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Lessons from Covid19 – Part 3: Where are we now? What’s next?

Lessons from Covid19 – Part 3: Where are we now? What’s next?

The Bridge

Across the healthcare delivery chasm, from where we are, to where we want to be.

Lessons from covid19 – Part 3: Where are we now? What’s next?

As the country starts to slowly evolve from “lockdowns” and “stay at home,” there is understandable fear that the relaxation of restrictions will result in a rebound effect. But unless one thinks that the entire population except essential workers can spend the next several months, rest of the year, next year, or longer isolated at home, there has to come a point when we smartly evolve out of the lockdown. Even some staunch proponents of staying at home, including Dr. Anthony Fauci, are starting to agree. The way we see it, there are three equally compelling and equally difficult tasks our country must accomplish going forward (and frankly should have been addressing better from the start of this pandemic):

  1. Care for covid patients
  2. Care for the non-covid patients
  3. Care for the economy

Policy makers cannot isolate their decisions to only one of these tasks without considering the other two. One does not rise above the other, and while the pace to tackle each might vary a bit, we have to deal with all three, just as in any war multiple tasks must be accomplished simultaneously. And just like in a war, every citizen has a role to play so that the country can accomplish all three tasks. We have prioritized (1) which is appropriate in the short term. We are working on tests, vaccines, social distancing, anti-viral development, we know density plays a major role (cities, nursing homes, poverty), and that the elderly and those with some chronic conditions are more vulnerable. But in the intermediate term, where we find ourselves now, if we do not address (2) and (3), the ongoing situation will make our public health efforts (which have been floundering in recent years with deaths of despair, joblessness, and poverty) even worse. The country has to deal with all three tasks, so we might as well quit fighting to prioritize one task over the others and get on with all three.

So how should the US move forward? It is clear that all states are gradually re-opening their economies. It is possible that those steps could lead to increased deaths. But no strategy is without deaths – and both covid and non-covid deaths must be considered. Given the past experience with flu epidemics, it is also likely that a second wave will hit at some point. To us the following would be reasonable steps for the US to follow going forward.

First, it probably goes without special emphasis that until we are through this pandemic we need:

  • More testing and tracing
  • Maintaining social distancing
  • Masks for all in public when proper social distancing is not possible
  • Ensuring there is an adequate supply of Personal Protective Equipment (PPE) for all essential workers, those in businesses essential for our infrastructure – e.g. healthcare, first responders, electric power, water, food processing, etc.

Assuming we will have some type of second wave, we would recommend the following:

Protect the most vulnerable, but do not re-instate blanket stay-at-home orders.

Instead, follow what the UK’s Imperial College actually felt was the best approach in their initial covid19 report, namely, do stay-at-home only for the segment of the population most at risk – those over age 70 – while letting the working age, lower risk population actually go to work. Many reports and the CDC covid19 tracker have shown that covid19 deaths are concentrated in the elderly population and individuals with significant underlying medical problems. In fact, CDC data as of 5/13/20 showed that ~80% of covid deaths are over age 65 and ~59% over age 75. In other words, the majority of deaths are not just over age 65, but over age 80. A preliminary analysis of the correlation between lockdown severity and excess deaths in Europe suggests that, “…while restrictions on movement were seen as a necessary tool to halt the spread of the virus, when and how they were wielded was more important than their severity.”

Take special steps to ensure the safety of patients and workers in nursing homes – that small subset of our population absolutely at most risk. The World Health Organization has reported that half of the deaths in Europe are coming from nursing homes. And while in the US the nursing home number currently stands at 33% of total deaths, the percentages vary significantly by location, with Minnesota and West Virginia reporting that as many as 80% of covid deaths in each state were in nursing homes. Specific steps would include restricting visitors, increasing testing and PPE access for staff and patients, as well as additional staff training to manage the risk and spread of infection. Ideally, hospitalized patients should be allowed readmission to nursing homes only if they have a positive blood covid antibody test. If only a diagnostic test is available, the patients should be discharged to a nursing facility only if there is a separate, designated covid isolation area or if the nursing facility is a covid designated facility.

The stay-at-home orders, as previously implemented, have significant implications for both the health AND livelihood of millions of people who do not fall into the “covid” category. It appears that to fight covid, we have gone further in shutting down the economy than happened with the most recent pandemics (we did not have data back to 1918). The chart below provides a perspective on previous pandemics with unemployment and GDP growth factored in as well:

Death per million Unemployment GDP growth
1918/19 Spanish Flu 6,553 N/A N/A
1957 H1N1 674 5.2% +2.1%
1968 H1N2 497 3.4% +4.9%
2020 Covid 19* 515 (303 – 727) 11.5% -5.6%
(CBO Est)
*Covid19 death rate based on estimates of 100,000-240,000 total covid deaths by Dr. Deborah Birx, Coronavirus Response Coordinator for the White House Coronavirus Task Force. Unemployment and GDP growth estimates are from CBO report May, 2020

Below are some of the impacts on the lives of people affected by the repercussions of our policies on the economy. Columbia University has estimated that 21M people will be added to poverty. The number of people relying on soup kitchens and food banks has already increased significantly. And as a recent The Hill editorial highlights,

“Mass layoffs during recessions increase both the short-term and long-term age-specific mortality risks of laid-off workers. For middle-aged male workers, mortality rates in the year after being laid off are 50 percent to 100 percent higher than they would have been otherwise. The effect of poverty on age-specific mortality is brutal. In the United States, the poor die 10 to 15 years earlier than the wealthy.”

While the CBO has estimated year end unemployment at 11.5%, others have estimated it could reach or exceed the peak unemployment seen in the Great Depression of 25%. In addition to health impacts of pushing people into unemployment and poverty shown above, there are also the issues of despair, depression, and other mental illness that will play out. Many of the laid off workers aren’t likely to get their jobs back. “Our best guess is something like … 40% (of employment reduction) is going to be permanent,” said Nicholas Bloom, an economics professor at Stanford University.

