Historic Crisis and Radical Change in U.S. Health Care

Dr. James Madara
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Throughout the first half of 2020, I had many conversations with U.S. health care leaders from government, industry, academia, and practice surrounding the chaotic challenges wrought by the pandemic. As we move into the back half of the year, many of the issues discussed surrounding our collective response to the novel coronavirus remain relevant. They signal that Health2047 and the American Medical Association are correctly aligned to address some of our health care system’s most pressing issues — and underscore the need to continue advancing its most promising opportunities. I’d like to share some of what I gleaned…


  • First, the enormous strain on hospitals and emergency practitioners during regional spikes in transmission takes a mighty toll beyond increased risk of exposure, as exemplified in the tragic late-April suicide of Dr. Lorna M. Breen, the emergency department medical director at a NewYork-Presbyterian hospital. To give you a sense of the burden, earlier that month, Dr. Omar Maniya, a senior resident in emergency medicine at a Brooklyn hospital, told the AMA’s Chief Experience Officer Todd Unger that his ED module had space for 15 patients. “But it’s a parking lot of stretchers now, and we squeeze in 85.” Things may have eased in New York, but those following the more recent plight of health care workers in Houston and Miami will note the continued pattern of inundation. In a country where physician burnout was already a serious problem before the pandemic, weeks or months of such conditions is intolerable.


  • At the same time, private primary care practices and specialty medicine from orthopedics to endocrinology face blank slates. People aren’t coming in…appointments are cancelled. On June 25, a HealthAffairs study reported that “virtually all in-person outpatient visits were cancelled in many parts of the country between February and May 2020.” Losses to primary care practices nationwide could top $15 billion this year, with decreases in practice volume (both specialty and primary care) anywhere from 50 to 70%. According to a July survey of close to 600 primary care clinicians in 46 states, nearly 90% continue to face significant difficulties obtaining medical supplies or finding sufficient resources to remain operational: “18% say they spend each week wondering if their practice or job will still be there next week.”


  • With unprecedented immediacy, much of primary care practice has moved to telehealth. The most remarkable statistic was given to me by former HHS National Coordinator for Health Information Technology Farzad Mostashari who is now the CEO of an independent practice group of 7,000 physicians. In his system, they’d increased the number of daily telehealth visits from around 80 a few years ago to approximately 100 per day in December 2019. In the six weeks bridging March and April 2020, that number leapt from 100 to 10,000 per day — a 100-fold increase in telemedicine visit daily volume in just 90 days. This incredible surge probably puts us 5 to 10 years ahead of where we thought we’d be at this time for telehealth adoption. But very soon we’re going to have to organize and fight to keep some of the relaxations and incentives in place that helped accelerate use and keep doctors practicing. Privacy and security considerations are going to be paramount. Looking to the future, the AMA’s Michael Tutty has put a group together to explore what effective telemedicine utilization in a financially sound hybrid practice should look like while identifying any current gaps.Well-known for his leadership in clinical quality improvement at Intermountain’s Institute for Health Care Delivery Research and as a contributor to Stanford’s Clinical Excellence Research Center, Dr. Brent James offered an interesting breakdown, estimating that about 45% of health care spending is for acute care — an appendectomy, injuries, pneumonia treatment, etc. Those things are obviously not going to be done by telemedicine.

    However, another 30% of the health care spend is acute self-limited — seasonal allergies, for example, that render patients so uncomfortable they’re eager to be seen quickly and have it taken care of. A substantial amount of acute self-limited care is amenable to telemedicine. The third bucket (comprising about 25% of the spend) is chronic disease management, where physician-to-patient telemedicine currently doesn’t work very well. But telemedicine combined with a peer-to-peer coupling — such as a support group or community coach — works pretty well for chronic management. In this segment, forming a dyad of physician and some kind of physician-extender is a strategic care-delivery enhancement, and the concept calls to mind the genius of First Mile Care’s service design, as well as elements of Zing Health.


  • Another interesting phenomenon is related to payment models and case-mix-type insurances. If you look at practices that have a portfolio mixture of capitation on one hand, and fee-for-service on the other, the fee-for-service business has collapsed. Of course, the capitation has not. So there are practices looking to extend their portfolio in the capitation area and explore more models akin to Zing. I’ve also started to hear capitation described another way by physicians as “prepaid medicine,” which becomes increasingly attractive as fee-for-service essentially evaporates.


Unilaterally, the coronavirus response has uncovered our pervasive need for administrative cost control and simplified orchestration, particularly with regard to technology infrastructure and the flow of information and data. We also need to address our now-obvious geographic supply chain dependencies and risks, determine whether there will be a potential tsunami of pent-up demand for delayed routine procedures and check-ups once capacity loosens up, and figure out how to establish healthcare resilience in the domain of a low-probability event that is massively consequential. Whether our attention to such issues will continue when/if coronavirus turmoil begins to ease remains to be seen.

That said, we can be proactive about what looms on the immediate horizon regarding capacity in the health system this fall. One thing we know we can do is increase flu vaccinations through concerted mass communications. In 2019, less than 50% of adults over 18 were vaccinated. One CDC model shows that if 90% of adults were vaccinated in a given year, we’d likely prevent a million flu-related hospitalizations — which would have a huge impact on our emergency health capacity for 2020 and 2021. Joint efforts with the Ad Council and PSAs have been effective in getting people to wash their hands frequently, practice social distancing, etc. Similar efforts could be undertaken regarding flu vaccination.

Overall, the AMA’s strategic arcs of lifelong learning, chronic disease reduction, and improving practice flow efficiency and environment provide an interesting prism from which to view COVID-19. The problems in those areas have all been exacerbated by the pandemic. Our work on COVID-19 has actually layered onto that framework and Health2047’s data utility, chronic care, radical productivity, and healthcare value pillars particularly. There remains enormous need to relieve physician burden, better leverage technology to advance health care practice, delivery, and training, explore more sustainable practice and business models, and surmount the menace of pervasive chronic disease.

At present, we remain in the grip of a historic crisis and our health care system still wrestles with a lot of chaos and uncertainty. But the health care community has also embraced some radical changes and started breaking down a lot of barriers — which should flavor our ventures to come and embolden us to promote the art and science of medicine for the betterment of public health.

— James Madara is Chairman of the Board at Health2047.

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