The Lasting Impact of the COVID-19 Pandemic on the Healthcare Delivery System.

– Welcome to Berkeley Conversations hosted by the BerkeleySchool of Public Health.

My name is Michael Lu.

I am Dean of the school.

Today we're gonna talkabout the impact of COVID-19 on our healthcare system.

Over the past month, you've heard a lot about how the pandemichas overwhelmed hospitals in New York city, Chicago, and many other parts ofthe nation and the world.

You've heard how from ourfrontline healthcare workers about the shortage oftesting PPEs and ventilators.

COVID-19 has certainlyexposed many vulnerabilities in our healthcare delivery system and the larger public healthsystem and need to be fixed before the next pandemic strikes.

But at the same time, COVID-19 is also transforming how healthcare is delivered.

It's driving the reimagining of healthcare with greater use of telehealth and other technological innovations.

So today we're gonnaexplore the challenges and opportunities that theglobal COVID-19 pandemic is creating for hospitalsintegrated delivery systems and clinics and especiallythose rural Americans and diverse populations.

We put together the broaderpanel of experts for you today featuring some of thetop healthcare leaders and researchers innovationstarting with Lynn Barr, CEO of Caravan Healthand executive director of the NationalAccountable Care Consortium from I'm proud to say isalso one of our school's most accomplished alums.

Jane Garcia, CEO of La Clinica de La Raza, a consortium of community health centers, which serves over 85, 000 people annually in 40 locations throughout the Bay Area.

And I'm also proud to addthat she's yet another alum from our school who's surelya change Baker in the world.

Dick Levy, former CEO of Medical Systems and chair of the board of Southern Health who now serves as chair of the board for our school of public health.

Dick is also a Cal alum witha PhD in nuclear physics.

Steve Lockhart, Chief Medical Officer, Asserta Health, who isthe only non-Berkeley alum or faculty on this panel.

He got his masters from Oxfordand then MD PhD from Cornell but then joined our sister campus at UCLA as a resident and faculty.

So we'll claim in as one of our own.

And Steve Shortell, ouresteem professor emeritus of health policy management, former Dean of theschool of public health.

This panel will bemoderated by Kim MacPherson one of Berkeley's mostdistinguished professors with a joint appointmentbetween hospice and school, in the School of Public Health.

Kim, director of healthpolicy management program and serves the executivedirector of health management and distinguished teaching fellow at Hos.

So we've got lots to talk about.

So let me turn this over now to Kim to begin the conversation.

– Well, thank you very much Michael.

I want to just add my welcome.

We're very excited about the panel today.

As you can hear, it'sa diverse and versatile and I think we're gonna have a really interesting conversation.

As we all know, thecurrent moment is unique.

We are seeing unprecedented things happening in our healthcare system.

We are seeing sort of a balanceof amazing acts of courage and heroism as our frontlinehealthcare providers lean in to take care ofpeople across the nation and across the world.

And at the same time weare seeing a bright light focused on the challenges thatwe knew were already there, see vulnerabilities in healthcare system and in the public health infrastructure and we now have, I think, even more importantopportunity to address them.

Some of the key things that the panel is gonna talk about today is what do we think isgonna happen moving forward? So obviously we're gonna move through the challenges of right now, but what is gonna be the lasting impact of what is happening right now on the healthcare delivery system? And as Michael said, specifically what might that mean for how the system serves diverse populationsand the underserved.

From the news every day, we're hearing about the financialchallenges that hospitals, clinics rural America arefacing delivering care.

I think just today the statistic came out that hospitals in theUnited States are losing $1.

4 billion a day.

And so that is obviouslyan issue right now.

it's leading to furloughs and layoffs and all kinds of very difficult decisions.

but the question will be what'sthat gonna mean over time and how do we perhapstake advantage of crisis to make change? Michael mentioned telehealth.

We are seeing exciting things emerge and perhaps what we'll continue to explore in the conversation todayis what else is happening that's innovative aroundsocial determinants, innovative around publicprivate partnerships.

Perhaps even as someone said today in an article I was reading from civic business group onhealth, a new social contract between the privatesector and the government as it relates to how weapproach care delivery.

So for our time together today, I have some questions for the panel and we're gonna start off with questions that are targeted to certain people although others may jumpin and probably will cause I know this group likes to make sure that they get to share their thoughts.

