2020: A Year of Struggles—and Progress—in U.S. Healthcare

Dec. 30, 2020
It’s been a year of struggle for U.S. healthcare, with the COVID-19 pandemic overshadowing everything else; yet progress has been made in important areas, and the coming new year offers promise

Let’s face it: 2020 has been an incredibly challenging year for U.S. healthcare.

The overriding development across the entire year, of course, has been the emergence of the COVID-19 pandemic worldwide, and its appearance in the United States at the beginning of the year (though it now appears that some individuals living in the U.S. had already been infected in December of last year, or perhaps even in November of last year). Everything else that happened in 2020 either paled in comparison with the impact of the pandemic, or in some way connected to it.

Before saying anything else, it will be absolutely necessary to salute the courage, dedication, and skill of all of our nurses, physicians, respiratory therapists, and other clinicians who have been caring for COVID-19 patients, and the dedication and courage of all of those who have been working in hospitals, clinics, nursing homes, and every other kind of patient care organization, from patient transport workers to environmental services staffers. Every single person who has been working in patient care organizations has contributed to the heroic effort to save lives and restore health. What’s more, senior healthcare IT leaders have engaged in heroic efforts that have been absolutely vital as well.

One of the key efforts that CIOs and everyone in healthcare IT led successfully in March was the lightning-fast transition both to remote care delivery wherever possible, as well as to remote operations wherever possible. As it became clear that the only way to safely deliver care during the exploding pandemic was to deliver it remotely as much as possible, CIOs, CTOs, and everyone else on their teams, worked virtually 24/7 for a number of days to facilitate that change, standing up levels of telehealth-based care delivery that were unprecedented. At the very same time, healthcare IT leaders needed to shift as many non-clinicians to remote work and operations as possible, almost equally quickly; and they did so with great skill and with tremendous consideration for the needs of their coworkers.

One of the “silver linings” in that entire situation is a phenomenon that many CIOs and other senior leaders at patient care organizations have shared with me and my fellow editors here at Healthcare Innovation, and that is the realization that yes, when it’s absolutely necessary, patient care organizations can move very fast to implement changes. A self-fulfilling belief in the healthcare field for—well, forever—has been that healthcare is a super-slow industry, one averse to change and innovation—and most of all, one constantly weighed down by ponderous decision-making and strategic planning processes. Well, when it became obvious that patient care organizations had days to “flip the switch” to the maximal proportion of remote care delivery and remote operations possible, everyone in hospitals, medical groups, and health systems was able to pull together and very quickly flip that switch. Was it messy? Yes. Did it feel a bit chaotic in certain ways? Yes. But every senior leader I and my fellow editors have spoken with said that it happened successfully—and quickly. And that was a good learning for the entire healthcare system.

One thing that healthcare IT leaders were very aware of was the potential range of cybersecurity vulnerabilities involved not only in moving so quickly, but even in the shift itself. As CynergisTek’s David Finn told me, there was no question that patient care organization leaders had to move extremely quickly, and then go back and look at the vulnerabilities; that was simply how things were. At the same time, he noted, it was very clear that individuals were having to use rather insecure platforms, something that CIOs, CISOs, and other organizational leaders would inevitably spend months addressing.

And all of that happened before the shocking attacks of late October. As Senior Editor David Raths wrote on Oct. 29, “The Washington Post is reporting that in the space of 24 hours, six hospitals across the country were hit this week with Ryuk ransomware attacks demanding up to $1 million, and that some hospitals have paid. In response, federal agencies have issued a warning saying that they have credible information of an increased and imminent cybercrime threat to more U.S. hospitals and healthcare providers.” With a number of integrated health systems severely affected, Raths wrote on that date that “The Cybersecurity and Infrastructure Security Agency (CISA), FBI, and the Department of Health and Human Services are warning healthcare providers to take precautions to protect their networks from these threats, including attempts to infect systems with Ryuk ransomware. CISA, FBI, and HHS encourage healthcare organizations to maintain business continuity plans to minimize service interruptions. They also suggest reviewing or establishing patching plans, security policies, user agreements, and business continuity plans to ensure they address current threats posed by malicious cyber actors.”

