By George W. Chapman
Various computer models have attempted to predict U.S. deaths from the coronavirus pandemic. The earliest estimates were upwards of one million deaths. These early predictions were based on spurious data from China, very little experience with the virus in the U.S., no established federal game plan or preparation, and no change to everyday life. A few months into this, we have more experience, we have a federal game plan and CDC guidelines are in place to mitigate the spread of the virus like distancing, hand washing and isolation. As of mid-April, models are predicting less than 100,000 deaths. In any event, life as we know it will be altered for months (years?) until a vaccine is discovered. However, it is important to keep things in perspective. Far more of us die every year due to other diseases and illnesses. Here are the major causes of death for 2018: Heart disease, 655,381; cancer, 599,274; Alzheimer’s and dementia, 267,311; emphysema/COPD, 154,603; stroke, 147,810; diabetes, 84,946; drug overdose, 67,367; pneumonia/flu, 59,690; liver disease, 55,918; renal failure, 50,504; car crash, 42,114; septicemia, 40,718; guns, 39,201; falls, 37,558; hypertension, 35,835; Parkinson’s, 35,598; digestive diseases, 31,015; arterial diseases, 24,808. In 2018 the U.S. population was 327 million.
Hospital Beds in NYS
Currently, New York state has 214 hospitals with about 35,000 beds. About 3,000 of those beds are equipped for intensive care, which is where patients on ventilators end up. Contrary to what some critics have said, Gov. Cuomo does not determine or control the number of beds in the state. Twenty years ago, in 2000, we had thousands more beds. The reduction of hospital beds over the last two decades is a reflection of what has happened across the U.S. Hospital closures and mergers, shaky bottom lines, wonder drugs, better technology and the proliferation of procedures now performed as outpatient have contributed to the reduction of, or need for, inpatient beds. Hospitals simply can’t afford to keep open enough beds for a pandemic every 20 years or so. Most budget for 90% occupancy. About one third of hospitals operate in the red; one third breakeven; one third make a modest profit. Even large hospital chains, both for profit and nonprofit, struggle financially. The COVID-19 has highlighted the fact that we do not have a unified healthcare system in the U.S. For hospitals, it has always been “every man for himself.” The pandemic has decimated already fragile operating margins. The $2 trillion plus stimulus package contains $100 billion for providers.
Ventilators
A hospital-style vent costs from $25,000 to $50,000. If the typical hospital is somewhere around breakeven, just as it can’t afford to stockpile unused beds, it can’t afford to stockpile ventilators for the every 20 year or so pandemic like COVID-19 let alone a smaller scale epidemic. Again, the U.S. does not have a healthcare system that would be prepared to deal with a pandemic or an epidemic. Most hospitals plan on using up to 90% of their vents on any given day. So, considering the thin operating margins of hospitals, it begs the question: “Who should finance an expensive and rarely used stockpile?” The next shortage facing hospitals will be the medications they need to treat the virus and other respiratory diseases. President Trump may have to use the Defense Production Act to force drug manufacturers to step up. About half of our U.S. population lives in an area where an uptick in the virus would overwhelm the number of ventilators available in local hospitals.
PPE
Highly infectious COVID-19 has drastically increased the need for personal protective equipment like surgical masks, gowns and gloves in hospitals and medical practices. Hospitals are going through their supplies 17 times faster than under normal conditions where typically only staff in the operating suite or treating patients in isolation wear PPE. Now everyone that comes into contact with any patient must wear PPE, since every patient is assumed to be a carrier, given the high number of asymptomatic COVID patients. To make matters worse, healthcare workers that wear PPE must also remove their clothes before entering their homes to avoid contaminating their homes and families.
Telemedicine
Most likely, because of the highly infectious virus, your provider has either postponed your upcoming routine office visit or has offered to “see” you via telemedicine. Medicare has relaxed privacy and billing requirements for providers, (MDs, NPs, PAs, social workers, therapists, mental health providers) making it far easier for them to offer and bill for virtual visits. Smart phones and personal computers are acceptable for virtual visits. Medicare will waive office copayments, but the 20% coinsurance and deductibles still apply. The virtual visit cannot be related to a prior visit, usually a follow up, that occurred within the prior seven days and does not lead to a personal visit within 24 hours or next available appointment. You must agree to the virtual visit verbally. Commercial insurers typically, but not always, mimic Medicare. If you are uninsured, Medicare will pay your provider normal Medicare rates. Telemedicine has been available for years, but providers and consumers alike have been slow to incorporate it into practice. COVID-19 may be the catalyst for the widespread acceptance and use of the virtual visit, especially as both consumers and providers adapt over the next several months. Medicare is also relaxing physician supervision of nurse practitioners and physician assistants, granting these two advanced practitioners more independence. Physicians will also be allowed to provide virtual care across state lines regardless of in which state they are licensed.
Testing
As of this writing, in mid-April, about 2 million of us have been tested for SARS 2/COVID-19. That is a start, but still not even 1% of the U.S. population of 330 million. There are plenty of labs to perform the tests including 4,900 CDC labs and 228,000 public health labs. The overwhelming problem right now is the inability for most of us to get tested. The shortage of testing presents another problem in that physicians cannot verify that a patient died of the virus if they were never tested. Consequently, fatalities due to the virus are probably somewhat understated, as scarce tests are being saved for the screening and diagnosis of the more ill patients. To get back to “normal,” if we ever do, it is imperative that all of us have immediate access to testing. Social distancing is working but until there is universal, or just better, testing epidemiologists believe it won’t be safe to “open up the country” again.
George W. Chapman is a healthcare business consultant who works exclusively with physicians, hospitals and healthcare organizations. He operates GW Chapman Consulting based in Syracuse. Email him at gwc@gwchapmanconsulting.com.