Headlines recently blared about the new review that looked at how effective masks are at preventing the transmission of flu-like disease. Cochrane reviews are well respected, and the media coverage about the recent review has been hard to parse. So is that it, end of story on masks? Not if you skip the media headlines and read the actual review!
https://mailchi.mp/28f390732e19/the-weekly-gist-march-10-2023?e=d1e747d2d8
While hospitals, payers, and private equity firms have long been competing to acquire independent physician groups, the COVID pandemic spurred a marked acceleration of the physician employment trend, with non-hospital corporate entities leading the charge.
The graphic above uses data released by consulting firm Avalere Health and the nonprofit Physicians Advocacy Institute to show that nearly three quarters of American physicians were employed by a larger entity as of January 2022, up from 62 percent just three years prior.
While hospitals employ a majority of those physicians, corporate entities (a group that includes payers, private equity groups, and non-provider umbrella organizations) have been increasing their physician rolls at a much faster rate.
Corporate entities employed over 40 percent more physicians in 2022 than in 2019, and in the southern part of the country—a hotspot for growth of Medicare Advantage—corporate physician employment grew by over 50 percent.
We expect the move away from private practice, accelerated by the pandemic, will only continue as physicians seek financial returns, secure a path to retirement, and look to access capital for necessary investments to help grow and manage the increasing complexities of running a practice.
https://mailchi.mp/28f390732e19/the-weekly-gist-march-10-2023?e=d1e747d2d8
Published this week in the Washington Post, this sobering article surveys the dismantling of our nation’s patchwork public health infrastructure, driven by a backlash to COVID pandemic restrictions. Positioning themselves as defenders of freedom, a coalition of conservative and libertarian activists, legislators, and judges have neutered many of the nation’s public health authorities. State health officials and governors in over half the country are now unable to issue mask mandates or order school closures without the permission of their state legislatures.
While the implications for a hypothetical “next COVID” are dire, we’re already seeing the consequences today: officials in Columbus, OH can no longer, for example, quarantine a child with measles, or shut down a restaurant experiencing a hepatitis A outbreak.
The Gist: The anti-public health backlash in the wake of COVID has now been codified, with far reaching consequences for future disease outbreaks. COVID protections for hospital-based healthcare providers are winding down, even in states like California which quickly embraced masking.
But now in over half the country, many reasonable responses to unknown future health threats won’t even be on the table, or will involve debate and legislative action, wasting precious response time.
In his second State of the Union speech on Feb. 7, President Joe Biden made it clear that the Administration is moving into the next phase of the COVID-19 pandemic—one in which the threats of disease and death are considerably diminished, and therefore no longer require the resources and urgent allocation of funds that the previous two years have.
“While the virus is not gone…we have broken COVID’s grip on us,” Biden said. “And soon we’ll end the public health emergency.”
The President outlined his reasons for not renewing the COVID-19 national and public health emergencies when they expire on May 11, which have been extended every 90 days since they were established in 2020. The decision represents a de-escalation in the way the government is treating the pandemic.
But health experts say now is not the time to let down our collective guard on SARS-CoV-2. “I don’t believe the virus has gotten the memo that the pandemic is winding down,” says Dr. Jeffrey Glenn, director of the Stanford Biosecurity and Pandemic Preparedness Initiative.
“There is a disconnect between the broad perception that the pandemic is behind us, and focusing on getting back to life as it was pre-pandemic,” says Wafaa El-Sadr, founder and director of the International Center for AIDS Care and Treatment Programs (ICAP) at Columbia University’s Mailman School of Public Health. “But the reality is that we still continue to have substantial transmission and deaths due to COVID in the U.S., and we are in a situation where the virus will be with us for a long time.”
Even when the emergency states end, therefore, the pandemic will not be over, they and others say.
One reason is that the definition of a “pandemic” is primarily based on the breadth and speed of a virus’ spread, and the amount of the world affected by a pathogen. It’s only partially related to the severity of disease caused by a virus like SARS-CoV-2, or even the amount of immunity a population may have against it.
