We spend a lot of our time helping health system executives craft and communicate enterprise-level strategy: entering new markets or businesses, developing new services, responding to competitive threats, exploring partnership opportunities. Strategy is about the “what” and “when”—what moves are we going to make, and when is the right time to make them?Answering those questions requires an understanding of industry and market forces, organizational capabilities, and consumer needs. But there’s another important component that often goes missing in the rush to get to the “how” of strategy execution: the “why”.
Yet understanding why we’re pursuing one path and not another is critical for aligning stakeholders: physicians, operators, and (importantly) the board. Joan Didion famously wrote that “we tell ourselves stories in order to live”, and we’d agree; the “why” is about storytelling. What’s the strategic narrative, or story, that frames our intended actions? Making sure that everyone involved—including our patients and consumers—has a clear understanding of why we’re opening a new facility, or launching a new service, or entering into a new partnership, is a key to success.
It’s about sharing the vision of our desired role as a system, and the part we see ourselves playing in improving healthcare. We’re sometimes criticized for spending so much time on “framing” and drawing “pretty graphics”, but we’ve come to believe that the ability to succinctly and compellingly describe the “why” of strategy is as important as coming up with the vision in the first place.And then, of course, delivering on the “why”—a job made easier if all involved are clear on just what it is.
President-elect Joe Biden on Monday announced the members of his coronavirus task force, a group made up entirely of doctors and health experts,signaling his intent to seek a science-based approach to bring the raging pandemic under control.
Biden’s task force will have three co-chairs: Vivek H. Murthy, surgeon general during the Obama administration; David Kessler, Food and Drug Administration commissioner under Presidents George H.W. Bush and Bill Clinton; and Marcella Nunez-Smith, associate dean for health equity research at the Yale School of Medicine. Murthy and Kessler have briefed Biden for months on the pandemic.
Biden will inherit the worst crisis since the Great Depression, made more difficult by President Trump’s refusal to concede the election and commit to a peaceful transition of power. The Trump administration has not put forward national plans for testing, contact tracing and resolving shortages in personal protective equipment that hospitals and health-care facilities are experiencing again as the nation enters its third surge of the virus.
“Dealing with the coronavirus pandemic is one of the most important battles our administration will face, and I will be informed by science and by experts,” Biden said in a statement. “The advisory board will help shape my approach to managing the surge in reported infections; ensuring vaccines are safe, effective, and distributed efficiently, equitably, and free; and protecting at-risk populations.”
The United States is recording more than 100,000 new coronavirus cases a day and, on many days, more than 1,000 deaths, a toll expected to worsen during the crucial 10-week stretch of the transition. It remains unclear whether Trump or his top aides will oversee and lead a robust response to the pandemic during the transition, which could further exacerbate the crisis Biden and Vice President-elect Kamala D. Harris inherit.
The 13-member task force also includes former Trump administration officials, including Rick Bright, former head of the Biomedical Advanced Research and Development Authority, who, after being demoted, spoke out against the administration’s approach to the pandemic. Luciana Borio, director for medical and biodefense preparedness on Trump’s National Security Council until 2019, is also on the panel.
The group includes several other prominent doctors:
· Ezekiel Emanuel, chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania.
· Atul Gawande, a surgeon at Brigham and Women’s Hospital and a professor at Harvard Medical School who is a prolific author.
· Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
· Eric Goosby, global AIDS coordinator under President Barack Obama and professor of medicine at the University of California at San Francisco School of Medicine.
· Celine R. Gounder, clinical assistant professor of medicine and infectious diseases at New York University’s Grossman School of Medicine.
· Julie Morita, executive vice president of the Robert Wood Johnson Foundation, a philanthropy focused on health issues.
· Loyce Pace, president and executive director of the Global Health Council, a U.S.-based nonprofit organization dedicated to global health issues.
· Robert Rodriguez, professor of emergency medicine at the UCSF School of Medicine.
Rebecca Katz, director of the Center for Global Health Science and Security at Georgetown University Medical Center, and Beth Cameron, director for global health security and biodefense on the White House National Security Council during the Obama administration, are serving as advisers to the transition task force.
Task force members will work with state and local officials to craft public health and economic policies to address the virus and racial and ethnic disparities, while also working to reopen schools and businesses, the transition team said in a news release.
While the makeup of the task force garnered widespread praise, Peter Hotez, dean of the National School of Tropical Medicine at the Baylor College of Medicine, said the group needs more geographic diversity.
“They are all from the Acela corridor or the [San Francisco] Bay Area,” he said. “Who is going to be the field marshal or the supreme allied commander who goes into middle of the country and get this done? The coasts are doing okay but the red states are being hammered and the deaths are going to be extraordinary. There needs to be a frank reckoning between leaders of the two parties, to say we cannot let this happen.”
Public health experts said Biden should use the transition to provide leadership as the pandemic continues through a deadly stretch and begin communicating a strong national message.
