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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.

“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.

 

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.
Why not Medicare-for-all take 2

Why not Medicare-for-all take 2

About a week ago, a group of progressive Democrats unveiled their latest plan for Medicare-for-all. While we wholly support universal coverage, we also have a number of concerns about this, and other Medicare-for-all proposals. We have previously outlined some of these concerns, but the latest developments seem to warrant a follow up discussion.

First, it seems like it may be beneficial to go back to some basics, specifically, a) what is the purpose of insurance and b) who/how should we pay for universal coverage. It appears that, as a country, we have largely lost sight of both items.

So, let’s start with the first, what is the purpose of insurance? It appears that in any sector (other than perhaps healthcare), the purpose of insurance is to protect/provide coverage against unexpected and primarily catastrophic events. We would be hard-pressed to find car or home insurance policies that cover routine items like oil changes or house painting. Instead, the policies focus on big ticket items like collisions, fires, floods, etc. While some individuals choose to purchase additional coverage for appliances or major repairs, basic car and home owners insurance cover truly ‘catastrophic’ events. And yet, when it comes to healthcare we have come to expect coverage from A to Z (although, ironically enough, the traditional Medicare program, does not have catastrophic coverage and 4 out 5 beneficiaries have supplemental policies to close this gap). If we truly aspire to provide universal health insurance coverage, it would behoove our elected leaders to start by providing basic catastrophic coverage to all (in fact, such a provision was included in the 2017 Cassidy-Collins proposal), rather than trying to push through a fully comprehensive package that would force them to use up all of their political capital AND break the county’s bank in the process.

And on that note, this latest proposal goes beyond even current traditional Medicare by offering to cover all expenses for all healthcare and medications. There would be no out of pocket payments by anyone. Non-government insurance would cease to exist, it would not be needed. This sounds very appealing to many. Yet, this proposal (and many others like it), fail to provide any detail on how much this new program will cost nor from whom the money will come. A quick digression, if we may, although many elected officials and the media like to talk about ‘free healthcare’, healthcare is not free, we are all paying for it in one way or another (see exhibit 1, the flow of funds in U.S. healthcare). So, whatever the final price tag might be, WE are all on the hook to pay for it.

Now, there are a number of ways that WE could pay for universal coverage (including the items shown in the above exhibit), but the ones that have been proposed thus far, include additional payroll and income taxes. It may be of interest to those pushing forward the latest proposal to learn from the experiences of Vermont, Colorado and California (see exhibit 2) and pressure test their assumptions.

Exhibit 2

They might also take note of how quickly the support for single-payer healthcare dwindles, when citizens are faced with the prospect of higher taxes or with the fact that people would lose their private health insurance coverage (see slides 5 and 9 in particular in Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage by the Kaiser Family Foundation).

And if the arguments above do not suffice, the skeptics among us, may be convinced by the opinion of the Nobel prize winning economist, Paul Krugman, on why single-payer is not a feasible goal for the U.S.:

  • “…single-payer would require a lot of additional tax revenue – and we would be talking about taxes on middle class, not just the wealthy…”
  • “Finally, and I suspect most important, switching to single-payer would impose a lot of disruption on millions of families who currently have good coverage through their employers.”

The math behind Krugman’s “most important point” on why single payer is hard to implement in the U.S., is not complex (as exhibit 3 below highlights). Whether the move to single-payer is based on our current traditional fee for service version of Medicare, or on the new proposal for a vastly enriched Medicare-for-all program, it has a number of implications:

  • 181 million people will lose their employer provided private insurance. Of course, not all of them will be opposed to an insurance-for-all option. Currently, the need to consider COBRA coverage or be temporarily uninsured acts as a barrier to employees who increasingly want to be much more mobile. So while we don’t think Medicare-for-all is the best pathway there, we (and others) strongly support universal healthcare insurance that is not tied to employment, but rather owned by individuals.
  • Another 20.4 million individuals currently enrolled in Medicare Advantage Plans (i.e., private insurance options within Medicare) will find their choices of private plans would cease.
  • And 65 million people in Managed Medicaid (i.e., Medicaid benefits administered by private payers) will find their care disrupted.

