Tag Archives: Pharmacy

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Some hospitals, surgery centers still aren’t performing cosmetic surgery

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Here in San Francisco, the city and health department issued a directive on May 15 allowing elective surgery. In the directive, it was very clear elective surgery, including cosmetic surgery and dental procedures, could move forward. For this reason, we began performing cosmetic surgery in our in-office AAAASF-accredited operating room the following Monday, May 18.

A full two months had passed after the last case in our office. Since that day, we’ve been busy going through our backlog of cases.

Based on previously scheduled cases and newly booked procedures, we’ll be operating at full capacity for the foreseeable future. While we have the luxury of performing cosmetic surgery in our own facility, not all facilities are proceeding with cosmetic surgery. Why not?

Facilities allowing elective cases but not performing cosmetic surgery

Based on a recent conference call with the leadership of one of the local hospitals, they explained they were deferring cosmetic surgery at their facilities for up to 6 months. The reason given was the need to clear their backlog of higher-tier cases. They of course were referring to this table developed by the Centers for Medicare and Medicaid. According to the table, cosmetic surgery is considered tier 1 and administrators should consider postponing.

However, there may be another underlying, unspoken reason facilities that generally handle insurance-based elective surgery are deferring cosmetic surgery for now.

Financial factors driving decision to defer performing cosmetic surgery?

According to a report from the American Hospital Association in this Becker’s Healthcare Review article, hospitals are estimated to lose $200 billion between March 1 and June 30. Of this, $161 billion is due to expected revenue losses from canceled services, including nonelective and elective surgery, and outpatient treatment.

But it’s worth noting that in the same article, Becker’s lists the top 10 specialties that generate the most revenue for a hospital through elective and non-elective procedures. Here’s the list based on the Merritt Hawkins 2019 Physician Inpatient/Outpatient Revenue Survey:

1. Cardiovascular surgery — Average revenue: $3.7 million

2. Cardiology (invasive) — Average revenue: $3.48 million

3. Neurosurgery — Average revenue: $3.44 million

4. Orthopedic surgery — Average revenue: $3.29 million

5. Gastroenterology — Average revenue: $2.97 million

6. Hematology/Oncology — Average revenue: $2.86 million

7. General surgery — Average revenue: $2.71 million

8. Internal medicine — Average revenue: $2.68 million

9. Pulmonology — Average revenue: $2.36 million

10. Cardiology (noninvasive) — Average revenue: $2.31 million

Notice which specialty is missing? Cosmetic plastic surgery is not a major driver of revenue for a hospital or hospital outpatient department (HOPD) such as hospital-owned surgery centers. Sure, cosmetic plastic surgery conjures images of expensive out-of-pocket, non-insurance-based breast augmentations, tummy tucks and mommy makeovers. But to a hospital, the facility fee paid by a cosmetic patient pales in comparison to the more lucrative facility fees paid by insurance companies for medically necessary hand surgery, hip or knee joint surgery, or minimally invasive cardiac procedures.

This is arguably the real reason hospitals across the U.S. will prioritize greater revenue-producing insurance-based procedures over cosmetic procedures. And while that’s certainly the hospital’s prerogative to make that financial decision, admitting it may avoid further uncomfortable and futile conference calls, like the one I was recently privy to.

Moving forward, surgeons, be they cosmetic plastic surgeons or other specialties where it’s feasible, should consider building their own accredited office-based operating room. Aside from better outcomes, a better experience for patient and doctor, it’s also nice being in charge of your destiny, professionally.

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Nurses: The professional progeny of Florence Nightingale

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Florence Nightingale, the founder and progenitor of the modern nursing profession, lit a spark several centuries ago that burns within millions of nurses to this day.

The lamp that she literally — or metaphorically — lit during the Crimean War continues to illuminate nurses’ paths forward, and her legacy is one that strengthens with age as her offspring continue to advance the profession. And in difficult times such as the current coronavirus pandemic, nurses fight the good fight around the clock.