“Clearly from the election outcomes, half the country doesn’t believe we’re in a crisis,” said Kavita Patel, a fellow at the Brookings Institution who worked on health policy in the Obama administration. Biden and Harris “have an incredible platform that can be used for communication. The country needs clear daily briefings that we thought we’d get from the White House coronavirus task force. They have an incredible platform, if not an official platform.”
Biden plans to call Republican and Democratic governors to ask for their help in developing a consistent message from federal and state leaders, according to three Biden advisers who spoke on the condition of anonymity because they were not authorized to speak publicly about these matters. He will urge governors to adopt statewide mask mandates and to provide clear public health guidance to their constituents, including about social distancing and limiting large gatherings.
The task force will have subgroups that focus on issues related to the response, including testing, vaccine distribution and personal protective equipment, according to two people familiar with the plans who spoke on the condition of anonymity to reveal plans that were not yet public.
In his victory speech Saturday, Biden addressed challenges in bringing the pandemic under control.
“We cannot repair the economy, restore our vitality or relish life’s most precious moments — hugging a grandchild, birthdays, weddings, graduations, all the moments that matter most to us — until we get this virus under control,” Biden said. “That plan will be built on a bedrock of science. It will be constructed out of compassion, empathy and concern. I will spare no effort — or commitment — to turn this pandemic around.”
Yet the plans Biden laid out on the campaign trail are set to collide with political realities. That includes a deeply divided nation in which more than 71 million people voted for Trump and the possibility of having to navigate a Republican-controlled Senate disinclined to support a greater federal role in testing and contact tracing, among other responsibilities now left mostly to the states.
Biden’s most ambitious plans will require significant congressional funding. Senate Majority Leader Mitch McConnell (R-Ky.) has said he would like to pass new coronavirus relief measures during Congress’s lame-duck session, and Congress faces a Dec. 11 government funding deadline. Biden and his team are poised to begin engaging with congressional Democrats on their priorities.
Biden’s plans include dramatically expanding testing and building a U.S. public health jobs corps to have 100,000 Americans conduct contact tracing. They also include ramping up production of personal protective equipment and implementing a vaccine distribution plan.
Murthy, who served as the 19th U.S. surgeon general, is a physician whose nomination was stalled in the Senate for more than a year because of his view that gun violence is a public health issue. Three months into the Trump administration, he was replaced as “the nation’s doctor” with more than two years left on his four-year term.
In 2016, he wrote a landmark report on drug and alcohol addiction, which put that condition alongside smoking, AIDS and other public health crises that previous surgeons general addressed. The report called the addiction epidemic “a moral test for America.” Murthy’s office sent millions of letters to doctors asking for their help to combat the opioid crisis.
The son of immigrants from India, he earned medical and MBA degrees at Yale before joining the faculty at Harvard Medical School, where his research focused on vaccine development and the participation of women and minorities in clinical trials.
After leaving his post as surgeon general, he wrote a book on loneliness and social isolation, including their implications for health, that grew out of his conversations with people in clinical practice and as surgeon general.
Several public health officials celebrated Nunez-Smith’s leadership role on the task force. Her research focuses on promoting health and health-care equity in marginalized populations, according to her Yale biography. She has also studied discrimination that patients endure in the health-care system — expertise that many said was welcome in an epidemic that is disproportionately affecting people of color.
Kessler was FDA commissioner from 1990 to 1997, during the George H.W Bush and Clinton administrations. He is well-known for his attempts to regulate cigarettes — an effort that resulted in a loss in the Supreme Court, which ruled that the agency did not have the authority. That prompted Congress to pass a law, enacted in 2009, that explicitly gave the agency that power.
Kessler, a pediatrician and lawyer, worked at the FDA to accelerate AIDS treatments and on food and nutrition issues. He oversaw the FDA’s development of standardized nutrition labels and notably ordered the seizure of orange juice labeled “fresh” because it was made from concentrate. He has written several books on diet, mental illness and other topics, and has served as dean of the medical schools at Yale and UCSF.
President-elect Joe Biden’s healthcare agenda: building on the ACA, value-based care, and bringing down drug prices.
In many ways, Joe Biden is promising a return to the Obama administration’s approach to healthcare:
Building on the Affordable Care Act (ACA) through incremental expansions in government-subsidized coverage
Continuing CMS’ progress toward value-based care
Bringing down drug prices
Supporting modernization of the FDA
Bolder ideas, such as developing a public option, resolving “surprise billing,” allowing for negotiation of drug prices by Medicare, handing power to a third party to help set prices for some life sciences products, and raising the corporate tax rate, could be more challenging to achieve without overwhelming majorities in both the House and the Senate.
Biden is likely to mount an intensified federal response to the COVID-19 pandemic, enlisting the Defense Production Act to compel companies to produce large quantities of tests and personal protective equipment as well as supporting ongoing deregulation around telehealth. The Biden administration also will likely return to global partnerships and groups such as the World Health Organization, especially in the area of vaccine development, production and distribution.
What can health industry executives expect from Biden’s healthcare proposals?
