Cartoon – Healthcare System in Crisis
Cartoon – Healthcare Ration(aliz)ing
No more snow days in the clinic
https://mailchi.mp/e38b070b8787/the-weekly-gist-december-18-2020?e=d1e747d2d8
It turns out it’s not just the kids who aren’t getting snow days this year. This week, we spoke with an executive at a health system hit hard by Wednesday’s Nor’easter, and asked how the system was faring with the expected 18 inches of snowfall. He replied that the medical group was as busy as usual.
With all the work this spring to expand telemedicine capabilities, clinic staff were able to reach out to patients the day before the storm, and proactively convert a majority of scheduled in-person clinic visits to telemedicine. “Normally we would’ve been closed, and most appointments rescheduled for weeks down the road,” he told us. Instead, they were able to keep most of those visits in their scheduled time slot.
“Now that we have a systemwide process for telemedicine, I don’t think we’ll have a reason for the clinic to take a snow day again.” It’s a clear win-win for the system and patients: patient care seamlessly goes on. It’s easy to see the many use cases for the ability to toggle between in-person and virtual visits. A parent is stuck at home with a sick kid, and can’t make her endocrinologist appointment? Moved to virtual! A patient has an unexpected business trip taking him out of town? Don’t cancel, let’s do that follow-up visit via telemedicine.
We’ve been worried about the slowdown in progress made on telemedicine as patients switched back to in-person visits across the summer and fall. The ability to continue patient care during a record-breaking snowstorm is a perfect illustration of why it’s critical not to “backslide” with virtual care: meeting patients where they are, regardless of circumstances, is an essential part of building long-term loyalty and care continuity.
Los Angeles hospitals brace for care rationing
Several hospitals in Los Angeles County are preparing for the possibility of restrategizing care delivery in the coming weeks amid growing COVID-19 hospitalizations, according to the Los Angeles Times.
Los Angeles County reported 6,018 COVID-19 hospitalizations Dec. 20 — a 2.5 percent increase from the day prior — with 1,198 patients in ICUs, according to the state’s data dashboard. Statewide, 17,750 patients are hospitalized with COVID-19, 3,710 of them in ICUs.
The LA Times obtained a document recently circulated among physicians at the four county-run hospitals that outlines resource allocation in crisis situations. The guidelines call for physicians to save as many patients as possible versus trying everything to save a patient, meaning those less likely to survive will not receive the level of care they would have otherwise. L.A. County Health Services Director Christina Ghaly, MD, told the LA Times that the guidelines were not in place as of Friday night.
California activated its “mass fatality” program last week, which coordinates mutual aid across several government agencies when more deaths take place in a period of time than can be handled by local coroner or medical emergency personnel, NPR reports.
Nearly all of the state is under stay-at-home orders, with residents prohibited from gathering with anyone outside their immediate household.
“I have yet to see any clear signals that things are slowing down, and I’m very concerned about the next two months,” Timothy Brewer, MD, an epidemiologist with UCLA Health, told the LA Times. He said UCLA Health is scheduling several infectious disease specialists to be on call at any time, and the biggest issue is that hospitals may quickly run out of providers who can administer ICU-level care.
Congress agrees on $900B COVID-19 relief package, $1.4 trillion funding deal: 7 things to know
Congressional leaders have reached an agreement on a $900 billion COVID-19 relief package and $1.4 trillion government funding deal with several healthcare provisions, according to Senate Majority Leader Mitch McConnell, R-Ky., and Minority Leader Chuck Schumer, D-N.Y.
Here are seven things to know about the relief aid and funding deal:
1. Congressional leaders have yet to release text of the COVID-19 legislation, but have shared a few key details on the measure, according to CNBC. Becker’s breaks down the information that has been released thus far.
2. The COVID-19 package includes $20 billion for the purchase of vaccines, about $9 billion for vaccine distribution and about $22 billion to help states with testing, tracing and other COVID-19 mitigation programs, according to Politico.
