By MIKE MAGEE

Naomi Orestes PhD, Professor of the History of Science at Harvard, didn’t mince words  as she placed our predicament in context when she said, “If you know your Greek tragedies you know power, hubris, and tragedy go hand in hand. If we don’t address the harmful aspects of human activities, most obviously disruptive climate change, we are headed for tragedy.”

At the time, as a member of the Anthropocene Workgroup, she and a group of international climate scientists were focused on defining and measuring nine “planetary boundaries,” environmental indicators of planetary health. At the top of the list was Climate Change because, one way or another, it negatively impacts the other eight measures.

Not the least of these “human perturbations” is the effect of global warming on access to clean, safe water, and the impact of violent weather cycles and rising sea levels on concentrated urban populations along coastal waters.

A less recognized, but historically well documented threat, is exposure to migrating vectors of disease as they contact unprepared human populations beyond their traditional camping grounds. The threat of avian flu among migratory birds has been well covered. Equally, over the past decade, North America has seen a range of novel infections, especially along our southern borders, from dengue, to chikungunya, to Zika.

The southern United States and its coastal populations are firmly in the cross-hairs. Their seas are rising at an alarming rate, and fouling fresh water supply with invasive sea water. Their soaring temperatures are only exceeded by record setting atmospheric river rainfalls and flooding events, and their “extreme poverty throughout Texas and the Gulf Coast states, where inadequate or low-quality housing, absent or broken window screens, and a pervasive dumping of tires in poor neighborhoods,” as reported in this weeks New England Journal of Medicine, assures a reemergence of one of this countries most significant, but now long forgotten killer diseases.

In 1853, the disease killed 11,000 in New Orleans, some 10% of the population. Twenty-five years later, it overwhelmed Mississippi Valley cities killing 20,000. Its latest major foray in the United States was in 1905 with 1000 deaths. Its’ absence over the past century is credited to public health and structural and engineering advances. But that was then, and this is now.

The disease is Yellow Fever, and red lights are blinking in a range of southern coastal cities from Galveston, TX, to Mobile, AL, to New Orleans, LA and Tampa, FL.. Experts say they may soon be in the same boat as Brazil was between 2016 and 2019 when it experienced a threefold increase in the historic prevalence of the disease among its population.

Public Health sleuths have uncovered that the 1878 epidemic in the Mississippi Valley was triggered by an El Nino spike the year prior. The warmer and wetter conditions are believed to have supported a large increase in Aedis aegypti mosquitos, the vector for the Yellow Fever virus.

Are we prepared? Recent experience in fighting Dengue fever in the southern statesis not encouraging, with WHO chief scientist Jeremy Farrar warning that Dengue might soon “take off” absent better mosquito eradication and screening prevention. U.S. Public Health experts say a Dengue foothold is nearly secured and the disease is fast on its way to becoming endemic in southern coastal states.

As for Yellow Fever, there is an effective vaccine, but it is also associated with rare but serious side effects. Antivaccine activism post-Covid would be a significant barrier now say experts. Adding to the challenge, no Yellow Fever vaccine is currently available from the U.S. Strategic National Stockpile. Mosquito surveillance programs are currently marginal, and response capabilities for mass vaccination in affected areas are severely limited.

The Anthropocene Workgroup is fully aware of these human instigated crises. In the prior Holocene Epoch of 11,700, we prided ourselves with being able to co-exist with other lifeforms and in equilibrium with a healthy planet. But beginning in 1950, the new Anthropocene Epoch has aggressively chipped away at planetary health, disrupting stabilizing cycles, and critically raising the temperature and acidity of oceans that cover and buffer 70% of the planet.

The return of Aedes aegypti, and the Yellow Fever virus it carries, is a dramatic harbinger of additional challenges to come if we are unable to limit “human perturbations” of our planetary cycles.

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Mike Magee MD is a Medical Historian and regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex.

Just one week before the ATA EDGE Policy Conference (12/7-12/9 Washington DC) we get a SNEAK PEEK at what’s topping the agenda – and the American Telemedicine Association (ATA)’s list of priorities for 2023 – to ensure that digital health and virtual care providers avoid the ‘telehealth cliff’ that could send us back to pre-pandemic scaling issues of both practice and reimbursement.

Kyle Zebley, SVP of Public Policy at the ATA and Executive Director of ATA Action (the ATA’s affiliate advocacy organization) gives us the skinny on where policies currently stand at the federal and state level and, more importantly, what’s in jeopardy of changing soon. The list is long – everything from interstate practice to originating site stipulations, in-person visit requirements (especially for tele-mental health visits), and a number of favorable reimbursement policies that made telehealth a covered benefit at federally qualified health centers, rural health clinics, and under some high-deductible health plans. And, these are just to name a few…

Right now, the pandemic’s public health emergency is still in effect until mid-January, and, though it is expected to be renewed, the renewal will only get us into the second quarter of 2023. Kyle gives us the in-depth details on what ATA is advocating for and how they’re doing it. Of particular interest is the work being done to preserve clinicians’ ability to deliver cross-state care. The details here are fascinating. Kyle explains the nuances of tactics like licensure compacts and common sense exceptions that are being explored to permanently extend cross-state telehealth care, as well as the role the federal government can play in helping these policies along by incentivizing states to adopt these them through a “carrot-and-stick approach.”