Broadly, healthcare executives can expect an administration with an expansionary agenda, looking to patch gaps in coverage for Americans, scrutinize proposed healthcare mergers and acquisitions more aggressively and use more of the government’s power to address the pandemic. Executives also can expect, in the event the ACA is struck down, moves by the Biden administration and Democratic lawmakers to develop a replacement. Healthcare executives should scenario plan for this unlikely yet potentially highly disruptive event, and plan for an administration marked by more certainty and continuity with the Obama years.
All healthcare organizations should prepare for the possibility that millions more Americans could gain insurance under Biden. His proposals, if enacted, would mean coverage for 97% of Americans, according to his campaign website. This could mean millions of new ACA customers for payers selling plans on the exchanges, millions of new Medicaid beneficiaries for managed care organizations, millions of newly insured patients for providers, and millions of covered customers for pharmaceutical and life sciences companies. The surge in insured consumers could mirror the swift uptake in the years following the passage of the ACA.
Biden’s plan to address the COVID-19 pandemic
Biden is expected to draw on his experience from H1N1 and the Ebola outbreaks to address the COVID-19 pandemic with a more active role for the federal government, which many Americans support. These actions could shore up the nation’s response in which the federal government largely served in a support role to local, state and private efforts.
Three notable exceptions have been the substantial federal funding for development of vaccines against the SARS-CoV-2 virus, Congress’ aid packages and the rapid deregulatory actions taken by the FDA and CMS to clear a path for medical products to be enlisted for the pandemic and for providers, in particular, to be able to respond to it.
Implications of Biden’s 2020 health agenda on healthcare payers, providers and pharmaceutical and life sciences companies
The US health system has been slowly transforming for years into a New Health Economy that is more consumer-oriented, digital, virtual, open to new players from outside the industry and focused on wellness and prevention. The COVID-19 pandemic has accelerated some of those trends. Once the dust from the election settles, companies that have invested in capabilities for growth and are moving forcefully toward the New Health Economy stand to gain disproportionately.
Shortages of clinicians and foreign medical students may continue to be an issue for a while
The Trump administration made limiting the flow of immigrants to the US a priority. The associated policy changes have the potential to exacerbate shortages of physicians, nurses and other healthcare workers, including medical students. These consequences have been aggravated by the pandemic, which dramatically curtailed travel into the US.
Healthcare organizations, especially rural ones heavily dependent on foreign-born employees, may find themselves competing fiercely for workers, paying higher salaries and having to rethink the structure of their workforces.
Providers should consider reengineering primary care teams to reflect the patients’ health status and preferences, along with the realities of the workforce on the ground and new opportunities in remote care.
Focus on modernizing the supply chain
Biden and lawmakers from both parties have been raising questions about life sciences’ supply chains. This focus has only intensified because of the pandemic and resulting shortages of personal protective equipment (PPE), pharmaceuticals, diagnostic tests and other medical products.
Investment in advanced analytics and cybersecurity could allow manufacturers to avoid disruptive stockouts and shortages, and deliver on the promise of the right treatment to the right patient at the right time in the right place.
Drug pricing needs a long-term strategy
Presidents and lawmakers have been talking about drug prices for decades; few truly meaningful actions have been implemented. Biden has made drug pricing reform a priority.
Drug manufacturers may need to start looking past the next quarter to create a new pricing strategy that maximizes access in local markets through the use of data and analytics to engage in more value-based pricing arrangements.
New financing models may help patients get access to drugs, such as subscription models that provide unlimited access to a therapy at a flat rate.
Companies that prepare now to establish performance metrics and data analytics tools to track patient outcomes will be well prepared to offer payers more sustainable payment models, such as mortgage or payment over time contracts, avoiding the sticker shock that comes with these treatments and improving uptake at launch.
Pharmaceutical and life sciences companies will likely have to continue to offer tools for consumers like co-pay calculators and use the contracting process where possible to minimize out-of-pocket costs, which can improve adherence rates and health outcomes.
View interoperability as an opportunity to embrace, not a threat to avoid or ignore
While the pandemic delayed many of the federal interoperability rule deadlines, payers and providers should use the extra time to plan strategically for an interoperable future.
Payers should review business partnerships in this new regulatory environment.
Digital health companies and new entrants may help organizations take advantage of the opportunities that achieving interoperability may present.
Companies should consider the legal risks and take steps to protect their reputations and relationships with customers by thinking through issues of consent and data privacy.
Health organizations should review their policies and consider whether they offer protections for customers under the new processes and what data security risks may emerge. They should also consider whether business associate agreements are due in more situations.
Plan for revitalized ACA exchanges and a booming Medicare Advantage market
The pandemic has thrown millions out of work, generating many new customers for ACA plans just as the incoming Biden administration plans to enrich subsidies, making more generous plans within reach of more Americans.
Payers in this market should consider how and where to expand their membership and appeal to those newly eligible for Medicare. Payers not in this market should consider partnerships or acquisitions as a quick way to enter the market, with the creation of a new Medicare Advantage plan as a slower but possibly less capital-intensive entry into this market.
