Post Election Symposium: Day 2

Session 3 Transcript

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

Margaret Murray:

Hello. My name is Meg Murray, and I’m the CEO of the Association for Community Affiliated Plans, otherwise known as ACAP, as well as a proud member of the Alliance for Health Policy. At ACAP we like to say that Medicaid is us. And by that I mean we’re the leading association advocating for Medicaid and Medicaid beneficiaries, and the safety net health plans who serve them.

Margaret Murray:

Because of our strong support for Medicaid, one of the main things we’ll be working with the new Congress and the new administration is to make sure that there’s adequate funding for Medicaid, particularly during the pandemic. We will be looking for the new Congress to support increased FMAP during the pandemic, as well as to have a trigger, so that the Congress has already decided that FMAP should be increased the next time we have an economic cataclysmic event like we have right now.

Margaret Murray:

We will also be working with the new Congress and the new administration to end the proliferation of junk insurance. The current administration has allowed these plans to be sold for up to three years. We believe that many beneficiaries will be snookered into buying these, which do not have all the protections of the Affordable Care Act, and we want to make sure that consumers are protected.

Margaret Murray:

So, that’s what we will be working for with the new Congress and new administration and I look forward to hearing the discussion today.

Sarah Dash:

Hello, and welcome to the third session in the Alliance for Health Policy 2020 Signature Series, Post Election Symposium. I’m Sarah Dash, President and CEO of the Alliance. And for listeners who are new to us welcome. We’re a nonpartisan resource for the health policy community, dedicated to advancing knowledge and understanding of health policy issues.

Sarah Dash:

Thanks for joining us today, where we will continue to grapple with the devastation of the ongoing COVID-19 pandemic, and how the election results could influence the health policy agenda in 2021 and beyond. Since the election news and results are still updating, please note that we’re recording this on Monday, November 16, at 2PM Eastern, in case anything has changed between now and when we broadcast.

Sarah Dash:

I’d like to take a moment to thank our 2020 Post Election Symposium sponsors for supporting this event. And I also would like to highlight our upcoming session where we will discuss the gaps in our healthcare system that COVID-19 exposed, and how that will impact the priorities of the incoming administration, Congress states and federal courts.

Sarah Dash:

You can also find recordings of yesterday’s discussions on our website and materials that accompany all of our sessions at allhealthpolicy.org. And now it’s my pleasure to introduce Dr. Ian Morrison, a New York Times bestselling author, consultant and futurist, specializing in long-term forecasting and planning with an emphasis on healthcare. Dr. Morrison currently serves as senior advisor to Concord Health Partners and on the Advisory Council of the Council of Accountable Physician Practices.

Sarah Dash:

Dr. Morrison has previously served as president of the Institute for the Future, and is the founding partner at the Strategic Health Perspectives, which is a joint venture between Harris Interactive and the Harvard School of Public Health Department of Health Policy and Management. Prior to his time at Strategic Health Perspective, he served as the chairman of the Health Futures Forum.

Sarah Dash:

Well, Ian, we’re so grateful to have you here today to provide your insights on what you think we can expect next year and beyond, and with that, I will turn it over to you.

Ian Morrison:

Well, Sarah thank you so much for having me, and it’s an honor to be with such distinguished faculty and a wonderful program. As you mentioned, I’m known as a futurist. My definition of a futurist is an economist who couldn’t handle the calculus. I’m in the sweeping generalization business and have been for a very long time. And the number one question I always get asked is, how do you become a futurist? I point out that my undergraduate major at Edinburgh University was geographic and economic change in Scotland 1580 to 1830, which is incredibly useful.

Ian Morrison:

But actually, it’s a useful training. I’ve been a student of structural change in society now for almost 50 years. And I ended up working in healthcare, ironically, I was trained as a geographer, an urban planner, moved to Canada, and then was working on my doctrine and I got offered a job to join the Institute for the Future, modestly entitled Institute for the Future, to work on a grant called Looking Ahead at American Healthcare that Bob Blendon when he was at Robert Wood Johnson had given the institute. And I got a chance to work with Bob in 1985 and pretty much ever since. And we have been close colleagues and I’ve learned so much from Bob Blendon over the years.

Ian Morrison:

But I’ve spent most of my time in the last 20 odd years working with health systems and healthcare stakeholders across the spectrum of the ecosystem and i continue to do so. And I wanted to share some comments about where I see the industry, and particularly the impact of healthcare, or the impact on healthcare of the COVID pandemic. So, if we can go to the next slide.

Ian Morrison:

I’ve been a student of the post-industrial economy now for 40 odd years. And if there’s one hallmark of post-industrial society, it’s the widening income gap between haves and have-nots, particularly the top 1%. I say to my kids, “Be in the top 1%, you’ll do just fine.” But these effects are also compounded by race and racism here in the U.S and in many other countries. Next.

Ian Morrison:

And when it comes to healthcare, if we look at the next slide, the one kind of mega trend if you like, that we’ve been watching over all the time I’ve been in the U.S, which is now 35 years, is the progressive unaffordability of healthcare, particularly in terms of out-of-pocket costs.

Ian Morrison:

I mean, the American public in my view, could care less how much it costs as a shared of GNP, but they worry about what they pay. And one tracer condition that, I was on the board of the California Health Care Foundation for a decade and we did a little study back in the day that showed that in 1970, if you provided health benefits for a family, it would cost about 10% of the minimum wage.

Ian Morrison:

Today, that equivalent number of health benefits for a family is 150% of the minimum wage, which really speaks to the progressive unaffordability of healthcare. Next please.

Ian Morrison:

And I mentioned the California Health Care Foundation back in 2005, Mark Smith, the then CEO, I was on the board and Mark invited me to join a meeting with Ulla Schmidt who is the German minister of health through much of the early 2000s. And she was on a listening tour, trying to understand how American healthcare works, and Mark and several others were gathered to talk about trends in American healthcare. And we got to the point in the conversation about money. Oh, by the way, she didn’t speak any English, which was a bit difficult. But actually, she had this translator guy, that simultaneous translation, so we actually got along fine.

Ian Morrison:

And we’re in the part of the conversation where we’re talking about the money, and I was explaining and waxing lyrical that the way it works in America is that doctors in hospitals charge some multiple of what actually costs to deliver the service maybe two or three times as much, to make the math work, because of the perceived underpayment by public payers. And I don’t speak German, but I believe she said, “What the f…” Expletive deleted.

Ian Morrison:

And she’s right, because if you go to the next slide, one of the hallmarks of American healthcare has been our different pricing level relative to other countries and over time. And there is this widening gap now between what private payers pay and what public payers pay, and you can debate all day long about it’s cost shifting, it’s not cost shifting, it’s real, and it’s a phenomenon that really underlies the financial engine of American healthcare. Next please.

Ian Morrison:

So, I would say and having been an advisor to large employers over the years, most employers are kind of complicit in this game, they’re not thrilled about it, but they don’t really do much to stop it, with some rare exceptions where they’ve massify their firepower or use their influence to create narrow networks. And the question is, will they stiffen the resolve here in the post-pandemic period, as they have been hit hard many of them in terms of their own core businesses. Next.

Ian Morrison:

What I would say is that, if I had to give a talk about trends in healthcare prior to the pandemic, the top trends really were the kind of confluence of what I just described, the rising commercial prices and financial gotchas in things like surprise billing, which by the way is not bug feature of certain business models like emergency room physicians who have been rolled up by private equity firms.

Ian Morrison:

The second mega trend was the growth of Medicare Advantage, which I think has been one of the engines of the value movement in American healthcare, as has managed Medicaid, and of course Medicaid expansion in the wake of the ACA, was the fact on the ground I think that really expanded coverage.

Ian Morrison:

But similarly, what we’ve seen prior to COVID, and I think will actually accelerate and perhaps even become a bigger force, is consolidation in the healthcare delivery system and the market power that it creates. And I say inevitable, partly because of not so much that it’s a good idea to consolidate, but that a lot of weaker players may capitulate.

Ian Morrison:

And there is a massive amount of money prior to the pandemic and even through the pandemic being invested in private equity and venture funds in healthcare, particularly in consumer facing digital health, but not exclusively in that area.

Ian Morrison:

And in the political realm and the policy realm, there have been prospects for Medicare for more, I wouldn’t say Medicare for all necessarily, of the fadable blending on that. But certainly, the possibilities in a Biden administration had there been a substantial Democratic Senate Majority of a public option for many Americans and an expansion of Medicare to a younger age ranges.

Ian Morrison:

And I would say that value-based care is why we call a stalled future. It’s not that we don’t believe in it, and certainly, I’m an advisor to the Leavitt Partners and a great fan of Governor Levitt and his team, and share the commitment and belief that value-based payment needs to be the inevitable goal of healthcare. But most of the action, I believe has been in Medicare and Medicaid rather than has been in the commercial, particularly self-insured employer space. And that remains the frontier to be tackled.