Moreover, strictly enforced “stay at home” policies lead to isolation – bad enough for multi-person households, but especially hard for single person households. As highlighted in a recent The New Yorker article, 28% of households, or 35.7 million people in the US live alone and this isolation has health implications:

“Prolonged loneliness can even increase mortality rates. In 2015, Julianne Holt-Lunstad, a neuroscientist and psychologist, published an analysis of seventy studies, involving 3.4 million people, examining the impact of social isolation, loneliness, and living alone. The results were notable in light of today’s pandemic. The review found that…social isolation led to an increased rate of mortality of twenty-nine per cent.”

Perhaps not surprisingly, the Substance Abuse and Mental Health Services Administration’s Disaster Distress Helpline saw a ~900% increase in call volume in March 2020 compared with March 2019.

This need for policy decisions to consider implications beyond the immediate threat of covid19, is starting to get recognized by some public health experts: “Dr. George Rutherford, head of infectious disease and global epidemiology at UCSF, points out the balancing act decision makers must perform. Bad economies are as hurtful to health as viruses.”

Do not re-institute policies that emptied out our medical centers of almost all but covid patients.  

Even in the worst hit (areas) stateslike New York and New Jersey, the share of hospital beds occupied by covid19 patients maxed out at ~40%, and in the vast majority of states never rose above the teens or even single digits. Instead, each location should look at how much covid patient capacity was used in the first round and determine how best to handle a second wave. It is of interest that the state of New York is suggesting that going forward hospitals need to maintain 30% of overall and ICU beds unoccupied.

The mandated cancellation of all elective procedures had a devastating impact on the healthcare delivery system, not only from a financial standpoint, but most importantly in its ability to care for the non-covid population. The University of Michigan has estimated there are 10,000 diseases impacting humans. The UK’s NHS has a list of more than 325 common diseases (including conditions like cancer, stroke, heart disease, MS, diabetes, etc.). And yet, all these other diseases, many extremely serious, seem to have been forgotten. Because of the unknown magnitude of resource use that might be required for covid 19, all of these diseases took a back seat (or for many, a couple months with no seat at all). Emptying out hospitals may have been the right strategy for some locations, but to date it appears to not be warranted in many locales. And there are repercussions to the patients that are put off. Some providers worry that, “…the toll on non-Covid patients will be much greater than Covid deaths.”

Moreover, many patients are delaying seeking care because a) they have been encouraged to stay home to protect healthcare workers and flatten the curve or b) they are scared of being exposed to covid in the healthcare setting. Data from various states are beginning to suggest that a “silent epidemic” of non-covid conditions is already in progress. As stated by Dr. Reginald Eadie, CEO of Trinity Health of New England, “Do the significant decreases in hospitalizations for these five serious illnesses [heart attack, heart failure, stroke, appendicitis, gallbladder disease] and the increase in at-home deaths suggest another public health crisis is on the way?” A recent letter to president Trump, signed by hundreds of physicians, outlines the many concerns about the growing negative consequences of the shutdowns on millions of non-covid19 patients. The non-covid patients in the US got short shrift in the first go around with covid. They should not get the same in a second wave.

And the situation is likely not unique to the US. A study by Imperial College, John Hopkins and others indicated that deaths from TB worldwide will likely be increased by 1.4 million people because of the covid mitigation policies. As reported by CNBC,

“This situation makes me sick, because (it) is totally avoidable,” Lucica Ditiu, executive director of the Stop TB Partnership, said via email. “We just need to keep in mind that TB, as well as other diseases, keep affecting and killing people every single day, not just Covid-19.”

In summary, leaders making decisions about the future of our country need to ensure that policies take into account all aspects of this national problem – impact on covid patients; impact on non-covid patients; impact on the long-term health and wellbeing of the population from damage to the economy. One does not rise above the other, we have to find a way to deal with all three simultaneously.

Lessons from the Covid19 Pandemic – part 2

Lessons from the Covid19 Pandemic – part 2

The Bridge

Across the healthcare delivery chasm, from where we are, to where we want to be.

 Lessons from the covid19 pandemic – part 2

Now that we have identified some of the key issues that landed us where we are, what can we do to address them going forward and not find ourselves flat footed again when the next pandemic strikes? And it inevitably will and likely much sooner than we expect – the annual flu numbers make the case that we have an epidemic on our hands every fall. Of note, here we focus primarily on recommendations that apply to the healthcare delivery system. Our views on the path forward, health status/SDOH, and preparedness will be addressed in follow up blogs.

So, here are our thoughts regarding the healthcare delivery system:

1.     Change provider reimbursement: The healthcare delivery world we live in, one of mostly fee-for-service (FFS), is characterized by caring for people and receiving reimbursement only when a patient comes to an office or hospital, and not having control over provider revenue or the flexibility to deploy resources (space, staff, supplies) in a way that creates the most value for patients. This is especially true in an emergency situation akin to the one we find ourselves in, where the delivery system needs to quickly and significantly expand capacity for a specific patient population (e.g., covid19), while continuing to provide care for those with chronic illness or acute trauma. Having the financial flexibility to leverage telemedicine or other models such as Hospital at Home or wellness care at home can go a long way in ensuring the ability to right-size capacity and give continuous patient access to needed care, without the dire financial consequences many hospitals are currently facing. Following mandates and executive orders, providers emptied their hospitals and offices for the projected covid19 patient surge that did not materialize in most places (the situation in NYC has thus far been an exception rather than the rule). Even the minority of providers that did see a covid19 surge still had significant weeks with few patients and thus a dearth of revenue. We suspect that when the crisis-induced dust settles, some of the providers that care for patients under “risk-based” arrangements (bundles, capitation, global budgets) are going to come out on top, both in patient care and financial terms.

2.     Encourage provider leadership: Healthcare professionals need to step up and take responsibility for their sector, rather than continuing to defer to Washington, DC or the state capitols on the best ways to take care of the patient populations and communities they serve. Instead of following blanket mandates and recommendations that do not fully reflect the demographics and needs of each community, providers should have created and stood by their own contingency plans based on their knowledge and experience with the community they serve. Providers should also take a more active role in the development and validation of new technology, rather than internally bristling while waiting for various federal agencies to give their green light on such endeavors.