The International Year of the Nurse and Midwife

May 2020 marks the 200th anniversary of Nightingale’s birth, and many around the world – nurses and non-nurses alike — celebrate this occasion. In its wisdom, the World Health Organization (WHO) chose in late 2019 to declare 2020 The International Year of the Nurse and Midwife, and this momentous passage is being recognized by myriad individuals and organizations. The WHO made its case eloquently and clearly:

“Nurses and midwives play a vital role in providing health services. These are the people who devote their lives to caring for mothers and children; giving lifesaving immunizations and health advice; looking after older people and generally meeting everyday essential health needs. They are often, the first and only point of care in their communities. The world needs 9 million more nurses and midwives if it is to achieve universal health coverage by 2030.

“That’s why the World Health Assembly has designated 2020 the International Year of the Nurse and the Midwife.

“Join WHO and partners including, the International Confederation of Midwives (ICM), International Council of Nurses (ICN), Nursing Now and the United Nations Population Fund (UNFPA) in a year-long effort to celebrate the work of nurses and midwives, highlight the challenging conditions they often face, and advocate for increased investments in the nursing and midwifery workforce.”

Who could not join in honoring nurses, the most trusted professionals in the United States year after year in the Gallup Poll? They are the very connective tissue of the healthcare system, and the Gallup organization reported the following in January 2020:

“For the 18th year in a row, Americans rate the honesty and ethics of nurses highest among a list of professions that Gallup asks U.S. adults to assess annually. Currently, 85% of Americans say nurses’ honesty and ethical standards are ‘very high’ or ‘high,’ essentially unchanged from the 84% who said the same in 2018. Alternatively, Americans hold car salespeople in the lowest esteem, with 9% saying individuals in this field have high levels of ethics and honesty, similar to the 8% who said the same in 2018.”

Florence Nightingale’s innovative work in hygiene, sanitation, infection control, the nursing process, and biostatistics continues to reverberate throughout the global community, and her initial spark never seems to diminish.

Are nurses valuable? The jury has indeed spoken multiple times, and the verdict is clear. And when we stop to witness the tremendous courage of nurses on the front lines of the COVID-19 pandemic, there can be no doubt as to their incalculable value.

Nightingale’s Progeny

Florence Nightingale’s progeny are clinicians who work in ICUs and ERs; ambulatory care centers; medical offices; schools, universities, and colleges; public health offices; homecare and hospice agencies; and myriad facilities housing the elderly, infirm, and disabled. They may be vocational/practical nurses; nurse practitioners and other advanced practice nurses (APRNs); nurses with ADNs or BSNs; or hold any number of master’s-level, Ph.D., or DNP designations.

Nonclinical nurses are just as crucial, and they can include researchers, educators, administrators, legal nurse consultants, expert witnesses, and other roles that often go unsung. Several even serve in Congress and state legislatures here in the United States.

A plethora of often unacknowledged nurse entrepreneurs also make their contributions, including inventors, writers, bloggers, podcasters, keynote speakers, coaches, and consultants.

Florence Nightingale would no doubt be exceedingly proud of the profession that nursing has become. She would be thrilled at the increased autonomy of nursing practice; and the depth and breadth of our individual and collective accomplishments. And if nurses can learn to use their voices and gain more personal agency and power as informed citizens and advocates, their power would be incalculable.

Nightingale’s original spark has gained significant fuel over the last two centuries, and it now burns as a beacon to all who see the profession for what it truly is. As Nurses Week 2020 comes and goes, we pause to celebrate the 200th anniversary of Nightingale’s birth and the yearlong celebration declared by the WHO.

The talented progeny of Nightingale are legion, and their central role in the maintenance of the health and well-being of most every citizen on this beautiful yet troubled planet of ours is irrefutable. Here’s to those trusted, courageous, and brilliant humans who always show up when duty calls, and always will.

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Telemedicine, webside manner, and barriers to care

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Telehealth and telemedicine have been gaining in popularity for a number of years, and medical providers’ ability to be effective in these very 21st-century roles has truly become a new expectation of practice.

In this time of the COVID-19 pandemic, the need for positive patient outcomes vis-à-vis telemedicine has never been so important, or so crucially put to the test. And when social and economic disparities loom large in terms of telemedicine reaching those most in need, we can experience a perfect storm of telehealth’s promises remaining largely unfulfilled.

Your Provider is Calling

When patients need medical counsel or symptom management during a situation like the novel coronavirus currently encircling the globe, the ability to provide such care over the phone or computer is paramount. In an effort to expose as few patients to potential infection as possible, telemedicine can mitigate risk while still accomplishing the goals of care.

