Last week LDI hosted a day-long conference on Medicare for All & Beyond. Our goal was to participate in one of today’s most pressing conversations in health care—how to expand health insurance to the 28 million people in the United States who are currently uninsured. We welcomed close to 300 people from across the spectrum to participate in this conversation, to consider the critical questions underlying today’s debate, and to look in depth at the challenges we face in expanding insurance coverage in our country. The conference gave us all plenty to mull over.
Overuse of medical care—the provision of services that can do more harm than good—remains a key driver of waste in our health care system. While most work on this topic has focused on individual overused services, we think it is valuable to conceptualize overuse as a systemic phenomenon, defined as the general tendency of an organization or region to overuse medical services. It turns out that regions and organizations have persistent patterns of overuse, and we’re beginning to understand why.
These days, it feels like every article is a COVID-19 article. In the last month alone, LDI Senior Fellows have outlined the unique challenges of delivering post-acute care during a pandemic (solution: more intensive care at home), described the rapid rollout of a robust telemedicine system at Penn (“three weeks to build an army”), and even evaluated the effects of the lockdown in Wuhan, China (it worked). But LDI Associate Fellows, who comprise clinical fellows, postdocs, and PhD students, many of whom work on the frontlines, have also added to the COVID-19 commentary, bringing the unique experience of being a trainee amidst a global pandemic.
To date, much of the policy and public health response to the novel coronavirus outbreak has been reactive and blunt -- triggered by the number of COVID-19 cases or deaths in a given area -- when it should be proactive and more precise based on a broader set of real-time data. State-level and hospital-level forecasting models can help plan mitigation strategies, but are limited by the reliability of the inputs to the models, which are primarily COVID-19 cases and deaths and best guesses as to the degree of local physical distancing.
Novel indicators are needed to supplement COVID-19 case and death data and predict where testing, action, and resources are most needed. These indicators can also assess response to distancing policies and help inform when restrictions can be eased. Fortunately, a rapidly emerging set of new data sources, including smartphone location data and novel hospital-reported measures can meet this need. Ideal indicators would proactively and preemptively drive policy by revealing upstream or proximal signals about symptoms, movement, or contact, that could then predict cases before they are identified.
Nested in communities across the US, nursing homes serve as a societal safety net. Nursing homes provide essential care to individuals unable to live in the community. Roughly 1.3 million residents live in nursing homes receiving assistance with daily activities of living such as meals, dressing, and socialization. Additionally, more than 3 million older adults are discharged annually to nursing homes following a hospital stay to receive rehabilitative services like physical therapy and skilled nursing care. More than 2,000 nursing homes in the US have reported Covid-19 cases within their facilities, often accompanied by heart-wrenching rates of death. Covid-19 puts into full view the regulatory structures and payment models that jeopardize care for long term care residents and those receiving post-acute care.
Over a four-year period, the federal government double-paid for the health care of 4,764 recipients of coronary revascularization procedures, leading to $214 million in redundant spending. This wasteful spending occurs due to policies governing the Medicare Advantage program for Veterans that do not reflect how the U.S. health care system is currently structured. We published these findings last week in JAMA Network Open.
This week, the Annals of Internal Medicine published a summary of Penn’s development of an interactive, Web-based tool to inform our hospital planning at the early stages of this pandemic. I’d like to give you a walkthrough of how we built a model that allowed us to estimate the resources we would need to care for the surge of patients we would likely see in the coming weeks and months.
The immediate task at hand for all of us is to mobilize resources and personnel to provide care to save the lives of those who contract COVID-19. However, even if the epidemic is brought under control soon, as we all fervently hope, there is a dark cloud for the future. Insurers are paying for coronavirus tests with little or no cost sharing, many of them have agreed to more generous benefits for treatment, and there may be mandates for coverage without cost sharing. And even for people with deductibles, insurers will be paying out billions of dollars in claims above those deductibles for those hospitalized for treatment. Then what?
From March 10-March 16, 2020, people in the U.S. started to realize that the COVID-19 threat was real, according to a new working paper by LDI Senior Fellows Hans-Peter Kohler, Iliana V. Kohler, and colleagues at Penn’s Population Studies Center. More than 5,400 people answered an online survey about their perceptions of the risks and consequences of the pandemic, as well as any steps they were taking to distance themselves from others. As identified cases increased from 959 to 4,632, and reported COVID-19 deaths increased from 28 to 85, perceptions of risks and consequences increased dramatically.
Hospitalized patients with COVID-19 have high rates of acute respiratory distress syndrome (ARDS). In one case series from Wuhan, China, a third of hospitalized patients infected with SARS-CoV-2 developed ARDS, and over half of those patients died. A new study by LDI Associate Fellow Catherine Auriemma sheds light on the mortality attributable to ARDS in sepsis patients, and provides the mortality benchmark for future studies of patients with COVID-19.
As increasing numbers of people domestically and abroad face mandatory “lockdowns,” we have new evidence that these severe restrictions on movement are effective in containing the spread of the novel coronavirus. In a just-released working paper, LDI Senior Fellow Hanming Fang, PhD and colleagues Long Wang, PhD, of ShanghaiTech University, and Yang (Zoe) Yang, PhD, of Chinese University of Hong Kong, quantify the effects of the lockdown of the city of Wuhan on January 23, 2020, showing that it played a crucial role in reducing cases of COVID-19 in other Chinese cities and halting the spread of the virus.
Being a teen can be challenging under any circumstances, particularly in the context of the country’s increasing rates of opioid addiction and overdose. While many studies address adult and pediatric populations, less is known about how opioids are prescribed to adolescents in acute care settings. In a recent study in the Journal of Child & Adolescent Substance Abuse, my colleagues Jennifer Pinto-Martin, Nicholas Giordano, Catherine McDonald, and I explored the patient and clinical factors associated with adolescent receipt of an opioid prescription upon discharge from acute care.