Americans expect the best care from their doctors. Decades of experience, thoughtful interdisciplinary planning, and evidence-based research mean providers are treating them based on widely accepted standards of care.
For example, someone who has experienced a heart attack would never be discharged from a hospital without being prescribed medications to mitigate future cardiac events. A patient with acute pulmonary issues would receive medications and resources for oxygen therapy, if appropriate. Stroke patients receive the acute hospital-based care they need to save their lives, as well as a constellation of other types of care and services to decrease complications and enhance recovery — pharmacological, dietary, and rehabilitative.
Physical therapy and occupational therapy are among the critical standards of care that would be included for all of these patients. These services help form the bedrock of ensuring good outcomes, decreasing secondary injury and complications, and reducing rehospitalizations.
In addition to serving as an important part of post-acute care, physical and occupational therapy provided by licensed therapists can help improve balance and mobility, improve cardiovascular function, reduce pain, and decrease falls. In fact, healthcare associated with falls costs the healthcare system tens of billions of dollars each year — and exercise interventions by physical therapists have helped to lower the risk of falls by 31%.
Eliminating or reducing access to physical and occupational therapy due to Medicare cuts would be devastating to patients’ health outcomes. Not only would it undermine the standards of care for many conditions, it would also complicate the lives and tenuous health situations of the millions of Americans who depend upon it.
Seniors nationwide, therefore, are extremely concerned about the 4.5% cut to their therapy providers in 2023 under the Medicare Physician Fee Schedule. If this cut is implemented, the physical and occupational therapy community will experience cuts totaling approximately 9% by 2024. The continued practice of annual Medicare cuts threatens the sustainability of the country’s physical and occupational providers, especially in rural and underserved areas where they are needed most.
Our nation’s Medicare beneficiaries understand how integral physical and occupational therapy are to standards of care — and they value it deeply. According to a recent survey, 9 out of 10 Americans over the age of 65 have favorable views of physical therapists, and the majority see considerable value in the services they provide. Nearly the same number (88%) expressed concerns that proposed Medicare payment cuts may eliminate alternatives for therapy outside of nursing homes and eliminate seniors’ ability to age in place. More than three in four respondents (76%) say it is important for them to be able to access their physical therapist when they cannot come into the office for an in-person appointment.
Care professionals across the healthcare continuum — from skilled therapists to physicians to nurse practitioners and physicians’ assistants — recognize the negative impact these cuts would have on their patients, and support efforts in Congress to address these cuts in the year ahead.
Bipartisan lawmakers in Congress have introduced legislation to block these harmful cuts from taking effect in 2023, an essential step toward ensuring all Americans can access quality physical therapy and other specialty services. The Supporting Medicare Providers Act of 2022 (H.R. 8800) would block Medicare’s Physician Fee Schedule cuts by providing an additional 4.42% to the conversion factor for 2023.
It’s inconceivable to think we can continue to provide thorough care without one of the most essential elements — therapy. We hope that Congress will act — and quickly before the end of the year — so that our critically important healthcare standards for patients suffering from a multitude of diseases, injuries, and conditions are not irrevocably undermined.
Citi, The American Hospital Association (AHA) and the Healthcare Financial Management Association (HFMA) recently hosted the 22nd annual Not-for-Profit Healthcare Investor Conference. The event was in person, after being virtual in 2021 and canceled in 2020 due to the pandemic. Leaders from over 25 diverse health systems, as well as private equity and fund managers, presented in panel discussions and traditional formats. The following summary attempts to synthesize key themes and particularly interesting work by leading health systems. The conference title was “Refining the Now, Reshaping What’s Next.”
Is Healthcare Headed for Best of Times or Worst of Times?
Clearly the pandemic showed how essential and adaptive the US healthcare industry is, and especially how incredible healthcare workers continue to be. It also exposed and accelerated many underlying dynamics, such as impact of disparities, clinical labor shortages and supply chain challenges. On balance, at this year’s conference presenters remained quite optimistic about the future, and felt that despite enormous pain, the pandemic has helped to accelerate positive transformation across healthcare.
At the same time, almost all presenters referenced future headwinds from labor and supply inflation, concerns about increasing payment pressures, and the continued need to address disparities and social justice. That being said, there was not much disclosure at the conference about just how bad things could get in the future given accelerated operational and financial risks.
As usual at such a conference, there was much passion, creativity, sharing and celebration. While each organization and market differ somewhat, the following are common themes discussed.
