Chartis Top Reads – Week of September 12 - September 18, 2021

Our research team breaks down this week’s top healthcare news.


Top Reads Overview

In an age of unprecedented change, staying current has never been more important. Our team at Chartis is curating news most relevant to the healthcare industry and tracking the topics that are trending on seven key issues: high reliability care, digital and advanced technology, financial sustainability, health disparities, the health ecosystem of the future, partnerships, and the provider enterprise. Each week, we break down what’s happening and why it matters.

The State of COVID-19

The Buzz This Week

Due to staffing shortages and exceeding capacity in ICUs, care delays are happening throughout the country. The impact of the postponements is being felt by numerous non-COVID patients with urgent and emergent conditions in surging locations who are unable to access the care they need. Below are stories from three different hospitals and health systems in the United States:

  • In Utah, Salt Lake City-based Intermountain Healthcare will be pausing all elective and non-emergent surgeries starting this week for at least the next few weeks amidst Delta variant surges. Intermountain is over capacity on ICU beds, with half of those beds occupied with COVID patients. Of Intermountain’s COVID hospitalizations, nearly 90 percent are unvaccinated patients.
  • In Alabama, a man facing a cardiac emergency was turned away from his local hospital for lack of ICU beds. His hospital tried contacting 43 other ICUs across 3 states before he was life-flighted to Mississippi. Unfortunately, the transfer came too late, and he died in a hospital 200 miles from home. He was vaccinated, and his family asked others to get their vaccine so ICU beds can be available for those needing care. Alabama continues to face ICU shortages with 60 more patients needing ICU beds than were available last week.
  • In upstate New York, 30 staff at Lewis County General Hospital quit over the health system’s vaccine mandate. Due to the resignations, the hospital said they had no choice but to pause deliveries until they were again able to safely staff the delivery unit. The resignations came after a policy change in New York requiring all healthcare workers to be at least partially vaccinated.

In an effort to bring the virus under control, President Biden announced last week that the administration plans to require vaccines for employees who work at healthcare facilities that receive Medicare or Medicaid reimbursement. Additionally, all employers with 100 or more employees would be required to have all employees vaccinated or undergo weekly COVID testing. In total, the requirements would cover 100 million workers.

Why It Matters

Following the initial COVID surge in the spring of 2020, many hospitals and health systems noted that they would never pause all non-emergent procedures again, yet due to the Delta variant and, in some cases, being short-staffed, that is exactly what many have had to do. Intermountain is certainly not alone in delaying care; MaineHealth and Indiana University Health are two other large systems that have also announced elective surgery delays due to COVID surges. Postponing procedures can cause potential harm to patients, especially when it is an urgent clinical need, but performing surgery without adequate staff and beds is not an option. Elective surgery delays also have a very detrimental effect on hospital financials. Health systems collectively faced losses of $60 billion a month in April and May of last year from delayed procedures, according to a recent analysis, and many are not in a financial position to withstand another year of similar losses.

Vaccination rates are up throughout the United States, but states like Alabama, Idaho, West Virginia, and Wyoming still sit at or below 40 percent of residents fully vaccinated. Unlike the majority of those hospitalized for COVID, patients impacted by staffing shortages and full ICU beds are often vaccinated. Many have taken precautions to flatten the curve only to be left without care when they need it. As the CEO of Intermountain Dr. Marc Harrison noted, “I will remind you that for all these patients that we have in the hospital right now with COVID, not a single patient is in the hospital with a complication of a vaccination, vaccinations are safe and they're effective and they're saving lives every day and by having folks who have chosen to not be vaccinated, we're seeing implications to our public health."

President Biden’s extensive mandates seek to change vaccination rates. While the requirements have received mixed reviews in certain sectors and geographies, they have been widely supported by healthcare leadership. The requirements may mean additional healthcare resignations from those who decide the vaccine means this is not the career path for them, but others may choose to get vaccinated and stay in their current jobs since they would have a hard time finding employment elsewhere without becoming vaccinated.

Provider Enterprise

The Buzz This Week

As the Baby Boomer generation ages, dementia is becoming more prevalent, and appropriately receiving increased attention from the medical community as well as the general public. Dementia is featured as a key topic in this month’s New England Journal of Medicine Catalyst, and care for elders — including those with dementia— is one of the areas of focus in the September issue of Health Affairs. As social awareness grows, conversations are prompted at many levels, including entertainment content. Several independent and studio films have been released recently, centered around dementia or featuring a character with some form of the disease, including The Father (2020), Supernova (2021), and Falling (2021).