While telehealth has been practiced in certain quarters for some time, it does appear that the Age of Telemedicine has indeed arrived. Smartphones and tablets are facilitating virtual visits between providers and patients, and a great deal can be accomplished when telemedicine is done well. But what challenges can stand in the way of success?

Providers Challenged by Telehealth

One particular challenge in telehealth is providers’ relative lack of training in conducting assessments, patient interviews, and therapeutic conversations that do not occur in person. Tuning into tone of voice, body language, and other aspects of patient visits can be less than optimal over phone or video, yet these cannot remain barriers when both patient health and provider liability are at stake.

In the age of COVID-19, patients are frequently frightened, confused, and often misinformed. Like people the world over, they may also be living with economic uncertainty, social isolation, and perhaps existential issues such as sick or dying loved ones, food insecurity, inability to access needed medications or treatments, or the threat of eviction or utility shut-offs.

In such dire circumstances, a physician, nurse practitioner, or other provider must have the means to dive deeper, perhaps providing supportive counseling, access to psychosocial and community resources, and taking the time for an empathic and reflective conversation. This can be a stretch for those unschooled in such conversations and may even pose challenges for those trained in mental health.

Yet another challenge is correctly assessing a patient’s physical status or symptoms via phone or video. Can edema or rales be properly identified over the phone? Can a patient’s report be trusted as altogether accurate? These are ongoing troubling questions.

Disparities Rear Their Ugly Head

It is all well and good when a relatively affluent patient accesses telehealth via a smart phone, tablet, or laptop. Such encounters are also more efficient and effective when patients have high-speed cable internet or reliable Wi-Fi.

For economically struggling communities in the inner city, suburbia, or rural areas, high-speed internet or Wi-Fi may simply be wishful thinking. For many patients, a tablet or smartphone may be completely out of reach, with many using basic “flip phones” of days gone by.

These types of economic and technological disparities pose even more insidious barriers to the delivery of effective telehealth visits, and the old nemesis of the “digital divide” rears its ugly head yet again when at-risk patients cannot receive care they clearly need.

Providers are hard-pressed to reach patients who lack adequate cellular service. And when a patient who cannot be assessed by video needs to be seen in person but lacks money for gas or will not come to the clinic for fear of infection with COVID-19, yet more barriers impede proper care.

Healthcare disparities are by nature borne by the poor, and consequently exacerbated by lack of access to the technologies that could benefit such at-risk communities. Herein lies a vexing conundrum of the 21st century.

Solutions Can Be Found

Webside manner and telehealth skill training should now be de rigeur in the education of all healthcare professionals. There is some promise in such training being integrated into medical education, and more will likely be coming online as COVID-19 continues to draw attention to such needs.

The art of listening, skills in motivational interviewing, and training in the development of empathy and compassion are not rocket science; perhaps one solution might be the consolidation of such training for mental health, medical, and nursing students through integrated curricula.

For underserved communities in both rural and urban environments, solutions must be found to mitigate technological barriers. In some cities, libraries and schools provide 24-hour high-speed public Wi-Fi that families and individuals can access from parking lots.

Meanwhile, in some localities, school buses are outfitted to serve as mobile Wi-Fi hotspots that can reach low-income communities so that students can participate in online learning, and, by default, parents may also access the internet for purposes such as telehealth. And if children from underserved communities could be outfitted with tablets or laptops and portable Wi-Fi devices, entire families would benefit in this manner, as well.

Some solutions may simply be tech band-aids, yet we must begin somewhere. If tech companies, healthcare institutions, government, philanthropic and grass-roots organizations, and schools training various healthcare professionals would coordinate efforts, many gains could be made.

In order to optimize the delivery of telehealth services, we need political will, public-private partnerships, and the societal desire to address disparities while shoring up the education and training of professionals who provide such services. With a more holistic approach to the maximization of telemedicine delivery and effectiveness, more patients will receive appropriate and safe care and providers will be more well-trained to meet those patients where they most need to be met.

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AR, VR show promise as innovative ways to control pain, reduce opioid prescriptions

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Pain management is a major sector in healthcare. The problem has always been there, and it always will be. As long as we have diseases, injuries and major surgeries, pain management will be an area healthcare providers grapple with.

But unlike disease, which can be cured in some cases, pain can only be managed. And the opioid crisis that was making headlines before the world health pandemic took center stage has spotlighted the need for alternative means of effectively treating pain.

