Trump sidelines public health advisers in growing rift over coronavirus response

https://www.washingtonpost.com/health/trump-sidelines-public-health-advisers-in-growing-rift-over-coronavirus-response/2020/07/09/ad803218-c12a-11ea-9fdd-b7ac6b051dc8_story.html?fbclid=IwAR0MI5VGiJQmUsyEpzYDj09Q0VVxxYMlHwx-UjfHdmMu1PdGD6uIzv8R2fM&utm_campaign=wp_main&utm_medium=social&utm_source=facebook

The Health 202: Health officials promise to ramp up pandemic ...

The June 28 email to the director of the Centers for Disease Control and Prevention was ominous: A senior adviser to a top Health and Human Services Department official accused the CDC of “undermining the President” by putting out a report about the potential risks of the coronavirus to pregnant women.

The adviser, Paul Alexander, criticized the agency’s methods, and said its warning to pregnant women “reads in a way to frighten women . . . as if the President and his administration can’t fix this and it is getting worse.”

As the country enters a frightening phase of the pandemic with new daily cases surpassing 62,000 on Wednesday, the CDC, the nation’s top public health agency, is coming under intense pressure from President Trump and his allies, who are downplaying the dangers in a bid to revive the economy ahead of the Nov. 3 election. In a White House guided by the president’s instincts, rather than by evidence-based policy, the CDC finds itself forced constantly to backtrack or sidelined from pivotal decisions.

The latest clash between the White House and its top public health advisers erupted Wednesday, when the president slammed the agency’s recommendation that schools planning to reopen should keep students’ desks six feet apart, among other steps to reduce infection risks. In a tweet, Trump — who has demanded schools at all levels hold in-person classes this fall — called the advice “very tough & expensive.”

“While they want them open, they are asking schools to do very impractical things. I will be meeting with them!!!” Trump tweeted Wednesday. Within hours, Vice President Pence had asserted the agency would release new guidance next week.

“The president said today we just don’t want the guidance to be too tough,” Pence told reporters. “And that’s the reason next week the CDC is going to be issuing a new set of tools.”

Analysts say the deepening divide is undermining the authority of one of the world’s premier public health agencies, which previously led fights against malaria, smallpox and HIV/AIDS. Amid the worst public health crisis in a century, the CDC has in recent months altered or rescinded recommendations on topics including wearing masks and safely reopening restaurants and houses of worship as a result of conflicts with top administration officials.

“At a time when our country needs an orchestrated, all-hands-on deck response, there is simply no hand on the tiller,” said Beth Cameron, former senior director for global health security and biodefense on the White House National Security Council.

In the absence of strong federal leadership, state and local officials have been left to figure things out for themselves, leading to conflicting messaging and chaotic responses. Trump’s decision to pull the U.S. out of the World Health Organization further undermined efforts to influence global strategies against the coronavirus, including how vaccines will be distributed.

The CDC, meanwhile, is increasingly isolated — a function both of its growing differences with the White House and of its own significant missteps earlier in the outbreak.

Those stumbles include the botched rollout of test kits likely contaminated at a CDC lab in late January, which led to critical delays in states’ ability to know where the virus was circulating. And the CDC’s initial decision to test only a narrow set of people gave the virus a head start spreading undetected across the country.

During a May lunch with Senate Republicans, Trump told the group the CDC “blew it” on the coronavirus test and that he’d installed a team of “geniuses” led by his son-in-law Jared Kushner to handle much of the response,” according to two people familiar with the lunch who spoke on the condition of anonymity.

“There is a view the CDC is staffed with deep state Democrats that are trying to tweak the administration,” said one adviser who also spoke on the condition of anonymity to reveal private conversations.

White House officials, who see the president’s reelection prospects tied to economic recovery, also say they’ve been deeply frustrated by what they view as career staffers at the agency determined “to keep things closed,” according to a senior administration official who spoke on the condition of anonymity to reveal internal deliberations.

Trump believes the CDC is “ineffective” and a “waste of time,” but doesn’t blame CDC Director Robert Redfield and generally likes him, said another official speaking on the condition of anonymity. “He just thinks he is a poor communicator,” the official added.

Joe Grogan, former head of the White House Domestic Policy Council, said Redfield had fans inside the White House who work on “addiction issues, on life issues, on HIV issues,” among other topics.

But he said Redfield has few political appointees to help him run a complex agency. “How do you run a place like that with … [few] appointees?” Grogan asked.

HHS Secretary Alex Azar called the director “a key scientific guide for the President and his administration, a trusted source for the American people, and a closely engaged partner of state and local governments.”

But Redfield is not a voice in coronavirus task force meetings, and “is never really in the Oval [Office] with the president,” said another senior administration official, who also spoke on the condition of anonymity to discuss the internal dynamics.

