationalizing and redistributing acute care assets within the
broader industry movement to value-based care delivery. The second article, which will publish next month,
examines gaps in care delivery and the related public policy challenges of providing appropriate, accessible
and affordable healthcare services in medically-underserved communities.]

In her insightful 2016 book, The Gray Rhino: How to Recognize and Act on the Obvious Dangers We Ignore,
Michelle Wucker coins the term “Gray Rhinos” and contrasts them with “Black Swans.” That distinction is
highly relevant to the future of American hospitals.

Black Swans are high impact events that are highly improbable and difficult to predict. By contrast, Gray
Rhinos are foreseeable, high-impact events that we choose to ignore because they’re complex, inconvenient
and/or fortified by perverse incentives that encourage the status quo. Climate change is a powerful example
of a charging Gray Rhino.

In U.S. healthcare, we are now seeing what happens when a Gray Rhino and a Black Swan collide.
Arguably, the nation’s public health defenses should anticipate global pandemics and apply resources
systematically to limit disease spread. This did not happen with the coronavirus pandemic.

Instead, COVID-19 hit the public healthcare infrastructure suddenly and hard. This forced hospitals and health systems to dramatically reduce elective surgeries, lay off thousands and significantly change care delivery with the adoption of new practices and services like telemedicine.

In comparison, many see the current American hospital business model as a Gray Rhino that has been charging toward
unsustainability for years with ever-building momentum.

Even with massive and increasing revenue flows, hospitals have long struggled with razor-thin margins, stagnant payment rates and costly technology adoptions. Changing utilization patterns, new and disruptive competitors, pro-market regulatory rules and consumerism make their traditional business models increasingly vulnerable and, perhaps, unsustainable.

Despite this intensifying pressure, many hospitals and health systems maintain business-as-usual practices because transformation is so difficult and costly. COVID-19 has made the imperative of change harder to ignore or delay addressing.

For a decade, the transition to value-based care has dominated debate within U.S. healthcare and absorbed massive strategic,
operational and financial resources with little progress toward improved care outcomes, lower costs and better customer service. The hospital-based delivery system remains largely oriented around Fee-for-Service reimbursement.

Hospitals’ collective response to COVID-19, driven by practical necessity and financial survival, may accelerate the shift to value-based care delivery. Time will tell.

This series explores the repositioning of hospitals during the next five years as the industry rationalizes an excess supply of acute care capacity and adapts to greater societal demands for more appropriate, accessible and affordable healthcare services.

It starts by exploring the role of the marketplace in driving hospital consolidation and the compelling need to transition to value-based care delivery and payment models.

COVID’s DUAL SHOCKS TO PATIENT VOLUME

Many American hospitals faced severe financial and operational challenges before COVID-19. The sector has struggled to manage ballooning costs, declining margins and waves of policy changes. A record 18 rural hospitals closed in 2019. Overall, hospitals saw a 21% decline in operating margins in 2018-2019.

COVID intensified those challenges by administering two shocks to the system that decreased the volume of hospital-based activities and decimated operating margins.

The first shock was immediate. To prepare for potential surges in COVID care, hospitals emptied beds and cancelled most clinic visits, outpatient treatments and elective surgeries. Simultaneously, they incurred heavy costs for COVID-related equipment (e.g. ventilators,PPE) and staffing. Overall, the sector experienced over $200 billion in financial losses between March and June 20204.

The second, extended shock has been a decrease in needed but not necessary care. Initially, many patients delayed seeking necessary care because of perceived infection risk. For example, Emergency Department visits declined 42% during the early phase of the pandemic.

Increasingly, patients are also delaying care because of affordability concerns and/or the loss of health insurance. Already, 5.4 million people have lost their employer-sponsored health insurance. This will reduce incremental revenues associated with higher-paying commercial insurance claims across the industry. Additionally, avoided care reduces patient volumes and hospital revenues today even as it increases the risk and cost of future acute illness.

The infusion of emergency funding through the CARES Act helped offset some operating losses but it’s unclear when and even whether utilization patterns and revenues will return to normal pre-COVID levels. Shifts in consumer behavior, reductions in insurance coverage, and the emergence of new competitors ranging from Walmart to enhanced primary care providers will likely challenge the sector for years to come.

The disruption of COVID-19 will serve as a forcing function, driving meaningful changes to traditional hospital business models and the competitive landscape. Frankly, this is long past due. Since 1965, Fee-for-Service (FFS) payment has dominated U.S. healthcare and created pervasive economic incentives that can serve to discourage provider responsiveness in transitioning to value-based care delivery, even when aligned to market demand.

Telemedicine typifies this phenomenon. Before COVID, CMS and most health insurers paid very low rates for virtual care visits or did not cover them at all. This discouraged adoption of an efficient, high-value care modality until COVID.

Unable to conduct in-person clinical visits, providers embraced virtual care visits and accelerated its mass adoption. CMS and
commercial health insurers did their part by paying for virtual care visits at rates equivalent to in-person clinic visits. Accelerated innovation in care delivery resulted.

 

THE COMPLICATED TRANSITION TO VALUE

Broadly speaking, health systems and physician groups that rely almost exclusively on activity-based payment revenues have struggled the most during this pandemic. Vertically integrated providers that offer health insurance and those receiving capitated payments in risk-based contracts have better withstood volume losses.

