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Our Take: Health System Executive Survey — observations from the editor

Oct 26, 2020

We are conducting an ongoing study of health system executives, in which we are tracking, among other things, the real-world impact of COVID-19 on how health care is being delivered in the U.S. Each quarter, we complete 25 to 30 personal interviews with pharmacy and medical executives and then follow the interviews with an online survey of a larger audience. (Our Take readers may recall that we announced this project in May. Contact me for access to the full report.)

It’s a powerful mixed-methods research model that gives us the benefit of in-depth interviews — a deep dive into learning how providers are managing through a crisis — and the ability to track quantitative information over time.

This kind of research is also really hard to do. For one thing, anyone watching the nightly news knows that the COVID-19 pandemic is highly dynamic. I recall interviewing a chief medical officer in late May from a health system in Texas who told me that he “hadn’t seen much” of the novel coronavirus. By the middle of July, that same health system — a highly esteemed institution with world-class providers — would be taxed beyond belief, with no ICU bed capacity, a low and rapidly vanishing supply of personal protective equipment, and stressed out doctors and nurses.

The aggressive nature of the pandemic puts pressure on us to turn around our key findings for our clients at breakneck speed; otherwise, our work product would be obsolete before we even generate the PDF.

It’s also difficult to run the numbers and find meaningful patterns in the data, while simultaneously telling providers’ stories that are sometimes inspirational, and other times heartbreaking.

“It gets frustrating. You try and go home and see a normal life but it’s not normal,” said one N.J.-based pharmacy director in May. ”I can’t see my mom. I can’t see my in-laws. Even with social distancing, I’m a big Petri dish. So, until we come up with a vaccine and this thing goes away, it’s horrifying to think I can’t go on vacation, I really can’t do much of anything … It takes a psychological toll on you because you don’t have anything really to look forward to, like when’s ‘normal’ coming again?”

That particular interview was difficult to get through. The despair in his voice was palpable.

What’s inspiring is hearing, firsthand, the stories of raw innovation in the face of a crisis. As one standout example, West Orange, N.J.-based RWJBarnabas implemented its Transitions of Care Management program, in which care for some patients with COVID-19 was transferred from the hospital to the home. Upon arrival, those with symptoms such as fever and shortness of breath (regardless of testing, since tests weren’t available) were sent home with pulse oximeters and were followed up frequently by a care team.

“I had all my primary care docs, I had a team for every region do telehealth visits daily, seven days a week, sometimes two times a day, to make sure that the patient does not decompensate,” one physician group leader told me. “And the minute the patient’s pulse ox goes below 90 or they start having symptoms of chest pain … I mean, we’re looking at them on camera … If we see them decompensating, we bring them back to the hospital for admission.”

RWJBarnabas also was able to source home oxygen initially through a charitable organization — oxygen was in short supply and home oxygen suppliers were hoarding inventory for chronic-need patients with conditions such as COPD or congestive heart failure.

Ultimately, the Transitions of Care Management program served more than 300 patients, with only 10% of them needing to be rehospitalized. I believe a paper about the program is being submitted for peer review.

Everyone, including me, heralds the widespread, immediate adoption of telemedicine as a major achievement in the early days of COVID-19. But we’ve found that the pandemic has led to other innovations in the delivery of care as well. Here’s what a few of our survey participants told us about positive changes that have occurred at their health system:

  • “Ability to be more accurate in identifying/risk-stratifying patients who should be prioritized to receive elective procedures sooner versus waiting longer.”
  • “Ability to practice to top of licensure, increased emphasis on underserved communities, decreased requirements for documentation.”
  • “In-hospital critical care setups that decrease the amount of time that staff need to actually enter a room. This includes electronic ICU remote monitoring, IV tube extensions, and so forth.”
  • “Increased use of EHR patient portal, increased engagement. Physicians more engaged in EHR data acquisition and patient outreach tools.”
  • “The increased awareness of and focus on infection prevention has been critical.  Maintaining this will be critical and transformative.”

My colleague Sadhna asked me the other day what’s the most important thing I’ve learned so far, after more than 50 interviews and nearly 300 online surveys. I thought about it, and it seems to come down to this: Health systems are just better as a result of being pushed to the brink and forced to innovate.

Better patient care overall, with increased attention to where and how care is delivered. Tighter infection control. More efficient management practices and workflow. Better and more frequent communication among staff and with patients. A significant increase in technology adoption, in smart ways. A focus on underserved and high-risk populations.

To that last point: in our recent survey, 79% of physician leaders say that they have increased their focus on health disparities as a result of COVID-19, compared with 56% in June (p<0.0001). The use of telemedicine has greatly improved their ability to reach this patient population.