The time to get involved is now, Health Tech! Get your start by watching this in-depth chat with Kyle to get caught up on where things stand, then check out ATA’s site for information on what you can do to support these on-going efforts to keep virtual care a growing vehicle for healthcare delivery.

* Special thanks to Wheel, sponsor of this special monthly WTF Health series on the policies that are changing telehealth and virtual care. Wheel is the health tech company powering the virtual care industry, provides companies with everything they need to launch and scale virtual care services — including the regulatory infrastructure to deliver high quality and compliant care. Learn more at www.wheel.com.

BY KIM BELLARD

The New York Times had an interesting set of op-eds last week under the theme “I Was Wrong.”  For example, Paul Krugman says he was wrong about inflation, David Brooks laments being wrong about capitalism, and Bret Stevens now fears he was wrong about Trump voters.  Nobody fessed up about being wrong about healthcare, so I’ll volunteer.  

I’ve been writing regularly about healthcare for over a decade now, with some strong opinions and often with some pretty speculative ideas.  I’ve had a lot to be wrong about, and I hope I will be wrong about many of them (e.g., microplastics).  Some of my thoughts (such as on DNA storage or nanorobots) may just be still too soon, but there are definitely some things I’d thought, or at least hoped, would have happened by now.

I’ll highlight three:

I thought we’d care more about our health  

Twenty plus years ago I was an evangelist for what we’d now call digital health.  Give people more, better health information and some useful health tools, then certainly they’d  use them to improve their health. If I’d known about smartphones or wearables I’d have been even more sure.

But, it turns out, not so much. Yes, we’re all pretty good about googling health information, many of us have health apps on our phones, and wearables are cool, but we’d be hard pressed to pinpoint exactly how our health has improved, generally speaking.  Our epidemics of obesity, diabetes, and other chronic conditions continue to grow, and our mortality rates were an embarrassment even before the pandemic’s effects. 

The pandemic exacerbated, but did not cause, health disparities that fall along racial, ethnic, and socioeconomic lines, ones that most countries would be embarrassed about but which the U.S. seems to tolerate without much political will around addressing them. ACA helped, but it was only a finger in the dike, and that dike is cracking.

Even worse, the pandemic proved that we care more about politics than our health, to the point many resist taking vaccines that have been proven safe and effective, or following simple public health measures like masking or social distancing. Even worse, many states are weakening public health departments’ powers generally.  How did taking care of our health become a political litmus test?

We’ve also shown that religion also trumps health, as evidenced by abortion restrictions. Some people’s religious views that a fetus is a person, even at conception, outweighs a woman’s rights to her own body, or even her own life. And those so-called “pro-life” believers only seem to care about the fetus during the pregnancy.  

I thought we’d care more about patients than profits

Silly me.

Twenty or even ten years ago seems like such a simpler time.  Hospitals hadn’t, for the most part, consolidated, franchised, or gone overseas.  Physician practices hadn’t been bought up in large numbers.  Private equity didn’t see specialists, air ambulances, nursing homes, or ER docs as huge profit opportunities.  Pharmaceutical companies hadn’t fully mastered how to extend their patents almost indefinitely in order to keep prices high.  Health insurers were happy if they could eke out margins in the low single digits.  

The healthcare system has gone all Martin Shkreli, finding profits anywhere and everywhere, the more the better.  There’s no evidence that hospital consolidation improves patient care and plenty of evidence that it raises prices. Medical school students see the income differentials and are increasingly opting to go into specialty fields.  Everyone has horror stories about prescription drug prices, yet Congress seems powerless to act, no doubt due to the pharmaceutical lobbying clout. No one thinks that private equity is looking to do anything but line their investors’ pockets. Health insurers have become so diversified that they have more revenue streams than we can count.

We’re closing in on health care at 20% of GDP. I remember people being alarmed when it hit 10%; how much more does it have to get before we recognize we’re chasing the wrong things?

I thought someone would figure out how to wreck healthcare 

Mark Zuckerberg’s famous motto was “move fast and break things,” and Facebook did both, somewhat to everyone’s chagrin (and, yet, we keep using Facebook…).  That attitude has never caught on in healthcare, ostensibly because it’s too dangerous for patients. But, I’ve come to suspect, it’s more that it is too dangerous for healthcare’s many vested interests.

I’ve been looking for several years for healthcare’s Uber, the entrant(s) that don’t care about how the industry has been structured (or regulated) and want to introduce a new, better consumer experience.  Big Tech was going to come in (especially Amazon). Walmart was going to come in.  Other retail companies, like Best Buy or video game companies, were going to come in. Well, they’re in, but I’m not seeing that much disruption.

We’ve got scores of digital health companies getting ridiculous amounts of money, and many of them are doing interesting things, but I don’t see many industry-wreckers among them.  They’re more in the “if we can just get 0.x% of healthcare spending, we’ll all be rich” mindset.

Again, Uber didn’t come along to improve the taxi industry’s technology or even its rider experience. It said, the taxi industry is a 1950’s model, with very restrictive regulations, so we’ll invent a new industry that replaces it. There’s a lot to criticize Uber for, but most of the “innovators” I see in healthcare are in the “improve taxi industry technology” category, not the blow-up-the-antiquated-healthcare-industry-model(s).

I’m convinced there is a healthcare system out there that is much cheaper, much more effective, much more convenient, and much more equitable.  But continuing to graft on to our healthcare system’s existing edifices isn’t going to get us to that.   