As CynergisTek’s CEO Caleb Barlow told me on Nov. 3, “The situation right now in healthcare is pretty alarming. What we have going back to the UHS [Universal Health Services, a 400-facility organization based in King of Prussia, Pa.] incident last month, is a series of ransomware attacks. That’s not new. But what was new starting with UHS is the change in adversarial intent. What do the bad guys want? Remember, these are criminal gangs…. We saw a marked change in adversarial intent here, meaning, starting with UHS, they were targeting an entire system, in the case of UHS, one with hundreds of hospitals and clinics. And they know if they take the hospital down, they’ll have to divert patients. And 80-90 percent of the time, the hospital organization will pay. And last month, in Düsseldorf [at the Düsseldorf University Clinic in Germany], we actually saw the first patient die because of a diversion. But now, if you take down a system, you’re really seeing a shift. Now, these criminals are trying to bring down patient care organizations during a pandemic. Why this is happening is open to speculation; but this isn’t entrepreneurial anymore, this is something different,” he noted.

So, on top of all the challenges involved in managing through the pandemic, a new cybersecurity landscape emerged in 2020, one that was demonstrably scarier than the already-very-scary one that had already existed. I’m sure some patient care organization leaders had days this year in which they just wanted to stay in bed.

Shifting into value—during the pandemic

But if the challenges around the pandemic and the emerging cybersecurity landscape were extremely daunting, real progress has happened this year in areas of genuine importance to the future of U.S. healthcare, in terms of the shift into value.

In that regard, it was great to be able to cover the virtual conference in November held by APG, America’s Physician Groups, known as the APG Colloquium 2020. Numerous really significant panel discussions took place during that virtual conference, including one entitled “Value Movement: Smooth Sailing? Or Clouds on the Horizon?” held on Nov. 17 and led by Don Crane, APG’s president and CEO. In that discussion, he was joined by Niyum Gandhi, executive vice president and chief population officer at the Mount Sinai Health System in New York City; David Joyner, CEO of the Hill Physicians Medical group, based in the San Francisco suburb of San Ramon; and Robert E. Matthews, president and CEO of MediSync, a Cincinnati-based consulting firm focused on medical group management.

Discussing why he and his colleagues at Mount Sinai in New York took the plunge and have rearchitected their entire delivery system to compel a movement forward into value-based care delivery, Gandhi said, “We want transformation, not incremental change; we want it at scale, not just in pockets; and we want it fast, not slow. But we can only get two of the three. So we can have at-scale change that’s slow, and you get that through the shared-savings programs. And that will take two decades. But to get this transformative change, we really need the time to get there. And health systems like Mount Sinai are embracing value by taking risk. And pressures will inevitably push us to a new model of high-value care, at scale, with real value; it will just take a while to get there.”

Gandhi acknowledged that his integrated health system is among a small minority pushing forward into risk-based payment. Indeed, on a superficial level, it might seem counterintuitive for hospitals, medical groups and health systems to push forward into risk during a financially perilous pandemic. But, in an APG Colloquium discussion panel held on Nov. 18 and entitled “Mid-Pandemic: Should We Be Doubling Down on Value?” Mark McClellan, M.D., Ph.D., director of the Robert J. Margolis Center for Health Policy at Duke University, and a former Administrator of the Centers for Medicare & Medicaid Services (CMS), put it this way: “COVID-19 has exposed some fundamental problems in our healthcare system, because of the fee-for-service payment system, which led to health systems having to scramble financially. And they had to move so quickly on telehealth, which they just weren’t prepared for. And not only through now three surges of COVID, but also the need to contain. Meanwhile, APG member organizations and others involved in value-based payment, were able to focus on care management and transitions, rather than having to scramble so much.”

