Carving a Leadership Path Forward: Perspectives from the Ground

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

Kate:

Hello and thank you for joining the final session of the Alliance’s 2020 Signature series, Post Election Symposium. I am Kate Sullivan Hare, Vice President of Policy and Communications at the Alliance for Health Policy. For listeners who are new to the Alliance, welcome we are a nonpartisan resource for the health policy community dedicated to advancing knowledge and understanding of health policy issues. In this final session, leaders from the ground will discuss the long-term vision for rebuilding the health system across a broad range of issues.

Kate:

I want to take a moment to thank our 2020 post-election symposium sponsors. We appreciate their support in making this summit happen and you can join today’s conversation on Twitter using the hashtag all health life and follow us at all health policy. We really want you to be active participants. So please get your questions ready. You should see a dashboard at the bottom of your screen with some icons. Use the two speech bubble icon labeled Q&A to submit questions you have for the panelists. At any time.

Kate:

We will collect these and address them during the broadcast. You can also use the Q&A icon to submit any technical issues you may be having. Finally check out our website, allhealthpolicy.org for symposium background materials, including speaker bios, resources lists and an experts list. Recordings of completed sessions will be made available there soon. Today, I am so pleased to be joined by an esteemed group of experts to have this conversation, I will direct you to their full bios on our website as I cannot do them justice over the time we have.

Kate:

First, we have Dr. Bob Kocher a partner at Venrock, where he focuses on healthcare, IT and services investments. He serves as an adjunct professor at Stanford University School of Medicine and a non-resident senior fellow and advisory board member at the Leonard D Schaeffer Center for Health Policy and Economics at USC. After Kocher previously served in the Obama administration as a special assistant to the president for healthcare and economic policy of the National Economic Council.

Kate:

Next I’m pleased to introduce Dr. Mark McClellan, the Robert J Margolis Professor of Business Medicine and Policy and founding director of the Duke-Margolis Center for Health Policy at Duke University. Previously, Dr. McClellan served as a senior fellow economic studies at the Brookings Institution where he is director of Healthcare Innovation and Value Initiatives. Dr. McClellan is the former administrator of CMS and former commissioner of the FDA.

Kate:

Next I would like to introduce Dr. Nirav Shah a senior scholar at Stanford University Clinical Excellence Research Center. Dr. Shah has previously served as Vice President and Chief Operating Officer for clinical operations for Kaiser Permanente at Southern California and as commissioner at the New York State Department of health. Finally, I am pleased to introduce KP Yelpaala. KP is the CEO and founder of Access Mobile International.

Kate:

Prior to founding Access Mobile in 2011, KP worked at Dopper Global Development Advisors and has served as one of the early employees of the Clinton Health Access initiative. He has taught at the University of Denver’s Josef Korbel’s School of International Studies and was appointed to and served on the governor of Colorado Small Business Council. Thank you all for joining us. Bob I’ll now turn it over to you.

Dr. Bob Kocher:

Thank you for having me. It’s a pleasure to be here and to talk with you. I’m looking forward to our conversation, when one thinks about COVID, there’s not a lot of silver linings that come to mind. Pretty much the worst pandemic you can imagine. But as I try to make lemonade out of it, there’s a couple of things that give me some hope and optimism. And I say this sitting in Palo Alto, in Silicon Valley, where I spent a lot of time with people trying to make the world better, it then sort of get us out of this mess.

Dr. Bob Kocher:

And, when I think about what triggers change in healthcare in America, you think about periods of glacial change, and then there’s these moments where things actually, really, spurts of innovation and what drives those moments in time, I think, are the alignment of incentives and then usually breakthroughs in technology and new information that allows people to see arbitragers that you couldn’t see before.

Dr. Bob Kocher:

With COVID-19, you couldn’t possibly have a stronger alignment of incentives to get us out of this pandemic fiasco and we’re benefiting from amazing types of technology, whether it’s new at-home testing, mobile phones, big data but more information that you can actually combine with the incentives. And so, we have a perfect moment to innovate our way out. We have a couple of other things going for us. We have now every single American, every single day wakes up and thinks about public health and NPIs and safety and vaccinations and [inaudible 00:05:12].

Dr. Bob Kocher:

And so we have a society that couldn’t possibly be more about public health and how to improve it. And so those conditions, I believe will create a set of opportunities, which will be helpful. And we’ll compress a bunch of innovation that would have taken decades into literally months. The first one is public health. And so we will see bi-partisan support for investments in public health like we haven’t seen for maybe a hundred years to recreate a public health care system.

Dr. Bob Kocher:

What we’ve observed is that the kind of this digital leftover public health system from the efforts of [MAC 00:05:47] vaccinations in the 40s, 50s, 60s, that hasn’t been sort of up to the challenge, for COVID-19 both, protections and then hopefully the scene of a vaccine. And so you’re going to see the private sector jump in. I believe that the night is a public health is going to become schools because we all, if you have, if we have kids, we couldn’t be more motivated to having to go back to schools.

Dr. Bob Kocher:

Not only because they weren’t more in schools, but because your mental health improves, if they go back to schools. So schools will be a place that will become focuses the public health and safety and prevention, employers won’t badly want to have their businesses behave more normally. And there’s a lot of circumstances where having people work together, actually creates more innovation and speeds decision-making and is valuable as the employers will become stewards of public health.

