Managing the effects of pandemic-induced burnout among healthcare professionals

By Dr. Seleem R. Choudhury

As the COVID-19 pandemic continues, healthcare workers face unprecedented levels of stress, fear, and anxiety. Situations that trigger chronic stress have always been present within the important and weighty work of caring for patients, but routine stressors are now intensified by the serious risks of working on the frontlines of a pandemic. Together, this creates a perfect storm of heightened risk of burnout.

Accounts of non-healthcare workers experiencing burnout from the challenges of working during a pandemic, such as learning to work remotely, constant technological mediation, and navigating new family schedules, are well documented. Though the phenomenon of burnout among healthcare professionals stretches back decades, the literature and recent data for U.S. healthcare workers during the pandemic is scarce (Jha, Shah, Calderon, Soin, & Manchikani, 2020).

Burnout: definitions and warning signs

The term “burnout” emerged in the early 1980s, and is defined by psychologists as “exhaustion that workers can experience when they have low job satisfaction and feel powerless and overwhelmed at work” (Mathieu, 2012).  A definition from a recent study by Dr. Sachin Jha, et al., emphasizes the root cause of burnout as long-term job stress, resulting in a “mixture of fatigue, cynicism, and exposure to inefficacy” (2020). Though often thought of as a form of primarily emotional exhaustion, the impact of burnout can go beyond mental health, manifesting in physical ailments (Figley, 1995). 

Burnout among healthcare professionals specifically has long been a concern.  The Bureau of Labor Statistics projects 200,000 RNs will be needed per year over the next six years. But, according to Nursing Solutions Inc., since 2015, the average hospital has turned over nearly 90 percent of its workforce—these are all pre-COVID-19 numbers (2020).

Although burnout has been around for many decades, it has been exacerbated by the unique challenges of the pandemic, and exposes the insufficient methods that have historically been used to mitigate the symptoms of burnout among healthcare workers.

COVID-related burnout

Numerous personal accounts and experiences regarding providing care during COVID include feelings of being overwhelmed and powerless. According to a survey of nearly 60,000 nurses by the National Order of Nurses, a French nursing union, 57 percent of France’s nurses have described their condition as a “state of professional exhaustion” since the beginning of the pandemic (2020). 

In the U.S., median self-reported stress, measured on a scale from 0 to 10, among intensive care unit clinicians increased from 3 to 8 during the pandemic (Society of Critical Care Medicine, 2020).

There are many root causes of the skyrocketing levels of burnout during the pandemic. Feelings of powerlessness are practically inevitable when, despite you and your colleagues’ constant efforts to fight the virus, you continue to see the same symptoms and give the same diagnosis repeatedly.

An article from researchers at Texas A&M University explains other sources of stress:

“Health care workers are experiencing added stress from multiple areas. Many of them are working longer shifts and experiencing more loss of life. The lack of personal protective equipment (PPE) and training on how to use new equipment causes many professionals to question if they have been exposed. This leads to fear that they could infect their family and loved ones. In addition to those fears, there is anxiety surrounding job security. To reduce the spread of infection, many states have stopped elective procedures and consequently, many health care professionals have been laid off or had their hours reduced” (Salazar, 2020). 

Additionally, Amnesty International has released new data showing that an estimated 7,000 health workers have died due to COVID-19 around the world so far (2020).  As of September 2020, the United States has suffered the second-highest death toll worldwide with 1,077 health workers dying from COVID, while the United Kingdom has the next-highest number of deaths at 649 (McCarthy, 2020).  Working in such a high-risk job—especially when you entered into the profession assuming that it would not cost you your life—must have an impact on an individual's psychological well-being. 

Responding to burnout

These are stressful times to be a healthcare professional. At all times, but especially under current circumstances, it is essential to be proactive to remain healthy mentally and physically and prevent burnout.

Individuals may benefit from the following strategies:

• Focus on meaning. Remember why you chose the healthcare profession.
• Try to set boundaries. In a global pandemic this is especially challenging, but where possible set time to disconnect from work.
• Strengthen your resilience. Take a 5-minute breather. Focus inward through journaling, yoga, etc.
• Practice mindfulness. Many studies show that mindfulness programs mitigate burnout symptoms.
• Stay positive, but also be realistic. Burnout is worsened when you expect too much of yourself.
• Practice gratitude. Gratitude has the power to improve our psychological health. Studies have shown it increases personal and professional well-being, boosts happiness, and helps to prevent depression (Chowdhury, 2020).
• Reach out to trusted peers or friends and talk it out (Rogers, Polonijo, & Carpiano, 2016).

Though individuals must recognize the importance of guarding themselves against burnout, healthcare organizations bear a great weight of responsibility in caring for their employees, creating an empathetic and supportive work environment, and providing resources to help their employees cope with the stresses of the pandemic.

Organizations should consider adopting the following strategies:

• Where possible, make sure that staff and providers have the necessary resources and skills to meet expectations. This is a crucial consideration, especially in regard to PPE.
• Organizations must understand that if staff and providers are working many hours, burnout is inevitable, and so provisions and appropriate support must be provided (Centers for Disease Control and Prevention, 2020).
• Organizational leaders need to express authentic empathy (Moss, 2020).
• There should be a robust support mechanism that is known, supported, and promoted consistently by leaders.  This process needs to be ready to employ when a staff member expresses a need (Moss, 2020).
• Ask the question: “Are you doing ok?” Pause and listen for the response. Don’t be afraid to hear what is said, and don’t take the response personally. Associate no stigma with struggling with burnout.
• Prioritize and organize workloads. Be sensitive to what is happening and ensure that priorities match the situation. Be judicious with the number of priorities.

There are many factors that have contributed to the sudden increase in burnout among healthcare professionals, including issues with the initial management of the virus outbreak such as rapidly increased workload hours, inadequate PPE, and a lack of consistently updated guidelines (Wang, Zhou, & Liu, 2020). Even with some of these early issues resolved, many others remain, and I join many other healthcare leaders in our concern that “the constant exposure may result in a permanent fracture in the mental health of many healthcare professionals” (Wang, Zhou, & Liu, 2020).

As leaders of healthcare organizations, we must reprioritize what is important to us at the organizational level.  Trying to do and focus on too many things will overload our teams at such a fragile time for their mental health. We must listen to ensure we fully understand the essential needs of our frontline staff during COVID-19, as stressors may also exist outside work that may contribute to the feelings of powerlessness.

Navigating this pandemic brings prolific uncertainty. It is essentially impossible to get away from the constant stressors in and out of work, and even the most resilient among us are not immune to the effects of burnout. It is imperative for the long-term health of our teams and organizations that we go above and beyond to offer support and resources to our employees on a continual basis.

Resources

2020 NSI National Health Care Retention & RN Staffing Report. Published by: NSI Nursing Solutions, Inc. March, 2020.

Chowdhury, Madhuleena Roy, BA. The Neuroscience of Gratitude and How It Affects Anxiety & Grief. January 9, 2020.

Clinicians Report High Stress in COVID-19 Response. Society of Critical Care Medicine. May 2020. 

COVID19: The National Order of Nurses warns of the situation of 700,000 nurses in France as the epidemic accelerates again. Ordres National des Infirmier. October 11, 2020.

Employees: How to Cope with Job Stress and Build Resilience During the COVID-19 Pandemic. Centers for Disease Control and Prevention. May 5, 2020.

Figley, C.R. (Ed). (1995) Compassion Fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel.

Global: Amnesty analysis reveals over 7,000 health workers have died from COVID-19. Amnesty International. September 3, 2020. 

Jha, Sachin “Sunny”, MD; Shah, Shalini, MD; Calderon, Michael David, MS; Soin, Amol, MD; and Manchikanti, Laxmaiah, MD (2020). The effect of COVID-19 on interventional pain management practices: A physician burnout survey. Pain physician, 23, S271-S282.

Mathieu, F., (2012) The Compassion Fatigue Workbook. New York: Routledge.

McCarthy, Niall. Where Most Health Workers Have Died From Covid-19. Statista. September 3, 2020.

Moss, Jennifer. Preventing Burnout Is About Empathetic Leadership. Harvard Business Review. September 28, 2020.

Rogers, E., Polonijo, A. N., & Carpiano, R. M. (2016). Getting by with a little help from friends and colleagues: testing how residents’ social support networks affect loneliness and burnout. Canadian Family Physician, 62(11), e677-e683.

Salazar, Alexandra. Infecting the mind: Burnout in health care workers during COVID-19. ScienceDaily. May 13, 2020.

Simmons, Micha’le. Three things executives can do to get ahead of leader burnout amidst Covid-19. Advisory Board. April 7, 2020.