3.     Re-evaluate the utility of regulatory requirements, starting with those relaxed by CMS during the pandemic (e.g., scope of practice laws, reimbursement for telemedicine services, some HIPAA provisions) to ensure the most effective and efficient delivery of care. The CDC and FDA could also benefit from a review of their regulatory processes and frameworks to ensure that a) they provide for more flexibility and agility by the healthcare sector to respond to emergency situations like the covid19 pandemic and b) to serve as a facilitator, rather than the bottle neck in allowing providers to deliver the best care to their patients. These government agencies do not practice medicine. Their role is to facilitate the work of those who do, by removing barriers, concentrating on logistics, and managing an effective supply chain.

4.     Strengthen the supply chain by creating incentives for healthcare manufacturers to a) diversify their manufacturing locations and b) to move beyond “just-in-time” manufacturing, and include the continuous production of “reserve supplies” and/or create and maintain reserve manufacturing capacity that can be quickly brought online to address a sudden peak in demand for products. In fact, if we actually decided to stop being complacent about the annual flu epidemic and tried to reduce its impact on society, it might behoove us to have additional PPE and other medical reserves on hand as part of the “new normal” in healthcare delivery.

5.     Ensure universal healthcare coverage and let people own their insurance, instead of having it be tied to their employer. Employers (that currently cover >50% of Americans) could still contribute to offset the cost of insurance premiums for their employees, but nobody would be subject to both loss of employment and a loss of healthcare coverage, especially in the midst of a pandemic and yet, that is exactly where we are. And while Congress appears to be working on an insurance fix to address covid19, we need more than a Band-Aid to address the lack of universal coverage in the country. Given the culture of the United States and in our view a need for a bipartisan solution, we feel that a coverage mechanism that builds on the successes of the Federal Employee Health Benefit program, with means-tested subsidies provided by the government, would be a great way to provide universal healthcare coverage.

Lessons from the Covid19 Pandemic –Part 1

Lessons from the Covid19 Pandemic –Part 1

The Bridge

Across the healthcare delivery chasm, from where we are, to where we want to be.

Lessons from the Covid19 Pandemic – part 1

As we continue to muddle through yet another week of uncertainty with covid19, we have been taking stock of the issues highlighted by the pandemic and trying to distill the lessons for our healthcare system and the country as a whole. To quote Rahm Emanuel “never let a crisis go to waste.” So, what do we see? In no specific order, the pandemic highlighted:

  1. A complete lack of preparedness, despite the annual flu epidemics that sicken tens of millions and lead to 20,000-60,000 deaths each year (including the 2009 swine flu pandemic and the 2017-2018 flu season), as well as the 2003 SARS outbreakMERS in 2012, the Ebola scare in 2014, and Zika in 2016. No one can claim the USA did not have plenty of warnings and the need to prepare was highlighted by president Bush in a 2005 address to the National Institutes of Health. And yet here we are, facing shortages of personal protective equipment (PPE), ICU beds, ventilators, pharmaceuticals, and with a testing capacity that lags so far behind what is needed, we may never reopen the country if we are to follow the latest provided guidelines.
  2. Lack of clarity and leadership at the national level, between contrasting and contradictory messaging from public health officials and the White House about the true state of affairs, to the lack of coordination of a national response around both mitigation measures, as well as the sharing and distribution of scarce resources like PPE and ventilators. No real guidelines or strategy were provided by our “leaders” thus pitting states against each other in the scramble to secure resources and issue directives to the general public.
  3. Useless nature of many healthcare regulations from the CDC, the FDA and CMSrecent essay by David Burda does a great job summarizing some of the regulations that have been “relaxed” to help address the covid19 pandemic, e.g., state licensing laws (as if our biology magically changes when we cross the border from CA to AZ), or telemedicine reimbursements (though it remains unclear why commercial insurers have not followed suit on something that makes so much sense in terms of patient care). And the fumbles around covid19 testing by CDC and the FDA are pretty well documented.
  4. Supply chain, supply chain, supply chain. We were frankly distraught to realize how little is actually made in the US these days, especially for such critical industries like healthcare. Considering that bringing manufacturing back was one of the key messages of the president’s platform, it gives us pause as to why we find ourselves lacking PPE, medications, nose swabs and other testing reagents, given that we are in the 4th year of his presidency. As a recent The Atlantic article observes, the pandemic is clearly showing that between off shoring and just-in-time delivery, “The way our modern supply chain is built is incredibly fragile.”
  5. The way we pay for healthcare is flawed. Although the movement from volume to value is alive and well, the majority of healthcare professionals continue to be paid fee-for-service, taking care of people and making money only when patients seek treatment. With many states and cities issuing mandates to cancel elective surgeries (a big source of revenue for hospitals) to ensure bed and ICU capacity for a predicted surge of covid19 patients, what was once thought to be a recession-proof industry is now furloughing workers, instituting pay cuts, and filing for bankruptcy.
  6. Health status and social determinants of health (SDOH) play a major role in patient outcomes. In addition to age, health status appears to have a significant impact on disease severity, putting people with some underlying medical conditions at a greater risk. Preliminary data are also showing a disproportionate impact of the virus on African Americans, Latino and Native American populations. While the healthcare delivery system shares some of the blame (see previous point about caring for people only when they are sick), much of the responsibility lies with our elected officials and addressing such SDOH like education, poverty, jobs, infrastructure, and the environment, that lie outside the realm and expertise of healthcare delivery organizations.
The Coronavirus Pandemic Has Highlighted Hospitals Weaknesses Study by the Lown Institute

The Coronavirus Pandemic Has Highlighted Hospitals Weaknesses Study by the Lown Institute

The Coronavirus Pandemic Has Highlighted Hospitals Weaknesses

Recently we shared one of DMSG Advisory Board Members, Rachel Rogers, MS, BSN-RN, Assistant Academic Director, Healthcare Management Program, University of Denver, University College’s white paper on our website about the dynamics of determining which hospital to go to for quality care, reasonable cost and accessibility to providers.

Rachel put this white paper together prior to the outbreak of the Coronoavirus. We were interested in finding a way to determine which hospital to go to “if I had a choice”. She did a great job of opening that door to analyzing this difficult process.

NOW, with the outbreak of the Coronavirus, the issues of hospital weaknesses have become more pronounced than before. Prior to COVID-19, hospital executives were aware of some concerns about hospitals in general, but now the issues have become more “front page news” so to speak.

So how do we as consumers/patients and healthcare providers/hospital executives expand our understanding of where we as patients want to go or how do we as hospital executives, solve these inadequacies?