Even Redfield’s supporters say he has failed to be an effective advocate for the agency.

“Bob Redfield’s commitment to public health is completely strong,” said William Schaffner, a veteran infectious-disease specialist at Vanderbilt University. But he said Redfield lacks the standing, deftness, and communication capacity to persuade skeptical audiences, including those in the White House, that protecting public health and fostering economic recovery are not opposing goals.

Redfield, for his part, downplayed Trump’s criticism of the CDC school reopeniing guidelines after a coronavirus task force briefing Wednesday, saying the agency and the president were “totally aligned.”

“We’re both trying to open the schools,” he said.

White House spokesman Judd Deere also disputed big differences, saying in a statement the White House and the CDC “have been working together in partnership since the very beginning of this pandemic to carry out the President’s highest priority: the health and safety of the American public.

“The CDC is the nation’s trusted health protection agency and its infectious disease and public health experts have helped deliver critical solutions to save lives. We encourage all Americans to continue to follow the CDC’s guidelines and use best-practices they have learned, such as social distancing, face coverings, and good hygiene, to maintain public health and continue our Transition to Greatness.”

But some health experts were indignant the agency had been ordered to rewrite guidance to reopen schools to “make it easier and cost less” — a demand that effectively “turns science on its head,” said Tom Inglesby, director of Johns Hopkins University’s Center for Health Security.

“CDC should be giving their best judgments on how to lower risks to make schools safer,” he said. “That’s their job. If they aren’t allowed to do that, the public will lose confidence in the guidance.”

Why are they ‘not shouting “fire”?’

The diminished role of the 74-year-old agency has bewildered infectious-disease experts, as well as members of the public seeking guidance.

After six states set one-day case records on July 3, Carlos del Rio, executive associate dean at Emory University’s School of Medicine, tweeted at Tom Frieden, a former CDC director, “Tom, where is @CDCgov ? Why are they not out there shouting ‘fire’?”

Frieden shot back: “They are still there, still doing great work, just not being allowed to talk about it, not being allowed to guide policy, not being allowed to develop, standardize, and post information that would give, by state and county, the status of the epidemic and of our control measures.”

Jeffrey Duchin, the health officer at Seattle and King County health department, added: “Agree. Muzzled, neutered and exiled.”

The agency has been largely invisible. After more than three months of silence, it resumed briefings for the public last month. There have been two.

By comparison, when the H1N1 swine flu pandemic hit the United States in the spring of 2009, the CDC held briefings almost every day for six consecutive weeks.

During this outbreak, the agency’s regular briefings ended abruptly after White House officials were angered when a top CDC leader warned that Americans could face “significant disruption” to their lives as a result of the virus’s spread to the United States.

CDC officials say they are still getting their message out, pointing to more than 2,000 documents providing pandemic-related information about reopening and staying safe for dozens of groups and venues, including funeral home directors, amusement parks, and pet owners. Each Friday, the CDC also posts CovidView, a weekly report of selected data and trends on testing, hospitalizations, and reported deaths.

But the information is posted without additional explanation or analysis.

“I want to hear a real person give me three minutes based on these findings,” said del Rio, also a global health and infectious-disease professor at Emory. “I want to see them in the news, being interviewed, giving us the data.”

Scientists at the CDC and former colleagues speak of deep frustration and low morale over its inability to fully share and explain scientific and medical information.

Researchers are fearful for their jobs and want to protect the integrity of the data they release. “If you want to say something, you’re thinking, ‘what’s the White House going to say and how are they going to use it,’ ” said one longtime scientist who spoke on the condition of anonymity for fear of retaliation.

The lack of briefings has fostered misunderstandings at times. In early April, for instance, when the agency reversed its position and recommended the use of cloth face coverings, CDC scientists gave no public briefings explaining why they made the change.

“It’s not rocket science,” said Nancy Cox, a virologist and former CDC official who led the influenza program for 22 years and was part of the agency’s response during the 2009 H1N1 swine flu pandemic. “But the reasoning behind those changes should be explained as clearly as possible and then you can get everyone on board.”

In the CDC’s absence, academic medical centers, public health and professional disease groups have filled the void by holding coronavirus briefings and providing analysis of key issues, data and research studies. Frieden, the president of Resolve to Save Lives, a New York nonprofit, has also been posting long Twitter threads analyzing the weekly CDC data released on Fridays.

Speaking ‘with an unfettered voice’

Alarmed at the agency’s diminished role, nearly 350 public health organizations sent a letter Tuesday to Azar urging him to advocate for the CDC. The agency must be allowed to speak based on the best available science “and with an unfettered voice,” said John Auerbach, president and chief executive of Trust for America’s Health, a public health nonprofit that led the effort.