Ian Morrison:

And of course, many health systems across the country we’re responding to new consumerism movement in healthcare, and I’m trying to create a digital front door. And I believe that there is a force for productivity in healthcare, through the rising promise of artificial intelligence. And I think that may be one of the things that will bail us out in the long run, in both the clinical area with innovations like dermatology or surgical pathology, imaging ophthalmology, pattern recognition done both with and enhanced by computers, as well as in the more administrative area.

Ian Morrison:

And the final mega trend I’ll point to is the whole area of physician burnout. And I think burnout is the wrong term. I mean, everybody works hard, right? Clinicians like to work hard. I think that the sense of alienation and frustration that many folk feel and demoralization in the face of unnecessary administrative hassle factors, has been a big driver. And this is obviously become more intense post COVID because of the sheer terror legitimately that many caregivers face every day in the face of dealing with patients who are sick and infected. Next please.

Ian Morrison:

And maybe just a couple of data points behind the sweeping rhetoric. It’s interesting to me as a person who as a fan of Medicare Advantage that we have seen, even in the Obama years with Democratic administrations, we’re not as gung-ho about Medicare Advantage, we saw continuous growth, and I believe that certainly my colleagues the Leavitt Partners, that they believe that this will grow materially over the next decade, regardless of national policy.

Ian Morrison:

The other counter trend is Medicaid expansion even with Republican administrations, and even in the Trump years, we’ve seen states expand Medicaid, most recently in Oklahoma and Missouri who are not noted as being hotbeds of socialism, and yet vast majorities of their population voted to expand Medicaid. Next please.

Ian Morrison:

So, COVID brought challenges to the health system and continue to do so. We have been obviously trying to focus on stopping the spread, and I’ve had uneven results in that. I think we’ve done quite well in serving the second learning how to do better. I’m not a clinician and that would be pertinent of me to weigh in on that. But certainly, some of the success stories have been remarkable in terms of being able to get the fatality rate down.

Ian Morrison:

But the real challenge I think remains how to balance the economic issues with the clinical pandemic. And it has proven very difficult not just here in the U.S but around the world and starting economic recovery. And I think most people have done it somewhat prematurely and have had to reassess their progress. Even my native Scotland in the last month or so was basically shut down again. Next please.

Ian Morrison:

And of course, the challenge really, and certainly the president, through the early part of the year was focusing much more on the rebound from the precipitous drop that took place in the economy in the first six months of the year, historic drops in jobs, if you go to the next slide, what we saw was basically all the jobs created in the last 20 years disappear in two months, which was massive and impactful across the board. Next.

Ian Morrison:

But we have seen significant recovery since then we’re down to about 10 million jobs year over year, unemployment rate has bounced up to 6.9%, but it’s higher for women and it’s higher for minorities. And alarmingly a significant proportion of those who are now unemployed, have been out of work 27 weeks or longer, which is always a bad indicator for not only the income of those households, but the social determinants of health that result. Next please.

Ian Morrison:

And so, it is important to consider where we go with regard to jobs, not the least of which is, will it cause us to reassess our commitment to using employer-sponsored coverage as the backbone of American healthcare? When you think about it historically, it’s kind of an accident that we do it this way, and my colleagues around the world think it’s a goofy idea. It was hard to explain to people in Glasgow why that would be so, an underserve cruel cartoon. By the way, it’s a fine and dandy idea when the unemployment rate is 3.7%, and everyone’s got job with health insurance, which is not necessarily the case.

Ian Morrison:

It’s not so fine and dandy an idea when the unemployment rate is 10%. And I think one of the things I’ve been looking for over the last six months is a change in public attitudes, and a sense of vulnerability, the public may feel about their employer-sponsored coverage. Next please.

Ian Morrison:

And I do want to point out that this pandemic, not only in terms of jobs but in terms of the impact on the actual clinical outcomes including deaths and hospitalizations, have disproportionately affected the folks who take the early bus, and we’ve seen it bounced back in income. And those of us who Zoom for a living are relatively unaffected, and doing very nicely, thank you.

Ian Morrison:

Those of us who live off capital rather than labor have done very well in the last year. But if you are a bus driver, or a hotel worker, or work in a restaurant, that’s not the same story. Next.

Ian Morrison:

And sadly, this has been, as I say, compounding the effects of race and racism show up in these alarming differences in mortality rates and impact by race. Next.

Ian Morrison:

So, my colleagues and I, we worked on some scenarios back in March to try and describe the arc of what may happen. And I won’t bore you with all the details, but we’ve used these to judge the unfolding reality. And they’re really cartoonish. I mean, they had data behind them and assumptions, but let me just describe them in cartoon form, because I think they are sort of instructive of the arc of the year so far.

Ian Morrison:

The big bounce back scenario was I think what many people were hoping for, which was, it was a one quarter event, much as it was in China, and we killed off the virus and we got back to normal. Well, that clearly hasn’t happened, except in two places. One is the stock market, which has bounced back and is ahead year over year. And the other is actually the health system, which I think has bounced back quite remarkably in the last three quarters, even though it’s been hammered by the pandemic in many ways.

Ian Morrison:

The second scenario was really presaging perhaps a blue wave, where the American public felt progressively insecure because of the pandemic and would vote for more faith in government to resolve those issues. And to some extent, that scenario has prevailed with president-elect Biden’s election, although there are counter currents in the fact that there was a very significant vote for President Trump and the Democrats didn’t gain massively in either the House or Senate.

Ian Morrison:

The third scenario is a bit like scenario one, only it takes a little longer, and we may eventually get to that new normal later on next year with the good news about vaccines. And I do think that the difference between scenario three and one is not only that it takes longer, but that some things will be different. And I do think in the long run, people are going to be more cautious about mobility, we’re not going to travel as much quite yet.

Ian Morrison:

Scenario four is like scenario two, it’s Biden administration with no money, right? Because one of the big overarching problems post-pandemic, is that the federal government is three trillion plus debt deficit, sorry, adding to the national debt with a cumulative debt over 100% of GNP, that’s not a terrific place to be.

Ian Morrison:

And so, this scenario was really around a willing administration without the ability to do anything. And that’s certainly true at the state level. I mean, I’ve been cruelly saying that people are defunding the police or the Senate, in the sense that there seems to be not much action in terms of bailing out particularly blue states at the state level.

Ian Morrison:

Scenario five, I have to credit my daughter who’s an epidemiologist by training and versus a consultant, but she lives in Seattle, and I asked her at the beginning of the pandemic what’s going to happen, and she said, “Well, they’re going to close it down, and then they’re going to open up again, and then they’re going to have to close it down again.” And she’s actually been dead on. That’s what’s gone on, not only here in the U.S, but in many parts of the world.

Ian Morrison:

And mercifully, it looks like we’re seeing scenario six, which science will save us, all of us I think hoped and prayed that we would have results from the massive investment in vaccines and in the science generally, and that the news of the last week or two has been very promising.

Ian Morrison:

However, I would say the converse of that scenario was scenario seven, which we didn’t even like to describe, which was civil unrest and no effect of virus. And I have to say, I think the next 60 days are going to look a bit like scenario seven, where we’re going to have people going to Thanksgiving, a third of whom say they’re going to meet as if it’s normal. And there is no vaccine in the arms of humans quite yet. And this false sense of security may compounded with 160 to 200,000 cases a day, will lead to a very ugly period over the next couple of months. I hope that’s not true, but I fear that it might be. Next please.

Ian Morrison:

And so, just in closing, I’ve been trying to think through what are the no matter whats of all of this. I do and I’ve always believed as many of my colleagues do that science will save us, we just don’t know when, and it looks like there may be hints of normalcy by the back end of next year.

Ian Morrison:

I actually believe that unemployment is still going to be down for some considerable time, and I’m not alone in that. I think the Federal Reserve believe that too. And I’ve gone out on a limb in saying that January 2020 was probably the all time high of private insurance in America. Because if you look forward, demographically the economy is good at generating low income jobs that require subsidy for insurance. And also, you’ve got this aging society where more and more are actively on Medicaid, Medicare sorry, and that potentially could have access to through policy changes.

Ian Morrison:

I think Medicaid coverage is likely to grow in any scenario. And that further as the virus has exposed the financial hydraulics of American healthcare and the overall dependency on procedure oriented fee-for-service surgical in particular, activity to make the math work for all providers.

Ian Morrison:

And I do think there’s going to be high anxiety amongst patients and families, not only about healthcare, but also about travel and other industries. If there’s a positive in the pandemic, it’s been the amazing speed and resilience people have used to pivot to digital activity, not only in health, but in all areas as evidenced by us gathering in this format. And I only hope that we don’t just pave the cow path as we futurist like to say, of just replacing visits with televisits, but rather use this moment to do a fundamental redesign of healthcare clinical processes and to enter, and be much more rich in their digital mix going forward.

