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Well, who would have thought …? I have been doing an in-class team exercise in my Health Care Executive MBA course for some twenty years, assigning teams as the C-Suite of a healthcare system with an impending pandemic. The exercise involves reflecting upon the need for preparation, complications that may occur, and recovery given such a situation. And now, unfortunately, here it is. I assure you I/we will never have to look prospectively at this type of exercise ever again.
There are so many elements associated with this situation from a health care system perspective, certainly more elements than I can bring up in the allotted space. However, let me begin (and it is fortunate that some of these elements have been thought through and implemented already).
First, our patients … the ramped-up ability to determine whether patients are exhibiting signs of the virus and appropriately triaging and quarantining. Many facilities have their protocols in place. But even here we begin to see complications. Viral symptoms looking so much like the common flu, and with delays in testing and results, we may be mixing those with viral symptoms similar to Corona but not afflicted with those who have true Corona, thereby infecting others in the quarantined areas. With respect to quarantining patients, as well as those patients with more severe symptoms requiring being quarantined in special intensive care units, there are family members who will be questioning (potentially aggressively) why they cannot be with their loved ones. This disease affects families physically and emotionally, not only the individual inflicted with the illness.
Our frontline care providers, they are at much greater risk then the population at large, with limited access to protective gear given the extent of the situation. Further, they themselves may be spreading the disease unknowingly. The one significant difference between viruses such as SARS, H1N1, Ebola compared to Corona is that with other viruses, contagion begins with symptoms. But with Corona, people are contagious for up to five days before they show symptoms (if they show symptoms at all). So, healthcare workers may be affected or unknowingly exposing people to the virus themselves.
And for those who are symptomatic or have been around one who is symptomatic, they must self-quarantine and refrain from coming to work. Others, due to issues associated with childcare may need to stay at home. And others will stay away and use sick time or personal days, given the risk to themselves and their family members and some of these individuals may be potentially supported by a union. Now, as a result, one is faced with a significant shortage of needed personnel. This now adds further to the crisis.
Regarding the financial stability of our heath care institutions, the realization is that 35 million people in the United States are currently uninsured and tens of millions more are underinsured given high and very high deductible plans (e.g. $2,500 to $6,500 deductibles). Given that the test is to be free, and with each test essentially costing $3,500, free is to the patient but not to the insurance company nor to the provider for those with no insurance. And if treatment, potentially extremely expensive treatment, is required, facilities will find that many of those insured will not be able to pay the deductible and copay and coinsurance amounts they are theoretically responsible for, especially given that many of them may have lost their jobs. And for those with no insurance at all, the levels of uncompensated and charity care provided by the health care system will be huge. Now add to this the delay and cancellation of all elective surgery and the already precarious financial situation of health care institutions in this country, this will be overwhelming.
And then there is the ethics … the potential shortage of beds and ventilators delves into the area of who will receive potentially lifesaving ventilators and Intensive Care Units beds and who will not. This cannot be arbitrary. Medical ethics is a very complex area but there is a potential methodology that might help … the concept of medical utility. This does not take away from the difficulty of the choices that might ultimately have to be made. Medical utility looks at a patient’s level of need but also the patient’s prospect of success. These two aspects of care may be at odds with each other. Rationing of ventilators and quarantined intensive care unit beds (and it would appear that this may indeed occur) may require making very difficult decisions as to needs of the patient, reflecting upon the level of need, and in turn the chance of survivability given the lack of life saving resources available.
This is only a small segment of the complexity of the issues we are facing. I only wish that this was still a class exercise and not the real thing.
Please stay safe all.