And then as we move through, some of the questions will be some that are more open ended for all.

We will also be takingquestions from our live audience and if you have one, please do submit that through the Facebook live portaland those will be passed us and we go consider those around about 45 minutes.

So my first question goes toboth Steve Lockhart and Jane.

Really would just love to hear from you from your sort of lens, from the front lines.

How are your provider managing right now? What's happening in terms of operations the workforce clinical care.

How is it feeling to you right now? Steve, maybe you could get us started and then we'll ask Janeto share what it's like on the clinic frontlines.

– Sure, thanks Kim.

And I think I would startby saying obviously COVID-19 is something that has changed dramatically how we think about how we give care.

And it's also changed ourorganizations to a certain extent, our provider organizations.

When I think about Sutter Health, which is an integrated healthcare system here in Northern California, serving three and a halfmillion patients in 22 counties and urban or rural and very, very diverse communities.

I think the key for us hasbeen to really stay focused on our not-for-profit mission to enhance the wellbeing ofthe communities we serve.

And while that sounds likeit's just a mission statement, it's really the only way inwhich we can stay focused on and effectively work througha pandemic like this.

So when it comes tothings like our workforce and our finances, for example, being an integrated system gives us the advantage of being able to shift really resourcesthat includes both supplies like PPE or personal protectiveequipment, but also staff.

So we have been fortunate enough to not have to furlough staff because we've been able toretrain our nursing staff for example, when we reduced the amount of electivesurgeries we're doing, actually eliminated electives.

We could then take recoveryroom nurses for example, and we could retrain them tobe able to do critical care.

We also have been able toshift people across the system.

And in addition, we have been able to through our philanthropy, we have a disaster relief fund that we had after the fires for staff.

That's pretty well fundedand the use of the PTO through our executives and so forth to be able to support our staff.

So we've not needed to do that.

I would say from a financial perspective clearly the impact has been significant and the help or the subsidization that has been availablethrough things like cares is insufficient to help help us through the financial impact of this.

So there will be alongterm financial impact.

The final comment I might make regarding the financialcomponents of COVID-19 as it affects caregiverorganizations like ours is that I think over thelast several decades, we've really been focusingin center health and others on being more affordable forour patients, our community.

And that means being as lean as we can, really eliminating any excesses in particular excess capacityduplication of services, all of those sorts of things.

Unfortunately, what that means is that when you hit a pandemic, where there is a requirement to search and increase capacity rapidlyand to a great degree, that comes in conflict.

And so I think as we go forward, the “new normal” will be how do we create an affordable healthcaresystem that at the same time has the ability to flex andthe resiliency to search and care for incidents like this because I think for thenext 18 months or so until we have a vaccine, we can anticipate that we will be in that capacity.

– Yeah, I think resiliencyis probably gonna come up a good amount on the panel today.

So I appreciate you bringing that out.

Let's turn to Jane andJane, if you could share just from the lens of LA Clinica what is it like on the front lines more in the clinic community? – I'm not gonna lie to you.

I've been doing this job for a long time and this is undoubtedlythe hardest we've ever had.

We have had to do temporary reductions, we've touched over 300 employees.

We've reduced 25% of our workforce.

We are a big dental providersoperating over 70 chairs.

And following the recommendation of the California DentalAssociation, we closed down all, almost all of our dental.

We have like 5% of our capacity open to treat only emergencies.

So that's been a big hit.

Immediately, we saw a declinealso in our patients coming in so that at this moment asthe dust has settled a bit, we're still losing about threemillion dollars every month.

And we worry of course about that.

We've had some relief, unfortunately as an employer with over 500 employees, we did not qualify for thepayroll protection program.

So that's unfortunate.

I think the good news forus is that we are able to do 90% of our visitsnow with using telehealth and as one of my employees mentioned, the genie is out of the bottle.

I think one of the positive things that one of the positiveoutcomes of all this is that telehealth it's been demystified.

And I think that it's very promising in terms of being able to conductmore of our work that way.

It's interesting becausein just the peanut and talking to the, some of our providers as I talked to our medical teamabout how are our patients, were accepting tele-health, and what we found is that mostly it was really, really positive.

First of all, 100% showrates, no, no show rates.

Everybody's at home.

I think people werereally, really grateful to get a call from us andit felt like somebody cared, they were lonely and hearing from us was really, really positive.

