Just as this book was going off to the printer, the coronavirus pandemic arrived. The publisher stopped the presses, ripped up the previous version of the coda, and asked that I take a few moments to consider if there was anything this examination of health care systems could illuminate about coronavirus and what coronavirus might tell us about health care systems. This new coda, written one week after New York City had begun its “pause” and the same weekend as Louisiana had declared its lockdown, is necessarily very preliminary. But here are 7 tentative thoughts that quickly emerged from the evidence around the world.
First, coronavirus is not a one-off or a black swan event. We should expect more emergency infectious disease outbreaks. Over the last 2 decades, the world has witnessed an outbreak almost every 3 years: SARS in 2003–2004, H1N1 swine flu in 2009–2010, MERS in 2014, Ebola in West Africa in 2014, Zika in 2016, Lassa fever in 2018, Ebola in the Congo in 2019, and now in 2020 COVID-19. Because of reasons including climate change, the progressive encroachment of humans into animal habitats, greater travel, and more mass displacements, these outbreaks are likely to occur regularly. Thus, health systems will need to be resilient and develop disaster plans that confront the possibility of overwhelming, if limited-term, demand—something they have typically not been prepared to do.
Second, and relatedly, as has become clear with COVID-19, competently and effectively addressing the widespread outbreak of a novel virus for which there is no established herd immunity in the general population is not fundamentally a test of the health care system. It is true that an outbreak can overwhelm the health care system and cause it to fail to adequately care for all patients. But fundamentally, the adequacy of the response depends upon political judgment and leadership to rapidly institute public health measures and the competence of public health infrastructure to implement them effectively and swiftly. The countries that have responded best to COVID-19 and were able to avoid massive outbreaks, high population mortality, and overloading the health care system were those that were able to (1) engender public trust with frequent and accurate pronouncements about the number of COVID-19 cases and other relevant matters, (2) implement physical distancing, (3) deploy extensive population-wide testing, (4) implement rigorous and extensive contact tracing, and (5) isolate and quarantine positive cases. These are not responses of any one health system but of governments and the public health system. While they are related, they are often separate governmental agencies and have very different purposes. Health care agencies typically address the financing of personal health care, while the public health agencies are supposed to focus on population-level problems.
Third, a standout response to COVID-19 was in Taiwan. In 2003 and 2004, SARS was a wake-up call. Health care officials there recognized that with incredibly tight trade and travel connections with China, they had a very high risk of exposure to any novel virus that might arise there. After SARS, the Taiwanese government prepared itself for an outbreak by putting in place the capacity to proactively identify people at risk of carrying the virus and by preparing a stockpile of personal protective equipment. With the novel coronavirus, the government immediately—in a single day—integrated patients’ National Health Insurance identification cards with data from its immigration and customs database. This allowed them to identify patients who had traveled recently to China and use that information to alert clinicians of patients with high infectious risk, who were then identified and quarantined. Having an excellent electronic health insurance card system with the ability to not only collect information but also to transmit information back to physicians greatly facilitated Taiwan’s response, which led to just 252 COVID-19 cases and 2 deaths at the end of March—far fewer than originally projected.
Fourth, COVID-19 exposed the serious flaws of both the Chinese and American health systems, but for different reasons. China deserves the widespread general criticism it received for its initial suppression of information about the novel disease and the way this endangered the entire planet. More relevant to this book is that China’s health care is hospital focused. Fundamentally, there are few other health care facilities. There are vanishingly few physician offices or other ambulatory centers to deliver care. Thus, mild, moderately, and severely ill patients with COVID-19 flooded into the hospitals, crowding together with infected and other noninfected patients, and overwhelmed the entire system. In Hubei province this required the emergency construction of 16 new hospitals, the influx of 30,000 health care workers, and the assembly of equipment and supplies from all over the country to tackle the torrent. While such construction and mobilization of material was nothing short of miraculous, the inevitable delay in getting these resources ready dramatically increased the mortality rate and was hugely inefficient and wasteful. A hospital-centric delivery system is poor at addressing emergent and widespread health needs.
COVID-19 also exposed multiple failings of the US system. The absence of universal coverage and the high-deductible health insurance of many Americans made it hard to convince people with suspect COVID-19 cases to seek medical attention, endangering the wider population—even those with good health insurance. This required emergency action to make COVID-19 testing and other interventions related to the disease free. This emergency response was reminiscent of the decision in the early 1970s to nationalize the payment for dialysis for all patients with chronic renal failure. The policy zigzag plugged one hole rather than comprehensively addressing the entire faulty health insurance system. This patchwork approach is both inequitable and inefficient—inequitable because it favors patients with one condition while ignoring equally worthy patients with other medical needs, and inefficient because it requires legislation, regulation, or other special actions that add ever more complexity to the system and is slow to be delivered.
