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Healthcare Forever Changed, Employers Can Aid Vaccinations, MD Racism Training-The HSB Blog 12/8/20

Coronavirus Has Changed Healthcare Delivery-Likely Forever

“Our Take”: On December 2nd the Cleveland Clinic announced it was postponing all “nonessential inpatient surgeries; from December 7th through January 4th, 2020, marking the second time the system has had to postpone elective surgeries due to the pandemic (the first following a statewide order in March of 2020). Postponements of highly profitable elective surgeries are but one of the ways that the Coronavirus has changed healthcare delivery, likely forever, leaving a digitally transformed, facility-lite but potentially less profitable system in its wake. However, providers and practitioners that embrace existing and emerging digital technologies can potentially replace lost revenues with virtual and remote care to those reluctant to use institutional settings, and even play a greater role for those looking to take charge of their own care.

Description: The forced deferral of elective procedures and routine clinical care has dramatically undermined the profitability of physicians and providers. A recent article in Health Affairs noted that between February and April 2020, hospital volumes declined almost 20% and while they had recovered somewhat by June/early July 2020 they remained well below pre-pandemic levels. Nevertheless, while patients have largely scaled back in-person care below pre-pandemic levels they have embraced accessing the system via telehealth, telebehavioral health, and even at-home or self-administered testing. These changes combined with the fact that the strain on the healthcare system has made patients more amendable to obtaining care from other levels of clinicians in the system (PA’s, LPN’s, Pharmacists, etc), have permanently altered by where and from whom patients will be willing to get care in the future. In addition, with nursing homes and long-term care facilities accounting for 38% of all deaths and 5% of all U.S. COVID cases according to the New York Times, seniors are now much more reluctant to seek care in those facilities. This human tragedy caused regulators and caregivers to seek additional evidence that facilities will embrace new ways of caring for the elderly in order to restore confidence in the safety and well being of patients at these facilities. Along those lines, seniors are now much more likely to attempt to age in place longer, which is more practical with the aid of certain technologies. Finally, while a vaccine will aid in the long-term recovery from COVID’s healthcare impact, the economic impacts will be long-lasting and unfortunately cause even more people to remain unemployed for longer periods of time. For example, according to the Bureau of Labor Statistics, by November 2020 the percentage of unemployed individuals who had been unemployed for 27 weeks or more rose to a seasonally adjusted 36.9%, up from 19.2% before the pandemic began, With research showing a direct correlation between the period one remains unemployed and their ability to eventually return to the workforce, many people will likely remain permanently unemployed and as a result, permanently lose employer-sponsored coverage. Given that by some estimates as many as 4M could remain permanently unemployed post-pandemic, and that employer-sponsored coverage is by far the most profitable form of coverage, effectively subsidizing Medicare and Medicaid, this shift in payor mix will further hurt providers.

Implications: The pandemic has brought about a of sea change for healthcare condensed into just a few short months. While the changes have put tremendous pressure on the finances of providers in the near-term if they don’t respond by embracing a dramatic change in business models they may not survive. While typically slow to embrace change, consumer acceptance of new delivery models and unprecedented regulatory responsiveness to COVID have created one last opportunity for the healthcare system to bring itself into the digital age on its own terms or risk being overhauled by outside forces. First and foremost, although there are highly effective vaccines on the horizon, and we are on the cusp of bringing this pandemic under control, there is no guarantee the world will not see another virus in the not-too-distant future. We must be prepared financially as well as clinically. Moreover, despite the current reimbursement and regulatory uncertainty surrounding many telehealth changes during COVID, providers have to embrace the new normal as this is what consumers have now come to expect. As Joseph Kvedar of the ATA put it “the doctor’s office is now in your living room”. Although some will cite potential reimbursement differences, given the low incremental cost to treat patients virtually, physicians should be able to see patients more efficiently provided they are given tools to help with administrative tasks. For example, virtual transcription tools could aid with paperwork to allow larger panel sizes at a fraction of the cost of physical scribes. In addition, early research indicates that missed appointments have decreased markedly with the implementation of telehealth with one study showing that overall missed app[intments telehealth are down over 35% and almost 24% for Medicaid patients. In addition, many forward-thinking elder care facilities are now embracing the use of telemedicine and other remote care tools to connect patients to clinicians (and families) and keep patients out of harm’s way or from going to centralized “nursing stations”. Bluetooth-enabled fall-detection systems, motion and video sensors, and other wearables now allow for real-time monitoring at a much more sophisticated and connected level than ever before, facilitating aging in place. Although dealing with the shift in payer mix will be difficult, in a transformed healthcare delivery system providers and physicians will need to reduce their reliance on high margin episodic and elective procedures. Over time we see the plethora of real-time sensors, monitors, therapeutics, recovery tools, and data science changing the very nature of healthcare from periodic check-in and repair to one of constant monitoring and fine-tuning.