On the other hand, when I talked to ourbehavioral health folks they reported something differentand it's not surprising.

So there was a lot more hesitation to do a visit via telehealthfor mental health.

And if you think aboutlow income communities where there are lots of peoplepotentially living in a house the ability to create the safe place where you can talk to yourprovider about what's going on is infinitely harder.

And we've heard others statistics where domestic violence reporting, child abuse reporting is down and certainly schools are a big source of the reporting extreme there.

But I think it's also the fact that lack of privacy in the homes.

And so we're definitely seeing that.

We're really excited about telehealth and the promise of that.

And especially whenour patients often have a really difficult time reachingus and parking's a problem and all kinds of issues.

I think the potential of creating stations that we might not haveconsidered two months ago is really gonna change that and I think that that's a very promising.

We are of course, extremelyworried about what happens when the bills need to be paidby our federal government, by our state government, by our local government.

And so many of those arebased on tax revenue.

And our history is thatwhen times get rough, low income communities are the first ones to feel the tap on the doorand the bill comes due.

So we're extremely worried about that.

But if anything we've learned is the importance ofcoverage for everybody.

And I think one of the populations that we still are strugglingto provide services to are our undocumented immigrants.

For the last year or so more maybe, we've been really strugglingwith public charge, which is the process bywhich a person in the family is determined whether theywere gonna be good citizens and whether they've used anyof the services like healthcare that would go against theirability to become citizens.

So those folks are undocumented immigrants are really staying homeand we worry about them.

And when a pandemic raises itsugly head like this one has, that issue becomes even more critical.

And from the school of public health and ensuring everybodyin population health, we begin to understandwhat a big, big mistake is.

I would also say that workforce is gonna be a really different, and I think our physicians are currently, they're operating on adrenaline right now.

They really are.

Not to mention that we went live with a new electronic healthrecord that was gutsy with Epic and that holds a lot of promise.

But I think our doctors are tired and I think that's something that we're gonna have to deal with.

And I am also very, Ithink that there's gonna be a role for health promotersto do some of the testing and some of the tracing thatis gonna have to be done to increase the testing.

So I think that there'ssome opportunities there for our communities.

– Well, thanks Jane.

I think you're right.

I think it's a whole new spirit to look at how we could work together between the care provision and the public health infrastructure.

And we'll explore that I thinkin a little bit in a minute.

But you mentioned a coupleof times in different ways, this issue of delayed care, people not coming infor dental appointments.

I'm guessing there's a lot of people for by whether it's behavioralhealth, chronic disease and perhaps Steve you'reseeing in the hospitals, delayed procedures, electivesurgeries and whatnot.

So we hear a lot about this delayed care and whether there is a bigbolus built up of demand and I've heard two different camps, one where it's gonna be a huge surge, it's gonna overwhelm the second we're able to accommodate it.

And others are saying, well, maybe not.

Maybe some of this care doesn't come back.

Maybe it wasn't necessary or maybe it was and people just aren't comingback either for trust issues or what have you.

What do you think about that? Are you planning or anticipating about care coming back, Steve, et cetera? Or how are you thinking about that and what do you think it's gonna take for patients to feel comfortableentering facilities again? – Well, Kim, I think some ofeverything you said was true, which is number one, thereis this pent up demand, but we've even seenduring the period of time where we've been doingemergency procedures, taking care of emergencies that folks have not beencoming in for emergency care at the rate that wewould have anticipated.

The heart attacks and strokes are down.

I don't think that people are having fewer heart attacks and strokes.

A recent story at one ofour hospitals here at summit where someone I thinkit was even in chronic, wind up needing a bypass surgery but was reluctant to come in.

So I think there's fear inthe community in general about what it means to cometo a healthcare facility particularly a hospital where they know that we are treatingpatients with COVID-19.

And I think so I thinkthat that's one thing.

As we look at the face opening or expansion of services, we're calling them medicallynecessary time sensitive.

So you go from emergency tothey're medically necessary.

There are things thatif we don't do them now will cause harm to the patient.

They're still concerned aboutwhether people will trust, have enough trust tocome in and seek care.

And Jane mentioned this earlier, but I wanted to highlight the fact because we're experiencing this too about communities of color and our African Americancommunity, for example, we have experienced already, even though California hasdone a lot to span coverage through Medicaid expansion and support of Affordable Care Act, that just how and when orAfrican American community is accessing care, it tends to be later which in the environment, the world of COVID it means coming in sicker and perhaps having less good outcomes.

