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Podcast Library > NextGen Advisors Podcasts > The Pandemic, Are We Really Past the Worst of it?

June 17, 2020

The Pandemic, Are We Really Past the Worst of it?

With the pandemic shifting from front page headlines amidst worldwide demonstrations against racism, NextGen Advisors take a moment to reflect on COVID-19 related issues we are likely to encounter in the months ahead in the new podcast episode.

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Transcript

Dr. Martin Lustick:

Hello, this is Dr. Marty Lustick, senior vice president with NextGen healthcare and principal with NextGen advisors. I'd like to welcome you to our podcast series featuring senior lead leaders from NextGen advisors team, use this series to address different topical subjects related to ambulatory care, exploring the successes and challenges that community providers experience from an operations, policy and strategy perspective. Today's topic is the pandemic. Are we really past the worst of it? In the wake of the dramatic death of George Floyd and the ensuing worldwide demonstrations, the pandemic quite suddenly faded into the news cycle background. Discussion of the latest theories regarding COVID-19, are taking a backseat and we even have the recently coined [inaudible] of COVID fatigue. To reflect on this shift in attention, I'd like to welcome my colleagues, Dr. Betty Rabinowitz and Graham Brown. Welcome Betty and Graham.

Dr. Betty Rabinowitz:

Hi, Marty. Good to be here.

Graham Brown:

Hello, Marty. Good to be with you as well.

Dr. Martin Lustick:

Good morning. As of today, the coronavirus map maintained by Johns Hopkins reveals that 21 states are still showing daily increases in the number of new cases of COVID-19. Graham, do you think we're moving too quickly to put COVID behind us?

Graham Brown:

You know Marty, I certainly recognize the collective desire to get back to life as normal. And I think many of us have experienced our own version of COVID fatigue, whether that's a need to return to work and open up a business, or seeing friends and family in person. That said, I definitely think from a public health and disease prevention perspective, many of the parts of the country moved far too quickly to reopen, and that the coming months will show the consequences of putting financial priorities ahead of public safety, through the continued increase of new cases and deaths. Just a handful of states really, actually satisfied the minimal criteria that the federal government had put out to ensure a two week downward trajectory of influenza-like cases, COVID like symptoms, along with the downward trajectory of cases and ensuring hospitals had both available capacity and robust testing programs in place at the community level. So, I think given those elements that were in a place here where things have absolutely opened up in a way that the community really isn't necessarily prepared to respond to them.

Dr. Martin Lustick:

Betty?

Dr. Betty Rabinowitz:

My sense is that what we are observing is a one size fits all approach at the state level or obviously at the national level as well, and that if we were better at applying some finesse to the process. I've been able to test more extensively and identify areas within states or counties or regions, where the trend was more positive, the criteria for reopening were occurring and to have opened those selectively. I think New York state has had a little bit more of a region by region, county by county approach, but it really depends on being able to test, track, isolate. And unfortunately, the ability to test on a broad scale has not yet been achieved since the beginning of the pandemic. We still have not resolved that dilemma.

Dr. Martin Lustick:

I'd like to ask a little bit more about this idea of painting with too broad of a brush that you mentioned. We looked at more granular data. Everyone talks about New York city as the epicenter of the pandemic, but their reported infection rate is about 1,600 per 100,000 residents. But if you look across the country, while New York's numbers are really high, if you correct for the population, you see areas that are much higher in terms of their infection rate. For example, Ford county, Kansas has over 5,400 cases confirmed per 100,000 residents, which is more than three times the rate of New York city. And there's examples like this from other rural areas like New Mexico and Texas and Oklahoma. What do you think the implications of this are for healthcare in those areas? Betty?