One of my favorite hospital executives/leaders, Patty Gabow, MD, retired CEO of Denver Health and Board Member of the Lown Institute, shared with me recently the following story from the Lown Institute which may help us all, both patients and hospital executives.

Here’s the background Patty shared with me:

“The Lown Institute has spent the last two years developing a new hospital ranking method. It utilizes 42 variables in 3 domains for the Medicare population: Patient Outcomes, Value of Care, and Civic Leadership. The outcome data uses a very sophisticated method that is superior to CMS’s method and other published methods.

They have partnered with the Washington Monthly, a DC-based publication that has a highly influential readership. Both the Lown Hospitals Index and the Washington Monthly Best Hospitals in America publication which uses the Lown Index have been released.

The Index is on the Lown website (  It is a very interactive website. I hope you can take a look at it . Many of the “usual suspects” did not do too well.”

My reaction was “this ought to be very interesting” and I wasn’t disappointed. The Lown Institute Hospitals Index does a great job of looking at the 42 variables Patty mentioned under each domain. Then they place a “grade” on the variables and the three domains. I was intrigued with the amount of detail that was included about hospitals in any state, but our primary interest is right here in Colorado.

The three main domains and a few of the variables  are listed below:

  1. Civic Leadership
    +Pay Equity
    +Community Benefit
    +Inclusivity (income, race, education)
  2. Value of Care
    +Avoiding Overuse
  3. Patient Outcome
    +Clinical Outcomes
    +Patient Safety
    +Patient Satisfaction

There is so much more information about the domains and variables when you open the link  You will find it hard to “put it down” so to speak.

Please share the Lown Institute Hospitals Index with others who may not see it here.

One day at a time,

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


Five Questions & Responses Providers Shared on DMSG Survey 6.23.20

Five Questions & Responses Providers Shared on DMSG Survey 6.23.20

June 23rd DMSG Meeting Survey Responses of Healthcare Providers

As part of the Planning Tool Survey that we did at our June 23rd DMSG meeting, pur guest speaker, Dana Jacoby, suggested that we add the following five questions to gain an understanding of what our healthcare providers were dealing with during this COVID-19 pandemic. I think you’ll enjoy seeing their responses below.

Here they are:

+Has COVID-19 caused you to reduce your services to the community?
60% said No
40% said Yes

+What percentage of furloughed employees do you plan to rehire?
100%  rehired = 36%
95% rehired = 7%
90% rehired = 7%
None furloughed= 43%
Other =  7%
(Total = 100%)

+Has the COVID_19 created leadership and/or culture challenges?
None = 12%
Short-Term = 52%
Long-Term and Short-Term = 18%
Long-Term = 18%
(Total -= 100%)

+Do you anticipate reducing services over the next 12-18 months?
No = 53%
Maybe = 29%
Yes = 18%
(Total = 100%)

+Are you adequately prepared if there is a COVID-19 resurgence?
Yes = 42%
No = 5%
Unsure at this time = 53%
(Total = 100%)

DISCLOSURE: As far as surveys go, our effort was fairly limited but did reflect those healthcare providers who completed the survey on June 23rd. So enjoy and feel free to email me at with any comments or responses to these questions you might have.

Chris Hadley
Founder and President

I don’t feel well. What do I do now?

I don’t feel well. What do I do now?

I don’t feel well. What do I do now?


Where should I go for my care? That is a loaded question. Do you have a choice?

  • Don’t have a choice – Trauma, Medicaid, where your physician has privileges
  • Have a choice – How do you find out where to go

Yep – super user friendly!!! Right???!!!

Using Hospital Compare from the CMS website, can compare hospitals against a number of variables. This tool is available for nursing homes 


I am a nurse. If someone…anyone in my family gets sick, I get a phone call, an email or a text. What should I do? Where should I go? Do you know anyone at (insert hospital name here)? For the most part, I do know what to do. I do not have all of the medical answers, for sure, but I can do a quick enough triage to know whether I have enough information to make a decision. Go to the emergency room. Make an appointment. Get a referral for a specialist. I agree with your doctor.

What if you don’t have a nurse or other medical professional in the family? How do you know where to go? How do you even know if you have a choice? These are questions asked every day by folks who are likely already stressed out by some health concern.

Luckily, if you have access to the internet, there is a wealth of information at your fingertips….if you know where to look.

The first question to ask is, “Do I have a choice of where to get my care?” That is a tricky question. It is best to check with your insurer to see which facilities are considered in-network. That will help keep your costs down for elective procedures. If you have a Primary Care Physician (PCP), ask where they “have privileges” to practice. This means they can be your primary doctor while you are in the hospital. Some PCPs do not practice in the hospital and leave the job of in-hospital care to a group of “Hospitalists.”

Urgent and Emergent Care is another whole can of worms and perhaps the topic of another blog. Suffice it to say that The Affordable Care Act of 2009 requires that insurers cover emergent care regardless of location or whether the provider in a location is in or out of network. If you need to go to the Emergency Room, call 911 or go to the nearest one!

Let’s get back to finding the best place for an elective procedure or hospital stay due for a non-urgent issue. Head to the Medicare website, “Hospital Compare” and follow along. After entering your zip code, you can see, at a glance, how many hospitals there are in a 25 mile radius, a list of those hospitals and a few key data points. Select the button to add up to 3 hospitals to your comparison list. I have my 3. Do you? Yes? Ok, now select . Across the top of the page, you will see seven tabs with different topics. Here are my tips for viewing this section.

  1. You will not notice much variation in any of the Acute Care Hospitals’ General Information. Skip it!
  2. The next tab is “Survey of Patients’ Experiences.”
    1. These are results of the “Hospital Consumer Assessment of Healthcare Providers and Systems” surveys.
    2. The results are much like when you go to the car dealership and they ask you for a 5 out of 5 rating. The same thing is true here. Notice words like “Always,” “Strongly Agree” and “Definitely.”
    3. If you want to see a little bit more information, select the “View More Details” button.
    4. What you will likely notice is that all of the major hospital systems are pretty close together as far as their patient experience scores go.
    5. The take home message in patient experience – There will be good things and bad things no matter where you go.
  3. The subsequent 5 tabs. Here is where you can go to see more specific information about topics like surgical site infections, outcomes and payment information on hip and knee replacements, readmission rates (like I got discharged from the hospital too soon and had to go back), and the like.
    1. I get a little nervous when I’m looking at something and the information says something like “sample too small.” What this says to me is that the facility isn’t doing a whole lot of this procedure and maybe it’s a good idea to find a place that is.