Enormous Workforce Challenges – Every speaker referenced workforce as being THE key issue they are facing, specifically retirement, recruitment, retention, well-being and cost. We have talked for years about a future caregiver shortage, but this reality was accelerated by the pandemic. The majority of health systems saw single-digit turnover rates grow to 20-30%, and the cost of temporary labor such as traveling nurses, decimate operating margins. The many strategies discussed at the conference went beyond simply paying more to attract and retain staff. A key question is whether organization-specific strategies will be enough, or whether we need a broader societal and industry-wide collaborative effort to dramatically increase training slots for nurses and other allied health professionals.
Pandemic Stressed Organizations and Accelerated Transformation – At the 2021 virtual Citi/AHA/HFMA conference, many posited that the country was past the worst of the pandemic. (In fact this author’s summary of last year’s conference was titled “Sunrise After the Storm”). That was before the Omicron wave hit hard in Q1 2022. First-quarter 2022 operating margins were negative for most but not all healthcare systems due to cumulative impact of Omicron, temporary labor and supply costs, especially since the governmental support that partially offset those costs in 2020 ended. Organizations and their teams remain resilient, but highly stressed. Risks and challenges associated with future waves continue, as well as high reliance on foreign drug and supply manufacturing. While highly distracting and painful, many organizations discussed how the pandemic actually accelerated the pace of transformation. Necessity drives required action, and at least temporarily overcomes political and cultural barriers to change.
Growing Pursuit of Scale, Including through M&A and Partnerships – All health systems continue to be highly complex with multiple competing “big-dot” priorities. Multiple systems described their current M&A and growth strategies, pursuit of scale, as well as how these strategies were impacted by the pandemic. While the provider community remains highly unconsolidated on a national basis, mergers are more frequent, including between non-contiguous markets. Systems said that larger size, coupled with disciplined management, can reduce cost structure and improve quality and patient experience. While some pursue scale through organic growth initiatives or M&A, others described success in creating scale by leveraging partnerships with “best-in-class” niche organizations and other outside expertise.
Health Equity, Diversity and ESG as Core to Mission – Consistent with last year, most speakers discussed their efforts to address health equity, social justice, diversity, and Social Determinants of Health. Many health systems have developed robust strategies quickly as the pandemic spotlighted the impact of existing disparities. There is increasing interest in Environment, Social and Governance (ESG) initiatives, including environmental stewardship to improve the health of their communities and the world by reducing their carbon footprint and medical waste.
Patient-Centric Care Transformation Continues as a Priority – The pandemic significantly accelerated the shift to telehealth and virtual care. Many health systems are increasing their efforts to design care around the patient instead of the traditional provider centric focus. While the need for inpatient care will always continue, more care is taking place in settings closer to or at home, with digital enablement. Expansion of personalized medicine, genetic testing and therapies, and drug discovery are transforming how healthcare is provided.
Affordability and Value-Based Care – US healthcare costs as a percentage of GDP increased from 18% in 2019 to almost 20% in 2020, mainly driven by the pandemic. There remains a dichotomy between reliance on fee-for-service payment and commitment to value-based care. Although only 11% of commercial payment is currently through two-sided risk arrangements, almost all presenting health systems discussed their strategies to continue moving to value-based care and to improve affordability. Some systems are leveraging their integrated health plans and/or expanding risk-based contracts. Many are trying to reduce unnecessary care through adoption of evidence-based models and to shift care to less costly settings.
Inflation and Accelerating Financial Pressures – Health systems are facing unprecedented increases in labor and supply costs, that are likely to continue into the foreseeable future. At the same time, commercial payment rate adjustments are “sticky low” as insurers and employers push back on rate increases. Governmental payment rate increases are less than cost inflation. In addition to current cuts like the re-implementation of sequestration, longer-term cuts to provider assessment programs, provider-based billing, disproportionate share and Medicaid expansion may severely impact many organizations over time. Benefits like 340b discounts are also experiencing pressure. Post-pandemic clinical-volume trends remain unclear, and additional governmental support associated with future pandemic waves is unlikely. Adding to these challenges, declines in stock and bond prices are negatively impacting currently strong balance sheets.
Conclusion: Best or Worst of Times in Healthcare?
Time will tell, in retrospect, if the next five years will be the best of times, worst of times, or both in healthcare. Optimists point to the resiliency of healthcare organizations; enormous opportunity to reduce unnecessary cost through adoption of evidence-based care and scale; pipeline of new cures and technology; and opportunities to address social and health equity. Pessimists point to likely unprecedented financial pressures and operational challenges due to endemic labor and supply shortages; high-cost inflation vs. constrained payment rates; and future uncertainty about the pandemic, the economy and investment markets.
