Brent James, MD: “Those practices and those hospitals have no choice. A number of them face going out of business, even with the loans the government's giving today.”
Hospital systems and primary care physician practices were consolidating before the onslaught of coronavirus disease 2019 (COVID-19). The internationally known and respected healthcare expert Brent James, MD, talks to Infection Control Today® about how COVID-19 now makes it a question of survival. James, a clinical professor at Stanford University School of Medicine, was at one time the chief quality officer and executive director of the Institute for Health Care Delivery Research at Intermountain Healthcare. He knows about both the provider and the health plan side, in other words. And the provider side is bleeding revenue mostly because of missed routine care and postponed elective surgeries. “COVID has consumed the resources of the health system in the vast majority of communities.”
Infection Control Today®: COVID-19 has forced people to put off routine care and elective surgeries. Where do you think that’s going to lead?
Brent James, MD: Well, a couple of ideas. First, I serve on a number of national health policy groups. And we’ve actually been calling in real experts to discuss exactly these topics, what’s happening out there on a broad scale. In that framework, the next thing to be said, it differs from community to community. So, among those likely to be listening to this video, one experience may not reflect all experiences across the entire board. On the other hand, there’s some markers that will help people see. Here’s the first big one. Turns out that primary care and standalone specialty care has taken a real hit with COVID. Visit rates have dropped dramatically. It’s not just the physician practices, small hospitals have taken a real hit too. So, here’s my first prediction. You’ve all seen in your communities the rate of consolidation. Smaller practices, independent practices join in larger systems. That has been happening. It’s accelerating. The reason is, is that those practices and those hospitals have no choice. A number of them face going out of business, even with the loans the government’s giving today. It’s going to be a shift. On the other hand this is really not a new thing. It’s an acceleration of an old thing. Some of the communities of your readers are going to be so far down this it will make very little difference. For others, it could really pick up the pace.
ICT®: Will there be layoffs with for healthcare workers because of that?
James: Potentially, I think when you consolidate services, especially at the administrative level, that can always happen. Also, to a lesser degree, at the specialty levels. Now, there’ll be some compensating factors. You’re right in thinking in those directions, that kind of large systemness. At one level, it protects people. But at another level, it only protects people who are part of the system. You see what I mean? It’s going to concentrate.
ICT®: Has anybody come up with any ideas about what to do about this?
James: I don’t know if it’s something that we do anything about. It’s something that’s just going to happen. But you can tell in your own community, how fast…. Now there’s a second element behind that. There has been a very remarkable slowdown in elective services. Many hospitals, of course, have taken a real hit by losing those services. Frankly, in a few communities, COVID has consumed the resources of the health system in the vast majority of communities. It’s partly based on fear among patients. People who should have been coming in aren’t well. As you would expect, as it normalizes a bit, as people get more experienced, the fears go away, and those rates are starting to come back up. Now, the other problem, of course, is that COVID and the shutdown have been associated with a major economic downturn. Here would be my advice to your readers. It will be about like 2008. We’ve been through major economic downturns before him. You lived through them. I’ve lived through them. We know what happens in the long haul. It will be mostly like that. We know how to make our way through them. Again, it differs from community to community. But I think that if you think of it that way, think of it as a major economic downturn. Was it a bit anomalous? Sure. The reason is, is it just cut off cold. But now most places are opening back up. There's still a bit of fear of people being afraid to come back and put themselves at what they see as at risk in a healthcare delivery environment. I think that will normalize pretty quickly. In fact, that’s one of our problems right now is maybe it’s normalizing too quickly, especially among younger patients. They’re not obeying the social distancing rules, the masking rules that would really help us out moving forward. But we know how to manage that. I think that’s a second thing right there. I treat it as a major economic downturn. We’ve lived through those before and we kind of know how they behave in our communities.
ICT®: Are you hearing from your business associates in private industry that they might hire infection preventionists or at least depend on IP expertise?
James: That’s the third area. I really wanted to talk about. I think that most infection control specialists, they have training that others do not have. Now I’m a biostatistician. As part of that I’m trained in epidemiology. It’s just a background. Let’s just say I’ve been pulling out of my closet and spinning up to full speed basic infection control principles at a population level. It means a certain amount of Bayesian analysis. Frankly, I need to resurrect sensitivity and specificity. The idea of a positive predictive value. I need to be able to share those with people. I see that happening at several levels. The first, of course, is just how do you control the spread of this disease—this specific disease—in the general population. I realized that many of us don’t have our hands strictly on those controls, but holy cow, I get hit on that every day. I bet that your readers do, too, on a regular basis, because they have that specialized expertise. The second thing, I’ve been amazed at how many care delivery groups—those physicians and nurses—they want guidelines. And they’re a little confused about where to find the right guidelines, you see. There’s a third area: Where is it going next? Looking forward, well, it means that I’ve had to spin myself up. I keep fairly careful track of that literature. I find trusted sources. Oh, there’s so much information all over the board, on the Internet, from various news agencies, and so much of it is just, frankly, wrong, just bad. And what people are really looking for is a trusted voice. Even if you’re not in direct control of the response to that system, people need your voice. But it means that a certain amount of preparation along the way so that you’re able to speak authoritatively and help people see a path through the thicket. Now, this isn’t going to be the last one. COVID’s just the current one. It’s a wonderful opportunity. There are so many other common infectious diseases that take a major toll every year. Maybe this is an opportunity to expand the good that we can do in a community at this time, given that people are finally listening a bit. I hear a lot of people saying that we really need to expand public health. What do they mean? Seems to me that we’d have a large voice in defining not just their future, but our future, as those conversations take place in our communities.