Wang J., Zhou M., Liu F. Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China [published online ahead of print, 2020 Mar 6]. J Hosp Infect. 2020; pmid:32147406

Read more from Dr. Seleem Choudhury at seleemchoudhury.com 

SDOH’s Cube - Compliments of Peter Kongstvedt

By Clive Riddle, September 30, 2020

Dr. Peter Kongstvedt over a decade ago, before Social Determinants of Health rose to more recent prominence, developed an illustration of how complex and intertwined the multitude of determinants are that impact a consumers' state of health, using the famous Rubik's Cube design as model.

Peter Kongstvedt, MD, FACP is a highly regarded national authority on the health care industry with particular expertise in health insurance and managed health care, and was recently emailing with me on the topic of SDoH, and shared his graphic from the past that he told me he'd "created many, many years ago in my attempts to increase awareness of the issue, though it wasn’t called SDoH then, so I grafted that on to the slide – just for you."

I was so taken with how applicable his blast from the past was for Social Determinants of Health, that I asked for his permission to share the illustration with you, so here you go - and think about applying other current determinant items as well that are being discussed in the world of SDoH, and how complex the variables are for any individual outcome - and you'll see the Rubik's challenge in front of those on the front lines of SDoH.

Viscous Cycle: Pandemic Elevating Nation’s Blood Pressure, Which Increases COVID-19 Vulnerability

By Clive Riddle, September 3, 2020

The pandemic has increased our population’s stress levels, which has increased blood pressure levels, which creates a population more vulnerable to potential damaging effects of COVID-19. Livongo has released a paper: Tracking COVID-19’s Effect on the Nation’s High Blood Pressure, that examines their own national dataset in this regard.

Livongo refers to a August 14^th CDC Morbidity and Mortality Weekly Report article: Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, which cites that “symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April–June of 2020, compared with the same period in 2019”, and presents findings from their survey taken June 24–30, 2020 that include “40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%).

Livongo reminds us that “while anxiety and stress do not directly cause long-term hypertension, episodes of psycho-social stress and anxiety are well known to cause dramatic spikes in blood pressure (BP).” They note there was a 136% increase in utilization of their myStrength behavioral health solution in the period from January to May.

Livongo’s dataset in this case is driven by Livongo for Hypertension Members that “regularly measure their BP with a monitor and cuff that connect wirelessly with Livongo’s smartphone app. Readings are automatically transmitted to our Applied Health Signals platform where participants can view results.”

Their analysis did indicate a pandemic BP spike, and they report “until late January of this year the percentage of our Members nationally with high BP in any given week was on average 62%. At the end of January, however, we saw a rise in high BP roughly corresponding with the announcement of the first confirmed case of COVID-19 in the US (Jan 21) and the first mass quarantine of residents in the Chinese city of Wuhan (Jan 23). From that point forward, the proportion of our Members with high BP has mostly remained at a heightened level above 62%. An initial analysis of data at the state level shows that in 30 states the percentage of Members with high BP has increased between January and August. According to the data, high BP reached another significant peak in early to mid April when 68% of our Members nationally registered high BP.”

The implications? Livongo reminds us that “while no more susceptible to COVID-19, this population is more at risk of serious illness, hospitalization, and death from the virus. As our BP data reveals, the stress and anxiety and social isolation we have all experienced has had an outsized and measurable impact on this at-risk population.”

Livongo wasn’t the first to note this pandemic spike. Back in May, St. Luke’s Kansas City released an article in which their medical director discussed the trend: Doctors seeing more patients with high blood pressure amid coronavirus pandemic.

The American Heart Association has recently updated a guidance page: Keeping a lid on blood pressure during the coronavirus crisis, noting the need to manage stress, and cautioning that “high blood pressure might raise your risk of experiencing severe complications from the coronavirus. Nearly half of U.S. adults have high blood pressure, or hypertension, which is defined as consistent readings of 130/80 or above.”

Thriving in COVID-19 Times

by Kim Bellard, August 27, 2020

These are, no question, hard times, due to the COVID-19 pandemic. Yes, these are hard times. But not for everyone.

No one should be surprised that Amazon is doing well, as more turn to online shopping and Amazon’s quick delivery, but The Wall Street Journal reports that Bog Box stores generally are doing well.

Similarly, if you’re a streaming service like Netflix or Disney+, the pandemic has been great for business. Video conferencing services like Zoom are booming. Car dealers are struggling, but not online car sales.

In healthcare, everyone seems to agree that the big winner has been telehealth. Industry leaders TelaDoc and Livongo merged, while rival Amwell got a $100 million investment from Google. No one is quite sure how much of the flexibilities introduced during the pandemic will persist once it recedes, but no one wants to miss out on what McKinsey predicts could be a $250b opportunity.

Of course, the pharmaceutical companies are doing fine in the pandemic. They’re the cockroaches of healthcare; they’re always going to survive. Some are even getting the federal government to directly pay for their vaccine research or therapeutics.

Health insurers are also proving to be big winners despite — or because of — the pandemic. Due to all those delayed/avoided treatments, they’re racking up huge profits so far in 2020.

The big loser is employer sponsored health insurance — or rather, the people who lost it. Kaiser Family Foundation estimates that 27 million people lost their health coverage due to losing their jobs in the pandemic.

Another big loser may be primary care practices, especially those not yet owned by health systems. Financial losses are predicted to be staggering, as patients stayed away in droves. As late as July, nearly 90% of primary care practices said they were still struggling due to COVID-19, according to a survey done for the Primary Care Collaborative.

Ann Greiner, president of PCC, said the report “is a clarion call to move to a new payment system that doesn’t rely on face-to-face visits and that is prospective so practices can better manage patient care.”

Hospitals also took a big hit, with the American Hospital Association predicting that losses would top $300b in 2020 due to the pandemic’s impacts. Some of these losses will be offset by the various federal bills (CARES and PPE), others by the rebound in the stock market, but some hospitals will continue to struggle — especially the already struggling rural hospitals.

During the pandemic, it has repeatedly struck me as a particular indictment of our healthcare system is that a health crisis causes so much disruption and so many financial losses. If a sick care system — which, let’s face it, is what we have — doesn’t do well when lots of people are sick, what are we doing?

In April of this year, Microsoft CEO Satya Nadella talked about the growth of its virtual platform Teams during the pandemic and declared, “In this era of remote everything, we have seen two years’ worth of digital transformation in two months.” Healthcare has also made some significant strides, but if all we take away from the pandemic is that maybe we should keep doing more telehealth, we’ll have missed the opportunity for real change.

The pandemic has important lessons for healthcare. We shouldn’t rely on employment for health insurance. We shouldn’t rely so heavily on elective procedures for health care revenues. We need to be more flexible about where and how people get their care.

This pandemic will eventually pass, in some form and with great damage. The healthcare system will survive, at least most of it. The challenge for us is to start making the changes needed for it to thrive even in the next crisis.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

The Latest on Physician Burnout in the Time of COVID-19

By Clive Riddle, May 29, 2020

After COVID-19 fully assaulted the United States in March, an article appeared in the April 9^th Harvard Medical School’s Lean Forward: A Double Whammy: The COVID-19 Pandemic and Burnout in Medical Professionals, sharing that “leaders are advising health care workers to think of the pandemic as a marathon, not a sprint. But how long can health care workers hold up in these challenging conditions?” They cited a recent study on China’s physician COVID-19 experience: “researchers in China conducted a cross-sectional study published in JAMA Network Open Journal in March 2020. The study involved 1257 health care workers in China during the coronavirus pandemic and reported troubling results; 50.4% had symptoms of depression, 34.0% reported insomnia, 44.6% reported symptoms of anxiety and 71.5% reported distress.”

A May 17^th Forbes article,  Doctor, Heal Thyself: Physician Burnout In The Wake Of Covid-19 quotes Nisha Mehta, MD, radiologist, physician advocate and keynote speaker: “For many physicians, Covid-19 may be the proverbial straw that breaks the camel’s back as they isolate themselves physically from their family and friends while encountering a surge of sickness and death.” They cite that “physician burnout was an epidemic BEFORE the Covid-19 pandemic. According to a 2018 study, 400 physicians die by suicide each year – double that of the general population. In addition, doctors have the highest suicide rate of any profession in the U.S including combat veterans. From an economic standpoint, studies estimate that physician burnout is costing the health care system approximately $4.6 billion per year.”

An example of a growing trend, at the start of this month Charlotte, N.C.-based Novant Health established a new task force that will screen front-line healthcare workers for burnout.