Guess who consumes 80% of the world’s opioid supply?

Yep. It’s us. It’s true that the overall opioid prescribing rate in the U.S. has been on the decline since 2012, and that’s certainly trending in the right direction. But the amount of opioids prescribed per person is still around three times higher than it was in 1999, according to the Centers for Disease Control and Prevention (CDC). So, opioids are still a significant problem in America.

Why do we use so much of the world’s opioid supply? It is estimated that over 100 million Americans suffer long-term, chronic pain.

AR/VR have stepped up to the plate

What were once mostly considered high-tech toys used primarily for gaming and entertainment, have taken on new uses. Augmented and virtual reality (AR & VR), combined with coping strategies like mindfulness training and stress-reduction, are being looked at as an effective alternative for people who live with chronic or difficult-to-treat pain, according to Patrick Allen, a principal of healthcare business consulting at EPAM Continuum.

AR and VR technologies can be programmed to offer an immersive experience designed to take a patient’s mind off of their pain. At the same time, feel-good endorphins are released, which provide even longer-term pain relief. There are very few, if any, side effects to AR/VR therapy, and that is a huge benefit.

Early results from studies conducted at some universities on the West Coast are very promising, per Allen. Still, using AR/VR for pain management likely won’t become a widespread practice until much more research is done and evidence is published.

Additionally, academia and the business sector will need to work together. A few key things need to be happening, including funding for research, starting the conversation about insurance coverage for this type of therapy and creating an effective and scalable business model.

Hope for the future

New ways of thinking to address the opioid epidemic are going to be needed if we want to save resources and lives. AR and VR are just two ways that medicine and technology are working together to innovate. This innovation partnership can and will take other forms, like research on more effective nonprescription treatments and deeper study and understanding of the neuroscience of pain.

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What we say in healthcare matters

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The next time I teach a group of healthcare professionals, I think I’m going to sprinkle glitter on them. You know how hard it is to limit its reach — glitter ends up everywhere!

This exercise would not be a lesson in germ transmission (although it sure could be). The purpose would be a visible reminder that our impact as providers spreads far and wide.

I’d hone in on communication, that what we say matters. To ourselves, our colleagues and in our personal lives.

It’s been said, every time we speak, “We’re either building people up or tearing people down.”

What ripples do we wish to create in the world? Because we do. Whether we’re conscious of it or not. Whether we mean to or not.

By listening, being clear and acting with kindness, we can contribute compassion, one connection at a time. What the world needs now is love, sweet love.

Listen first

Remember learning that an accurate diagnosis could be attained 80% of the time solely from a thorough history and physical examination? And to save the diagnostic tests for the other 20%?

Two decades ago, the Kaiser Permanente healthcare system begin examining physician-patient communications using videotaping. Many important findings and implications came from this work; perhaps, most notable is that it only took three more minutes per visit for physician-patient outcomes to radically improve.

Only three more minutes! By shifting the focus to eliciting the patient’s story, listening and explaining, both the physician and patient felt much more satisfied and realized better results.

I watched a smidgen of a TV show not long ago where a hospitalized elderly heart transplant patient said to his nurse, “I’m not going to make it this round — it feels different this time to me.” The nurse immediately responded, “Don’t talk like that. I’m here and I will make sure you do.”

What a missed moment! She had the perfect opening right then and there to listen and explore end-of-life issues. Later, just as a transplant match was found, he coded and died.

Be clear

Setting an intention prior to speaking can clarify the message we’re trying to deliver. Consider the “take away” beforehand.

When talking, be mindful of timing, verbiage and nonverbal behaviors. Keep it concise and to the point.

Successful communication is not just what is said but what is actually heard. All of us have filters, blinders and projections that skew our interpretations.

After you’ve said your say, it’s helpful to check-in with the receiver. Using Nonviolent Communication principles, ask, “Would you be willing to tell me what you just heard me say?” to make sure that you’re both on track.

Be kind

Too often, all that glitters is not gold.

While it’s important for “you to be you” and “they to be they” as the popular phrase purports, good communication is really about connection and unity. Speak without haranguing or judgment.

No one’s feelings are less important than another’s. We all have the same basic needs and they’re not that many.

We’ve got to get off our yoga mats and take Sunday sermons out into the streets. Practicing empathy is what we are being called to do.