Ian Morrison:

And one last slide I believe. Yeah. Thank you. I would hope, and you’re going to hear from our distinguished panel coming up. But I would hope that we take this moment in our history to pivot towards a longer term future that is more based on value-based payment models and principles, that we take this chance to redesign our care processes to embed more digital mix in telehealth and virtual care. And that we rethink and integrate better funding of public health, behavioral health, social services and healthcare going forward.

Ian Morrison:

I’ve long believed as people like George Halvorson have, that the end game for American healthcare might look like something on a bipartisan basis, that you might turn Medicare Advantage for all, supported tax finance, but having elements of competition, would be a unique American healthcare system. I think there is still a possibility of that, but certainly, in a polarized and divided country, it’s hard to see how that happens in the short run. But with the great leaders you have, Sarah, I think if anyone could pull it off, it’s America.

Sarah Dash:

Well, great. Thank you so much Ian, and that was a real tour de force of really a lot of insights. And so, I’m really excited, now we can get into a little bit of Q and A. I want to start with what you talked about here in terms of advocating for the opportunity to take a fundamental redesign of clinical processes. And I wanted to just acknowledge something about the pace of change. I mean, no matter what we think of this pandemic, the upheaval and pace the of change has been tremendous in terms of just like the rapid adoption of telehealth and those sorts of things. But at the same time, as you pointed out, the whole value agenda has crept along.

Sarah Dash:

Given the financial challenges that are facing providers right now, given the statistics you mentioned about, just the incredible wage gaps that we have, how that’s going to translate to coverage, and then how that’s going to then translate to the differential between public and private payment rates. I mean, how do providers, and I’m speaking very broadly here about providers, how do they take that stuff? What’s their incentive?

Ian Morrison:

Well, I think that’s a key question. I mean, since the pandemic has been raging, done a lot of advisory work with health systems and particularly large physician groups too. And what I would note is that those who had value-based payment models, whether they be capitated or in some kind of prepaid arrangement, I’m thinking of my friends at Kaiser obviously, but also folks like the Henry Ford Health System in Detroit who I worked with recently. I mean, those payment models prove resilient through the pandemic.

Ian Morrison:

But there is a counter trend where most American healthcare still predominantly playing the game I described at the beginning, right? On a fee-for-service basis. And what I also see, as my joke about, we’re not moving from volume to value, we’re moving from volume to volume, from inpatient volume to outpatient volume. And I have to say, I sit through these board retreats, and they’re celebrating massive increases in utilization when they occur, right? So, there is an addiction if you like, to that fee-for-service engine.

Ian Morrison:

But you mentioned another point, I think it’s critical. And I have been in actually, reverential all of the leaders of many of these large hospital and health systems across the country. The resilience that they have shown, and the speed and agility they have shown. I mean, I’ve been a critic of the industry for 30 years, and always teasing them that they move at this speed of glacial erosion normally, but they’ve actually, in many instances done 20 years of innovation in 20 days. It’s been really quite remarkable. And I just hope we can make that time clock of, hurry up offense a little bit more permanent in our health system.

Sarah Dash:

Yeah. And how do we take that? I just want to follow up on that point. 20 years of innovation in 20 days is pretty remarkable. What mechanisms are there? How do we learn from that? How does the health system translate that into something that sticks?

Ian Morrison:

Yeah, I think that’s the key thing. I mean, I did a panel with a number of CEOs just a few weeks ago, where all of them in their own way described that transformation resilience and stressed obviously, that part of it was building a culture of decision making that was much more rapid, that they hope to make permanent. But they also, I think these leaders who have been around a while, recognize that you can’t be constantly in panic mode. Battlefield medicine was what we were practicing in many parts of the country at the height of the pandemic, and presumably right now with some of our colleagues in the Midwest, and we feel for them.

Sarah Dash:

Yeah.

Ian Morrison:

But we can’t keep that pace up forever. And so, I think it’s balancing on the one hand a renewed sense of agility, and on the other not to stress or overstress your people and your organizations.

Sarah Dash:

Yeah. So, on that point, you mentioned as three of your mega trends, physician burnout, consumerism, and AI. And you even mentioned, you think AI has a really important role to play here. Is there some kind of coalition that, not a formal coalition, but I mean, is there a world in which the angry consumers that they want the more convenient care, the providers that are just exhausted, and the technology can come together and in some way help to advance our health goals in this country?

Ian Morrison:

I think that’s a very positive framing of what could happen. Here’s the challenge. Historically, healthcare has proven immune to technology improving productivity, right? If anything, technology has made it more expensive, not less expensive. And I think AI represents a real, and I’m not talking about replacing doctors, I described clinical AI as Hamburger Helper for doctors, it makes us scarce resource go farther, right? But that can enhance productivity dramatically. And where there are potentially massive improvements.

Ian Morrison:

Because remember, we have the most bureaucratic health system in the world, right? In terms of people in offices faxing things to each other. I think there can be dramatic improvement through AI in the administrative processes, both internally and throughout the health ecosystem, so that we don’t have armies of people doing revenue cycle for example. And I think that’s where we could see significant improvement in productivity in our institutions.

Sarah Dash:

Yeah.

Ian Morrison:

And you mentioned that the third piece which is, consumers looking for cheaper solutions, are maybe going to settle for chatbot services as a front end of primary care. And I’d watch for that, there are a number of entrants both domestically growing and entering from other parts of the world, who potentially should could revolutionize the economics of primary care using AI.

Sarah Dash:

Yeah, thanks. And you said something which we don’t hear a lot, which is fax machine. And maybe we just need to ban fax machines as a starting point and then-

Ian Morrison:

The fax machine should have been our business 30 years ago. So-

Sarah Dash:

[crosstalk 00:33:28].

Ian Morrison:

… they use mostly fax machines. They have to teach students in medical school how to use a fax machine, and none of them have ever seen one.

Sarah Dash:

That seems like a waste of time. So, I want to also ask you about the health inequity. I mean, you started off by talking about the income inequality, which has only worsened as a result of COVID and the way that the economy has turned. Obviously, we’ve seen these huge inequities. I mean, how do you think we’d begin to find our way out of that and towards a better future?

Ian Morrison:

Well, I mean, I can just give you one example. I’m proud to serve on the board of the Martin Luther King Hospital in Los Angeles, which came back from being closed in the early 2000s, for a bunch of reasons it was rebuilt and reformed and reborn, to serve the community. And I have to say, Elaine Batchlor, our CEO and the team have done a stunning job through the pandemic, in responding to COVID that we were probably 60% COVID at the height in July, and have weathered that storm, and even though there is a bit of a resurgence the last week or two, but I would say there’s that…

Ian Morrison:

MLK is an example of investment by federal state local government in providing a beacon of quality in an underserved community. And I think we need to think more imaginatively, like I believe we have a MLK on the leaders who created it, to find a new way to bring resources to underserved communities that lift them up and give them hope for the long run. I think it’s going to happen one community at a time, but we need a national policy that encourages them.

Sarah Dash:

Yeah, thank you. And I just want to do a couple more questions. I mean, one, you talked about Medicare Advantage for all as maybe being a very long-term end game. And we saw this in the debate, we saw that the Medicare for all model was was obviously roundly defeated in Democratic primaries, but we have such a discomfort still in this country, or we have just not settled around the proper role for public and private. And personally I think if we learn anything in COVID, it’s just like the importance of both sectors. I mean, you see it with the vaccine development, you see it with the efforts both on the ground with the public health departments and then with private sector efforts which we’re going to talk about a little bit on our next panel.

Sarah Dash:

I mean, how do you think the public sector and the private sector respectively, need to step up to meet this challenge?

Ian Morrison:

Right. Well, I mean, I think the great Bob Blendon would probably say that one of the distinguishing differentiation between the red and blue teams is their belief in the role of government, and the ability of government to pull stuff off. So, I think we are more divided than any other country I’ve lived in or studied in that measure. But the belief in government Canadians, I’m married to a Canadian, my son was born in Canada, I have a lot of family members in Canada. I would saying, Canadians are different from Americans, they described themselves as unarmed Americans with health insurance, right? But they believe in government more, and the power of government.

Ian Morrison:

That’s why I hope that we can find some common ground around something like Medicare Advantage for all because it concedes to the other side, that on the one hand, universality is important, and on the other a role for competition and the private sector has a legitimate role to play, and that those are ideological decisions that a divided country have just got to get over and find a way to work together.

Ian Morrison:

So, I think it can be. If you look at the Australian system for example, I believe that that might be a better model than thinking about Canada, where we’ve essentially got a base with where everyone’s in the same primary care system, we have the right to trade up with your own money, not to a different level of outcome, but to a little bit better amenity, and you get employers out the way and you make that a consumer choice.

Ian Morrison:

I think there are ways in which you could build what I’ve called the floors and ceilings model, where you have a basic floor below which no American falls, and the right to trade up to certain things when you don’t have money, provided those differences are not dramatic in terms of clinical outcomes or health services.