 

Exhibit 3

Another key argument we often hear from single payer advocates is that we need single-payer because ‘other countries achieve universal coverage that way.’ In our latest blog, we have already alluded to the fact that there are many ways to get to universal coverage that have been used by other countries. Moreover, even countries with single-payer coverage (e.g., Australia, Italy, U.K., Canada – although the latter is not even true single-payer), have a supplemental private insurance market (see table 1 here), highlighting the fact that single-payer does not all healthcare problems solve.

Given the culture and history of the U.S., a more politically feasible and fiscally responsible proposal for universal coverage would be to extend the Federal Employee Health Benefit Program (FEHBP) to all U.S. citizens. Even single-payer advocates like Alexandria Ocasio-Cortez recently tweeted about how great her congressional insurance is. We believe that the ‘You Get What We Have’ would be readily embraced by the American public across the political spectrum, and legislation could require that all participating insurers are non-profit (click here for an overview of the FEHBP).

US Healthcare From an International Perspective

US Healthcare From an International Perspective

The Bridge

First, spoiler alert – there is no perfect healthcare system. Every system has pros and cons, and if you don’t believe us, maybe you would consider the conclusions reached by the Organisation for Economic Cooperation and Development (OECD) in their report, “Health Care Systems: Getting More Value for Money”:

  • “There is no health care system that performs systematically better in delivering cost-effective healthcare.”
  • “It may thus be less the type of system that matters but rather how it is managed.”
  • “Both market-based and more centralized command-and-control systems show strengths and weaknesses.”

Nevertheless, we continue to see healthcare systems rankings in the media, with the US consistently at the bottom, while the system ranked best changes depending on whom you ask, what you ask, and what measures you use.

If you were trying to rank a country’s healthcare system, what criteria would you use? We often hear that the US system is terrible because we spend a lot (which we do), but our life expectancy is not commensurate with the spending. But is life expectancy a good measure of the healthcare delivery system? The US is a big country with a diverse population and when we look more closely, what we find is that sub-segments of the US population have the best life expectancy in the world, while others are on par with developing nations, despite getting care in the same system.

Moreover, if fatal injuries are excluded from life expectancy calculations, US life expectancy rises to the top. Should we really hold the healthcare system accountable for murders, car fatalities, and drug deaths (although the healthcare system bears significant responsibility for the recent opioid related epidemic)?

Some of the reasons for why higher US healthcare spending does not translate to higher life expectancy include:

  • Focus on acute care, rather than measures to address lifestyle, environmental, and social circumstances that have a much greater impact on overall population health than health care delivery. Moreover, as we have discussed previously, the money spent on these social determinants of health isn’t generating a good return on investment.
  • High use rate of expensive diagnostics (e.g., CT, MRI) and interventions (e.g., C-sections, knee replacements), that again have limited impact on life expectancy.

Thus, we would argue that life expectancy is a poor measure of the healthcare delivery system, since it depends on many additional factors beyond healthcare delivery.

So, if not life expectancy, what can we use for comparison? We feel that mortality amenable to healthcare is a better measure of the healthcare delivery system and especially so, when applied judiciously. What do we mean by that? Again, taking into consideration that the US is a large and diverse country, it makes more sense to compare for example MN and WI with Sweden.

So, what does mortality amenable to healthcare look like for the US as a whole? Once again we find that some segments of the US populations have access to the best healthcare in the world, while others fall significantly far behind. In fact, the top five states in the United States consistently rank among the best OECD nations, while the bottom five states trail all of OECD. Perhaps, when it comes to healthcare quality, we may be better served by within-US, rather than international comparisons, and strive to learn from those providers who are consistently able to deliver high-value care within the context and constraints of the current US healthcare system.