If you are looking for a rehabilitation hospital or skilled nursing facility, also has “Nursing Home Compare” This is a great place to start looking for a longer term care facility if needed. In this comparison, you can see health inspections, fire safety information and quality of care.

It’s probably a good idea to still call that family nurse or doctor friend. We’ll wonder what’s wrong if you don’t!

By Rachel Rogers, MS, BSN-RN, University of Denver
Assistant Academic Director/Assistant Teaching Professor

Healthcare Management Program


“Find And Compare Information About Hospitals | Hospital Compare”. 2019. Medicare.Gov.


“Affordable Care Act Implementation FAQs – Set 1 – Centers For Medicare & Medicaid Services”. 2019.

Digital Health – Perfectly Positioned Across Populations

Digital Health – Perfectly Positioned Across Populations


Digital Health – Perfectly Positioned Across Populations

The emergence of Digital Health technologies (Telehealth, Telemedicine, Virtual Health and Wearable Devices) in the U.S. is becoming rapidly prevalent to serve population health. Digital Health’s inherent ability to accommodate generational norms and values is its key.  As people become more mobile, its important telemedicine becomes entrenched so that healthcare delivery and health systems alike can:

  • accurately track the needs of the patient,
  • provide timely responses which many times are critical and
  • serve the greater good by providing data which informs new innovations and more efficient processes.

As a next step large scale participation will be the key to providing adequate sample sizes for more accurate data and to realize new innovations.  To accomplish this, we must first explore whether it’s likely that each generation will buy into these technologies.

Generation Z’ers

First, let’s begin with the Gen Z’ers (those born 1995 – 2015) inclination for being “wired,” have largely never known a world without electronic devices that provide seemingly infinite access to information.  Smartphones, Wi-Fi and Google are what older generations may consider innovations, but for a population which makes up 24.3% of the collective U.S. population, these have always been part of their life (Grace et al., 2017; U.S. Census, 2016).  Digital Health comes naturally to Z’ers, its helps to manage their lives and minimize trips to their physicians.  For instance, when a Gen Z’er does need medical advice, they are much more likely to seek attention from a provider virtually.


Moving on, we turn to Millennials (those born 1981 – 1996). Similar to Gen Z’ers and projected to become the largest generation in 2019, they also embrace a life prevalent with technologies a generation that has championed the retail clinic for basic medical needs is also in the technological “sweet spot” we know today.  While Millennials weren’t necessarily born into the smartphone revolution, they still were at a perfect age to adapt and develop an affinity for the advances which made their lives not only easier, but innovations that didn’t disrupt their day-to-day break necking pace.  Pennic (2019) illustrates:

Nearly one-third (29 percent) of respondents have used some form of virtual care — up from 21 percent in 2017 — and almost half (47 percent) have used a walk-in/retail clinic. Further, consumers would prefer non-traditional methods over traditional ones for certain basic medical needs, including cold/virus treatment (65 percent vs. 48 percent), flu shots (62 percent vs. 54 percent) and checking vitals (59 percent vs. 54 percent).

Given that Millennials are projected to become the largest generation, coupled with the 24.3%t Gen Z population, a major challenge in institutionalizing telemedicine across generations is complete.  In turn, as the health industry conversation surrounding social determinants gains momentum, biometric data sent from these wearable devices to data warehouses and/or physicians monitoring patients provides information on not only who may or may not need care in a given moment but also with population health trends.  In fact, according to HIT Consultant (2019) who published Accenture Survey: Millennials and Gen Z Embracing Virtual Care Models (2019) state, “Half (51 percent) of all respondents said they use a wearable or mobile app to manage their lifestyle and healthcare conditions and more than half (53 percent) use virtual nurses to monitor health conditions, medications, and vital signs.”  But what’s in it for those Gen X’ers and Baby Boomers and are they likely to conform?

Generation X’ers

Gen X’ers (those born 1965 – 1980) sometimes called the “middle child” of generations, turns out to be a perfect label in this vein because they are incredibly adaptable.  For those of us who are middle children or parents of them, we likely understand how adaptable and resilient they must be for their survival.  Gen X’ers were young professionals at the inception of Personal Digital Assistants (PDA’s).  This generation’s need for convenience combined with their ability to adapt are both compelling for the emergence and prevalence of virtual care.  However, the “middle child” generation, or at least those who reside on the side of an old-fashioned need for human interaction, may or may not be as welcoming to seeing a doctor on the smartphones.  Let’s split the difference and for those are opposed to interfacing with doctor on a digital device and/or virtual doctor, would still likely find it convenient to don a wearable device since this is minimal hassle.

Baby Boomers

Last and perhaps the toughest sell for telemedicine are the Baby Boomers (those born 1946 – 1964).  It’s reasonable to assume this generation likely has the largest number of people that maybe will struggle with technology.  However, let’s remember that at least for the purposes of the topic surrounding telemedicine/virtual health, we really are only focusing on the capabilities of wearable devices which do not require a ton of technical savvy.  According to Ryback (2016), “Baby Boomers grew up making phone calls and writing letters, solidifying strong interpersonal skills. Yet as they got older, they actually became fluent in technology and now use cell phones and tablets.”  Additionally, let’s also remember that either the Gen X’ers, Millenials or even the Gen Z’ers will be charged as primary caregivers as the Baby Boomers get older requiring more care.  If a Baby Boomer would prefer to remain as independent for as long as possible by not being forced into geriatric care, Digital Health may be a critical key.  For instance, if a Baby Boomer is unable to drive but needs immediate care, it could either be triggered by a wearable device which transmits the need for care to a nurse who then dispatches medical professionals to the patient.

As with most things, there are always pros and cons depending on how we choose to steer our perspectives.  When it comes to these ground-breaking Digital Health innovations, it seems there is enormous potential to serve a large number of people across generations.  The generational characteristics may in some ways be generalizations, but that doesn’t mean they are not well-founded.  We would venture that even through this short argument it is conceivable the Digital Health benefits has potential across generational populations and a high likelihood of continued adoption and innovation.