3. Lawmakers are also expected to include a provision changing how providers can use their relief grants. In particular, the bill is expected to allow hospitals to calculate lost revenue by comparing budgeted revenue for 2020. Hospitals have said this tweak will allow them to keep more funding.
4. The agreement also allocates $284 billion for a new round of Paycheck Protection Program loans.
5. The COVID-19 relief bill also provides $600 stimulus checks to Americans earning up to $75,000 per year and $600 for their children, according to NBC. It also provides a supplemental $300 per week in unemployment benefits.
6. The year-end spending bill includes a measure to ban surprise billing. Under the measure, hospitals and physicians would be banned from charging patients out-of-network costs their insurers would not cover. Instead, patients would only be required to pay their in-network cost-sharing amount when they see an out-of-network provider, according to The Hill. The agreement gives insurers 30 days to negotiate a payment on the outstanding bill. After that period, they can enter into arbitration to gain higher reimbursement.
7. Lawmakers plan to pass the relief bill and federal spending bill Dec. 21.
Lie of the Year: Coronavirus Downplay and Denial
A Florida taxi driver and his wife had seen enough conspiracy theories online to believe the virus was overblown, maybe even a hoax. So no masks for them. Then they got sick. She died. A college lecturer had trouble refilling her lupus drug after the president promoted it as a treatment for the new disease. A hospital nurse broke down when an ICU patient insisted his illness was nothing worse than the flu, oblivious to the silence in beds next door.
Lies infected America in 2020. The very worst were not just damaging, but deadly.
President Donald J. Trump fueled confusion and conspiracies from the earliest days of the coronavirus pandemic. He embraced theories that COVID-19 accounted for only a small fraction of the thousands upon thousands of deaths. He undermined public health guidance for wearing masks and cast Dr. Anthony Fauci as an unreliable flip-flopper.
But the infodemic was not the work of a single person.
Anonymous bad actors offered up junk science. Online skeptics made bogus accusations that hospitals padded their coronavirus case numbers to generate bonus payments. Influential TV and radio opinion hosts told millions of viewers that social distancing was a joke and that states had all of the personal protective equipment they needed (when they didn’t).
It was a symphony of counter narrative, and Trump was the conductor, if not the composer. The message: The threat to your health was overhyped to hurt the political fortunes of the president.
Every year, PolitiFact editors review the year’s most inaccurate statements to elevate one as the Lie of the Year. The “award” goes to a statement, or a collection of claims, that prove to be of substantive consequence in undermining reality.
It has become harder and harder to choose when cynical pundits and politicians don’t pay much of a price for saying things that aren’t true. For the past month, unproven claims of massive election fraud have tested democratic institutions and certainly qualify as historic and dangerously bald-faced. Fortunately, the constitutional foundations that undergird American democracy are holding.
Meanwhile, the coronavirus has killed more than 300,000 in the United States, a crisis exacerbated by the reckless spread of falsehoods.
PolitiFact’s 2020 Lie of the Year: claims that deny, downplay or disinform about COVID-19.
‘I always wanted to play it down’
On Feb. 7, Trump leveled with book author Bob Woodward about the dangers of the new virus that was spreading across the world, originating in central China. He told the legendary reporter that the virus was airborne, tricky and “more deadly than even your strenuous flus.”
Trump told the public something else. On Feb. 26, the president appeared with his coronavirus task force in the crowded White House briefing room. A reporter asked if he was telling healthy Americans not to change their behavior.
“Wash your hands, stay clean. You don’t have to necessarily grab every handrail unless you have to,” he said, the room chuckling. “I mean, view this the same as the flu.”
Three weeks later, March 19, he acknowledged to Woodward: “To be honest with you, I wanted to always play it down. I still like playing it down. Because I don’t want to create a panic.”
His acolytes in politics and the media were on the same page. Rush Limbaugh told his audience of about 15 million on Feb. 24 that coronavirus was being weaponized against Trump when it was just “the common cold, folks.” That’s wrong — even in the early weeks, it was clear the virus had a higher fatality rate than the common cold, with worse potential side effects, too.
As the virus was spreading, so was the message to downplay it.