House Democrats echoed those concerns in a separate letter to Azar last month. Reps. Diana DeGette of Colorado and Frank Pallone Jr. of New Jersey, who chairs the House Energy and Commerce Committee, said they were troubled by reports that administration officials are considering narrowing the CDC’s mission and embedding more political appointees at the Atlanta-based agency.

Traditionally the CDC has one political appointee, the director. Now it has Redfield and five other political appointees, including two advisers who were added in recent weeks.

“Now more than ever, the American people need a robust and effective CDC that is not repeatedly undermined by others in the administration, including the President and the Vice President,” the letter said.

White House Chief of Staff Mark Meadows views the agency as a problem and has criticized the CDC repeatedly to other administration officials, said a senior administration official.

White House and HHS officials are discussing what the CDC’s “core mission needs to be,” said one adviser familiar with the talks who spoke on the condition of anonymity to comment on policy deliberations. The discussions were first reported by Politico.

Over the years, the agency that was founded to fight malaria now works on virtually every aspect of public health. “It has tried to be everything to everyone,” the adviser said, suggesting the agency might need to refocus more narrowly.

On the global front, administration officials are also weighing a $2.5 billion initiative called the President’s Response to Outbreaks that would move a significant portion of national and international pandemic responses to the State Department, according to a draft obtained by The Post. Details were first reported by Devex.

“There is no clear leadership role for CDC” in this plan, said Jennifer Kates, a senior vice president for global health and HIV policy at the Kaiser Family Foundation. “In global health, you need an engaged CDC.”

Taken together, the administration efforts seem “designed to position CDC to the margins,” said one federal health official who spoke on the condition of anonymity for fear of retaliation.

‘Boogeyman where there aren’t any’

The report that drew the email attack, accusing the agency of undermining the president, had provided detailed but incomplete information about pregnancy risks related to the coronavirus. It found pregnant women with covid-19 were more likely to be hospitalized, admitted to an intensive care unit, and to need ventilator support than infected women who are not pregnant.

The sender, Alexander, a specialist in health research methods, is a senior adviser to Michael Caputo, a longtime Trump ally who was recently appointed assistant HHS secretary for public affairs , which includes the CDC.

The email was directed to Redfield and Caputo.

Even amid the intense criticism of the agency, the email “crosses the line,” said the official, who was aware of the content.

Like all of the CDC’s reports, the analysis itself noted several limitations. One key one that researchers acknowledged was that they did not have data to indicate whether the pregnant women were hospitalized because of labor and delivery, or because they had covid-19.

Administration officials are “seeing political boogeymen where there aren’t any,” the federal health official said, adding that such narratives could further hamper the U.S. response.

“It could feed the fire to limit the flow of scientific data and communication to the general population,” the official said. “People are getting sick and dying. Can we just focus on the science?”

Alexander said in his email that the lack of data about why women were hospitalized was a “key issue.”

“The CDC is undermining the President by what they put out, this is my opinion and sense, and I am reading it and can see the subtle and direct hits,” he wrote.

Alexander, also a part-time assistant professor at McMaster University in Hamilton, Ontario, did not respond to emails and telephone calls seeking comment.

Caputo said in an interview that he agreed with Alexander. The CDC represents itself as the gold standard for public health agencies, he said, “but in the case of pregnancy analysis, it wasn’t even bronze.”

He called CDC’s track record “spotty” and “questionable,” pointing to Zika diagnostic testing errors in 2016.

“In many cases over the years, regardless of administration, the CDC has undermined presidents and themselves,” Caputo said, referring to leaked drafts of CDC guidances. “Who says the CDC is the sole font of wisdom when it comes to detecting and fighting deadly pathogens?”

Experts say that even with some big unanswered questions, the pregnancy findings represent the best available evidence and are important. The lack of data reflects decades of long-neglected national surveillance on pregnancy.

“I don’t think this is frightening women,” said Denise Jamieson, who heads the obstetrics and gynecology department at Emory University and Emory Healthcare. True, the report “suffers from completeness of data,” she said. But now doctors can be more confident that pregnant women are more likely to have severe disease and use “this really important information” to counsel patients, she said.

 

 

Merkel says pandemic reveals limits of ‘fact-denying populism’

https://thehill.com/policy/international/506393-merkel-says-pandemic-reveals-limits-of-fact-denying-populism?fbclid=IwAR1gnqKU3igIHkK-e2p4iZjGPTfswBYJFMjvf3ewGH9uRPNIp5ROr6y5qns#.XwZdo2fqr7s.facebook

Covid-19 has exposed the limits of 'fact-denying populism', Merkel ...

German Chancellor Angela Merkel told European Union (EU) countries Wednesday that the coronavirus pandemic is showing the limits of “fact-denying populism” as she urged the bloc to reach an agreement on an economic recovery package.

Merkel said that the EU “must show that a return to nationalism means not more, but less control,” according to France 24.