That said, there are still opportunities for the US as a whole to learn from other nations, for example along the following dimensions:

  • Universal coverage is a very good goal and there are multiple ways to get there. UK, Netherlands, and Singapore are three good examples of that. All have universal coverage, but very different ways to get there, using the approach that takes into consideration each country’s culture. For example, Netherlands offers choice of private insurance plans and gets to universal coverage by imposing significant penalties for not having insurance (130 percent of the premium over the period of being uninsured).
  • Value-based evaluation of new diagnostics and interventions. The UK analyzes expensive new drugs and technologies for both outcomes and cost per patient through The National Institute for Health and Care Excellence (NICE). If we are seriously concerned about healthcare costs, these analyses are important.
  • Cost and patient outcomes transparency. The website of the Singapore Ministry of Health publishes data on average hospital bills for common conditions/procedures. Patients have access to information on the costs of specific surgeries and diagnostic procedures, by insurance and ward type.

In conclusion, we once again agree with the position of the OECD, “Policy makers should…adopt best practices from many different health care systems that exist in the OECD and tailor them to suit actual circumstances.”

US spends too little on social welfare: Fact or fiction?

US spends too little on social welfare: Fact or fiction?

US spends too little on social welfare: Fact or fiction?

As we had alluded to previously (see comments section here), we have been hearing the argument “we don’t spend enough money on social services in the US” for quite some time now. So, let’s dissect this argument one step at a time.

First, what exactly do we mean by social spending and how does the US compare with other developed nations? Since good international comparative data on the topic of social spending are hard to find, it is very easy to adjust available data to suit one’s argument. Thus, rather than trying to come up with a single definition and measure of social benefit expenditures, below we highlight some key categories of spending that fit (at least in our minds) into the broad definition of social welfare expenditures.

In the US, it is politically correct and convenient to count social spending as only public/ government spending. Taking the OECD definition of social expenditures, which includes the following social benefit areas:

“old age, survivors, incapacity-related benefits, health, family, active labour market programmes, unemployment, housing and other social areas…public spending on early childhood education and care up to age 6”

and looking at public expenditures as a percentage of GDP, we find that the US ranks #24 out of 35 OECD members, but still above both Australia and Canada, countries often cited as doing more for their citizens than the US (see Figure 1 here). Moreover, when looking at sub-categories of general government spending, we find that in 2015, US spending as percentage of GDP is ranked (among OECD members) as 1st in health; 2nd in defense; 7th in public order and safety; 8th in education – quite a bit better than our overall ranking.

Moreover, social spending is actually more than public/ government spending alone. Interestingly, when both public and private social spending (as defined above by OECD) are accounted for and include the full range of social benefit transfers, the US ranks second only to France in total net social spending as a percentage of GDP (see Figure 4 in same OECD report).

Since spending on health is included in the OECD definition of social expenditures and the US is a known outlier in terms of healthcare spending, a follow up argument we often hear is: “We spend too much on healthcare and not enough on other social services.” While we absolutely agree that US healthcare is in dire need of improvement (both in terms of effectiveness and efficiency), a look at the available data shows that even if we subtract out healthcare expenditures, total spending on “other” social services in the US stands at roughly 13% of GDP and again above some comparison countries (Australia, Canada, Switzerland).

So, maybe the question we should be asking ourselves is not, “are we spending enough on social services?”  Maybe what we should be asking instead is, “are we getting what we are paying for in social solutions?” This is a question of value, that in many ways parallels the one being asked about the state of US healthcare.

Unfortunately, whether one uses broad measures (e.g., overall social spending vs. income inequality) or more specific examples (e.g., spending on education vs. secondary and tertiary graduation rates), Figures 7 and 9 here suggest that we are not getting good value for all the money we spend. Moreover, while the US government spends more on public safety as a percentage of GDP than many OECD nations or the EU28 (see Table 1 here), our rates of incarceration are some of the highest in the world, with some US states spending more money on incarceration than higher education. And while directing some of the “waste” away from healthcare into other social services seems like a sound idea, simply pouring more money into the existing system without any regard for how it is being spent, is unlikely to generate better social outcomes whether the benefit in question is education or income assistance programs.