By that main criterion, COVID-19 is still very much with us, with around 200,000 new cases and 1,000 deaths a day globally. The latest Omicron variants quashed any hope of the pandemic ending any time soon. While they do not cause more serious infections than past variants, they have mastered the challenge of hopping more efficiently from one infected person to another.
Even though the pandemic is far from over, many health experts agree that ending the U.S. national emergencies is justified at this point. When these measures were first implemented in 2020, most people were immunological sitting ducks for the virus. The declarations were designed to devote financial resources and personnel to controlling the impact of infections on the population’s health as much as possible by shoring up the health care system and later by providing free vaccinations. U.S. officials decided to end the national and public health emergencies in May primarily because most people have either been vaccinated or have recovered from an infection (or both), so the population’s immunity stands at a higher level. COVID-19 cases—both overall and the severe kind—have declined considerably since those early days.
But the continuing stream of infections means that the virus is still reproducing and churning out mutations. So far, those variants haven’t caused more serious disease—but that’s purely by chance, which makes public health experts uncomfortable with declaring victory just yet. Even though COVID-19 cases are no longer inundating most hospitals, that means it’s time to rethink the COVID-19 response, not abandon it.
The best way forward at this point is to refine and target COVID-19 services to optimize the chances of controlling the virus where it may be causing the most health problems. “I think we need to move away from universal guidance on vaccines and boosters and mitigation measures where everybody gets the same guidance, to a more differentiated and tailored approach based on the different characteristics—both socioeconomic and clinical—of different groups of people,” says El-Sadr. “We are at a different moment in the pandemic, so the moment is now for a different message.”
That message isn’t to put COVID-19 completely behind us, but to move forward armed with the lessons we’ve learned from our experience—the most important of which is never to underestimate SARS-CoV-2.
https://mailchi.mp/3a7244145206/the-weekly-gist-december-9-2022?e=d1e747d2d8
The long hours, stressful conditions, and labor shortages brought on by the pandemic have done serious harm to the physician workforce. The graphic above tracks physician burnout, a combination of emotional exhaustion, loss of agency, and depersonalization that has become the primary measure of the pandemic’s toll on workers, to reveal that physicians are demoralized like never before.
Physician burnout levels had been decreasing since 2014, in part due to practice consolidation and the expansion of team-based care models. Burnout reached its lowest levels in 2020—perhaps explained by a pandemic-induced sense of purpose—but 2021 then saw a dramatic spike in every measure of physician dissatisfaction, as the heroic glow of the early pandemic faded, and an overtaxed and understaffed delivery system became the new norm.
In explaining how the pandemic has impacted their career decisions, surveyed physicians list unsustainable burnout and stress as their top concern, and 11 percent say they have exited the profession, either for retirement or a non-clinical job, in the past two years. Four in ten surveyed physicians report changing jobs since 2020, mainly within similar or different practice settings, citing a desire for better work-life balance as their primary motivation. (It should be caveated that these data are from a smaller survey of 534 physicians, 40 percent of whom identified as “early career”.)
While the solutions here aren’t new, they are challenging: we must continue to implement team-based care models that provide physicians top-of-license practice and improved work-life balance, remove administrative tasks wherever possible, and ensure that we are communicating and engaging physicians—employed and independent alike—in organizational strategy and decision-making.
A viral hurricane is making landfall on health care systems battered by three pandemic years. With the official start of winter still weeks away, pediatric hospitals are facing crushing caseloads of children sick with RSV and other viral illnesses. Schools that promised a “return to normal” now report widespread absences and even closures from RSV and flu in many parts of the country, contributing to parents missing work in record numbers. With this year’s flu season beginning some six weeks early, the CDC has already declared a flu epidemic as hospitalizations for influenza soared to the highest point in more than a decade.