Without naming any specific nations, Merkel said: “We are seeing at the moment that the pandemic can’t be fought with lies and disinformation, and neither can it be with hatred and agitation.”

“Fact-denying populism is being shown its limits,” she added. “In a democracy, facts and transparency are needed. That distinguishes Europe, and Germany will stand up for it during its presidency.”

The pandemic has killed more than 100,000 people in the 27 EU nations and sparked what is expected to be the largest recession the continent has experienced in decades.

On Tuesday the EU released a report predicting the bloc’s economy will contract more than initially expected due to coronavirus-related lockdowns.

Merkel on Wednesday joined EU Economy Commissioner Paolo Gentiloni in urging the commission to quickly reach an agreement on the 750 billion-euro stimulus package proposed earlier this year.

“The depth of the economic decline demands that we hurry,” Merkel told lawmakers, according to The Associated Press. “We must waste no time — only the weakest would suffer from that. I very much hope that we can reach an agreement this summer. That will require a lot of readiness to compromise from all sides — and from you too.

 

 

 

 

Outsourcing A Hospital Turnaround And The Team Involved

Outsourcing A Hospital Turnaround and The Team Involved

Outsourcing A Hospital Turnaround and The Team Involved - HealthTechS3

Hospitals are constantly faced with challenges that require them to reassess how they deliver care to their communities.  Continuous improvement is necessary as expense inflation consistently outpaces reimbursement gains.  However, more fundamental issues threaten hospital fiscal viability such as payor mix deterioration, population or market share declines, and utilization changes. Amplify this environment with a difficult EMR installation and a “perfect storm” creates a fiscal crisis that necessitates a turnaround.

If covenants are breached, bond agreements often require an external and independent consulting firm that is engaged to help create and oversee the implementation of a turnaround plan.  Otherwise, a CEO must make a value judgment on whether to outsource the turnaround balancing cost considerations with an honest assessment of (1) their management team’s bandwidth, and (2) ability to prepare and execute a turnaround.

There are multiple models for outsourcing a turnaround.  In a complete outsourcing, an engagement letter with the “performance improvement” consulting firm would include an assessment phase and the preparation of a comprehensive plan that covers all areas of operations followed by implementation support services.  The firm may require an on-site presence of one year or more to assess, validate, and assist in the implementation of recommended interventions.  This can be effective, but the fees can easily reach seven figures even for modest community hospitals.  In addition, even in a complete outsourcing there is still a major demand on the time of senior leadership.  As a result, management sometimes chooses to limit the scope of a performance improvement engagement, which results in a partial outsource.  The limitation may be to only outsource the plan development in the form of a report.  This would detail the operational interventions and the implementation steps, but it would leave the heavy lifting of implementation to existing leadership.   Alternatively, the scope may be limited by excluding certain areas of review.  While there may be valid reasons for the latter approach, limiting the areas of review can be counterproductive to a turnaround plan because many issues are systemic such as patient throughput or revenue cycle.  Further, restricting certain areas for review may create the appearance of “untouchables” or “sacred cows,” which should be avoided in a turnaround.

While the CEO should always be the ultimate leader of the turnaround, the CFO is indispensable in the process whether it is fully or partially outsourced or done completely in-house.  These abilities are not always in the CFO’s skill set; some executives are most effective in a steady-state as opposed to a turnaround environment. The CEO will be relying on the CFO to demonstrate the following traits, which require a large degree of emotional intelligence:

  • Delegate some responsibility to their lieutenants but communicate the financial imperative and manage overall execution of the turnaround
  • Appropriately raise the alarm when progress is not being made. Too much alarm can be seen as crying wolf and too little can add to complacency.
  • Do not be averse to confrontation but do not create it where it is not necessary. Only use the CEO for those most difficult situations where it cannot be avoided to ensure execution remains on point.

Human nature dictates that self-interest may compromise the CFO’s objectivity.  There will be times when the best interest of the organization and the individual are in conflict.  If the incumbent CFO is not up to the task, replacing them with an interim CFO with turnaround experience is a better option.

An experienced interim CFO in a turnaround situation has several advantages.   First, it can afford the CEO the opportunity to underscore the urgency of the situation by making an example. The experienced interim CFO understands their primary role is to be a key asset in the execution of the turnaround.   They are not there to make friends but to influence people (although the best ones do both).  Because they are not angling for promotions or favor for future consideration from the board, they are apolitical, and their intentions are more transparent.  Having been through turnarounds before, they possess the tools to assist the CEO and the board navigates the ups and downs.  Perhaps most importantly, the interim CFO is in the best position to tell the CEO and the board things they may not want to hear such as the need to give up independence or consult bankruptcy counsel if the situation warrants.