The Employer’s Role in Creating a COVID-19 Testing and Vaccination Infrastructure

Event: On November 30, 2020, Benefits Pro released an article explaining why employers will be well-positioned to support large-scale vaccination efforts. As employers are typically responsible for vaccinating about 25% of the U.S. population for flu, they can bring the same strength and efficiency to a COVID-19 response through testing and vaccination.

Description: Many employers have already initiated testing programs in an effort to responsibly bring employees back to the worksite. For example, CVS Health has included retail and onsite point-of-care testing where physical distancing can be difficult. In addition, Delta Air Lines is providing employee COVID-19 testing with a rapid-response option for flight crews to help employees and customers build confidence about traveling with Delta. As employers already educate and engage their employees, they can help employees overcome any apprehensions or barriers to access, achieving a more widespread immunity. As a result, employers will be well-positioned to support a large-scale vaccination effort.

Implications: Just as employers have supported influenza preparedness, they can build on the infrastructure they’ve already created for immunizations to support the national COVID-19 testing and vaccination infrastructure. Employer-provided vaccinations could be the first step for companies to finally open their offices. This could bring more productivity and well-being among the employees. Companies could require or financially incentivize employees to be vaccinated in order to physically come in to work to promote the vaccine. Rolling out employer-provided vaccinations could also reduce health disparities as companies can cover workers from underserved communities and backgrounds. While some may not have access to a vaccine in a vulnerable neighborhood, his / her employer may provide another means of accessing the vaccine at a more convenient time or place. Employers could also educate the employees and customers to encourage them to trust the vaccine in order for a safe return to the workplace. While there may be some logistical obstacles in vaccinating employees at work such as refrigeration, freezing or even ultra-cold storage, which could complicate the transportation, storage, and location decisions, many employers may be large enough or work with trade associations to figure out ways to overcome these.

Antiracism Training in Medicine

Event: On December 3rd, JAMA Health Forum published an article addressing the ongoing racism and biases not only occurring today, but specifically within the healthcare realm. Given a rise in the deaths of unarmed African Americans, disparities in infection and death rates due to the Coronavirus, and lack of both healthcare and everyday resources during this unprecedented time, healthcare organizations are being urged to address racism and discriminatory practices within their organizations to promote better patient outcomes and health equity.

Description: As a result of the visibility that racial injustice and discrimination have been given outside of healthcare, addressing this issue within healthcare has become a key issue. Currently, many medical programs lack cultural competency as well as diversity and inclusion training within their curriculum, leaving medical professionals ill prepared when treating patients of other ethnicities. As a result, many organizations have incorporated mandatory antiracism practice and training to address racism and bias and to advance health equity. Although this serves as a significant steppingstone, the article states that more can be done to make real advances as opposed to surface level training activities that ultimately show no improvement in antiracism competencies or in institutional measures of inclusion, equity, or health outcomes.

Implications: As a result of the pressing need to assure that healthcare workers are adequately trained, several recommendations have been proposed including: 1) aligning antiracism training with the mission, vision, values, and priorities of the institution to provide that it is factored into the institution’s strategic goals, success metrics and incentives to ensure that it is effective, 2) establishment of steering committees made up of diverse institutional leaders, faculty, staff, and students to oversee and direct training, 3) ensuring institutions are building antiracism vocabulary to promote consistent communication and developing a longitudinal anti racist training curriculum that ultimately meets stakeholder needs, and, 4) developing external partnerships to build trust with vulnerable communities and community organizations and to create good relationships between students and trainees to avoid, consciously or unconsciously, harming participants. By incorporating these recommendations into healthcare organizations and curriculum, healthcare professionals can successfully fulfill their oaths and ethical responsibilities to treat patients, students, trainees, and colleagues with the utmost respect and equity.