Sarah Dash:

Great, thanks. Well, just in closing, a third of the world’s new normal have come up various times over the last few months, and I know it’s a little hard to tell yet. Do you have any guesses as to what a new normal in healthcare could look like in the near term like next couple of years?

Ian Morrison:

Well, I was with the board of an insurance company just a couple of days ago, and one of the things that came up was one of the board members run a medical university that trained allied health professionals, and she was telling me that since the pandemic, there has been an explosion in interest of people wanting to get into the healthcare system, not as a moneymaker, but as a calling.

Ian Morrison:

I actually think that one of the things that we will reflect back on is what this has done to public attitudes towards caregivers, to the health professions. And in actual fact, I think while we’re going through this very difficult next three months, we will probably emerge on the other side celebrating our health system greatly, which will make it maybe a little bit more difficult to tamper with the game, if you like, from a policy point of view.

Ian Morrison:

But I do think the upside of the pandemic will be if we can use and harness the engine of innovation, and the speed and agility of reforming to change the way we deliver care, that’s more humane, that’s more equitable, and that’s more innovative, quite frankly, going forward. That would be a good new normal for us to achieve.

Sarah Dash:

Thank you Ian. Well, with huge gratitude to those who are on the frontlines caring for COVID patients, trying to prevent those cases, who are working in the labs to develop the vaccines and the tests and the treatments, we are grateful for that. And Ian, I’m grateful to you for spending the time with us at the Alliance today, to talk about what the future may hold.

Ian Morrison:

My pleasure. Thank you for having me.

Sarah Dash:

Thank you. And with that, don’t forget to join us for our next panel at noon.

 

Session 4 Transcript

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

Kate:

Hello and thank you for joining the final session of the Alliance’s 2020 Signature series, Post Election Symposium. I am Kate Sullivan Hare, Vice President of Policy and Communications at the Alliance for Health Policy. For listeners who are new to the Alliance, welcome we are a nonpartisan resource for the health policy community dedicated to advancing knowledge and understanding of health policy issues. In this final session, leaders from the ground will discuss the long-term vision for rebuilding the health system across a broad range of issues.

Kate:

I want to take a moment to thank our 2020 post-election symposium sponsors. We appreciate their support in making this summit happen and you can join today’s conversation on Twitter using the hashtag all health life and follow us at all health policy. We really want you to be active participants. So please get your questions ready. You should see a dashboard at the bottom of your screen with some icons. Use the two speech bubble icon labeled Q&A to submit questions you have for the panelists. At any time.

Kate:

We will collect these and address them during the broadcast. You can also use the Q&A icon to submit any technical issues you may be having. Finally check out our website, allhealthpolicy.org for symposium background materials, including speaker bios, resources lists and an experts list. Recordings of completed sessions will be made available there soon. Today, I am so pleased to be joined by an esteemed group of experts to have this conversation, I will direct you to their full bios on our website as I cannot do them justice over the time we have.

Kate:

First, we have Dr. Bob Kocher a partner at Venrock, where he focuses on healthcare, IT and services investments. He serves as an adjunct professor at Stanford University School of Medicine and a non-resident senior fellow and advisory board member at the Leonard D Schaeffer Center for Health Policy and Economics at USC. After Kocher previously served in the Obama administration as a special assistant to the president for healthcare and economic policy of the National Economic Council.

Kate:

Next I’m pleased to introduce Dr. Mark McClellan, the Robert J Margolis Professor of Business Medicine and Policy and founding director of the Duke-Margolis Center for Health Policy at Duke University. Previously, Dr. McClellan served as a senior fellow economic studies at the Brookings Institution where he is director of Healthcare Innovation and Value Initiatives. Dr. McClellan is the former administrator of CMS and former commissioner of the FDA.

Kate:

Next I would like to introduce Dr. Nirav Shah a senior scholar at Stanford University Clinical Excellence Research Center. Dr. Shah has previously served as Vice President and Chief Operating Officer for clinical operations for Kaiser Permanente at Southern California and as commissioner at the New York State Department of health. Finally, I am pleased to introduce KP Yelpaala. KP is the CEO and founder of Access Mobile International.

Kate:

Prior to founding Access Mobile in 2011, KP worked at Dopper Global Development Advisors and has served as one of the early employees of the Clinton Health Access initiative. He has taught at the University of Denver’s Josef Korbel’s School of International Studies and was appointed to and served on the governor of Colorado Small Business Council. Thank you all for joining us. Bob I’ll now turn it over to you.

Dr. Bob Kocher:

Thank you for having me. It’s a pleasure to be here and to talk with you. I’m looking forward to our conversation, when one thinks about COVID, there’s not a lot of silver linings that come to mind. Pretty much the worst pandemic you can imagine. But as I try to make lemonade out of it, there’s a couple of things that give me some hope and optimism. And I say this sitting in Palo Alto, in Silicon Valley, where I spent a lot of time with people trying to make the world better, it then sort of get us out of this mess.

Dr. Bob Kocher:

And, when I think about what triggers change in healthcare in America, you think about periods of glacial change, and then there’s these moments where things actually, really, spurts of innovation and what drives those moments in time, I think, are the alignment of incentives and then usually breakthroughs in technology and new information that allows people to see arbitragers that you couldn’t see before.

Dr. Bob Kocher:

With COVID-19, you couldn’t possibly have a stronger alignment of incentives to get us out of this pandemic fiasco and we’re benefiting from amazing types of technology, whether it’s new at-home testing, mobile phones, big data but more information that you can actually combine with the incentives. And so, we have a perfect moment to innovate our way out. We have a couple of other things going for us. We have now every single American, every single day wakes up and thinks about public health and NPIs and safety and vaccinations and [inaudible 00:05:12].

Dr. Bob Kocher:

And so we have a society that couldn’t possibly be more about public health and how to improve it. And so those conditions, I believe will create a set of opportunities, which will be helpful. And we’ll compress a bunch of innovation that would have taken decades into literally months. The first one is public health. And so we will see bi-partisan support for investments in public health like we haven’t seen for maybe a hundred years to recreate a public health care system.

Dr. Bob Kocher:

What we’ve observed is that the kind of this digital leftover public health system from the efforts of [MAC 00:05:47] vaccinations in the 40s, 50s, 60s, that hasn’t been sort of up to the challenge, for COVID-19 both, protections and then hopefully the scene of a vaccine. And so you’re going to see the private sector jump in. I believe that the night is a public health is going to become schools because we all, if you have, if we have kids, we couldn’t be more motivated to having to go back to schools.

Dr. Bob Kocher:

Not only because they weren’t more in schools, but because your mental health improves, if they go back to schools. So schools will be a place that will become focuses the public health and safety and prevention, employers won’t badly want to have their businesses behave more normally. And there’s a lot of circumstances where having people work together, actually creates more innovation and speeds decision-making and is valuable as the employers will become stewards of public health.

Dr. Bob Kocher:

And then health systems, and most communities will be kind of the organizing forces between for public health, because they will have both the clinicians who can deliver public health, the systems to track it and the freezers just run the vaccines in the end to do the medicines. And so I think you’re going to see public health become central to each of these large parts of every community. And you’re going to have public health departments the counties actually be the people that actually are the chief financial officers.

Dr. Bob Kocher:

They will do the counting, accounting, hold people accountable, do the reporting, and then they will use their resources to go fill the gaps. And where are the gaps going to be? There’ll be in nursing homes, which we’ve seen, have struggled. There’ll be in prisons for sure. There’ll be homeless communities. And there’ll be among the under health care served areas of the community. So they will go be the [inaudible 00:07:22], I believe.

Dr. Bob Kocher:

The second big thing that’s going to emerge is they have to coordinate all this is going to be open data and data sharing. And that’s the two conditions can give incentives and information. We will have, I think, much more interoperability of data and data sharing and access to data because of COVID-19. That we’ve ever had before. This might be the thing that leads to interoperability, the long hope for connections of EHRs. Why would that happen? Well, everyone’s going to need to show their COVID test results to do a lot of things for quite a long time.

Dr. Bob Kocher:

And you’re going to get those tests in all kinds of places. So having ways to share that data is important, but even more important for vaccinations, you’ll probably need two doses of a shot. You need to prove you’ve gotten those two doses. You need to prove that you’ve been vaccinated to do many things. Whether it’s go to soul cycle or go to your office, or certainly go travel. And so you’ll need data-sharing to make that work. And people will want to be doing testing and giving vaccinations because it will profitable and somebody exchange they’ll need to connect their computers to the system to share that data.

Dr. Bob Kocher:

The third thing is and I see this daily is tremendous interest in creating companies to help do this. We have the benefit of many years of successful technology, product creation, consumer product company formation and great alumni and CEOs who now want to come work on the most important problem in society, which is public health and COVID-19. And so we have a great deal of talent and the capital coming to create companies to do all the things I just said. And so you’re going to see continued creativity and successes in virtual healthcare of all kinds, whether it’s primary care or special-need care.