Dr. Bob Kocher:

And then health systems, and most communities will be kind of the organizing forces between for public health, because they will have both the clinicians who can deliver public health, the systems to track it and the freezers just run the vaccines in the end to do the medicines. And so I think you’re going to see public health become central to each of these large parts of every community. And you’re going to have public health departments the counties actually be the people that actually are the chief financial officers.

Dr. Bob Kocher:

They will do the counting, accounting, hold people accountable, do the reporting, and then they will use their resources to go fill the gaps. And where are the gaps going to be? There’ll be in nursing homes, which we’ve seen, have struggled. There’ll be in prisons for sure. There’ll be homeless communities. And there’ll be among the under health care served areas of the community. So they will go be the [inaudible 00:07:22], I believe.

Dr. Bob Kocher:

The second big thing that’s going to emerge is they have to coordinate all this is going to be open data and data sharing. And that’s the two conditions can give incentives and information. We will have, I think, much more interoperability of data and data sharing and access to data because of COVID-19. That we’ve ever had before. This might be the thing that leads to interoperability, the long hope for connections of EHRs. Why would that happen? Well, everyone’s going to need to show their COVID test results to do a lot of things for quite a long time.

Dr. Bob Kocher:

And you’re going to get those tests in all kinds of places. So having ways to share that data is important, but even more important for vaccinations, you’ll probably need two doses of a shot. You need to prove you’ve gotten those two doses. You need to prove that you’ve been vaccinated to do many things. Whether it’s go to soul cycle or go to your office, or certainly go travel. And so you’ll need data-sharing to make that work. And people will want to be doing testing and giving vaccinations because it will profitable and somebody exchange they’ll need to connect their computers to the system to share that data.

Dr. Bob Kocher:

The third thing is and I see this daily is tremendous interest in creating companies to help do this. We have the benefit of many years of successful technology, product creation, consumer product company formation and great alumni and CEOs who now want to come work on the most important problem in society, which is public health and COVID-19. And so we have a great deal of talent and the capital coming to create companies to do all the things I just said. And so you’re going to see continued creativity and successes in virtual healthcare of all kinds, whether it’s primary care or special-need care.

Dr. Bob Kocher:

Lots more access to behavioral health which is terrific because we all need it. And that’s the one area in healthcare that we’ve underserved people. You’ll see a lots of creativity in how to work. So we’ll have smaller offices on the edge of cities where you can go have quiet places to work and watch that bandwidth, but not sort of a large open Facebook style offices, I think in the future and a new set of office rules around, “Don’t come if you’re sick.” And so, for many years before COVID, it’d be a badge of honor to go to work when you have a curvature of 101.

Dr. Bob Kocher:

That will no longer be okay. And so there’ll be a lot more work-from-home type setups and a lot more interesting safety and hygiene and keeping us. So I think that these are some of the things we can look forward to. And I think together the incentives and information will help us have the most successful vaccination program we’ve ever had at getting people vaccinated that people will want to do it, that they’ll feel confident. And that actually we’ll all realize that it’s in our interest to kind of play along, with public health measures, because if we do that, we’ll all be better off. So thank you for the chance to kick us off. I look forward to the comments from the other folks.

Dr. Mark McClellan:

Great. Kate, terrific to be with you and the Alliance, always enjoy these events and the Alliance plays a critical role in helping to get out good ideas. Especially long-term ideas like Bob was just talking about that are very relevant for policy. I also really like working with Bob because he’s such an optimist and I really want to believe what he said about, we’re going to get to this brighter future, thanks to what we’ve learned here.

Dr. Mark McClellan:

But then I look at where we are today and we definitely have a ways to go. And what I’d like to focus on in my comments is sort of the from here to there, with the policy steps that are really critical, I think in the weeks ahead to help us get there from a situation to more now with a million new cases per week of COVID with hospitals in many parts of the country, full or bursting. And with the potential for a thousands more deaths is a lot. And a lot more closures and economic disruption in the short term.

Dr. Mark McClellan:

And I know there’s a congressional interest on both sides of the aisle after divisive election, and it can be hard to come together to take some steps to get there. But, as Bob said, there are good reasons for doing so. And I just wanted to highlight a few things that can help get us from here to there in terms of COVID 19 response with an emphasis on a resilient healthcare system, economy, that can be better prepared not only to be productive and more equitable, but also to prevent something like this from ever happening again. First off in the short run, we obviously need some mitigation measures, to step up.

Dr. Mark McClellan:

We’ve always known that heading into winter was going to be the toughest time for the virus. We’re seeing a lot of closures, and as I mentioned, hospitalizations around the country. We know some additional steps that could help here, whether it’s additional use of mass, including mass mandates, additional distancing measures that could be pegged to local situations on the ground, not a national lockdown and they are likely going to require some additional impacts on business and it’s better to do that predictably than have to go to a sort of full lockdown mode, like many European countries are doing and some parts of the country, not that far away of all the way from now.

Dr. Mark McClellan:

That does mean some congressional action on something like a paycheck production program. Again, some financial relief for the affected businesses to get through this immediate period would be really helpful. But beyond that, it looks good. I mean, the news on vaccines really couldn’t be better and we should have a vaccination starting a month from now based on the results from Pfizer and Moderna. I think there are good reasons to believe that especially given the fact that the other vaccines coming later based on similar kinds of targets, the spike protein on the virus and they’ve had similar kinds of preliminary results showing good antibody responses, good immune responses that they may well be effective too.