———

Barring some sort of miraculous life extension technology, I’m not going to live long enough to see what a 22^nd century healthcare system looks like.  I have high hopes for it, and none of those hopes include it being similar to today’s system.  

I hope that is barely visible to us and that we don’t even necessarily think of it as a health care system (or, at least, a medical care system), because health is so woven into our lives.  I definitely hope that health is no longer a function of your income, race/ethnicity, gender, or location.  

I just hope I’m not wrong about all that too. 

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

With 61% of American adults reporting a negative behavior change – troubled sleep, changes in diet, increased alcohol consumption, more time on screens, etc. – as a result of the pandemic, AND healthcare payers looking at 2022 cost increases in the range of 8-10%, one has to wonder just how bad our collective health has become thanks to the past two years.

Jeff Ruby, CEO of tech-enabled habit change provider, Newtopia, shares some startling stats about our population’s health, particularly when it comes to those lifestyle-related metabolic disorders that his company is trying to prevent. And, thus, we get into a fiery conversation about condition prevention versus condition management… at-risk payment models versus per-member-per-month models… behavior change versus prescription drugs… and whether or not a biz like Newtopia (running at-risk on goals related to prevention) is better placed or worse off as a result of this population that, though sicker and riskier than before, is showing up in greater numbers to try their program.

It’s clear where Jeff stands with his genetics-plus-behavioral-psychology-based platform, but questions about how to best handle our population’s health as the pandemic wans are still very much up for debate. Even on the public markets – Newtopia was one of the first digital health companies to go public during the pandemic, hitting the Canadian TSX as $NEWUF in March 2020 – investors’ sentiment for virtual care just isn’t what it used to be. Maybe we can apply some behavior change psychology there too? (wink, wink) Though Jeff talks about “uncertainty about how US healthcare works” in the context of the market, it seems like that “uncertainty” is also pervasive in our approach to spending for chronic care – especially now. Are dollars toward prevention dollars that are better spent? A compelling case is made…

BY KIM BELLARD

There’s an old military adage that generals are always fighting the last war.  It’s not that they haven’t learned any lessons, it’s more than they learned the wrong lessons.  I fear we’re doing that with the COVID pandemic.  

The next big health crisis may not come from another COVID variant; it may not be caused by coronavirus at all.  Even if we learn lessons from this pandemic, those may not be lessons that will apply to the next big health crisis.  

What started me thinking about this is a C4ISRNET interview with Mike Brown, the Director of the Defense Innovation Unit, and DARPA Director Dr. Stefanie Tompkins.  Dr. Tompkins and Mr. Brown are both watching the war in the Ukraine closely.  As Dr. Tompkins says in the interview, the war is a “really good test” about the programs her agency has invested in and/or is investing in for the future.

E.g., Russia has clear advantages in numerical superiority, and in “traditional” weapons like tanks, airplanes, ships, and artillery, but Ukraine has been able to blunt the invasion through asymmetrical warfare, using things that DARPA helped foster, including Javelin missiles, drones, satellite imagery, secure communications, and GPS.  Even Russia’s vaunted cyber capabilities have been overmatched by Ukraine’s own capabilities.  Current DARPA investments like hypersonic missiles and AI are being tested.

I’m comforted that DARPA and DIU are learning in real time what lessons their agencies can learn to help fight future wars, but I’m wondering who in our healthcare system, and who in our governments (federal/state/local), are not just fighting COVID but learning the bigger lessons from it to fight future crises.  

I trust that smarter people than me are looking at this, but here are some the lessons I hope we’ve learned:

Information: it’s shocking, but we don’t really know how many people have had COVID.  We don’t really know how many have it now.  We like to think we know how many have been hospitalized and how many have died, but due to reporting inconsistencies those numbers are, at best, approximations.  

We need early warning systems, like through wastewater monitoring.  We need standardized public health reporting, with real-time data and a central repository in which it can be analyzed.  We need easy-to-understand dashboards that both public officials and the public can access and base their decisions on.  We can’t be building these during a health crisis.

Supply Chains: just-in-time, globally distributed supply chains are a marvel of modern life, bringing us greater variety of products at more affordable prices, but, in retrospect, we should have understood that in a global health crisis they would prove to be an Achilles heel.  Masks and other PPE, ventilators, vaccines and other prescription drugs have all suffered from supply chain issues during the pandemic.  Shortages led to unevenly distributed supplies and higher prices.  

We’re never going back to the days of local production, but we do need to prioritize what things need to be produced regionally/nationally, how that production can scale in time of crisis, and how that production should be fairly allocated.  The mechanisms to do that can’t be built on the fly.

The sick and the dead: Among the many images of the pandemic’s worst (so far) days, some of the most haunting are the ones of hospitals filled to overflowing, with patients on gurneys in hallways, or the refrigerator trucks filled with dead bodies.  Our healthcare system’s capabilities for both were simply overwhelmed – as was the healthcare workforce.

Hospital beds are expensive to build, and expensive to maintain.  We can’t afford a healthcare system that builds them for the worst case scenario.  But we can learn from innovative efforts during the pandemic, like building temporary hospitals that can be expanded or contracted as needed.  

Similarly, there has to be a strategy for dealing with dead bodies during a global health crisis, especially one in which those bodies themselves may carry ongoing risks.  Existing morgues, mortuaries, and even graveyards may not be sufficient.  There needs to be a plan.