Dr. Bob Kocher:

Lots more access to behavioral health which is terrific because we all need it. And that’s the one area in healthcare that we’ve underserved people. You’ll see a lots of creativity in how to work. So we’ll have smaller offices on the edge of cities where you can go have quiet places to work and watch that bandwidth, but not sort of a large open Facebook style offices, I think in the future and a new set of office rules around, “Don’t come if you’re sick.” And so, for many years before COVID, it’d be a badge of honor to go to work when you have a curvature of 101.

Dr. Bob Kocher:

That will no longer be okay. And so there’ll be a lot more work-from-home type setups and a lot more interesting safety and hygiene and keeping us. So I think that these are some of the things we can look forward to. And I think together the incentives and information will help us have the most successful vaccination program we’ve ever had at getting people vaccinated that people will want to do it, that they’ll feel confident. And that actually we’ll all realize that it’s in our interest to kind of play along, with public health measures, because if we do that, we’ll all be better off. So thank you for the chance to kick us off. I look forward to the comments from the other folks.

Dr. Mark McClellan:

Great. Kate, terrific to be with you and the Alliance, always enjoy these events and the Alliance plays a critical role in helping to get out good ideas. Especially long-term ideas like Bob was just talking about that are very relevant for policy. I also really like working with Bob because he’s such an optimist and I really want to believe what he said about, we’re going to get to this brighter future, thanks to what we’ve learned here.

Dr. Mark McClellan:

But then I look at where we are today and we definitely have a ways to go. And what I’d like to focus on in my comments is sort of the from here to there, with the policy steps that are really critical, I think in the weeks ahead to help us get there from a situation to more now with a million new cases per week of COVID with hospitals in many parts of the country, full or bursting. And with the potential for a thousands more deaths is a lot. And a lot more closures and economic disruption in the short term.

Dr. Mark McClellan:

And I know there’s a congressional interest on both sides of the aisle after divisive election, and it can be hard to come together to take some steps to get there. But, as Bob said, there are good reasons for doing so. And I just wanted to highlight a few things that can help get us from here to there in terms of COVID 19 response with an emphasis on a resilient healthcare system, economy, that can be better prepared not only to be productive and more equitable, but also to prevent something like this from ever happening again. First off in the short run, we obviously need some mitigation measures, to step up.

Dr. Mark McClellan:

We’ve always known that heading into winter was going to be the toughest time for the virus. We’re seeing a lot of closures, and as I mentioned, hospitalizations around the country. We know some additional steps that could help here, whether it’s additional use of mass, including mass mandates, additional distancing measures that could be pegged to local situations on the ground, not a national lockdown and they are likely going to require some additional impacts on business and it’s better to do that predictably than have to go to a sort of full lockdown mode, like many European countries are doing and some parts of the country, not that far away of all the way from now.

Dr. Mark McClellan:

That does mean some congressional action on something like a paycheck production program. Again, some financial relief for the affected businesses to get through this immediate period would be really helpful. But beyond that, it looks good. I mean, the news on vaccines really couldn’t be better and we should have a vaccination starting a month from now based on the results from Pfizer and Moderna. I think there are good reasons to believe that especially given the fact that the other vaccines coming later based on similar kinds of targets, the spike protein on the virus and they’ve had similar kinds of preliminary results showing good antibody responses, good immune responses that they may well be effective too.

Dr. Mark McClellan:

And so that means the distribution, public education engagement around vaccination is really important in the weeks ahead too. And there’s a lot of infrastructure already in place. Thanks to operation works feed, lots of potential vaccine availability. But as Bob said we do still have some challenges. Many of those are information technology-related getting a vaccine, a registry system in place that can deal with multiple vaccines, multiple doses people, maybe being in different places when they get them connecting all the States and territories.

Dr. Mark McClellan:

So that’s some hard work. And then just the engagement with states and local officials in helping not only get vaccines to where they’re needed and good administration programs, but also the public awareness of what the data on the vaccines actually show after all they’ve heard this past year, what the actual facts are, and ways to help them get vaccines they need. Especially in underserved areas. There’s still some few issues to work out around making sure that, this could be done without copays that there were pop-up centers or whatever it takes to serve.

Dr. Mark McClellan:

To get the vaccines out to all Americans. Building on that could help rejuvenate a public health system, especially if we can use same data systems to do a better job of tracking or do a good job of tracking what actually happens to the tens of millions of people. We’re going to start getting vaccinated in the days ahead. But I do want to emphasize that this is likely to be a gradual process. So two shots, couple of months before people even get the vaccine, before they have a significant level of immunity.

Dr. Mark McClellan:

And then it’s going to be a gradual process for that growing number of individuals to have an impact on just how rapidly COVID is spreading in the country. So in the meantime, we do need to continue these other measures that get us to economic recovery and more capacity for reopening as soon as possible, but it is going to be gradual and we’re going to still need mass and distancing for a while. And helping to build more of a public sense of participation, behind these important steps that we all need to keep taking together, even as we’re getting closer to the end of this.

Dr. Mark McClellan:

I really do think this is the last big, acute surge in cases that we’ll hopefully ever see, from COVID-19 in this country. But it is going to get worse over the coming weeks before it gets better, especially if we don’t together take those further steps. There’s some other important policy steps that can help us get to a Bob’s future that we can take in the near term.

Dr. Mark McClellan:

One of those, is building out our capacity around delivering the therapies that work. so, up until recently, what you told people, if they were diagnosed with COVID, you can get a test, tell us about your contacts and isolate. Stay at home. Don’t go anywhere near healthcare, unless you’re really sick and need to be hospitalized because our hospitals are being hit so hard, especially now.

Dr. Mark McClellan:

Well now with the monoclonal antibody treatments available at work, kind of manmade versions of the, same response that’s making these vaccines effective, the antibodies that neutralize the virus, first one’s been approved by FDA from Lilly and another one, probably coming soon, several more in the works, the supplies limited, but when given early to people who are in high-risk groups, not late, you got to do it before, but the infection and the immune systems for the individuals gets out of control.

Dr. Mark McClellan:

And we see all those big complications in the hospital, but we can get those people treated early back in significantly reduce deaths, hospitalizations and the burden on the healthcare system as well. The problem is we don’t have a healthcare system set up to do that. You need special infusion sites just for COVID patients. Even though you usual patients who get infusions are cancer patients or people with other serious illnesses, these will be people who are not feeling less in the way of symptoms need to get treated early, in a place that’s not going to spread the virus.

Dr. Mark McClellan:

And we’re just now thinking about and starting to set up the systems for doing that is going to take some new payment approaches and some really thoughtful ways of distributing the limited supply of antibody in hand, would add to that as well. Some opportunities for doing a lot better with testing, to help contain outbreaks, where you have had a big increase in testing capacity in the labs, the diagnostic tests of what people should be getting if they’ve got symptoms. And we want to make sure, whether or not they have COVID for isolation purposes and now really important for treatment purposes, as well.

Dr. Mark McClellan:

But we’ve also seen a lot of growth in so-called point of care screening tests. The antigen tests that are not quite as sensitive but can get results back in 15, 20 minutes, that costs much less. There is a first fully home use test approved by FDA just yesterday. So the capacity of these tests is really increasing and they can be used to make opening safer. There was a CDC report on what we’ve done here at Duke in terms of a regular screening protocol along with distancing and mass and other managers that has really helped us avoid any significant outbreaks and spread on campus.

Dr. Mark McClellan:

It’s actually helped our students maintaining much lower rate of COVID infections than what we’re seeing in the regular community. And Bob made the important point about reopening schools which is incredibly important and could be done, with some good sharing of knowledge about steps that districts that are opening are taking how to avoid transmission of cases. Cases do occur if you’re opening a school. People do have COVID. The important thing is, can you prevent those cases from spreading in schools? Can you detect them early and just like we did at Duke, can you get the rate of infection down in the students, the population affected below what it would be if they were just out in the community without any good control systems in place.

Dr. Mark McClellan:

And regular repeat testing is starting to be used by a number of schools, for their faculty, for students, New York City is piloting some version of LA School District. With the Rockefeller Foundation, we’re working with many more, we do need some federal support for this. Some additional federal funding and some further guidance from CDC, looking at what the best practices are for making testing a key part of getting us to faster, broader reopening sin.

Dr. Mark McClellan:

And then just one more point case already go on for a few minutes, but, Bob talked about a more innovative healthcare system. One thing that we’ve seen in this COVID response is that our healthcare system is really not supported in a way that helps it respond quickly and focus on what’s best for patients. Instead with most places in the US, hospitals and physicians paid on a fee for service basis when we needed them the most in the spring, what happened was their revenues fell through the floor.

Dr. Mark McClellan:

There was some fast help from CMS and from private insurers to shore up, tele-health visits and things like that. But I want to contrast that with organizations, some of which Bob works with and I think, PML works with as well that have built in things like tele-health, remote monitoring, team-based community approaches to care into their basic business models. They generally have to be paid differently not on a traditional fee for service basis, but more on a person basis, like in Medicare advantage or in like an advanced accountable care organization.

