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Author: Chris Hadley

Interactive Conversation Sept. 10th with Dr. Stacey Rizza, Mayo Clinic Infectious Disease Specialist

Interactive Conversation Sept. 10th with Dr. Stacey Rizza, Mayo Clinic Infectious Disease Specialist


This is a “can’t miss”  opportunity this Thursday to hear Dr. Stacey Rizza, the Executive Medical Director for International Academic Affairs at Mayo Clinic, Rochester, MN. speak to our DMSG Community.

In addition to her role as Executive Medical Director for International Affairs, Dr. Rizza is the Associate Dean of the Mayo Clinic School of Health Sciences, the Associate Director for Diversity and Inclusion, Mayo Clinic Transplant Center and President of the Mayo Clinic Staff. She has also served on committees and held roles within the Infectious Disease Society of America, the World Health Organization (WHO), and the Center for Disease Control (CDC).

This will be a more interactive webinar with Dr. Rizza as she shares with us “What We Know Now” about the COVID virus. Bring your questions and join us Thursday.

You can register for the meeting on the link below:

I look forward to this educational opportunity for you as you join our DMSG Community to hear what Dr. Rizza has to share.

Warmest Personal Regards,







As COPIC’s CEO, I always look to our mission of improving medicine in the communities we serve as a “true north” on the decisions we make. In the wake of COVID-19, this mission still guides our efforts along with another source of inspiration—the dedication of the medical providers, group practices, medical facilities, and hospitals we work with. During this crisis, they have shown a steadfast commitment to their patients and each other. Everyone has stepped up to the challenge and we believe it is our responsibility to help those on the frontlines of this pandemic as well as the broader health care community. Here’s what COPIC is doing to provide support in the fight against COVID-19:

Pledged $250,000 through the COPIC Medical Foundation for the procurement of personal protective equipment (PPE) for Colorado medical providers

  • With the concern over the shortage of PPE, our Foundation secured 85,000 KN95 masks that were distributed through the Colorado Department of Public Health to local health departments and then out to hospitals and facilities/clinics.
  • This was done in partnership with Governor Polis’ Innovation Response Team Task Force.

Sharing our expertise to guide medical providers through the challenges of COVID-19

  • As physicians struggle to understand the ever-changing guidelines and how to best care for their patients and staff, COPIC’s team of physicians, attorneys, and other experts are working tirelessly to review federal and state laws and regulations, and provide clarity through trusted guidance.
  • We have drawn upon our experience to help medical providers navigate complex COVID-19 situations affecting areas such as privacy, telehealth, scope of practice, and liability.
  • In addition to our core support in medical/legal issues, COPIC’s extended services provide guidance on human resources issues related to COVID-19 and communication guidance from an outside PR/communications firm.
  • Insureds have direct access to expert support through our Legal and HR Helplines, as well as our 24/7 Risk Management Hotline, which connects them with a physician risk manager.
  • COPIC has moved several of our key programs that would normally occur in person to now be available in a virtual format; these include Our Practice Quality Reviews and Facility Assessments, educational seminars, and Practice Administrator meetings.

Addressing the personal, emotional toll COVID-19 is having on medical providers

  • In addition to the open-access support services, such as the CareLine being offered through the Colorado Physician Health Program, COPIC is identifying and contracting with resources in each of our markets to provide confidential, no-cost access to psychologists, psychiatrists, or licensed clinical social workers who understand the pressure health care providers are under.

 Offering a policy specifically designed for the ease of adding new providers to help manage COVID-19

  • To help ease the strain on medical practices and facilities, COPIC established a COVID-19 Physician Program.
  • This program provides temporary liability coverage for physicians who do not have other available insurance coverage, and who will be providing professional services to a COPIC-insured practice or facility to address COVID-19.

Collaborating with key partners in health care

  • COPIC continues to work closely with our “friends in health care” to share information, resources, and expertise in an effort to provide much-needed support and play a role in developing solutions to address COVID-19.
  • In addition, our staff has assisted state medical association partners by identifying ways to work together to support their members.

Enabling our employees to continue to offer a high-level of customer service

  • COPIC’s management team moved quickly to mobilize and allow employees to work remotely to protect their health and that of their family.
  • These efforts included implementing opportunities for virtual employee engagement and support during the transition to a remote-working environment.

As we move forward, COPIC will continue to build upon existing partnerships and the strong relationships we have established over the years. By working together, I am confident that we will continue to support members of the health care community during this time of need.


Gerald Zarlengo, MD, COPIC’s CEO and Chairman

Lessons from covid19 – part 4: The role of health status

Lessons from covid19 – part 4: The role of health status


Lessons from covid19 – part 4: The role of health status

With contributions from Rujuta Takalkar and Natalia Wilson, MD, MPH

We concluded the first blog in this series with the observation that health status appears to be a major modulator of disease severity. While the majority of covid19 cases appear to be mild, older adults and people with pre-existing conditions are at greater risk of hospitalization and death from COVID, with conditions like hypertension, obesity, and diabetes topping the list of key culprits.

