By: Ray Fabius, MD and Brent Ling, MSPH
July 16, 2020
The tenants of population health management strategies, if tailored to meet the unique need of the moment, can be a highly successful approach to protecting your employees, patients, or those covered by your plan from damaging effects of COVID. As we’ve faced pandemic threats in the past, and most certainly will again in the future, it is important at this moment to clarify what strategies have shown to work best for each of the accumulating phases or periods of the current pandemic. Inspired by the tweeted graphical illustration of 4 waves of a pandemic shown below, I will be convening a panel discussion around this framework for the PHA Innovation Summit and Capitol Caucus on October 27th & 28th, 2020. Join us then to hear from executive leaders representing Behavioral Health, Intensive Care Delivery, Primary Care, Chronic Care, and the Payer perspective on effectively targeted responses to these disparate, but accumulating impacts of the pandemic.
Inspired by the above tweet by Victor Tseng, MD @VectorSting, the below framework will help illustrate the multiple compounding pop health impacts of COVID-19
The Playbook :Moving From Chaos to Containment
Benchmark pandemic response teaches us that the safest reaction to the early “chaos” period of opaque information on the infector or the mode of transmission is to overreact with disinfecting, isolation and other protections. That approach was crucial to our success when I had to respond to SARS and protect 50,000 GE workers in China and SE Asia during my tenure as GE Global Medical Leader. Equally important is to establish communications channels and report on the facts as they become known, on at least a daily basis. This has been more recently labelled as a version of “information therapy”. Providing information is therapeutic, as is the understanding that leadership is completely focused on managing the situation. This allows the country or organization to move from chaos to containment. Again, overreacting is warranted. Hesitation and uncertainty about whether to lockdown or for how long, needs to be met with a swift decision to immediately lock down for as long as it takes to contain the spread. In this phase identification of every case with exquisite contact tracing can save millions of lives. If done right the lockdown periods are short and business can return to normal much sooner, as we see in Iceland, South Korea, New Zealand and Australia.
When Containment Fails
When containment fails you must move to mitigation. Here we try to reduce the casualties as best we can with periods of mass openings and closings until herd immunity is established naturally or through immunization. This country will likely see over 250,000 deaths before the end of 2020 unless there are more successful treatments identified. And while all of this is tragic, it only accounts for the tip of the iceberg of the pandemic impact from a population health standpoint. While companies and governments focus on COVID 19 itself, the disruption of population health is devastating the wellness of the American and global citizenship.
The Impact of COVID-19 on Population Health
Primary prevention is the hallmark of public health. One could argue that immunizations are the single greatest human achievement. In fact, many remain deeply committed to the hope and even expectation that science and technology will rescue us from the grips of this pandemic though effective vaccines. Ironically, studies have demonstrated, due to shrinking vaccination rates, that the vaccines that we do have are increasingly underutilized, creating further worry about a potential outbreak of viruses worse than COVID-19 such as polio. This is, in part, due to the disruption of primary care. The practices of pediatricians, family doctors and internists have been largely closed except for emergent care for the last few months leading to tremendous financial burdens on the PCPs and threatening the foundation of health care in our country.
During this pandemic, hospitals and intensivists, overtaxed by those who have succumbed to the coronavirus, are less able to attend to those with catastrophic events such as heart attacks or strokes. Additionally, some of these patients have contracted COVID-19 while being treated for something else. Others, fearful of going to the hospital, have elected to stay home; the consequences are numerous, and tragic.
Generally incurable, chronic illness affects 133 million Americans or roughly 40% of our total population. In order to control these conditions like diabetes, heart disease and emphysema there is a need for frequent visits to primary care and specialists, laboratory surveillance and management of medication regimes. All of this has been disrupted as well. Worse yet, 81 million of the 133 million are presently trying to manage multiple chronic conditions with minimal contact and support from health care providers who themselves are adjusting by limiting office visits and expanding use of telemedicine.
Perhaps most disturbing is the mental toll. From the lack of clear understanding of this infection to the requirement to socially isolate, we are suffering as social, rational beings. We are stressed, worried and scared. For people already dealing with a mental illness this can cause acute exacerbation of dysfunctional mental illness with devastating consequences. For the rest of us it is challenging especially when access to social and mental health services are limited. How long can essential workers put in double time without burning out? And how can the 58% of Americans who have less than $1000 saved, manage through the consequences of massive furloughs and unemployment?
Finally, and it is to state the obvious that COVID-19 has accentuated disparities of care and the health impact of social determinants. Communities are suffering all of the above impacts disproportionately. Hispanic Americans, African Americans, and Native Americans have felt both the viral and economic burden of COVID-19 far worse than Caucasian Americans. In the world’s most advanced and free nation, we must do better. The population health profession has generally embraced the commitment to treating all who have the infection without burdening them with out-of-pocket financial liabilities; we must remain committed and accountable to this important & impactful promise.
The Significant and Urgent Priorities
COVID 19 is training everyone on important concepts of population health. We remain obligated to keep the healthy – healthy. We must continue to provide preventive services and full service, broad access primary care. We cannot abandon those with chronic illness. And hospitals must be a beacon of hope for those with true emergencies. For the provider community it will be necessary to bifurcate. There needs to be identification of and separate delivery systems or services for the COVID-19 positive and those free or already over this infection.
Patients with COVID need to have access to primary care and emergency services. All of the rest of us need full-service population health. All Constituents of Health Care Must Contribute to Produce an Effective Pandemic Response
For employers, benefit design adjustments, implementation of public health guidelines, infection control, and work environment adjustments will all be necessary. Successful employers understand that the health, safety and wellbeing of their workforce is a most important business strategy that the C-suite cannot delegate to human resources but rather incorporate a health-first culture into the company’s vision, mission and values. They realize that much more needs to be done long term to mitigate the impact of this and other pandemics such as obesity, opioids, unhealthy lifestyles and racism. They have provided a benchmark for others to follow by adopting a corporate culture of health, safety and wellbeing.
For insurers, it is time to support a universal safety net and find creative ways to assist our providers financially through this pandemic or their networks will be permanently compromised.
For the pharmaceutical industry and the research community we are counting on your focus and collaboration to deliver effective and accessible treatments and vaccines.
And for all of us as patients, we must re-double our efforts to be healthier. The COVID-19 virus has accentuated the importance of being well. If you are not overweight and you are free of chronic conditions you are more resilient and resistant. These six things every day will help you stay healthy, support your family and loved ones, be an effective contributor to the economic rebuild, and reduce your need for medical treatment and interventions.
- eat 5 fruits and vegetables
- get 30 minutes of exercise
- sleep 7 hours
- don’t smoke
- drink alcohol in moderation
- manage your weight
WE ARE ALL IN THIS TOGETHER.
Brent Ling, MSPH is the Executive Director at PHA