Rather than spending more money, the US has to look at existing social expenditures as an INVESTMENT and manage these expenditures on an ongoing basis to continuously improve social outcomes, by relentlessly learning from both international and within-US success stories (does that sound familiar?). Social spending needs to be built into a balance sheet (which the US does not currently keep), otherwise everyone will continue to ignore how the funds are managed with no expectations for measurable ROI. This, in turn, will require a shared vision, a shared reality that recognizes the evidence above, and strong leadership from policy makers – all sorely missing in Washington, DC at this time.

Coming to grips with the value of social welfare expenditures is particularly important due to the profound demographic shifts happening around the world over the coming decades. As the OECD social spending report highlights (see Figures 1 and 2) – the vast majority (79%) of public social spending comes in two categories: health and pensions, both heavily influenced by demographics. Thus, rather than focusing simply on the absolute levels of social spending, both the US (with its aging Baby Boomer population) and the EU27 (projected to see a 68% increase in the number of adults over age 65 over the next 50 years) could benefit from a closer evaluation of: a) the sustainability of government social welfare expenditures, given that working age populations will be increasing much less than the older beneficiaries and b) what we get in return for the significant funds already being spent on social welfare.

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“What Maryland’s All Payer Rate Setting Tells Us About Traditional Medicare Payment Rates”

“What Maryland’s All Payer Rate Setting Tells Us About Traditional Medicare Payment Rates”

What Maryland’s All Payer Rate Setting Tells Us About Traditional Medicare Payment Rates

With some political leaders calling for the US to move to Medicare-for-all and California weighing a proposal to have all patient care reimbursed at Medicare rates, it is worth taking a step back to examine the level of traditional Medicare’s provider payment rates. Specifically, do the current payment rates ensure high quality and access for Medicare beneficiaries, while keeping high-value providers in business. Our review of the latest MedPAC report to Congress and statements made by the Medicare Actuary paints a pretty grim picture, as far as delivering on the above objectives.

The March, 2018 MedPAC report shows that aggregate hospital margins from Medicare have gone from -4.9% in 2010 to -9.6% in 2016, and are projected to be -11% in 2018. It is of interest to note that MedPAC looks only at Medicare ‘allowed’ costs – which removes many other expenses incurred by hospitals such as private rooms for patients, telephones and TVs in patient rooms, marketing communications, interest on certain borrowed funds, etc. Thus, true Medicare margins, that are based on total costs, are actually worse than those reported by MedPAC.

Low Medicare payment rates and their implications for both beneficiaries and providers have also been the subject of repeated commentary by the Medicare Actuary, e.g.,

  • “Limiting (Medicare) cost growth to a level below inflation would represent an exceedingly difficult challenge… Providers for whom Medicare constitutes a substantial potion of their business…might end their participation in the program”
  • “…the prices paid by Medicare for most health services will fall increasingly short of the cost of providing such services. If this issue is not addressed by subsequent legislation, it is likely that access to, and quality of, Medicare benefits would deteriorate over time for beneficiaries.”

The CMS Maryland experience
So, how can we estimate the true magnitude of the problem with current Medicare provider payment rates? One state in the US, Maryland, has had all payer rate setting for over 40 years. The Health Services Cost Review Commission (HSCRC), an independent agency established by the Maryland legislature in the early 1970s, is charged with setting uniform hospital service rates. As such, all Maryland payers are charged the same rates approved by the commission (with a modest discount allowed for Medicare and Medicaid). While Maryland can certainly work on improving efficiency (and is moving in that direction with the recent transition to global budgets), one would presume that the present rates are set to meet the following goals of the commission:

  • “Ensure that hospitals have the financial ability to provide efficient, high quality services to all Marylanders
  • Increase the equity or fairness of hospital financing”

If the above presumption is true, then Maryland’s all payer rates can shed light on the adequacy of traditional Medicare’s payment rates to accomplish the same two objectives.