Without focusing on just COVID-19, The May issue of The Journal of the American Board of Family Medicine featured are series of studies on physician burnout. In Joy in Work for Clinicians and Staff: Identifying Remedial Predictors of Burnout from the Mini Z Survey, Niharika Khanna, Russ Montgomery and Elena Klyushnenkova remind us that “Joy in medical practice is an important marker of clinician satisfaction related to structural and cultural aspects of the practice.”

Their study involved the CMS Transforming Clinical Practice Initiative (TCPI), which provided coaching and learning support to practices during transition to new models of value-based care. Specifically, Maryland practices participated in the Garden Practice Transformation Network (GPTN) as a part of the TCPI. During practices assessment, the authors measured prevalence of burnout and identified its remediable predictors among GPTN-Maryland practices.

 They found “prevalence of burnout symptoms was 22%, with 35% enjoying their work. A 100-point Time Constraints/Teamwork (T/T) score was constructed using factors significantly associated with burnout symptoms. T/T score increase by 1 unit was associated with 10% increase in the odds of moving from the group experiencing burnout or stress to the group who found ‘joy in work’.”

In Indicators of Workplace Burnout Among Physicians, Advanced Practice Clinicians, and Staff in Small to Medium-Sized Primary Care Practices, Debora Goetz Goldberg, Tulay G. Soylu, Victoria M. Grady, Panagiota Kitsantas, James D. Grady and Len M. Nichols remind us that “burnout is defined as a ‘syndrome of emotional exhaustion, depersonalization, and a sense of low personal accomplishment that results in decreased effectiveness at work.’ Numerous studies have concluded that burnout is a serious problem for physicians, advanced practice clinicians, nurses, and other health care professionals. Recent research indicates that primary care physicians experience a higher rate of burnout than most other physician specialties.”

Their study analyzed survey responses from 1273 healthcare professionals from 154 small to medium-sized primary care practices participating in the EvidenceNOW initiative in Virginia. They found “workplace burnout was reported by 31.6% of the physicians, 17.2% of advanced practice clinicians, 18.9% of clinical support staff, and 17.5% of administrative staff. Regardless of burnout status, results show all healthcare professional groups had high levels of anxiety. Providers had significantly higher scores for anxiety than all other healthcare professionals. Providers who experienced higher levels of anxiety and withdrawal were more than three times as likely to report burnout compared to those who experienced low levels in these domains.”

They recommend that “programs should focus on strengthening the work environment of small to medium-sized practices to improve organizational capacity for change and address high levels of anxiety experienced by physicians, advanced practice clinicians and staff.”

Here’s hoping our healthcare heroes can somehow find joy in work, and a strengthened work environment in these COVID-19 times.

What changes in healthcare due to COVID-19 will remain after the pandemic is finally in the rear view mirror?

By Clive Riddle, May 1, 2020

The new issue of MCOL ThoughtLeaders asks the question: “What changes in the business of healthcare are taking place during this pandemic that will most likely continue when the pandemic is behind us?” Here’s some highlights of what experts see on the road ahead:

Here are some of the lasting changes Lindsay Resnick, EVP, Wunderman Thompson Health, predicts:

1. Virtual care and telehealth education, acceptance and uptake – from scalability to care management to customer experience, plan for it.
2. Surge in uninsured and COVID-19 as a pre-existing condition will revitalize the push for healthcare reform, and keep healthcare a central 2020 election issue.
3. Changes in consumer spending combined with healthcare’s growing ‘out-of-pocket culture’ will exacerbate delays in care: treatments, prescriptions, elective procedures.
4. New, more prominent roles for nurse practitioners and physician assistants throughout the care continuum are here to stay.
5. Economic downturn and unemployment will be big influencers in insurance product selection
6. Sites of care will continue to move away from hospitals and physician offices to an array of retail clinic options and at-home care alternatives.

Ewa Kisilewicz , Principal, BDC Advisors, Among other things says “COVID-19 has deepened consumer desire to stay away from hospitals. Consumer-centric providers will respond by adding non-hospital ambulatory capacity. Since mid-March, CMS and states released a set of waivers to address anticipated staff shortages caused by COVID-19. While waivers will expire post-COVID, it will be difficult to go back to the ‘pre-COVID norm’ on the changes that improve patient access and expand scope of practice in medically underserved areas – in so far as they do not create patient safety concerns. Once these regulatory barriers are knocked down, there will be little justification to build them back up again.” She also says “physician practice acquisition by non-traditional competitors will also be “fast forwarded” and cause health systems to rethink physician engagement.”

Patrick Horine, CEO, DNV GL Healthcare, noted that “big data, artificial intelligence, and integrated information systems have been evolving for some time in healthcare, but the pandemic has brought about the importance of more timely information being available, connecting providers, tracking & reporting capabilities and the ability to use the data and apply artificial intelligence to it.” He also counsels that a “critical importance to hospitals as well as the government moving forward, is the emergency preparedness, business continuity and contingency planning that will enable a more effective response for any future pandemic,” and that “it will be essential not only within healthcare, but also in companies, and in life, that we have more diligent infection prevention practices in place as well as modification of behaviors to stay healthy.”

Mark Lutes, Chairman, Epstein Becker & Green, PC cautions that “the Public Health Emergency (“PHE”) will leave many health care providers (hospitals, SNFs, hospices, physician groups) seriously weakened…Those providers that are not strongly capitalized will seek new sources of capital and debt relief. In many cases, they will align with better capitalized competitors or new entrants willing to recapitalize the assets. The credit worthiness of patients/consumers has also been impacted by the PHE. The cohort of patients with commercial coverage will shrink lowering providers’ margins. These consumers may find themselves in managed Medicaid or Marketplace options affording less patient choice. Providers will need to be organized in such a way to successfully contract with the organizers of the networks serving these options.

Hank Osowski, Managing Partner, Strategic Health Group  reminds us that the Telemedicine paradigm shift in how care is delivered “will likely impact staffing and real estate models.” He also laments that “what is disturbing however is how reactionary the response has been for many sectors of the healthcare industry.”

And finally, Terri Welter, Principal, ECG Management Consultants, discusses in more detail the following:

• Financial positions are compromised, prompting market repositioning.
• Strategy One: Aggressively renegotiate health plan contracts
• Strategy Two: Reshape service lines to bolster margins.
• Outpatient growth will accelerate.
• Strategy Three: Invest in building the ambulatory network.
• Strategy Four: Revisit capital investment plans.
• Strategy Five: Change the economic and service relationship between physicians and consumers
• Health plan networks will become bigger competitors for health systems and their physician networks.
• Strategy Six: Partner with independent medical groups.
• Strategy Seven: Restructure health system physician enterprise organizations

Hiding Our Heads in the Sand

By Kim Bellard, April 24, 2020

There are so many stories about the coronavirus pandemic — some inspiring, some tragic, and all-too-many frustrating. In the world’s supposedly most advanced economy, we’ve struggled to produce enough ventilators, tests, even swabs, for heaven’s sake. I can’t stop thinking about infrastructure, especially unemployment systems.

The U.S. is seeing unemployment levels not seen since the Great Depression, and occurring in a matter of a couple months, not several years. Many unemployment systems could not manage the flood of applications.

The word that has been repeatedly used to describe unemployment systems is “antiquated.” Many are still mainframe systems based on COBOL, dating as far back as the 1960’s. New Jersey Governor Phil Murphy lamented: “We have systems that are 40 years-plus old, and there’ll be lots of postmortems. And one of them on our list will be how did we get here where we literally needed COBOL programmers?”

And, let’s be fair: it’s not just state unemployment systems dependent on COBOL; many key federal systems are as well, including some used by the IRS, HHS, Treasury, and DoD, not to mention many banking systems.

There had been precious little money spent on upgrading the systems to more modern architectures, or even to retaining the programmers who could keep them running. When making budget decisions, it often seems like there will always be time to modernize…until there isn’t. Like in a pandemic.

We’re a nation that tends to underfund public pensions, at the local, state, and federal levels. We’re a nation whose infrastructure — e.g., roads, bridges, railroads, dams, water and sewer systems — is rated D+ by the American Society of Civil Engineers. And, as the COVID-19 pandemic is making so very evident, we’re a nation that has been extremely shortsighted in funding public health.

A new report from the Trust for America’s Health minces no words. President and CEO John Auerbach charges: COVID-19 has shined a harsh spotlight on the country’s lack of preparedness for dealing with threats to Americans’ well-being. Years of cutting funding for public health and emergency preparedness programs has left the nation with a smaller-than-necessary public health workforce, limited testing capacity, an insufficient national stockpile, and archaic disease tracking systems — in summary, twentieth-century tools for dealing with twenty-first-century challenges.