Obviously, it is necessary that the hospital must continue to operate safely, securely, and legally during a turnaround.  This can be a difficult balancing act, not just for the CFO but for all senior management.  The CFO must continue to safeguard the assets of the organization.  Likewise, other members of senior management must push back if a turnaround plan may imperil patients, visitors or staff, or violate the law.  Consequently, it may be beneficial to bring in other interim C-Suite leaders who are able to effectively manage the multiple critical priorities during a turnaround in addition to, or instead of, an interim CFO.  However, this must be carefully weighed against continuity of management and the organization’s ability to attract and retain talent.  Senior management turnover creates stress on the organization and is ultimately a reflection on the CEO.

There is not a one-size-fits-all approach to creating and executing a turnaround plan.  Outsourcing to consulting firms can infuse new ideas and analytical talent, but it is expensive and still often leaves management with the bulk of the responsibilities.  Experienced interim management can add independence and objectivity to create a glidepath for execution.

 

 

 

 

Fauci: US seeing ‘disturbing’ new surge of infections

https://thehill.com/policy/healthcare/504087-fauci-country-seeing-disturbing-new-urge-of-infections?userid=12325

Fauci: US seeing 'disturbing' new surge of infections | TheHill

Anthony Fauci, the administration’s top infectious disease doctor, told a House panel on Tuesday that the country’s response to the COVID-19 pandemic has been a “mixed bag,” adding that a new increase in cases is “disturbing.”

“In some respects, we’ve done very well,” Fauci said during an Energy and Commerce Committee hearing, specifically praising the way New York has been containing the worst outbreak in the country to date.

“However, in other areas of the country, we are now seeing a disturbing surge of infections that looks like it’s a combination, but one of the things is an increase in community spread. And that’s something I’m really quite concerned about,” Fauci said.

There are now about 30,000 new cases per day in the United States. The number of new cases had leveled off at about 20,000, and stayed there for weeks before rising this past weekend.

The rise in the U.S. comes as the Trump administration has sought to paint a rosier picture of the U.S. outlook. Both President Trump and Vice President Pence have inaccurately tried to attribute the increase in cases to more tests being performed.

The new spike in the U.S. is being driven in part by worsening outbreaks across the South and Southwest, including in Arizona, Texas, Florida and the Carolinas, even as the situation has greatly improved in once hard-hit states in the Northeast like New York and Massachusetts.

Many of the states now being hit hard were on the more aggressive side in reopening their economies.  

“Right now, the next couple of weeks are going to be critical in our ability to address those surgings in Florida, in Texas, in Arizona, and in other states,” Fauci said on Tuesday.

 

 

 

 

A Scalpel Instead Of A Sledgehammer: The Potential Of Value-Based Deductible Exemptions In High-Deductible Health Plans

https://www.healthaffairs.org/do/10.1377/hblog20200615.238552/full/?utm_campaign=HASU+6-21-20&utm_medium=email&utm_content=COVID-19%3A+Face+Mask+Mandates%2C+Immigration+Detention+Facilities%2C+Symptom+Monitoring%3B+Treatment+Of+Opioid+Use+Disorder%3B+Supreme+Court+LGBT+Decision%3A+Implications+For+The+ACA&utm_source=Newsletter

UM V-BID Center (@UM_VBID) | Twitter

High-deductible health plans (HDHPs) covered more than 30 percent of enrollees in employer-sponsored plans in the United States in 2019, up from 4 percent in 2006. In 2020, the Internal Revenue Service defines HDHP as any plan with a deductible of at least $1,400 for an individual or $2,800 for a family. An HDHP’s total yearly out-of-pocket expenses (including deductibles, copayments, and coinsurance) cannot be more than $6,900 for an individual or $13,800 for a family. However, this limit does not apply to out-of-network services.

The growth of HDHPs is driven by the pursuit of reduced health care spending and premiums for both employees and employers through channeling elements of consumerism and managed care. Often, HDHPs are offered along with a savings option (health savings account or health reimbursement arrangement) in a consumer-directed health plan.

Recently, however, there have been concerns about the out-of-pocket cost burdens imposed on patients by HDHPs and other plans. Reducing these costs has been the focus of major policy proposals, including prescription drug bills from both the House and the Senate; forthcoming plans for the Center for Medicare and Medicaid Innovation to test value-based insurance models following the president’s executive order 13890 on Protecting and Improving Medicare for Our Nation’s Seniors; and H.R. 2774, the Primary Care Patient Protection Act of 2019, which would create a primary care benefit for all HDHP holders, allowing for up to two deductible-free primary care office visits each year.

It is becoming increasingly clear that HDHPs’ indiscriminate reductions in care usage may not be the best way to contain health care costs. In this post, we suggest that combining the principles of HDHPs and value-based insurance design (VBID), by offering deductible exemptions for high-value services, could provide nuanced incentives with potential to preserve access to the most important services while reducing use of only more wasteful care.

