This article is co-authored with David Beier and Avik Roy.
The 1918 influenza pandemic—the world’s worst viral pandemic of the twentieth century—called into bold relief the deep interconnections among the health of all individuals regardless of race, gender, ethnicity, or income. Despite that fact, the 1918 flu led to few meaningful health care reforms.
Let’s not make the same mistake again. COVID-19 is, hopefully, a once-in-a-lifetime crisis. It has led to a devastating loss of more than 140,000 US lives, and a dramatic disruption in how we all live. It has forced the US health care system to respond and adapt in a multitude of ways. Some of these health system changes are good, such as the embrace of telemedicine and the rapid initiation of COVID-19 testing, treatments, and clinical trials. Some changes are not so good, such as the cancellation of elective surgeries, reduction in access to specialty care and diagnostic testing for non-COVID-19 patients, as well as nursing layoffs as a result of significant decreases in both practice revenue and margins of up to 50 percent.
The most notable changes flowing directly from dealing with COVID-19 include greater need for mental health services; expanded telehealth services; and the need to manage severe stresses arising around supply-chain management of personal protective equipment (PPE), essential medicines, and diagnostic and serologic testing. Staff shortages and mismatches between health care needs and type of health staff available have also arisen.
As we face months more of dealing with the COVID-19 pandemic, we ponder what changes should be made now and to make the US health care system better when things return to a new normal, and, God forbid, in the event of future pandemics. Here are 10 actions that will lead to better post-pandemic health care in the United States.
Adding Public Health To The Curriculum
Medical schools do not sufficiently emphasize instruction on how infectious diseases emerge and spread. COVID-19 must be used to help the next generation of doctors better understand the role of biostatistics, epidemiology, data science, disease surveillance, viral genomics, non-pharmaceutical interventions, and contact tracing of various public health issues.
Some schools are already changing their curriculums for their incoming class of medical students. It is important that we learn from what worked and what didn’t work. For example, policy responses designed to combat influenza pandemics may not be as effective in addressing coronavirus pandemics, and vice versa, and students will need to learn to apply scientific thinking to novel pathogens that do not fit established patterns.
Getting Serious About Evidence-Based Care
The urgency to figure out how to treat COVID-19 and its high mortality has led to a stunning increase in interest in pre-prints of articles regarding treatments and potential vaccines for the disease, enrolling patients in clinical trials, and adopting new treatments as well as stopping ineffective ones. We believe that this will lead to the creation of global data sets and integration of artificial intelligence and machine learning in key specialties, including radiology and diagnostic medicine. Prior to COVID-19, it took 17 years for breakthroughs to become implemented widely in clinical practice. That is far too long of a lag given the tools we now have at our disposal.
Using “Real-World Evidence”
The Food and Drug Administration (FDA) has dramatically changed its approach to evaluating new diagnostic tests and treatments to enable new entrants to bring tests to market. Between February 2 and May 28, the FDA issued emergency use authorization for 114 (polymerise chain reaction) PCR tests. The FDA was similarly permissive about letting new antibody tests enter the market, but after negative data emerged about test performance the FDA took action to increase oversight of these tests.
Allowing patients to access tests rapidly and only increasing regulation when a real-world need emerged is antithetical to pre-COVID-19 FDA approaches. A continuation of this approach when a technology or diagnostic offers large potential benefit, with real-time monitoring of clinical data, would be a more productive approach than the FDA’s pre-COVID stance. Since the agency’s new approach is less costly for developers of new technologies, continuing it would prompt more innovations to enter the market. This also could lead to more adaptive clinical trial designs—which allow modifications to ongoing trials in response to emerging evidence—as seen with Genentech’s Actemra trial.
Creating Spare Capacity
As the severity of COVID-19 become clear, states scrambled to create surge capacity. While fairgrounds and convention centers were transformed into field hospitals by the National Guard, the big question was how we would staff these facilities with clinicians. While states rapidly created reciprocity to accept out-of-state licenses, there were few excess clinicians in other states since the pandemic was impacting everyone, everywhere.
California addressed this labor shortage by creating a State Health Corps of retired and in-training clinicians. We think this could become a national model, since we need to draw upon new and unused pools of labor in times of crisis. Once we get through this acute phase of our crisis, we hope that these clinicians undergo structured training modeled on the National Guard so that they are well prepared to mobilize and work productively when called upon for future crises. One important addition would be the creation of a new emergency use electronic health record that is easily connectable to all existing systems and able to access critical data to improve patient care, safety, and coordination. As an incentive, student debt could be forgiven in exchange for service.