Payers and health systems should use this opportunity to design more tailored plan options and consumer experiences to enhance margins and improve health outcomes.
Payers with cash from deferred care and low utilization due to the pandemic could turn to vertical integration with providers as a means of investing that cash in a manner that helps struggling providers in the short term while positioning payers to improve care and reduce its cost in the long term.
Under the Trump administration, the FDA has approved historic numbers of generic drugs, with the aim of making more affordable pharmaceuticals available to consumers. Despite increased FDA generics approvals, generics dispensed remain high but flat, according to HRI analysis of FDA data.
Pharmaceutical company stocks, on average, have climbed under the Trump administration, with a few notable dips due to presidential speeches criticizing the industry and the pandemic.
Providers have faced some revenue cuts, particularly in the 340B program, and many entered the pandemic in a relatively weak liquidity position. The pandemic has led to layoffs, pay cuts and even closures. HRI expects consolidation as the pandemic continues to curb the flow of patients seeking care in emergency departments, orthopedic surgeons’ offices, dermatology suites and more.
Lawmakers and politicians often use bold language, and propose bold solutions to problems, but the government and the industry itself resists sudden, dramatic change, even in the face of sudden, dramatic events such as a global pandemic. One notable exception to this would be a decision by the US Supreme Court to strike down the ACA, an event that would generate a great deal of uncertainty and disruption for Americans, the US health industry and employers.
After an exhausting and contentious election campaign, and a vote count that was prolonged by enormous voter turnout and record-breaking use of early and mail-in voting, the major news networks have now made their calls. Joseph R. Biden, Jr. will be the 46th President of the United States, and Kamala D. Harris will be the first woman, and first person of color, to become Vice President. Securing an electoral victory by achieving razor-thin victories in a number of battleground states, President-elect Biden received the largest number of votes of any candidate in American history. Although the Trump campaign vowed to pursue legal challenges to the validity of the election, Biden’s win appeared to be secure.
The election results came in the midst of a dramatic acceleration of the coronavirus pandemic.Over the last week, the average number of new cases per day in the US surpassed 96,000, up 54 percent from just two weeks earlier. On Friday the nation recorded a pandemic-high 132,700 new cases, along with at least 1,220 COVID deaths. Hospitalizations were up in most states, hospital bed and workforce capacity are strained, and public health experts warned that the coming weeks and months will bring even worse news. Unsurprisingly, the pandemic was a top issue on the minds of voters. According to exit polls, however, the electorate was deeply divided on the issue: 82 percent of Biden voters cited the pandemic itself as one of the most important issues in determining their vote, with only 14 percent of Trump voters agreeing. Conversely, 82 percent of Trump voters said the economy was the most important issue on their minds, as opposed to Biden voters, only 17 percent of whom listed the economy as their top issue. Based on that data, it appears that at least one important split among the electorate was “lives” versus “livelihoods”—whether the pandemic response, or its impact on the economy, was of greatest concern.
In the coming weeks, attention is likely to turn in earnest to addressing both aspects of the issue during the lame duck period. Senate Majority Leader Mitch McConnell (R-KY) has signaled that he intends toresume negotiations on a stimulus package with Democrats in the House, whose majority was diminished in the election. At this writing, it appears likely that control of the Senate will come down to the results of two runoff elections in Georgia, and McConnell will undoubtedly want to make the case that Senate Republicans have taken decisive action to bolster the economic recovery. It’s also possible that, as part of the Trump administration’s Operation Warp Speed, a coronavirus vaccine will be granted approval by the end of the year. Health officials at both federal and state levels must continue to work closely together to tackle the complex logistics of distributing and administering the vaccine, and it will be critical for the incoming administration to seek ways to collaborate with the Trump team to ensure a smooth transition of this vital work.
The outcome of the Senate runoffs in Georgia will determine whether the Biden administration must work with divided Congress, or an evenly split Senate in which Vice President-elect Kamala Harris casts the deciding vote. In either case, given the political realities underscored by the electoral result, it’s very unlikely than any of the more sweeping proposals in the Biden campaign platform—lowering the eligibility age for Medicare, establishing a government-run “public option” insurance plan, extending premium subsidies to middle-income workers—will advance very far. Rather, as we’ve discussed before, we’d expect a Biden administration’s first actions to focus on an enhanced federal response to managing the pandemic, including issuing a national mask mandate, enhancing efforts to augment and coordinate personal protective equipment (PPE) supply, and rejoining the World Health Organization.
As we look to the next two years, most healthcare policy changes are likely to come in the form ofregulatory reform, such as reversing waivers for Medicaid programs to establish work requirements and withdrawing flexibility for short-term plans that fail to comply with the Affordable Care Act (ACA). Other Trump-era regulatory changes might continue. There’s broad bipartisan support for efforts to make value-based Medicare payment reforms more successful, to increase price transparency, and to address the issues of surprise billing and the cost of prescription drugs. But even in if Democrats beat the odds and win back control of the Senate, we believe the Biden administration will have other legislative priorities that will supersede any attempt to dramatically overhaul healthcare coverage—voting reforms, climate change legislation, immigration reform, and long-overdue infrastructure investments.