Modern Healthcare notes that while provider data is not yet available, organizations such as Virginia Care Partners, an integrated network and commercial ACO; Optum Health (with two-thirds of its revenue risk-based); and MediSys Health Network, a New Yorkbased NFP system with 148,000 capitated and 15,000 shared risk patients, are among those navigating the turbulence successfully. As the article observes,

…providers paid for value have had an easier time weathering the storm…. helped by a steady source of
income amid the chaos. Investments they made previously in care management, technology and social
determinants programs equipped them to pivot to new ways of providing care.

They were able to flip the switch on telehealth, use data and analytics to pinpoint patients at risk for
COVID-19 infection, and deploy care managers to meet the medical and nonclinical needs of patients even
when access to an office visit was limited.

Supporting this post-COVID push for value-based care delivery, six former leaders from CMS wrote to Congress in
June 2020 calling for providers, commercial insurers and states to expand their use of value-based payment models to
encourage stability and flexibility in care delivery.

If value-based payment models are the answer, however, adoption to date has been slow, limited and difficult. Ten
years after the Affordable Care Act, Fee-for-Service payment still dominates the payer landscape. The percentage of
overall provider revenue in risk-based capitated contracts has not exceeded 20%

Despite improvements in care quality and reductions in utilization rates, cost savings have been modest or negligible.
Accountable Care Organizations have only managed at best to save a “few percent of Medicare spending, [but] the
amount varies by program design.”

While most health systems accept some forms of risk-based payments, only 5% of providers expect to have a majority
(over 80%) of their patients in risk-based arrangements within 5 years.

The shift to value is challenging for numerous reasons. Commercial payers often have limited appetite or capacity for
risk-based contracting with providers. Concurrently, providers often have difficulty accessing the claims data they need
from payers to manage the care for targeted populations.

The current allocation of cost-savings between buyers (including government, employers and consumers), payers
(health insurance companies) and providers discourages the shift to value-based care delivery. Providers would
advance value-based models if they could capture a larger percentage of the savings generated from more effective
care management and delivery. Those financial benefits today flow disproportionately to buyers and payers.

This disconnection of payment from value creation slows industry transformation. Ultimately, U.S. healthcare will not
change the way it delivers care until it changes the way it pays for care. Fortunately, payment models are evolving to
incentivize value-based care delivery.

As payment reform unfolds, however, operational challenges pose significant challenges to hospitals and health
systems. They must adopt value-oriented new business models even as they continue to receive FFS payments. New
and old models of care delivery clash.

COVID makes this transition even more formidable as many health systems now lack the operating stamina and
balance sheet strength to make the financial, operational and cultural investments necessary to deliver better
outcomes, lower costs and enhanced customer service.

 

MARKET-DRIVEN CONSOLIDATION AND TRANSFORMATION

Full-risk payment models, such as bundled payments for episodic care and capitation for population health, are the
catalyst to value-based care delivery. Transition to value-based care occurs more easily in competitive markets with
many attributable lives, numerous provider options and the right mix of willing payers.

As increasing numbers of hospitals struggle financially, the larger and more profitable health systems are expanding
their networks, capabilities and service lines through acquisitions. This will increase their leverage with commercial
payers and give them more time to adapt to risk-based contracting and value-based care delivery.

COVID also will accelerate acquisition of physician practices. According to an April 2020 MGMA report, 97% of
physician practices have experienced a 55% decrease in revenue, forcing furloughs and layoffs15. It’s estimated the
sector could collectively lose as much as $15.1 billion in income by the end of September 2020.

Struggling health systems and physician groups that read the writing on the wall will pro-actively seek capital or
strategic partners that offer greater scale and operating stability. Aggregators can be selective in their acquisitions,
seeking providers that fuel growth, expand contiguous market positions and don’t dilute balance sheets.

Adding to the sector’s operating pressure, private equity, venture investors and payers are pouring record levels of
funding into asset-light and virtual delivery companies that are eager to take on risk, lower prices by routing procedures
and capture volume from traditional providers. With the right incentives, market-driven reforms will reallocate resources
to efficient companies that generate compelling value.

As this disruption continues to unfold, rural and marginal urban communities that lack robust market forces will
experience more facility and practice closures. Without government support to mitigate this trend, access and care gaps
that already riddle American healthcare will unfortunately increase.

 

WINNING AT VALUE

The average hospital generates around $11,000 per patient discharge. With ancillary services that can often add up to
more than $15,000 per average discharge. Success in a value-based system is predicated on reducing those
discharges and associated costs by managing acute care utilization more effectively for distinct populations (i.e.
attributed lives).

This changes the orientation of healthcare delivery toward appropriate and lower cost settings. It also places greater
emphasis on preventive, chronic and outpatient care as well as better patient engagement and care coordination.
Such a realignment of care delivery requires the following:

 A tight primary care network (either owned or affiliated) to feed referrals and reduce overall costs through
better preventive care.

 A gatekeeper or navigator function (increasingly technology-based) to manage / direct patients to the most
appropriate care settings and improve coordination, adherence and engagement.

 A carefully designed post-acute care network (including nursing homes, rehab centers, home care
services and behavioral health services, either owned or sufficiently controlled) to manage the 70% of
total episode-of-care costs that can occur outside the hospital setting.