Jane also mentioned theissue of undocumented workers and the impact that thewhole immigration crisis, I'll call it a crisis because really it has been over the last three years, I think something thatwe've noted has resulted in our Latin X communitynot wanting to come in for fear that there will besome other further repercussion, whether it's from the billing piece or whether it's from justnot wanting to be known or identified by whatwill happen to this data.

We have an electronicrecords where this goes, there's a lot of fear and notall of it is unsubstantiated.

So I think what we'veseen is that COVID-19 is really rip the bandaidoff of the inequities that have existed in our society and also in our healthcare system.

So those are some thingsthat we, we have experienced, certainly, et cetera, taking care of diverse groups of patients is that there's significantconcern about whether or not people are going to access us in the way in which they should.

– Yeah, so it's really rebuilding trust, it sounds like on multiple levels.

It's old wounds and old lack of trust and then it's issues withelements like public charge and then it's also now thisother other layer of is it safe? Is it physically safe for me to go? And how, and when do it.

So it sounds like it's nowbecome an even more multifaceted, multilayered challenge.

Lynn, I wanted to get yourperspective on this question and how is it playing outin the rural environments that you're so involved in? Are people delaying care? How's it looking in that environment? – Yeah, it's really devastating and I think we all underestimated the impact of this on the consumer.

A lot of people thought, well, we're just gonna close down this elective surgeries for a while and then we're going open it up and everybody's coming right back and the consumer's not coming.

And so we're seeing drops in volume, that range from 20 to 60%, most of them around the 40 to 60% range.

Typically, we work with 250 health systems across the country from rangingfrom 1, 000-bed hospitals to four-bed hospitals.

We're seeing layoffs roughlyaround 20% being fairly common.

And in our independentpractices are just closing and so without the supportof the local health system without employment of physicians, one of the things that'sjust really shocking to me is watching the income drop of the people that areputting their lives at risk.

And this is only in America, right? We're not seeing this anywhere else.

And at the same time, and Idon't think it's their fault, but it is the way our system's built.

Our insurers are not laying people off.

And in our system where wegive all the money to payers and then they pay providers and we have a situation like this, our providers don't get paid, 'cause they're in fee for service.

And so if there's ever a time where I think this whole systemis imploding, it's right now because fee for service doesn't work when there's no service.

And it is unconscionable that we're cutting theincome of our hospitals and our physicians and yet our payers haven't seen record profits.

And how's that gonna get fixed? I don't really know.

– I wanted to add if I might that in we had beenseeing a steady decline in the number of Medicaidpatients coming in and the health plans werein the same position.

We just got our numbers for March and already we're seeing an increase in the number of Medicaidpatients and that's March.

So I think we're gonna continue to see that growth in that populationreally, really change.

And Medicaid, access to specialty care has always been an issue for us.

So I think that issue of access, especially for ourchronically ill patients, it's very disconcerting to us.

– Yeah, really important points.

I think you also brought up, Lynn, little bit about justpublic health infrastructure and how the we haven't investedin it and we're really, some of these systemic issues around policy and reimbursement are really bringing those to light.

I wanted to engage Dick a little bit here and see what you thought Dick about some of the gaps in thepublic health infrastructure.

It seems to me that they couldbenefit some innovations, some investment areas aroundsurveillance, contact tracing and then how does that thenintegrate with the care system that some of these other folkson the panel engage with? You and I talked a little bit about how a lot of the researchand development investment has really been targeted towards sort of thebiomedical type outcomes that we see in the care delivery.

But maybe that's gonna need to shift and maybe we need to bethoughtful about moving R&D into new realms that reallyfocus on public health needs that would voice some of this.

Would you share a little bitof your thinking about that? – Yeah, gaps are really an understatement.

We spend $3.

8 trillion a yearon healthcare in this country and about 2.

5% of that isspent on public health.

Now that's changed widely inthe last two or three months.

And you know about the crash programs to fix COVID-19 problems and develop tests and all that sort of thing.

But that's expanding into tests for how do we predict future epidemics? How do we predict future faster ways of developing drugs to respond? How do we develop classsolutions for drugs that can work on mutations of the present diseases, et cetera? So there's a lot of hightechnology work going on that wasn't going on before.