Unless, that is, the Supreme Court throws a spanner in the works by overturning the ACA. Should the Court rule that the individual mandate is not severable from the rest of the law, and that the entire ACA is unconstitutional, the new administration would be forced to take quick action to protect coverage and insurance protections for millions of Americans. In that event, healthcare would rocket to the top of the agenda. Either the Biden team would be forced to find a compromise solution that could pass a divided Congress, or (if Harris is the tie-breaking vote) find a way to use the budget reconciliation process to address coverage. That potential drama lies months in the future, as we won’t know the outcome of the case until next spring. We’ll monitor the oral arguments in the ACA case closely, and let you know what we hear, and what we think it means for the future of the case.
In the coming weeks, we’ll be watching for answers to some of the big healthcare questions that lie ahead: How will the Trump administration handle the worsening pandemic situation in the 75 days between now and Inauguration Day? Will any new stimulus package include additional economic relief for healthcare providers? When and how will a COVID vaccine become widely available? And perhaps most importantly, what toll will the “third wave” of the pandemic take on a nation already exhausted by a difficult year, and a bitter political fight? Surely one reason to be optimistic is that, having turned out to vote in the largest numbers in a century, Americans are more engaged than ever in finding a way forward amid the problems that confront us. Let’s hope our political leaders from across the ideological spectrum will rise to the occasion, and meet this difficult moment with positive, constructive solutions.
Alignment between CEOs and CFOs has become even more essential during the pandemic.
Many health systems halted elective surgeries earlier this year at the height of the pandemic to conserve resources while caring for COVID-19 patients. Now, in many areas, those procedures are returning and hospitals are slowly resuming more normal operations. But damage has been done to the hospital’s bottom line. Moving forward, the relationship between top executives will be crucial to make the right decisions for patients and the overall health of their organizations.
During the Becker’s Healthcare CEO+CFO Virtual Forum on Aug. 11, CEOs and CFOs for top hospitals and health systems gathered virtually to share insights and strategies as well as discuss the biggest challenges ahead for their institutions. Click here to view the panels on-demand.
Here are six takeaways from the event:
1. The three keys to a strong CEO and CFO partnership are trust, transparency and communication.
2. It’s common for a health system CEO and CFO to have different priorities and different opinions about where investments should be made. To help come to an agreement, they should look at every decision as if it’s a decision being made by the organization as a whole and not an individual executive. For example, there are no decisions by the CFO. There are only decisions by the health system. The CFOs said it’s important to remember that the patient comes first and that health systems don’t exist to make money.
3. Technology has of course been paramount during the pandemic in terms of telehealth. But so are nontraditional partnerships with other health systems that have allowed providers to share research and education.
4. When it comes to evaluating technology, there’s a difference between being on the cutting edge versus the bleeding edge. Investing in new technology requires firm exit strategies. If warning signs show an investment is not going to give the return a health system hoped for, they need to let go of ideals and stick to the exit strategy.
5. Communication and transparency with staff and the public is key while making challenging decisions. Many hard decisions, including furloughs or personnel reductions, were made this spring to protect the financial viability of healthcare organizations. These decisions, which were not made lightly, were critiqued highly by the public. One of the best ways to ensure the message was not getting lost in translation and to help navigate the criticism included creating a communication plan and sharing that with employees, physicians and the public.
6. The pandemic required hospitals to think on their feet and innovate quickly. Many of the usual ways to solve a problem could not be used during that time. For example, large systems had to rethink how to acquire personal protective gear. Typically, in a large health system amid a disaster, when a supply item is running low, organizations can call up another hospital in the network and ask them to send some supplies. However, everyone in the pandemic was running low on the same items, which required innovation and problem-solving that is outside of the norm.
The coronavirus is spreading at dangerous levels across much of the United States, and public health experts are demanding a dramatic reset in the national response, one that recognizes that the crisis is intensifying and that current piecemeal strategies aren’t working.
This is a new phase of the pandemic, one no longer built around local or regional clusters and hot spots. It comes at an unnerving moment in which the economy suffered its worst collapse since the Great Depression, schools are rapidly canceling plans for in-person instruction and Congress has failed to pass a new emergency relief package. President Trump continues to promote fringe science, the daily death toll keeps climbing and the human cost of the virus in America has just passed 150,000 lives.
“Unlike many countries in the world, the United States is not currently on course to get control of this epidemic. It’s time to reset,” declared a report released this week by Johns Hopkins University.
Another report from the Association of American Medical Colleges offered a similarly blunt message: “If the nation does not change its course — and soon — deaths in the United States could be well into the multiple hundreds of thousands.”