ICT®: Do you have an idea of what direction you’d like to see public health going?
James: I think that we knew in the past, how to handle a major epidemic. It’s very clear that because the time between was so long we dropped the ball. There’s no question. Here in Utah, I have a former Secretary of HHS, we spend a little time together from time to time—Mike Leavitt. He was there during SARS-1. And hearing Secretary Leavitt talk about what we learned with SARS-1. And then how frankly, the Bush administration was on top of it, the Obama administration actually lowballed that, they took money out of it to support the ACA insurance expansion program. I thought that was a major policy mistake at the time. Turns out it was. The Trump administration, of course, did not follow through and pull it back. And then we find ourselves a day late and $1 short when the real crisis hit. So, here’s an opportunity to lay some foundation for the next one. We know how, but it takes leadership. And it’s not just at a national level. It’s done at your local level. Who’s the voice that’s going to help people understand that moving forward in your community.
ICT®: What about the insurers? How are they doing these days?
James: They’re standing on the sidelines a little bit. They have pluses and minuses. Their payments for COVID patients are up but frankly, for insurance, general use of services are down so much that most of them are doing quite well financially. It’s a a bit of a mixed bag for them, but for most of them, this has been a little bit of a financial windfall. I don’t see them…. Maybe this is just my bias as a physician. I’ve never seen insurance companies really leading in this site. It’s not their natural sweet spot typically. It’s not how they typically think about their role.
ICT®: How do they typically think about their role?
James: They think about it as supplying funding for healthcare and making sure that only necessary services are provided. They do a series of important functions. One is transaction processing, claims processing. Surprisingly difficult. They do actuarial risk analysis to figure out how to price. They do network formation. There’s a series of things that they do. The thing they don’t do is deliver care.
ICT®: Has any country in the world handled this right?
James: There’s a clear winner to my mind in the world. And not just mine, a number of our colleagues who watch these things, too. Taiwan. Taiwan’s done it right. They are a wonderful example of doing it right. South Korea was doing well. They got surprised. Singapore was doing surprisingly well. They left a hole in their defenses and their immigrant worker population in large dormitories and high rate of spread. Outside of that they’re a pretty program. There are countries like New Zealand that have done very, very well. We have to remember, they’re an island in the ocean, and they can close their borders. So, they’re kind of a special case. But Taiwan, a short distance from China. Massive amount of travel. Early-on exposure. They learned from SARS-1. They were ready. They were ready with testing and were ready with contact tracing. They’ve had less than 200 deaths in a population of around 24 million. It’s dramatically different from the experience of the rest of the world. So that’s the one to study. Right there. They had some special factors in their culture, wearing a mask was already really common. As it turns out, COVID-19 is mostly spread through respiratory droplets. It’s an upper respiratory infection. Mostly through respiratory droplets as a main route. And, so, masks are effective. Of course, most masks—the way people mostly wear them—it’s not effective in protecting yourself. It’s just effective in protecting others. That was part of their society. People before this happened routinely wore masks. It was an easy step. Their contact tracing. Let’s just say they may not have quite the sensitivity to human rights that we have. They did a great job of identifying and isolating potential infectors. They’re the one to study.
ICT®: Let’s circle back to what you said about hospital systems. As we’re going through a situation where when we need more healthcare workers, they seem to be getting laid off.
James: So, people will get laid off, first of all, to answer your question, but we need to be more precise than that. It’s what kind of healthcare workers will get laid off. You said hospitals and hospital services. I think they’re going to mostly come back. So, people associated with hospital services, it will take a while for it to swing back. Currently, most hospitals are reopening their doors, they have a backlog. We call it elective, but it’s really hard to draw a hard, black line between essential and non-essential surgical services. Maybe we can delay, but that doesn’t mean they’re not essential. So, they have a bit of a backlog and they’ve been working it off. So those services are coming back nicely. We need to wait until the population at need—also sometimes the population at risk, particularly the elderly—feel confident coming back into a healthcare setting. So, part of the problem is just fear in the patient population. But I predict over time that’s probably going to ameliorate. It typically does. And as that happens, we’ll actually be working off a bit of a backlog for a while, but it’ll come back up over time. Again, remember though, anytime we’ve had a major economic downturn, there’s a drop in demand for healthcare services: 2008 was a pretty strong one. That one is a good experience. That’s close enough in our recent history that most of us remember it. We know what it was like. We’ve seen it. Well, here it comes again. And it’s probably a pretty good model. The anomaly is of course, with COVID, it shut us down cold. That was a little bit different, but I think that’s a temporary phenomenon that’s now starting to sweep back up. But the economic downturn; that’s going to be with us for a while.