“There are lots of sources of misinformation, and there are lots of elected officials besides Trump that have not taken the virus seriously or promoted misinformation,” said Brendan Nyhan, a government professor at Dartmouth College. “It’s not solely a Trump story — and it’s important to not take everyone else’s role out of the narrative.”
Hijacking the numbers
In August, there was a growing movement on Twitter to question the disproportionately high U.S. COVID-19 death toll.
The skeptics cited Centers for Disease Control and Prevention data to claim that only 6% of COVID-19 deaths could actually be attributed to the virus. On Aug. 24, BlazeTV host Steve Deace amplified it on Facebook.
“Here’s the percentage of people who died OF or FROM Covid with no underlying comorbidity,” he said to his 120,000 followers. “According to CDC, that is just 6% of the deaths WITH Covid so far.”
That misrepresented the reality of coronavirus deaths. The CDC had always said people with underlying health problems — comorbidities — were most vulnerable if they caught COVID-19. The report was noting that 6% died even without being at obvious risk.
But for those skeptical of COVID-19, the narrative confirmed their beliefs. Facebook users copied and pasted language from influencers like Amiri King, who had 2.2 million Facebook followers before he was banned. The Gateway Pundit called it a “SHOCK REPORT.”
“I saw a statistic come out the other day, talking about only 6% of the people actually died from COVID, which is very interesting — that they died from other reasons,” Trump told Fox News host Laura Ingraham on Sept. 1.
Fauci, director of the National Institute of Allergy and Infectious Diseases, addressed the claim on “Good Morning America” the same day.
“The point that the CDC was trying to make was that a certain percentage of them had nothing else but just COVID,” he said. “That does not mean that someone who has hypertension or diabetes who dies of COVID didn’t die of COVID-19 — they did.”
Trump retweeted the message from an account that sported the slogans and symbols of QAnon, a conspiracy movement that claims Democrats and Hollywood elites are members of an underground pedophilia ring.
False information moved between social media, Trump and TV, creating its own feedback loop.
“It’s an echo effect of sorts, where Donald Trump is certainly looking for information that resonates with his audiences and that supports his political objectives. And his audiences are looking to be amplified, so they’re incentivized to get him their information,” said Kate Starbird, an associate professor and misinformation expert at the University of Washington.Weakening the armor: misleading on masks
At the start of the pandemic, the CDC told healthy people not to wear masks, saying they were needed for health care providers on the frontlines. But on April 3 the agency changed its guidelines, saying every American should wear non-medical cloth masks in public.
Trump announced the CDC’s guidance, then gutted it.
“So it’s voluntary. You don’t have to do it. They suggested for a period of time, but this is voluntary,” Trump said at a press briefing. “I don’t think I’m going to be doing it.”
Rather than an advance in best practices on coronavirus prevention, face masks turned into a dividing line between Trump’s political calculations and his decision-making as president. Americans didn’t see Trump wearing a mask until a July visit to Walter Reed National Military Medical Center.
Meanwhile, disinformers flooded the internet with wild claims: Masks reduced oxygen. Masks trapped fungus. Masks trapped coronavirus. Masks just didn’t work.
In September, the CDC reported a correlation between people who went to bars and restaurants, where masks can’t consistently be worn, and positive COVID-19 test results. Bloggers and skeptical news outlets countered with a misleading report about masks.
On Oct. 13, the story landed on Fox News’ flagship show, “Tucker Carlson Tonight.” During the show, Carlson claimed “almost everyone — 85% — who got the coronavirus in July was wearing a mask.”
“So clearly (wearing a mask) doesn’t work the way they tell us it works,” Carlson said.
That’s wrong, and it misrepresented a small sample of people who tested positive. Public health officials and infectious disease experts have been consistent since April in saying that face masks are among the best ways to prevent the spread of COVID-19.
But two days later, Trump repeated the 85% stat during a rally and at a town hall with NBC’s Savannah Guthrie.
“I tell people, wear masks,” he said at the town hall. “But just the other day, they came out with a statement that 85% of the people that wear masks catch it.”