The country is exhausted, but the virus is not. It has shown a consistent pattern: It spreads opportunistically wherever people let down their guard and return to more familiar patterns of mobility and socializing. When communities tighten up, by closing bars or requiring masks in public, transmission drops.
That has happened in some Sun Belt states, including Arizona, Florida and Texas, which are still dealing with a surge of hospitalizations and deaths but are finally turning around the rate of new infections.
There are signs, however, that the virus is spreading freely in much of the country. Experts are focused on upticks in the percentage of positive coronavirus tests in the upper South and Midwest. It is a sign that the virus could soon surge anew in the heartland. Infectious-disease experts also see warning signs in East Coast cities hammered in the spring.
“There are fewer and fewer places where anybody can assume the virus is not there,” Gov. Mike DeWine (R) of Ohio said Wednesday. “It’s in our most rural counties. It’s in our smallest communities. And we just have to assume the monster is everywhere. It’s everywhere.”
An internal Trump administration briefing document prepared by the Federal Emergency Management Agency and obtained Friday by The Washington Post counted 453,659 new infections in the past week.
Alaska is in trouble. And Hawaii, Missouri, Montana and Oklahoma. Those are the five states, as of Friday, with the highest percentage increase in the seven-day average of new cases, according to a Post analysis of nationwide health data.
“The dominoes are falling now,” said David Rubin, director of the PolicyLab at Children’s Hospital of Philadelphia, which has produced a model showing where the virus is likely to spread over the next four weeks.
His team sees ominous trends in big cities, including Baltimore, Chicago, Detroit, Indianapolis, Kansas City, Louisville, Philadelphia, St. Louis and Washington, with Boston and New York not far behind. And Rubin warns that the expected influx of students into college towns at the end of this month will be another epidemiological shock.
“I suspect we’re going to see big outbreaks in college towns,” he said.
Young people are less likely to have a severe outcome from the coronavirus, but they are adept at propelling the virus through the broader population, including among people at elevated risk. Numbers of coronavirus-related hospitalizations in the United States went from 36,158 on July 1 to 52,767 on July 31, according to The Post’s data. FEMA reports a sharp increase in the number of patients on ventilators.
The crisis has highlighted the deep disparities in health outcomes among racial and ethnic groups, and data from the Centers for Disease Control and Prevention this week showed thathospitalization rates due to the coronavirus are roughly five times higher among Black, Hispanic and Native Americans than Whites.
Thirty-seven states and Puerto Rico will probably see rising daily death tolls during the next two weeks compared with the previous two weeks, according to the latest ensemble forecast from the University of Massachusetts at Amherst that combines more than 30 coronavirus models.
There are glimmers of progress. The FEMA report showed 237 U.S. counties with at least two weeks of steady declines in numbers of new coronavirus cases.
But there are more than 3,100 counties in America.
“This is not a natural disaster that happens to one or two or three communities and then you rebuild,” said Beth Cameron, vice president for global biological policy and programs at the Nuclear Threat Initiative and a former White House National Security Council staffer focused on pandemics. “This is a spreading disaster that moves from one place to another, and until it’s suppressed and until we ultimately have a safe and effective and distributed vaccine, every community is at risk.”
A national strategy, whether advanced by the federal government or by the states working in tandem, will more effectively control viral spread than the current patchwork of state and local policies, according to a study from researchers at the Massachusetts Institute of Technology published Thursday in the Proceedings of the National Academy of Sciences.
The coordination is necessary because one state’s policies affect other states. Sometimes, that influence is at a distance, because states that are geographically far apart can have cultural and social ties, as is the case with the “peer states” of New York and Florida, the report found.
“The cost of our uncoordinated national response to covid-19, it’s dramatic,” said MIT economist Sinan Aral, senior author of the paper.
Some experts argue for a full six-to-eight-week national shutdown, something even more sweeping than what was instituted in the spring. There appears to be no political support for such a move.
Neil Bradley, executive vice president of the U.S. Chamber of Commerce, said fresh federal intervention is necessary in this second wave of closures. Enhanced federal unemployment benefits expired at the end of July, with no agreement on a new stimulus package in sight.
“Congress, on a bipartisan basis, was trying to create a bridge to help individuals and businesses navigate the period of a shutdown,” Bradley said. “Absent an extension of that bridge, in light of a second shutdown, that bridge becomes a pier. And then that’s a real problem.”
With the economy in shambles, hospitals filling up and the public frustrated, anxious and angry, the challenge for national leadership is finding a plausible sea-to-sea strategy that can win widespread support and simultaneously limit sickness and death from the virus.
Many Americans may simply feel discouraged and overtaxed, unable to maintain precautions such as social distancing and mask-wearing. Others remain resistant, for cultural or ideological reasons, to public health guidance and buy into conspiracy theories and pseudoscience.
DeWine is struggling to get Ohio citizens to take seriously the need to wear masks. A sheriff in rural western Ohio told the governor Wednesday that people didn’t think the virus was a big problem. DeWine informed the sheriff that the numbers in his county were higher per capita than in Toledo.