Hardest to solve are healthcare workforce shortages.  It’s not easy to train new healthcare workers, and retaining them when they’re stressed beyond belief proved to be a challenge.  In a crisis, we need them all working at the top of the licenses, able to cross workplaces and even state lines, and properly supplied and compensated.  None of those is a “normal” state of affairs for our healthcare system, and all are inexcusable in a crisis.

Telehealth: telehealth seemed to finally gets its day during the pandemic, with relaxed regulation, improved reimbursement, provider adoption, and consumer preference.  It took pandemic to make us realize that making sick, potentially contagious, patients travel to get care is not a good idea.

That being said, now that the pandemic is in a more manageable phase, the bloom seems to be off the telehealth rose, with regulations being reapplied, providers not fully incorporating into their practice patterns, and patients returning to in-person visits.

Hey: it’s 2022.  We have the technology to do telehealth “right.”  Aside from, say, a heart attack or an auto accident, telehealth should always our first course of action.  Our licensing, our reimbursements, and our work flows need to facilitate this – not just to prepare for the next health crisis, but simply as part of a 21^st century healthcare system. 

Communication: One of the most unexpected results of the pandemic is the distrust of public heath advice – vilifying public health officials, spurning mitigation efforts like masking or isolation, and spurring on the already-present anti-vaxx movement.  “Science” is seen as in the eye of the beholder. It’s an information war, and health is losing.

We need the tools to fight the health information war more effectively. We need to learn how to communicate more effectively.  We need to reestablish faith in science.  We need responses to a health care crisis to be a health issue, not a political one.  

————

We will be taken by surprise by the next health crisis.  We had plans for a pandemic, but, when it hit, we fumbled every response.  Next time we’ll be expecting another COVID, and, if it’s not, we’ll be caught flat-footed again.  

The current crisis is, to use Dr. Tompkins’ words, a really good test for whether we’re working on the right things for our next health crisis.  I’m not so sure we are.  

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

BY ROSEMARIE DAY

When the Affordable Care Act (ACA) was signed into law twelve years ago today, Joe Biden called it “a big f-ing deal.”  Little did he, or anyone else at that time, realize how big of a deal it was. Just ten years later, America was engulfed in a global pandemic, the magnitude of which hadn’t been seen in a century. Two years after that, the numbers are chilling: over 79 million people were infected, at least 878,613 were hospitalized, and 971,968 have died.

As bad as these numbers are, things would have been much worse if the ACA hadn’t come to pass. The ACA created an essential safety net that protected us from even more devastation. Covering over 20 million more people, it is the single largest health care program created since the passage of Medicare and Medicaid in 1965. Thanks to the ACA:

• The estimated 9.6 million people who lost their jobs during the pandemic didn’t have to worry as much about finding health care coverage if they got sick from Covid (or anything else) – they could shop for subsidized insurance on the public exchanges or apply for Medicaid. This helped millions of people to stay covered, which saved thousands of lives. In fact, the overall rate of uninsured people has not increased significantly during the pandemic, thanks to the safety net of these public health care programs.

• The 79 million people who got Covid didn’t have to worry about whether their infection’s aftermath would result in acquiring a pre-existing condition that would prohibit them from buying health insurance in the future (if they couldn’t get coverage through their jobs).

• Those who were burnt out from the pandemic and joined the Great Resignation did not have to worry that they would be locked out of health insurance coverage while they took a break or looked for a new job. According to the Harvard Business Review, resignation rates are highest among mid-career employees (those between 30 and 45 years old), a stage of life when health insurance is critical, given the formation of families and the emerging health issues that come with age. 

The ACA’s remarkable safety net framework made it far easier for policy makers to deploy federal funds during this unprecedented emergency. The American Rescue Plan Act , a $1.9 trillion coronavirus relief bill signed by President Biden on March 11, 2021, included provisions that built on the ACA, including more generous premium tax credit subsidies. Its predecessor, the Families First Coronavirus Response Act (FFCRA) of 2020 enhanced Medicaid funding and required states to provide continuous Medicaid coverage.

• For working- and middle-class people, the health insurance exchanges (both state and federal) provided one-stop shopping with enhanced federal subsidies which made health insurance more accessible for people who lost their employer-sponsored insurance. Many Americans who needed health insurance turned to the ACA marketplaces to find a plan. Amid the recent surge in resignations, the Biden administration announced that sign ups hit an all-time high of 14.5 million when open enrollment ended in January 2022.

• For lower income people, the Medicaid program was there, stronger than ever, thanks to 38 states opting into the ACA’s expansion of the program. An increased federal matching contribution helped states to finance Medicaid enrollment during the worst of the economic downturn and prevented Medicaid disenrollments.

• Additional benefits from these measures included reducing health disparities, ensuring mental health coverage, and helping new moms with more robust coverage.

Despite the ACA’s strong foundation and the many good things worth celebrating on its twelfth anniversary, there are difficulties ahead. The expanded premium subsidies and enhanced Medicaid funding are only temporary – both are set to expire this year. With that will come a loss of insurance coverage as people struggle to afford what’s on offer. On top of this, the public health emergency will be unwinding which will bring continuous Medicaid coverage to an end. And there are still too many uninsured people in this country (27.4 million). Retaining the expanded ACA benefits and finding other ways to build upon the ACA’s foundation are critical issues for the mid-term elections this fall.  