The situation will undoubtedly vary by market and organization as reflected in conference presentations, but all systems will likely face substantial pressure. As one speaker noted “humans have a great ability to respond to pain,” so this may be the inflection point where more healthcare systems radically accelerate necessary change to improve health, make healthcare more equitable and affordable, with higher quality and better outcomes. Some health systems are clearly doing that, with pace, nimbleness and passion. Can the industry as a whole accomplish it successfully?
The explosion of apps, wearables, and other health tech solutions targeted at employers has overwhelmed and frustrated many HR executives who make decisions about employee health benefits. At a recent convening of health insurance brokers we participated in, several bemoaned the challenge of helping their clients understand which solutions might bring real value.
One shared, “For the past few years, it’s felt like ‘App-apalooza’ out there. CHROs [chief human resource officers] get pitches for new apps every day…there are literally thousands out there saying they’ll reduce costs and improve employee health, but it’s next to impossible to tell which ones of them actually work.”
Brokers expressed surprise at how little evidence, or in some cases, actual patient and client experience, some health tech companies brought to the table: “We have startups coming to our clients talking about their millions of dollars in funding, but when you dig into what they’re actually doing, not only can they not show outcomes data, you find out they’ve only worked with a few dozen patients!”
But among the sea of apps purporting to manage any and every employee health need, from chronic disease to fertility to sleep quality, brokers reported their clients were finding value in a few distinct areas.
Technology-based mental health solutions received high marks for increasing access to care, with the prediction that “tele-behavioral health could become a standard part of most benefits packages very quickly”.
More surprisingly, employers shared positive feedback on the impact of virtual physical therapy solutions: “I was skeptical that it would work, but people like being able to rehab at home. And not only is it cheaper, we’re seeing higher adherence rates.”
But even the best apps are often challenged by a lack of connectivity to the rest of a patient’s healthcare. The technologies that will have the greatest staying power will be those that not only deliver results, but are able to move beyond point solutions to become part of an integrated care experience, meaningfully connected to other providers involved in a patient’s care.
Federal officials waited months before making all American adults eligible for a COVID-19 booster shot — meaning millions of Americans may not have the strongest possible protection as they head into holiday travel.
Why it matters: Critics say the confusing process undermined what has now become a critical effort to stave off another wave of the pandemic.
Most vaccinated people, even without a booster, still have very strong protection against serious illness or death. But a third shot drastically increases people’s defenses against even mild infections, which could in turn help reduce the virus’ spread.
And some vulnerable vaccinated adults are at risk of serious breakthrough cases.
What they’re saying: “We have a consensus. Boosters are very important in maintaining people’s defenses against COVID. We need to get as many people vaccinated and boosted [as possible] as the winter sets in,” David Kessler, the chief science officer of Biden’s COVID response, said in an interview.
Context: Preliminary data released months ago suggested a significant decline in the vaccines’ effectiveness at preventing infection, although they held up well against severe disease.
Based on that data, the Biden administration had hoped to begin allowing booster shots in September for any American adult who was at least eight months removed from their second dose.
The CDC and the FDA opted instead to only authorize boosters for seniors, people with high-risk medical conditions and people at high risk of infection, before opening them last week to everyone at least six months out from their initial shots.
In the meantime, red and blue states alike decided to ignore the CDC and open up booster eligibility on their own, and breakthrough infections have become increasingly common.
Millions of people who weren’t technically eligible for boosters got them anyway, and a large portion of the most vulnerable patients still haven’t gotten one.
Where it stands: Only 41% of vaccinated Americans 65 and older have received a booster shot, as have 20% of all vaccinated adults, per the CDC.
“Some of us were there several months ago. Some wanted more data. In the end, there’s a convergence of opinions. It’s the way an open scientific public health process should work,” Kessler said.
Between the lines: The U.S. drug approval process — with its insistence on high-quality data and careful expert reviews — is the world’s gold standard precisely because it moves deliberately. Regulators have been trying this whole time to figure out how to adapt that system to a fast-moving pandemic.
Some federal officials, as well as many outside experts, said there wasn’t enough data to make a broad booster recommendation earlier this fall.
Early on, many public health experts also argued that it was unethical to give Americans a third shot while much of the rest of the world awaited their first shots.
Israel embraced boosters before the U.S. beginning over the summer, and its emerging data has been key to making the case that boosters are needed and can help bring surges under control. However, experts still don’t know how long the enhanced protection they give will last.
What they’re saying: “Some argued early on that the primary series was good enough and we should conserve doses for the world. What’s emerging is that all people in the world are going to need to be boosted,” a senior administration official said.
“Everyone has a different threshold for how much data they need in making a decision,” the official added. “What made this different is that there’s a pandemic underway, and many saw we were heading into a winter surge.”