“The way I’ve explained to people, if we want to have Friday night football in the fall, if we want our kids back in school, what we do in the next two weeks will determine if that happens,” DeWine said.
The crucial metric
The coronavirus has always been several steps ahead of the U.S. government, the scientific community, the news media and the general public. By the time a community notices a surge in patients to hospital emergency rooms, the virus has seeded itself widely.
The virus officially known as SARS-CoV-2 can be transmitted by people who are infectious but not symptomatic. The incubation period is typically about six days, according to the CDC. When symptoms flare, they can be ambiguous. A person may not seek a test right away. Then, the test results may not come back for days, a week, even longer.
That delay makes contact tracing nearly futile. It also means government data on virus transmission is invariably out of date to some degree — it’s a snapshot of what was happening a week or two weeks before. And different jurisdictions use different metrics to track the virus, further fogging the picture.
The top doctors on the White House coronavirus task force, Deborah Birx and Anthony S. Fauci, are newly focused on the early warning signs of a virus outbreak. This week, they warned that the kind of runaway outbreaks seen in the Sun Belt could potentially happen elsewhere. Among the states of greatest concern: Indiana, Kentucky, Ohio and Tennessee.
Fauci and Birx have pointed to a critical metric: the percentage of positive test results. When that figure starts to tick upward, it is a sign of increasing community spread of the virus.
“That is kind of the predictor that if you don’t do something — namely, do something different — if you’re opening up at a certain pace, slow down, maybe even backtrack a little,” Fauci said in an interview Wednesday.
Without a vaccine, the primary tools for combating the spread of the virus remain the common-sense “non-pharmaceutical interventions,” including mask-wearing, hand-washing, staying out of bars and other confined spaces, maintaining social distancing of at least six feet and avoiding crowds, Fauci said.
“Seemingly simple maneuvers have been very effective in preventing or even turning around the kind of surges we’ve seen,” he said.
Thirty-three U.S. states have positivity rates above 5 percent. The World Health Organization has cited that percentage as a crucial benchmark for governments deciding whether to reopen their economy. Above 5 percent, stay closed. Below, open with caution.
Of states with positivity rates below 5 percent, nine have seen those rates rise during the last two weeks.
“You may not fully realize that when you think things are okay, you actually are seeing a subtle, insidious increase that is usually reflected in the percent of your tests that are positive,” Fauci said.
The shutdown blues
Some governors immediately took the White House warnings to heart. On Monday, Kentucky Gov. Andy Beshear (D) said at a news conference that he had met with Birx the previous day and was told he was getting the same warning Texas and Florida received “weeks before the worst of the worst happened.”
To prevent that outcome in his state, Beshear said, he was closing bars for two weeks and cutting seating in restaurants.
But as Beshear pleaded that “we all need to be singing from the same sheet of music,” discord and confusion prevailed.
Iowa Gov. Kim Reynolds (R) said Thursday she wasn’t convinced a mask mandate is effective: “No one knows particularly the best strategy.”
Earlier in the week, Tennessee Gov. Bill Lee (R) demurred on masks and bar closures even as he stood next to Birx and spoke to reporters.
“That’s not a plan for us now,” he said. He added emphatically, “We are not going to close the economy back down.”
The virus is spreading throughout his state, and not just in the big cities. Vacationers took the virus home from the honky-tonks of Nashville and blues clubs of Memphis to where they live in more rural areas, said John Graves, a professor at Vanderbilt University studying the pandemic.
“The geographical footprint of the virus has reached all corners of the state at this point,” Graves said.
In Missouri, Gov. Michael L. Parson (R) was dismissive of New York’s imposition of a quarantine on residents from his state as a sign of a worsening pandemic. “I’m not going to put much stock in what New York says — they’re a disaster,” he said at a news conference Monday.
Missouri has no mask mandate, leaving it to local officials to act — often in the face of hostility and threats. In the town of Branson, angry opponents testified Tuesday that there was no reason for a mask order when deaths in the county have been few and far between.
“It hasn’t hit us here yet, that’s what I’m scared of,” Branson Alderman Bill Skains said before voting with a majority in favor of the mandate. “It is coming, and it’s coming like a freight train.”
Democratic mayors in Missouri’s two biggest cities, Kansas City and St. Louis, said that with so many people needing jobs, they are reluctant to follow Birx’s recommendation to close bars.
“The whole-blanket approach to shut everybody down feels a little harsh for the people who are doing it right,” said Jacob Long, spokesman for St. Louis Mayor Lyda Krewson. “We’re trying to take care of some bad actors first.”
Minneapolis Mayor Jacob Frey also got a warning from Birx. On Wednesday, he said all bar drinking must move outside.
“We don’t want to be heading in the direction of everybody else,” said Kristen Ehresmann, director of the infectious-disease epidemiology division at the Minnesota Department of Health. She acknowledged that some options “are really pretty draconian.”
The problem is that less-painful measures have proven insufficient.