A recent study shows that support for the ACA and universal health care has increased during the pandemic. We shouldn’t “let a good crisis go to waste.” We need to make our voices heard and commit to building the future. We’ve had to expend far too much energy over the past decade defending the ACA and protecting it from repeal. The pain we’ve endured during this pandemic should not be for naught. Now is the time to assume an expansive posture of building toward universal health care. Retaining the expanded ACA benefits is an important incremental step. As difficult as the pandemic has been, it is providing a once-in-a-century opportunity to address America’s unfinished business in health care. The ACA is an excellent foundation. Let’s build on that so that we have a lasting cause for celebration.

Rosemarie Day is the Founder & CEO of Day Health Strategies and author of Marching Toward Coverage:  How Women Can Lead the Fight for Universal Healthcare (Beacon Press, 2020).  Follow her on Twitter:  @Rosemarie_Day1

By RICHARD ISAACS

You’ll recall that we ran a long piece (pt 1, pt 2) about Medicare Advantage from former Kaiser Permanente CEO George Halvorson earlier this year. Here’s a somewhat related piece from the current head of The Permanente Medical Group about what actually happened there and elsewhere during the pandemic–Matthew Holt

The COVID-19 pandemic has provided important lessons regarding the structure and delivery of health care in the United States, and one of the most significant takeaways has been the need to shift to value-based models of care.

The urgency for this transformation was clear from the pandemic’s earliest days, as shelter-in-place orders caused patient visits to brick-and-mortar facilities to plummet. That decline dealt a financial blow to many fee-for-service health care providers, who are paid per patient visit, treatment or test performed — regardless of the patient’s health outcome.

Prepaid, value-based health care systems, on the other hand, have demonstrated that they are better equipped to respond to a continually evolving health care landscape. Because they are integrated, with a focus on seamless care coordination, and they are accountable for both the quality of care and cost, these systems can leverage technologies in different ways to rapidly adapt to major disruptions and other market dynamics. Priorities are in the right place: the patient’s best interests. Value is generated by delivering the right level of care, in the right setting, at the right time.

Because value-based care focuses on avoiding chronic disease and helping patients recover from illnesses and injuries more quickly, it has the promise to significantly reduce overall costs in the United States, where nearly 18% of gross domestic product was spent on health care before the pandemic — significantly more than comparable countries. That figure rose to nearly 20% in 2020 during the pandemic.

While providers may need to spend more time on implementing new, prevention-based services and technologies, they will spend less time on managing chronic diseases. And thanks to the preventive approach of value-based health care organizations, society benefits because less money is spent managing chronic diseases, costly hospitalizations and medical emergencies.

Value-based organizations drive additional societal benefits. They understand that building trust with patients requires cultural competency — tailoring services to an individual’s cultural and language preferences. During the pandemic, building trust was especially important with underserved communities, where mistrust of health care systems is prevalent.

Previous long-term investments in telehealth and remote patient monitoring technologies served value-based organizations well during the early days of the pandemic, when 80% of care delivery occurred via telemedicine. Supported by a relaxation of regulations to help the broader health care system deal with COVID-19 patient surges, doctors delivered more telehealth services via video and telephone appointments; hospitals shifted more care into the home with telemedicine and coordinated care teams; and health care organizations deployed more resources to deliver culturally responsive care.

While the percentage of in-person visits has increased again, patients clearly appreciate the ease and convenience of receiving care via telehealth at home, or wherever and whenever they need it. Many physicians have said they got to know patients better through video visits, because patients are more open to discussing health conditions from the comfort of home. A recent report by McKinsey & Company shows that telehealth utilization is 38 times higher than before the pandemic.

Even before the pandemic, Permanente Medical Groups had explored ways to deliver acute care at home. Both the Northwest Permanente medical group and The Permanente Medical Group in Northern California launched advanced-care-at-home programs that leverage physician-led command centers, community care teams, the organization’s comprehensive electronic health records and remote monitoring to ensure hospital-grade, person-centered care for patients with complex conditions such as sepsis, pneumonia, and coronavirus.

When unprecedented surges led to hospital beds overflowing with COVID-19 patients, value-based health care systems harnessed the power of remote patient monitoring to improve capacity. Building on those efforts, Kaiser Permanente with Mayo Clinic last year announced an unprecedented collaboration to invest about $100 million in a technology company, Medically Home Group, to advance a new health care delivery model that enables more patients to receive acute-level care and recovery services at home. This is part of a movement involving several coalitions of health care systems working to move acute care into the home.

As with telehealth video and phone visits, delivering hospital-level care at home provides another opportunity for health care organizations to gain more visibility into social factors that affect patient health outcomes, such as medication adherence, diet, or food insecurity. The importance of addressing social determinants of health became especially evident during the pandemic as data revealed the disproportionate mortality rate from COVID-19 in Black and Latino communities. Likewise, while value-based health care organizations for years have made non-English-language assistance available to patients, the high death toll in underserved communities underscored the need for even more effective, culturally appropriate communication.

To make sure their messages resonated, these organizations partnered with community leaders who could provide the information and reassurances needed to advance vaccine acceptance. Similar programs included responsive pop-up “vaccine clinics on wheels” that went directly to parks and schools, neighborhood barber shops and beauty salons, and places of worship in underserved urban and rural communities. These efforts offer a window into what the future of value-based care will look like both inside and outside of traditional care settings.