 An IT infrastructure that can facilitate care coordination across all providers and settings.

Quality data and digital tools that enhance care, performance, payment and engagement.

Experience with managing risk-based contracts.

 A flexible approach to care delivery that includes digital and telemedicine platforms as well as nontraditional sites of care.

Aligned or incentivized physicians.

Payer partners willing to share data and offload risk through upside and downside risk contracts.

Engaged consumers who act on their preferences and best interests.

 

While none of these strategies is new or controversial, assembling them into cohesive and scalable business models is
something few health systems have accomplished. It requires appropriate market conditions, deep financial resources,
sophisticated business acumen, operational agility, broad stakeholder alignment, compelling vision, and robust
branding.

Providers that fail to embrace value-based care for their “attributed lives” risk losing market relevance. In their relentless pursuit of increasing treatment volumes and associated revenues, they will lose market share to organizations that
deliver consistent and high-value care outcomes.

CONCLUSION: THE CHARGING GRAY RHINO

America needs its hospitals to operate optimally in normal times, flex to manage surge capacity, sustain themselves
when demand falls, create adequate access and enhance overall quality while lowering total costs. That is a tall order
requiring realignment, evolution, and a balance between market and policy reform measures.

The status quo likely wasn’t sustainable before COVID. The nation has invested heavily for many decades in acute and
specialty care services while underinvesting, on a relative basis, in primary and chronic care services. It has excess
capacity in some markets, and insufficient access in others.

COVID has exposed deep flaws in the activity-based payment as well as the nation’s underinvestment in public health.
Disadvantaged communities have suffered disproportionately. Meanwhile, the costs for delivering healthcare services
consume an ever-larger share of national GDP.

Transformational change is hard for incumbent organizations. Every industry, from computer and auto manufacturing to
retailing and airline transportation, confronts gray rhino challenges. Many companies fail to adapt despite clear signals
that long-term viability is under threat. Often, new, nimble competitors emerge and thrive because they avoid the
inherent contradictions and service gaps embedded within legacy business models.

The healthcare industry has been actively engaged in value-driven care transformation for over ten years with little to
show for the reform effort. It is becoming clear that many hospitals and health systems lack the capacity to operate
profitably in competitive, risk-based market environments.

This dismal reality is driving hospital market valuations and closures. In contrast, customers and capital are flowing to
new, alternative care providers, such as OneMedical, Oak Street Health and Village MD. Each of these upstart
companies now have valuations in the $ billions. The market rewards innovation that delivers value.

Unfortunately, pure market-driven reforms often neglect a significant and growing portion of America’s people. This gap has been more apparent as COVID exacts a disproportionate toll on communities challenged by higher population
density, higher unemployment, and fewer medical care options (including inferior primary and preventive care infrastructure).

Absent fundamental change in our hospitals and health systems, and investment in more efficient care delivery and
payment models, the nation’s post-COVID healthcare infrastructure is likely to deteriorate in many American
communities, making them more vulnerable to chronic disease, pandemics and the vicissitudes of life.

Article 2 in our “Future of Hospitals” series will explore the public policy challenges of providing appropriate, affordable and accessible healthcare to all American communities.

 

 

 

40% of Americans still putting off care

Posted on by • Posted in 2020 Election Issues, Chronic Care Management, Chronic Conditions, Chronic Diseases, Clinical Testing, Coronavirus, Crisis, Crisis Management, Deferred Healthcare, Economic Crisis, Economy Reopening, Employer-Based Health Insurance, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, False Hope, False Narrative, Health Insurance Coverage Adequacy, Health Policy, Infection Control, Infection Control Plan, Infectious Virus, Leadership Decentralized, Misinformation, Misinterpret, Mislead, Misleading, Mistake, Mistrust, Mixed Message, Mortality, National Strategy, Out of Control, Out of Pocket Expenses, Pandemic, Preexisting Conditions, Public Health, Public Perception, Public Safety, Public Trust, Quarantine, Social Distancing, Underinsured, Unemployment, Unemployment Insurance, Uninformed • Leave a comment

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40% of Americans continue to put off medical care - Axios

Roughly 40% of Americans have postponed getting medical care due to the coronavirus outbreak. That number has stayed around 40% in all 12 weeks of the Census Bureau’s Household Pulse Survey.

Why it matters: Hospitals and doctors started rescheduling surgeries and other appointments as early as mid-May, and many patient volumes are mostly back to pre-pandemic numbers, Axios’ Bob Herman writes.

  • But this data suggests there is still a major backlog of Americans who need care — a phenomenon that existed well before the pandemic.

 

 

 

 

The Mask Slackers of 1918

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As the influenza pandemic swept across the United States in 1918 and 1919, masks took a role in political and cultural wars.

The masks were called muzzles, germ shields and dirt traps. They gave people a “pig-like snout.” Some people snipped holes in their masks to smoke cigars. Others fastened them to dogs in mockery. Bandits used them to rob banks.

More than a century ago, as the 1918 influenza pandemic raged in the United States, masks of gauze and cheesecloth became the facial front lines in the battle against the virus. But as they have now, the masks also stoked political division. Then, as now, medical authorities urged the wearing of masks to help slow the spread of disease. And then, as now, some people resisted.