Fortunately, CMS-commissioned evaluation reports of the Maryland All-Payer Model have done some detailed work on this particular topic. Specifically,

  • “The analyses compared the weighted average payment per inpatient admission in Maryland and a comparison group for the same mix of admissions… also examine the weighted average payment per hospital outpatient visit. Using the same mix of admissions and hospital outpatient visits controls for utilization differences between Maryland and the comparison group so the comparison only reflects payment rate differences.”

The latest evaluation report shows that between 2011 and 2016, Maryland Medicare rates for inpatient admissions were 33-40% higher than in the comparison group paid at traditional Medicare rates. The payment gap was even wider for outpatient hospital services, with Maryland Medicare payment rates (FY2013-2016) coming in at 55-62% higher than those of the matched comparison group paid at traditional Medicare payment rates. Clearly, the present policies of increasing traditional Medicare payment rates by less than inflation, have created a major Medicare payment shortfall, which (absent major changes) will get even bigger in the coming years. The rate gap further suggests that the under age 65, privately insured patient population, is currently subsidizing the care of Medicare beneficiaries. Thus, trying to put all patients on traditional Medicare payment rates would make the Medicare Actuary’s worrisome conclusions even more dire. Conversely, assuming Maryland is doing a good job setting payment rates, going to Medicare-for-all using the Maryland model, would require massive increases in rates over what Medicare presently pays everywhere else. Unless there was a change in provider efficiency, there would need to be ~40% increase in what Medicare pays for inpatient admissions and ~60% increase in payment for outpatient hospital services.

Medicare payment policies could benefit from a major overhaul
Based on the various sources of evidence presented above, we believe that Medicare payment rates are too low and getting worse every year. That said, we also believe that it is incumbent on the delivery system to improve efficiency and thus get better value. While providers would certainly welcome increases in Medicare payment rates, changes in payment rates alone will not be sufficient to drive improvement in healthcare delivery.

As we think about what providers should be paid, it would behoove us to remember a Commonwealth Fund blog by Dr. Stuart Guterman and others, which stated that: “… payment levels must be carefully calibrated to ensure providers’ financial viability while providing incentives to reduce costs and safeguards to ensure high quality.” Unfortunately, our conclusion is that traditional Medicare payment rates and policies fall short of the Commonwealth Fund recommendations. The financial viability of the US healthcare provider depends heavily on private payers (and thus the younger and employed population), while traditional Medicare is characterized by wide variation in service utilization, costs, and patient outcomes.

We believe that accomplishing the objectives described by Guterman et al., can best be accomplished by payment structures that ensure the financial viability of high value providers – those getting better patient outcomes at lower than average costs. In turn, the rates should be based on the real costs of doing business by these highest value providers (and not what Medicare currently pays them) plus a 2-4% margin, since even non-profit organizations need reserves to address changing staffing needs, replace aging equipment, etc. With regard to the need for a positive margin by providers, it is of interest to note that the Maryland HSCRC agrees. It has established hospital profitability targets of 2.75% operationally and a 4% total margin.

While we have detailed such value-based payment approaches in previous publications, it may be worth re-iterating a couple of the key components. Again, taking the state of Maryland as an example, Figure 1 shows the distribution of risk-adjusted quality index (based on the 90-day complication rate for hip/knee replacement) vs. the corresponding cost per episode of care. A base payment rate could be set at the 80thor 90thpercentile of the delivery organizations that are in the high value quadrant (i.e., those that get better than average quality at lower than average cost). A further quality withhold (e.g., 5%) could be used to ensure that providers don’t sacrifice effectiveness in the name of efficiency or that we do not reward low quality providers for simply being low cost. HSCRC has an objective establishing “rates sufficient to meet ‘full financial requirements’ of efficient/effective hospitals.” The pay for value approach we outlined above would create a strong incentive for providers to move to high value. If we truly desire a high value healthcare delivery system, we would be more likely to get it, if we actually paid for value.

2 thoughts on “What Maryland’s All Payer Rate Setting Tells Us About Traditional Medicare Payment Rates”

  1. Excellent piece – and the last sentence is so critically important.

    “The pay for value approach we outlined above would create a strong incentive for providers to move to high value. If we truly desire a high value healthcare delivery system, we would be more likely to get it, if we actually paid for value.”