Dr. Mark McClellan:

And so that means the distribution, public education engagement around vaccination is really important in the weeks ahead too. And there’s a lot of infrastructure already in place. Thanks to operation works feed, lots of potential vaccine availability. But as Bob said we do still have some challenges. Many of those are information technology-related getting a vaccine, a registry system in place that can deal with multiple vaccines, multiple doses people, maybe being in different places when they get them connecting all the States and territories.

Dr. Mark McClellan:

So that’s some hard work. And then just the engagement with states and local officials in helping not only get vaccines to where they’re needed and good administration programs, but also the public awareness of what the data on the vaccines actually show after all they’ve heard this past year, what the actual facts are, and ways to help them get vaccines they need. Especially in underserved areas. There’s still some few issues to work out around making sure that, this could be done without copays that there were pop-up centers or whatever it takes to serve.

Dr. Mark McClellan:

To get the vaccines out to all Americans. Building on that could help rejuvenate a public health system, especially if we can use same data systems to do a better job of tracking or do a good job of tracking what actually happens to the tens of millions of people. We’re going to start getting vaccinated in the days ahead. But I do want to emphasize that this is likely to be a gradual process. So two shots, couple of months before people even get the vaccine, before they have a significant level of immunity.

Dr. Mark McClellan:

And then it’s going to be a gradual process for that growing number of individuals to have an impact on just how rapidly COVID is spreading in the country. So in the meantime, we do need to continue these other measures that get us to economic recovery and more capacity for reopening as soon as possible, but it is going to be gradual and we’re going to still need mass and distancing for a while. And helping to build more of a public sense of participation, behind these important steps that we all need to keep taking together, even as we’re getting closer to the end of this.

Dr. Mark McClellan:

I really do think this is the last big, acute surge in cases that we’ll hopefully ever see, from COVID-19 in this country. But it is going to get worse over the coming weeks before it gets better, especially if we don’t together take those further steps. There’s some other important policy steps that can help us get to a Bob’s future that we can take in the near term.

Dr. Mark McClellan:

One of those, is building out our capacity around delivering the therapies that work. so, up until recently, what you told people, if they were diagnosed with COVID, you can get a test, tell us about your contacts and isolate. Stay at home. Don’t go anywhere near healthcare, unless you’re really sick and need to be hospitalized because our hospitals are being hit so hard, especially now.

Dr. Mark McClellan:

Well now with the monoclonal antibody treatments available at work, kind of manmade versions of the, same response that’s making these vaccines effective, the antibodies that neutralize the virus, first one’s been approved by FDA from Lilly and another one, probably coming soon, several more in the works, the supplies limited, but when given early to people who are in high-risk groups, not late, you got to do it before, but the infection and the immune systems for the individuals gets out of control.

Dr. Mark McClellan:

And we see all those big complications in the hospital, but we can get those people treated early back in significantly reduce deaths, hospitalizations and the burden on the healthcare system as well. The problem is we don’t have a healthcare system set up to do that. You need special infusion sites just for COVID patients. Even though you usual patients who get infusions are cancer patients or people with other serious illnesses, these will be people who are not feeling less in the way of symptoms need to get treated early, in a place that’s not going to spread the virus.

Dr. Mark McClellan:

And we’re just now thinking about and starting to set up the systems for doing that is going to take some new payment approaches and some really thoughtful ways of distributing the limited supply of antibody in hand, would add to that as well. Some opportunities for doing a lot better with testing, to help contain outbreaks, where you have had a big increase in testing capacity in the labs, the diagnostic tests of what people should be getting if they’ve got symptoms. And we want to make sure, whether or not they have COVID for isolation purposes and now really important for treatment purposes, as well.

Dr. Mark McClellan:

But we’ve also seen a lot of growth in so-called point of care screening tests. The antigen tests that are not quite as sensitive but can get results back in 15, 20 minutes, that costs much less. There is a first fully home use test approved by FDA just yesterday. So the capacity of these tests is really increasing and they can be used to make opening safer. There was a CDC report on what we’ve done here at Duke in terms of a regular screening protocol along with distancing and mass and other managers that has really helped us avoid any significant outbreaks and spread on campus.

Dr. Mark McClellan:

It’s actually helped our students maintaining much lower rate of COVID infections than what we’re seeing in the regular community. And Bob made the important point about reopening schools which is incredibly important and could be done, with some good sharing of knowledge about steps that districts that are opening are taking how to avoid transmission of cases. Cases do occur if you’re opening a school. People do have COVID. The important thing is, can you prevent those cases from spreading in schools? Can you detect them early and just like we did at Duke, can you get the rate of infection down in the students, the population affected below what it would be if they were just out in the community without any good control systems in place.

Dr. Mark McClellan:

And regular repeat testing is starting to be used by a number of schools, for their faculty, for students, New York City is piloting some version of LA School District. With the Rockefeller Foundation, we’re working with many more, we do need some federal support for this. Some additional federal funding and some further guidance from CDC, looking at what the best practices are for making testing a key part of getting us to faster, broader reopening sin.

Dr. Mark McClellan:

And then just one more point case already go on for a few minutes, but, Bob talked about a more innovative healthcare system. One thing that we’ve seen in this COVID response is that our healthcare system is really not supported in a way that helps it respond quickly and focus on what’s best for patients. Instead with most places in the US, hospitals and physicians paid on a fee for service basis when we needed them the most in the spring, what happened was their revenues fell through the floor.