In 1918 and 1919, as bars, saloons, restaurants, theaters and schools were closed, masks became a scapegoat, a symbol of government overreach, inspiring protests, petitions and defiant bare-face gatherings. All the while, thousands of Americans were dying in a deadly pandemic.

The first infections were identified in March, at an Army base in Kansas, where 100 soldiers were infected. Within a week, the number of flu cases grew fivefold, and soon the disease was taking hold across the country, prompting some cities to impose quarantines and mask orders to contain it.

By the fall of 1918, seven cities — San Francisco, Seattle, Oakland, Sacramento, Denver, Indianapolis and Pasadena, Calif. — had put in effect mandatory face mask laws, said Dr. Howard Markel, a historian of epidemics and the author of “Quarantine!”

Organized resistance to mask wearing was not common, Dr. Markel said, but it was present. “There were flare-ups, there were scuffles and there were occasional groups, like the Anti-Mask League,” he said, “but that is the exception rather than the rule.”

At the forefront of the safety measures was San Francisco, where a man returning from a trip to Chicago apparently carried the virus home, according to archives about the pandemic at the University of Michigan.

By the end of October, there were more than 60,000 cases statewide, with 7,000 of them in San Francisco. It soon became known as the “masked city.”

“The Mask Ordinance,” signed by Mayor James Rolph on Oct. 22, made San Francisco the first American city to require face coverings, which had to be four layers thick.

Resisters complained about appearance, comfort and freedom, even after the flu killed an estimated 195,000 Americans in October alone.

Alma Whitaker, writing in The Los Angeles Times on Oct. 22, 1918, reviewed masks’ impact on society and celebrity, saying famous people shunned them because it was “so horrid” to go unrecognized.

“The big restaurants are the funniest sights, with all the waiters and diners masked, the latter just raising their screen to pop in a mouthful of food,” she wrote.

When Ms. Whitaker herself declined to wear one, she was “forcibly taken” to the Red Cross as a “slacker,” and ordered to make one and put it on.

The San Francisco Chronicle said the simplest type of mask was of folded gauze affixed with elastic or tape. The police went for gauze masks, which resembled an unflattering “nine ordinary slabs of ravioli arranged in a square.”

There was room for creativity. Some of the coverings were “fearsome looking machines” that lent a “pig-like aspect” to the wearer’s face.

The penalty for violators was $5 to $10, or 10 days’ imprisonment.

On Nov. 9, 1,000 people were arrested, The San Francisco Chronicle reported. City prisons swelled to standing room only; police shifts and court sessions were added to help manage.

“Where is your mask?” Judge Mathew Brady asked offenders at the Hall of Justice, where sessions dragged into night. Some gave fake names, said they just wanted to light a cigar or that they hated following laws.

Jail terms of 8 hours to 10 days were given out. Those who could not pay $5 were jailed for 48 hours.

On Oct. 28, a blacksmith named James Wisser stood on Powell and Market streets in front of a drugstore, urging a crowd to dispose of their masks, which he described as “bunk.”

A health inspector, Henry D. Miller, led him to the drugstore to buy a mask.

At the door, Mr. Wisser struck Mr. Miller with a sack of silver dollars and knocked him to the ground, The San Francisco Chronicle reported. While being “pummeled,” Mr. Miller, 62, fired four times with a revolver. Passers-by “scurried for cover,” The Associated Press said.

Mr. Wisser was injured, as were two bystanders. He was charged with disturbing the peace, resisting an officer and assault. The inspector was charged with assault with a deadly weapon.

That was the headline for a report published in The Los Angeles Times when city officials met in November to decide whether to require residents to wear “germ scarers” or “flu-scarers.”

Public feedback was invited. Some supported masks so theaters, churches and schools could operate. Opponents said masks were “mere dirt and dust traps and do more harm than good.”

“I have seen some persons wearing their masks for a while hanging about their necks, and then apply them to their faces, forgetting that they might have picked up germs while dangling about their clothes,” Dr. E.W. Fleming said in a Los Angeles Times report.

An ear, nose and throat specialist, Dr. John J. Kyle, said: “I saw a woman in a restaurant today with a mask on. She was in ordinary street clothes, and every now and then she raised her hand to her face and fussed with the mask.”

Suffragists fighting for the right to vote made a gesture that rejected covering their mouths at a time when their voices were crucial.

At the annual convention of the Illinois Equal Suffrage Association, in October 1918, they set chairs four feet apart, closed doors to the public and limited attendance to 100 delegates, the Chicago Daily Tribune reported.

But the women “showed their scorn” for masks, it said. It’s unclear why.

Allison K. Lange, an associate history professor at Wentworth Institute of Technology, said one reason could have been that they wanted to keep a highly visible profile.

“Suffragists wanted to make sure their leaders were familiar political figures,” Dr. Lange said.

San Francisco’s mask ordinance expired after four weeks at noon on Nov. 21. The city celebrated, and church bells tolled.

A “delinquent” bent on blowing his nose tore his mask off so quickly that it “nearly ruptured his ear,” The San Francisco Chronicle reported. He and others stomped on their masks in the street. As a police officer watched, it dawned on him that “his vigil over the masks was done.”

Waiters, barkeeps and others bared their faces. Drinks were on the house. Ice cream shops handed out treats. The sidewalks were strewn with gauze, the “relics of a torturous month,” The Chronicle said.