Fifth, some US physicians were able to adapt their investment in chronic care coordination to facilitate their response to COVID-19. Many primary care physicians in the United States were overwhelmed and uncertain how to proceed—order tests, manage COVID-19 patients, and change their practices. However, there were others who quickly determined that the patients at highest risk from COVID-19 were the elderly with multiple chronic conditions. For practices that had instituted innovative chronic care coordination, these were precisely the kind of patients being followed by coordinators. One primary care practice organization I know of (because the venture firm I work with invested in it), Village MD, was able to identify all high-risk patients and immediately, proactively reach out to them. This allowed coordinators and other staff to inform patients about their risks and the symptoms of COVID-19, advise them to self-quarantine, encourage them to limit visitors, and educate them about how to safely use the health care system, such as calling ahead if they needed emergency services. Village MD was also able to work with their patients to provide telemedicine services instead of in-person visits. Practices that quickly implemented advanced chronic care coordination had an advantage in responding to the outbreak and protecting high-risk patients.
Sixth, the COVID-19 pandemic has changed medical delivery in many countries. Many of these changes need to become permanent. Because of the virus’s infectiousness, many routine clinical activities have moved to text, phone calls, video calls, and other modes of virtual medicine. They will be done just as well as when performed face-to-face. In addition, new phone apps or “add-on” technologies will be developed. These virtual medicine interventions should be viewed not as improvised adaptations to COVID-19 but as improvements that become integrated into routine care. A permanent expansion in virtual medicine should allow more time to be devoted to face-to-face interaction for the chronically ill who need more extensive management.
Similarly, because of the threat of overwhelming the system, criteria for hospital admission, performing procedures, and other clinical services have become more stringent. It is important that the medical systems do not revert to practice B.C.—Before COVID-19. In a Washington Post op-ed, one physician, Dr. Jeremy Faust, described how, in the B.C. system, physicians would admit patients to the hospital with “small, but non-trivial chances of having a serious medical problem that further testing and observation may reveal.” All the hospital demands imposed by COVID-19 have changed this calculation. Faust used the case of a stroke patient to illustrate the kinds of changes in clinical decision making:
If a physician is evaluating a patient who may have had a stroke, but who did not go to an emergency room until a few days later, we would normally perform a “stroke work-up” to gather more information. We get a CT scan of the brain in the ER, and in some cases, a second more detailed one with dye. We check some bloodwork and make sure that the symptoms aren’t being caused by a “stroke mimic,” such as an infection that can temporarily worsen the symptoms of a previous stroke, for instance. This all takes a few hours.
However, even in a patient whose symptoms have disappeared and who is “back to baseline,” we often admit them to an observation unit or to the hospital to complete the work-up. That usually includes an MRI and other tests, which can take up to a day or more.
But, if we are being honest, we all have come to learn that the “yield” of investigations such as the one described here is pretty low. These patients are not eligible for urgent treatments. About the best that neurologists can do is offer medications that might prevent a future stroke.
The new, much higher threshold for hospital admission needs to become permanent to avoid unnecessary and inefficient care.
Similarly, to conserve personal protective equipment and redirect health care personnel, elective surgery and other procedures have been discontinued at many hospitals and ambulatory surgical centers. When the COVID-19 threat abates, physicians should reassess how many of those procedures were really necessary or whether they were done more for hard-to-justify reasons such as convenience, financial remuneration, and the like. When elective procedures can resume, there should be a higher threshold for performing them too.
These COVID-19-induced changes in physician practices could significantly improve medical care, convenience, and safety as well as reduce costs.
The final observation from the COVID-19 pandemic returns to the main purpose of this book: the importance of other countries. Clearly, COVID-19 reminds us all that the nearly 200 countries of the world are deeply interlinked. Not just in the usual economic, travel, resource ways but also in terms of health. Health outbreaks that happen in one country have an effect on all countries. It is truly impossible to isolate different countries. Countries must work together.
More importantly, the pandemic emphasizes to everyone that studying other countries is very valuable. That question my audiences kept asking me—Which country has the best health care?—is fundamentally right. COVID-19 has made abundantly clear that we can and must learn from how different countries responded and how the viral outbreak affected different countries’ health systems. Every country can learn from Taiwan’s felicitous use of its health insurance card system to address the urgent public health and health care situation. Other countries might learn from medical practices that were able to adapt a system built for chronic care to handle an acute infectious illness. And we can learn from countries that had poor responses to COVID-19 about the dangers of not sharing information and not implementing public health measures rapidly. If countries truly seek out the lessons from each other about what finance, delivery, and other health system arrangements enhanced the COVID-19 response, then patients everywhere will greatly benefit in ways that go beyond the immediate crisis. That seems like a worthwhile objective from the fight against a frightening new disease.