Dr. Mark McClellan:

There was some fast help from CMS and from private insurers to shore up, tele-health visits and things like that. But I want to contrast that with organizations, some of which Bob works with and I think, PML works with as well that have built in things like tele-health, remote monitoring, team-based community approaches to care into their basic business models. They generally have to be paid differently not on a traditional fee for service basis, but more on a person basis, like in Medicare advantage or in like an advanced accountable care organization.

Dr. Mark McClellan:

Those organizations we’ve done studies now did much better. They were financially stable coming through the first part of this crisis. They didn’t need big enough federal bailouts. They already had tele-health and home-based programs in place. And that kind of longitudinal data, capability that Bob was talking about to track patients, identify the high-risk patients and provide care for them at home, even if they had advanced conditions like cancer or otherwise, they’ve been able to do more to address social factors, influencing outcomes.

Dr. Mark McClellan:

I hope that in any further relief that we provide healthcare providers, as part of getting out of this public health emergency and the healthcare providers deserve it, not just the hospitals, but primary care groups and others have been hit even harder that it’s done in a form that doesn’t go back to the old normal, which was fragmented and expensive and real problems with access and did not work well with this pandemic, but instead to support moving them into new approaches to payment and care delivery, which is much more consistent with what Bob was talking about is what healthcare should look like in the future.

Dr. Mark McClellan:

But that’s gotta be a sort of a conscious policy choice that we really want to move in our policy responses to the pandemic, to relief and rebuilding in a way that’s better than it was before that helps more providers move away from fee for service and into more robust and resilient innovative care delivery models.

Kate:

That was really fascinating. And now I’m going to turn it over to Nirav.

Dr. Nirav Shah:

Well, thank you, Kate. It’s great to be here. I thought I’d spend a few minutes talking about technology and the Unified American approach. So, we all know that nature abhors a vacuum and that leadership is never more apparent than when it’s missing. And in the absence of federal leadership, the private sector actually has stepped up to the degree they can. When would you imagine a world where Apple and Google would work together to create an open source exposure notification system now being promoted by the Linux Foundation across the world and being used in many countries to great effect.

Dr. Nirav Shah:

COVID Act now is a group of technologists who started up and volunteer to create the only County level data available across the United States. So the counties can understand how they’re doing in real-time. Kinsa is a private company that’s distributed 2 million smart thermometers across the country and provides an up to three week early warning system for COVID hotspots where nothing else does work. We know hospital cases is too late. We know that cases of COVID are too slow, to understand hotspots, but this system exists today.

Dr. Nirav Shah:

So technology can do a lot, but the message with technology is that it’s about cooperation, not competition. And when we’ve seen the great advances, it’s because vaccine companies have been working with governments, working with scientists in an open nature, not just open source, open data, but open science broadly. And so I think that’s been one of the positive messages we’ve seen coming out of this pandemic. We really urgently need a unified national approach. How can we justify morally and on many other levels, keeping bars open and closing schools.

Dr. Nirav Shah:

This has to change in the near future, but won’t change soon enough. Other countries have figured it out and they’ve kept their economies open because they have a Unified National Approach. Taiwan has done quarantine very well. South Korea has done testing very well. Japan has done their masks and hygiene pretty well. New Zealand has the advantages of being an Island, but, they’ve eradicated COVID. No one has been successful with a herd immunity approach, which is just letting the virus run wild.

Dr. Nirav Shah:

Even Vietnam, a developing nation by any measure has done much better than the US and it’s because of strong federal leadership that allows for a single plan that everyone follows. You don’t need a silver bullet. You don’t need just one thing. We can do several things well enough and get this virus under control. And it has to start by renewing our trust in science. I’m glad that most people today trust Dr. Fowchee. That’s a very good thing, but if we want to get past this, vaccine acceptance will be really important. So let me end by asking an important question, how long a COVID tale do Americans want to tolerate?

Kate:

Thank you very much. That is quite a question to ponder and I would like to turn it over now to KP.

KP Yelpaala:

Great. Thanks. Lots of great points made. So I want to hone in kind of building on these themes on health inequity. And the thing that’s clear with COVID-19 is that the virus has thrived on vulnerabilities in this country driven by economic, racial and social inequity. That is where COVID morbidity is. That is where COVID mortality is. And so I just want to make a few points briefly about our observations on the digital divide. So there’s been a huge concern of digital health innovation because of COVID.

KP Yelpaala:

But because of what we’ve just described, the challenges that a lot of these innovations and these digital tools are not reaching the populations most vulnerable. And so on the one hand, we have to consider that in our response. And then what’s the relationship with those populations with the health system, with the private sector, with schools? I mean, I think that this is going to have an impact not just for COVID testing, but for vaccinations.

KP Yelpaala:

So there’s a lot of conversation about things that is digital front door tools or ease the pathway for people that are not operating accessing healthcare through a digital domain into that space. This has a unique lens for vulnerable populations. On the urban side, just where we kind of have some stats. If you look at, African-American population, in 2014, about 20% of that population accessed internet only through a mobile phone. So they were not broadband enabled or not on desktops.

KP Yelpaala:

That number I know is higher now, and that trend similarly for the LatinX. So the ability of healthcare to be mobile first is key. The cost of broadband in urban areas for underserved populations is high, and a lot of people are not able to afford it. In rural areas, there have been some initiatives with the FCC and the Rural Broadband Commission to expand access. But I think that this domain of space in terms of connectivity, cost, is a significant opportunity for bi-partisan, arrangements that collaborate between public and private sector and at a federal and state level.