Why Did HDHPs Fail To Deliver Their Intended Consequences?

The intended premise of HDHPs is that beneficiaries facing the full costs of health care services during the deductible phase will engage in price shopping and subsequently choose care commensurate with expected benefits of that care. The hope is that the combination of lower prices and a different mix of services could increase the value of health care used while also reducing costs. Unfortunately, evaluations of HDHPs suggest that consumers neither price shop nor can they discriminate between high- and low-value care when facing high deductibles; accordingly, they reduce use of both essential and inessential services. Not only is this behavior likely to lead to worse health for beneficiaries, but short-term savings for both the beneficiary and the insurer may be offset by increased long-term spending associated with preventable adverse health events. The lack of the hoped-for response to HDHPs (price shopping and reduction in unnecessary care only) may stem from a lack of price transparency, inability to pay for essential care during the deductible phase, or inadequate information about the value of alternate health care services and technologies.

The evidence on HDHPs should not be surprising. It matches older evidence from the RAND Health Insurance Experiment, where cost sharing caused people to reduce consumption of both appropriate and inappropriate care. The RAND experiment demonstrated that consumers may not have enough information available freely to them to address uncertainty and make rational choices about which services to purchase and which to forgo. For this reason, we suggest a variation on VBID, in which deductible exemptions for established high-value services would inform and incentivize beneficiaries to use the most valuable care, while disincentivizing low-value options. Such recommendations have been made in different forms in the literature but have not been widely adopted.

Tying-In Value Conversations Within HDHPs

VBIDs have developed over the past 15 years on the premise that when everyone is required to pay the same out-of-pocket amount for health care services whose benefits depend on patient characteristics, there is enormous potential for both underuse and overuse of care. It is also true that health services can be underused and overused when there are differential health-related returns across services, but patients are unaware of the differences. VBIDs have been used by insurers as a mechanism to address this information problem, by signaling the value of alternative health care technologies to consumers through variable cost sharing.

To date, most applications of VBID have focused on applying such designs to copays but not to deductibles. Moreover, most applications have applied reduced cost sharing for targeted high-value drugs, and only a few have also implemented concomitant increased cost sharing for low-value drugs. This means that the cost differences that the consumers faced between high- and low-value products continued to be small. Consequently, results of such applications show the promise of VBID, but to a limited scale, owing to the relative inelasticity of demand for care related to small copay variation. Tying value-based cost sharing within deductibles could generate a bigger “nudge” to align use with value.  

Only one study evaluated the application of VBID on cost sharing within an HDHP plan. This research analyzed Kaiser Permanente of Northern California, where patients were switched to HDHPs, but some of them were offered free chronic disease medications. Resulting improvements in adherence due to zero cost sharing for chronic disease medications were shown to offset the HDHP-associated adherence reduction, especially for patients with poor adherence at the start. Importantly, adherence improvements did not occur for more clinically complex patients, or patients living in poorer neighborhoods. The inclusion of active counseling in VBID plans has potential to address these limitations.

In another example of VBID, a not-for-profit health plan in the Pacific Northwest implemented a formulary that tied drug copays to cost-effectiveness. Researchers found larger shifts in demand within drug classes in which copays were simultaneously reduced for high-value treatments and increased for low-value treatments, compared to drug classes in which the copays only moved in one direction. The overall effect of the VBID implementation was welfare-increasing but small, perhaps because the price dispersion faced by the patient between high-value and low-value alternatives was still too low to alter demand.

Other applications of VBID, where cost sharing was removed for primary care visits, were found to reduce total spending, mainly due to reductions in use of emergency department (ED) and other outpatient services. A plan that bundled copays for back pain physical therapy found reductions in ED use, in addition to eventual reductions in primary care use, and better adherence to care guidelines.

Value-Based High-Deductible Plans

We suggest that value-based high-deductible plans (VHDP), which combine the principles of HDHPs and VBID, and have been suggested as “a natural evolution of health plans,” could provide a robust alternative in insurance markets and achieve the goals of both low costs and high value of health care delivery. Our enthusiasm for such designs stems from the dispersion of price-elasticities observed when a value-based system was implemented on copayments. We expect such dispersion can be expanded substantially when VBID is applied to develop VHDPs. Specifically, VHDPs would nudge consumers toward high-value technologies (for example, preventive medications) by exempting their costs from the deductibles, while also providing consumers with transparency on the full costs of low-value services (for example, MRI for back pain or headache), and disincentivizing their use. This would generate a more elastic demand for low-value services, which in turn could move the markets for insured health care services toward more efficient outcomes.