Follow up questions to think about?

  • Did your generation summary resonate with you?
  • Are there ways you might want to engage more with Digital Health after reading this?
  • Do you see the potential for new ways to use Digital Health?

With these answers in mind, think about possible cost and time savings.


By Dr. Bobbie Kite, University of Denver
Bobby Balke, University of Denver

Article Written 7.12.19, shared here on 7.7.20


Facts and Trends. LifeWay. (2018, October 31). 10 Traits of Generation Z. Retrieved from

Pennic, J. (2019, February 15). Accenture Survey: Millennials and Gen Z Embracing Virtual Care Models.

Retrieved from

Ryback, R. (2016, February 22). From Baby Boomers to Generation Z. Retrieved from





A Note to Hospital & Health System CEOs & Boards, by David Pate, MD, Part IV

A Note to Hospital & Health System CEOs & Boards, by David Pate, MD, Part IV

A Note to Hospital and Health System CEOs and Boards

The Time to Seriously Reevaluate Your Organization’s Strategy is Now

Part IV

This is the last of a four-part blog series on reevaluating your organization’s strategy. If you read the first three blog posts, you have considered the following very important factors as you contemplate what your strategy should be:

  • Your financial repositioning following the pandemic.
  • The financial pressures on the individuals, companies and local governments you serve.
  • The potential impact of the 2020 elections.
  • The potential impact of the Supreme Court’s decision on the constitutionality of the ACA.
  • The threats caused by disruptors and especially private equity and venture capital firms.
  • The changing consumer expectations and their fears about seeking services at hospitals.
  • The upcoming realignment of the health care delivery system, particularly for critical access hospitals, community hospitals and independent physicians.
  • The stability of your relationships with your employed physicians.

So, here is my question for you. I am willing to bet money that you have told your board at sometime in the past that fee for service is the problem and value is the answer, or your boards have heard about this at a conference or from an outside speaker, or you have had consultants that have told you and your board this, and most likely all three are the case. Am I right? If so, do you still believe that? Has anything changed to convince you that the current health care spending is sustainable and that the pressures on politicians to address insurance coverage, health care costs, the viability of social security and Medicare, and drug costs will go away, especially during an economic downturn? Are you convinced that employers are going to continue to willingly incur ever rising health care costs in the face of a downturn in their own business?

If these questions were not enough to get your attention and convince you that you are going to have to make a decision as to whether you continue to milk fee for service for all its worth or whether you change strategic direction and pursue value, let’s consider the numbers. Ask your CFO to create a graph or table or whatever method she wants to portray the numbers and take a look at the following 3 or 5-year trends (up to year-end 2019; let’s not confuse things by including the disruption caused by coronavirus):

  • Inpatient and outpatient episodes provided to Medicare and Medicaid beneficiaries as a percentage of all episodes of care for which there was a payer. (In other words, is there a trend in patients moving onto Medicare and Medicaid, which will obviously impact your revenue per case?)
  • Growth in inpatient services vs. growth in outpatient services
  • Net revenue per adjusted admission vs. cost per adjusted admission

There certainly are parts of the country that have been relatively spared from declining fee for service revenues and/or profitability, but my guess is that the majority of hospitals and health systems have been seeing a shift in payor mix to more lower revenue governmental payers at the expense of higher revenue commercial payers, a movement of services that used to provided as an inpatient to lower revenue outpatient settings (get ready for a movement of all but the highest risk total hip replacements to the outpatient setting), and rising costs per case that will threaten your profitability if you cannot also get increases in revenue per case, which you will be unable to get from governmental payers.

As has oft been quoted, “never let a good crisis go to waste.” I would urge you to forecast your profitability under fee for service, given what I imagine were deteriorating metrics even prior to coronavirus, but also with the environmental factors I discussed in the earlier blog posts of economic conditions, cost pressures on your customers, new market entrants and disruptors, changing relationships for physicians, and a continued movement of inpatient services to outpatient settings.

Then, I go back to my earlier question – do you still believe that fee for service is the problem and value is the answer? If not, stop saying it. If so, read on, because I am going to argue that now is the perfect time to make the shift in your business model.

I know this is hard. I have led a transformation of my organization’s business model, and it is not easy. We undertook preparations for a shift in our business model for seven years and then pulled the switch on January 1, 2017, moving nearly a third of my health system’s revenue largely to percent of revenue arrangements (think global capitation). You might ask why then and why that much.

Why then was because my team and I and our board saw the writing on the wall. We realized that change was coming and that it would be far better to make that change while we were still doing well in our current business model to help fund early losses that would be associated with a change in business model. Secondly, we expected, and it turned out to be correct, that there would be a first to market mover advantage. Plus, we had used that preparatory time to gain the alignment of our staff and physicians. Everyone knew this was the right thing to do and people were excited to do it.

Why that much was because of human nature. I hear of many health systems who say that the answer is in moving to value, but they only pay it lip service with putting 2 – 4 percent of their revenue at risk. That level of risk is not enough to change behavior of your leadership team, your physicians or your staff. I can assure you that it is difficult to make the investments necessary to manage risk if you only have several percent of your revenue involved. And, the organization will not change its behavior. When you have a downturn in finances, the first response will be to increase volumes.

We know from history that many companies have failed in transforming their business models when they were still doing well in their current business model, even when they were convinced that change was coming.

The reason that health care leaders should look at transforming their business model now is that almost no hospital or health system is doing well in their historical business model today. And, if they look at their 3 to 5-year trends, as I suggested above, I think most will conclude that fee for service was on the decline even before coronavirus. Then, if you consider the changed environmental factors I have presented in the earlier part of this series, I think most will conclude that things do look bleak, at least for the next few years.

But, I always prefer making strategic decisions based on opportunity rather than merely responding to threats (though I think anyone would be foolish to ignore the threats). It turns out that the coronavirus has actually presented tremendous opportunities for being more successful in moving to value now than we had when we did this back in 2017. What are those opportunities?