New skills, training and research will be needed by physicians and care teams who will increasingly reflect the diversity of patients and communities served. For example, robust data will be needed to better understand the disparities associated with COVID-19, or for any medical condition. While the U.S. Department of Health and Human Services toward the end of 2020 released guidance that requires labs to include race and ethnicity — along with age, sex and ZIP code — when reporting COVID-19 test results, this data wasn’t required prior to August 2021. To get a better picture of how any disease affects a community, it’s best to collect detailed data from the start.

The health care industry can look to Medicare Advantage, the federal government’s health program that measures and rewards quality coverage and care, as a model for effective, coordinated, managed care. Because Medicare pays a fixed amount per enrollee to providers offering Medicare Advantage plans, care organizations have a powerful incentive to keep patients healthy. The program utilizes the Centers for Medicaid & Medicaid Services Star Ratings system to measure and publicly report plan performance, providing patients with transparency and choice when shopping for quality coverage. In 2022, 89% of all Medicare Advantage enrollees were in plans rated 4 stars or higher.

In addition to improving care quality and patient satisfaction, Medicare Advantage promotes value-based care by reducing health care costs and improving health outcomes for a diverse population of seniors and individuals with disabilities. The program costs U.S. taxpayers 9.5% less per enrollee than traditional Medicare. Medicare Advantage enrollees are 13.4% more likely to be screened for breast cancer compared to those in traditional Medicare, and Medicare Advantage has a 57% lower rate of avoidable hospitalizations for patients with major complex conditions when compared to fee-for-service Medicare.

The pandemic demonstrated the success of value-based models, which take accountability for patient outcomes, and which continue to make necessary, long-term investments to improve care delivery, reduce disparities and focus on population health. Now is the time for a wider range of health care organizations to mobilize by aligning incentives to build a system of care that is more responsive, coordinated, equitable and sustainable.

Richard S. Isaacs, MD, FACS is CEO and executive director, The Permanente Medical Group; president and CEO, Mid-Atlantic Permanente Medical Group, and co–chief executive officer, The Permanente Federation.

By MARIE DUNN

A little more than 20 years ago, the IOM report To Err is Human catalyzed the profession around the realization that our health care system was killing around 98,000 people a year from medical error. I am part of a generation of professionals that learned to adopt systems thinking; to measure, monitor, and improve; and to ultimately improve quality of care. 

Today, we face a different set of challenges. Health care is in the midst of a global pandemic, a reckoning with systemic racism, not to mention the great resignation. But also, we face a climate crisis. Are these things connected? Is there something we all can do? The answer is undoubtedly yes, and I write to advocate for climate change to be included on this list of strategic and moral imperatives for health care leaders everywhere. 

Why is that?

• Even today, the health care industry’s contribution in emissions to climate change is killing people. In 2018, greenhouse gas emissions from the health care industry alone resulted in the loss of 388,000 disability adjusted life years.
• The impacts of climate change on health are inextricably connected to issues of systemic racism. For example, communities that were red-lined (racist housing policy that led to systematic underinvestment) experience higher temperatures than communities that were not, and higher temperatures take lives.
• Climate change makes conditions more favorable for the spread of some infectious disease, including pandemics, but also illnesses like Lyme and waterborne illnesses that have significant impacts on health.

As the world shifts, it’s time for health care leaders to develop a new set of strategic priorities that address the health system’s need for preparation and resilience in this landscape. 

So with that context, what can you do to effect change?

First, get up to speed on the intersections of health and climate. The information is out there, so dedicate some time to consuming it. Health Care without Harm is the leading non-profit in the US focused on this topic, with many great resources to draw from. I have learned tremendously from publications like The Lancet’s Countdown on climate change and health issues and the books Environmedics and All We Can Save. 

Reading is important, but don’t let it be your only action. Here are some steps to take.

Take a look at how climate intersects with your organization’s strategic plan and embed measures that link your organization’s success to its work on climate change. There are two primary ways your organization can demonstrate its efforts to impact climate change. 

One set of actions is to mitigate emissions. This might look like efforts to switch to renewable energy, review your organization’s investment portfolio, and most importantly in health care, reduce emissions coming from the supply chain. 

The other set of actions relate to adaptation. In short, since climate change is already happening, this is about creating a set of strategies that help your community—however, you define that community (local, regional, national)—more effectively respond to the impacts of climate change that exist today and will get worse in the future.

It’s nearly impossible to maintain progress on an initiative without a way to measure progress, so this means it’s important to incorporate measures related to climate into your organization’s strategic plan. On the mitigation front, this might look like striving to become a net-zero institution (Kaiser in the US and the NHS are leaders on this journey). On the adaptation front, maybe your organization picks a few measures from the recent Lancet Climate change and health report that are relevant to your community and tracks efforts and progress. 

Help people make connections between climate and existing strategic projects and skills. 

Too often, climate change feels far away from and unrelated to the pressing problems at hand. Also in a moment of big problems, there might be fear that we can’t turn away from something as big as the Covid-19 response. I am not advocating that we turn away from these near-term imperatives, but I do believe we need to add a climate-conscious lens. Make the links to show that by doing the hard work we’re already doing, with a climate lens, we can have even more impact. For example:

• Are you having conversations about social determinants of health? Link these conversations to climate–climate change is a social determinant of health. 
• Are you trying to improve your supply chain? As many organizations consider the effectiveness of their supply chains in the wake of a pandemic, this is the moment to add a sustainability lens. As the world becomes more emissions conscious, so will health care. Health care organizations wield tremendous purchasing power that can be used to positive ends here. It’s easy to think that being sustainable might always be more expensive. But there’s a lot of waste in health care, so efforts to reduce have the chance to not only reduce emissions but reduce costs. 
• Are you having conversations about value-based payment? There is readily available information on heat waves and air quality, and these environmental conditions have real impacts on human health. Review the CDC’s assessment of regional impacts of climate change on health. Is there a way to systematically add some indicators related to heat, air quality, or other relevant factors to your care management program program, with a set of related interventions, so you can better help your communities adapt? 