I’ll never forget the kindness a janitor showed me one weekend while I was working at hospice. I was in the empty office, finishing some charting, when I received a very distressing call and burst into tears.

Thinking I was alone, I didn’t hold back feeling the full force of the news. I sobbed.

Some moments later, this man, who I had never met before, came over to me and asked if I was OK. If there was anything he could do. What a blessed soul!

Listen, be clear and act kind. What we say matters.

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Digital natives, digital immigrants, and healthcare technology

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Twenty-first-century healthcare is replete with the unstoppable exponential growth of technology and innovation. From EMRs and medication-dispensing robots to digitally networked bedside devices and the inevitable emergence of medical augmented reality, the ability to adapt to new technologies is crucial for any individual seeking a sustainable career in medicine, nursing, and the broader healthcare spectrum.

Will certain groups of healthcare workers fall by the wayside? When some individuals adapt and others fall behind, will healthcare technology Darwinism be at work? And can those wishing to catch up vis-à-vis technology successfully do so and remain competitive?

Introducing the Digital Native and Digital Immigrant

In 2001, author Mark Prensky published an article introducing the world to the terms “digital native” and “digital immigrant.” Coming at the turn of the century, Prensky presciently noted that those born with digital technologies almost literally in their hands would be the members of society who move us collectively forward into a tech-centric future due to their apparently preternatural gifts for navigating new software, hardware, apps, and technologies.

Digital natives are identified as those individuals born into a world of digital tech and media saturation. While research continues to assess the impact of maturing in such an environment, the fact remains that digital natives were handed these tools by prior generations.

Members of older cohorts (which Prensky dubbed digital immigrants) are those who did not grow up in a world steeped in these technologies but have learned to incorporate them into their lives with varying degrees of enthusiasm, skill, and success. Even older millennials (those born during most of the 1980s) are considered digital immigrants since cell phones and personal computers were not ubiquitous until their later adolescence.

Some older individuals have been known to cast aspersions on younger workers’ different methods of learning, interacting, and communicating, but the truth is that those older workers are no longer in the majority. In a paper published in 2014, it was recognized that that year was when more digital natives were practicing medicine than digital immigrants. Thus, the tide was turning long before 2020.

Are Digital Natives More Valuable Employees?

Some research disagrees with Prensky’s original assertions and argues that digital natives are no more adept at technology than their digital immigrant peers. To wit:

It’s unclear and unproven whether digital natives actually do differ in their cognitive abilities from digital immigrants. What is clear, however, is that this idea feeds into three widespread misconceptions about Millennials:

MYTH 1: Digital natives possess inferior social skills or are more likely to avoid personal interaction in favor of digital interaction.

MYTH 2: Digital natives are much better at multitasking than digital immigrants.

MYTH 3: Digital natives have natural instincts about how to use or fix computers and other digital products.

Our findings (and other research studies) suggest that all these assertions are false.

For many positions in the clinical realm, academia, research, and other areas of professional pursuit, facility with computers and software are a plus. A number of employers request or require that candidates be conversant with commonly-used software, including popular EMRs such as Epic. A job candidate who can claim Epic super-user status and avid use of tools such as Google Drive, PowerPoint, or Excel may indeed seem more attractive than a candidate thus lacking.

Evidence shows that, while some digital immigrants may struggle with certain tech interfaces, many have adapted and can thrive; and, as noted above, their younger peers may not always have a clear edge. Conversely, other research disagrees, demonstrating that the average 14-year-old far outpaces the average 45-year-old in tech-savviness.

In this rapidly changing world, many digital natives must recognize that, in order to remain professionally competitive, they need to consistently pivot as tech evolves over time. In short, being tech-savvy in the healthcare job marketplace has become an important skill set to publicize loud and clear on a resume or online professional profile.

And today’s 14-year-olds? They will one day find themselves in school studying medicine, physical therapy, or speech language pathology, and their career path will most certainly be paved with technology.

Digital Natives: The Demographic Future is Certain

If there is one thing for certain, it’s that a time will come when all medical and healthcare professionals will be digital natives. After all, as baby boomers and Gen Xers age out of the workforce, their particular brand of digital immigrant professionalism will be a thing of the past, except for older millennials who themselves are now beginning to enter their 40s and still have a few decades of employment ahead of them prior to retirement. Still, those workers will be in a rapidly shrinking minority.

