Testing, as a mainstay of an effective response to COVID-19, requires sufficient supply to meet the demand. However, since the pandemic hit the US, this has not been the case. While governments have focused on procuring and producing additional tests, researchers have focused on finding ways to make the tests we do have more efficient.
In a new study published in JAMA Oncology, my colleagues and I find that behavioral nudges can promote high-value, evidence-based prescribing of specialty drugs in cancer care. For patients with breast, lung, and prostate cancer with bone metastases, clinicians face a decision between two therapies of comparable effectiveness but dramatically different cost. Guidelines endorse the use of either zoledronate or denosumab, bone-modifying agents that protect against skeletal complications. But zoledronate costs as little as $215 a year while denosumab costs as much as $26,000 a year.
Amid a surging Covid-19 pandemic that has overwhelmed hospitals, several states — including California, New York, New Jersey, Pennsylvania, and Washington— have told nursing homes that they must accept Covid-19-positive patients when they are discharged from the hospital. This decision drew immediate pushback from nursing home officials, who care for an extremely vulnerable population. They say an influx of patients with Covid-19 would put their other residents and staff at risk for infection and that they lack the tools — such as adequate staffing and the ability to isolate patients — to care for patients with active Covid-19 infection.
Because much of the decline in economic activity is driven by a lack of consumer demand and businesses' hesitation to open their doors, rather than the shelter-in-place policies, economic revival will only occur once we can ensure public safety through rigorous public health measures that slow the virus to a halt – or a vaccine. Only public health will return the United States to normal economics.
Back in February, when COVID-19 didn’t prevent us from gathering in a room with 300 people, Penn LDI’s conference, Medicare for All and Beyond dug into some of the major sticking points around health care reform. We capped off the day with a discussion on political feasibility, in which an expert panel shared their insights on public opinion and the viability of various reform proposals. Since that time, Americans are living through a generation-defining pandemic, a public health threat that most would have found unimaginable only a few months ago. What is politically feasible now may be very different from what our panel discussed in February. Could a pandemic usher in dramatic health care reform in the United States? We reconnected (virtually) with our panel to hear their latest thoughts. Several themes emerged from these conversations:
During the COVID-19 pandemic, the vast majority of clinical research visits have stopped, with the recognition that any in-person contact adds risk that, for the time being, outweighs any research without direct benefit. Researchers have adopted this new normal, often under the premise that this too shall pass. Soon enough, when going to the grocery store becomes a mundane errand instead of a momentous event preceded by days of planning, our work lives – including research – will resume as well. But is that true?
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?