The spread had been halted. But a second wave was on the horizon.

By December, the San Francisco Board of Supervisors was again proposing a mask requirement, meeting with testy opposition.

Around the end of the year, a bomb was defused outside the office of San Francisco’s chief health officer, Dr. William C. Hassler. “Things were violent and aggressive, but it was because people were losing money,” said Brian Dolan, a medical historian at the University of California, San Francisco. “It wasn’t about a constitutional issue; it was a money issue.”

By the end of 1918, the death toll from influenza had reached at least 244,681, mostly in the last four months, according to government statistics.

In January, Pasadena’s city commission passed a mask ordinance. The police grudgingly enforced it, cracking down on cigar smokers and passengers in cars. Sixty people were arrested on the first day, The Los Angeles Times reported on Jan. 22, in an article titled “Pasadena Snorts Under Masks.”

“It is the most unpopular law ever placed on the Pasadena records,” W.S. McIntyre, the chief of police, told the paper. “We are cursed from all sides.”

Some mocked the rule by stretching gauze across car vents or dog snouts. Cigar vendors said they lost customers, though enterprising aficionados cut a hole in the cloth. (They were still arrested.) Barbers lost shaving business. Merchants complained traffic dropped as more people stayed home.

Petitions were circulated at cigar stands. Arrests rose, even of the powerful. Ernest May, the president of Security National Bank of Pasadena, and five “prominent” guests were rounded up at the Maryland Hotel one Sunday.

They had masks on, but not covering their faces.

As the contagion moved into its second year, so did the skepticism.

On Dec. 17, 1918, the San Francisco Board of Supervisors reinstituted the mask ordinance after deaths started to climb, a trend that spilled over into the new year with 1,800 flu cases and 101 deaths reported there in the first five days of January.

That board’s decision led to the creation of the Anti-Mask League, a sign that resistance to masks was resurfacing as cities tried to reimpose orders to wear them when infections returned.

The league was led by a woman, E.J. Harrington, a lawyer, social activist and political opponent of the mayor. About a half-dozen other women filled its top ranks. Eight men also joined, some of them representing unions, along with two members of the board of supervisors who had voted against masks.

“The masks turned into a political symbol,” Dr. Dolan said.

On Jan. 25, the league held its first organizational meeting, open to the public at the Dreamland Rink, where they united behind demands for the repeal of the mask ordinance and for the resignations of the mayor and health officials.

Their objections included lack of scientific evidence that masks worked and the idea that forcing people to wear the coverings was unconstitutional.

On Jan. 27, the league protested at a Board of Supervisors meeting, but the mayor held his ground. There were hisses and cries of “freedom and liberty,” Dr. Dolan wrote in his paper on the epidemic.

Repeal came a few days later on Feb. 1, when Mayor Rolph cited a downturn in infections.

But a third wave of flu rolled in late that year. The final death toll reached an estimated 675,000 nationwide, or 30 for every 1,000 people in San Francisco, making it one of the worst-hit cities in America.

Dr. Dolan said the story of the Anti-Mask League, which has drawn renewed interest now in 2020, demonstrates the disconnect between individual choice and universal compliance.

That sentiment echoes through the century from the voice of a San Francisco railway worker named Frank Cocciniglia.

Arrested on Kearny Street in January, Mr. Cocciniglia told the judge that he “was not disposed to do anything not in harmony with his feelings,” according to a Los Angeles Times report.

He was sentenced to five days in jail.

“That suits me,” Mr. Cocciniglia said as he left the stand. “I won’t have to wear a mask there.”

 

 

 

 

Graphic of the Day: Citizens Who Lost Healthcare Coverage Since the Pandemic Began

Posted on by • Posted in 2020 Election Issues, ACA, Chronic Care Management, Chronic Conditions, Chronic Diseases, Coronavirus, Deferred Healthcare, Employer-Based Health Insurance, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Out of Pocket Expenses, Pandemic, Preexisting Conditions, State of the Union, Underinsured, Unemployment, Unemployment Insurance, Uninsured • Leave a comment

Image may contain: text that says 'CITIZENS WHO LOST HEALTH CARE COVERAGE SINCE THE PANDEMIC BEGAN 27,000,000 US AUSTRALIA BELGIUM CANADA CHILE DENMARK FINLAND FRANCE GERMANY GREECE HUNGARY ITALY JAPAN NEW ZEALAND PORTUGAL SOUTH KOREA SPAIN SWEDEN TURKEY UK'

Cartoon – Jobless Economic Recovery

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Unemployment Figure Cartoons and Comics - funny pictures from ...

Cartoon – Unemployment Rate vs. Unemployed

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Editorial cartoon: The shadow of unemployment

A large racial divide exists in the concern over ability to pay for COVID-19 treatment

Posted on by • Posted in 2020 Election Issues, ACA, Chronic Care Management, Chronic Conditions, Chronic Diseases, Coronavirus, Deferred Healthcare, Employer-Based Health Insurance, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Out of Pocket Expenses, Preexisting Conditions, Prescription Drugs, Short Term Health Insurance, Skinny Health Plans, Social Determinants of Health, Underinsured, Unemployment, Unemployment Insurance, Uninsured, Vaccine • Leave a comment

https://www.healthcarefinancenews.com/news/large-racial-divide-exists-concern-over-ability-pay-covid-19-treatment

Nonwhite adults say they’re either “extremely concerned” or “concerned” about the potential cost of care.

