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Omicron, health care and what's really going on in America's hospitals

An ICU floor at UMass Memorial Hospital in Worcester. (Erin Clark/The Boston Globe via Getty Images)
An ICU floor at UMass Memorial Hospital in Worcester. (Erin Clark/The Boston Globe via Getty Images)

Once again, hospitals across the country are swamped by COVID. But omicron is not the whole story.

“COVID has put a huge strain on the hospital system, obviously it’s an unprecedented crisis, but that’s not the only thing going on here,” Jonathan Cohn, senior national correspondent at HuffPost, says.

There are long-standing problems with the American health care system that set hospitals up to be overwhelmed just when the need is greatest.

“The American health care system is famously mixed up. It famously puts its priorities in the wrong places.”

So who’s to blame for that?

“You can pick out almost any group who’s involved in health care and say, ‘Hey, something you’ve done has actually made it harder for us to deal with a situation like COVID.’”

Today, On Point: We hear what’s really going on in America’s hospitals.

Guests

Dr. Vivian Lee, president of health platforms at Verily Life Sciences, a digital health care company. Senior lecturer at Harvard Medical School and Massachusetts General Hospital. Author of “The Long Fix: Solving America’s Health Care Crisis with Strategies that Work for Everyone.” (@DrVivianLee)

Also Featured

Dr. Laura Forman, chief of emergency medicine at Kent Hospital in Warwick, Rhode Island.

Dr. Jeanne Noble, professor of emergency medicine at UCSF in San Francisco. (@JeanneNoble18)

Interview Highlights

On how the pandemic has revealed the fault lines in the medical system

Dr. Laura Forman: “The pandemic has shone a light on a lot of the fault lines in the medical system in this country, that we’ve all known have been here for a long time. But now, with the added burden of the pandemic, we can’t ignore them anymore. The emergency department gets used for a lot of [non-emergency] care and we’re happy to do that, but it is very costly to the system.

“And so one of the things that we have been thinking about a lot in emergency medicine, both at my hospital and I think across the country, is how do we better provide the right care, at the right time in the right place for patients without a costly emergency department visit?

“There are a lot of public health initiatives that I think are gaining traction now in the pandemic because emergency departments can’t function as a safety net, that they’ve always been able to be for the society. So I am hopeful. It’s funny to say, but in the pandemic, I’m very hopeful that this will actually be a good thing for medicine. Because it’ll force us to deal with some of these issues that have been here for decades.”

Even in pre-pandemic circumstances, hospitals and hospital systems run on very thin operating margins. What does that mean?

Dr. Vivian Lee: “The operating margin is just the amount of what’s left over after the whole business has paid for all of its expenses. And so a 2% to 3% margin means that the vast majority of all of the funds that are collected for caring for patients is used to pay for the physician, to pay for the nurses, to pay for the equipment, to pay for the hospital’s operations. And so all that’s left is about 2% to 3% of left over what you might call profit. But of course, it’s used to say invest in new buildings or new resources. And that is very thin compared to most other businesses that might operate on an 8% or 10% margin.

“And as a result, it makes the whole system very vulnerable. It means that you have to be much more efficient. So, for example, you have to have just enough staff, as Dr. Forman alluded to, in the emergency room. But if all of a sudden something unexpected happens, like a pandemic and you’re overwhelmed, you don’t have much extra capacity. Because you’ve operated in such a lean, lean way that you just can’t tolerate any unexpected developments.”

On the problem of boarding

Dr. Vivian Lee: “Boarding is a consequence of just as we talked about before, not really being able to predict how many visits you’re going to have in any given time, and not having any extra capacity, because we’re operating so lean. And when I hear that, it reminds me that today, really, a lot of the challenges because of the COVID pandemic and we do have, you know, ordinarily when you know that there’s going to be crisis, or you have a sense that there’s going to be some kind of unpredictability, you want to create some early warning systems.

“Like the meteorology service helps us anticipate a hurricane that might be brewing first as a tropical storm. And in the case of COVID, we now, having done cycle after cycle of it, we know that there are actually very effective early warning systems that could be put into place if we had a more functional public health system. There are really excellent wastewater programs now that enable us to detect very early on these surveillance studies of early infectious diseases, for example.

“So that would help us better anticipate the needs in emergency departments. The other part of the boarding problem is not having enough beds in the hospital. And there, you know, because our business model has so favored having patients in the hospital, that’s where you generate the most money. That’s where there’s the most profit.

“We haven’t actually embraced a lot of these models that have been picked up in other parts of the world, like in the UK and in Australia and Japan, of encouraging some of the care that can be done and taken care of at home to move to the home. For example, patients who may need an infusion of intravenously, for example of antibiotics for several days.