KP Yelpaala:

I want to talk a little bit also about public private partnerships and social capital. So as we think about who responds and why, it’s clear that when it comes to, for example, certain LatinX or African-American populations, this is lack of trust with certain institutions they’ve in some cases had a poor experience interacting with healthcare and specifically this whole system. So our ability to engage and to get them pulled into the system, particularly those developing digital health innovations is key. And we’re looking at some data here in Colorado, this is anecdotal or looking at some data on frontline workers here in the state, and those that have access to free testing.

KP Yelpaala:

And what we’re finding is those who identified as white are more than two times likely to have multiple COVID tests compared to the African-American segment. And at the same time that African-American segment where free testing is available and accessible, they are the most likely to not have even had one test. So this is what we’re seeing. This is anecdotal, we’re actually unpacking this data but let’s just think about that for a second and what that means as we move through the chain, the vaccinations. So my third point is really about also how the public and private sector interact.

KP Yelpaala:

And I think it’s not just about big tech, big companies, but it’s also about small companies and small tech. And if we think about groups embedded in communities that have trust, and that look to certain institutions for information, that’s where we’re going to get the most responsiveness and the opportunity to engage. So this means we have to be more nuanced and trying to understand the reasons why certain pockets of populations don’t engage, whether it’s testing or vaccinations.

KP Yelpaala:

And then I think as we unpack that, you find, for example, with contact-tracing, someone may be more likely to sign up for contact-tracing with their barber. As I do, when I go with my son to the barbershop, than with a big company. If the state government comes and says, “We’ve got contact tracing with Apple and Google.” People might be less likely to opt into that, than contact tracing at their local restaurant. So I think even how big tech, small tech and community boards interact, there’s a lot of opportunity to set the infrastructure now so that we can mobilize people’s behaviors into those pockets that get us enough people vaccinated to get to that herd immunity.

KP Yelpaala:

So those are just a few things where I think we can unpack more later, but health inequities and our ability to make sure that everybody accesses these digital innovations, that everybody is engaged. And then ultimately the behaviors that we want from a public health perspective, we can see those in those populations most impacted is I think the heart of the issue.

Dr. Mark McClellan:

[inaudible 00:32:02] our moderators. So, we might need to continue this conversation, briefly, on our own. And if I could just pick up on a point that KP mentioned about the need for a broad band is one key component of addressing the really large health inequities that we’ve seen so far. I’m actually worried that those may get worse. And that may be one of the longterm concerning legacies from, this pandemic that even at a time when this country is really trying to come to terms with some issues around equity in general.

Dr. Bob Kocher:

And I would add then, as we think about vaccination, we as a country struggled to get 40 million flu shots that a year and to achieve populational level immunity, we’re going to have to get two shots and probably 150 million people. So when you think about access and inequity, well, every academic medical center and big health system has a great refrigerator to handle ultra cold storage vaccine and places to get vaccinations, but where we needed was actually in the underserved areas, the more rural parts of the country, and how will we do that?

Dr. Bob Kocher:

We need a different workforce. Actually, I want the barber to give the vaccination to you next time you come into the store. So I want to have a way to use that person to do it by watching a one-hour training course, I’d be able to pick up the supplies at the local post office and be able to do that at scale, how will we track the data, but we’ll need some sort of data sharing mobile application that maybe Linux makes that can easily enter in that data so that it doesn’t matter where you got to get that shot.

Dr. Bob Kocher:

And so I think that’s the public private partnership style that we need to be thinking about if we’re going to achieve a goal, which I think we should have of getting the country to be vaccinated by Labor Day, probably next year. So school is going to open. Because if it takes the normal pace of doing public health and vaccinating people we have another year and a half getting this vaccine rolled out. And that’s just way too long. And so that’s why I like to have the Biden Administration and [barbers 00:34:09] come together and figure this out.

Dr. Mark McClellan:

I remember that it’s even a shorter issue than that. In that, so far the inequities that have arisen are primary because of differences in exposure, differences in access to testing, to prevent outbreaks. It hasn’t really been on the therapeutic side yet, but as Bob just talked about, there’s a real risk that could emerge with vaccine availability and uptake becoming uneven, even in the shorter term.

Dr. Mark McClellan:

I do want to highlight this point about antibody treatments, which are available now but require outreach to let people know that if it’s not just a matter of having symptoms, but getting tested when you’re not very sick, especially if you’re in a high-risk group, because this treatment, which could really reduce your risk of going in the hospital or having serious complications needs to be given, sooner rather than later and definitely before your COVID progresses.

Dr. Mark McClellan:

And that’s sort of the opposite message that we’ve been giving people and for people who are not very well connected to the health system anyway and don’t have a whole lot of trust, this is an even bigger issue. So unless we take some steps right now around access to, the monoclonal antibodies and hopefully build on that. Hopefully will get to barbers giving vaccines. I hadn’t heard that one before, but that’s a nice goal.

Dr. Mark McClellan:

But, hopefully we can build on some short-term steps to get there, but these are really urgent challenges that need to be addressed right now, or this barriers that we’re seeing are going to extend not only from differences in rates and the impact of differences in co-morbidities, but now to differences in availability and use of treatments that really work.

KP Yelpaala:

Can I just build on Bob’s point and Mark’s point where I think that’s spot on. What we’ve been working on here in Colorado and Georgia is what we’re calling this connected community of care model and what we’ve been trying to do, for example, in Colorado, we partnered with COVIDCheck Colorado, which is the largest statewide testing initiative. It does schools. So there are more than 24 school districts. Now, the state is tapped them to support community testing, leveraging those schools as anchor institutions and then doing outreach into the community.