Although nearly two thirds of the US population has at least one chronic condition, some demographic groups suffer from chronic disease at a higher rate than the general population. They are also more vulnerable to additional medical conditions, including communicable diseases (e.g., the flu). In the case of covid, there are subgroups of most vulnerable people. One group are older adults, with 80% of those aged 65+ having at least one chronic condition and 68% having two or more. Racial and ethnic minorities, especially African Americans, Latinos, and Native Americans, comprise another vulnerable subgroup. These populations are more likely to have underlying chronic conditions such as diabetes, heart disease, and obesity. Sadly, but perhaps not surprisingly, these vulnerable populations are bearing a disproportionate burden of covid morbidity and mortality.

Americans aged 65+ account for ~80% of all covid deaths in the US, with nursing homes residents accounting for over 40% of all covid deaths in the US. Even with the recent trends, that show the disease skewing toward a younger demographic, the 65+ population still accounts for the highest share of covid hospitalizations. Minorities are also over-represented in national covid statistics. According to the CDC data, African Americans account for 23% of all covid deaths and 33% of all covid hospitalizations, while making up only 13% of the total US population. These trends are even more pronounced at the local level. For example, an analysis of hospitalizations in the Oschner Health System in Louisiana showed that Blacks account for ~77% of hospitalized covid cases and ~71% of covid deaths, while making up 31% of the overall patient population. Native Americans are another minority group that has been heavily impacted by the virus. In Arizona, the mortality rate for Native Americans is five times higher than other racial and ethnic groups, while The Navajo Nation, which spans the states of Arizona, Utah, and New Mexico, experienced the highest per-capita infection rate, surpassing that of New York. It should be noted, that the above Oschner study also highlighted that once health status is accounted for, the impact of race/ethnicity disappears.

Why is this happening? Health status is a complex interplay between the determinants of health – one’s behavior, genetics, social circumstances, healthcare, and environmental exposures. The social determinants of health (SDOH) broadly encompass these last three areas and are very influential on behavior and health outcomes. Key areas of consideration are economic stability, education, neighborhood and built environment, health and health care, and social and community context. Even a cursory review of these SDOH begins to paint the picture of why COVID-19 is disproportionately affecting some populations.

“Socioeconomic status [SES] is the most powerful predictor of disease, disorder, injury and mortality we have,” says Tom Boyce, MD, chief of UCSF’s Division of Developmental Medicine within the Department of Pediatrics.” According to the WHO, the poor and those with less education present with higher prevalence of behavioral risk factors for chronic disease, including smoking, physical inactivity, and poor nutrition. They are also more likely to be overweight or obese. In the US in 2017, nearly 40 million people lived in poverty, including 4.7 million Americans age 65 and older. In terms of race/ethnicity, Native Americans have the highest poverty rate of any racial group at 24%, followed by Blacks (22%) and Hispanics (19%). And unfortunately, the latest CDC data support WHO conclusions: Current cigarette smoking is highest among Native Americans (~23% vs ~14% in the overall US population); Hispanics and non-Hispanic Blacks have the highest prevalence of physical inactivity (32% and 30%, respectively vs 15% in the overall US population); and while the overall rate of obesity in the US sits at ~42%, Blacks have the highest age-adjusted prevalence of obesity (~47%), followed by Hispanics (~45%).

Breaking out of these behavioral risk patterns is particularly difficult for those with low SES due to limited choices and opportunities presented by their surrounding environment, as well as inadequate healthcare and health education. Low SES communities are more likely to be found in areas without adequate sanitationhigher rate of environmental pollution, and limited access to fresh, healthy food. For example, The Navajo Nation has 13 grocery stores for a population of roughly 300,000 (to compare, Arizona has approximately 45 grocery stores per 300,000 people) and 30% of those on the reservation do not have access to running water in their homes. Moreover, long-standing farm subsidy policies have contributed to an environment where, “’energy-dense’ foods, such as fried or processed foods, tend to cost less on a per-calorie basis when compared with fresh fruit and vegetables.”

Low income families are also more likely to be uninsured, with minorities lacking insurance at a higher rate than non-Hispanic whites. Even those low-income families who qualify for Medicaid, often encounter gaps in access to healthcare service and variable quality care. And despite having a dedicated healthcare system (the Indian Health Service, IHS), Native American communities have very limited access to providers as a result of lack of adequate funding towards the IHS. Some patients on the Navajo Nation must travel over 200 miles round-trip to receive specialty care. Limited resources have hindered Native communities’ ability to implement public health promotion and disease prevention initiatives.

Finally, the higher rate of chronic disease in these vulnerable populations is further exacerbated by living and working conditions characterized by high density (e.g., nursing homes, urban settings, multi-generational households) where social distancing is difficult.

Given the key role of health status in covid morbidity and mortality, and the impact of SDOH on health status, what can the healthcare delivery system contribute to improving patient outcomes?