This demographic shift towards a healthcare workforce comprised of 100% digital natives will be a phenomenon to track over time.

Will the longitudinal research reveal that digital natives have more difficulty with company loyalty, managing relationships, or respecting authority? Will the legacy of digital immigrants be that of generations who adapted well as the medical workplace changed and technology became central to success? Will we eventually see that technology was an equalizer that left fewer healthcare workers behind than some originally predicted?

The forward march of healthcare technology is beyond deniability, and how certain cohorts of medical professionals adapt to this ongoing revolution will be a fascinating case study for the history of 21st-century healthcare.

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When the failing US response to the COVID-19 crisis really began

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Beyond all the political posturing — both Democratic accusations of Trump administration failures and equally fervent Trump administration declarations of triumph and blame-shifting — one thing has largely been overlooked. It wouldn’t have mattered who was in charge when it became clear we were beginning a prolonged health crisis early in 2020.

The failures to adequately respond began years ago and continued through three administrations, both Republican and Democratic.

Failure to Respond: The Early Years

In 2005, Health and Human Services Secretary Mike Leavitt was initially unimpressed with some early warnings of a possible pandemic. Then, he began consulting with experts at the Center for Disease Control and reading the scientific literature on viral transmission. Soon, he became a convert.

The increasing interconnections between countries, businesses and individuals as the world shifted to global commerce and travel made it all but certain that sooner or later the U.S. would be faced with a serious viral pandemic ending thousands of lives and endangering millions more.

Leavitt took his concerns to President Bush. Bush listened and even delivered a speech outlining a national pandemic strategy. Even earlier, in 2003, the Strategic National Stockpile had been created to provide respirators, masks and other medical equipment needed when a pandemic hit. Clearly, some relatively high-ranking administration executives already understood the danger.

But despite the fact that there had already been the 2002 SARS epidemic and a new outbreak of the H5N1 “avian flu,” in 2003, overall, the U.S. response to Leavitt’s warnings, and then Bush’s, was more like Gable’s at the end of “Gone With the Wind” — we didn’t give a damn. Secretary Leavitt even became a figure of fun on the Jay Leno show, with Leno dismissing Leavitt’s urgings that Americans stockpile canned food for a prolonged viral emergency as unnecessary and even silly. “Powdered milk and canned tuna?” Leno laughed, saying he’d prefer bird flu.

Things Fall Apart: 2009 to 2019

In 2009, the promised viral outbreak occurred: the H1N1 swine flu. The government drew on the resources provided in the Strategic National Stockpile to deal with it. But instead of understanding that the predicted risks were real, with the swine flu as a demonstrated proof, following that outbreak, the depleted Stockpile was never completely replenished because funds to do so were never allocated. Bush persevered, however, and his administration began a project to assure there would be a stockpile of ventilators in the event of a pandemic.

The ventilator story is maddening. In 2009, the Obama administration contracted for 40,000 ventilators. Five years later, the company with the ventilator contract withdrew without having produced even one ventilator. Five more years of fumbling followed, and a new ventilator contract with a different company wasn’t signed until late 2019 — after COVID-19 had already begun in Wuhan, China.

One explanation for the government’s failure to respond to the viral threat is 9/11. From then on, the nation focused its attention on terrorism. In a classic case of misplaced priorities, from 1995 through 2016 the U.S. suffered a total of 3,393 deaths from terrorist attacks and, as of April 27, 55,429 deaths from COVID-19.

Lessons Learned?

The literature and outrage over the Trump administration’s faltering and tardy response to the crisis is already well-known. I won’t repeat it here because, for one thing, the real story is a little more complicated than “good Trump, bad Trump.” There’s plenty of blame to go around. The fact is, the only way we could have done an adequate job of responding to this would have required adequate supplies of ventilators, masks and other medical equipment from the Strategic National Stockpile.

We had the chance to replenish and expand that stockpile in 2009 and fluffed it. By 2019, it was already years too late. The critical question now is: how will respond to this costly lesson in unpreparedness once the current crisis has passed?

Will Americans overcome their widespread distrust of science and begin listening to medical experts who almost unanimously predict more outbreaks to come? Or will we choose to continue using the COVID-19 crisis as a political football? It really is time for Americans to give up their tribal antagonisms long enough to make and fund pandemic plans before the next outbreak occurs.