Dr. Betty Rabinowitz:

The biggest risk in those areas is that limited resources will become very quickly overwhelmed. So these are areas where there are community hospital that have suffered incredibly in the years prior to COVID with financial pressures, closure of some of these hospitals. So many of these areas are being served by struggling community hospitals that have reduced the number of their ICU beds, have probably struggles with staffing those ICUs with qualified board certified intensivists, and they will easily be overwhelmed where you'll start seeing patients from those areas needing to be transported to larger centers to get the kind of care that they're going to need, or these hospitals being completely overwhelmed by patients that they're unable to care for. So if ever there were areas where lockdown, social distancing, public health interventions to reduce the spread were needed, those are those areas.

Dr. Martin Lustick:

Graham, your thoughts?

Graham Brown:

I agree with Betty. I think there was this kind of false sense of security that rural areas because the population is more broadly spread around, were going to be safer environments. And the concern that I have is really kind of twofold. I think there's a couple telling sources of information that worry me. The Harvard Global Health Initiative conducted a recent compilation of available ICU beds. The most current data from CMS was only from 2018. And so they went forward and actually looked at all of the available hospital beds, ICU beds, and then a total of those two. And when you look at those jurisdictions you just mentioned Marty, New Mexico, Texas, and Oklahoma, given what they have available now, if we call that a hundred percent availability, this Harvard Initiative really projected what was the forecast of the potential burden of new cases and how prepared are these environments to actually address the care needs. Right now, New Mexico needs 512% of the capacity they have to serve cases over the coming 12 months. Texas needs 227% of the capacity they have. Oklahoma needs 206% of the capacity they have. So I think there's really a great deal of preparedness that hospitals, community organizations in these areas need to be undertaking now. The new case rates in those jurisdictions is increasing today and I think that they're going to get swamped pretty quickly. A related area that really concerns me, I think we've seen just as of May, skilled nursing facilities and long-term care facilities were required to report to CMS on the number of cases that are occurring. And I wish that they had been required to do that from the beginning of the pandemic, but we do have data now from the end of May and nursing homes are seeing 30.2 deaths per 1,000 residents. So these environments are particularly at risk and I don't think are really prepared to meet the needs of the population and their care. And it kind of builds on the point that Betty was just making a moment ago, where they might not have the level of staffing resources in terms of real bodies to serve the patients, let alone the clinical training and some of the kind of advanced care needs and systems of support that are going to care for this population effectively. So those areas really concern me.

Dr. Martin Lustick:

So interesting in my personal experience, the county that I happen to live in, in upstate New York, over half of the confirmed cases in our county are from nursing homes. And of the 30 deaths we've had in this county, which is sort of rural suburban, 29 have been nursing home residents. So your point is well taken there. Another point you made that is striking to me is, as I was looking at the information about the rural areas, my hope was, well, maybe they can just transfer their patients to the cities in their state where they have better capacity, but based on the numbers you quoted from the Harvard assessment in those states where they have these rural outbreaks, they don't actually have the capacity in the state overall to deal with the demand that's going to be there.

Graham Brown:

Mm-hmm (affirmative).

Dr. Martin Lustick:

So, that's really concerning. Let's move on a little bit here. If you step back again, it's clear that overall the curve for the U.S. as a whole has flattened. And as we've been talking, there's still some hotspots. But on top of that, we've mentioned the opening of businesses. In addition, we've seen these massive demonstrations in response to the death of George Floyd. It seems like this would have the potential to dramatically worsen the pandemic. Graham, what were your thoughts about the impact of the demonstrations?

Graham Brown:

Well agreed. I think there's many folks that went to those demonstrations that were wearing masks and doing some level of prevention, but when you're in a crowd of several thousand people, you're coming into pretty close contact. And so, even though some precautions may have been taken, I'm not sure that they're really going to be the level of prevention that we would've sought. I think those waves are coming sooner rather than later, given there's a two to four week window after the time of exposure until people infected with the virus start showing symptoms. I think this prognostication that a second wave is coming in the fall and winter aligned with the flu season, is a bit of a false bet. And in the face of these recent demonstrations, it's probably more are likely that we're going to see multiple waves and that those waves are really going to be starting now in the next couple weeks.

Dr. Martin Lustick:

Betty?