KP Yelpaala:

But then we’re also partnering with churches, barbershops other community organizations now but the hope is we can build a model for popup testing in the community and those relationships through trusted parties, so that when the vaccination comes, to your point, Bob, then the barbershop, the church, all these stakeholders become part of the fabric of mobilizing the community. It can’t just be an opt-in model. We just put up something and say, “Come if you will.” Right? So I think, I just wanted to add that. I think some great points we’re doing similar stuff in Georgia as well.

Kate:

[crosstalk 00:37:03] that’s a great point. Go ahead.

Dr. Nirav Shah:

Let me just add a little nuance to what KP said, which might’ve been missed. There is a digital divide in this country, but when you look at broadband use, the divide is big. When you look at mobile use, the divide is actually very small. 2019 Pew Surveys showed that 79% of African-Americans, 80% of LatinX and 82% of white families across America had access to a smartphone, with a mobile plan in the household. So if you go mobile first with some of our approaches, we can actually bridge that digital divide.

KP Yelpaala:

Exactly.

Kate:

Thank you. I’d like to ask, what are the key intersections that happened between the economy, the financial markets and healthcare, both positive and negative. How can policy makers support positive collaborations and limit these negative intersections?

Dr. Mark McClellan:

I think, just one comment where financial support has been really important. And then I’ll turn it over to here from our Silicon Valley of people. This is a time when there’s actually a lot of investment going on in healthcare despite how tough the economy looks and it comes to diagnostics or companies going public with new, kind of capabilities to diagnose health problems earlier and more accurately, or companies that are involved in new models of care along the lines.

Dr. Mark McClellan:

And we’re hearing about from KP and Nirav. It’s almost like this big recession isn’t happening, given the amount of investment taking place. What I hope policy can do to get us from where we are now to that future that Bob and Nirav and KP have described, and some warnings about is really providing some more clear signals that we don’t want to go back to healthcare as usual. And just a few examples of this would be, signals for bigger investments in better more convenient, point of care, testing technologies, diagnostic technology.

Dr. Mark McClellan:

So we did that for vaccines, it worked, we got to have much bigger supply of vaccines, coming online soon. If we did the same thing for testing, we could fill in some of the gaps that many of the underserved communities are facing now and being able to diagnose some patients early get them into treatment, but increasingly to prevent the kind of asymptomatic spread that has been so rampant in many lower income communities and essential workplaces.

Dr. Mark McClellan:

We have the technology, we just haven’t deployed it at scale and really brought the private sector investment, to their clear signals from the Federal Government would help with that. And I think also clear signals from the Federal Government that we don’t want to just bail out, hospitals and other providers, but we want to rebuild better. We want to support healthcare organizations that develop exactly these kinds of capabilities to get out in the community, to use broadband effectively.

Dr. Mark McClellan:

That means, I think, a different kind of payment for healthcare. And we’re seeing this happen in the private sector now. Health plans like Blue Cross of North Carolina have set up, their version of a COVID relief program for their primary care practices is to give them some upfront funding now to sustain their practices to invest in exactly the kinds of things we’ve been talking about sustainable ways of delivering care at home, the data sharing with public health and the practices also make a commitment to move into a medical home or ACO models over time to where they’re not going to be paid in the future, just based on fee for service.

Dr. Mark McClellan:

They’re going to be more resilient if there is another downturn caused by a public health emergency, but they’ve also got more flexibility to put more resources into these new Care Models. And that in turn is going to bring in a lot more of the private sector investment that Nirav and Bob and KP have been talking about.

Dr. Nirav Shah:

So, Mark, I think we’re at risk of wasting a good crisis, right? We did more with one month of COVID than 10 years of payment reform did to get rid of unnecessary care. And what we’re seeing is for example, a large health system in upstate New York went to 80% tele-health visits for primary care, which is what everyone wanted. But today they’re back at 12% tele-health visits, not because patients don’t want to do tele-health it’s because of the additional revenue that the system currently creates for in-person visits.

Dr. Nirav Shah:

When you’re seeing your cardiologist in a clinical visit, they pull out their portable ultrasound and add another a hundred dollars to your visit, right? That’s the reality of today’s payment mechanisms. And if we don’t lock these gains in, I think we will go backwards much faster than we had thought possible.

Dr. Bob Kocher:

All right. So we’ve already given up on the gains. This [inaudible 00:42:25] from yesterday creating a pattern. And what you can see is that we just got out of necessary care for a couple months and actually, care’s above pre-COVID levels because we know from Fee-for-service that, people do more even care to keep their revenue where it needs to be. And we’re seeing that. Which is why Mark’s payment reform comments are fundamental.

Dr. Bob Kocher:

We’re going to work our way out of it. I do think also from an innovation perspective, CMS and where they can figure out that they plan to keep telemedicine, reimbursement, in the program, because right now it’s only authorized and it’s part of the emergency. That would be a terrific thing to do. And then another thing that’s been very helpful for the testing world is to have the government say that your lab will be a network and you can get reimbursed.

Dr. Bob Kocher:

And so all of these new tests have had the benefit that they’re able to get reimbursement quickly and not go through the many month process of credentialing and plan appointment and negotiating rates. And so that the public policy folks should work to make sure there’s not fraud, waste and abuse and egregious charges, but this sort of access to the markets than super important to bring particularly testing innovation to the market, but also telemedicine.