While the healthcare delivery system isn’t well equipped to take on the broad societal issues facing our vulnerable populations, healthcare delivery organizations can and should take some proactive steps to improve their overall health outcomes. At the minimum, healthcare providers must be aware of SDOH issues and how these issues impact patient health. Moreover, medical centers can track the health outcomes of all of their patients with chronic conditions by physician and SDOH characteristics, and develop interventions to improve patient health status. Providers can also implement regular SDOH screenings to identify patients at high risk for chronic conditions, and collaborate with social/community organizations on prevention and health promotion programs. Finally, the healthcare system could also benefit substantially from funding studies within actual delivery organizations to improve those factors that most impact our health over a lifetime – namely, our individual personal behaviors.

Ent Regular Financial Checkup During a Crisis

Ent Regular Financial Checkup During a Crisis

Regular Financial Checkup Key to Health During a Crisis

For healthcare providers and practitioners, chances are that “business as usual” is anything but that during the ongoing COVID-19 pandemic. With the uncertainty of the situation and the restrictions we are facing as our economy slowly reopens, it is critical to know what steps you should take to ensure you follow the best path forward.

Assess your situation to figure out how to move ahead

Nobody knows your practice as well as you do. Sit down and honestly assess the impact COVID-19 has had on it. In some cases (we’re looking at you, Zoom and Uber Eats), stay-at-home guidelines might have actually been a good thing, resulting in increased awareness, and potentially revenue. However, like many other healthcare practices, you may have experienced the opposite and were forced to furlough employees, modify business plans or even temporarily shut down. Many medical professionals were no longer able to do elective procedures and had to shift more to telehealth conferences as well as postpone procedures and exams that were not COVID-19 related, causing a significant health issue to non-COVID-19 patients.

As you continue to work through procedures for your practice including telehealth and infection protective guidelines with face masks, personal hygiene, temperature checks and reception areas now in patients’ automobiles, you have found ways to improve your chances of survival. This is how you will have to function as a business while the COVID-19 pandemic exists.

Communicate with all stakeholders

Most people would agree that communication is important in the best of times. In the middle of a pandemic such as this, as a healthcare provider, it is even more important. In addition to applying for PPP funds for payroll expenses, your leadership in your office is important to protect your other healthcare providers and office staff with PPE and guidelines for them to communicate with your patients. So continue to make it a priority to proactively reach out to those professionals that work with your patients during these uncertain times to lessen the impact of your economic losses.

“Don’t put your head in the sand and hope that all of the bad things will go away. They won’t,” said Mike Steppenbacker, vice president of corporate banking at Ent. “This is the time where you have to step up to the plate and work with your advisory resources, specifically your banker if you have medical office building loans or practice lines of credit. Whenever possible, we work with our business members at Ent to come up with a plan that will work for everybody.”

The earlier you begin the process of communicating to those who might be able help, the more options you will typically have available to you. Wait too long, and the number of options could decrease greatly.

Pay attention to everything else that might help your financial situation

After you’ve shored up your immediate patient care and practice business concerns, turn your attention to anything you can think of that might make a difference to your financial situation, both personally and professionally. Ask yourself these key questions.

  • If you typically have cash on hand, is it earning as much interest as it could be?
  • Is your bank or credit union assessing fees that could be avoidable?
  • How about various insurance policies? Are there less expensive options that you are not considering?
  • Look at your personal loans and lines of credit (home mortgages and HELOC’s)

Sometimes all it takes is a call to your current provider to realize a discount on your services. If they won’t work with you, shop around and be willing to change if someone else will give you a better deal while still maintaining a service level that allows your practice and personal family finances to recover.

Though it may seem that a global health pandemic might lead to increased business for healthcare providers, that varies from one medical specialty to another and from one health system to another. By giving your finances the same, careful attention you provide to protect your staff and patients, you can give yourself the best opportunity to survive, and thrive, during these challenging times.

About Ent

Founded in 1957, for the second consecutive year Ent is ranked Colorado’s #1 credit union by Forbes. A different kind of financial institution, Ent is committed to improving members’ financial quality of life with better rates, lower fees and Ent Extras Cash Rewards. With $6.8+ billion in assets, Ent serves more than 385,000 members at 39 convenient service centers all along the Front Range.  Ent is an Equal Housing Opportunity and Equal Opportunity Lender, insured by the NCUA.


For more information, contact:

Gary McDonald
Business Banker
(719) 922-7286

Q & A with Dana Jacoby, President/CEO, Specialty Networks Consulting

Q & A with Dana Jacoby, President/CEO, Specialty Networks Consulting



1. What are the most common challenges that investors, clinics or other care providers encounter when looking to create larger platforms via merger or acquisition?

 The biggest challenges of the past few years include incongruent clinic and/or provider selection, cultural collaboration, and/or creating appropriate synergies pre- and post-merger. Clients of ours who have gone through a merger or an acquisition realize that the process is not for the faint of heart.

The loss of culture, the over- or underinflation of value, integration misses or misalignment should all be addressed long before the larger scale platform, merger or acquisition is designed, developed or created.