People of color are far more likely to worry about their ability to pay for healthcare if they are diagnosed with COVID-19 than their white counterparts, according to a new survey from nonprofit West Health and Gallup.

By a margin of almost two to one (58% vs. 32%), nonwhite adults report that they are either “extremely concerned” or “concerned” about the potential cost of care. That concern is three times higher among lower-income than higher-income households (60% vs. 20%).

The data come from an ongoing survey about Americans’ experiences with and attitudes about the healthcare system. The latest findings are based on a nationally representative sample of 1,017 U.S. adults interviewed between June 8 and June 30.

There’s also a disturbing trend when it comes to medication insecurity. Overall, 24% of U.S. adults say they lacked money to pay for at least one prescribed medicine in the past 12 months, an increase from 19% in early 2019. Among nonwhite Americans, the burden is growing even more quickly. Medication insecurity jumped 10 percentage points, from 21% to 31%, compared with a statistically insignificant three-point increase among white Americans (17% to 20%).

WHAT’S THE IMPACT?

All of this results in what Tim Lash, chief strategy officer for West Health, called a “significant and increasing racial and socioeconomic divide” in Americans’ views on the cost of healthcare and the impact it has on their lives. When polling started in 2019, one in five Americans were unable to pay for prescription medications within the past 12 months. That number now stands at one in four. The bottom line is that the situation is getting worse.

Amid broad concern about paying for the cost of COVID-19 or other medical expenses, health insurance benefits are likely more important than ever to U.S. workers. The survey found that 12% of workers are staying in a job they want to leave because they are afraid of losing healthcare benefits, a sentiment that is about twice as likely to be held by nonwhite workers as white workers (17% vs. 9%).

However, Americans step across racial lines in their overwhelming support for disallowing political contributions by pharmaceutical companies, and for government intervention in setting price limits for government-sponsored research and a COVID vaccine.

Nearly 9 in 10 U.S. adults (89%) think the federal government should be able to negotiate the cost of a COVID-19 vaccine, while only 10% say the drug company itself should set the price. Similarly, 86% of U.S. adults say there should be limits on the price of drugs that government-funded research helped develop.

Regarding the influence of pharmaceutical companies on the political process, 78% of adults say political campaigns should not be allowed to accept donations from pharmaceutical companies during the coronavirus pandemic.

THE LARGER TREND

Concerns over payment aren’t the only race-related disparities found in healthcare. Dr. Garth Graham, the vice president of community health at CVS Health, said during AHIP’s Institute and Expo in June that although African Americans make up 13% of the U.S. population, they account for about 24% of COVID-19 deaths.

He attributed some of the driving factors for these particular COVID-19-related disparities to the social determinants of health, the over-predominance of African American and Latino frontline workers, and the higher incidence-rates of chronic illness such as diabetes and hypertension in minority groups.

On June 19 – Juneteenth, as it’s known for many Black Americans – 36 Chicago hospitals penned an open letter declaring that systemic racism is a “public health crisis.”

“Systemic racism is a real threat to the health of our patients, families and communities,” the letter reads. “We stand with all of those who have raised their voices to capture the attention of Chicago and the nation with a clear call for action.”

 

 

 

 

30 million unemployed lose extra jobless benefits, as talks between Congress and the White House are at an impasse

Posted on by • Posted in 2020 Election Issues, Coronavirus, Crisis, Crisis Management, Deferred Healthcare, Economic Crisis, Economic Recovery, Employee Furlough, Employee Hiring Freeze, Employee Layoffs, Employee Pay Cuts, Employer-Based Health Insurance, Health Insurance Coverage Adequacy, Infection Control, Infection Control Plan, Infectious Virus, Job, Job Loss, Job Market, Job Search, Job Security, Out of Pocket Expenses, Pandemic, Preexisting Conditions, Public Good, Public Health, Public Safety, Public Welfare, Underinsured, Unemployment, Unemployment Insurance, Uninsured • Leave a comment

https://www.washingtonpost.com/us-policy/2020/07/31/congress-bailout-unemployment-insurance/?utm_campaign=wp_main&utm_medium=social&utm_source=facebook&fbclid=IwAR209BwfddkZBp9kx4ot4BY41ncIlgSEDRHn7Ykg4RwGrys6O1dIUeCBjQY

30 million unemployed to lose extra jobless benefits, as talks ...

White House Chief of Staff Mark Meadows says Democrats rejected reasonable offers to extend unemployment insurance; Pelosi disputes pointing out House passed a bill to extend benefits back in May.

Nearly 30 million workers have lost $600 in enhanced weekly unemployment benefits that have kept much of the economy afloat these past four months during the coronavirus pandemic, as top lawmakers in Congress and the White House remain at an impasse over how and whether to extend the benefits.

Most of the last checks went out this week, but the program officially ended Friday, a day that Democrats and Republicans spent trading barbs over who was to blame for the failed negotiations.

White House Chief of Staff Mark Meadows said Democrats had rejected reasonable offers, while House Speaker Nancy Pelosi (D-Calif.) derided Republicans for trying to advance a short-term fix that would have extended the benefits for just a week.