Kate:

I’d like to go to a question from the audience. Next week, when we’re having our Zoom Thanksgiving dinners and Uncle Fred pipes in from across the computer monitor across the dining room, he says that he’s bristling about the steps needed to gain more control over the virus. And he brings up Sweden as an example of a country that has banked more on herd immunity and less on public health requirements in populations. Have any of you studied this and what is the response to that assertion?

Dr. Nirav Shah:

Sorry, Uncle Fred you’re wrong. Herd immunity has never worked. It will not work with COVID. We have already seen documented cases of reinfection in people who’ve had one slightly different strain of COVID and then another strain to date. Published in the literature in Pew reviewed medicine, literature in the US already. So a herd immunity strategy alone will fail miserably it’ll result in more deaths of the most vulnerable people who are in nursing homes, where we’re seeing already half the deaths in America are in long-term care in nursing homes, underserved minorities represent half the deaths. These are the kinds of people who will suffer with a herd immunity approach.

Dr. Bob Kocher:

If uncle Fred were wanting to have a thoughtful conversation, the thing you have to figure out is how do you protect the people who are vulnerable? And the reason that’s impossible is we don’t know who’s actually vulnerable. We know that age is a risk factor, but there’s a whole lot of people who are not aging in nursing homes who get sick and die and have long-term complications. And as Nirav points out, there’s also reinfection.

Dr. Bob Kocher:

And so sure if you could perfectly split the population and put it on an Island in New Zealand, all of the people who are at high risk and keep all the healthy people who will not have similar symptoms here, maybe you could do it, but we have no way today upfront to figure out what your risk status is. And so it’s just a chance that we’re taking, if you just say old people, well, there’s a whole lot of people will be harmed by that.

Dr. Bob Kocher:

We also don’t have a public health system that’s great at keeping you safe, for a year and a half if you can keep contact and keeping you sane. And so if we had a system that had great mental health care and food service and housing security and income security, perhaps you could consider it, but we don’t have that set up anywhere in the country.

Kate:

Great. Well, Uncle Fred has that have your arguments to counter Uncle Fred? Another question we had from the audience is how should policymakers deal with the growing financial pressure on government programs? We have the nearing bankruptcy of the Medicare hospital fund, deficits over 100% of the US economy. How can we address those concerns while addressing demands to finance, defeating the current pandemic and preparing for future ones?

Dr. Bob Kocher:

We should ignore those fiscal concerns for a while. The cost of capital is very low. We need to stimulate the economy, protect jobs and invest in public health. And so in the future, we can think about what to do, but in the meantime, we should try to protect our GDP because we keep our economy alive and get out of COVID sooner, we’ll be able to grow. And that’s the best way to manage steps that is to grow the economy. And so, the Republicans had no trouble spending money prior to COVID and during COVID to stimulate the economy, we should continue that path to try to actually invest in the economy and infrastructure. And then we will have to deal with this, but not now.

Dr. Mark McClellan:

Just that to add to that, I mean, it is impressive how low long-term interest rates, continue to be. But, as Bob said, it does mean that we need to have some investments now to get to economic recovery faster. It doesn’t mean spending lots of money on everything and to I think a recurrent theme in this discussion today is how you spend the money for recovery matters. It’s one thing to spend money to provide assistance to hospitals and health systems that have been disrupted.

Dr. Mark McClellan:

But if it’s done in a way that simply encourages them to go on with that excellent graphic, I guess. That Bob flashed up on the screen for a minute and then going back to where we were, as opposed to building the kind of healthcare system that we need for a more productive healthcare for a healthier, more equitable population, that’s what’s really going to lead to long-term economic growth. And you get several of, you said there is kind of a silver lining here in terms of an opportunity to do this better.

Dr. Mark McClellan:

And I hope we can find some bipartisan ways to do that. That would be the best way to reduce the deficits for the longterm and hopefully to get us to the real cause of the long-term deficits is our healthcare is really expensive and really inefficient. So we’ve got a chance to do something about that now, even as we’re making more investments to get out of the pandemic.

Dr. Nirav Shah:

[crosstalk 00:48:44]. And that marked point it’s going upstream, right? We’ve paid the downstream, hospitals. We haven’t actually made those investments in public health that we all believe should happen today. Today, millions of faxes are being received by Local Public Health that need to be transcribed into other systems to actually understand how COVID is moving across our society. That’s today. So as much as we’d like to think, we all agree that public health should be invested in, it hasn’t happened. We haven’t moved upstream in many other areas in our economy as well. And that’s the opportunity to think differently about how do we build back better.

KP Yelpaala:

[crosstalk 00:49:25]. And also, I just want to add, let’s not forget that small business is such a key driver of the economy of country that we can’t abstract what this growth means from a big business versus a small business perspective. And right now it’s small businesses that have been hammered and unfortunately many of them are not going to come out of COVID and they will not reopen. And so this conversation also needs to consider small business how people that run small businesses access care, insurance, so on and so forth. And that’s going to be also a major issue in my view.

Kate:

I’m curious to know your thoughts from our previous session with Ian Morrison, about employer sponsored insurance and whether it should continue or whether we should be trying other mechanisms to cover Americans given the very dramatic loss of health coverage with people losing their jobs this spring. Well, should we be trying these other mechanisms to cover Americans?