“The disease transmission we’re seeing is more than what would have been expected if people were following the guidance as it is laid out. It’s a reflection of the fact that they’re not,” she said.
‘A tremendous disappointment’
Wisconsin Gov. Tony Evers (D) tried to implement broad statewide measures early in the pandemic, only to have his “Safer at Home” order struck down by the state’s Supreme Court.
With cases in his state rising anew, he tried again Thursday, declaring a public health emergency and issuing a statewide mask mandate.
“While our local health departments have been doing a heck of a job responding to this pandemic in our communities, the fact of the matter is, this virus doesn’t care about any town, city or county boundary, and we need a statewide approach to get Wisconsin back on track,” Evers said.
Ryan Westergaard, Wisconsin’s chief medical officer, said he is dismayed by the failures of the national pandemic response.
“I really thought we had a chance to keep this suppressed,” Westergaard said. “The model is a good one: testing, tracing, isolation, supportive quarantine. Those things work. We saw this coming. We knew we had to build robust, flexible systems to do this in all of our communities. It feels like a tremendous disappointment that we weren’t able to build a system in time that could handle this.”
There is one benefit to the way the virus has spread so broadly, he noted: “We no longer have to keep track of people traveling to a hot spot if hot spots are everywhere.”
We’re hearing from medical groups around the country that in the past few weeks, office visit volumes have quickly approached pre-COVID levels. Some are even busier, running at 110 percent of their February volumes, or more. At the same time, practice has become more stressful, with doctors balancing virtual care with in-person visits, new safety procedures slowing operations, and staff and patients worried about COVID exposure. Everything feels different, and irrespective of the number of patients on today’s schedule, all of the changes make a physician feel like she’s working harder than before.
A chief clinical officer from a Midwestern health system relayed the discord this has created when discussing incentives: “Our doctors were fully on board with the need to reduce salaries back in April, so we all took a 15 percent pay cut through the summer. Now that they’re busy again, they want to be bumped back to 100 percent. But the system’s financial picture hasn’t changed.”
The growing disconnect between how hard many staff are working and the economic reality of the system isn’t unique to doctors. But physicians, most of whom have their compensation tied to individual productivity, may feel it more acutely. While there are no easy solutions, it’s critical to discuss this disconnect openly, rather than letting resentment fester under the surface.
The pandemic has brought to light the brittleness of health system and physician practice finances. Prescient systems will use this moment to work with their doctors to rethink practice and align compensation with the financial success of the system, while meeting doctors’ needs for stability and security.
Healthcare is Hard: A Podcast for Insiders; June 11, 2020
Over the course of nearly 20 years as Chief Research Officer at The Advisory Board Company, Chas Roades became a trusted advisor for CEOs, leadership teams and boards of directors at health systems across the country. When The Advisory Board was acquired by Optum in 2017, Chas left the company with Chief Medical Officer, Lisa Bielamowicz. Together they founded Gist Healthcare, where they play a similar role, but take an even deeper and more focused look at the issues health systems are facing.
As Chas explains, Gist Healthcare has members from Allentown, Pennsylvania to Beverly Hills, California and everywhere in between. Most of the organizations Gist works with are regional health systems in the $2 to $5 billion range, where Chas and his colleagues become adjunct members of the executive team and board. In this role, Chas is typically hopscotching the country for in-person meetings and strategy sessions, but Covid-19 has brought many changes.
“Almost overnight, Chas went from in-depth sessions about long-term five-year strategy, to discussions about how health systems will make it through the next six weeks and after that, adapt to the new normal. He spoke to Keith Figlioli about many of the issues impacting these discussions including:
Corporate Governance. The decisions health systems will be forced to make over the next two to five years are staggeringly big, according to Chas. As a result, Gist is spending a lot of time thinking about governance right now and how to help health systems supercharge governance processes to lay a foundation for the making these difficult choices.
Health Systems Acting Like Systems. As health systems struggle to maintain revenue and margins, they’ll be forced to streamline operations in a way that finally takes advantage of system value. As providers consolidated in recent years, they successfully met the goal of gaining size and negotiating leverage, but paid much less attention to the harder part – controlling cost and creating value. That’s about to change. It will be a lasting impact of Covid-19, and an opportunity for innovators.
The Telehealth Land Grab. Providers have quickly ramped-up telehealth services as a necessity to survive during lockdowns. But as telehealth plays a larger role in the new standard of care, payers will not sit idly by and are preparing to double-down on their own virtual care capabilities. They’re looking to take over the virtual space and own the digital front door in an effort to gain coveted customer loyalty. Chas talks about how it would be foolish for providers to expect that payers will continue reimburse at high rates or at parity for physical visits.
The Battleground Over Physicians. This is the other area to watch as payers and providers clash over the hearts and minds of consumers. The years-long trend of physician practices being acquired and rolled-up into larger organizations will significantly accelerate due to Covid-19. The financial pain the pandemic has caused will force some practices out of business and many others looking for an exit. And as health systems deal with their own financial hardships, payers with deep pockets are the more likely suitor.”