A storm of these proportions should demand not only crisis clinical measures, but also community prevention efforts. Yet instead of deploying public health strategies to weather the storm, the U.S. is abandoning them.
Even before the arrival of the so-called tripledemic, U.S. health systems were on the brink. But as the fall surge of illness threatens to capsize teetering hospitals, the will to deploy public health measures has also collapsed. Pediatricians are declaring “This is our March 2020” and issuing pleas for help while public health efforts to flatten the curve and reduce transmission rates of Covid-19 — or any infectious disease — have effectively evaporated. Unmanageable patient volumes are seen as inevitable, or billed as the predictable outcome of an “immunity debt,” despite considerable uncertainty surrounding the scientific underpinnings and practical utility of this concept.
The Covid-19 pandemic should have left us better prepared for this moment. It helped the public to understand that respiratory viruses primarily spread through shared indoor air. Public health practices to stop the spread of Covid-19 — such as masking, moving activities outdoors, and limiting large gatherings during surges — were incorporated into the daily routines of many Americans. RSV and flu are also much less transmissible than Covid-19, making them easier to control with common-sense public health practices.
Instead of dialing up those first-line practices as pediatric ICUs overflow and classrooms close, though, the U.S. is relying on its precious and fragile last lines of defense to combat the tripledemic: health care professionals and medical facilities.
Warnings and advisories recently issued by U.S. public health leaders, clinical leaders, politicians, and the media have consistently neglected to mention masking as a powerful short-term public health strategy that can blunt the surge of viral illness. Instead, recent guidance has exclusively promoted handwashing and cough etiquette. These recommendations run counter to recent calls to build on improved understanding of the transmission of respiratory viruses.
In the U.S.’s efforts to “move on” from thinking about Covid, it has created a “new normal” that is deeply abnormal — one in which we normalize resorting to crisis measures, such as treating patients in tents, instead of using common-sense public health strategies. Treating Covid like the flu — or the flu like Covid — has effectively meant that we treat neither illness as if it were a serious threat to health systems and to public health. Mobilizing Department of Defense troops and Federal Emergency Management Agency personnel to cover health system shortfalls is apparently more palatable than asking people to wear masks.
The tripledemic has already claimed its first child deaths in the U.S., adding to a large ongoing death toll from Covid. Allowing health systems to reach the brink of collapse will lead to many more preventable deaths among pediatric and other vulnerable patients who can’t access the care they need.
By any accounting, these losses are shocking and tragic. But they should strike us as particularly abhorrent and shameful because the tripledemic is a crisis that leaders, health agencies, and institutions have, in a sense, chosen. Over the past year, the Biden administration and its allies have repeatedly encouraged the public to stand down on public health measures, with the President even stating in September that “the pandemic is over.” By moving real risks out of view and failing to push for more robust measures to mitigate Covid, these messages have put the country on a path to its present circumstances, in which pediatric RSV patients are transferred to hospitals hundreds of miles away because there is no capacity to treat them in their own communities.
Living with viruses should mean embracing simple public health measures rather than learning to live with staggering levels of illness and death. Leaders in public health and medicine should issue timely and appropriate guidance that reflects the latest science instead of second-guessing the prevailing winds in public opinion. Instead of self-censoring their recommendations out of fear of political consequences, they should continue to promote the full range of public health strategies, including masking in crowded indoor public places during surges.
The tripledemic should bring renewed urgency to policies that will reduce the toll of seasonal illness on health, education, and the economy. Improvements in indoor air quality in public spaces, including schools, child care centers, and workplaces, can limit the spread of diseases and have many demonstrated health and economic benefits, yet the U.S. continues to lack standards to guide infrastructure or workplace safety standards. Paid leave enabling workers to stay home when they are ill can reduce the transmission of disease as well as loss of income, yet the U.S. is one of the only high-income countries without universal paid sick leave or family medical leave.