And the fact that we spent solittle has really showed up in the fact that we werenot ready for this pandemic.

It caught us by surprise.

It should not have caught us by surprise.

We weren't ready.

And second, the World Health Organization does a yearly or amonthly or yearly summary of evaluation ofhealthcare in each country.

We ranked in embarrassing 37th of all the countries in the world.

So even though we're spendingall this money on healthcare, we are underrepresenting publichealth in this expenditure.

The big changes are coming I think, not just in the technology as we continue to spendmore money on public health, but in of these health services areas.

You've already heard about what's going on and the heavy thinking is going on about an equal access to healthcare amongst certain populations.

We're also taking better careof the homeless population.

Now we're starting to.

We're finding housing and food for people who are living on the streets and taking care of them.

That's part of public health and that has a big impacton the whole population.

We're looking more into thechronically ill older population and finding that some of ournursing homes just don't work.

They're unsafe, they'renot doing a good job and we're moving peopleout of those nursing homes and establishing new certification for ongoing nursing homes.

Again, this is public health that has not been happening very much.

And then finally we're realizingthat both the recession and COVID are causing a lotof mental health problems and we're gonna have to addressthose mental health problems and they do not need necessarily the traditional healthcaredelivery system.

They need more of apublic health counseling, that sort of thing.

All these things are starting to happen as we spend more time andmoney on public health.

Now, will this continue? Well, that's hard to say.

If the COVID virus went away tomorrow, we'd probably go back tothe old way of doing things.

Unfortunately, the public, the COVID virus is not gonna go away tomorrow.

It might be six months, it might be a year, it might be four years and I believe we will not getthe genie back in the bottle.

We are gonna continue todo some of these things just out of habit.

And I can see a very positive outcome for public health in general.

– That's great.

I appreciate that andI do think it weaves in a lot of the things that obviously the folks on this panel care a lot about, which is how do we raise theprofile of public health, make sure it's adequately funded, that there's the right kindof targeted R&D to support it and then I think betterknitting it together with the care delivery sector so that we don't have surprisesand we don't have gaps? We have been working on certain things to try to improve populationhealth and inequities.

One of the ones that Iwanted to circle back to and ask Steve Shortell and Lynn is we have been trying toget away for fee for service for quite some time.

This idea of paying for volume, which obviously is Lynne Ithought said very eloquently it doesn't work right nowwhen there's no services.

So we need, we need othermethods and we know this and we've been experimenting with outcomes and value-based reimbursementand payment mechanisms, which are the general waythat we affect change.

We haven't gotten as farperhaps as we would like.

And I know some of theearly data that we saw is that many folks who are involved in accountable care organizationsand other structures are very anxious about COVID'simpact on those mechanisms.

So Steve Shortell, I wonder maybe if you could say a littlebit about what you think this bodes for accountablecare organizations, value-based payment.

And then of course I wanted to also get Lynn's thoughts on that, but we haven't had a chance tohear from Steve Shortell yet.

So Steve, could you give ussome thinking about that? – Sure Kim.

Yeah, there's no question about it.

I think Lynn said it very well that the fee for service system, the COVID-19 has exposed it as a disaster.

And just another data point, we're doing some research now with the American MedicalGroup Association.

I was on a call with them last Friday.

I think it was, and they have about, and these are the big medicalgroups in the country.

They have about over 400 ofthem belong to that association and they have only about40% of their medical groups that have reserves beyond twomonths or up to two months.

And all the rest are very troubled indeed.

So the question is howfast can we accelerate the move towards awayfrom fee for service? Capitation, globalcapitation, global budgets where you earn the money up front, where per member per month, if they sign up with your delivery system, you have that budget there and you have every incentive in the world to innovate and so forth.

So temporarily, CMS obviouslyhas had to slow down the extent to which they're gonna move to these value-based payments.

But I think I would foreseein the next year or two an acceleration towards that.

We certainly need universal coverage to go along with that as well.

And just to underscoresomething that Dick has said about the lack of preparedness in part of the delivery system, but as a country at large, and I just want to underscore something that Michael Dean Lu put into the Washingtonpost a week or so ago.

It's really a global phenomenon.

We really need a globalearly warning system then within our own country, a much more of a nationalreally well coordinated emergency preparedness system also.