Tom Frieden, formerly of the CDC, warns: “We need an army of contact tracers in every community of the US to be ready to find every contact and warn them to care for themselves and stop spreading it to others.” Unfortunately, as Brian Castrucci of the de Beaumont Foundation told Time: “We waited until the house was on fire before we started interviewing firefighters.”

Oh, now we’re seeing why we need to invest in public health. Now we see why we need to invest in better UI systems. Now we see why things like the federal emergency stockpile and the Defense Production Act are important. It’s not like we didn’t know that pandemics could happen and how devastating they could be; we just chose to not be prepared.

We’ve been hiding our heads in the sand.

We’ll get through this pandemic. Not all of us, and not without too many of the rest us suffering in many ways. We’re told that we’re probably not going back to “normal,” at least not anytime soon, that we’ll have to adjust to a “new normal.” I just hope that the new normal includes a more clear-eyed perspective on being prepared for when pandemics and other catastrophes do strike.

We may never be fully prepared for when emergencies do hit, but we certainly can do better than we’ve done so far with this one.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard) 

Seven Indirect COVID-19 Healthcare Business Implications, and Nostalgia for a 2020 Top Ten Healthcare Issues Infographic

By Clive Riddle, March 20, 2020

The HealthCare Executive Group (HCEG) recently released their 2020 HCEG Top 10 Infographic​ with summary data and insights garnered from the 10​th​ Annual  Industry Pulse Research Survey, which is shared below.

Of course, HCEG prepared the infographic based on their survey conducted well before COVID-19 sucked all the current oxygen out of the room in which most other healthcare issues are being discussed. Their survey results would undoubtedly look much different today, and almost feels nostalgic in a way.

Which poses the question – so how is COVID-19 impacting other key aspects of the business of healthcare.  Boundless information and discussion from true experts is coming forth daily on the public health implications and matters related directly to the pandemic. But what about the indirect implications, that will emerge as the year progresses?

Here’s a short list of seven items that come to mind, beyond the oft-stated concerns that the available healthcare clinician and support labor pool is at risk of being diminished from applicable quarantines, lack of personal protective equipment, and sickness within the healthcare workforce; as well as major concerns about hospital bed capacity:

1. RePrioritization: The strain on healthcare organizations while addressing COVID-19 issues, both as a provider and as an employer, will continue to cause other aspects of delivery of services to suffer as resources and attention are re-prioritized.
2. Deferral Cost: This will cause mounting deferral of non COVID-19 related care. Initially non COVID-19 healthcare costs and utilization will be lower than average, but after COVID-19 hopefully runs its course, these costs will escalate well above benchmark levels both due to pent-up demand plus increased services and costs with applicable worsening conditions resulting from deferral of care.
3. Uninsured: The uninsured population will increase significantly due to the economic slowdown driven by the pandemic and required response. Various past legislative and administrative measures to chop away at the ACA during the past three years will result in a weakened safety net.
4. Uncertainty: Uncertainty will reign in the short term for the general, and healthcare business environment, causing longer range business strategic initiatives to be paused.
5. Recession: Healthcare capital spending, M&A activity, and long-range initiative funding such as SDOH investments will thus slow down as this new Recessions escalates.
6. Policy: Healthcare election year policy reform issues will morph, both addressing public health policy issues, as well as coverage issues as the uninsured population increases.
7. Permanent Changes: Some required changes to clinical and business practices during this pandemic will evolve into longer range changes in clinical practices and how healthcare organizations do business.

Successful healthcare organizations in 2020 will somehow juggle and balance navigating the COVID-19 landscape while still keeping an eye on the ball of all the other issues that remain or result after COVID-19 hopefully subsides.

Speaking of keeping an eye on the other balls being juggled, and thus getting back to the HCEG infographic, here’s a reminder of their top ten items 2020 listed in the infographic, which we someday, somehow need to find our way back to, when we’re ready to move forward:

1. Cost& Transparency
2. Consumer Experience
3. Delivery System Transformation
4. Data & Analytics
5. Interoperability / Consumer Data Access
6. Holistic Individual Health
7. Next Generation Payment Models
8. Accessible Points of Care
9. Healthcare Policy
10. Privacy / Security

 

The Visits, They Are A-Changing

By Clive Riddle, February 7, 2020

Many facets of daily American life woven into the fabric of the Greatest Generation and Boomers have been gradually unraveling -  Attending church regularly, Belonging to service clubs, and Golfing for example. Is having a primary care doctor another?

The February issue of the Annals of Internal Medicine features the research article: Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008–2016.  The authors pose the issue, that despite well documented value to primary care visits and relationships, "there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline." They conclude: "commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care."

 

Their study of 142 million primary care visits among 94 million member-years found that PCP visits declined 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Yet visit rates to specialists remained stable and visits to urgent care, retail clinics, and telehealth increased by 46.9%. They also found that the decline was largest among the youngest adults (−27.6%), healthier patients - those without chronic conditions (−26.4%), and lowest-income area residents (−31.4%).

Prior studies prompted the authors to examine this trend. Some previous indicators include:

• The Kaiser Family Foundation Health Tracking Poll in July 2018 found that 26% of all adults don’t have a primary care doctor – and that rate grows much higher for younger age groups: 45% without a PCP for age 18029; 28% for age 30-49; 18% for age 50-64 and 12% for age 65+.

• A study published in the November/December 2019 issue of the Annals of Family Medicine: National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015, found that PCP visits per capita declined 20% during this time period, while visit duration increased 2.4 minutes per visit, and visits addresses 0.3 more diagnoses and 0.82 more medications per visit. The authors offered the hypothesis that “the decline in primary care visit rates may be explained in part by PCPs offering more comprehensive in-person visits and using more non–face-to-face care.”  But perhaps this could also be explained by an aging case mix (fewer younger people seeking visits) that require more visit intensity.

• A study published in the EBRI March 2018 Issue Brief Consumer Engagement in Health Care Among Millennials, Baby Boomers, and Generation X Findings from the 2017 Consumer Engagement in Health Care Survey, reported that "Eighty-five percent of Baby Boomers have a PCP, compared with 78 percent among Gen Xers and 67 percent among Millennials."

Further studies and time will tell how much of this generational shift away from PCP visits is due to alternative points of care,  vs. cost issues, vs. changes in perception of the value of primary care, or perhaps – just maybe – PCPs are doing too good a job with younger generations in communicating electronically via patient portals and other means, and participating in plans with nurse call line options and web based care information that renders the lowest level of primary care physician visits unnecessary.

What's Predicted in Healthcare for the Dawn of a New Decade

by Clive Riddle, January 3, 2019

As we enter 2020, what are prognosticators sensing the start of the new decade will bring forth in the healthcare arena? Here's nine recent HealthSprocket lists that peek into year ahead:

Deloitte offers these ten overall Healthcare and Life Sciences Predictions 2020:

1. Health consumers in 2020: Informed and demanding patients are now partners in their own healthcare
2. Health care delivery systems in 2020: The era of digitized medicine - new business models drive new ideas
3. Wearables and mHealth applications in 2020: Measuring quality of life not just clinical indicators
4. Big Data in 2020: Health data is pervasive- requiring new tools and provider models
5. Regulation in 2020: Regulations reflect the convergence of technology and science
6. Research and Development in 2020: The networked laboratory - partnerships and big data amidst new scrutiny
7. The pharmaceutical commercial model in 2020: Local is important but with a shift from volume to value
8. The pharmaceutical enterprise configuration - the back office in 2020: Single, global, and responsible for insight enablement
9. New business models in emerging markets in 2020: Still emerging, but full of creativity for the world
10. Impact of behaviors on corporate reputation in 2020: A new dawn of trust

Becker's Hospital Review summarized these S&P 7 healthcare trends to watch in 2020 with a financial marketplace perspective: 

1. Changes in healthcare may speed up
2. Industry disruption will continue
3. Rating deterioration will continue
4. Mergers among payers and other players will pressure pricing
5. M&A activity in the healthcare industry will remain elevated
6. Opioid litigation settlements will accelerate
7. Medical device makers will see a stable 2020

On the life sciences front, Syneos Health offers these Pharma Trends for 2020: 

1. The Many Points of Care - shifting away from where clinic exists to wherever patient goes
2. Better, By Design - big shifts in clinical research user experience
3. The Trust Deficit - initiatives to win trust back from people
4. Patient Value - patient-centricity
5. Digital Amplification and Innovation - digital experiences taking another big step forward
6. The Value Evaluation - to show initial population-relevant data and defend value against constant change
7. Answering to Real World - get ahead of both regulatory requirements and payer expectations
8. Connected Communications - personal communications that understand where people are in their individual journeys
9. Rapidly Changing Life Experience - Our world is changing and aging faster than ever before
10. New Strategic Blueprint - resetting focus on core assets, building ROI models around the yield of data investments