Greater effort must also be made to increase vaccination coverage for flu and Covid and bring an RSV vaccine online as quickly as possible. Only about half of high-risk adults under 65 received a flu shot last year, a gap that can be closed with more energetic vaccination campaigns. Reducing annual flu deaths using a broader range of strategies enabled by the pandemic — rather than pegging Covid deaths to them — should be the goal.
Amid the many sobering stories of the tripledemic, there is some good news. As the experience of Covid-19 has shown, it is possible to limit the toll of respiratory viruses like flu and RSV. However, this work requires resources, appropriate policies, and political will. Americans don’t need to accept winter disease surges and overrun health systems as an inevitable new normal. Instead, the country should see the tripledemic as a call to reinvigorate public health strategies in response to these threats to the health of our communities.
https://www.axios.com/2022/11/26/china-covid-outbreak-lockdown-economy
A new COVID calamity is hammering China, with a surge in infections prompting a return of lockdowns, including in some manufacturing areas that supply the West.
Why it matters: In addition to the human misery for the world’s most populous country, the effects will be felt around the globe, Axios China author Bethany Allen-Ebrahimian reports from Taipei.
Rare protests broke out today in China’s far western Xinjiang region. Crowds shouted at hazmat-suited guards after a deadly fire triggered anger by prolonged COVID lockdowns, Reuters reports.
What’s happening: The moment of truth for China’s zero-COVID policy has finally come.
Reality check: China’s doctors have warned Xi Jinping that the healthcare system isn’t prepared for the huge outbreak likely to follow the easing of strict anti-COVID measures, the Financial Times reports.
The big picture: “Zero COVID” restrictions have damaged the economy and undermined people’s trust in government.
Between the lines: Chinese leaders made a huge, politically motivated mistake. They resisted the import of Western-made mRNA vaccines (including Pfizer and Moderna) for its citizens. These vaccines were only recently made available to foreigners.
https://www.axios.com/2022/11/28/china-dilemma-unwinding-covid-zero
China is facing an increasingly precarious situation as new COVID cases soar and the population seems to be hitting a breaking point with the government’s stringent zero-tolerance policies.
Why it matters: The world’s most populous nation has massive vulnerabilities heading into this winter, starting with the fact the vast majority of its population has yet to be exposed to the virus and has little ‘natural immunity.’
State of play: Overall, China’s number of reported COVID cases and COVID deaths are far lower than other nations, but there have been recent reported spikes in overall numbers of cases and some new deaths.
Reality check: China’s doctors have warned that the health care system isn’t prepared for the huge outbreak likely to follow any easing of public health measures, Axios’ Bethany Allen-Ebrahimian writes.
Between the lines: Another concern is the potential evolution of a new, more dangerous variant if there’s a huge surge of infections, Christian Drosten, Germany’s most prominent virologist, told Bloomberg.
Be smart: China’s officials are scrambling to address the vaccine problem.
The bottom line: China’s zero-COVID policy has kept cases in China relatively low compared to the rest of the world.
https://www.advisory.com/daily-briefing/2022/10/10/covid-resurgence
While infections, hospitalizations, and deaths from Covid-19 have been steadily declining in the United States in recent months, experts warn that rising cases in Europe may be “a harbinger for what’s about to happen in the United States,” Rob Stein writes for NPR’s “Shots.”
Currently, several models project that U.S. Covid-19 infections will continue to decline at least until the end of 2022. However, researchers caution that there are multiple variables that could change current projections, including whether more infectious strains start circulating around the nation.
According to Stein, “[t]he first hint of what could be in store is what’s happening in Europe.” Recently, many European countries, including the U.K., France, and Italy, have seen an increase in Covid-19 infections.
“In the past, what’s happened in Europe often has been a harbinger for what’s about to happen in the United States,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “So I think the bottom line message for us in this country is: We have to be prepared for what they are beginning to see in Europe.”
