The incoming Biden administration will be challenged to address flex capacity, the supply chain, and real-time data as we transition from coronavirus disease 2019 (COVID-19) response to durable recovery.
Much of the national conversation in recent months has focused on the need to quickly contain and heal the US health economy in response to the coronavirus disease 2019 (COVID-19) crisis. The incoming Biden administration and 117th Congress will be challenged to move beyond the crisis, which will require a laser focus on getting as many Americans vaccinated as quickly as possible and funding a multi-trillion-dollar economic relief package.
The shift from crisis response to durable recovery will emphasize the intersectional forces we contend our national leaders must manage in the years and decade ahead. While some of the intersectional forces of change playing out in US health care are in fact cyclical, we believe that much of what is unfolding is secular. As with any significant crisis, the first-order impact of COVID-19 has been an acceleration of these secular forces already underway.
Digitization, Democratic Reform, and Demographics
Over the last decade, 3 secular forces of change have been in play: digitization, democratic reform, and demographics. We believe they will cause the decade to be viewed as one of the most consequential for US health care in the post–World War II era.
As the Great Recession unfolded in the late 2000s and early 2010s, the Obama-era federal stimulus package included tens of billions of dollars for the HITECH Act. The Meaningful Use regulations it spawned drove pervasive electronic health record (EHR) adoption. The second- and third-order impacts of that digitization have been profound. And yet, as COVID-19 unfolded, our information technology systems were a complicated patchwork that left public health officials without the data needed to match critical provider supply with shifting pandemic demand.
The Democratic-led Affordable Care Act was a second force of change. Among its key provisions, the legislation extended Medicaid to nonelderly adults with incomes up to 138% of the federal poverty line. As unemployment exploded in the first half of 2020, Medicaid enrollment increased. States like Oklahoma have already expanded Medicaid, with others inching toward expansion, creating a de facto single-payer framework for all 50 states. The pandemic exposed the importance of ensuring that our health and care infrastructure extends to Americans in every zip code from the urban core to rural communities.
Third, in 2011, the first Baby Boomers turned 65, making 10,000 seniors eligible for Medicare each day. The demographic shift means the number of Medicare enrollees will double in the next 20 years. COVID-19 has been particularly tough on the elderly and reinforced the need for us to think about new technologies like teleservices as a more meaningful part of the care continuum.
In the context of these major secular forces of change, we believe COVID-19 exposed a set of new questions that must be part of the ongoing national conversation around how US health care should operate in emergent and nonemergent times alike. We believe the transition to the 117th Congress under the new Biden administration is the right time to frame them.
1. How do we build flex capacity into our payment models?
Prior to COVID-19, the federal government had been incentivizing health systems to cut down on more expensive acute care, primarily through programs designed to limit readmissions to the hospital. Thus began the deconstruction of the traditional brick-and-mortal model of care delivery.
The transition away from an asset-intense model was challenged when the influx of patients with COVID-19 exceeded available beds. The major hot spots had no choice but to immediately scale up both their physical and virtual treatment capacity. Illustratively, NewYork-Presbyterian at the outbreak epicenter expanded from 450 to 900 intensive care unit beds to accommodate the surge of COVID-19 patients not covered by current payment incentives. Yet, it was clear that in addition to flexing the use of physical capacity, the home as a venue was trumpeted as nonemergent patients preferred the comfort of home to exposure risk in a health facility. Although providers were initially forced to accelerate telehealth adoption to meet demand, CMS eventually removed financial barriers through accommodations incentivizing expanded use of digital modalities.
Broad-based change in the payment model will be required to accommodate flexibility in acute supply during times of crisis. The current model, which is designed to limit physical capacity, should allow providers to scale care delivery mechanisms up and down to include both bed supply and digital platforms. But how do you build an organization that has a level of resiliency and flexibility because of the unknowns associated with it? Ultimately, developing a core competency in quickly flexing our care delivery infrastructure will need to be part of how we define future payment models.
2. How do we achieve a reliable health care supply chain?
The sophistication of the US health care supply chain has long lagged behind other industries. With incentives to cut costs, most essential supplies from pharmaceuticals to personal protective equipment have increasingly been produced outside the United States to secure the least expensive option. COVID-19 brought the nation’s supply chain to its breaking point, both in terms of quality and availability, with supplies critical to the health of US citizens fully dependent on other countries with their own outbreaks to manage.
In effort to increase reliability, health system CEOs agree that we have no choice but to minimize our dependency on a foreign supply chain. If we are going to be ready for the next hurricane or pandemic, we have to make tradeoffs on price to balance “just in time” inventory and increase domestic production.
Going forward, we will need to build a reliable supply chain that can support a national infrastructure for healthcare. Similar to how 9/11 prompted the government to define and prioritize critical areas underlying US safety, we will need to adequately invest in and protect the life-saving supplies deemed critical to the health and well-being of US citizens. To ensure reliability, we must consider health care as part of national security and build strategies comparable to how we manage our national defense assets.
3. How do we leverage real-time data infrastructure?
Some 10 years after the passage of the HITECH Act, the pervasiveness of readily available and increasingly precise clinical data and analytical tools such as artificial intelligence are changing the face of medicine. Even well before COVID-19, the sophistication of digitized information was beginning to provide greater depth of understanding and treatment of diseases specific to individual patients.
But as we saw from the onset of COVID-19, we did not have time to pull disparate databases together to examine the effects of the disease on the individual. “Real-time” or concurrent data are necessary to monitor a patient when the course of the disease is uncertain. With notable regional variation in spread of the disease, more robust national data architecture would have been invaluable in developing more precise projections and response strategies.
As clinical data become more useful, health systems, which are frequently the central collection and processing entity, see the data as a core asset with value to improve diagnosis and treatment for an individual. Hand in hand with value to the individual is the value of aggregated data to not only the health system but also leaders across the nation. The establishment of a national data infrastructure holds the promise to help track spread and surge, understand underlying chronic conditions, and advance new treatment protocols to more effectively manage health at the population level.
The use of personal health information as a critical component of national surveillance will dually magnify the role of clinical data as a national security asset and individual concerns for data privacy. This balance will be at the heart of political debate, health policy development, and provider engagement over the decade of the 2020s.
A System of Health and Care
As we headed into the 2020 election season, Gallup reported that the third year of the Trump presidency had “seen the largest degree of political polarization in any presidential year. Eighty-two percentage points separated Republicans' (89%) and Democrats' (7%) average job approval ratings of President Donald Trump.” As COVID-19 has surged across the nation, this gap has been evident in public sentiment on topics from crisis response to economic reopening.
The strategic opportunity sitting with the new Biden administration is building a shared factual view of how US health care must operate in times of crisis and calm alike. COVID-19 not only accelerated a set of secular forces already playing out in US health care, but it also exposed critical gaps that must be more fully addressed by the next round of nonpartisan reform.
We need a true “system” of health and care. It must be able to provide flex capacity in time of pandemic response, be supported by a domestic supply chain that can provide front-line caregivers the resources they need to safely care for critically ill patients, and leverage the promise of digitization to allow leaders to effectively manage supply and demand as hotspots emerge across our large and diverse country.
Speed of decision-making must be part of system-level thinking around these 3 areas. Whereas decision velocity in Washington slowed over the course of the 2010s, the 2020s demand a different model. The best leaders understand the intersectional forces of change that are unfolding and craft holistic system-level strategies to influence them. They have a compelling vision for the future state of the health economy that looks far different than today. They have the ability to build the coalitions required to move us toward it.