The assault on hospitals
On March 24, registered nurse Melissa Steiner worked her first shift in the new COVID-19 ICU of her southeast Michigan hospital. After her 13-hour day caring for two critically ill patients on ventilators, she posted a tearful video.
“Honestly, guys, it felt like I was working in a war zone,” Steiner said. “(I was) completely isolated from my team members, limited resources, limited supplies, limited responses from physicians because they’re just as overwhelmed.”
“I’m already breaking, so for f—’s sake, people, please take this seriously. This is so bad.”
Steiner’s post was one of many emotional pleas offered by overwhelmed hospital workers last spring urging people to take the threat seriously. The denialists mounted a counter offensive.
On March 28, Todd Starnes, a conservative radio host and commentator, tweeted a video from outside Brooklyn Hospital Center. There were few people or cars in sight.
“This is the ‘war zone’ outside the hospital in my Brooklyn neighborhood,” Starnes said sarcastically. The video racked up more than 1.5 million views.
Starnes’ video was one of the first examples of #FilmYourHospital, a conspiratorial social media trend that pushed back on the idea that hospitals had been strained by a rapid influx of coronavirus patients.
Several internet personalities asked people to go out and shoot their own videos. The result: a series of user-generated clips taken outside hospitals, where the response to the pandemic was not easily seen. Over the course of a week, #FilmYourHospital videos were uploaded to YouTube and posted tens of thousands of times on Twitter and Facebook.
Nearly two weeks and more than 10,000 deaths later, Fox News featured a guest who opened a new misinformation assault on hospitals.
Dr. Scott Jensen, a Minnesota physician and Republican state senator, told Ingraham that, because hospitals were receiving more money for COVID-19 patients on Medicare — a result of a coronavirus stimulus bill — they were overcounting COVID-19 cases. He had no proof of fraud, but the cynical story took off.
Trump used the false report on the campaign trail to continue to minimize the death toll.
“Our doctors get more money if somebody dies from COVID,” Trump told supporters at a rally in Waterford, Mich., Oct. 30. “You know that, right? I mean, our doctors are very smart people. So what they do is they say, ‘I’m sorry, but, you know, everybody dies of COVID.’”
The real fake news: The Plandemic
The most viral disinformation of the pandemic was styled to look like it had the blessing of people Americans trust: scientists and doctors.
In a 26-minute video called “Plandemic: The Hidden Agenda Behind COVID-19,” a former scientist at the National Cancer Institute claimed that the virus was manipulated in a lab, hydroxychloroquine is effective against coronaviruses, and face masks make people sick.
Judy Mikovits’ conspiracies received more than 8 million views in May thanks in part to the online outrage machine — anti-vaccine activists, anti-lockdown groups and QAnon supporters — that push disinformation into the mainstream. The video was circulated in a coordinated effort to promote Mikovits’ book release.
A couple of months later, a similar effort propelled another video of fact-averse doctors to millions of people in only a few hours.
On July 27, Breitbart published a clip of a press conference hosted by a group called America’s Frontline Doctors in front of the U.S. Supreme Court. Looking authoritative in white lab coats, these doctors discouraged mask wearing and falsely said there was already a cure in hydroxychloroquine, a drug used to treat rheumatoid arthritis and lupus.
Trump, who had been talking up the drug since March and claimed to be taking it himself as a preventive measure in May, retweeted clips of the event before Twitter removed them as misinformation about COVID-19. He defended the “very respected doctors” in a July 28 press conference.
When Olga Lucia Torres, a lecturer at Columbia University, heard Trump touting the drug in March, she knew it didn’t bode well for her own prescription. Sure enough, the misinformation led to a run on hydroxychloroquine, creating a shortage for Americans like her who needed the drug for chronic conditions.
A lupus patient, she went to her local pharmacy to request a 90-day supply of the medication. But she was told they were only granting partial refills. It took her three weeks to get her medication through the mail.