  2. Denis and Bob:

    A great reminder that the Medicare for All advocates do not really understand the financial implications of their aspirations…there also is a hope that administrative savings will arise as marketing, customer service and claims processing needs diminish–really? Hope your summer going well…keep the conversation going…

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

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

Denis A. Cortese, MD, joined Arizona State University (ASU) in 2010 as Foundation Professor, Director of ASU’s Healthcare Delivery and Policy Program, and President of the non-profit Healthcare Transformation Institute based in Phoenix, AZ. He is an Emeritus President and CEO of the Mayo Clinic, and former head of the Mayo Health Policy Center.

Professional activities as a staff member of Mayo Clinic were in the field of pulmonary medicine including interventional bronchoscopy, critical care, with special interests in early and advanced stage lung cancer, liver and lung transplantation. Activities in education included the medical school and director of the pulmonary-fellowship training program.  Research was focused on NIH funded endoscopic laser photodynamic therapy for early stage lung cancer and on NdYAG-laser phototherapy of advanced stage airway obstructing cancer.

In addition to his current ASU academic position, Dr. Cortese currently serves on the board of trustees of Dartmouth-Hitchcock, and the boards of directors for Cerner Corporation, Essence Global Holding Corporation, and Pinnacle West.

Dr. Cortese is a member of the Institute of Medicine of the National Academy of Sciences, where he served as the original chair of the Roundtable on Value and Science-Driven Health Care; a National Associate of the National Research Council; an honorary member of the Royal College of Physicians (London) and the Academia Nacional de Medicina (Mexico).

He formerly served in the following positions: member of the health advisory board of RAND; member, and served as the chair of the board, of the Health Care Leadership Council in Washington, DC.; member of the Harvard/Kennedy Health Policy Group; member of the Division on Engineering and Physical Science (DEPS) of the National Academy of Engineering.

Dr. Cortese received his undergraduate degree from Franklin and Marshall, an MD from Temple University, and completed residency training in Internal Medicine and Pulmonary Diseases at the Mayo Clinic. He is a recipient of an Ellis Island Award (2007) and the National Healthcare Leadership Award (2009).

Robert K. Smoldt, MBA is Chief Administrative Officer Emeritus of the Mayo Clinic and currently serves as Associate Director of Arizona State University’s Healthcare Delivery and Policy Program. He served as a member of the Mayo Clinic Board of Trustees and Mayo Clinic Executive Committee from 1990 through 2007, and is presently pursuing U.S. health reform in close partnership with Dr. Denis A. Cortese. Mr Smoldt served two terms on the Board of Catholic Health Initiatives and continues as a member of its Finance Committee.

Mr. Smoldt earned a BS from Iowa State University and an MBA from the University of Southern California. He has given numerous presentations and is a recognized speaker on the healthcare environment. Mr. Smoldt has provided leadership at Mayo Clinic facilities in Rochester and Scottsdale. He has completed two terms as secretary of the Mayo Clinic Rochester Board of Governors and served on the Mayo Clinic Scottsdale Board of Governors as a senior advisor from 1998 to 2000.

He has been involved in healthcare administration for over 30 years — both with the U.S. Air Force and the Mayo Clinic. Mr. Smoldt joined Mayo in 1972, and he has worked in a variety of administrative positions in both medical and surgical departments. Prior to his CAO role, he served as chair of the Department of Planning and Public Affairs.

Mr. Smoldt has also been active in Medical Group Management Association, along with other members who manage and lead medical facilities across the nation — and work together to improve the knowledge, skills and the effectiveness of medical group practices. He has chaired the organization’s research and marketing committees and has acted as moderator of its international conference in London, UK. Most recently, he was a member of the Medical Group Management Association National Awards Committee, which honors those who make significant leadership contributions to healthcare administration, delivery or education in medical group practice and presents the following awards: Harry J. Harwick Award for Lifetime Achievement Award, Physician Executive Award, Fred Graham Award and Medical Practice Executive of the Year Award.

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