Dr. Mark McClellan:

Those organizations we’ve done studies now did much better. They were financially stable coming through the first part of this crisis. They didn’t need big enough federal bailouts. They already had tele-health and home-based programs in place. And that kind of longitudinal data, capability that Bob was talking about to track patients, identify the high-risk patients and provide care for them at home, even if they had advanced conditions like cancer or otherwise, they’ve been able to do more to address social factors, influencing outcomes.

Dr. Mark McClellan:

I hope that in any further relief that we provide healthcare providers, as part of getting out of this public health emergency and the healthcare providers deserve it, not just the hospitals, but primary care groups and others have been hit even harder that it’s done in a form that doesn’t go back to the old normal, which was fragmented and expensive and real problems with access and did not work well with this pandemic, but instead to support moving them into new approaches to payment and care delivery, which is much more consistent with what Bob was talking about is what healthcare should look like in the future.

Dr. Mark McClellan:

But that’s gotta be a sort of a conscious policy choice that we really want to move in our policy responses to the pandemic, to relief and rebuilding in a way that’s better than it was before that helps more providers move away from fee for service and into more robust and resilient innovative care delivery models.

Kate:

That was really fascinating. And now I’m going to turn it over to Nirav.

Dr. Nirav Shah:

Well, thank you, Kate. It’s great to be here. I thought I’d spend a few minutes talking about technology and the Unified American approach. So, we all know that nature abhors a vacuum and that leadership is never more apparent than when it’s missing. And in the absence of federal leadership, the private sector actually has stepped up to the degree they can. When would you imagine a world where Apple and Google would work together to create an open source exposure notification system now being promoted by the Linux Foundation across the world and being used in many countries to great effect.

Dr. Nirav Shah:

COVID Act now is a group of technologists who started up and volunteer to create the only County level data available across the United States. So the counties can understand how they’re doing in real-time. Kinsa is a private company that’s distributed 2 million smart thermometers across the country and provides an up to three week early warning system for COVID hotspots where nothing else does work. We know hospital cases is too late. We know that cases of COVID are too slow, to understand hotspots, but this system exists today.

Dr. Nirav Shah:

So technology can do a lot, but the message with technology is that it’s about cooperation, not competition. And when we’ve seen the great advances, it’s because vaccine companies have been working with governments, working with scientists in an open nature, not just open source, open data, but open science broadly. And so I think that’s been one of the positive messages we’ve seen coming out of this pandemic. We really urgently need a unified national approach. How can we justify morally and on many other levels, keeping bars open and closing schools.

Dr. Nirav Shah:

This has to change in the near future, but won’t change soon enough. Other countries have figured it out and they’ve kept their economies open because they have a Unified National Approach. Taiwan has done quarantine very well. South Korea has done testing very well. Japan has done their masks and hygiene pretty well. New Zealand has the advantages of being an Island, but, they’ve eradicated COVID. No one has been successful with a herd immunity approach, which is just letting the virus run wild.

Dr. Nirav Shah:

Even Vietnam, a developing nation by any measure has done much better than the US and it’s because of strong federal leadership that allows for a single plan that everyone follows. You don’t need a silver bullet. You don’t need just one thing. We can do several things well enough and get this virus under control. And it has to start by renewing our trust in science. I’m glad that most people today trust Dr. Fowchee. That’s a very good thing, but if we want to get past this, vaccine acceptance will be really important. So let me end by asking an important question, how long a COVID tale do Americans want to tolerate?

Kate:

Thank you very much. That is quite a question to ponder and I would like to turn it over now to KP.

KP Yelpaala:

Great. Thanks. Lots of great points made. So I want to hone in kind of building on these themes on health inequity. And the thing that’s clear with COVID-19 is that the virus has thrived on vulnerabilities in this country driven by economic, racial and social inequity. That is where COVID morbidity is. That is where COVID mortality is. And so I just want to make a few points briefly about our observations on the digital divide. So there’s been a huge concern of digital health innovation because of COVID.

KP Yelpaala:

But because of what we’ve just described, the challenges that a lot of these innovations and these digital tools are not reaching the populations most vulnerable. And so on the one hand, we have to consider that in our response. And then what’s the relationship with those populations with the health system, with the private sector, with schools? I mean, I think that this is going to have an impact not just for COVID testing, but for vaccinations.

KP Yelpaala:

So there’s a lot of conversation about things that is digital front door tools or ease the pathway for people that are not operating accessing healthcare through a digital domain into that space. This has a unique lens for vulnerable populations. On the urban side, just where we kind of have some stats. If you look at, African-American population, in 2014, about 20% of that population accessed internet only through a mobile phone. So they were not broadband enabled or not on desktops.

KP Yelpaala:

That number I know is higher now, and that trend similarly for the LatinX. So the ability of healthcare to be mobile first is key. The cost of broadband in urban areas for underserved populations is high, and a lot of people are not able to afford it. In rural areas, there have been some initiatives with the FCC and the Rural Broadband Commission to expand access. But I think that this domain of space in terms of connectivity, cost, is a significant opportunity for bi-partisan, arrangements that collaborate between public and private sector and at a federal and state level.

KP Yelpaala:

I want to talk a little bit also about public private partnerships and social capital. So as we think about who responds and why, it’s clear that when it comes to, for example, certain LatinX or African-American populations, this is lack of trust with certain institutions they’ve in some cases had a poor experience interacting with healthcare and specifically this whole system. So our ability to engage and to get them pulled into the system, particularly those developing digital health innovations is key. And we’re looking at some data here in Colorado, this is anecdotal or looking at some data on frontline workers here in the state, and those that have access to free testing.

KP Yelpaala:

And what we’re finding is those who identified as white are more than two times likely to have multiple COVID tests compared to the African-American segment. And at the same time that African-American segment where free testing is available and accessible, they are the most likely to not have even had one test. So this is what we’re seeing. This is anecdotal, we’re actually unpacking this data but let’s just think about that for a second and what that means as we move through the chain, the vaccinations. So my third point is really about also how the public and private sector interact.

KP Yelpaala:

And I think it’s not just about big tech, big companies, but it’s also about small companies and small tech. And if we think about groups embedded in communities that have trust, and that look to certain institutions for information, that’s where we’re going to get the most responsiveness and the opportunity to engage. So this means we have to be more nuanced and trying to understand the reasons why certain pockets of populations don’t engage, whether it’s testing or vaccinations.

KP Yelpaala:

And then I think as we unpack that, you find, for example, with contact-tracing, someone may be more likely to sign up for contact-tracing with their barber. As I do, when I go with my son to the barbershop, than with a big company. If the state government comes and says, “We’ve got contact tracing with Apple and Google.” People might be less likely to opt into that, than contact tracing at their local restaurant. So I think even how big tech, small tech and community boards interact, there’s a lot of opportunity to set the infrastructure now so that we can mobilize people’s behaviors into those pockets that get us enough people vaccinated to get to that herd immunity.

KP Yelpaala:

So those are just a few things where I think we can unpack more later, but health inequities and our ability to make sure that everybody accesses these digital innovations, that everybody is engaged. And then ultimately the behaviors that we want from a public health perspective, we can see those in those populations most impacted is I think the heart of the issue.

Dr. Mark McClellan:

[inaudible 00:32:02] our moderators. So, we might need to continue this conversation, briefly, on our own. And if I could just pick up on a point that KP mentioned about the need for a broad band is one key component of addressing the really large health inequities that we’ve seen so far. I’m actually worried that those may get worse. And that may be one of the longterm concerning legacies from, this pandemic that even at a time when this country is really trying to come to terms with some issues around equity in general.

Dr. Bob Kocher:

And I would add then, as we think about vaccination, we as a country struggled to get 40 million flu shots that a year and to achieve populational level immunity, we’re going to have to get two shots and probably 150 million people. So when you think about access and inequity, well, every academic medical center and big health system has a great refrigerator to handle ultra cold storage vaccine and places to get vaccinations, but where we needed was actually in the underserved areas, the more rural parts of the country, and how will we do that?

Dr. Bob Kocher:

We need a different workforce. Actually, I want the barber to give the vaccination to you next time you come into the store. So I want to have a way to use that person to do it by watching a one-hour training course, I’d be able to pick up the supplies at the local post office and be able to do that at scale, how will we track the data, but we’ll need some sort of data sharing mobile application that maybe Linux makes that can easily enter in that data so that it doesn’t matter where you got to get that shot.

Dr. Bob Kocher:

And so I think that’s the public private partnership style that we need to be thinking about if we’re going to achieve a goal, which I think we should have of getting the country to be vaccinated by Labor Day, probably next year. So school is going to open. Because if it takes the normal pace of doing public health and vaccinating people we have another year and a half getting this vaccine rolled out. And that’s just way too long. And so that’s why I like to have the Biden Administration and [barbers 00:34:09] come together and figure this out.