2. What are some of the best practices for overcoming these hurdles that you’ve encountered in your practice?

 As simplistic as it may sound, the most critical best practice for overcoming hurdles in M&A or large strategic integration is to plan ahead. The integration and cultural immersion process should begin long before the actual deal or acquisition is ever announced. A careful assessment of each target entity can be very important to determine cultural fit, potential scalability issues, prioritization, key employee issues and leadership objectives.

implementation is the failure to analyze cultural fit upfront. Every entity has its own culture, standards and attitudes. The ability or lack thereof to address this upfront can lead to immediate or long-term failure, neither of which serves for a good situation post-merger. With the emotion, stress and varying agendas of stakeholders involved in any deal, leaders may become complacent with or distracted by the larger issues and forget that the seemingly small stuff can make or break a deal.

3. In which sectors of the healthcare industry does technology investment appear to be picking up more rapidly, and how do you see the adoption of emerging tech factoring into M&A going forward?

 Your question is somewhat difficult to answer, as technology investment is increasing across all healthcare sectors right now. The investment in electronic medical records, claims data initiatives, population health management and artificial intelligence are all affecting healthcare, pharmaceutical and life sciences company opportunities right now.

Meanwhile, Google, Alphabet, Amazon and Apple continue to make news as they compete for the next generation of healthcare wearables, devices and breakthroughs. In a recent speech at the 2019 HIMSS Conference, Seema Verma, administrator of the Centers for Medicare and Medicaid Services, stated that actuaries are predicting that if nothing is done to better control healthcare costs, by 2026 we will be spending one in every five dollars on healthcare. As a result of this large opportunity to cut costs and create efficiencies, technology investments in healthcare is going to be tremendous.

4. What impacts do you anticipate from FDA’s acceleration of approval processes and push for frameworks around digital health?

The FDA’s certification process for new technologies has been too slow for entrepreneurs to access and therefore innovate within digital healthcare. As of the FDA’s FY2019 budget, there is now room for the implementation of a Center of Excellence for Digital Health, which establishes a pre-certification process for innovations in digital health. This will not only expand the FDA’s reach to entrepreneurs with a more rapid certification process but also keep digital health innovation at the forefront.

While the FDA may be making it easier for developers to get certification, the frameworks the FDA are executing around digital health will ensure that patient safety is kept a priority while also continuing to motivate innovation. Additionally, it pivots the FDA’s focus to the software developers in digital health and technology, rather than the product, which incentivizes developers to innovate within this field while allowing the FDA direct access to fixing and updating the software.

Healthcare in the future is going to be driven by new and innovative healthcare technologies that consumers will engage with on a daily basis. Even today we are seeing wearable devices, over-the- counter genetic testing and apps to track our activities becoming more popular and prevalent than ever before. I expect to see a massive pool of data generated by these everyday technologies from which consumers will gain greater personalized insights. This data will also be something that doctors will be able to use for providing a more holistic and reliable overview of a patient’s health over a vast period of time. Rather than documenting a patient’s  blood  pressure on that day and having to compare it to   the last measurement from months prior, doctors will no longer have to fill in the gaps using guesswork. Instead, they will gain a more  complete,  comprehensive and certified measurement of the patient’s health. Additionally, consumers of these technologies will become stakeholders in their own health in a way that is not accessible to them today, empowering people to gain knowledge about their own bodies and bear witness to the changes of a healthier lifestyle.

5. What are the most salient differences in how financial sponsors and strategics approach dealmaking in healthcare? How have these evolved over time in your experience?

 The most significant differences between strategic and financial acquirers is how they work to evaluate a healthcare entity or business. Strategic buyers focus heavily on synergies and integration capabilities, while financial buyers tend to look at standalone cash-generating capabilities and the capacity for earnings growth.

Financial buyers also often buy healthcare entities partially with debt, which causes them to scrutinize the business’ capacity to generate cash flow to service a debt load. The biggest evolution around strategics vs. financial buyers in healthcare has been that not all buyers can be neatly categorized due to the evolutions and synergies happening across healthcare. As a result of this trend, “strategics” may be looking to boost their earnings and end up acting like financials as they approach a target. Other times, “financials” already own a medical practice or healthcare company in a specific space and are looking to make strategic add-ons, so they will evaluate a business more like a strategic. The other large-scale change that is occurring right now is that we are seeing a unique synergy of “complementary” businesses vs. “like” businesses. This trend is causing some interesting dealmaking and deal flow that are very custom and unlike anything I have seen previously. The synergies of physician practices, payor entities, electronic medical record companies and drug delivery companies are an example of the meld of deal flow that looks nothing like past strategic or financial sponsor acquisition or deal strategy.

Strategic buyers focus heavily on synergies and integration capabilities, while financial buyers tend to look at standalone cash- generating capabilities and the capacity for earnings. growth.

6. What best practices around integration have you observed post-transaction in the course of your practice?

 There are five best practices we suggest around deal integration related to post-transaction success. The critical component driving best-practice deal flow success hinges on strategic discipline. Deal flow leadership can help to mitigate the risks of an inherently risky business.

