Lessons from the covid19 pandemic – part 1

As we continue to muddle through yet another week of uncertainty with covid19, we have been taking stock of the issues highlighted by the pandemic and trying to distill the lessons for our healthcare system and the country as a whole. To quote Rahm Emanuel “never let a crisis go to waste.” So, what do we see? In no specific order, the pandemic highlighted:

1. A complete lack of preparedness, despite the annual flu epidemics that sicken tens of millions and lead to 20,000-60,000 deaths each year (including the 2009 swine flu pandemic and the 2017-2018 flu season), as well as the 2003 SARS outbreak, MERS in 2012, the Ebola scare in 2014, and Zika in 2016. No one can claim the USA did not have plenty of warnings and the need to prepare was highlighted by president Bush in a 2005 address to the National Institutes of Health. And yet here we are, facing shortages of personal protective equipment (PPE), ICU beds, ventilators, pharmaceuticals, and with a testing capacity that lags so far behind what is needed, we may never reopen the country if we are to follow the latest provided guidelines. 
2. Lack of clarity and leadership at the national level, between contrasting and contradictory messaging from public health officials and the White House about the true state of affairs, to the lack of coordination of a national response around both mitigation measures, as well as the sharing and distribution of scarce resources like PPE and ventilators. No real guidelines or strategy were provided by our “leaders” thus pitting states against each other in the scramble to secure resources and issue directives to the general public.
3. Useless nature of many healthcare regulations from the CDC, the FDA and CMS. A recent essay by David Burda does a great job summarizing some of the regulations that have been “relaxed” to help address the covid19 pandemic, e.g., state licensing laws (as if our biology magically changes when we cross the border from CA to AZ), or telemedicine reimbursements (though it remains unclear why commercial insurers have not followed suit on something that makes so much sense in terms of patient care). And the fumbles around covid19 testing by CDC and the FDA are pretty well documented. 
4. Supply chain, supply chain, supply chain. We were frankly distraught to realize how little is actually made in the US these days, especially for such critical industries like healthcare. Considering that bringing manufacturing back was one of the key messages of the president’s platform, it gives us pause as to why we find ourselves lacking PPE, medications, nose swabs and other testing reagents, given that we are in the 4^th year of his presidency. As a recent The Atlantic article observes, the pandemic is clearly showing that between off shoring and just-in-time delivery, “The way our modern supply chain is built is incredibly fragile.”
5. The way we pay for healthcare is flawed. Although the movement from volume to value is alive and well, the majority of healthcare professionals continue to be paid fee-for-service, taking care of people and making money only when patients seek treatment. With many states and cities issuing mandates to cancel elective surgeries (a big source of revenue for hospitals) to ensure bed and ICU capacity for a predicted surge of covid19 patients, what was once thought to be a recession-proof industry is now furloughing workers, instituting pay cuts, and filing for bankruptcy. 
6. Health status and social determinants of health (SDOH) play a major role in patient outcomes. In addition to age, health status appears to have a significant impact on disease severity, putting people with some underlying medical conditions at a greater risk. Preliminary data are also showing a disproportionate impact of the virus on African Americans, Latino and Native American populations. While the healthcare delivery system shares some of the blame (see previous point about caring for people only when they are sick), much of the responsibility lies with our elected officials and addressing such SDOH like education, poverty, jobs, infrastructure, and the environment, that lie outside the realm and expertise of healthcare delivery organizations.