The other thing I would suggest, Kim, is that I think we'regonna see an acceleration of if you will, greater consolidation and vertical integration.

Raise prices, the FTC, there'sways of dealing with that.

There's some evidence for that, but if you just look at what COVID-19 has exposed at this point in time, Lynn said it well, independentpractices going away You can no longer be asmall mom and pop shop.

You have to be part of a larger entity of some sort or a voice inthat entity and so forth.

I think we're going to see acceleration of more consolidation, larger systems, more physicians being employed in order to deal withthese kinds of situations, but also to have a better interface with some of the socialdeterminants of health and the partnerships withsome of the community and social service agencies also It's very hard to deal with one off fragmented kinds of providers.

It's somewhat easier to do whenyou're a part of an entity, that can really deal withthose kinds of partnerships.

– Yeah thank you Steve.

I mean obviously we're allprobably very well aware of seeing a huge wave of consolidation, merger and acquisition activity and the recent sort ofpushback against that when there's overlappingmarkets by the FTC.

We've actually seen interestingly, some announcements these past 12 months of people intending tomerge and then pulling back because conditions didn't look favorable.

So it'd be interesting to seeif that does accelerate again and if the governmentturns a favorable eye and recognizing that.

I would also say the phenomenonthat we've been seeing of private equity buyingup lots of practices and rolling them up, it will be interesting to see the future of that.

I think on one hand it's obviously an infusion of adifferent kind of capital, but the other hand, the returnsthat private equity expects make that precarious for markets and precarious for the physicians.

And we've already seen some information.

Lynn, I see you nodding.

Maybe you want to makea comment either on that or just on the role of ACOs and what you thinkabout more consolidation and the need to pullsmaller providers together.

– Yeah, I mean, I see the same thing.

Steve is all of our large medical groups informed us two weeks ago, they're not gonna beable to pay their bills, every one of them.

So the little guys are mostly employed.

But so if they're employed they're fine.

But if they're independent, I'm wondering when our doctors and nurses are gonna go on strike.

When are physicians gonnasay, I no longer have income because of this messed up system.

When our nurses saying, I can'tbelieve I'm getting laid off in this environment whenI'm putting my life at risk.

And so I think there's somebig changes on the horizon that are gonna come from the consumers and from the workforce and the government will haveto respond as opposed to lead.

As far as ACOs go, I was so grateful to see a letter fromMed Tech to CMS saying, You can't base a benchmark on 2020 “and if you paid people shared savings, “it's a random event, ” because the way that we do national and regional benchmarking will not work.

And so you need to stop.

Otherwise this is just gonna be a mess.

At the same time, andCMS has own data shows it costs $100 per patientper year to be in an ACO.

So if you don't think thatyou could get paid fairly, and it's good that they'retaking risk off the table during the public health emergency and I don't see that ending in 2020 and possibly not in 2021.

But it's just a mess.

I mean none of these systems work and the idea that the capitation, we could move to a capitated environment.

Well, that works ifyou've got centers scale, but for the majority of the healthcareinfrastructure in this country, which is populated by abunch of small actors, nobody has the kind of scalethat they can take risks.

And we've got all the different payers.

And so it's like, oh, I couldtake risks on this slice and this slice and that slice.

It's not working for the providers at all.

So I'm hoping that thisis an opportunity for us to all sit back andthink about single-payer and think about a way thatwe can provide a salary for at least our primary care providers and make sure that we haveaccess to care for all Americans because right now it's just a mess.

And our physicians and the people that are putting their lives at risk are the ones that arebearing the brunt of it.

– Very powerful.

Very well said.

And I think it raises this point that I wanted to turn to now, and this is really to the whole group talking about what hasbeen the federals response.

And are we feeling thatwe're getting what we need in terms of stimulus bailouts? We've certainly seen a lot of changes, temporary changes in reimbursementfor COVID related cases.

We've seen some advancedpayments, we've seen some grants, we've seen some changes inpolicies around telehealth, around licensure and what'spermissible to be reimbursed.

So there's been some interesting movement, but I guess I would ask the group and maybe we go back toSteve Lockhart to start.

Do you feel that it'ssufficient and if not, what else do we need? We're right now, I thinkhaving a powerful moment on this webinar saying weneed real profound change.

The system was vulnerable.