“The president has been very clear for us to be aggressive and forward-leaning to make sure that they get protected, and yet what we’re seeing is politics as usual from Democrats on Capitol Hill,” Meadows said, addressing reporters in the White House briefing room.

As he was speaking, Pelosi held a news conference on Capitol Hill, where she criticized Republicans for proposing the short-term extension with their backs against the wall.

“What are we going to do in a week?” Pelosi asked as she explained why Democrats rejected the proposal to continue enhanced unemployment benefits at the current $600 weekly level for an additional week.

As many as 30 million workers, including gig workers and the self-employed, are currently receiving some form of unemployment insurance, which has been supplemented by $600 in extra benefits each week — on top of whatever state unemployment benefits a worker gets — since the crisis deepened in March.

Many economists and workers credit the additional money with helping them keep up with basic bills during the crisis: rent, mortgage, car and credit card payments, as well as everyday expenses like food. Most states cap weekly unemployment benefits well below $600; some pay as little as $275 a week as their maximum.

Candida Kevorkian, 53, her son and her daughter-in-law have all been laid off and live together with her two grandchildren in a two-bedroom apartment in South San Francisco, Calif. She worked at the Westin St. Francis hotel; her son worked at the Moscone Center, a convention center downtown; and her daughter-in-law worked at a Marriott.

The extra $600 Kevorkian gets brings her overall jobless benefits to about $1,050 a week before taxes. But she has about $1,700 in other fixed expenses on top of rent, which is $2,350 — after she negotiated with her landlord to lower it from $2,850. The family has already cut back on clothing, shoes and food, including cooking with meat once a week. She says she has little hope that her job will return given how poorly the public health side of the crisis is going, and she said she feels powerless.

“People are taking decisions for you and your life,” she said. “In the middle of this pandemic they’re playing with us.”

Back in March, when the economy was beginning to fail, because of the forced shutdowns to stop the spread of the virus, lawmakers rallied around the idea that they were rushing to shore up the economy through a short-lived public health crisis, agreeing to pass more than $2 trillion in stimulus that they thought would see the nation through the summer, when they hoped the pandemic would ease.

But surging coronavirus cases have spurred many states to reverse course and close down restaurants and bars again, weighing on the economic recovery. The novel coronavirus has killed more than 150,000 people in the United States, according to data gathered by The Washington Post.

Indeed, the pandemic outlasted the original relief efforts Congress passed.

Jim Quebman, 61, an engineer in Thousand Oaks, Calif., was initially told he’d be back at work in two weeks when he was furloughed in March from his job at a machine shop. But the date for his return keeps getting pushed back.

He’s been relying on the $600 he gets from the federal government, in addition to $450 in state benefits, to keep up to date with his monthly payments: $2,200 in property taxes, $1,200 to keep his health insurance once his employer stops paying in August, a $300 car payment and other expenses like food and repairs.

Without the $600, he said he might have to have to raid his 401(k) retirement savings.

“I’ll be in trouble within two months, basically,” he said. “How can you retire if you don’t have a pension and health care, that’s paid by, let’s say, a government.”

Raven Holmes, 38, a single mother of two who lost her job as an secretary in New Haven, Conn., back in February, said she already instituted a series of cuts in anticipation of the benefits’ expiration. She started carpooling to the grocery store, split a BJ’s Wholesale Club card with family to buy food in bulk, and has stopped getting takeout or restaurant food.

She also said she’s begun visiting food banks to help feed her and her two sons.

“Once you have absolutely nothing, it’s not hard at all,” she said, about accepting charity.

The longer Congress stalls, the more likely it is that she will have to plead with her landlord, utility companies, and other bill-holders to let accounts go into arrears until she lands on her feet again.

“Money is not a resource that can be depleted. It’s a man made thing: if you need more make more,” she said. “There are other countries — their citizens are fine, nobody is suffering and everybody is healthy. All our government wants is money in their pockets, while the people are poor and starving and scrounging.”

The wrangling over whether and how to extend jobless benefits has occupied Washington for months.

Eager to avoid blame for Friday’s expiration of the enhanced unemployment aid, Republicans have increasingly coalesced around the idea of a short-term fix. But Democrats have repeatedly rejected that approach and continue pushing for a wide-ranging $3 trillion bill the House passed in May. That bill would extend unemployment benefits through January.

Senate Majority Leader Mitch McConnell (R-Ky.) unveiled a $1 trillion counterproposal Monday, but it was quickly rejected by many members of his own conference and has increasingly seemed irrelevant as Republicans look to a short-term fix.

Senate Republicans have proposed cutting the $600 weekly federal benefit to $200 per week for two months while giving states time to transition to a more complicated system that would aim to replace 70 percent of a worker’s prior wages. A second proposal emerged this week that would give states the choice to implement the $200 bonus or move to a system that would replace up to 66 percent of wages.

Pelosi and Meadows have held meetings for four days straight, along with Treasury Secretary Steven Mnuchin and Senate Minority Leader Charles E. Schumer (D-N.Y.).

Pelosi said such a short-term extension might make sense if a deal were in sight on a larger bill and more time was needed to complete it. But, she said, that is not the state of play as the parties remain far apart.

“We anticipate that we will have a bill, but we’re not there yet,” Pelosi said.