And Managed Healthcare Executive adds the pharmaceutical benefit perspective with Eight Trends Expected to Shape Managed Care Pharmacy in 2020:

1. Continued shift to value-based care
2. Increased integration of medical and pharmacy benefits
3. Drug prices will continue challenging patients, payers, and providers
4. Medication systems will gain connectivity
5. Precision medicine will mature
6. Ongoing emphasis on social determinants of health (SDoH)
7. Pharmacists emerge as primary care providers.
8. Consumers will become more cautious about prescribed medications

With respect to life sciences and healthcare, the Cleveland Clinic published their annual Top 10 Medical Innovations for 2020:

1. Dual-Acting Osteoporosis Drug
2. Expanded Use of Minimally Invasive Mitral Valve Surgery
3. Inaugural Medication for Transthyretin Amyloid Cardiomyopathy
4. Therapy for Mitigation of Peanut Allergies
5. Closed-Loop Spinal Cord Stimulation
6. Biologics in Orthopaedic Repair
7. Antibiotic Envelope for Cardiac Implantable Device Infection Prevention
8. Bempedoic Acid for Cholesterol Lowering in Statin Intolerant Patients
9. PARP Inhibitors for Maintenance Therapy in Ovarian Cancer
10. Drugs for Heart Failure with Preserved Ejection Fraction

Turning to technological oriented trends, Health Data Management lists these 8 Healthcare trends that will rock medical care in the 2020s:

1. Artificial intelligence
2. Digital health tools
3. Imaging technology
4. Data sharing and interoperability
5. Patient communication and engagement
6. Payer evolution
7. Precision medicine
8. Virtual or remote care

In the same vein, Forbes published 9 technology trends that will transform medicine and healthcare in 2020:

1. AI and Machine Learning
2. Robotics
3. Computer and Machine Vision
4. Wearable Tech
5. Genomics
6. 3D Printing
7. Extended Reality (Virtual, Augmented and Mixed Reality)
8. Digital Twins
9. 5G

How does all this shape health policy? The Hill tells us there will be Five health care fights to watch in 2020:

1. Drug pricing
2. Surprise billing
3. ObamaCare
4. Medicare for All
5. Vaping

And finally, here's a summary of Seven Quick Takes on Healthcare Trends Shaping 2020 previously posted in mcolblog:

1. Election Year Policy Angst
2. Expanding Impact of Medicaid Expansion
3. One More Year for SDoH Before ROI Naysayers
4. Viral Value Based Payment
5. Health Technolytics - Healthcare Analytics + Technology
6. Morphing Point of Care and Coverage
7. Behind the Veil of Pricing Transparency and the CMS Final Rule

Happy New Year and New Decade!

Corrective Lens Needed for 2020 Healthcare Vision

By Clive Riddle, December 19, 2019

How did two decades of the new Millennium already fall into the rear view mirror? Weren’t we just bracing healthcare organizations for all the fallout that was supposed to emanate from Y2K?

It’s a shame we don’t have corrective lens that can adjust for hindsight, as we attempt to seek 20/20 vision into 2020 and beyond. None the less, here’s seven quick takes on trends that should shape our new year:

1. Election Year Policy Angst - Its not just Democrat vs Trump policy proposals – it’s also what fallout is coming from the forever legal saga surrounding the ACA, congressional proposals, state proposals and ballot initiatives, and lobbying clout. A lot is at stake and a lot is uncertain.
2. Expanding Impact of Medicaid Expansion - While Medicaid Expansion policy falls under the above discussion, the impact of Medicaid Expansion is a category unto itself: the coverage disparities between states; the resulting funding disparities for hospitals; the health improvement metrics where expansion is firmly in place; the transformation of dominant product mix for health plans and much more.
3. One More Year for SDoH Before.. - Speaking of impact of Medicaid Expansion, growth of Social Determinant of Health initiatives were totally fueled from that source. Good vibes are abundant from the embrace of SDoH by plans and providers, which will continue to reach a crescendo. Then a year from now, as always happens with shiny new trends, naysayers and boo birds will start to emerge questioning the ROI.
4. Viral Value Based Payment - No end seems to be in sight for value based payment models and arrangements. They will continue to spread and mutate into new forms.
5. Health Technolytics - The rapid evolution of healthcare technology platforms, devices and analytics will continue to make healthcare organization analytic capabilities more powerful and impactful. Will the humans in the organization be able to keep pace?
6. Morphing Point of Care and Coverage - the lines drawn for where people get their care continue to blur with telehealth, retail sites, mergers of cross-industry forces, e-commerce and other disruptors. Where is this all headed? One thing is certain – disruption will abide.
7. Behind the Veil of Pricing Transparency - CMS hospital pricing transparency regulations will have more of an operational impact in 2020 – and what new pricing transparency initiatives lie ahead for other healthcare stakeholders? (see Election Year Policy Angst)

Is there a trend or issue for 2020 that could potentially have a significant impact for healthcare stakeholders that might be flying under some organizations’ radar? That’s the question posed in the current issue of MCOL ThoughtLeaders.  Some of the above takes are reflected in the ThoughtLeader panel’s responses. Here’s some key snippets they shared:

Patrick Horine, CEO, DNV GL Healthcare says “the push for more transparency of healthcare providers has reached an all-time high. The demands for transparency of pricing, coverage, costs, performance quality raises many challenging questions and concerns as to what should be shared.”

Hank Osowski, Managing Partner, Strategic Health Group tells us “there exists a curtain of uncertainty that is masking what could potentially be one of the most impactful and disruptive periods in the industry’s history. This uncertainty is driven by two dynamics which will help to determine our future: a ruling on the constitutionality of the Affordable Care Act (“ACA”) and the likely turmoil to be created by the elections of 2020. The healthcare industry may not be prepared for the disruption. “

Mark Lutes, Chairman, EpsteinBeckerGreen notes that “an important emerging trend is attention to serious illness management (“SIM”) in the subacute settings—ideally the home. The trend is embryonic yet terribly important — both from quality and cost perspectives. There are significant opportunities to improve patient satisfaction and to optimize the application of resources by focusing on the development of appropriate care models.”

Neal Hogan, Director, BDC Advisors, shared that “value based payment (which looks a lot more like the traditional fee-for-service model than risk) seems to be a signpost on the road to population health---if that is where our system is truly heading. We need to start matching the reality to the rhetoric so we can be clear about how to win in an era of consumerism and transparency.”

William DeMarco, Founder and President, Pendulum HealthCare Development Corporation, comments: “the issues that are under the radar for many organizations who see only one or two options, are the vast variety of CMS models which are emerging and reemerging in different forms that are altering reimbursement as well as delivery of care.”

And Lindsay Resnick, Executive Vice President, Wunderman Thompson Health, summarizes that we should “expect the healthcare community to step-up efforts in cross-industry collaboration. While we’ll continue to see vertical and horizontal M&A reshape the landscape, collaborative partnerships will thrive.”

Tracking the Evolution of Top Health Trends and Issues During the Trump Era

By Clive Riddle, December 13, 2019

Every December, the PwC Health Research Institute - like many other organizations – releases their compiled list of the top health issues from their perspective, for the coming year. This year their headline question posed from their list is “will digital start to show an ROI?” PwC hasn’t been married to the Dave Letterman Top Ten format – this and last year they identified six key issues, two years ago it was a dozen, three years ago they did pick ten.

 Here’s a summary of their top six issues for 2020 from their 53-page report:

1. A looming tsunami of high prices – “facing a tsunami of high-priced gene and cell therapies and ever-rising provider prices in 2020” stakeholders will pursue “creative ways to finance care, spread risk and ensure that their money is paying for value.”
2. Regulation trumps policy – “the outcome of the 2020 election is unlikely to bring about profound” change but the election will determine the fate of Trump policies on Medicaid, ACA, pricing transparency and trade.
3. Consumers inch closer to DIY healthcare – Consumers will “finally reap benefits from the enormous investments in data collection, storage and analysis that have been made by the US health industry.”
4. US health organizations are seeking opportunities overseas and through innovation. Beware of the tax risks.
5. A whole new you: Deals as makeovers – with “strategic deals not to just grow larger but instead to expand into new identities with platforms anchored in value, innovation, customer experience and population health.”
6. Equity and inclusion, not just diversity, as a business imperative – “health companies will align diversity, equity and inclusion initiatives with business goals and identify blind spots.”