As a long hoped-for sign of the “return to normal”, most children went back to in-person learning this fall. And with the patchwork of COVID safety protocols and masking policies across school districts, classrooms became a learning lab for scientists studying the efficacy of masking and other precautions.
Unsurprisingly, getting a bunch of unvaccinated kids back together caused a surge in pediatric COVID cases. But recent Centers for Disease Control and Prevention (CDC)data from 500 counties demonstrate just how effective mask mandates have been at mitigating outbreaks.
The graphic above shows that cases in counties without school mask mandates increased at nearly three times the rate of those with mask mandates. In the five-week period spanning the start of the school year, cases in counties without a mask mandate rose by 62.6 cases per 100K children, while cases in counties with a mask mandate rose by only 23.8 per 100K. COVID outbreaks are incredibly disruptive to learning; according to a recent KFF survey, nearly a quarter of parents report their child has already had to quarantine at home this school year following a possible COVID exposure.
Even once vaccines are approved for children under 12, recent data suggest that a majority of parents will be hesitant to vaccinate their child. Just over half of 12- to 17-year-olds have received at least one dose of the vaccine so far, and only a third of parents of 5- to 11-year-olds plan to vaccinate their child right away, once the shot is approved.
Many want more information, or are worried about side effects—concerns that will best be assuaged by their pediatricians and other trusted sources of unbiased information.
Two pieces of hopeful news on the COVID front this week.
First, pharmaceutical manufacturer Merck announced this morning that molnupiravir, the oral antiviral drug it developed along with Ridgeback Biotherapeutics, reduced hospitalizations among newly diagnosed COVID patients by 50 percent. A five-day course of the drug was so successful in Merck’s clinical study that an independent monitoring group recommended halting the study and submitting the pill to the Food and Drug Administration (FDA) for emergency use authorization. Molnupiravir is activated by metabolism, and upon entering human cells, is converted into RNA-like building blocks, causing mutations in the COVID virus’s RNA genome and interfering with its replication. For that reason, the drug is unlikely to be prescribed during pregnancy, but otherwise the therapy seems to hold great promise in adding to the limited armamentarium available to fight the pandemic. One possible concern: the drug’s price tag. The federal government has agreed to purchase 1.7M courses of the drug at $700 per course, and with most insurance companies having returned to normal cost-sharing for COVID treatments, the drug may be out of reach for some patients. Still, a major clinical development to be celebrated, and more to come as Merck’s drug is vetted by the FDA.
At $20 to $40 per dose, with costs fully absorbed by the federal government, and remarkable effectiveness at preventing severe disease, hospitalizations, and deaths, vaccines remain far and away our best frontline weapon for fighting the COVID pandemic. Promising, then, that the much-debated vaccine mandates have begun to demonstrate success in increasing vaccination rates, even among those who have thus far resisted getting the shot.
Despite concerns about massive staffing shortages among hospitals resulting from the implementation of its mandate, the state of New York found that 92 percent of healthcare workers had been vaccinated by Monday, when the mandate went into effect. That was a 10-percentage-point increase from a week earlier, holding promise that the Biden administration’s planned federal mandate for healthcare workers could have the desired effect.
California’s mandate for healthcare workers went into effect yesterday, and was credited with boosting vaccination rates to 90 percent at many of the state’s health systems. Among private employers considering mandates, the experience of United Airlines may also be instructive: its employee mandate led to the vaccination of more than 99 percent of its workers, resulting in the termination of only 700 of its 67,000 employees. Of course, everyone prefers carrots to sticks, but sweepstakes and bonuses have only gotten so far in encouraging people to get vaccinated—now it appears mandates have a useful role to play as well.
With 56 percent of the population fully vaccinated, the US now ranks 43rd among nations, just ahead of Saudi Arabia and far behind most of Europe. In the next few days we’ll reach the grim milestone of 700,000 COVID deaths in this country—anything that helps stop that number from growing further should be welcome news.
Interest in the antiparasitic drug Ivermectin has increased drastically as of late thanks to the belief that it can help to prevent and/or treat Covid-19. In today’s episode we examine recent data on the efficacy of Ivermectin as an antiviral and discuss the history behind how it gained this reputation.
Howard Stern was reflecting this week on the coronavirus deaths of four conservative talk-radio hosts who had espoused anti-vaccine and anti-mask sentiments when he took aim at those who have refused to get vaccinated.
“I want my freedom to live,” he said Tuesday on his SiriusXM program. “I want to get out of the house. I want to go next door and play chess. I want to go take some pictures.”