Dr. Mark McClellan:

I remember that it’s even a shorter issue than that. In that, so far the inequities that have arisen are primary because of differences in exposure, differences in access to testing, to prevent outbreaks. It hasn’t really been on the therapeutic side yet, but as Bob just talked about, there’s a real risk that could emerge with vaccine availability and uptake becoming uneven, even in the shorter term.

Dr. Mark McClellan:

I do want to highlight this point about antibody treatments, which are available now but require outreach to let people know that if it’s not just a matter of having symptoms, but getting tested when you’re not very sick, especially if you’re in a high-risk group, because this treatment, which could really reduce your risk of going in the hospital or having serious complications needs to be given, sooner rather than later and definitely before your COVID progresses.

Dr. Mark McClellan:

And that’s sort of the opposite message that we’ve been giving people and for people who are not very well connected to the health system anyway and don’t have a whole lot of trust, this is an even bigger issue. So unless we take some steps right now around access to, the monoclonal antibodies and hopefully build on that. Hopefully will get to barbers giving vaccines. I hadn’t heard that one before, but that’s a nice goal.

Dr. Mark McClellan:

But, hopefully we can build on some short-term steps to get there, but these are really urgent challenges that need to be addressed right now, or this barriers that we’re seeing are going to extend not only from differences in rates and the impact of differences in co-morbidities, but now to differences in availability and use of treatments that really work.

KP Yelpaala:

Can I just build on Bob’s point and Mark’s point where I think that’s spot on. What we’ve been working on here in Colorado and Georgia is what we’re calling this connected community of care model and what we’ve been trying to do, for example, in Colorado, we partnered with COVIDCheck Colorado, which is the largest statewide testing initiative. It does schools. So there are more than 24 school districts. Now, the state is tapped them to support community testing, leveraging those schools as anchor institutions and then doing outreach into the community.

KP Yelpaala:

But then we’re also partnering with churches, barbershops other community organizations now but the hope is we can build a model for popup testing in the community and those relationships through trusted parties, so that when the vaccination comes, to your point, Bob, then the barbershop, the church, all these stakeholders become part of the fabric of mobilizing the community. It can’t just be an opt-in model. We just put up something and say, “Come if you will.” Right? So I think, I just wanted to add that. I think some great points we’re doing similar stuff in Georgia as well.

Kate:

[crosstalk 00:37:03] that’s a great point. Go ahead.

Dr. Nirav Shah:

Let me just add a little nuance to what KP said, which might’ve been missed. There is a digital divide in this country, but when you look at broadband use, the divide is big. When you look at mobile use, the divide is actually very small. 2019 Pew Surveys showed that 79% of African-Americans, 80% of LatinX and 82% of white families across America had access to a smartphone, with a mobile plan in the household. So if you go mobile first with some of our approaches, we can actually bridge that digital divide.

KP Yelpaala:

Exactly.

Kate:

Thank you. I’d like to ask, what are the key intersections that happened between the economy, the financial markets and healthcare, both positive and negative. How can policy makers support positive collaborations and limit these negative intersections?

Dr. Mark McClellan:

I think, just one comment where financial support has been really important. And then I’ll turn it over to here from our Silicon Valley of people. This is a time when there’s actually a lot of investment going on in healthcare despite how tough the economy looks and it comes to diagnostics or companies going public with new, kind of capabilities to diagnose health problems earlier and more accurately, or companies that are involved in new models of care along the lines.

Dr. Mark McClellan:

And we’re hearing about from KP and Nirav. It’s almost like this big recession isn’t happening, given the amount of investment taking place. What I hope policy can do to get us from where we are now to that future that Bob and Nirav and KP have described, and some warnings about is really providing some more clear signals that we don’t want to go back to healthcare as usual. And just a few examples of this would be, signals for bigger investments in better more convenient, point of care, testing technologies, diagnostic technology.

Dr. Mark McClellan:

So we did that for vaccines, it worked, we got to have much bigger supply of vaccines, coming online soon. If we did the same thing for testing, we could fill in some of the gaps that many of the underserved communities are facing now and being able to diagnose some patients early get them into treatment, but increasingly to prevent the kind of asymptomatic spread that has been so rampant in many lower income communities and essential workplaces.

Dr. Mark McClellan:

We have the technology, we just haven’t deployed it at scale and really brought the private sector investment, to their clear signals from the Federal Government would help with that. And I think also clear signals from the Federal Government that we don’t want to just bail out, hospitals and other providers, but we want to rebuild better. We want to support healthcare organizations that develop exactly these kinds of capabilities to get out in the community, to use broadband effectively.

Dr. Mark McClellan:

That means, I think, a different kind of payment for healthcare. And we’re seeing this happen in the private sector now. Health plans like Blue Cross of North Carolina have set up, their version of a COVID relief program for their primary care practices is to give them some upfront funding now to sustain their practices to invest in exactly the kinds of things we’ve been talking about sustainable ways of delivering care at home, the data sharing with public health and the practices also make a commitment to move into a medical home or ACO models over time to where they’re not going to be paid in the future, just based on fee for service.

Dr. Mark McClellan:

They’re going to be more resilient if there is another downturn caused by a public health emergency, but they’ve also got more flexibility to put more resources into these new Care Models. And that in turn is going to bring in a lot more of the private sector investment that Nirav and Bob and KP have been talking about.

Dr. Nirav Shah:

So, Mark, I think we’re at risk of wasting a good crisis, right? We did more with one month of COVID than 10 years of payment reform did to get rid of unnecessary care. And what we’re seeing is for example, a large health system in upstate New York went to 80% tele-health visits for primary care, which is what everyone wanted. But today they’re back at 12% tele-health visits, not because patients don’t want to do tele-health it’s because of the additional revenue that the system currently creates for in-person visits.

Dr. Nirav Shah:

When you’re seeing your cardiologist in a clinical visit, they pull out their portable ultrasound and add another a hundred dollars to your visit, right? That’s the reality of today’s payment mechanisms. And if we don’t lock these gains in, I think we will go backwards much faster than we had thought possible.

Dr. Bob Kocher:

All right. So we’ve already given up on the gains. This [inaudible 00:42:25] from yesterday creating a pattern. And what you can see is that we just got out of necessary care for a couple months and actually, care’s above pre-COVID levels because we know from Fee-for-service that, people do more even care to keep their revenue where it needs to be. And we’re seeing that. Which is why Mark’s payment reform comments are fundamental.

Dr. Bob Kocher:

We’re going to work our way out of it. I do think also from an innovation perspective, CMS and where they can figure out that they plan to keep telemedicine, reimbursement, in the program, because right now it’s only authorized and it’s part of the emergency. That would be a terrific thing to do. And then another thing that’s been very helpful for the testing world is to have the government say that your lab will be a network and you can get reimbursed.

Dr. Bob Kocher:

And so all of these new tests have had the benefit that they’re able to get reimbursement quickly and not go through the many month process of credentialing and plan appointment and negotiating rates. And so that the public policy folks should work to make sure there’s not fraud, waste and abuse and egregious charges, but this sort of access to the markets than super important to bring particularly testing innovation to the market, but also telemedicine.

Kate:

I’d like to go to a question from the audience. Next week, when we’re having our Zoom Thanksgiving dinners and Uncle Fred pipes in from across the computer monitor across the dining room, he says that he’s bristling about the steps needed to gain more control over the virus. And he brings up Sweden as an example of a country that has banked more on herd immunity and less on public health requirements in populations. Have any of you studied this and what is the response to that assertion?

Dr. Nirav Shah:

Sorry, Uncle Fred you’re wrong. Herd immunity has never worked. It will not work with COVID. We have already seen documented cases of reinfection in people who’ve had one slightly different strain of COVID and then another strain to date. Published in the literature in Pew reviewed medicine, literature in the US already. So a herd immunity strategy alone will fail miserably it’ll result in more deaths of the most vulnerable people who are in nursing homes, where we’re seeing already half the deaths in America are in long-term care in nursing homes, underserved minorities represent half the deaths. These are the kinds of people who will suffer with a herd immunity approach.

Dr. Bob Kocher:

If uncle Fred were wanting to have a thoughtful conversation, the thing you have to figure out is how do you protect the people who are vulnerable? And the reason that’s impossible is we don’t know who’s actually vulnerable. We know that age is a risk factor, but there’s a whole lot of people who are not aging in nursing homes who get sick and die and have long-term complications. And as Nirav points out, there’s also reinfection.

Dr. Bob Kocher:

And so sure if you could perfectly split the population and put it on an Island in New Zealand, all of the people who are at high risk and keep all the healthy people who will not have similar symptoms here, maybe you could do it, but we have no way today upfront to figure out what your risk status is. And so it’s just a chance that we’re taking, if you just say old people, well, there’s a whole lot of people will be harmed by that.

Dr. Bob Kocher:

We also don’t have a public health system that’s great at keeping you safe, for a year and a half if you can keep contact and keeping you sane. And so if we had a system that had great mental health care and food service and housing security and income security, perhaps you could consider it, but we don’t have that set up anywhere in the country.