So, using the PwC annual list as a yardstick, how has a view of the top healthcare issues for coming year evolved during the Trump years? Using previous Healthsprocket lists that summarized the PwC issues, here’s how they viewed the coming year for 2019, 2018 and 2017:

PwC: 6 top health industry issues of 2019

1. Digital therapeutics and connected care reshape the life sciences industry
2. The Affordable Care Act in 2019: Still Alive
3. Your company’s new, upskilled health worker of the future is you
4. Tax reform has only just begun for healthcare companies
5. Creating the Southwest Airlines of healthcare
6. Private equity: Healthcare’s new growth accelerator

PwC: Top 12 health industry issues of 2018

1. The healthcare industry tackles the opioid crisis
2. Social determinants come to the forefront
3. Price transparency moves to the statehouse
4. Natural disasters create devastation that lasts long after the event passes
5. Medicare Advantage swells in 2018
6. Health reform isn't over, it's just more complicated
7. Securing the internet of things
8. Patient experience as a priority and not just a portal
9. Meet your new coworker, artificial intelligence
10. Healthcare's endangered middlemen: PBMs, wholesalers
11. Real-world evidence a growing challenge for pharma
12. Tax reform moves forward

PwC - Top 10 health issues for 2017

1. Under a new administration, the fate of the ACA remains unclear
2. Pharma’s new strategic partner? Patients
3. Easing the training wheels off value-based payment
4. Insert your card here for healthcare
5. Paging Dr. Drone: It’s time to prepare for emerging technologies
6. The battle against infectious diseases sparks invention
7. Rx cauliflower: Nutrition moves to population health
8. Putting the brakes – gently - on drug prices
9. A year of new partnerships and collaborations
10. Preparing medical students for work in a value-based world

Taking the Healthcare Time Machine to 2040 – Two Separate Peeks into the Future

by Clive Riddle, October 4, 2019

Several days ago, I – like numerous others – received a mysterious email from Robert Pearl, MD informing us that “It’s 2040 and the U.S. health system is the best in the world.” He asks, “How did it happen?” and informs us “that question is more difficult to answer than what happened.”

The mystery quickly solved itself, as his new article in Forbes was released that same day: “It’s 2040: How Did American Healthcare Become The Best In The World?” Doctor Pearl quickly explains his thought experiment posed in his email and in the opening of his article: “As far-fetched as this outcome may seem, the purpose of the question is to consider what, specifically, could spark major change in U.S. healthcare. Below are 12 possibilities, each based on the comments and credentials of recent Fixing Healthcare [his podcast] guests.”

So remember – his list derived from his podcast guests isn’t the specific fixes, but rather what movements caused the fixes to happen:

1. Global Disruption
2.  Twenty-first Century Tech
3. The Power Of Moments
4. Bright Spots
5. Transparency: "was it because doctors and hospitals were required to disclose their pricing and quality outcome data"?
6. Healthcare Voting: after "Americans exercised their rights at the polls and demanded change from elected officials?"
7. Consumerized Care: after "doctors, hospitals and health plans put patients first, resulting in a more consumer-centric and affordable form of healthcare"?
8. Battling Burnout
9. Modern Heroes: "was American healthcare saved by a new batch of medical visionaries?"

10.  Social Determinants: "did public health advances in U.S. society lead to better outcomes and greater life expectancy"?

11.  Patient Power: "did patients band together online and use their collective voice to inspire major healthcare changes?"

12.  Internet Reliability: "did sweeping internet regulations help people avail themselves of reliable information and the best medical care possible?"

Now that we’ve considered what might drive healthcare change into 2040, let’s peek into another examination of 2040 done earlier this year by the Deloitte – entitled: Forces of change – The future of health, and opens like this: “The future of health will likely be driven by digital transformation enabled by radically interoperable data and open, secure platforms. Health is likely to revolve around sustaining well-being rather than responding to illness. Twenty years from now, cancer and diabetes could join polio as defeated diseases. We expect prevention and early diagnoses will be central to the future of health.”

We are told that “By 2040 (and perhaps beginning significantly before), streams of health data—together with data from a variety of other relevant sources—will merge to create a multifaceted and highly personalized picture of every consumer’s well-being;” and that “consumers—armed with this highly detailed personal information about their own health—will likely demand that their health information be portable.”

Deloitte says they “anticipate that by 2040 successful companies will identify and compete in one or more of the[se] new business archetypes:

Data and Platforms:

• ·         Data conveners (data collectors, data connectors, and data securers)
• ·         Science and insights engines (developers, analytics gurus, insight discoverers)
• ·         Data and platform infrastructure builders (core platform developers, platform managers and operators)

Well-being and care delivery

• ·         Health products developer (application developers, inventors/innovators, manufacturers)
• ·         Consumer-centric health/virtual home and community (virtual health providers and enablers, and wellness coaches)
• ·         Specialty care operators (world-class health centers, event-specific facilities)
• ·         Localized health hubs

Care enablement

• ·         Connectors and intermediaries (enterprise tool developers, supply chain designers and coordinators, delivery service providers)
• ·         Individualized financiers (N of 1 insurers, catastrophic care insurers, government safety net payers)
• ·         Regulators (market leaders and innovators, government regulators and policy makers)

So what should we do armed with this glimpse into 2040? Deloitte advises "as stakeholders prepare for the future of health, they should consider the following actions:"

• ·         Build new businesses
• ·         Forge partnerships; and
• ·         Appeal to the newly empowered health consumer

As for me, my primary objective will be to still be alive to see what happens.

Costs & Transparency Number One for 2020 on HCEG’s Top 10 List

By Clive Riddle, September 12, 2019

Once  September is upon us and Pumpkin Spice lattes invade your nearest Starbucks, Christmas decorations should be arriving any day at your nearest Costco, and its not too early to think about what  are the top issues we will be facing in the business of healthcare in new year ahead.

 The Healthcare Executive Group has been doing exactly that for the past decade, presenting their top 10 list of issues at this time for the next year, have announced that for 2020 “Costs & Transparency was voted as the #1 issue/challenge facing healthcare by over 100 C-Suite and director level executives in the industry.”

HCEG explains that “executives from payer, provider and technology partner organizations were presented with a list of over 25 topics. Initially compiled from webinars, roundtables and the 2019 Industry Pulse Survey, the list was augmented by in-depth discussions during the [HCEG Annual] Forum, where industry experts explored and expounded on a broad range of current priorities within their organizations.”

Ferris W. Taylor, HCEG Executive Director in a statement comments that “It shouldn’t be surprising that costs and transparency is at the top of the list along with the consumer experience and delivery system transformation. Data, analytics, technology and interoperability are still ongoing challenges and opportunities. At the same time, executives need to be cautious, as individual health, consumer access, privacy and security are on-going challenges that also need to remain as priorities.”

Here, verbatim is the 2020 HCEG Top 10 Challenges, Issues and Opportunities:

1. Costs & Transparency - Implementing strategies and tactics to address growth of medical and pharmaceutical costs and impacts to access and quality of care.

2. Consumer Experience - Understanding, addressing and assuring that all consumer interactions and outcomes are easy, convenient, timely, streamlined,  and cohesive so that health fits naturally into the “life flow” of every individual’s, family’s and community’s daily activities.

3. Delivery System Transformation - Operationalizing and scaling coordination and delivery system transformation of medical and non-medical services via partnerships and collaborations between healthcare and community-based organizations to overcome barriers including social determinants of health to effect better outcomes.

4. Data & Analytics -  Leveraging advanced analytics and new sources of disparate, non-standard, unstructured, highly variable data (history, labs, Rx, sensors, mHealth, IoT, Socioeconomic, geographic, genomic, demographic, lifestyle behaviors) to improve health outcomes, reduce administrative burdens and support transition from volume to value and facilitate individual/provider/payer effectiveness.

5. Interoperability / Consumer Data Access - Integrating and improving the exchange of member, payer, patient, provider data and workflows to bring value of aggregated data and systems (EHR’s, HIE’s, financial, admin and clinical data, etc) on a near real-time and cost-effective basis to all stakeholders equitably.

6. Holistic Individual Health - Identifying, addressing and improving the member/patient’s overall medical, lifestyle/behavioral, socioeconomic, cultural, financial, educational, geographic and environmental well-being for a frictionless and connected healthcare experience.

7. Next Generation Payment Models - Developing and integrating technical and operational infrastructure and programs for a more collaborative and equitable approach to manage costs, sharing risk and enhanced quality outcomes in the transition from volume to value. (bundled payment, episodes of care, shared savings, risk-sharing, etc).

8. Accessible Points of Care - Telehealth, mHealth, wearables, digital devices, retail clinics, home-based care, micro-hospitals; and acceptance of these and other initiatives moving care closer to home and office.