The shock jock, who advocated for the coronavirus vaccine to be mandatory, then turned his attention to the hesitancy that has played a significant role in the U.S. spread of the virus, leading to what Rochelle Walensky, director of the Centers for Disease Control and Prevention, has called a “pandemic of the unvaccinated.”He pointed to unvaccinated people who are “clogging” up overwhelmed hospitals, calling them “imbeciles” and “nut jobs” and suggesting that doctors and nurses not treat those who have not taken a coronavirus vaccine.
“I’m really of mind to say, ‘Look, if you didn’t get vaccinated [and] you got covid, you don’t get into a hospital,’ ” he said. “You had the cure and you wouldn’t take it.”
Stern’s comments come after several other celebrities expressed to their large social media audiences their frustration with the ongoing lag in vaccinations when hospitals are being pushed to their limits by the highly transmissible delta variant.
More than 185,000 coronavirus infections were reported Wednesday across the United States, according to data compiled by The Washington Post. Nearly 102,000 people are hospitalized with covid-19; more than 26,000 are in intensive care units. A slight decline in hospitalizations over the past week has inspired cautious optimism among public health leaders.
While there is not a nationwide vaccine mandate, President Biden is expected to sign an executive order Thursday requiring that all federal employees be vaccinated, without an alternative for regular coronavirus testing to opt out of the mandate, The Post reported. The order affecting the estimated 2.1 million federal workers comes as Biden plans to outline a “robust plan to stop the spread of the delta variant and boost covid-19 vaccinations,” the White House said.
Health officials, doctors and nurses nationwide have urged those still hesitant to get vaccinated — and some have gone a step further. Jason Valentine, a physician in Mobile, Ala., informed patients last month that he would not treat anyone who was unvaccinated, saying there were “no conspiracy theories, no excuses” preventing anyone from being vaccinated. Linda Marraccini, a doctor in South Miami, said this month that she would not treat unvaccinated patients in person, noting that her office would “no longer subject our patients and staff to unnecessary risk.”
The summer surge also has led celebrities to use their platform to either call on unvaccinated people to get vaccinated or to denounce them for not doing so. Actor and activist Sean Penn said the vaccine should be mandatory and has called on Hollywood to implement vaccination guidelines on film sets. Actors Benicio Del Toro and Zoe Saldana were part of a vaccine video campaign this year to help debunk misinformation about coronavirus vaccination. When actress Melissa Joan Hart revealed her breakthrough coronavirus case last month, she said she was angry that the nation “got lazy” about getting vaccinated and that masking was not required at her children’s school.
Late-night talk host Jimmy Kimmel suggested Tuesday that hospitals shouldn’t treat unvaccinated patients who prefer to take ivermectin — a medicine long used to kill parasites in animals and humans that has soared in popularity despite being an unproven covid-19 treatment and the subject of warnings by health officials against its use for the coronavirus. After noting that Anthony S. Fauci, the chief medical adviser to Biden, warned that some hospitals might be forced to make “tough choices” on who gets an ICU bed, the late-night host quipped that the situation was not difficult.
“That choice doesn’t seem so tough to me,” Kimmel said. “Vaccinated person having a heart attack? Yes, come right in; we’ll take care of you. Unvaccinated guy who gobbled horse goo? Rest in peace, wheezy.”
Stern has featured front-line workers on his show and has advocated for people to get vaccinated against the coronavirus. In December, the host interviewed Cody Turner, a physician at the Cleveland Clinic, about how the front-line doctor struggled with his mental health while treating infected patients when a vaccine was not widely available.
“We are drowning and we are in hell, and people don’t understand, not only what’s happening to people, you know, but patients across this country,” Turner said.
Stern was a fierce critic of President Donald Trump’s response to the pandemic, saying last year that his former friend was “treasonous” for telling supporters to attend large rallies, despite the risk of infection, in the run-up to the presidential election.
On his eponymous program this week, Stern referred to four conservative talk-radio hosts who bashed the vaccine and eventually died of the virus: Marc Bernier, 65; Phil Valentine, 61; Jimmy DeYoung, 81; and Dick Farrel, 65. In the weeks and months leading up to their deaths last month, all four men had publicly shared their opposition to mainstream public health efforts when coronavirus infections were spiking.
“Four of them were like ranting on the air — they will not get vaccinated,” Stern said Tuesday. “They were on fire … they were all dying and then their dying words were, ‘I wish I had been more into the vaccine. I wish I had taken it.’ ”
After he played a clip of Bernier saying he would not get vaccinated, Stern suggested that the coronavirus vaccine be considered as normal as a measles or mumps vaccine.
“When are we going to stop putting up with the idiots in this country and just say it’s mandatory to get vaccinated?” he asked.