“What about all the people who were silenced and just lost access to their staple medication because people ran to their doctors and begged to take it?” Torres said.No sickbed conversion
On Sept. 26, Trump hosted a Rose Garden ceremony to announce his nominee to replace the late Ruth Bader Ginsburg on the U.S. Supreme Court. More than 150 people attended the event introducing Amy Coney Barrett. Few wore masks, and the chairs weren’t spaced out.
In the weeks after, more than two dozen people close to Trump and the White House became infected with COVID-19. Early Oct. 2, Trump announced his positive test.
Those hoping the experience and Trump’s successful treatment at Walter Reed might inform his view of the coronavirus were disappointed.
Trump snapped back into minimizing the threat during his first moments back at the White House. He yanked off his mask and recorded a video.
“Don’t let it dominate you. Don’t be afraid of it,” he said, describing experimental and out-of-reach therapies he received. “You’re going to beat it.”
In Trump’s telling, his hospitalization was not the product of poor judgment about large gatherings like the Rose Garden event, but the consequence of leading with bravery. Plus, now, he claimed, he was immune from the virus.
On the morning after he returned from Walter Reed, Trump tweeted a seasonal flu death count of 100,000 lives and added that COVID-19 was “far less lethal” for most populations. More false claims at odds with data — the U.S. average for flu deaths over the past decade is 36,000, and experts said COVID-19 is more deadly for each age group over 30.
When Trump left the hospital, the U.S. death toll from COVID-19 was more than 200,000. Today it is more than 300,000. Meanwhile, this month the president has gone ahead with a series of indoor holiday parties.
The vaccine war
The vaccine disinformation campaign started in the spring but is still underway.
In April, blogs and social media users falsely claimed Democrats and powerful figures like Bill Gates wanted to use microchips to track which Americans had been vaccinated for the coronavirus. Now, false claims are taking aim at vaccines developed by Pfizer and BioNTech and other companies.
- A blogger claimed Pfizer’s head of research said the coronavirus vaccine could cause female infertility. That’s false.
- An alternative health website wrote that the vaccine could cause an array of life-threatening side effects, and that the FDA knew about it. The list included all possible — not confirmed— side effects.
- Social media users speculated that the federal government would force Americans to receive the vaccine. Neither Trump nor President-elect Joe Biden has advocated for that, and the federal government doesn’t have the power to mandate vaccines, anyway.
As is often the case with disinformation, the strategy is to deliver it with a charade of certainty.
“People are anxious and scared right now,” said Dr. Seema Yasmin, director of research and education programs at the Stanford Health Communication Initiative. “They’re looking for a whole picture.”
Most polls have shown far from universal acceptance of vaccines, with only 50% to 70% of respondents willing to take the vaccine. Black and Hispanic Americans are even less likely to take it so far.
Meanwhile, the future course of the coronavirus in the U.S. depends on whether Americans take public health guidance to heart. The Institute for Health Metrics and Evaluation projected that, without mask mandates or a rapid vaccine rollout, the death toll could rise to more than 500,000 by April 2021.
“How can we come to terms with all that when people are living in separate informational realities?” Starbird said.
A tall order: Rolling out the COVID-19 vaccine to all
https://mailchi.mp/e38b070b8787/the-weekly-gist-december-18-2020?e=d1e747d2d8
As the first Americans receive COVID vaccines, supplies remain limited even for the highest-risk populations. And with doses now in the pipeline, states are facing more intense questions about how they will prioritize vaccine delivery across demographic and at-risk groups. The graphic above shows an estimated vaccination timeline, based on the Centers for Disease Control and Prevention’s (CDC) recommended schedule. It illustrates the relative size of different populations in each allocation phase, along with the likely difficulty of targeting them and verifying eligibility. The first phase is divided into three waves (1a, 1b, 1c) for at-risk populations and essential workers, while the second phase includes the rest of the adult population, as well as children (though pediatric clinical trials are still in early stages).