It brings to mind the famous quote by Nietzsche, and I’m paraphrasing here, “That which does not kill us, makes us stronger.” The nation’s providers have been tested and stressed to the breaking point, but they’ve become stronger.

They’ll need that extra strength. We’re going to see a wave far bigger than the one in July. It’s already starting: Today, only three states have an Rt<1. (If Rt is above 1.0, the virus will spread; when Rt is below 1.0, the virus spread slows down.)

My heart goes out to the providers and essential workers who are facing a very, very dark winter.

– John Marchica

What else you need to know

Purdue Pharma agreed to pay $8.3 billion and dissolve the company as part of a global settlement announced by the Department of Justice (DOJ) on Wednesday. Facing thousands of lawsuits in connection with its role in the country’s opioid epidemic, Purdue, the maker of OxyContin, filed for Chapter 11 bankruptcy protection a year ago. According to the DOJ, Purdue has agreed to plead guilty to three federal criminal charges, for which it was assessed a fine of $3.544 billion, and will forfeit an additional $2 billion. Purdue further agreed to resolve the federal government’s civil claims with a settlement of $2.8 billion.

When the company emerges from bankruptcy restructuring as a “public benefit company” governed by a trust (and no longer owned by the Sackler family), under the settlement agreement it will pay $225 million of the $2 billion forfeiture and the DOJ will waive the balance of $1.775 billion. The public benefit company will continue to manufacture OxyContin as well as drugs to counteract opioid abuse; earnings will go toward paying fines and penalties, and that money will be used to help fight opioid abuse. Without admitting any wrongdoing, the Sackler family agreed to pay $225 million in civil penalties. The DOJ said the resolutions do not release Purdue or the Sackler family from future criminal charges that might arise from ongoing investigations.

Highmark and Horizon recently reported results from their value-based reimbursement models showing that the programs have yielded substantial savings and led to improvements in quality metrics. Specifically, Highmark said its True Performance reimbursement program for primary care physicians helped avoid $1.1 billion in health care costs from emergency department visits and hospital readmissions during a recent three-year period. Last month, Horizon Blue Cross Blue Shield of New Jersey announced that the shared-accountability arrangement it has in place with Atlantic Health System lowered the total cost of care for patients/members by 5% in the program’s first year and reduced unnecessary hospitalizations by 9%. Through their arrangement, Horizon and Atlantic Health System share financial accountability for the health, outcomes, and total cost of care for a population of patients.

Priority Health launched new health plans last week centered on virtual care. The Grand Rapids, Mich.-based insurer introduced its MyPriority Telehealth PCP plans for the 2021 plan year. Members in these plans are assigned a primary care physician through Doctor on Demand, and all visits occur virtually. To see a specialist in person, plan members will need a referral from their PCP. Emergency care is excluded from the referral requirement. The plans offer full coverage for preventive care, as well as benefits such as lower copays on prescription drugs and chronic care management, Priority Health noted.

Adventist Health launched what it is calling a Well-Being Division, a step that marks the Roseville, Calif.-based health system’s “commitment from delivering care to improving well-being and quality of life for entire communities, which in turn improves health outcomes for individuals,” Adventist Health said in a blog post. The new division stems from Adventist Health’s acquisition of a company called Blue Zones earlier this year. Blue Zones was founded by National Geographic Fellow Dan Buettner, who identified what he referred to as “blue zones” around the world in which people live “extraordinarily long and/or happy lives.” Adventist Health said the Blue Zones model “lifts well-being at the population level by making health choices easier in all the places people live, work, learn, pray, and play.”

CMS approved a Medicaid waiver for Nebraska that will create a two-tiered system for newly eligible enrollees. The new Heritage Health Adult demonstration will be implemented on April 1 and run through March 31, 2026. Enrollees who complete certain “engagement activities” — for example, working 80 hours per month — will be eligible for “Prime” coverage, which includes vision, dental, and over-the-counter drug coverage as additional benefits. Those who do not complete engagement activities will be covered under the “Basic” benefit package.

Gilead Science’s Veklury (remdesivir) was granted full FDA approval on Thursday, making it the first drug to be approved in the U.S. as a treatment for COVID-19. The drug is indicated for individuals age 12 or older who require hospitalization and should only be administered in a hospital or other health care setting that can provide acute care comparable to inpatient hospital care. Younger patients can still gain access to the drug under a revised emergency use authorization (EUA) while clinical trials continue to assess its safety and efficacy in this population, the FDA noted in a press release.

In separate news, Gilead announced on Friday that it has completed its $21 billion acquisition of Immunomedics.

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