Primary Care Leaders Call for Clarity About Booking and Recall IT Systems for COVID Jabs and Distributing a COVID-19 Vaccine Across the U.S. - A Look at Key Issues

Event: A recent article in Mobihealthnews highlighted the raised concerns in the U.K. about the IT system that will be used to book and recall patients for administration of both doses of the COVID-19 vaccine. Analogous to the U.K., the U.S. faces similar challenges in the rollout of the vaccine distribution process, as presented in an article by the Kaiser Family Foundation.

Description: Questions surrounding the logistics of the distribution of the COVID-19 vaccine remain as concerns have been raised that the current booking system is not prepared for the vaccine rollout. The biggest challenge lies in how national mass vaccination centers would link to primary care IT systems to view records of those who received the vaccine to ensure that the entire population is vaccinated. Under Britain's National Health Service (NHS), DrDoctor has launched a solution aiming to streamline the vaccine booking process by linking two required appointments. The Medicines and Healthcare products Regulatory Agency (MHRA) has an AI tool that will process adverse reactions to COVID vaccines in the U.K. Vaccine distribution in the U.S. faces similar but more complex challenges. First, funding for vaccine distribution is critical to health outcomes because there is a strain on state and local public health infrastructures. Secondly, logistics and monitoring are also expectd to be an issue because government-led distribution has never before been done in the U.S for the entire population over a short period and this will be done individually by each state. Actual vaccination sites and accessibility to these sites remain an issue and follow up with each individual who has received the vaccine to ensure they receive the same vaccine on time. Similar to MHRA, the U.S. is implementing an enhanced safety monitoring system to track vaccine adverse events. Lastly, getting the public to trust the vaccine is crucial to positive health outcomes because of concerns around the speed with which the vaccine came to market, general concerns around safety, efficacy and side effects and the concerns raised within the context of the political differences during the election.

Implications: There is no doubt that distributing the COVID-19 vaccine will be a massive, complicated effort in both the U.K. and U.S. While planning for distribution has been underway for months, there are still numerous questions and concerns about how challenges will be overcome. Operation Warp Speed has provided pharmaceutical companies with over $10 billion to support research, development, manufacturing, and distribution of COVID-19 vaccines, yet challenges remain. COVID-19 has disproportionately affected specific populations who are vulnerable and may face severe outcomes if not vaccinated. The accessibility of sites for equitable access to the vaccine remains unclear due to the transportation and location-based barriers to health care. The CDC and local jurisdictions are currently implementing a new vaccine tracking system to monitor vaccine administration; however, it remains unclear if the new system will integrate with existing immunizing information systems. Successfully addressing the barriers and challenges identified is essential to ensure the most excellent health benefits accrues from administering COVID-19 vaccinations across the globe.

DeepMind AI's Protein Folding Prediction Achieves Unprecedented Accuracy, Opening Doors to New Disease Treatments

Event: On November 30th the DeepMind subsidiary of Google announced it has cracked a decades-old protein-folding challenge with an artificial intelligence system called AlphaFold. DeepMind noted that “figuring out what shapes proteins fold into is known as the ‘protein folding problem’, and has stood as a grand challenge in biology for the past 50 years”. This discovery could eventually help identify new treatments for diseases, among other nonmedical uses.

Description: DeepMinds’ winner for the Critical Assessment of protein Structure Prediction (CASP) competition, AlphaFold’s average error in predicting protein structure is a distance of 1.6 angstroms, which roughly translates to 0.1 nanometers, or the width of an atom. Among a collection of the most difficult protein targets, the system’s median score dipped down to 87 Global Distance Test (GDT). By understanding the protein-structure, it will play a key role in developing cures for diseases such as Alzheimer’s, Parkinson’s, cystic fibrosis and Huntington’s. DeepMind also announced working on predicting protein structures within the COVID-19 virus of which the technology will play a key role in environmental sustainability.

Implications: Such machine learning techniques bring new breakthroughs in both human health and fundamental biology and will bring better understanding of the body via accurate protein-structure prediction. Since a protein’s shape is closely linked with its function, and the ability to predict this structure unlocks a greater understanding of what it does and how it works, developing treatments for diseases or finding enzymes that break down industrial waste, are fundamentally tied to the shapes of proteins and the role they play. This discovery will dramatically reduce the time and cost involved in determining a proteins structure versus current methods. Not only will this help researchers develop new cures for diseases associated with misfolded proteins but it will also brings major breakthroughs in understanding the disease and in drug discovery.


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