  • People are currently hesitant to proceed with “elective” procedures. (Note: This is bad for fee for service!)
  • Many people have tried telemedicine services for their health care during the pandemic and they like the convenience and safety of it. (Note, in those cases where payers pay less for telehealth visits than for in-office visits, this is also bad for fee for service)
  • Physicians are currently providing a lot of the services that previously would have been provided in the office by phone or by skipping the office visit altogether. (Again, bad for fee for service) Here is an example. My wife had an open reduction and internal fixation of her humerus in December, just before this outbreak. She was scheduled to come in and see the surgeon for a post-op visit last month, at which time she would have an x-ray to check alignment of her bone fragments. The physician’s office cancelled the office visit and just directed my wife to get the x-ray and then the doctor would call her. We did and it saved us time and convenience. Okay, you might argue, well that visit should have been included in the global surgical services fee, but you are missing the point. How many services were we making patients come in for that weren’t necessary? And, because of the pandemic, we actually have physicians deciding what is necessary and what is not, which is exactly the thinking we want under value arrangements, rather than insurance companies making those decisions under fee for service. Further, most every health system has access problems. This is why urgent care clinics, retail clinics, telehealth providers and other disrupters have been able to capitalize on this opportunity to see patients that health systems otherwise would have seen. But, now, with this change in behavior to not make patients come in to the office that don’t need to be seen despite the incentives under fee for service, under value arrangements, we still meet those patients’ needs less costly without an office visit, but we also have just freed up time to see a patient who does need to be seen who we otherwise would not have seen and they either may have gone to one of these alternative care sites or worse, their condition may have deteriorated by the time we could see them to the point that it is now more expensive to care for.

All of these present opportunities for us to manage risk, to lower costs, to promote better access, and to provide care in ways to patients that they are likely to prefer. And, we can look at other opportunities that disruptors were already beginning to pursue even before the coronavirus outbreak, such as mobile health care services that bring care to the patient’s home and hospital-at-home services.

And, the ultimate beauty of this is that while the disruptors and those who are promoting the disaggregation of health care services can beat us at fee for service, very few of them can or, even if they could, would want to manage global risk arrangements. Health systems are uniquely positioned to do this. And, large employers like Walmart, have already realized what I have been arguing for a decade now. The answer is not in a lower unit price. The answer is in controlling utilization and getting high quality services when they are needed. Fee for service does not incent either of these goals. As other employers come to realize this is true, I think private equity and venture capital firms may be happy they sold their health care holdings several years from now.

You know how you fared under fee for service during this pandemic. How would you have fared under full value arrangements? Well, just compare the quarterly earning reports for hospital companies versus those of the insurance companies. There is your answer. Now, I know you are thinking, but this pandemic is going to end sometime, perhaps next year, and things will go back to normal. If you are thinking this, you need to go back and reread the first parts of this blog series.

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A Note to Hospital & Health System CEOs & Boards, Part III, by David Pate, MD

A Note to Hospital & Health System CEOs & Boards, Part III, by David Pate, MD

A Note to Hospital and Health System CEOs and Boards

This is part III of a four-part blog series entitled, “The Time to Seriously Reevaluate Your Organization’s Strategy is Now.”

The health care delivery system in the U.S. is about to realign. The pandemic has likely accelerated alignment decisions that hospitals and physicians were already considering or would likely soon consider even if it were not for the coronavirus.

With all that has happened, do you remember back to last year and the year before? Do you remember the discussions from leaders all across the country that fee for service was the problem with the American health care system and value was the answer? Now, I should be clear. When I refer to value, I mean risk – downside risk. We won’t align incentives with pay for performance or upside only arrangements and shared savings arrangements are unlikely to work in the long-term, they haven’t so far.

While it seemed that health care leaders across the country and even CMS and HHS agreed that the answer was in moving to value, that was the easy part. The hard part is how? I will have more to say about this in Part IV.

But questions circulated as to how big do you have to be to take on risk? What is the role for a critical access hospital in a value world? What about an independent community hospital? What about independent physicians?

For small or independent hospitals, before the pandemic, the question of survival as an independent entity was largely a strategic one – a question that revolved around the world view of the board and CEO. How long would the world remain the same relative to health care? Could the hospital ride it out in fee for service and maintain its independence for the foreseeable future, or even if change was coming, could we ride it out for now, but still have time to make a different decision later if the world does change? For a number of these hospitals, the pandemic has stressed already challenging financials and now the question may be not only the strategic one, but one of financial survival.

For independent physicians, many may never have faced an existential financial threat to their practice before. The pandemic has likely financially impacted nearly every practice negatively. Unlike hospitals, physician practices do not ordinarily strive to have a significant number of days of cash on hand. They typically have few reserves for a situation like this. Most often, a significant cash flow event will cause physicians to make up for it by reducing expenses (lay off staff) and reducing their incomes, both of which are very unpleasant.

Even before coronavirus, many physicians were considering where health care was headed and what their best options would be. While physicians generally value independence and by nature, like to be the ones in charge and making decisions, independence comes at a cost. Practice expenses increase every year, but except for large groups or physicians in short supply, they often have little leverage with managed care companies and may not see revenues increase enough to cover the increasing expenses. Plus, regulations continue to become more burdensome, submitting claims and collecting payments has generally become more challenging given the number of insurers and the differing rules for each payer, and administration of the office continues to become more complicated and less fun.

After this pandemic, or even during it, many physicians may be rethinking their risk tolerance and may seek greater security and ease of practice administration through employment. Others may wish to remain independent, but may seek other revenue streams to provide greater protection, or at least more control, in anticipation of another disruption to their practice.

So, what does this all mean for health system leaders? First of all, open up your channels for communication. Smaller hospitals may want to have exploratory conversations. Even if your health system is not interested in acquiring that hospital, you will need to consider the implications if that hospital is acquired by one of your competitors.

The other thing is you need to begin conversations with your physicians – both employed and independent. You need to know how these physicians are doing, what they are feeling, what concerns they have and whether your relationship is secure.

One of the first questions is whether they felt supported and protected during the pandemic. Unfortunately, I have heard directly or indirectly from physicians across the country who did not feel supported. Physicians who did not feel cared for and did not feel that they had adequate protections. Unfortunately, there were some isolated instances where leaders did not respond productively to care givers’ concerns about safety. I cannot imagine that those physicians will feel any loyalty to those hospitals or those leaders, if they don’t feel respected and cared for.