ICT®: What did former Secretary Leavitt had to say about all this?
James: He basically said what I just said and he published it, by the way. It was testimony to Senator Lamar Alexander’s Committee on Health, Education Labor and Pensions. You get him and his staff. It wasn’t just Governor Leavitt. They have strong opinions about it. But it had to do with careful central coordination and planning. By this point, we know that the initial modeling was off. So, it was a wiser approach to how we modeled. It was having the necessary supplies. It was a clear consistent message down to the states and to the people of the United States about what’s high risk, what’s not high risk. You don’t want to trust those kinds of things to the news media. The news media is not a reliable source of information. And then, of course, the supplies, a properly coordinated response. But of course, Mike Leavitt would have started this probably in November, December of last year. That’s when we were first getting a signal.
ICT®: What surprised you most about this whole thing? Is there something that sticks out in your mind?
James: Things that I, and not just me, but any trained epidemiologist should see as obvious. You know, as a statistician, we call them proportional hazards models. That means there’s not just one risk. There’s a human tendency, probably evolutionarily built into us, that we focus on the one big threat—that saber-toothed tiger that’s about to eat us, right? Well, COVID is kind of a slow tiger that eats us a little bit at a time. But the fact is, is even as you focus on that threat, you shouldn’t lose track of the other threats. And that’s my biggest disappointment. People that should have known better focused just on this one threat. I thought our national leadership should have been a little bit broader in their application. There are real health risks associated with this that aren’t directly from the SARS-CoV-2 virus. I wish that we had been broader in our understanding.
ICT®: Could you give us some examples?
James: Here’s one that’s topical for me because I get involved in health policy level nationally. We were talking an awful lot about the social determinants of health. Social networks, access to care, access to safe housing, food, water, a whole series of things like that. We knew that they were associated with major significant health risks. Associated with mortality rates. We were trying to call attention to it. Well, it turns out that damage to social determinants of health is associated with a major economic downturn. So, SARS-2 hits the streets, we shut down our economy. People lose jobs. We try to backfill with government programs, but a little bit unsuccessfully. We haven’t seen the end of it yet. But we weren’t considering the health consequences of the economic downturn. It’s not about the money, at least not directly. It’s about the lives. And you’re balancing these two and how do you balance the back and forth? It’s that kind of a conversation. Now to really have that conversation takes some real training and expertise. But then how do we tap the kind of training expertise as well? How do we make that available to people so that it reduces the fear levels? It gives people a clear path forward to a greater degree. They know what’s safe, they know what’s dangerous. They don’t see just the one risk, they see the other risks too, so they can kind of balance them out. And that means we respond more intelligently. We respond more wisely, than we have.
ICT®: And the social determinants of health have come into play in this epidemic, too.
James: Oh, heavens, yes. And we’re seeing it especially in underserved populations. They have higher risk factors to begin with in terms of comorbid diseases, obesity, other risk factors directly associated with social determinants of health. They have poor access to the health system. So, we see disproportionate mortality rates in African American communities, for example. If you look at the way that those diseases play out, that was completely predictable.
ICT®: Is there anything you’d like to add, Doctor James?
James: I’ll give you one thing. OK. This comes from some of the national groups in which I participate. I’m really hoping—both fingers crossed, and it would take a minor miracle—but what I’m hearing is to really have an effective vaccine could take two, three or four years. The earliest we would probably have it is at the end of 2021. Now, it’s not just developing a vaccine that actually works and testing it and showing that it works. The complications associated with it. It’s getting it available at scale. It’s getting a good distribution network, picking the populations that are higher or highest risk. There’ll be all sorts of hype around this coming up. The best expertise that I’ve been able to find suggests that probably it’s two to three years out. Now we could get lucky. Let’s hope for it right? What will happen short term is far better treatment. We already have readily available steroids that we’ve used forever that seem to stop cytokine storm and get better outcomes for people with the most serious disease. What I’m hearing is, around November or December, monoclonal antibodies will be available at scale that could be a game-changer in terms of treatment of the disease. Now, the reason I mentioned this, I believe that your constituency, infectious disease doctors know about this stuff, they know how to track it. Again, it’s supplying that expert voice by tracking those things so that people have a realistic expectation about what comes next and how they need to behave. This is within our reach, but it does take some specialized training, a little bit of wisdom along the way. Where do we turn for wisdom? Where do we turn for knowledge? Some groups it seems to me are heading shoulders above the rest. So, guys, get out there and get to work.
This interview has been edited for clarity and length.