Investing In Safer Housing
The highest mortality outbreaks of COVID-19 have been in skilled nursing facilities, prisons, and homeless encampments. Forty-five percent of all US deaths from COVID-19 have occurred in nursing homes and assisted living facilities, places that house only 0.6 percent of the US population. COVID-19 has laid bare the health consequences for vulnerable populations living in nursing homes, congregate living, jails/prisons, detention centers, and areas of acute poverty. Efforts to improve the safety of these living situations will make communities safer by lowering local infection rates. Programs to provide more home-based care; hygienic congregate housing; workers who are both safely protected with PPE from becoming infected and also non-infection carrying based upon negative PCR tests; and PCR screening of high-risk populations can deliver very tangible benefits to society. We hope that these move from a progressive dream to funded initiatives.
Ensuring Providers Stay In Business
COVID-19 is crippling the balance sheets of the health care system we are depending on to treat us. This is happening precisely at the time when we most want our health care system to invest in PPE, additional workers to meet the surge of demand, and testing capacity. We predict that far more health care providers will opt into arrangements that pay them a per-patient-per month fee or shared savings so they are protected from sudden drops in demand and revenue. Even better, we think hospitals could be offered additional incentives to invest in buffer capacity that can be brought online when needed.
Adopting Telehealth For Real
Prior to COVID-19, telehealth was a niche business among commercial health plans for patients needing low-acuity urgent care. As a result of COVID-19, nearly all patients and providers have been forced to use telemedicine services, out of fear that going to the doctor may be dangerous. We think that payers will continue to reimburse telehealth, and we hope that Medicare continues to allow seniors to access telemedicine.
Moreover, we think the tremendous increase in demand will spur innovations to make telemedicine useful for treating many more diseases. These innovations are likely to include incorporating biometric data, enabling group visits with specialists and primary care doctors to improve coordination, and offering real-time second opinion visits and universal electronic health record connectivity. Telehealth can also dramatically improve access to behavioral health care and improve efficacy by helping support patients between visits, too.
Delivering On Mental Health Parity
Pandemics are stressful and can exacerbate mental health conditions. As a direct consequence of the pandemic, it is widely expected that the suicide rate and mental health treatment need will dramatically increase. Sadly, access to metal health care services is uneven and sometimes unethically limited.
Significant improvement in the enforcement of existing federal laws requiring parity of coverage for mental health services, as compared to coverage for physical health services, is needed. What is also needed is greater access to caregivers, both safely in-person and virtually. A new program to train and deploy thousands of new community mental health workers, modeled after new programs elsewhere in the world, could help a great deal.
Creating Effective Public-Private Partnerships
California Governor Gavin Newsom launched a state COVID-19 Testing Task Force co-led by Blue Shield of California, the largest health plan in the state, and the California Department of Public Health. This partnership was able to ramp up testing in California from 2,000 tests per day to more than 110,000 tests per day in 12 weeks, a faster increase than any other state. By bringing in outside talent and leverage, the state was able to respond faster and better.
We hope that this type of inclusive approach is used more often by governments to solve problems. Public and private sector may be useful for tackling challenges such as excess mortality among African Americans and Hispanics and to speed the development of new vaccines and treatments.
Insisting On Better Information
Myths, falsehoods, faulty assumptions, poor modeling, and poor information undermined the US response to the pandemic. Public health authorities found themselves without strong enough tools to collect basic data such as infection rates, hospitalization rates, and mortality rates, let alone data stratified by age, health status, residential status, and other risk factors.
Despite the extraordinary concentration of morbidity and mortality in long-term care facilities, not until late May were all states reporting long-term care fatalities to the public or to the federal government. An improved nationwide system of public health reporting in long-term care facilities would aid greatly in addressing infectious disease deaths.
There has been no uniform standard for counting COVID-19 fatalities. For example, patients who die of non-COVID-19-related causes, but carry a positive test result, are often counted as COVID-19 fatalities; it is also likely that a significant number of individuals have died of COVID-19-related causes where the virus went undetected.
We hope that the experience with COVID-19 leads to a global disease surveillance system of data sharing and monitoring. This would allow us to simultaneously learn about emerging diseases and understand what actions would be useful to reduce spread and improve care.
While a pandemic is never the incentive one would want to spur innovation, these 10 actions could provide a modest silver lining and lead to a better health system. We hope policy makers seize upon the emergence of many of these ideas today and take action to ensure that they persist. This can be done by simply continuing funding for services such as telemedicine, which should actually be cost saving, and adding items such as loan repayment for national service or data interoperability to subsequent stimulus packages.
In the meantime, we will keep physical distancing and rooting for the world’s most rapid development of a very safe and effective vaccine.
Ten Actions For Better Post-Pandemic Health Care In The United States was originally published on Health Affairs.