Dr. Betty Rabinowitz:

I agree with Graham, I think Memorial Day was a kind of demarcation of opening up in a lot of states. And I think there's a clear correlation with that event, the gatherings, the picnics, the partying that occurred with the uptick in cases. So, I think there's some advantage to these activities occurring outdoors, a lot of these folks were in motion, but there was variability in mask wear when you looked at these crowds. And obviously, this is going to be a, this was a risky as people felt necessary behavior, but it's going to offer a challenge in some of the areas where there's going to be an uptick case.

Dr. Martin Lustick:

Yeah. I heard an interesting hopeful anecdote on the news last night in Georgia, there was a beauty salon that opened in May where two of the staff got infected and they tracked 140 people who were exposed to them. It was a little disturbing that only 40 of the 140 agreed to be tested, but of those 40 people who were tested, they were all negative. Now, both the staff members were wearing masks and so were the clients and they had taken other measures in the shop to minimize contact among the people who were there. But it's a little bit hopeful even though it's only a case study of one that maybe wearing masks and taking these other precautions is somewhat effective here.

Dr. Betty Rabinowitz:

Interestingly, the mask issue is revisited again and again, and the evidence is clearly mounting that there is advantage to the wearer and the people surrounding the wearer as well. And that one of the thoughts is that a society like Japan where people wore masks against pollution, during flu season it was very socially acceptable to be in public spaces wearing a mask. I can remember touring Europe and seeing Japanese tourists wearing masks and thinking it was very unusual years back. So, that some of the behavior of the pandemic in Japan where they've gotten it attended very good control stems back to the routine wearing of masks. And I saw just this morning comments by Andrew [Cuomo] about his disappointment that police officers in some of the demonstrations were not uniformly wearing masks, even though the New York city police department suffered very large numbers of infected officers and some deaths. So, it's difficult to understand why it's become politicized, it's become controversial, but it's very unfortunate because I think it is truly one of the major things we can do as we move in the company of other humans to prevent spread of the infection.

Dr. Martin Lustick:

Thank you for that. Let's go to one final question. So as we've discussed, there's a lot of uncertainty in this space and there's certainly a strong potential for things to get worse before they get better. What are your thoughts on how providers should be positioning themselves for the months ahead? Graham?

Graham Brown:

Carefully, the reality of this. The American Medical Association came out with some very good practical guidance for [inaudible] practices. And I really hope provider is look at those guidelines carefully and follow them. They include making a strategic reopening plan, opening incrementally, balancing staff that don't need to be in the clinic environment continuing to work from home, implementing safety and control measures, ordering PPE now to make sure that there's a supply on hand and you're not having vendors show up with PPE while there's patients in the clinic, having tele triage programs, all of those different efforts I think. So there's a lot of good guidance out there and I think that while practices clearly want to get their doors open again and continue to serve the population that they take care of, they need to do that in a very practical and thoughtful way to protect their community in the long term. We can't just trade off short-term measures for long-term implications here, and I think those are the factors that we really need to be thinking about day to day in the reopening efforts.

Dr. Betty Rabinowitz:

My sense is that it's a golden opportunity for primary care physicians who are regarded as trusted advisors, as far as it pertains to people's health and prevention and wellness to take a very clear stance in the community regarding the importance of maintaining social distancing, maintaining vigilance, and caution around vulnerable populations and setting an example with their staff and their behavior for their patients about safety and prevention. It's so important that healthcare in a certain way, reclaim the pandemic as part of their domain of experts as is a medical issue, it is not a political issue. Obviously has political underpinnings, it needs to be funded, et cetera, I'm not naive to that, but physicians and care teams need to take the dominant voice and work in communities to continue caution and preparedness.

Dr. Martin Lustick:

Well, thank you. On that note, I'd like to thank our listeners for joining us today, and to thank Dr. Betty Rabinowitz and Graham Brown for sharing their insights and perspective on this important topic. If you enjoyed today's discussion, consider subscribing to our podcast. This is Dr. Marty Lustick with NextGen healthcare, have a great day.