Even if the physicians did feel respected and cared for, and I am sure that this is the case for the vast majority of hospitals and health systems, they may have concerns about the hospital’s finances and their long-term viability. They may be concerned that the path to financial recovery means cutting physician salaries, because this is exactly what would have happened in their private practice when they were independent when cash flow was impacted. In my experience, physicians are very unlikely to come to the leaders and express their concerns or worries directly. Instead, they may assume the worst and look for a more stable and secure arrangement. Therefore, you need to have these conversations with your physicians and be open and honest about your situation and your plans to recover.

And, even if the physicians felt respected and cared for, and even if they are not concerned about the financial viability of the hospital, you are unlikely to know who is meeting with your physicians and what they are offering. As I mentioned in Part II, private equity and venture capital firms will be looking for better returns than they can make in the bond or stock markets for the foreseeable future. Health care will be one of the opportunities they pursue. They already were prior to coronavirus. Plus, as I mentioned in that previous blog post, they can play off of patient fears about going to hospitals.

I mean no disrespect to physicians. They are brilliant people and amazing professionals who make tremendous sacrifices for their patients, often at the expense of their families and/or their own well-being. But, as brilliant as they are, they are often unsophisticated about business. These private equity and venture capital firms can make all kinds of representations about how much better life can be, how they will be in charge and making all the decisions, how they will have a seat at the table, how they will be far more secure, and the amazing returns they can expect. I haven’t seen one yet that was upfront with physicians and explained the risks and made clear that the way the firm would make more money is to become more efficient (i.e., staff reductions – all that control physicians thought they were going to have over staff and personnel matters – gone), more productive (i.e., all that control over your schedule and how often you would see patients – gone), add more services (i.e., drive more volume for higher revenue-generating services), and that in 3 – 5 years, when the cash flow and profit margin are increased, the firm plans to sell the practice (i.e., you will have a new owner and you don’t have a say in who that is, it will be whoever offers us the most money).

As part of your review of your strategy, you must reassess your physician relationships. Your strategy will do you no good if you do not have engaged physicians to drive the strategy forward.




A Note to Hospital and Health System CEOs and Boards, Part II, by David Pate, MD

A Note to Hospital and Health System CEOs and Boards, Part II, by David Pate, MD

A Note to Hospital and Health System CEOs and Boards

The Time to Seriously Reevaluate Your Organization’s Strategy is Now

Part II

In Part I of this series, I encouraged health care leaders and their boards to reevaluate their strategic plans in light of the impact of the pandemic as well as the changes in health care that we likely will face with the new normal. In Part II, let’s continue the exploration of what some of these new pressures will be.

As hospital leaders, facing the tremendous financial pressures that you have experienced with loss of revenues and services, you are likely focusing on increasing your revenues by restarting services, as well as cutting expenses since those lost revenues will take quite some time to recover. Guess what? Almost every company and individual you serve will be doing the same thing. While there are exceptions, most companies experienced a significant loss of revenue and will only slowly be able to regain their business. Individuals, too, have lost work and income and likely have incurred more debt. For those who regain work, their hours may be limited, their commissions may be a lot less, and they, too, are likely looking for cuts to their household expenses. It is not likely that most had met their deductible before the coronavirus shut things down. Meeting their deductible now may be a significant deterrent to them seeking any “elective” services anytime soon.

Given the financial realities we are facing, I would suggest that unlike the past, we cannot “make it up on volume.” We have to think differently. Companies and governments will all be looking for cost reductions and health care costs will be a line item with a target on its back. I would also caution health care organizations to no longer think of ourselves as immune from market forces. I would challenge you to think of one industry or one company that has been successful in the long-term by ignoring consumer’s complaints that their product or service is too expensive for substantial numbers of their customers.

I want to suggest that things are different. I want to point out that disruption was coming to health care and I want to make the argument that coronavirus will only accelerate that disruption. Let me explain.

First of all, let me remind you that disruption was already underway before the coronavirus outbreak. You likely haven’t considered that free standing imaging centers, ambulatory surgery centers, free-standing cardiac cath labs and physician-owned surgical hospitals have largely come about and expanded over the last three to four decades. Even more recent was the development of so-called “micro-hospitals.” Also, more recent, the development of telemedicine and telehealth services. Even more recently, mobile health care services to provide primary care or urgent care to people in their homes and also very recent, the design of hospital-at-home services. We can all think of additional examples of disrupters looking to break into the $3T health care industry to get their bite at this, but making services more convenient, more affordable, and a better experience.

Okay, so no one is surprised by this. What is my point? My point is that coronavirus has just handed them a big helping hand. First of all, patients are already saying that they are going to put off all of those services that make hospitals money under fee for service. Surveys indicate that some will put those services off 3 months, some 6 months and some a year. Oh, and what do you think happens if we do have another bigger, deadlier second wave this fall? You would be foolish to think that patients are not going to consider the appeal of these non-hospital settings to receive care as opposed to hospitals where they take care of patients with COVID, even though their concerns may be unfounded.

Second, given at least an economic recession and possibly a depression, the financial pressures on people and the companies or local governments they work for are going to be immense. The appeal of benefit design to drive employees to lower cost settings will be significant.

Further, coronavirus did a lot to force some people to try out telehealth services who before would not have considered them or preferred an in-office visit. From the surveys I have seen, it appears that many who tried it liked it and may enjoy the convenience of it in the future. If hospitals and health systems don’t make this offering available, there are plenty of telehealth companies who will step in to provide it.

Now, I’ll explore this more in Part III, but let’s consider this. The bond market and the stock market are likely not going to be great investment vehicles for the short-term. There will be a lot of private equity and venture capital looking for places to safely and profitably invest their money. It would be a serious misstep for us not to assume a lot of it will go into health care. This, coupled with physicians who have had their businesses turned upside down, probably for the first time in their careers, will be willing partners to create new opportunities for financial returns that can take advantage of the new market realities.

It is not my intention to only identify the problems facing health systems. I will talk about solutions, but first, it is important to finish exploring these challenges because change is hard, and few are willing to make sufficient changes until forced to do so. I want to make the case that while people naturally tend to believe making changes are risky; I want to make the argument that not making change is riskier.

In Part III, let’s discuss physician challenges and opportunities.