Other than preparing for the post- transaction phase well in advance, the following five categories home in on the practices that separate the “best” deals and dealmakers from those that are subpar or unsuccessful:

  1. Define your success factors: How will you measure success, maintain customer or patient focus, and align strategies, processes and systems? How will you ensure stability, customer and employee communication and operational continuity?
  2. Integration plan: Do you have a plan for your systems to integrate? Are there specific systems that need to be built for your “go live” on day one? What does the operative structure look like on the first day the combined entity acts as one company or strategic partnership?
  3. Leadership: How do you define and communicate the logic behind the deal? How do you manage shareholder expectations? How does the new entity create systems or make decisions? What is the new operating agreement and/or are the expectations of the board or C-Suite?
  4.  Define the integration process: What does the first 30, 60, 90 days look like? How do you define success in year 1, 3, 5 and beyond? Who holds the roadmap outlining the strategy behind your successes?
  5. Reporting metrics: What reports are available to you, your team and the leadership to create rigor and accountability? At a minimum you should have leadership dashboards or reports, management reports, KPIs for key staff, integration reports and post-mortem reporting on the deal.
  6. Culture and consideration: How  do you gauge if the cultures are a fit? How isyour leadership operating on a day-to-day basis? What is the communication strategy with the staff? How do you know the culture is conducive to short- and long- term success?

*Special thanks to Katie Cahn, Wesleyan University ‘ 20, for her contribution to this article.

 Questions? Contact Dana Jacoby at or 202.997.6974




On Sept. 10th at 12:30 p.m. MDT, the DMSG will have Stacey Rizza, MD, Executive Medical Director for International Academic Affairs and Infectious Disease Physician at Mayo Clinic in Rochester, Minnesota as our guest speaker. She has served on committees and held roles within the Infectious Disease Society of America, the World Health Organization (WHO), and the Center for Disease Control (CDC).

In late April, Mayo Clinic’s Dr. Rizza, consulted with Hilton properties as it collaborated with Reckitt Benckiser Group, maker of Lysol and Dettol to develop processes and team member training to help Hilton guests enjoy an even cleaner and safer stay from check-in to checkout.

In late June, Delta Airlines announced it is consulting with Mayo Clinic on COVID-19 testing for employees and safety measures. Mayo will assist in administering the tests and analyzing the findings. Based on the results, Mayo will make recommendations to Delta on how to  update its existing policies and safety measures, as reported in Becker’s Hospital Review, August 2020 issue.

Join us as Dr. Stacey shares an understanding of the COVID virus itself, staying safe, impact of a vaccine and immunity. These are all areas of interest and concern as we move into this school year for our children and their teachers as well as parents. Also with new hot spots of COVID cases showing up in recent weeks, it will be helpful to understand what we know now.

Click on the link below to join us;

I look forward to this educational opportunity as I’m sure you will!

One day at a time,


Chris Hadley
Founder & President
Denver Medical Study Group, Inc.



Three Things to Know about Herd Immunity by Dr. David Pate

Three Things to Know about Herd Immunity by Dr. David Pate

Herd Immunity for SARS-CoV-2

What is herd immunity?

The concept of herd immunity is used in the context of contagious, infectious diseases (most often viruses) and usually vaccine-induced immunity. The idea is that there are some in our population who may not be able to be vaccinated (e.g., newborns or those who have significant immunocompromise, especially when all we have is a live virus vaccine), those who can be vaccinated but may not develop a robust immune response (in some cases due to limitations of the available vaccine and in some cases the elderly who may not generate the same level of immune response as someone younger) and those who simply refuse to get vaccinated.

Herd immunity describes the point at which enough people in that population are immune (it could be through natural infection, but more often as a consequence of vaccination) that the virus cannot efficiently transmit within that population, so while a single of small group of people may be able to be infected for any of the reasons I stated above, generally you don’t see large outbreaks as we currently are for COVID.

Herd immunity helps protect those who remain susceptible to infection in the population because the large number of immune persons means that these vulnerable individuals are far less likely to be exposed to someone who can transmit the virus to them.

What determines the level of immunity a population needs to have so that we have herd immunity?

It is important to understand a few principles. First, the more contagious a virus is, the higher the level of immunity required in a population to provide herd immunity. For example, measles is one of the most contagious viruses. To avoid outbreaks of measles, we believe at least 94% of the population needs to have immunity.

Second, this was much simpler before we became a global society. Just to illustrate the point, let me make up a scenario. So, my best executive assistant ever just had a baby this month. Let’s say that in Boise, we have great herd immunity for measles. But, let’s say that she decides to go to a resort town in Idaho for the holidays later this year to be with family and to go out shopping for gifts in this resort town. However, this resort town is comprised of antivaccers, and the level of immunity is only in the low eighties. There are other visitors to this resort town and one family brings a child who develops measles while visiting. Measles begins to spread like wildfire (just to put things into perspective, measles is probably about 6 – 7 times more contagious than COVID). While my assistant’s child was not yet at the age to be vaccinated and thus remains susceptible, but was reasonably well protected in Boise, this beautiful little girl is now highly vulnerable in this community they have traveled to. So, when we speak of herd immunity, we are talking about the percentage of immunity within populations, but it is important to know that the virus can continue to spread in populations that have not achieved herd immunity, and susceptible persons may benefit from the protections of herd immunity in one population, but if they move or travel to an area with a population without herd immunity, they will have to take many more precautions since they will no longer have the benefit of protection within the herd.