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Searching for COVID-19 treatments: The RECOVERY trial

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As the number of confirmed cases of coronavirus disease 19 (COVID-19) continues to rise, researchers work to discover new treatments and vaccines. Currently, there are no specific treatments for COVID-19.

However, in December 2019, with less than 500 confirmed COVID-19 cases worldwide, a small trial was initiated at the Jin-Tan Hospital to investigate whether anti-viral drugs, such as lopinavir-ritonavir, commonly used to treat human immunodeficiency virus (HIV) infection would relieve the symptoms of COVID-19.

In addition to other medications, protease inhibitors lopinavir and ritonavir are used to treat HIV by decreasing the amount of HIV in the blood. When lopinavir and ritonavir are taken together, ritonavir also helps to increase the amount of lopinavir in the body so that the medication will have a greater effect.

In this randomized, open-label trial, 199 patients (median age, 58 years) were randomly assigned in a 1:1 ratio to receive either lopinavir-ritonavir (400 mg and 100 mg, respectively) twice a day for 14 days in addition to standard care or standard care alone. The primary end point was the time to clinical improvement, defined as the time from randomization to either an improvement of two points on a seven-category ordinal scale or discharge from the hospital, whichever came first.

Results showed that lopinavir-ritonavir treatment added to standard supportive care was not associated with clinical improvement or mortality in seriously ill patients with COVID-19 different from that associated with standard care alone. However, in the modified intention-to-treat analysis, which excluded three patients with early death, the between-group difference in the median time to clinical improvement (median, 15 days vs 16 days) was significant.

Of note, the overall mortality in this trial (22.1%) was substantially higher than the 11% to 14.5% mortality reported in initial descriptive studies of hospitalized patients with COVID-19, indicating that a severely ill population had been enrolled.

The findings from this study will be part of the new Randomised Evaluation of COVid-19 thERapY (RECOVERY) trial, which provides a platform to evaluate about 20 treatments that are currently thought to have potential for treating COVID-19. The chief investigator in the RECOVERY trial will be Peter Horby, Professor of Emerging Infectious Diseases and Global Health in the Nuffield Department of Medicine at the University of Oxford, who was also part of the small trial in Wuhan. In contrast to the usual six to nine months for a trial to get started, the RECOVERY trial enrolled the first patient in nine days.

Taking a cue from trials in China that are kept simple, RECOVERY is using a very short protocol and minimal burden on hospital staff who are currently overwhelmed by ensuring simple data collection. The RECOVERY trial is classified as an Urgent Public Health Research Study.

Another trial is currently recruiting in the United Kingdom, Randomized, Embedded, Multifactorial Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP), evaluating the impact of treatment in severely ill patients. The researchers in both the RECOVERY and REMAP-CAP trials will be working together to learn as much as possible for each other.

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Telehealth is keeping doctors, patients connected in the days of COVID-19

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As the world grapples with the mitigation efforts (hello, social distancing) required to navigate a global pandemic, healthcare practices of every type are getting up to speed and rolling out telehealth services, online chat, virtual appointments and all kinds of remote services. They are working with consultants to train their teams on how the technology works and then crafting messaging to get the word out to their patient base.

Truthfully, telemedicine is not the new kid in school, it’s just, quite suddenly, the popular one.

Telemedicine is an extremely useful tool. And even more so in this season as a way for doctors to provide needed care without risking potential exposure in a clinic setting. It’s good for providers and it’s good for patients. Win-win.

Don’t be Scared! Expanded Guidelines Make Telehealth a Streamlined Transition

If telehealth is new to your practice and you’re concerned about complicated billing processes, tricky reimbursement issues and even technology challenges, don’t be! The transition is not as difficult as it might appear to be.

Worried about how to bill for and code telemedicine visits? Don’t be.

Medicare now allows physicians to bill for professional services nationwide in all settings, including a patient’s home via FaceTime, Zoom, Google Hangouts or other teleconferencing technology, as well as waived HIPAA requirement violations.

Additionally, the American Medical Association has published a document outlining how providers should be using CPT codes to document telehealth treatments during the coronavirus emergency. The document outlines 11 different scenarios for treating patients and the appropriate CPT codes to qualify for Medicare reimbursement. All take into account the emergency actions announced earlier this month by the Centers for Medicare & Medicaid Services to remove barriers to the use of connected health platforms.

Worried about your patients (or your providers) being tech-savvy enough to “do” a telehealth visit? Don’t be.

Doctors and patients only need a computer or smartphone with a camera and a headset with a microphone to engage in basic telemedicine appointments with an app such as Zoom, Doxy.me, Skype, Google Hangouts, and even FaceTime. For tips on conducting telehealth appointments, please click here.

The Future is Now so Get Comfortable

In these uncertain times, all of us are being forced to adapt to new ways of living and doing life. This certainly includes medical providers who must embrace new ways of communicating with and treating patients.

While telehealth was once a service limited to rural areas or special cases, almost overnight, it’s become an essential tool in the healthcare industry, which must adapt and carry on alongside this world health pandemic. And it’s likely here to stay.

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Americans are concerned they can’t afford coronavirus care

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During the coronavirus crisis, Americans have plenty of fears about the virus and their health and well-being, a new Kaiser Family Foundation survey says. In it, 39% of those who responded also said they are facing financial strife and that they had either lost a job or some income because of the virus.

For many, the study suggests, financial strains are growing more and more troublesome with each passing day. But the virus is not just a burden from a financial perspective. Forty-five percent said the stress of trying to protect their families from the virus is affecting their overall mental health, with 34% even saying they can’t get needed medical care not related to COVID-19.

Patients’ fears about being able to afford care because of a lack of financial means may not be unfounded.

There are efforts in place to protect citizens financially. New York state now requires insurers to not collect premiums for the next two months from individuals and small businesses because of financial hardships brought on by the virus, and health plans in the state must still pay claims for the individual and small group plans through June 1. Health plans also cannot report late payments to credit rating agencies during this period.

Likewise, key insurers are waiving cost-sharing for COVID-19-related costs and tests. President Donald Trump announced on April 3 that uninsured Americans can seek coronavirus treatment for free as the federal government is agreeing to cover hospitals’ expenses. A $100 billion fund will include the provision for healthcare providers that were part of a historic enormous $2 trillion coronavirus stimulus package passed by Congress in March.

“Today I can so proudly announce that hospitals and health care providers treating uninsured coronavirus patients will be reimbursed by the federal government using the economic relief package Congress passed last month,” Trump said at that day’s White House coronavirus task force briefing.

“That should alleviate any concern that uninsured Americans may have about seeking the coronavirus treatment,” he added, saying the order was “very much in favor of our great people.”

With the federal government’s steps, it also is expanding free testing for the coronavirus. The testing for the virus free for many people who need it, including the uninsured.

Per Consumer Reports, in addition to free tests, the “Families First Coronavirus Response Act” requires that coronavirus-related doctor visits be covered by all private insurers; public programs such as Medicare and Medicaid; and for the uninsured, without any cost to the patient.

However, Americans may still feel the pinch in their wallets the cost of being treated for COVID-19, the disease cause by the virus, could still be expensive, especially if you need to go to the emergency room or are admitted to the hospital, Adler says.

This is especially true for the almost half of Americans with a high-deductible health insurance plan (HDHP), which requires you to pay more of your healthcare costs before insurance kicks in. An HDHP plan has a deductible of at least $1,400 for an individual or $2,800 for a family, as defined by the IRS. And surprise medical bills could still be a problem for anyone who seeks treatment.

If a person does test positive for the coronavirus and is being admitted to the hospital, they will be charged for the care. None of the federal legislative actions address the cost of treatment, Consumer Reports note.

These individuals can expect treatment for an infectious disease to be typically covered in accordance with an individual’s benefit plan, however.

That said, most who test positive are allowed to practice self-care at home. Only if a patient shows severe symptoms — severe shortness of breath, weakness, and is unable to stay adequately hydrated — should they be required to seek emergency care.

Back to the Kaiser survey: As unsettling as the responses may be, nearly 75% said they feel the worst of the pandemic is still looming, with about 60% saying they are concerned about putting themselves at risk of COVID-19 in cases where they are not able to stay home to miss work. Those most likely to possess this fear include healthcare workers and their families (69%), lower-income workers (72%), and hourly and gig workers (61%).

As people respond to the virus by protecting themselves through social distancing and sheltering in place — Americans are concerned about more than their health, and their finances are top of mind for most.

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