The stresses of what we'vedone to it with pandemic are really pressuretesting it to the limits and we can see that.

What do we need? Is it that public, privatesocial contract readjustment? What might that take? – Well, I think thateveryone on this webinar has pointed out that this is a crisis like we haven't seen in a century.

And so along with that crisiscomes a great opportunity to make systemic and largechanges in our system.

I mean, when we look at what happened after the Second World War in Britain.

So this is our moment to do that.

And my greatest fear is thatwe won't take this opportunity to make changes.

We have seen some regulatory modulation that's allowed us, for example, to compensate telehealth with this.

We've seen some modulation that's allowed, the FDA has allowed foremergency use authorizations to come up with more newdrugs, testing and so forth to expedite some of those things.

But fundamental systemic changes are the things that we really need.

And I think that we, unfortunately, right now, it feels as if the Americanpublic is very divided and even the clear scientific and experiential worldthat we're living in and the things that we wereexperiencing and going through have not been enough yet toshake everyone loose to say, look, we really need to change.

And again, coming back to we've talked a lot about health equity, which I consider a componentof quality of care.

It's an element of thequality of care we provide because everybody's not gettingthe same high quality care then we don't have qualityin our healthcare system.

And I think that COVID-19 has simply exposed it for what it is and I think this is where that systemic change needs to come.

So will we get it? I think there are aregulatory pieces that we need that I'm hoping that thefederal government can do through legislation and regulation.

I personally feel thatthe piecemeal approach that we have tried overthe last 40 or 50 years hasn't really worked.

That there's probably somequantum and radical changes that we need to make.

And I won't lay out myentire political philosophy on this webinar, but Ithink it's very clear that any rational cention being that we need to move towards a system where everyone is not only covered, but they have access and they have quality and it's affordable andthat the financial burden, as Lynn was mentioning, itdoesn't fall on the providers and it doesn't fall on the patients, but it falls on all of us.

Just as we've seen withthe social interventions, it's taken all of us tomake a dent in this disease.

It's gonna take all of us tomake a dent in our healthcare, to provide this much neededpublic health support and so on.

So I think that a system inwhich we are sharing that burden and the financialbenefits are not accruing to other parts of our societyis gonna be important.

– I think Dick wanted to chime in on that.

So I'll move to Dick next.

– Yeah, I have to say something.

I have to say something cynical here.

I think radical systemic change coming down from thegovernment would be wonderful, but I don't think it's realistic that we can expect that to happen.

However, a lot of what Steve said, we have done some little things and I think those little things could be expanded to big things and I'll give you two examples.

The regulatory environment that we face in healthcare is ridiculous.

We have over 110, 000rules and regulations, state and federal regulations, and some of them don't make sense at all.

This could be reviewed.

A lot of these regulationsmake sense at all in today's environment.

Different regulations could be put in.

This is something that might be doable.

Second, the whole reimbursementsystem that we have today, the pay per service, that's true.

I don't know if we'll getrid of fee per service, but we're paying a huge amount of money for heroic interventions on the end for patients who are gonna die anyway and we're not paying anywhere near enough for preventative medicineand public health and these kinds of things.

The reimbursement schemethat comes from CMS could be totally changedwithout changing the fact that we have reimbursements.

So I don't think it's good that expect we can totally change the government.

We're not gonna do that realistically, but we can change somevery specific things that the government has control over.

And I think that could happen and maybe will happen because of this.

– So jumping in very quickly, Kim.

We might think of twokinds of wake up calls.

This is clearly a wake up call.

We have a wake up call where you wake up and you turn over in bed andyou go back to sleep, right? And then there's the wake up call where you get up and you attack the day.

So the question before us is what kind of crisis or wakeup call is this going to be? It's not about repairingour current system.

The current system is broken.

If you go back to that and backslide, you can try to work harder, et cetera.

It's just not gonna work.

We really need to reinvent andreimagine how we deliver care and how it pay for care in this country and what those underlyingdeterminants of health are, which aren't so much thehealthcare delivery system.

And you need to reallyget at the root cause of some of the inequities, which is the institutional and structural racism that wehave in this country as well.

Yes, the federal governmentcan do a few things, but a lot of it's gonna fall on us.

We need the kind of leadership, the curious leaders, and then we need thepeople who are competent, effective change makers, one of our schools models.