Those who are relying the benefits have been watching the debate unfold wearily.

“Just a few men have to make this decision for how many million people? Ten guys to make a decision over these millions of people’s lives?” said Willie Woods, 60, who has been furloughed from his job as a hotel banquet server in New Orleans since April and is also losing the extra $600 a week in jobless benefits. “This country not taking care of American citizens like they’re supposed to. We didn’t bring this pandemic home. We were at work, and you hit us with a pandemic.”

 

 

 

 

Fewer than 10% of primary care practices have stabilized operations amid COVID-19 pandemic

Posted on by • Posted in 2020 Election Issues, Access, Access & Quality of Healthcare, Cash, Cash Reserves, Deferred Healthcare, Employee Protections, Employer-Based Health Insurance, Financial Pressure, Financial Viability, Financially Distressed, Health Insurance Coverage Adequacy, Health Policy, Healthcare Providers, Office Visit, Out of Pocket Expenses, Pandemic, Pandemic Fatigue, Personal Protective Equipment (PPE), Physician, Physician Practice Management, Preexisting Conditions, Primary Care, Primary Care Delivery Model, Rev Cycle Management, Revenue Cycle, Supply Chain, Telemedicine, Underinsured, Unemployment, Unemployment Insurance, Uninsured, Virtual Healthcare, Virtual Visit, Worker Protection, Worker Rights • Leave a comment

https://www.fiercehealthcare.com/practices/fewer-than-10-primary-care-practices-have-stabilized-operations-amid-covid-19-pandemic?mkt_tok=eyJpIjoiWTJGaE1qTTRaalpsT1dGayIsInQiOiJTNWFxb3VcL3J3ZmE4ZWV0bFwvOGJCYUc0Ukd3TWp4WlM1SzBzT01aeVJIUGlsSWkwNTlVajJxekJqUUsrcWoxZ0IwTUNqVlhTWVJLQmZkSk1XNGtKVEdCOWg3NmRWeFdldFpsSmlONnFvTTFGQ2l1bzQ4S3ZqNWpoaUx2d1pHaSs1In0%3D

Fewer than 10% of primary care practices have stabilized ...

Four months into the COVID-19 pandemic, fewer than 10% of U.S. primary care practices have been able to stabilize operations.

Nearly 9 in 10 primary care practices continue to face significant difficulties with COVID-19, including obtaining medical supplies, meeting the increasing health needs of their patients, and finding sufficient resources to remain operational, according to a recent survey of close to 600 primary care clinicians in 46 states.

Only 13% of primary care clinicians say they are adapting to a “new normal” in the protracted pandemic, the survey found.

More than four months into the pandemic and at a time when 39 states are experiencing an increase of COVID-19 cases, fewer than 4 in 10 clinicians feel confident and safe with their access to personal protective equipment, according to the survey from the Larry A. Green Center in partnership with the Primary Care Collaborative, which was conducted July 10 to July 13.

Among the primary care clinicians surveyed, 11% report that staff in their practice have quit in the last four weeks over safety concerns.

A primary care provider in Ohio said this: “The ‘I can do 4-6 weeks of this’ transition to ‘this feels like a new/permanent normal’ is crushing and demoralizing. Ways to build morale when everyone is at a computer workstation away from other staff (and patients) feels impossible.”

“In the first few months of the pandemic, the country pulled together to stop the spread of the virus, and it seemed like we were making progress. Primary care clinicians and practices were working hard, against tremendous challenges,” said Rebecca Etz, Ph.D., co-director of The Larry A. Green Center in a statement.

“But now the country is backsliding, and it’s clear that primary care doesn’t have enough strength to deal with the rising number of cases. If primary care were a COVID-19 patient, it would be flat on its back,” Etz said.

The survey conducted by the Larry A. Green Center is part of an ongoing series looking at the attitudes of primary care clinicians and patients during the COVID-19 pandemic and the abilities of practices to meet patients’ needs.

Close to 40% of primary care providers report they are maxed out with mental exhaustion and 18% say they spend each week wondering if their practice or job will still be there next week.

In addition to feeling stressed, clinicians and their practices are also experiencing upheaval. The survey found that 22% of clinicians report skipped or deferred salaries, and 78% report preventive and chronic care is being deferred or delayed by patients.

Primary care clinicians report that 42% of in-person volume is down but overall contact with patients is high, while 39% report not being able to bill for the majority of work delivered, the survey found.

“Given the rapidly rising infection rates and persistent lack of PPE, more than a third of primary care clinicians are reporting feeling unsafe at the office, and 20% are cutting back on face-to-face visits while doing more remote outreach,” said Ann Greiner, president and CEO of the Primary Care Collaborative in a statement.

Greiner said this is a clear signal that payers must advance or retain parity for telehealth and telephonic calls.

“It also is a clarion call to move to a new payment system that doesn’t rely on face-to-face visits and that is prospective so practices can better manage patient care,” she said.

Providers say they need more support from private insurers, particularly when it comes to reimbursing for telehealth and telephone visits. 

According to the survey, a primary care doctor in Illinois said, “Recently told we would not be able to conduct telephone visits due to lack of reimbursement. I work in a low-income Medicare population which has low health literacy and no technology literacy. We were 80% telephone and 20% Zoom and in-office. This further exemplifies the extreme health care disparities in the U.S.”