“Most of that can be done actually in the home setting very safely, and actually even more comfortably for patients. Provided nurses can say go and visit them in the home. And that can actually offload some of that pressure for beds in the hospital. So on both ends, on the receiving end in the emergency department, we could do better in anticipating. And then similarly, we could actually do better at getting patients out of the hospital, or some patients out of the hospital who don’t actually need to be there.”

Is there room for improvement within the United States health care system?

Dr. Vivian Lee: “Oh, absolutely. I think we were all really envying those systems in the last couple of years. They haven’t really been set up because these systems have been so competitive. Our health care business is really a a very competitive industry. And so traditionally that kind of coordination, collaboration hasn’t existed. But I’m hopeful that through the pandemic, some of the some of the connections that have been made will continue to persist even post-pandemic. And enable more coordination so we can be more resilient as communities, rather than hospital by hospital.”

On new models for American health care

Dr. Vivian Lee: “One of the consequences of the COVID pandemic is actually that some of these newer models are taking hold. So, for example, in the Medicare business. Traditionally, Medicare has been fee for service, and it just means that doctors get paid every time they do something to people. But there’s been a growing segment of the Medicare market called Medicare Advantage. About a third of all seniors now are in a Medicare Advantage program. And during the pandemic, what we saw in the Medicare Advantage model, which pays doctors differently, it rewards doctors for keeping people healthy.

“And so in those Medicare Advantage medical groups, when they were caring for their seniors, they actually took the dollars from Medicare and said, Oh, you know what? Let’s think about our seniors and keep them healthier by, for example, delivering their medications to their homes, sending nurses out to their homes, maybe taking our clinics and converting them to urgent care setting.

“So our patients don’t have to go to a scary emergency department, instead can come into the clinic for urgent things that are happening to them. So this model of using those dollars to do more home care … and other more proactive preventative measures, it is happening today. And we’ve seen it move much more quickly since the pandemic. Because people are coming to realize that our old business model really, really hasn’t served us that well, especially during this crisis.”

On innovations that will drive our health care system forward

Dr. Vivian Lee: “Fundamentally, it’s not only my opinion, but I think the opinion of most health leaders on both sides of the aisle is that we need to change that business model. That the business model of fee for service is just been leading to more and more high end utilization of care, sometimes not necessary, at the expense of primary care and public health and all the things that we’ve seen fall short during the COVID pandemic. And so if we continue on this path that we’re already on. So everything I described about Medicare moving more and more to Medicare Advantage, those kinds of trends are already underway.

“And as I said, they’ve been supported under both under both parties, vigorously. So if we can continue to do that, then the market forces in this country, whether it’s the drive to efficiency, the drive to profitability, whatever it is, will push us to create and continue to innovate in ways that will lead to better health. We will be bonusing doctors and hospitals for keeping us healthy. And the way in which they will become profitable or continue to be profitable is by leveraging technology. The technology transfer that’s happened, the transformation that’s happened in every other industry has yet to really take hold in health care.

“I mean, think about the way you bank today compared to how you might have banked 20 years ago, for example. You know, we never really have to go into a bank anymore. We can do everything at home. We can manage our financial health, deposit checks, figure out our balances, make our payments all automatically. Imagine if we could do that much, much more across health care. If my kid has a rash, I don’t need to drive them in to see the pediatrician. I can take a picture. Maybe the artificial intelligence on the picture can tell me if that rash is infectious or not. Or I can at least send it over to the pediatrician or the dermatologist, and I can know whether to go to school or not.

“There’s so many things that I could be doing that could lower the utilization. I could use much better predictive analytics and be able to say, You know what? This family is at higher risk of developing this cancer. Let’s get them in for early screening so they don’t develop the cancer. That technology is available today. So all we need to do is, in my view, create the economic incentives, the business models. Or continue to move forward, I shouldn’t say create, because we’re already down that path. But let’s accelerate that and let that innovation really drive us forward.”

From The Reading List

Washington Post: “Inside a Rhode Island hospital E.R. overwhelmed by omicron” — “Mary Balcerzak’s nightmare was coming to an end. The coronavirus-positive woman spent 10 hours sitting with other infected patients in a small emergency department meeting room before health-care workers were able to find a bed for her in tiny Room 25.”

Vox: “The frustrating Covid-19 test reimbursement process is a microcosm of US health care” — “As of January 15, Americans with private insurance are able to submit their at-home testing bills to their insurer in order to get reimbursed.”

This article was originally published on WBUR.org.

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