Third, even within a population with herd immunity, we have examples such as religious and communal living communities within those populations with herd immunity that did not believe in vaccinations and were relatively isolated anyway because those communities were closed and not being exposed to the contagion, but later had significant outbreaks when persons form those communities made an international trip and then returned to their communal setting, bringing the infection with them.

What is the level of immunity in the population needed to protect the vulnerable from COVID?

Short answer, we don’t know. I have seen or heard projections anywhere from 10 – 90%. That doesn’t help us much.

So, most of us have most commonly heard the projection of 60% of the population with immunity to protect the vulnerable from continued outbreaks of COVID. Where did that number come from?

Well, there are mathematical models to predict the levels of immunity required for herd immunity. The simplest is the equation 1 – 1/R0, where R(R naught) is the number of people that an infected person will infect when at the beginning of an outbreak, at which time no mitigation strategies have yet been implemented. That number for SARS-CoV-2 is believed to be between 2.2 and 2.7. So, if we plug in R= 2.5, we get 1 – 1/2.5 = 0.6, i.e., the projection that herd immunity will require 60% of the population to be immune.

Now, while this is a convenient little equation, you may not be surprised to know that life is more complicated than this and that while this mathematical projection may be directionally correct, as I alluded to above, there are many factors that may contribute to what level of immunity will be required for herd immunity in different settings. For example, differing susceptibility levels in different populations could alter the level of immunity required for herd immunity. If young people are less susceptible to infection, a developing country with a much lower average age might require a lower level of immunity for herd immunity than a more advanced nation with a higher life expectancy. Social interactions can also impact this. In populations living in high density housing, significant crowding, or where people must show up to work sick in order to avoid losing employment, then higher levels might be necessary.

So, let’s go back to our equation, realizing it is not precise, it may not project the level of immunity required for populations that vary significantly from others in terms of their susceptibility, social interactions and risks for exposure, but with that said, let’s see if we can make sense of the range of 10 -90% that you can find out there, depending on whose projections you are taking.

One more thing about Rbefore we begin. If a person who is infected infects less than one person on average, the virus is not transmitting efficiently and is unlikely to produce outbreaks and community spread of the infection. In other words, with an Rof <1, we don’t have a lot of concern about the need for herd immunity. So, if Rwas 1.1 for this virus (which I don’t know anyone who believes that), then the level of immunity for herd immunity would be projected to be 1 – 1/1.1 = 0.1 or 10%. This is why I don’t currently believe that these low-end projections for herd immunity for this virus of 10 – 20%. In addition, while we still don’t know the percentage of Americans who have been infected, if you assume that 40% of all the infections have been asymptomatic (this is a reasonable assumption) and if you look at the confirmed cases of COVID in the country and if you assume that everyone who was infected is now immune (another fact that we doubt is the case), you can end up with an estimate that about 10.8% of the US population has been infected so far. Obviously, we have not achieved herd immunity as COVID cases are soaring around many parts of our country, so projections as low as 10% certainly don’t seem likely.

If you use the range that is commonly believed to be the Rfor this virus of 2.2 to 2.7, then you get a range of projections for the percent of the population with immunity needed to get herd immunity of 0.55 – 0.63, or 55 – 63%. That seems right to me, but as I said, we just don’t know. To the extent that these numbers are somewhere close to the levels of immunity required for herd immunity, we are a long ways off from achieving herd immunity, and given the impact on our economy, health care costs, the burdens on hospitals, the complications that some people appear to be developing post-COVID and the lives lost with just getting to 10 – 11% of Americans infected, there simply isn’t a reasonable basis to support the lock granny up, throw caution to the wind and get back to life as normal proposals to accelerate us getting to herd immunity, if that is even possible.

What do I mean, “if that is even possible?”

Well, herd immunity is based upon durable immunity in the herd. We still don’t know whether people who have been infected with SARS-CoV-2 are immune, and if so, for how long? There has been a lot of talk about antibodies, as if that was the entire basis for immunity (which it is not). But, studies on patients who have recovered from COVID are not particularly reassuring regarding the antibody response. Studies have suggested that not everyone makes antibodies following infection, oftentimes the antibodies produced are not the desirable types of antibodies that we would guess would be protective, even those who do make these best kinds of antibodies often do not produce them at high levels and a significant proportion of those who do develop antibodies experience a significant decline in their antibody levels in as little as two to three months. If antibodies are critical to the immune response against this virus (and I am not sure they are), and if these studies have accurately described the antibody response, then we would likely never have herd immunity through natural infection.

