Tag: Pandemic

Some Like It Hot! A Century-Old Disease on Our Southern Shores

Oct 30, 2023

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.

‘Breaking Down Interstate Barriers to Telehealth Delivery’ Tops ATA’s Priorities for 2023

Dec 1, 2022• 1

by JESSICA DAMASSA, WTF HEALTH

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.

I Was Wrong

Jul 26, 2022• 1

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:

The Pandemic, Bad Habits, Riskier Population Health & The Case for Prevention Coming from Newtopia

May 5, 2022

BY JESS DaMASSA, WTF HEALTH

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…

Learning from This War

May 3, 2022• 1

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

Celebrating the 12th Anniversary of the Affordable Care Act in a Pandemic: Where Would We Be Without It?

Mar 23, 2022

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

What the Pandemic Taught Us About Value-based Care

Feb 17, 2022• 4

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.

Climate Change: The Future of the Quality Movement

Nov 18, 2021

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?

A Hamiltonian View of Post-Pandemic America

Jul 12, 2021• 2

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.

Pandemic Accelerants: Life Under the “New-Normal.”

Mar 8, 2021• 1

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.”