After the Flood

I keep thinking about the COVID-19 pandemic as a flood. 

You know the water is rising, you usually know how high it will get and even when, but there's just not much you can do about it.  You can put in levees or floodwalls, maybe throw up some sandbags, but for big floods the water is going to have its way.  It creeps up and subsumes everything in its path.  Inevitably, the waters do recede, but leave their mark.  Some things survive, some are badly damaged, some are simply swept away. 

Looking at the coronavirus statistics every day is like watching the water rise, and I wonder what our healthcare system will look like once the pandemic flood subsides.

Before the current pandemic the U.S. already had plenty to be unhappy with about its healthcare system.  It cost too much, it delivered care unevenly, its focus seemed too oriented to profit instead of to quality, and, most importantly, it didn't actually seem to be keeping us healthy.  No one seemed happy about it -- not patients, not clinicians, not even the army of administrators who have infiltrated it.  But, we assured ourselves, at least it would be there for me/us if I/we had a health crisis.

That seems like wishful thinking now.  As Dr. Siddhartha Mukherjee wrote in What the Coronavirus Crisis Reveals About America Medicine, in the wake of this pandemic "the medical infrastructure of one of the world’s wealthiest nations fell apart, like a slapdash house built by one of the three little pigs."  

Credit: CNN

We can't get enough essential personal protective equipment (PPE).  We can't accurately test sufficient numbers of people.  We're overwhelming the healthcare system in hot spots.  Our health care heroes -- doctors, nurses, first responders, and the myriad of workers who support them -- are working long hours, putting themselves at greater risk, and struggling to figure out how to best help patients.

The pandemic is wrecking havoc on our healthcare system.  Costs for PPE are skyrocketing.  We're having to reconfiguring health care facilities to reduce risks of exposure. The weaknesses of our supply chains have been exposed.  Many parts of our healthcare system are working past peak capacity, while others have been idled. Deferral of most "elective procedures" have made very clear how much our health system is dependent on them; even in a pandemic, many hospitals are being forced to cut staff as a result.

Already vulnerable hospitals have become even more vulnerable.    Nursing homes are struggling to absorb new costs to deal with COVID-19, and we're realizing that their very nature makes them petri dishes for such a pandemic.  Many primary care physician practices are floundering; less than half think they can stay open for another month.  Private equity firms that had bought up hospitals and specialty practices are rethinking their investments. 

People like to point to telehealth as one innovation that the pandemic has spurred.  Patients and physicians who had previously never tried it are now becoming fans.  Regulatory barriers and reimbursement limitations are being addressed.  Almost half of physicians now report using telehealth, drive largely due to COVID-19 concerns. 

Still, though, whether telehealth advances persist after the pandemic subsides remain to be seen.  We're still struggling with reimbursement, the inter-state licensing issues have not gone away, and the relief from HIPAA requirements is not permanent. 

People rebuild in flood plains even after being hit by a flood; we may be stupid enough to try to go back to the healthcare system we used to know once we lose our alarm about COVID-19.  That would be stupid.  As Dr. Mukherjee put it: "Medicine needs to do more than recover; it needs to get better."

Here are a few thoughts about how:

Telehealth:  It's the 21st century; time to bake telehealth fully and firmly into our healthcare ecosystem.  Just as retail and offices are unlikely to return to pre-pandemic norms, relying more on virtual options, healthcare must as well.  

Supply chain: We're still going to import some healthcare supplies from abroad.  But we do need to spread our dependencies over more options, including more domestic options, and ensure that they have the ability to scale up when needed.  

Nursing homes: Nursing homes/assisted living facilities weren't a great option for residents' health even before the pandemic, and the pandemic has exposed what a terrible option they are during such outbreaks.  We need 21st solutions for supporting people in staying safely at home.  

Unnecessary procedures: We've known for decades that too many of our health care services are unnecessary and sometimes inappropriate.  We've taken a meat-axe to them during the pandemic, chopping needed services as well as unnecessary ones.  The post-pandemic period should be the time to finally take a hard look at what we really should be doing to/for patients.

Infrastructure: We have too many buildings for what should be an increasingly virtual system.  The buildings we do have need to be more nimble, as the scramble for ICU beds has shown.  Our systems need to produce data that is more shareable, searchable, and real-time.  And we have too many layers of bureaucracy that add to costs but not to outcomes.   

Public Health: It is usually only visible during public health crises, but public health needs to be seen as an ongoing investment not just in managing such crises, not just in avoiding them, but also in improving our health.  It should be the base of our healthcare system, not an adjunct to it.

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Credit: MGMA

Right now, we're still watching the water, hoping it is no longer rising and waiting for it to recede.  Right now we know there is damage to our healthcare system, but not how bad it will be.  Right now, we're more focused on establishing the "new normal" for our daily lives, but not what the new normal for our healthcare system should be.  

As hard as it is to think past the pandemic, we must.  Returning to something that resembles "normal" is way too low a bar when it comes to health care.  Pandemics like this only come along perhaps once in a century, so we have a unique opportunity to, as Dr. Mukherjee says, make our healthcare system better.  We mustn't miss it.