Now, don’t get too discouraged. First of all, our experience, though early, is that we have not seen a lot of cases where we believe a person previously infected with COVID has become re-infected. I don’t rule this possibility out, but if it does occur, it does not seem to be common. And, it may be because we have been chasing the wrong thing – antibodies. Oftentimes, with viruses, we find that the cellular immune response (see my prior blog post about this, as well as a soon upcoming one) is actually the most important. It may be that there are much higher levels of immune protection in our population than we think, since tests for cellular immunity are far more complicated, less available and not able to be performed in other than highly specialized laboratories. Regardless of this, it is very possible that the vaccines will stimulate a strong cellular immune response and a better antibody response than natural infection does, and in fact, with two vaccines for which we have data from early trials, that appears likely to be the case. The next challenge – get enough people vaccinated when a safe and effective vaccine is available that we can get somewhere around 60% of our population with durable immunity to this virus.



COVID-19: Are We Kidding Ourselves When We choose to wear or not wear Face Masks???

COVID-19: Are We Kidding Ourselves When We choose to wear or not wear Face Masks???

COVID-19: Are We Kidding Ourselves When We choose to wear or not wear Face Masks???


There continues to be more things to talk about in healthcare now, primarily because the covid pandemic has magnified all the negative issues in healthcare but also some of the positive issues. One of the potential positive issues relates to something that we all have an opinion about—face masks!! Some say it’s political and others say “no, it’s all healthcare related”. Some won’t wear them and others wear them over their mouths but not their noses. There are all kinds of face masks, surgical, non-surgical, large, small, pattern masks, bandannas, shields, you can think of others as well.what are we overlooking here when we talk about face masks?

But are we kidding ourselves when we talk about wearing/not wearing face masks?

I think Dr. Gawande, surgeon at Boston Mass General Brigham Health System and New Yorker reporter, has helped me get answers to questions I have not only about face masks but other elements of protection as well. See below:

  1. Are face masks by themselves effective to prevent me from spreading or getting the covid virus?
  2. Is there one kind of material better than another for a face mask? How should the face masks fit?
  3. If not by themselves, what else should I do when I go out of my house, office or car?
  4. What experiences have hospitals had protecting their healthcare providers and other employees from getting the covid virus?

In an article by Dr. Atul Gawande, surgeon at Mass General Brigham and reporter for The New Yorker, May article on reopening, he talks about the “combination therapy” —-hygiene measures, screening, distancing, and masks. Skip one and the treatment won’t work. But if taken together, and done seriously, they shut down the virus!

If you click on the link above to Dr. Gawande’s article, you’ll find out a lot of things that will be helpful to understand these elements properly—what their strengths and limitations are—if they are going to work for you.

Don’t go on what others say about the various elements of combination therapy, read the article by one of the experts, Dr. Gawande, and you’ll begin to function better without fear when you are out in the public.

May you be safe in your daily activities and in your strategy to protect not only yourself but other family members and friends as well.

One day at a time




Chris Hadley
President & Founder
Denver Medical Study Group

“How, Not When” by Denis Cortese, MD and Bob Smoldt, MBA

“How, Not When” by Denis Cortese, MD and Bob Smoldt, MBA


How, not when Blog

As new Covid 19 cases have spiked recently in states like Texas and Florida, it is not unusual to hear that the main reason for the spikes is that these states started opening their economies too soon. However, that claim ignores the fact that there are other states that started opening their economies at the same or even earlier time, and so far have accomplished gradual reopening while maintaining decent Covid experiences. Since there are legitimate public health issues from runaway Covid infections, non-Covid patients not getting the care they need, and also from forcing more and more people onto unemployment and poverty, it seems to us that rather than just wringing our hands over “states who started reopening too soon,” it would be more useful to see what might have allowed some states to start reopening successfully – thus better addressing the above public health issues.

Of the thirteen “rabbit” states that started reopening their economies early, we will look at four. Two have received much national publicity recently because new confirmed Covid cases and hospitalizations have increased significantly – Texas and Florida. Two have received hardly any national publicity, because they have been progressing relatively well with the pandemic – Indiana and Colorado. To us, it is very important to analyze what Indiana and Colorado have done. We should learn from our successes, as well as our failures.

All four states imposed a “Stay at Home” order by early April – IN on March 23; CO on March 25; FL on April 1; TX on April 2. By early May all four were starting to reopen their economies – CO on April 27; TX on April 30; IN on May 4; FL on May 4.

We will focus on each state’s experience with new hospital admissions by day since their start of reopening. Because TX does not report new daily hospitalizations, but rather daily Covid hospital census, we are using the data from Texas Medical Center in Houston as a proxy – the Houston metro area accounts for >25% of all Covid hospitalizations in Texas and its daily hospitalization census trends parallel that of the state as a whole. We (and others, including the governor of Colorado) put a greater emphasis on hospital admissions, rather than cases, because case numbers can be skewed by the number of tests being conducted.

Public health experts watch hospitalizations closely because it can indicate how severe an outbreak is in an area. It’s considered a better measure than new cases because it’s not as reliant on the availability of testing.

Moreover, since PCR tests can detect live, dead or even fragments of the virus, there isn’t a clear correlation between a positive PCR test and clinical disease presentation or progression.