Dr. Bob Kocher:

I’ll take that. First of all, this is an interesting recession because in the great recession, when people lost their jobs, we ended up having 50 million people uninsured. And that’s what led to the affordable Care Act in this recession. We’ve lost more jobs. We currently have a $10 million job or 10 million [inaudible 00:50:48]. And we haven’t had that many people become uninsured because we have access to the individual market to subsidized insurance.

Dr. Bob Kocher:

And so people can’t access insurance at an affordable price today and private markets. We have Medicaid expansions in most states, so people can get access to Medicaid. I was talking to one of our gyms, from California this morning. And they said that actually, that may have helped a record number of people apply and get Medicaid, this year across the country. Because of the availability of it in this recession.

Dr. Bob Kocher:

We have a medical program with Medicaid marriage options. And so we have a hybrid market that actually is working quite well and disrupting it is both unpopular and unnecessary. I think we should do a lot to make sure that Medicaid is available in the states that haven’t expanded it. We could do more to make the subsidies greater. So people in the individual market can afford insurance, but actually getting rid of the whole thing as a silly idea and a federalized spending in a bunch of ways, but probably isn’t necessary.

Dr. Bob Kocher:

And there’s no evidence that it would make the healthcare system more innovative. We’re able to create payment models like Mark described perfectly fine in the current system and we know how it works. And so I think that it’s sort of a fool’s errand to go try to redo all the way we finance health insurance. We should be working on set on how to use this crisis for benefits. So let’s make sure we get payment reform. Let’s keep independent primary care doctors independent. Let’s create data operability, let’s get public health to be bolstered. Let’s not screw around with how we finance insurance.

Dr. Nirav Shah:

Every health plan in America has as part of its strategy right now to grow government business. Many are saying Medicare advantage specifically, but they’re also talking more broadly because know the Robin Hood approach of using commercial rates to overpay and make up losses on government business is not a viable long-term strategy. So I think that whatever the approach will be, we know what the strategies today are for every health plan in America, and that is to grow government business. And they’re competing head to head on that.

Kate:

Terrific, well, we are approaching the end of our time. So I just wanted to ask each of our panelists, if you have any final thoughts that you want to leave with us before we close.

Dr. Mark McClellan:

Maybe I can start with just a comment about, we’ve talked a lot in this event about resilience, been a great discussion, for those of you who are more interested more about these payment reforms that could help if you just type into Google Duke Margolis Resilience Healthcare, there’s a whole set of proposals, including some endorsed by six of the recent, CMS administrators, both parties on how to do it.

Dr. Mark McClellan:

And I really hope we can take some steps now to keep the health disparities that have emerged here and that were there to begin with. Just become more obvious, to make some progress on that. We need to do it right away with the monoclonal antibodies and potentially other effective treatments that are coming that are in limited supply. And they’re going to take some work to get access. We’ve talked about the vaccines. To Nirav’s point about public health, we do have an opportunity to rebuild public health.

Dr. Mark McClellan:

I would encourage all of those advocates for the public health community to be thinking about what that should look like though, heading into the 2020s. It’s not going to be the public health of before. We’ve got the opportunities for, timely, if not perfect, but timely and effective diagnostic testing that can be done cheaply in communities and workplaces. Not just in traditional public health sites that are sending out the testers and the contact tracers. We can build it in a lot more effectively than in the past, especially if we move our healthcare upstream too. Thanks.

Dr. Bob Kocher:

I would say I encourage people to spend time with the moderate senators that are going to have to vote for whatever we want to have happen to make healthcare better. And so I think it’s important to get Susan Collins, Lisa Murkowski, Mitt Romney and Joe Manchin to actually really [inaudible 00:55:05] that improving the health system and public health, improves the economy and American competitiveness and the things that they most care about because we need to send it to you.

Dr. Bob Kocher:

We’ll want to make the investments in public health, in testing, in healthcare payment reforms to actually keep them amount of and use the crisis. And until we have a core set of Republicans that are aligned with Democrats here, we’re not going to get what we want done. So I think that’s actually the important message is that we have to get the moderate Republicans to want to do it.

Kate:

Thank you. KP and Nirav any final thoughts?

Dr. Nirav Shah:

Sure, so I think the virus has held up [crosstalk 00:55:48]. Go ahead, KP. Sorry, go ahead, KP.

KP Yelpaala:

Okay. I’ll just be brief. I think lots of great comments made. One thing is clear to me that cross-sector partnerships are needed and community-based partnerships. And so I want to map that back to Mark’s comments about payment reform. Somehow when we look at for responding and the need for communities to come together, I think the payment reform will need to support kind of more social determinants of health, community driven models.

KP Yelpaala:

And that’s going to go a long way. I think, in helping us out. Also, I think, on infrastructure, it feels to me like a very strong opportunity for bipartisan engagement, moving beyond just rural broadband, but looking also at mobile wireless. So I think a lot of the prior funding and channels have been around rural broadband, for example, I think we need to be engaging with [inaudible 00:56:42] as well.

Kate:

Great, great. Well, thank you very much everybody. And clearly we could have this go on all afternoon and I really want to thank our panelists for joining us today. This has just been a terrific way to wrap up our post-election symposium. We would like you to join us for our next event on Friday, November 20th, where we will be discussing the health policy impacts of the US census. The Alliance wants our programming to be centered on our audience community.

Kate:

So I would like to ask you to please take the time to complete the very brief evaluation survey that you’ll receive immediately after the broadcast ends, as well as via email later today We truly value your feedback. A recording of this webinar and additional materials will be available on the Alliance’s website. Thank you so much for tuning into our Post Election Symposium.