Look for your community. 

I don’t consider myself a climate change expert, and I am guessing you might not be either. 

But as health care professionals, we have a lot to bring to the table on the conversation about climate, in the same way that we have a lot to learn from folks who are working in other domains. What I do know is that no single person will solve this challenge, and that finding community is important.

Here are some ideas:

• Involve your supply chain and finance teams. Often behind the scenes, these teams will play a pivotal role in helping your organization move forward. 
• Take advantage of existing infrastructure. The CDC has invested in capacity for climate and health in a number of states through its BRACE program. Look to see what might exist in your community to draw on and build from.
• Reach out to your partners in public health or health care delivery. Health care delivery systems and public health have complimentary roles to play. Braiding resources and initiatives will help communities go further together.
• Seed funding to community-based organizations. As in so many health care efforts, community-based organizations play a critical role. These are likely not new relationships, but relationships already in place through other initiatives. Community-based organizations by their nature run on small budgets. Think about ways to flow resources into these organizations to secure them as partners and align your efforts in approaching them around topics like VBP, climate, and other efforts. Look for ways for them to lead in approaching the communities they serve.
• Build on your community data resources (HIEs, etc). Many community-based data programs are in the process of re-envisioning their future. Can these organizations be community resources to provide a data set or service that no single organization can provide where it comes to a topic like climate change?

Lead with small tests of change. 

When faced with the Institute of Medicine’s staggering assessment of error in medicine, we led with conviction, small tests of change, and systems thinking. This topic is gaining momentum, with institutions like the National Academies and HHS stating their intent to take action. However, the market forces are not in place as of yet to put climate change on the agenda of every health care organization. This is where your voice, conviction, and action matter. Chances are that there is something small you can do today to help effect change in your organization and build momentum. Small tests of change make a big difference.

Marie Dunn, MS, is a public health professional and long-time health executive working at the intersection of analytics, population health, and climate.

By MIKE MAGEE

“In countries where there is great private wealth much may be effected by the voluntary contributions of patriotic individuals, but in a community situated like that of the United States, the public purse must supply the deficiency of private resource. In what can it be so useful as in prompting and improving the efforts of industry?”

Those were the words of Alexander Hamilton published on December 5, 1791 in his “Report on the Subject of Manufactures.” He was making the case for an activist federal government with the capacity to support a fledgling nation and its leaders long enough to allow economic independence from foreign competitors.

Today’s “foreign force” of course is not any one nation but rather a microbe, gearing up for a fourth attack on our shores with Delta and Lambda variants. This invader has already wreaked havoc with our economy, knocking off nearly 2% of our GDP, as the nation and the majority of its workers experienced a period of voluntary lockdown.

Our leaders followed Hamilton’s advice and threw the full economic weight of our federal government into a dramatic and direct response. Seeing the threat as akin to a national disaster, money was placed expansively and directly into the waiting hands of our citizens, debtors were temporarily forgiven, foreclosures and evictions were halted, and all but the most essential workers sheltered in place.

Millions of citizens were asked to work remotely or differently (including school children and their teachers) or to not work at all – made possible by the government temporarily serving as their paymaster and keeping them afloat.

As we awake from this economic coma, many of our citizens are reflecting on their previously out-of-balance lives, their hyper-competitiveness, their under-valued or dead-end jobs, and acknowledging their remarkable capacity to survive, and even thrive, in a very different social arrangement.

If our nation is experiencing a trauma-induced existential awakening, it is certainly understandable. America has lost over 600,000 of our own in the past 18 months, more people per capita than almost all comparator nations in Europe and Asia. This has included not just the frail elderly, but also those under 65. In the disastrous wake of this tragedy, 40% of our population reports new pandemic-related anxiety and depression.

A quarter of our citizens avoided needed medical care during this lockdown. For example, screening PAP smears dropped by 80%. And so, Americans’ chronic burden of disease, already twice that of most nations in the world, has expanded once again. There will be an additional price to be paid for that.

The Kaiser Family Foundation’s most recent Health System Dashboard lists COVID-19 as our third leading cause of death, inching out deaths from prescription opioid overdoses. Year-to-date spending on provider health services through 2020 dropped 2%, but pharmaceutical profits, driven by exorbitant pricing, actually increased, bringing health sector declines overall down by -.5% compared to overall GDP declines of -1.8%. The net effect? The percentage of our GDP devoted to health care in the U.S. actually grew during the pandemic – a startling fact since our citizens already pay roughly twice as much per capita as most comparator nations around the world for health care.

In the “pause”, other nations have been soul-searching as well. A common theme has been work. Two of the most popular discussions include remote work from home and the four-day workweek. These discussions were already well underway pre-pandemic in Germany, Spain, New Zealand, Iceland and beyond. But now, they are cropping up in U.S. corporations like PepsiCo and Verizon as Human Resource departments grapple with scarce or reluctant employees, and consider paid time off, flexible work schedules, and remote work arrangements.