Indeed, that perception had been validated the day before during an APG Colloquium panel entitled “Organized Physician groups: Adaptations to COVID-19,” in a comment by Stacey Hrountas, CEO of the Sharp Rees-Stealy Medical Group in San Diego. “Seventy percent of our revenue is prepaid,” Hrountas said, “and, hallelujah, because it saved us during COVID!” And Hrountas’s comment was not isolated to success during COVID; she reinforced, when asked how her organization had changed or evolved recently, the key role of analytics use. “We’ve really honed in on our reliance on technology an data,” she emphasized.

She’s not alone. As I wrote on Dec. 7, “Earlier this fall, leaders at the Eden Prairie, Minn.-based Optum corporation released the results from their third annual Optum Survey on AI in Health Care. Among the survey’s findings include that healthcare executives project a quick return on AI investments and nearly all said hiring AI talent is a top priority. The survey also found the top three applications health care executives plan to tap AI for – all of which can help improve health care in the current and post-COVID-19 world – include monitoring data from Internet of Things devices, such as wearable technology (40 percent); accelerating research for new therapeutic or clinical discoveries (37 percent); and assigning codes for accurate diagnosis and reimbursement (37 percent).

As a press release published to Optum’s website on Oct. 27 stated, “Health care executives today believe artificial intelligence (AI) will deliver value for the industry faster than previously thought, according to a new survey of 500 senior health care executives representing leading hospitals, health plans, life sciences and employers. The third annual Optum Survey on Artificial Intelligence (AI) in Health Care found that 59 percent of executives surveyed expect their organizations will see a full return on their AI investments in under three years, nearly double the 31 percent of leaders surveyed in 2018 who expected to break even that quickly. Further, health care executives’ confidence in AI’s ability to deliver operational efficiencies or improved clinical performance increases as their organizations progress on the maturity curve: among the respondents who identified as being in the late stages of AI deployment, 57% indicated they would reach their ROI in less than two years. Expectations for faster return on AI investments grew even among those in earlier stages of deployment, indicating growing confidence in the technology.” The press release went on to note that, “In addition, leaders across industry segments expect to see tangible cost savings from their AI investments faster – an average of 3.6 years in this year’s survey, down from 4.7 years in 2019 and 5.3 years in 2018.” The press release quoted Robert Musslewhite, CEO of OptumInsight, who stated, “This year’s findings further confirm our belief in the potential of AI to deliver insights and operational efficiencies that unlock better performance across health care. It is encouraging to see so many organizations express confidence in AI’s ability to facilitate the pursuit of our industry’s shared goals: better health outcomes, better consumer experiences, and less physician burnout—all at a lower total cost of care.”

In an interview following a panel discussion on the topic of AI, Managing Editor Rajiv Leventhal asked Sandeep S. Vijian, M.D., chief medical officer at Parkview Medical Center in Dallas, about the results coming out of that Optum survey, including that 57 percent of survey respondents had indicated that they would reach a return on investment in AI in less than two years, Dr. Vijian stated that “I think those estimates are very reasonable. I believe what healthcare executives have started to realize is that on an accounting spreadsheet, to drive revenue, either you're going to drive more volume or you're going to increase the quality of care,” Vijian said. “In order to achieve one or both of those goals for physicians who are practicing, you are going to have to give them the tools to practice more efficiently. Whether volume or quality, they just need to be able to get the information they need to make therapeutic decisions. Moreover, they need to get the information that is on the surface invisible to them. So if you [as the physician] are seeing 10 patients in a day, and that was all you did that day, you would have the luxury of doing an hour history and physical exam, and an interview [with the patient] to get into the nitty gritty of social determinants of health and their home environment. But that’s not true of medical practice today; most providers are responsible for seeing several times that number of patients each day. So AI has become an investment in efficiency to find the information that traditional EMRs just don't provide in an easy, readable format.”