Kate:

Great. Well, Uncle Fred has that have your arguments to counter Uncle Fred? Another question we had from the audience is how should policymakers deal with the growing financial pressure on government programs? We have the nearing bankruptcy of the Medicare hospital fund, deficits over 100% of the US economy. How can we address those concerns while addressing demands to finance, defeating the current pandemic and preparing for future ones?

Dr. Bob Kocher:

We should ignore those fiscal concerns for a while. The cost of capital is very low. We need to stimulate the economy, protect jobs and invest in public health. And so in the future, we can think about what to do, but in the meantime, we should try to protect our GDP because we keep our economy alive and get out of COVID sooner, we’ll be able to grow. And that’s the best way to manage steps that is to grow the economy. And so, the Republicans had no trouble spending money prior to COVID and during COVID to stimulate the economy, we should continue that path to try to actually invest in the economy and infrastructure. And then we will have to deal with this, but not now.

Dr. Mark McClellan:

Just that to add to that, I mean, it is impressive how low long-term interest rates, continue to be. But, as Bob said, it does mean that we need to have some investments now to get to economic recovery faster. It doesn’t mean spending lots of money on everything and to I think a recurrent theme in this discussion today is how you spend the money for recovery matters. It’s one thing to spend money to provide assistance to hospitals and health systems that have been disrupted.

Dr. Mark McClellan:

But if it’s done in a way that simply encourages them to go on with that excellent graphic, I guess. That Bob flashed up on the screen for a minute and then going back to where we were, as opposed to building the kind of healthcare system that we need for a more productive healthcare for a healthier, more equitable population, that’s what’s really going to lead to long-term economic growth. And you get several of, you said there is kind of a silver lining here in terms of an opportunity to do this better.

Dr. Mark McClellan:

And I hope we can find some bipartisan ways to do that. That would be the best way to reduce the deficits for the longterm and hopefully to get us to the real cause of the long-term deficits is our healthcare is really expensive and really inefficient. So we’ve got a chance to do something about that now, even as we’re making more investments to get out of the pandemic.

Dr. Nirav Shah:

[crosstalk 00:48:44]. And that marked point it’s going upstream, right? We’ve paid the downstream, hospitals. We haven’t actually made those investments in public health that we all believe should happen today. Today, millions of faxes are being received by Local Public Health that need to be transcribed into other systems to actually understand how COVID is moving across our society. That’s today. So as much as we’d like to think, we all agree that public health should be invested in, it hasn’t happened. We haven’t moved upstream in many other areas in our economy as well. And that’s the opportunity to think differently about how do we build back better.

KP Yelpaala:

[crosstalk 00:49:25]. And also, I just want to add, let’s not forget that small business is such a key driver of the economy of country that we can’t abstract what this growth means from a big business versus a small business perspective. And right now it’s small businesses that have been hammered and unfortunately many of them are not going to come out of COVID and they will not reopen. And so this conversation also needs to consider small business how people that run small businesses access care, insurance, so on and so forth. And that’s going to be also a major issue in my view.

Kate:

I’m curious to know your thoughts from our previous session with Ian Morrison, about employer sponsored insurance and whether it should continue or whether we should be trying other mechanisms to cover Americans given the very dramatic loss of health coverage with people losing their jobs this spring. Well, should we be trying these other mechanisms to cover Americans?

Dr. Bob Kocher:

I’ll take that. First of all, this is an interesting recession because in the great recession, when people lost their jobs, we ended up having 50 million people uninsured. And that’s what led to the affordable Care Act in this recession. We’ve lost more jobs. We currently have a $10 million job or 10 million [inaudible 00:50:48]. And we haven’t had that many people become uninsured because we have access to the individual market to subsidized insurance.

Dr. Bob Kocher:

And so people can’t access insurance at an affordable price today and private markets. We have Medicaid expansions in most states, so people can get access to Medicaid. I was talking to one of our gyms, from California this morning. And they said that actually, that may have helped a record number of people apply and get Medicaid, this year across the country. Because of the availability of it in this recession.

Dr. Bob Kocher:

We have a medical program with Medicaid marriage options. And so we have a hybrid market that actually is working quite well and disrupting it is both unpopular and unnecessary. I think we should do a lot to make sure that Medicaid is available in the states that haven’t expanded it. We could do more to make the subsidies greater. So people in the individual market can afford insurance, but actually getting rid of the whole thing as a silly idea and a federalized spending in a bunch of ways, but probably isn’t necessary.

Dr. Bob Kocher:

And there’s no evidence that it would make the healthcare system more innovative. We’re able to create payment models like Mark described perfectly fine in the current system and we know how it works. And so I think that it’s sort of a fool’s errand to go try to redo all the way we finance health insurance. We should be working on set on how to use this crisis for benefits. So let’s make sure we get payment reform. Let’s keep independent primary care doctors independent. Let’s create data operability, let’s get public health to be bolstered. Let’s not screw around with how we finance insurance.

Dr. Nirav Shah:

Every health plan in America has as part of its strategy right now to grow government business. Many are saying Medicare advantage specifically, but they’re also talking more broadly because know the Robin Hood approach of using commercial rates to overpay and make up losses on government business is not a viable long-term strategy. So I think that whatever the approach will be, we know what the strategies today are for every health plan in America, and that is to grow government business. And they’re competing head to head on that.

Kate:

Terrific, well, we are approaching the end of our time. So I just wanted to ask each of our panelists, if you have any final thoughts that you want to leave with us before we close.

Dr. Mark McClellan:

Maybe I can start with just a comment about, we’ve talked a lot in this event about resilience, been a great discussion, for those of you who are more interested more about these payment reforms that could help if you just type into Google Duke Margolis Resilience Healthcare, there’s a whole set of proposals, including some endorsed by six of the recent, CMS administrators, both parties on how to do it.

Dr. Mark McClellan:

And I really hope we can take some steps now to keep the health disparities that have emerged here and that were there to begin with. Just become more obvious, to make some progress on that. We need to do it right away with the monoclonal antibodies and potentially other effective treatments that are coming that are in limited supply. And they’re going to take some work to get access. We’ve talked about the vaccines. To Nirav’s point about public health, we do have an opportunity to rebuild public health.

Dr. Mark McClellan:

I would encourage all of those advocates for the public health community to be thinking about what that should look like though, heading into the 2020s. It’s not going to be the public health of before. We’ve got the opportunities for, timely, if not perfect, but timely and effective diagnostic testing that can be done cheaply in communities and workplaces. Not just in traditional public health sites that are sending out the testers and the contact tracers. We can build it in a lot more effectively than in the past, especially if we move our healthcare upstream too. Thanks.

Dr. Bob Kocher:

I would say I encourage people to spend time with the moderate senators that are going to have to vote for whatever we want to have happen to make healthcare better. And so I think it’s important to get Susan Collins, Lisa Murkowski, Mitt Romney and Joe Manchin to actually really [inaudible 00:55:05] that improving the health system and public health, improves the economy and American competitiveness and the things that they most care about because we need to send it to you.

Dr. Bob Kocher:

We’ll want to make the investments in public health, in testing, in healthcare payment reforms to actually keep them amount of and use the crisis. And until we have a core set of Republicans that are aligned with Democrats here, we’re not going to get what we want done. So I think that’s actually the important message is that we have to get the moderate Republicans to want to do it.

Kate:

Thank you. KP and Nirav any final thoughts?

Dr. Nirav Shah:

Sure, so I think the virus has held up [crosstalk 00:55:48]. Go ahead, KP. Sorry, go ahead, KP.

KP Yelpaala:

Okay. I’ll just be brief. I think lots of great comments made. One thing is clear to me that cross-sector partnerships are needed and community-based partnerships. And so I want to map that back to Mark’s comments about payment reform. Somehow when we look at for responding and the need for communities to come together, I think the payment reform will need to support kind of more social determinants of health, community driven models.

KP Yelpaala:

And that’s going to go a long way. I think, in helping us out. Also, I think, on infrastructure, it feels to me like a very strong opportunity for bipartisan engagement, moving beyond just rural broadband, but looking also at mobile wireless. So I think a lot of the prior funding and channels have been around rural broadband, for example, I think we need to be engaging with [inaudible 00:56:42] as well.

Kate:

Great, great. Well, thank you very much everybody. And clearly we could have this go on all afternoon and I really want to thank our panelists for joining us today. This has just been a terrific way to wrap up our post-election symposium. We would like you to join us for our next event on Friday, November 20th, where we will be discussing the health policy impacts of the US census. The Alliance wants our programming to be centered on our audience community.

Kate:

So I would like to ask you to please take the time to complete the very brief evaluation survey that you’ll receive immediately after the broadcast ends, as well as via email later today We truly value your feedback. A recording of this webinar and additional materials will be available on the Alliance’s website. Thank you so much for tuning into our Post Election Symposium.