Colorado was the earliest to start reopening on April 27. While newly confirmed cases were still on the rise at the time the reopening was announced (April 20th), new Covid hospital admissions had already dropped significantly. Peak confirmed Covid cases happened on April 23 (just 4 days before reopening) at 969, while Covid hospital admissions had peaked two weeks before reopening, on April 14 at 282. By the first of July, new daily hospital admissions dropped to 30.

Daily new Covid-19 hospitalizations and 7-day rolling average for the state of Colorado

Indiana, the other state that seems to have kept covid-19 under control, began re-opening on May 4th, and with a similar trajectory in hospitalizations as Colorado. Peak Covid hospital admissions occurred on March 31 at 181 and dropped to 38 by July 1, 2020.

Daily new Covid-19 hospitalizations and 7-day rolling average for the state of Indiana

As for the two states that have seen a recent major surge in both cases and hospitalizations (Florida and Texas), it is of interest to note that in both locations, new daily hospitalizations were essentially flat prior to re-opening and for about a month following the initial re-opening date.

Daily new Covid-19 hospitalizations and 7-day rolling average for the state of Florida
Daily new Covid-19 hospitalizations and 7-day rolling average for Texas Medical Center in Houston, TX

In our view, a major reason for the success in Colorado and Indiana is that each has made a serious effort to actually follow the four needed elements to control this virus. What are the four elements?  They were well pointed out in an article by Dr. Atul Gawande in a May article on reopening.  He comments on how his medical center had been doing it for its own employees. It is well stated in his own words,

The Boston area has been a covid-19 hotspot. Yet the staff members of my hospital system here, Mass General Brigham, have been at work throughout the pandemic. We have seventy-five thousand employees—more people than in seventy-five per cent of U.S. counties. In April, two-thirds of us were working on site. Yet we’ve had few workplace transmissions. …in the face of enormous risks, American hospitals have learned how to avoid becoming sites of spread. …These lessons point toward an approach that we might think of as a combination therapy—like a drug cocktail. Its elements are all familiar: hygiene measures, screening, distancing, and masks. Each has flaws. Skip one, and the treatment won’t work. But, when taken together, and taken seriously, they shut down the virus.

To us, a key phrase in this quote is “when taken together, and taken seriously.” Both Colorado and Indiana have stressed repeatedly to wash hands, test, socially distance, and use face coverings/ masks.  In our view, Florida and Texas were both much more cavalier in their implementation of reopening – especially with regard to social distancing and face coverings/ masks.

While it remains to be seen if Colorado and Indiana can maintain their success with keeping Covid in check, the two states have shown us that, it is possible to start reopening the economy and not have a Covid resurgence take over the efforts. While many claim that reopening the economy was the mistake of Florida and Texas, in our view it was not the reopening itself, but how it was carried out. We need to get our economy going again to help reduce the upcoming public health issues that are and will be coming from limiting healthcare access for non-Covid patients, as well as our massive unemployment and expansion of poverty – both of which will also increase social disparities of health. Let’s get our economy going again, but do so in steps and in keeping with what has been shown to work in some of our states.


9.29.16 DMSG Meeting Recap w Senator Aguilar, MD—LOOKING BACK NOW

9.29.16 DMSG Meeting Recap w Senator Aguilar, MD—LOOKING BACK NOW


Amendment 69 on the November, 2016 Ballot: Universal Health Care System Proposal

Senator Irene Aguilar, M.D. Keynote Speaker

T.R. Reid, Author, Lecturer, Documentary Film Maker, Panelist (left)
Jeffrey R. Helton, PhD, CMA, CFE, FHFMA, Panelist (right)

 The following quote is from the DMSG’s President during his introductory comments on Sept. 29, 2016: “Sen. Aguilar, M.D., is the only practicing physician in the Colorado state legislature and the force behind the creation of ColoradoCare, Amendment 69, which creates a universal health care system in the state of Colorado. Amendment 69, if passed on November 8, 2016, will be a modification to the Constitution of Colorado.”

Sen. Aguilar shared with us the benefits of Amendment 69 including (1) everyone contributing including employers, employees, non-payroll and the self-employed, (2) savings from reduced complexity and bulk negotiation and (3) the prioritization of care of complex, high cost patients.

As most of you remember the results of the voting for Amendment 69, it was soundly defeated by approximately 80% against to 20% for the amendment.

It’s now the summer of 2020 and we’re looking at another national election this November with one of the main issues being healthcare—-with all the weaknesses and failures extremely magnified by the COVID-19 pandemic and our country’s inability to respond to the situation. We have never, to my knowledge, had an economic depression that was caused by non-monetary issues, in other words, the coronavirus pandemic.  So this is a new “road to travel”.

But in looking back to Senator Aguilar’s slide presentation on September 29, 2016, there seems to be a lot of the same issues today as there were then. The phrases “Universal Care”  and the “Federal Employees Health Benefits Program (FEHB)” are surfacing this time around.

So, the question now is where do we go now? If you have some ideas, I’d like to hear them. 

Feel free to email me at

Chris Hadley
Founder and President
Denver Medical Study Group, Inc.