In health care, where we know that both quality and value are at least partially unobservable to the patient, efficient outcomes are typically not attainable, especially when cost sharing indiscriminately alters prices. A VHDP would provide nuanced cost sharing to influence behavior in a manner similar to prices in traditional markets, therefore resolving information asymmetries for low-value services, reducing distortions, and increasing social welfare. In addition, such a policy could improve equity by ensuring that all beneficiaries have access to the highest-value services, even in the deductible phase of a benefit package. Such plans are certainly in line with the spirit of the recent bipartisan legislation (signed by President Donald Trump under executive order 13877) that allows health savings account eligible high-deductible health plans the flexibility to cover essential medications and services used to treat chronic diseases prior to meeting the plan deductible.

Challenges To Adoption Of Value-Based HDHPs

While value-based pricing improves beneficiaries’ ability to observe value, and therefore reduces the information asymmetries inherent in health care markets, the definition of “value” is an open question. Current legislative options being considered by both political parties in Congress aim to regulate and reduce drug pricing. While these efforts are important, and reduced prices would likely factor into premiums and out-of-pocket costs for consumers, these policy proposals do not necessarily tie price reductions to the value of drugs. That is, they are not tied to any specifically desired outcome of care. As mentioned, earlier VBID applications have been designed to impact health outcomes by using cost-effectiveness in formulary design to signal value. However, many other attributes of care, in addition to cost-effectiveness, should be considered by payers (both public and private) in determination of deductible-exemption status in a VHDP. These attributes include if a service has positive externalities (such as vaccinations) and if a service is unlikely to have moral hazard consumption (such as trauma care or chemotherapy). These, and other elements of value, could be included in decisions about which services should be exempt from the deductible. The decision of which elements to consider in this decision will depend on the stakeholders and perspectives (for example, payer, health system, employer, societal).

A potential downside of VHDPs is plan complexity, but improved communication (perhaps through health plan stewards) could address this limitation; active counseling has already been effective for this purpose in VBID. It would be relatively straightforward to incorporate the cost-sharing design of VHDPs to a value-based tiering system, now widely used in cost sharing.

Qualitative studies of VBID have identified additional barriers to VBID implementation. For example, patients are skeptical of value-based tradeoffs, do not necessarily trust the information provided by their plan, and may resist changes in care delivery. Payers tend to be skeptical of the clinical significance of adherence improvements from VBID and have expressed concern over low return on investment and administrative and information technology hurdles. Finally, providers are concerned about changes to patient behavior that puts their practice at financial risk.

These concerns are important, but potentially addressable with education and carefully planned implementation, to allow VHDPs to strike a nuanced balance between reducing moral hazard consumption of care and adequate risk protection. Such a balance is critical to controlling health spending while maintaining access to the highest-value services and reducing financial uncertainty.

 

 

 

 

Navigating a Post-Covid Path to the New Normal with Gist Healthcare CEO, Chas Roades

https://www.lrvhealth.com/podcast/?single_podcast=2203

Covid-19, Regulatory Changes and Election Implications: An Inside ...Chas Roades (@ChasRoades) | Twitter

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.”

 

 

 

 

Trump says Covid-19 is ‘dying out.’ Experts fear his dismissiveness could prolong the crisis

Trump says Covid-19 is ‘dying out.’ Experts fear his dismissiveness could prolong the crisis

The Trump Administration Paid Millions for Test Tubes — and Got ...

The White House is taking a new position on the coronavirus pandemic: a daily count of 750 deaths is a testament to the federal government’s successful pandemic response.

On Wednesday, when U.S. health officials reported nearly 27,000 new Covid-19 cases, President Trump said in a television interview that the virus was “dying out.” He brushed off concerns about an upcoming rally in Tulsa, Okla., because the number of cases there is “very miniscule,” despite the state’s surging infection rate. In a Wall Street Journal interview Wednesday, Trump argued coronavirus testing was “overrated” because it reveals large numbers of new Covid-19 cases, which in turn “makes us look bad,” and suggested that some Americans who wear masks do so not only to guard against the virus, but perhaps to display their anti-Trump animus.

But a range of public health experts told STAT that this messaging not only diverts attention from a pandemic that has already caused 120,000 U.S. deaths, but has more practical implications: It could make it difficult for local governments to enlist the public in the mitigation measures necessary to reduce the continued spread of the virus.

“The science behind how people process public warnings in a crisis supports this: You have to have people speaking with one voice,” said Monica Schoch-Spana, a medical anthropologist at the Johns Hopkins Center for Health Security. “You need a chorus.”

Conflicting directives can make it more difficult for recommendations coming from state and local leaders to have an impact, said Sara Bleich, a professor of public health policy at Harvard’s T.H. Chan School of Public Health.

“It sends a mixed message, which is confusing, particularly because while many people will get infected, most will not get severely sick, so it’s easy to say this won’t happen to me,” she said. “And it’s that sort of attitude that will keep us in this situation for a very long time.”