9. Healthcare Policy - Dealing with repeal/replace/modification of current healthcare policy, regulations, political uncertainty/antagonism and lack of a disciplined regulatory process. Medicare-for-All, single payer, Medicare/Medicaid buy-in, block grants, surprise billing, provider directories, association health plans, and short-term policies, FHIR standards, and other mandates.

10. Privacy / Security - Staying ahead of cybersecurity threats on the privacy of consumer and other healthcare information to enhance consumer trust in sharing data. Staying current with changing landscape of federal and state privacy laws.

Corresponding with Executive Director Ferris Taylor, I asked who the list has changed and evolved during the past five years. Ferris replied that “everything has changed in healthcare in the last 5 or so years and that is reflected in the changes in the HCEG Top 10. The Affordable Care Act was really the 'accessible care act' - upwards of 20 million more people now have insurance but affordability in terms of premiums and escalating deductibles have affected everyone. It shouldn't be surprising then that cost and transparency has gone to the top of the list. For 2020, the HCEG Top 10 relate much more to how central the consumer is for all stakeholders. Healthcare is finally coming into the 21st century with digital technology, holistic individual health and a focus on the consumer journey in everything we do." 

Growing where you are already planted

Kristin Rodriguez, Health Plan Alliance, June 24, 2019

 

Dan Michelson, CEO of Strata Decision believes integrated delivery systems need to shift their focus from buying and building hospitals to leveraging their existing platforms to generate growth and often more profitable streams of revenue.  This creates the ability for delivery systems to become a hub for health and healthcare in the future.

What needs to occur for this transformation to take place? 

In an article published in Becker's Hospital Review recapping the 2019 JP Morgan Healthcare Conference, Michelson outlines six ideas for integrated delivery systems to get started on leveraging their existing platform.  Each represents a formidable challenge, but if we work together and take advantage of resources available to us, we can start moving in the right direction.

1. Embrace the digital front door: Healthcare providers have long excelled at building relationships and trust once consumers walk into our hospitals and clinics.  We need to harness the ability to create that same meaningful relationship, without limiting ourselves to a physical location.  
   
   Benjamin Isgur, Health Research Institute Leader at PwC Health Research Institute, echoes this advice.  At the recent Alliance Spring Leadership Forum, he underscored that Private Equity investors are particularly interested in anything that gets closer to the consumer.  And consumers themselves are eager for a new era of care delivery, with new venues and new menu options.  If we don't offer consumers a more convenient alternative, someone else will. 
2. Get serious about affordability: This isn’t just about transparency or about reallocating resources more thoughtfully.  It is bigger than combining clinical and financial data.  The healthcare cost problem is huge and policymakers, drug manufacturers, insurers, delivery providers and consumers all play a role.
   
   It's important we avoid the danger that is “everyone’s problem” becoming “no one’s problem.”  As part of integrated systems, Alliance members are particularly well positioned to get a strong line of sight on this challenge.
3. Don't just provide, prevent: Michelson points to the “strong strategic rationale associated with taking on a broader role of driving health versus only providing healthcare” in the communities we serve.  Policymakers understand this too; Medicaid and Medicare Advantage plans are encouraged more and more toward payment models and benefit design approaches that take on more than just clinical care.
   
   Just a few themes in the government-sponsored care space include VBID, telehealth, benefit flexibility, and behavioral health integration, all of which present unique opportunities to leverage the network, venues of care, community partnerships, and more to reimagine the system’s role in the local healthcare landscape.
4. Partner to innovate, or miss out: Becoming a hub isn’t just about the digital front door or food farmacies. It also means creating a space for innovators to gather, where research and education can occur so that ongoing evolution becomes a core competency of the system.
5. Target chronic conditions and specific services: This builds on the center of excellence model in profound ways.  Systems that craft a powerful experience for specific chronic conditions or targeted services stand a better chance of maintaining a relationship with those consumers.  Michelson notes that this is both an opportunity and a threat for integrated systems, as we compete more and more with new platforms gaining competency in serving chronic conditions, like those of CVS Health and Walgreens. 
6. Don’t just aggregate data – use it:  An Alliance member and informatics leader said that he envisions the day when his informatics teams can stop being data archeologists and can instead be data analysts.  The truth is that integrated systems are still solidifying their competency as data aggregators.  But it’s not enough.  It’s time to turn our attention to applied analytics: practical data sets that provide decision support so that we can gain better insights and pivot our platforms even faster.

With payers big and small across the country, the Alliance member network is a veritable think tank for executives wrestling these questions and challenges.  Join us and work elbow to elbow with your peers at our upcoming events designed exclusively for Alliance organization leaders. You can also meet and hear from Dan Michelson at the Fall Leadership Forum 2019.

Ten Takeaways From PwC’s Medical Cost Trend Behind The Numbers 2020

By Clive Riddle, June 21, 2019 

PwC's Health Research Institute has just released their 14th annual report on medical cost trends: Medical cost trend: Behind the numbers 2020, which projects the 2020 trend to be a six percent cost increase. As PwC's HRI describes their 47-page report, they project "the growth of private medical costs in the coming year and identifies the leading trend drivers.... based on the best available information through June 2019. HRI conducted 55 interviews from February through June 2019 with health industry executives, health benefits experts and health plan actuaries whose companies cover more than 95 million employer sponsored large group members about their estimates for 2020 and the factors driving those trends. Also included are findings from PwC’s 2019 Health and Well-being Touchstone Survey of more than 550 employers from 37 industries as well as PwC HRI’s national consumer survey of 2,500 US adults."

Here’s Ten Takeaways from their 2020 report: 

1. Small Uptick: The Medical Cost trend, still rounding to double digits in 2007 (11.9%) and 2008 (9.9%), trended downwards subsequently, to round to six percent since 2016 (6.2%), but have ticked up since the low-water mark of 5.5% in 2017 (and 5.7% in 2018-2019.)
2. Price, Not Utilization: “Prices have been a larger component of employer benefit costs than utilization since 2004; utilization has hovered around zero percent growth since 2006. Utilization by individuals with employer-based insurance decreased by 0.2 percent from 2013 to 2017 while prices rose 17 percent during that time.”
3. Impact of High Deductibles: “Average deductibles for employer-sponsored plans tripled between 2008 and 2018. This increase likely has led to a low utilization trend because employees are delaying or forgoing care due to their deductible.”
4. Stall in HDHP Growth: “The shift to HDHPs by employers seems to have stalled. With 84 percent of employers offering an HDHP option in 2019 and a tight labor market, employers may not be as quick to push HDHPs in 2020.
5. Acceleration in Retail Rx Spending: “Starting in 2020, retail prescription drug spending growth for private health insurance will begin to increase, hitting between 3 percent and 6 percent annually through 2027.24 The growth in spending can be attributed to the waning impact of generics on the market and the introduction of new drugs.”
6. Specialty Drug Million Dollar Drugs Pipeline: The portion of total retail drug spending on specialty drugs continues to grow. “We are at an inflection point with drugs in the pipeline. We thought hep C was expensive at nearly $100,000 per treatment. Many drugs in the pipeline are life-altering and come with a price tag of $1 million to $2 million per treatment.”
7. Growth in Chronic Disease Spending: "Spending by employers on individuals with chronic diseases is nearly quadruple [3.5x] that of healthy individuals while spending on individuals with complex chronic diseases is eight times higher" [8.2x].
8. Growth in Onsite Clinics: “38 percent of large employers offered an onsite health clinic in 2019, up from the 27 percent that offered a clinic in 2014. An additional 13 percent said they were considering adding one.”
9. Telehealth Potential: “49 percent of consumers with employer coverage said they are willing to use telehealth in place of an in-person visit.”
10. Underutilized Wellness and Prevention programs: “For decades, employers have invested in health and wellness and prevention, yet participation remains low.....The small population of employees who participate in their employers’ health and wellness programs generally believe the programs have had a positive impact on their health.”

The Short List of Major Healthcare Implications from A Declining Birth Rate

By Clive Riddle, May 17, 2019

Like most of the industrialized world. the U.S. birth rate is declining, as evidenced in the new  CDC National Center for Health Statistics National Vital Statistics System May 2019 report on "Births: Provisional Data for 2018."  (the final birth report is scheduled to come out this fall.) The big news from the report is the number of births was the lowest in 32 years, and the fertility rate reached another record low.