“We look around the world and see countries such as Germany and France are seeing increases as we speak,” said Lauren Ancel Meyers, director of the UT COVID-19 Modeling Consortium at the University of Texas at Austin. “That gives me pause. It adds uncertainty about what we can expect in the coming weeks and the coming months.”
However, Justin Lessler, an epidemiologist at the University of North Carolina who helps run the COVID-19 Scenario Modeling Hub, noted that the United States may not have the same experience as Europe, largely because it is unclear whether Europe’s increase is related to individuals’ vulnerability to new strains.
“If it is mostly just behavioral changes and climate, we might be able to avoid similar upticks if there is broad uptake of the bivalent vaccine,” Lessler added. “If it is immune escape across several variants with convergent evolution, the outlook for the U.S. may be more concerning.”
Some researchers believe the United States is already experiencing early signs of this. “For example, the levels of virus being detected in wastewater is up in some parts of the country, such in Pennsylvania, Connecticut, Vermont and other parts of Northeast,” Stein writes. “That could an early-warning sign of what’s coming, though overall the virus is declining nationally.”
“It’s really too early to say something big is happening, but it’s something that we’re keeping an eye on,” said Amy Kirby, national wastewater surveillance program lead at CDC.
According to David Rubin, the director of the PolicyLab at Children’s Hospital of Philadelphia, which tracks the pandemic, Covid-19 infections and hospitalizations are already rising in some parts of New England, and other northern regions, including the Pacific Northwest.
“We’re seeing the northern rim of the country beginning to show some evidence of increasing transmission,” Rubin said. “The winter resurgence is beginning.”
Unless a “dramatically different new variant emerges,” it is “highly unlikely this year’s surge would get as severe as the last two years in terms of severe disease and deaths,” Stein writes.
“We have a lot more immunity in the population than we did last winter,” said Jennifer Nuzzo, who leads the Pandemic Center at the Brown University School of Public Health.
“Not only have people gotten vaccinated, but a lot of people have now gotten this virus. In fact, some people have gotten it multiple times. And that does build up [immunity] in the population and reduce overall over risk of severe illness,” Nuzzo said.
Another factor that could affect the severity of the impact of rising infections is the number of people who receive updated Covid-19 vaccines, which help boost waning immunity from previous infections or shots.
However, the United States’ booster uptake has been slow. “Nearly 50% of people who are eligible for a booster have not gotten one,” said William Hanage, an associate professor of epidemiology at the Harvard T.H. Chan School of Public Health. “It’s wild. It’s really crazy.”
Since updated boosters became available in September, less than 8 million of the over 200 million people who are eligible have received one.
According to Nuzzo, it is critical for people to stay up to date on their vaccines, especially with the high likelihood of another Covid-19 surge. “The most important thing that we could do is to take off the table that this virus can cause severe illness and death,” Nuzzo said.
“There are a lot of people who could really benefit from getting boosted but have not done so,” she added.
https://www.medpagetoday.com/opinion/second-opinions/101004?trw=no
Millions are about to lose Medicaid while still eligible.
President Biden recently said that the pandemic is “over.” Regardless of how you feel about that statement or his clarification, it is clear that state and federal health policy is and has been moving in the direction of acting as if the pandemic is indeed over. And with that, a big shoe yet to drop looms large — millions of Americans are about to lose their Medicaid coverage, even though many will still be eligible. This amounts to a self-inflicted wound of lost coverage and a potential crisis for access to healthcare, simply because of paperwork.
An August report from HHS estimated that about 15 million Americans will lose either Medicaid or Children’s Health Insurance Program (CHIP) coverage once the federal COVID-19 public health emergency (PHE) declaration is allowed to expire. Of these 15 million, 8.2 million are projected to be people who no longer qualify for Medicaid or CHIP — but nearly just as many (6.8 million) will become uninsured despite still being eligible.
Why Is This Happening?
This Medicaid “cliff” will happen because the extra funding states have been receiving under the Families First Coronavirus Response Act (FFCRA) since March 2020 was contingent upon keeping everyone enrolled by halting all the bureaucracy that determines whether people are still eligible. Once all the processes to redetermine eligibility resume, the lack of up-to-date contact information, requests for documentation, and other administrative burdens will leave many falling through the cracks. A wrong address, one missed letter, and it all starts to unravel. This will have potentially devastating implications for health.
When Will This Happen?
HHS has said they will provide 60 days’ notice to states before any termination or expiration of the PHE — and they haven’t done so yet. It also seems incredibly unlikely that they would announce an end date for the PHE before the midterm elections, as that would be a major self-inflicted political wound. So, odds are that we are safe until at least January 2023 — but extensions beyond that feel less certain.
What Are States Doing to Prepare?
CMS has issued a slew of guidance over the past year to help states prepare for the end of the PHE and minimize churn, another word for when people lose coverage. Some of this guidance has included ways to work with managed care plans, which deliver benefits to more than 70% of Medicaid enrollees, to obtain up-to-date beneficiary contact information, and methods of conducting outreach and providing support to enrollees during the redetermination process.
However, the end of the PHE and the Medicaid redetermination process will largely be a state-by-state story. Georgetown University’s Center for Children and Families has been tracking how states are preparing for the unwinding process. Unsurprisingly, there is considerable variation between states’ plans, outreach efforts, and the types of information accessible to people looking to renew their coverage. For example, less than half of all states have a publicly available plan for how the redetermination process will occur. While CMS has encouraged states to develop plans, they are not required to submit their plans to CMS and there is no public reporting requirement.
Who Will Be Hurt Most?
If you dig into the HHS report, you will see that the disenrollment cliff will likely be a disaster for health equity — as if the inequities of the pandemic itself weren’t enough. A majority of those projected to lose coverage are non-white and/or Latinx, making up 52% of those losing coverage because of changes in eligibility and 61% among those losing coverage because of administrative burdens. Only 17% of white non-Latinx are projected to be disenrolled inappropriately, compared to 40% of Black non-Latinx, 51% of Asian American, Native Hawaiian, and Pacific Islander, and 64% of Latinx people — a very grim picture. This represents a disproportionate burden of coverage loss, when still eligible, among those already bearing inequitable burdens of the pandemic and systemic racism more generally.
Another key population at risk are seniors and people with disabilities who have Medicaid coverage, or those who aren’t part of the Modified Adjusted Gross Income (MAGI) population. Under the Affordable Care Act, states are required to redetermine eligibility at renewal using available data. This process, known as ex parte renewal, prevents enrollees from having to respond to, and potentially missing, onerous re-enrollment notifications and forms. Despite federal requirements, not all states attempt to conduct ex parte renewals for seniors and people with disabilities who have Medicaid coverage, or those who aren’t qualifying based on income. Excluding these groups from the ex parte process has important health equity implications, leaving already vulnerable groups more exposed and at risk for having their coverage inappropriately terminated.
What Can Be Done?
There are ways to mitigate some of this coverage loss and ensure people have continued access to care. HHS recently released a proposed rule that would simplify the application for Medicaid by shifting more of the burden of the application and renewal processes onto the government as opposed to those trying to enroll or renew their coverage. We could also change the rules to allow states to use more data, like information collected to verify eligibility for the Supplemental Nutrition Assistance Program (SNAP), in making renewal decisions, rather than relying so much on income. The Biden administration also made significant investments into navigator organizations, which can help those who are no longer eligible for Medicaid transition to marketplace coverage. Furthermore, states should use this as an opportunity to determine the most effective ways to reach Medicaid enrollees by partnering with researchers to test different communication methods surrounding renewals and redeterminations.
As the federal government and state Medicaid agencies continue to prepare for the end of the PHE, it is critical that they consider who these burdensome processes will affect the most and how to improve them to prevent people from falling through the cracks. More sick Americans without access to care is the last thing we need.
HENRY KOTULA 