In some ways, we remain the nation that Hamilton described in 1791. We have been unable to come fully to grip with our racist past, and have used both our state and federal governments – not to provide economic room for our citizens to survive foreign competitors – but rather to maintain the status-quo advantages of home-grown “haves” over “have-nots.”

On the surface, Red vs. Blue America seems ill-prepared to start anew, to learn from and progress off the back-end of this historic pandemic.

Americans have had a year and a half to reflect and think about work and life, priorities and the future. Our discomfort with the current arrangement is palpable. Is this the America we want?

What if we managed to spread our nation’s resources more equitably? What if we eliminated “non-real work” and allowed remote work as the rule rather than the exception. What if health care and early childcare programs were universal, and not tied to one’s job? What if technologic innovation was employed to advance equity and justice? What if we decided that making our lives better was the goal instead of just maximizing our GDP.

Wouldn’t that be a better way to live? A better America?

Mike Magee, MD is a Medical Historian and Health Economist and author of “Code Blue: Inside the Medical Industrial Complex.“

By MIKE MAGEE

Confrontation is good. Governor Abbott’s “We are getting out of the business of telling people what they can and cannot do” was “Neanderthal thinking” as President Biden said. Insurrectionist Richard Bennett, whose feet sat on Speaker Pelosi’s desk two month’s ago, does need to cool his jets in jail awaiting trial. And states lagging in immunizing teachers, opening schools, and accelerating their vaccine efforts need to realize that they will be held accountable by voters in the near future.

That is surface turbulence, but quietly below the surface, there are other transformational forces underway fueled by pandemic accelerants.

How long would it have taken under normal circumstances to advance equitable access to broadband and tech devices for all students in America? A decade from now, would we have advanced teacher skills in long-distance learning to the degree we are now witnessing? And how many at-home workers will be willing to return to off-site offices in the near future?

These are just a few of the questions being considering as we return to “normal” or life under the “new-normal.” And while we are all doing our best to cope with the fear and worry that comes with change, most of our collective anxiety is now focused on economic security and jobs.

This past month we added 379,000 jobs. Sounds great, that’s if you ignore the fact that there remain 9.5 million fewer jobs in our economy compared to a year ago, or that first-time jobless claims rose last week. As former Federal Reserve economist Julia Coronado reported, “We’re still in a pandemic economy.”

The Bureau of Labor Statistics in 2019 reported 3.7% growth for the coming decade. The newest update downgraded that to 1.9% if the pandemic impact is “strong”, and 2.9% if it is “moderate.”

More significant is that the pre-pandemic 2019 BLS report predicted a series of permanent changes including more remote work, higher tech service demands, further declines in travel and entertainment, and greater investment in public health and health services.

The study went to the trouble of assessing the prospects for 800 detailed ocupations over the next decade. Recently updated, the largest increases post-pandemic were in the medical, health-science and technology fields. For example, jobs for epidemiologists were projected to increase 25%.

The largest declines, as you might expect, were projected in transportation, travel and hospitality. Hidden deeper were signs of a changing world order – like the fact that if you are a computer savvy teen with only a high school education, your likely employment in the future will be in software development, not as a cashier.

In contrast to the rosy health sector jobs projections, three years ago, a deep dive into the health sector revealed huge potential for manpower shifts.

With health care now consuming close to 1 of every 5 dollars in America, the sector was a major employer. Many of those jobs delivered zero benefits when it came to patient care. In fact, there were16 health care jobs for every one physician, and 8 of those 16 were non-clinical.

A shift to a centralized health insurance system, while preserving local choice and autonomy over care delivery, carried estimated savings of up to $1 trillion off of our nearly $4 trillion annual health care expenditure. Of course that means many insurance agents, coders, billers, and data specialists would lose their jobs. What would become of them?

Likely they would follow the money. But how might that $1 trillion be best spent? The best answer was embedded in the startling fact that the U.S. is the only developed nation that spends more on health care than all other social services combined. These services – including housing, education, transportation, environmental protection, sanitation, safety and security –are all proven determinants of health.

Let’s focus on one – transportation for the elderly. 52 million people, or 16% of the American population, are over 65.  Of these, 30% have skipped their doctor appointments citing transportation problems as the cause. Missed appointments cost the health sector $200 per incident and $150 billion annually by one estimate. There are 76.4 million Baby Boomers with 10,000 crossing the age 65 threshold every day. By 2030, 21% will be over 65, and over 1/5 will be non-drivers, and 1/5 have no children to lend a hand.

In 2017, one enterprising health sector veteran saw an opportunity and seized it. Mark Switaj, a 15-year emergency medical technician created RoundTrip based in Philadelphia. Contracting with local providers and insurers, his computerized Uber like patient transportation system was able to deliver a 4% no-show rate.

How are they doing in 2021 in the middle of the pandemic? They’ve adjusted. Here’s a post from February 25, 2021: “Over the past year, as health systems have battled COVID-19 patient census surges, mobilized testing efforts, and shifted outpatient appointments, patient transportation is an essential service underpinning each of those efforts. Leading institutions like Christiana Care, Children’s Hospital of Philadelphia, and Tufts Medical Center. launched Roundtrip in the middle of the pandemic. Those organizations understood the criticality of the transportation barrier and the value their clinical teams would gain with a tool for coordinating rides for their most vulnerable patients.”

 Mike Magee, MD is a Medical Historian and Health Economist and author of “Code Blue: Inside the Medical Industrial Complex.“