Here's highlights from the report: 

• The provisional number of births for the United States in 2018 was
• 3,788,235, down 2% from 2017 
• The general fertility rate was 59.0 births per 1,000 women aged 15–44, down 2% from 2017 a
• The total fertility rate declined 2% to 1,728.0 births per 1,000 women in 2018
• Birth rates declined for nearly all age groups of women under 35, but rose for women in their late 30s and early 40s
• The birth rate for teenagers aged 15–19 was down 7% in 2018 to 17.4 births per 1,000 women
• Rates declined for both younger (aged 15–17) and older (aged 18–19) teenagers
• The cesarean delivery rate decreased to 31.9% in 2018; the low-risk cesarean delivery rate decreased to 25.9%
• The preterm birth rate rose for the fourth year in a row to 10.02% in 2018
• The 2018 rate of low birthweight was unchanged from 2017 (8.28%)

In a Q&A session with report author Brady E. Hamilton, Ph.D. posted in the NCHStats blog, Hamilton is asked if there was a specific finding that surprised him, which he replied "the record lows reached for the general fertility rate, the total fertility rate and birth rates for females aged 15-19, 15-17, 18-19, and 20-24 are noteworthy. In addition, the magnitude of the continued decline in the birth rate for teens aged 15-19, down 7% from 2017 to 2018, is also historic." Hamilton was non-committal about the trend going forward, stating “these data do not answer the question of why the number of births dropped in 2018 or if the decline will continue.”

But assuming the trends do continue, which certainly the opinion of many, there are certainly major implications for healthcare, including this short-list: 

• Impact of reduced demand for hospital and physician OB services
• Impact of increased births from higher-age mothers, with greater care complexities involved
• Longer range reduced demand for hospital and physician pediatric services
• Longer range reduced available Medicare funding from employed workforce, with growing imbalance of senior retired population compared to working population

Healthcare Incumbents: Watch Your Sides as Well As Your Back For Disruptions

By Clive Riddle, March 22, 2019 

Reuters reports that “United Parcel Service Inc wants to get beyond U.S. doorsteps with a new push into healthcare.” They tell us “the world’s largest package delivery firm is preparing to test a U.S. service that dispatches nurses to vaccinate adults in their homes, Reuters has learned, as the company and its healthcare clients work to fend off cost pressures and competitive threats from Amazon.com.” 

Deloitte, in a recent paper on the Health Plan of Tomorrow, that is the subject of an upcoming webinar, asks who will win the future of healthcare and health insurance: incumbents or disrupters> They tell us that “incumbents’ decisions will determine wither disrupters will be willing to partner with them in the transformation or compete and disrupt their business models.” 

Disrupters and Incumbents, it seems, are relative terms. We often think of disrupters as startups, and incumbents as established companies. But clearly the terms apply to lines of business, as opposed to the business as a whole. So UPS the incumbent in package delivery can become a disrupter in healthcare. Existing healthcare incumbents need to not just watch their backs for startup disrupters seeking to pass them by, but watch their sides as well, from established disrupters. 

UPS has touted healthcare supply chain management for some time. Then in May last year they announced “Chris Cassidy as vice president of global healthcare logistics strategy. He is charged with leading and advancing UPS’s commitment to the healthcare supply chain, which remains a top company priority….Cassidy possesses 18+ years of global logistics and business change experience, holding various supply chain operations, strategy and transformation roles at global healthcare company GlaxoSmithKline (GSK).”

Reuters states that “the world’s largest package delivery firm is preparing to test a U.S. service that dispatches nurses to vaccinate adults in their homes, Reuters has learned, as the company and its healthcare clients work to fend off cost pressures and competitive threats from Amazon.com UPS did not disclose which vaccines it would be using in the project, but drug and vaccine maker Merck & Co told Reuters it is looking at partnering with the company for the initiative.” 

How far and how disruptive this plays out to be remains to be seen, but the transformative potential is there for more healthcare to be transferred from provider settings to the home. And then of course, when patients with more complex needs have to set foot outside the home into provider settings and back again, there is now the disruption taking place with UberHealth and Lyft Healthcare, who have been around long enough to be incumbents in personal transportation but now disrupt in healthcare transportation. The Uber and Lyft disruption is being further fueled by SDOH (Social Determinants of Health), causing CRM incumbent Salesforce to recently roll “out new ‘social determinant’ tool for patients who need other kinds of help, like a ride to the doctor.” And now Uber and Lyft face startups like Veyo solely focusing on peer-to-peer healthcare transportation. 

So who is an incumbent and who is a disruptor? While answering be sure to watch your sides as well as your backs.

An Innovative Acquisition for HCA

by Clive Riddle, March 15, 2019

Nashville-based HCA Healthcare has just announced that HCA will become the majority owner of the parent company of Galen College of Nursing, one of the largest educators of nurses in the nation.  HCA, of course, is one of the nation’s leading providers of healthcare services, comprising 185 hospitals and approximately 1,800 sites of care.

The announcement states that “The innovative new strategic partnership brings together two of the top nursing organizations in the country in order to increase access to nursing education and provide career development opportunities in nursing to improve patient care. With 94,000 registered nurses, HCA Healthcare is one of the largest employers of nurses in the country, with nurses holding positions from bedside caregivers in a variety of healthcare settings to leadership positions throughout the organization.”

Hospital funding and partnerships for nursing education certainly isn’t new. For example, here’s a website providing a state-by-state listing of 123 such hospital arrangements, which they acknowledge is only a partial list.

But what is innovative is to move beyond strategic partnerships with an outright acquisition.  Not only does the move create synergy for HCA’s staff career development, it should also serve as a burse recruitment tool for HCA, in an environment where hospitals compete for nursing staffing.

Furthermore, this perhaps signals that healthcare organizations will continue to peek and climb further out-of-the-box with acquisitions beyond traditional M&A of other healthcare providers.  Deloitte, in a discussion of the Health Plan of Tomorrow that is the subject of an upcoming webinar, writes that "buy, share or build? is a question many health plan leaders will face as they begin this transformation journey. And accessing these capabilities may require an industry-agnostic approach. As new players break the rules around who plays what role in the industry, health plans may need to turn to want might today be considered strange bedfellows: competitors, providers, manufacturers, technology companies, transactional sector companies, and/or other industries for answers."

The same holds true for healthcare providers as for health plans.  And so HCA and Galen seem to be pairing up on a transformative journey as well.

The End of Health Insurance

By Kim Bellard, February 20, 2019 

Paul Tullis has an interesting article in Bloomberg about how self-driving cars might kill auto insurance “as we know it.” After all, if human error is responsible for 90% of auto accidents, and those humans are taken out of the equation, what’s left to insure? 

Many people don’t think much about autonomous vehicles, but Mr. Tullis reports that Michelle Krause, an Accenture insurance expert, says that their impact on auto insurance “…comes up in every strategic conversation” within insurers. 

It made me wonder: what would it take to kill health insurance…as we know it? 

Let’s think about what health insurance is for: Averting losses, Budgeting and Subsidization. I’ll take these in reverse order: 

Subsidization

Health insurance is not the right mechanism to do wealth transfers. It’s not what it is designed for, and it is not what it is good at. 

Budgeting

We need to stop expecting health insurance help us budget for expenses that, in any other aspect of our lives, we’d be paying for ourselves. 

Averting losses

Even if we accomplished both of the above, health insurance would still probably not look too different than it does now. Our healthcare system would still have catastrophic expenses, and we’d be looking for protection against them. We’d still have networks, negotiated prices, and tensions between those who deliver health care and those who pay for it. 

We have to attack the root problem, which is not just the prices, but also the costs. Some examples of how this can happen: 

Virtual care will allow us to get advice and even treatment where/when we want it, and increasing reliance on A.I. rather than human expertise will both cut direct costs and, hopefully, unnecessary treatments. 

DIY health is a trend that has promise to greatly impact costs. Whether it is hearing aids, insulin pumps, or “biohacking,” we’re starting to move away from reliance on expensive solutions from traditional healthcare sources to cheaper, even home-grown solutions.

Robots, right now, fall within the “more technology, more expensive” ethos of our current healthcare system, but that cannot last. Robots will get smarter and more versatile, we’ll get better at building them, and they’ll allow us to take costs out of healthcare in the way they’ve taken costs out of manufacturing. 

Hospitals are, as I’ve stated previously, “19th century institutions operating under 20th century business models in the 21st century.”

Prescription drugs are one of the biggest pain points for consumer healthcare spending. Part of this looks a lot like greed, part of it is the U.S. not negotiating prices as other countries do, and part of it reflects the long pipeline for drug discovery and development. The former two are more price issues than cost ones, but the latter one is one 21st century technology can help address.

We shouldn’t accept the status quo; not in how care is delivered, not in how much care costs, and certainly not in how it is financed. If auto insurers are discussing merging with automakers, Apple is thinking about its post-iPhone era, Ikea wants to become the “Amazon of furniture,” and Amazon’s own future may be more about cloud computing than retail, then certainly health insurers should be looking to a very different future.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting