Wednesday, April 29, 2020

How is Sweden's Coronavirus Health Policy Working So Far ?

A trauma surgeon and trained epidemiologist in California gives an eye-opening update on how Sweden's Coronavirus strategy has been playing out so far:

"There has been a lot of talk about Sweden and how they are going about business as usual during this SARsCoV2 outbreak. Some reports on Sweden range from "no one is dying in the streets there" to "they will be sorry". 

Let's unpack the talk about Sweden and their mitigation practices.

First some numbers: Sweden has a population of 10.23 million people. The median age is 41. 88% of people live in urban communities. The population density for all of Sweden is 64 people per square mile.

Stockholm, Sweden's capital and largest city has a population of 1.2 million with a population density of 10,500 people per square mile when including the urban surrounding area. 

Putting that in perspective New York City has a population density of 26,403 people per square mile.

The first death from SARsCoV2 in Sweden was in early March and as other countries like Norway and Denmark were locking down Sweden chose a different model than the ones put forth by the Imperial College in London or the Information Health Metrics Evaluation group at the University of Washington.

It is true Sweden did not lock down the country. And because of that I see Sweden as a kind of soft nonpharmacological intervention (NPI) control group.

Here is what they did and did not do:

*Grade schools remained open so parents can continue working.
*People have been asked to practice social distancing but are not mandated to do so or stay home.
*Many Swedes say they are not "huggy" people so keeping their distance is easy.
*Masks in public are not mandatory though some people chose to wear them.
*Without a formal lockdown however the mass transit in Stockholm is less crowded and cities less populated.
*Just like here in the US more people are working from home in Sweden.
*Sweden modified many businesses to reduce close contact.
*There are no large gatherings like sports. The teams play but there are no fans.
*Gyms and pools are open.
*Bars are open but you can only drink at a table not at the bar itself thereby limiting crowds and contact.

Below in the comments are the Swedish Public Health Agency recommendations, which sound pretty familiar.

Contrary to all of the talk about how Sweden's approach toward voluntary mitigation their cases and deaths are higher than their neighbors they snuggle next to (Norway: cases 7660, deaths 206 and Finland: cases 4740, deaths 199).

Their new cases parallel the United States log or exponential curve, a level steady number.

Sweden's new case doubling time is 18 days (the US is 18 days as well).

According to the Swedish Intensive Care Registry before the SARsCoV2 pandemic Sweden had 526 ICU beds.

That capacity was increased to 1131 beds as of April 24 and further by the construction of military tent hospitals shortly after that.

On April 24, 533 ICU beds were filled with COVID19 patients. By April 28th the Swedish ICU registry data, attached below, shows the number of ICU patients has doubled to 1,372.

The demographics of those critical care patients are similar to those in the US with an average age of 59.

Deaths, the final grim metric to look at, paint a less than rosy picture for how the Swedish model of minimal mitigation is working.

The doubling time for deaths in Sweden is 13 days (it is 13 days in the US as well). Good news right? No.
When we look at deaths per capita, per one million people.
Not such good news.

The total number of cases in Sweden as of today (4-28) is 19,621 and the deaths 2,355.

This gives the country the dubious award of being in the top 25 COVID19 prevalence countries and the highest number of deaths for all Nordic countries.

Their current death to case rate gives them a Case Fatality Rate of 12.

This is partially due to the abysmal testing Sweden is doing, even worse than the testing by the US. The rate of testing is 5 tests to yield one case of SARsCoV2.

The economic impact of the SARsCoV2 pandemic on Sweden is hitting their business sector nearly as hard as the rest of the EU countries.

Many business owners are experiencing financial uncertainty. Employees are being laid off and receiving government support.

Sweden's government has begun to intervene with a proposal that employers will now be able to reduce their employees' working hours by up to 80 per cent and that central government will cover the majority of the cost as well as assume the entire cost of all sick pay during April and May.

The government has begun injecting capital into small businesses in order to keep them solvent. Overall the forecast is for Sweden's low debt era to end due to the pandemic and its bailout.

So overall do I think Sweden's no lockdown approach is working?

Well the numbers don't lie so I say a polite….no. But I would be happy to see if they prove us all wrong in the long run once "the fog of war" fades.

One area to watch for is what if any difference in mental health challenges are experienced by people living with mandated mitigation versus Sweden’s voluntary version.
Dr. Eileen Natuzzi, MD, MPH, FACS
Acute Care Surgeon

Sunday, April 12, 2020

How Private-Equity Firms Squeeze Hospital Patients for Profits

Interesting article giving background on the perverse effect of Private Equity on health care and how it effects hospitals and doctors. One caveat that I see is that the author refers to the driving force as the "patchwork structure of the health-care industry" - a buzz-phrase generally generally used by those who propose that the only solution is universal health care/ socialized medicine/ government-run system ( choose your favorite euphemism)-  instead of health insurance reform and free market health care reforms.

While a discussion of "fair market pricing" is not the focus of the article, the author properly criticizes surprise exorbitant hospital charges (which really should be transparent).  however, she doesn't point out that the issue of patients being charged at out-of-network costs for *emergency* care is indicative of an egregious, legalized abusive practice currently improperly codified by state regulators into the health insurance regulations-and which should be changed-  since financing for emergencies is the central purpose of insurance overall-  in any form.

Rather she lumps it together with higher out of network costs for  patients who voluntarily accepted a narrow networks for elective outpatient care and procedures based on the doctors' contractual agreement with the payer. While this too can be debated, it is not the same issue as emergency care. In any event , the description of the perverse incentives and behaviors of  PE companies in medicine overall ( though not specifically in radiology) are valuable. 
"  Much of her research has focused on the ways that private-equity firms—investment funds that purchase companies and try to increase their profitability—reshape the businesses that they buy. Appelbaum and her frequent collaborator, Rosemary Batt, a management and labor-relations expert at Cornell University, were in the midst of a research project looking at the role of private equity in health care.

They knew that two of the largest private-equity firms, Blackstone and K.K.R., owned Envision Healthcare and TeamHealth, large physician groups that staff hospitals around the country with doctors; they found that bills from doctors within those groups were responsible for much of the sudden increase in surprise medical bills. (A spokesperson from TeamHealth said that the company does not send out-of-network charges directly to patients, but litigates them with insurance companies. A spokesperson from Envision Healthcare declined to comment.)

“We already knew a lot about P.E. buying up doctors’ practices,” Appelbaum told me recently. “Now surprise medical bills were out of sight. That’s their business model.” Appelbaum suspected that the P.E. companies were behind the practice, as well as behind the ad campaign to stop the legislation.

Appelbaum grew up in Philadelphia, where her father ran an appliance store. Neither of her parents had gone to college; Appelbaum earned a master’s in mathematics and a Ph.D. in economics from the University of Pennsylvania. Her research centered on the relationship between workers and a company’s management. When Appelbaum started out, the prevailing view was that companies could make themselves more productive by investing in their workers. In the nineteen-nineties, she and Batt undertook a study and found that, for example, giving workers more decision-making authority over how work got done led to increased company profits.

The book that they produced from this research, “The New American Workplace,” was published in 1993. But in the years after, the thinking in the business world shifted. A newly dominant business philosophy, called “shareholder value theory,” held that companies exist primarily to deliver profits to their shareholders, and that managers should increase revenue and cut costs, with little regard for the long-term effects......

In 2018, Appelbaum and Batt started working on a report for the Institute for New Economic Thinking, a think tank, about private-equity firms buying companies in the health-care industry. “It’s been an ongoing interest of ours because we felt that it was the worst sector private equity could be involved in,” Batt said. The stakes were higher than in toy retailing: health care was a complex and heavily regulated industry, and drastic cost reductions had the potential to affect people’s safety.

When they looked into it, they found that the patchwork structure of the health-care industry had created an opportunity for P.E. firms. Physician-staffing companies could choose to opt out of contracts with insurance companies, even if the hospitals where their doctors worked did have contracts with those companies.

This left the staffing companies free to send much higher bills to patients treated there; the patients were captive customers, with no opportunity to shop around for doctors with more reasonable fees. (The same thing was happening with air-ambulance transportation companies, which had been bought up by P.E. firms.) “We think of it as a market failure,” a spokesperson for Senator Alexander told me. “This is something that happens when patients don’t have much choice between providers, whether in an emergency procedure or an elective procedure.”

In 2019, as debate about surprise billing started to filter into the news, and the bills were being formulated in Congress, Appelbaum wrote a short piece, for The Hill, called “Private Equity Is a Driving Force Behind Devious Surprise Billing.” In it, she was one of a handful of people to publicly make the connection between EmCare (a division of Envision Healthcare) and TeamHealth and their Wall Street owners..."

Saturday, April 11, 2020

If This is a War, Where are the War Correspondents?

In a recent briefing, President Trump proclaimed: "...The people of United States are in a war against an invisible enemy which has attacked 144 countries. He added that the US citizens are enduring a national trial for which everyone has to support each other. Trump gave an update on the medical equipment and supplies and said that he will fight coronavirus and will not stop until he wins the war against it. "

But an invisible enemy presents a problem. You can't personally see it, hear it, or feel it - and sometimes may have no way of knowing it's out there until it's too late.It doesn't necessarily provide you with the first hand sensory information or knowledge to verify that it's out there. You are more reliant on the reports of experts and journalists to bring you the information necessary to making informed decisions. 

So if this is a war, then where are the war correspondents? 

One important problem with the current pandemic is that the non medical general public sitting at home don't have the context which only comes from getting insider's first-hand view of what is happening at hospitals.
It's very different from what they're experiencing at home, are experiencing financially, and what they see on the internet.
During World War II and subsequent wars in the pre-internet age, the important and _dangerous_ role of the war correspondent was to integrate with the front line troops to bring the American public news from to make them aware of what was happening "over there" so that the could fully understand, tolerate and do what it takes to support the war effort.
Why is this important? "News coverage gives combatants an opportunity to forward information and arguments to the media. By this means, conflict parties attempt to use the media to gain support from their constituencies and dissuade their opponents.[2] The continued progress of technology has allowed live coverage of events via satellite up-links and the rise of twenty-four hour news channels has led to a heightened demand for material to flll the hours." 
In the current war, the battle grounds are the hospitals- which, due to very legitimate fear of infection and spread, are not even permitting family members of critically ill - and dying - patients in to see their loved ones, let alone the media.
The public is getting daily update by talking heads in TV studios, some on stages with political agendas/ ambitions in upcoming elections , or patriotically working remotely in their their living rooms - cocooned in safety from the front lines.
As an article from The Atlantic warns,  "Reporting from war zones has always been a dicey proposition, but the last few years of covering conflicts have become a particularly dark and depressing time for journalists in conflicts."  ( The Life of a War Correspondent Is Even Worse Than You Think )
In the battle against a life-threatening pandemic, the situation is even worse- as not only are there are exceedingly few "war correspondents" on the front lines to make this real to the public, but those fighting the battle in the trenches lack the time and energy to report the news. 
Interviews conducted or filmed in TV in studios do not have the immediacy and reality as those on the ground and are more likely to be viewed as contrived. Given the distrust of the media and the partisan political lens that many view the situation from their living room, there is a dangerous tendency to be complacent and dismiss or minimize the medical threat in the era of "fake news'.
The majority of the physicians in the trenches are too busy fighting to serve this purpose of providing first hand information necessary to enlist public support.
For this reason, I think it's critical for health care workers to not only discuss the medical aspect among themselves, but to excel in their vital roles as medical educator to take to social media in much larger numbers and tell the personal stories - their own and of their colleagues- so that the public can get an accurate, first hand view of what's happening on the ground from physicians and health care workers that they personally know and trust- while directing them to reliable scientific voices and sources, influence the debate and properly inform public policy.