What’s more, in that same interview, Garrett Vygantas, M.D., managing director in the venture group at OSF Innovation, a division of the Peoria, Ill.-based OSF HealthCare, said that “I don't see any reason why you couldn't expect earlier value capture. I understand that the pace of change in healthcare in general is slower than in other industries, but when there's top-down leadership, engagement, and a culture around efficient deployment, I can't see why you wouldn't expect to capture value earlier. We've seen examples in this current pandemic where technologies were deployed at a much more rapid pace. So, from the standpoint of whether it can be done or can't be done, that question is answered. It’s really an issue of culture and the leadership driving those efficiency changes.”

And the leveraging of data analytics, including AI-powered analytics, to advance population health management and care management, has turned out to be one of the truly bright spots in the landscape of 2020, as patient care organization leaders move forward to innovate and to prove their value in a healthcare system being prodded forward by the purchasers and payers of healthcare.

Another very bright spot: the quickly broadening engagement around the social determinants of health (SDOH). In that regard, it was delightful to do a group phone interview with healthcare leaders in Prince George’s County, Maryland, a county with a population of over 909,000 residents that lies just outside the border of the District of Columbia, and whose very diverse population includes a large sub-population of residents living in poverty or who are economically disadvantaged.

As I noted in a report published on Dec. 12 regarding SDOH-related collaborative work, “One community in which a concerted effort among different stakeholder organizations has been moving forward strongly has been in the Maryland county of Prince George’s County, just east of Washington, D.C. There, the Prince George’s Healthcare Alliance, Inc., a non-profit organization, has been providing ‘community care coordination services to high risk, high need, high utilizers in healthcare,’ as the alliance’s website explains.” In that interview, Barbara Banks-Wiggins, executive director of the Prince George’s Healthcare Alliance; Ernest L. Carter, M.D., Ph.D., Health Officer of the Prince George’s County Health Department (PGCHD); and Caitlin Murphy, special assistant to the Health Officer at the Prince George’s County Health Department, all spoke to me regarding the intensive public health collaboration taking place in Prince George’s, around efforts to address SDOH on the ground level.

Banks-Wiggins noted that Dr. Carter had introduced a county-wide population health management model, using federal grant funding to extend the reach of the public health department there. “Through the grant money, we will give providers funding open new practices in this community, so we went from one to five; and then improve outcomes by addressing their social needs, including through the use of community-based social workers,” Banks-Wiggins noted. “And the health outcomes were astonishing. What was interesting was Dr. Carter realizing that once this grant is over, we can’t stop this work, because otherwise, people will go back to the same issues challenging their outcomes. So in 2015, we developed a primary care strategy, which stated that we needed an organization to help collaborate with providers. So the Health Department is the reason why the Health Alliance has been doing this work.”

And Carter noted that “The goal here is to meet all of the health needs of an individual, whether they have a tremendous number of needs, or few, or none. As a public health department, we need a system to help manage an entire population. And we’re developing a public health information network that will allow us to address all the factors that influence a person’s health, including their behavioral health, environment, and social determinants, as well as their clinical health. And this all stems from the development of our community care team. When someone is homeless, there are a lot of needs and issues, but there’s no information system helping to manage that. So you need to have information at your fingertips and to help you analyze their situation, right at the right time, so that you can make the right decisions, whether to refer them to a resource, for example.”

The Prince George’s County situation is one that is very hope-inducing. Intelligently leveraging data analytics to address the social determinants of health, Prince George’s leaders are genuinely moving the needle on improving the health of their entire population.

There are many more areas I could have touched on in this blog; but, looking at the overarching developments of this past year, it’s clear to me that the leaders of patient care organizations, in concert with the payers and purchasers of healthcare and with public health and healthcare policy leaders, have what it takes to move the healthcare system forward going into the future. For all the challenges of 2020, we’ve seen real progress in efforts to improve the health of entire communities. There is much to look forward to in 2020 in U.S. healthcare—and I look forward to sharing with you, our readers, our team’s reporting and analysis of the progress that will be made in the coming year in this enormous enterprise called the U.S. healthcare delivery and payment system. 2020 is over; on to 2021!

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