Per the Mayo Clinic, dementia refers to a broad group of symptoms “affecting memory, thinking or social abilities,” severe enough to impact daily living. Alzheimer’s is a specific brain disease that is one form of dementia, and the most common, accounting for 60-80 percent of dementia cases, per the Alzheimer’s Association. There are an estimated 6.2 million Alzheimer’s cases in the U.S. population of those age 65 and older; by 2050, that number is expected to double.

Caring for people with dementia is incredibly challenging. Affected individuals can experience confusion, anxiety, depression, pain, fear, and resistance. Often patients with dementia are not sick enough to be in a hospital but still require constant care, landing them in skilled nursing facilities or falling under the care and responsibility of family members. As stated by the Alzheimer’s Association, “Of the total lifetime cost of caring for someone with dementia, 70 percent is borne by families — either through out-of-pocket health and long-term care expenses or from the value of unpaid care … Compared with caregivers of people without dementia, twice as many caregivers of those with dementia indicate substantial emotional, financial, and physical difficulties.” The direct cost of caring for adults with Alzheimer’s was $305 billion in 2020, and is projected to be more than $1.1 trillion by 2050 (per year, in 2021 dollars). Neither figure includes unpaid caregiving.

The total cost of caring for dementia patients is expected to rise not only because prevalence is increasing as the population ages and people are living longer with the disease, but also because drug treatments are incredibly expensive. In June 2021, the FDA approved Biogen’s monoclonal antibody, aducanumab, for the treatment of Alzheimer’s. The accelerated approval was highly controversial, as two phase 3 studies failed to show a statistical, clinical benefit of the drug, and the only positive study showed a modest signal on neuropsychological tests, but no measurable clinical benefit or functional improvement noticeable to patients or family members. It sparked objections from medical professionals and some resignations from the FDA advisory panel. However, some patients and families are desperate for something new to try to combat the disease, to move it from a terminal disease to a chronic condition, and are willing to try Biogen’s drug in the hopes that it does, in fact, have a noticeable positive impact. The cost? The FDA recommended an annual cost of $2,500 to $8,300; Biogen has been talking about a cost of $56,000 per year— an enormous burden for a family to pay out of pocket, and a cost that will drive up Medicare, Medicaid, and private insurer expenditures. For the latter, it may lead to higher premiums or restrictive approval guidelines/exclusions.

Why It Matters

With the growth of dementia prevalence and challenges associated with caregiving, finding more compassionate, effective, sustainable, and cost-effective approaches to care will be crucial for the survival and quality of life for affected patients — and their families. NEJM Catalyst conducted a survey of its Insights Council members in May 2021, including clinicians, clinical leaders, and executives at healthcare organizations. 81 percent of the respondents said their patient population included some level of prevalence of dementia, and 41 percent said their current dementia services were inadequate. Even if new and emerging drug treatments are found to be impactful, it is doubtful that these treatments will eliminate the need for comprehensive daily care.

Several experts have underscored the importance of interdisciplinary care, as well as support for family members who will provide the bulk of the non-hospital care. Dr. Robert Sawyer, a neuropsychologist and Co-Director of the Center for Brain Health at Ochsner Health in Louisiana described the more successful approaches to dementia care in a recent Health Affairs piece: “What happens is you typically start with a primary care visit, followed by one with a specialist. But if no one really ‘owns’ their care, then patients often get lost to follow-up ... If you look at some of the successful dementia work being done, it’s really focused on quality, cost, and value, but in a multidisciplinary way. They use an integrated practice where you have a disease condition such as dementia, and then you have professionals there who can do the diagnosis, manage the psychiatric/neurologic conditions, handle the immense psychosocial issues, and provide caregiver education/support.”

Technology has shown the promise of easing some of the pain points of caregiving for those with dementia, and the experience of the patient. A 2019 article in Nature suggests that “Technologies that augment existing care can maintain a person comfortably in their community, maximize individual autonomy, and promote social participation. However, to date, such technologies have rarely been used in dementia care.” These technologies can be fairly simple and inexpensive. An example is a smart speaker that can tell a person the day of the week and date, the weather forecast, and can be programmed to control heat and lighting via an approved caregiver’s smartphone. More complex technologies include robots that can help with directions and physical guidance, and provide two-way interaction - not replacing a human caregiver, but alleviating the loneliness and isolation often felt by dementia patients.

Those affected by dementia require coordination and dedication from family members, neighbors, other companions, and medical professionals. Because of the complexity of the disease and its manifestations, it will take coordination between these parties, informed by continued research and education, and potentially with the support of certain pharmaceuticals and technologies, to effectively care for dementia patients and provide the right level of support to their caregivers.


    Contributors

    Roger A Ray, MD
    Chief Physician Executive
    [email protected]

    Alexandra Schumm
    Principal, Vice President of Research
    [email protected]

    Abigail Arnold
    Senior Research Manager
    [email protected]


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