While the president has for weeks, if not months, underplayed the pandemic, his sharp and repeated remarks this week represent a remarkable attempt from the leader of American government to effectively declare the U.S. Covid-19 epidemic over.

The president’s rhetoric comes at a time that his coronavirus task force, which once conducted daily briefings, has not addressed the public since May. The president’s resumption of campaign rallies flouts federal guidance that encourages mask use (Trump’s campaign will hand out masks and hand sanitizer at the rally, but has not said it will require attendees to use them) and discourages large indoor gatherings. And the president has repeatedly claimed, misleadingly, that persistently high U.S. case totals are simply the result of increased testing.

Health experts say that political leaders preaching caution and modeling proper behavior — such as wearing a mask and demonstrating proper hand hygiene — can send a powerful signal to people that these steps can not only protect them, but their communities. They say that, essentially, national and state leaders need to walk the walk in a situation when individual behavior, like staying home when sick and cooperating with contact tracing, can make a large impact in curbing contagion.

Trump’s counterproductive behavior, Schoch-Spana said, extends far beyond the consistently dismissive tone he has taken toward the health risks of Covid-19. With few exceptions, the president has refused to wear a mask in public, and has insisted on continuing in-person briefings and White House events that effectively defy federal health guidance about gathering indoors in large groups.

“It’s not just words, it’s actions,” she said. “So when you have the nation’s top executive refusing to wear a mask, holding meetings where people are shoulder to shoulder, where he’s signing executive orders — that is also a form of communication.”

Experts also say continued federal commitments to combating the virus are crucial as the public grows tired of abatement measures. Instead, Trump has only elevated his monthslong campaign of downplaying the virus.

And Vice President Mike Pence, in a Wall Street Journal op-ed, framed the declines in cases and deaths since April as “testament to the leadership of President Trump” — even as hundreds of Americans are still dying every day and cases are not dropping further.

Rep. Donna Shalala (D-Fla.), who served as health secretary during the Clinton administration, said she hoped Americans would listen to public health guidance from local officials, not Trump and Pence.

“The president of the United States is dangerous to the health of the people of my district, because he’s giving out misinformation and false hope,” she said. “For those that believe him, they’re putting themselves and their families at risk.”

Public health experts have raised a number of issues with the administration’s messaging.

For one, a plateau of cases and deaths should not be celebrated, they say. While some countries in Europe and Asia have not only flattened their curve but driven them down, that hasn’t happened in the United States. Daily cases and deaths dipped from the peak in April, but have averaged about 20,000 and 800, respectively, for weeks.

Beyond those numbers representing real people getting sick and dying, there are other problems with sustained high levels of spread. The more cases there are, the more difficult it is for the surveillance system, including contact tracing, to keep up. It’s also more likely that some of the cases will spiral into explosive spread; 20,000 cases can turn into 40,000 a lot faster than one case can turn into 20,000.

Plus, a failure to suppress spread now could lead to more prolonged disruptions to daily life. If transmission rates come fall are still what they are now in certain communities, that makes it harder to reopen schools, for example.

Experts also point to evidence suggesting that the daily case and death numbers won’t stay flat for long. While new cases in the Northeast and Midwest are declining, a number of states in the West and South — Arizona, Texas, Florida, California, and Oregon among them — have reported record number of new cases this week. What worries public health officials is that, without measures to stem those increases, those outbreaks could keep growing. Those thousands of new cases also signal that, in a week or two, some portion of those people will show up in the hospital, and, about a week after that, a number of them will be dead, even as clinicians have learned more about treating severe Covid-19.

Some states in the South and West are already reporting record hospitalizations from Covid-19.

The White House’s shrug has been echoed by some governors, who insist, like Pence and Trump, that increased testing explains away the rise in cases. That is certainly one reason; testing has become more widespread, so states are capturing a more accurate reading of their true case burden.

But experts say increased testing can only account for some of the data states are reporting. Other metrics — including rising hospitalizations, filling ICUs, and the increasing rate of tests that are positive for the virus — signal broader spread.

Until Wednesday, leaders of Texas and Arizona also bristled at efforts from city and county officials to institute mask requirements, but acceded to growing pressure even as they have not ordered statewide mandates.

Cameron Wolfe, an infectious disease expert at Duke University, said he was seeing a growing “fatigue” among the public to keep up with precautionary steps like physical distancing and mask wearing. People letting down their guard was coinciding with an increase of cases in states, including North Carolina.

He said medical experts and health workers needed to model proper behavior to show others that the coronavirus epidemic was still something that required action. But, he added, “that also comes from political leaders buying into this.”

Federal and state authorities, he said, need to be “taking this to heart. That has not yet happened. That needs to change if we’re going to get people to buy into this.”