Unsurprisingly, the CDC recommends that those most at risk for infection and severe disease—healthcare workers and nursing home residents—receive the 20M doses available by year’s end. While most states are generally adhering to the initial recommendations on priority groups for phase 1a set by the CDC’s Advisory Committee on Immunization Practices (ACIP), several have made adjustments. At least three are including law enforcement personnel in phase 1a, and others are further categorizing healthcare workers into high-, medium-, and low-risk groups. This weekend, ACIP will reconvene to create its official recommendations for phases 1b and 1c, which include the much larger populations of adults over age 65, and those with high-risk medical conditions.
Beyond eligibility guidelines, larger questions loom. How would someone “verify” that they have a high-risk condition? Who will reach out to older Americans to let them know they are eligible, and where to access the vaccine? As vaccine rollout continues, providers should anticipate the role they will likely play in managing patients “in the queue”, documenting eligible conditions and establishing regular information channels to keep people informed about the current status of vaccine planning and access.
It will be darkest before dawn
https://mailchi.mp/e38b070b8787/the-weekly-gist-december-18-2020?e=d1e747d2d8
But first, we have a difficult period to get through. This week again saw record-breaking numbers of cases, hospitalizations, and deaths from COVID-19, with Thursday alone bringing more than 238,000 new cases—and a staggering 3,293 fatalities.
Nearly 115,000 Americans are currently hospitalized with COVID, a rise of 16 percent from just two weeks ago, and in many places a precarious capacity situation has turned perilous. Conditions have worsened precipitously in California, with only Tennessee, Oklahoma, and Rhode Island registering more daily COVID cases per 100,000 population than the Golden State, although cases are still on the rise across 80 percent of states and territories.
Intensive care availability in Southern California hit zero, with ICU volume there expected to double or triple by this time next month. The same stresses are playing out in dozens of markets across the country, leading to a staffing sustainability crisis that can’t be solved through paying overtime, cancelling vacations or looking to travel nurses to fill the gaps in a now nationwide crisis. With the Christmas and New Year’s holidays still ahead, experts predict COVID cases won’t peak until sometime in mid-January, with a peak in hospitalizations and deaths following several weeks after.
Several states and cities tightened restrictions on gatherings and issued new stay-at-home orders, in an effort to keep new cases at a level that allows hospitals to manage through the next several weeks and maintain care quality and access for COVID and non-COVID patients alike. The coming weeks will require every American to take greater precautions than at any time during the course of this pandemic.
The vaccine offensive gets underway
https://mailchi.mp/e38b070b8787/the-weekly-gist-december-18-2020?e=d1e747d2d8
On Monday, at Long Island Jewish Medical Center in New York City, critical care nurse Sandra Lindsay rolled up her sleeve and became the first American to receive Pfizer and BioNTech’s newly approved COVID vaccine, opening a new front in the nation’s battle with the coronavirus pandemic.
By Friday, nearly 50,000 doses of the vaccine had been administered nationwide, with millions more expected before year’s end. Amid a complex rollout that has already raised questions about the timely distribution of doses, the Food and Drug Administration (FDA) confirmed that it was safe to use every last drop of the Pfizer vaccine, including the excess amount used to fill the five-dose vials of the precious medicine—meaning many vials may have enough to immunize a sixth person.
Based on Thursday’s recommendation from a key panel of experts, the FDA is expected to approve a similar vaccine from Moderna as soon as Friday evening, with doses of that vaccine beginning to be administered by next week. The Moderna vaccine comes in smaller packages with less-demanding storage requirements, making it suitable for a wider distribution across smaller settings and remote areas.
Pharmacy chains CVS and Walgreens were set to begin administering shots to nursing home residents in Ohio, Connecticut, and Florida on Friday, as part of an agreement with the US government to vaccinate staff and residents in 75,000 long-term care facilities nationwide.
In an interview this week, Secretary of Health and Human Services (HHS) Alex Azar said that the vaccine could be widely available to the general public as soon as late February or early March. While it’s surely tempting to fixate on every setback, second guess every decision about prioritization and distribution, and fret over every isolated report of an adverse vaccine reaction, it will be important in the coming weeks to keep the big picture in mind: we are on the way to beating back the coronavirus. The end is nigh.
Quote of the Day
HENRY KOTULA 