It's gonna take a lot ofpublic, private partnerships in order to really getat what produces health and whether or not thiscrisis is gonna be enough to get us out of bed and attackthat or go back to sleep, I think largely remains to be seen.

But it's a challenge for all of us.

– Thanks to you both, Jane.

– I think I'm very hopefulthat payment reform will be a continuing discussion.

And I think certainly the advocates and all of us as providershave a say in that and that door has been opened.

So I think we have areally good shot at it.

But the other piece ofit is gonna be workforce.

And even prior to this pandemic, we had what at least 25% of our physicians getting ready to retire, a huge shortage with regards to primarycare and prevention with so many of our medical professionals going into specialty care.

So the system in terms ofgenerating the workforce isn't aligned even if we were to get universal coverage tomorrow.

The workforce is not aligned with that.

And I think that is an opportunity as we talk about population health, the social determinants of health, that we open up opportunitiesfor our community members who could make some of those home visits and determine what blood sugars are, what the heart rates are.

So I think that there are some technological solutions to this, but we're gonna have to think more broadly and we're gonna have to beopen to other types of workers out in the field.

– That's great.

And Jane, that's perfectbecause what I wanted to do now is turn to some of the live questions that we've been getting and one of them is actually for you Jane, and it's on this topic about what do federallyqualified health centers need? Telemedicine isn't gonnabe enough to fill the gap.

What beyond technology solutions do you think your environment needs? There's no silver bullet obviously, and it sounds like telehealthhas been a good option for both some of your workforceand many of your clients.

But what are the limits for that and what else do we needto be thinking about to stem the growingdisparities that we see and how to reach the more vulnerable, harder to reach populations.

I'm paraphrasing, but that's a question that somebody from our live audience really wanted you toshare your thinking on.

– Yeah, technology isa huge problem for us as federally qualified health centers.

As you know you purchasea piece of equipment and it's out of, it's no longer thelatest thing by tomorrow.

And so for community health centers, we've really struggled withtechnology and paid for it.

And I'm hoping that oneof the outcomes for us, for La Clinica anyway, is that we come out with somenice telehealth technology, but that doesn't solve the question of our community members.

What do we have to do withthem for them together to make sure that they have access? So it's not gonna doas a whole lot of good if we have technology, butthe people we're serving doesn't have access to that same level.

And so I think thatthat's a big part of it and we're very excited.

I mentioned that we've gone to EPIC, which is the electronic health record that the centers in the Kaisers and a lot of our hospitals use.

And I think the potentialthere to coordinate care across different delivery systems and to actually have a shot at bending the cost curve is incredible.

And so I think the possibilities of doing better by ourcommunity members is really big.

But we have to be able do it.

– Thank you.

Another question that'sactually coming from our own, Hector Rodriguez another professor in health policy and management.

I'm thinking this might be for you, Lynn.

He's calling out thelatest IGS poll of voters that indicate that rural voters are more likely to beskeptical of social distancing and really want the shelterin place to end more rapidly.

And how might that then play out with rural patient expectations and demand for inpatientcare or inclinic care? Any thoughts on that? – Well it's been very difficult because they don't see it intheir community and therefore, why do they have to stay home? But it's just a matter of time and then then at the same ruralcommunities flip in a week or two because suddenly they're seeingthat the influx of patients, so the meat packing plant and Sioux Falls a lot of it like Logan's port Indiana, which is one of ourfirst ACO participants, they have a big Tyson plantand so they're being affected in really big ways.

And also their nursinghome quality in rural areas is really horrendous.

They have a much higherproportion of one star, and two star nursing homes.

And so they're seeing these big influxes of patients from that.

But politically, there is us versus them, this is an urban problemversus a rural problem, or it's as urban peoplebringing it to my town.

So that's been a real challenge, but what's interesting is thosepatients are staying home.

So those patients are voluntarily not coming into the healthcare system.

So you put all the rhetoric aside, the consumer moves with their feet and they are not coming to rural healthcarefacilities for healthcare even if there's no casesin their community.

They are staying home.

People are sheltering in place regardless of what thegovernment is saying and they're not going tohealth care facilities and they don't want, andthey'll go to restaurants, and bars, concerts, every placeelse before they come back.

So we were successful in getting about four to five million cashinfusion per rural hospital in the last round of the Cares Act.

And we think that's gonnacarry them six months.

We estimated that hundreds weregoing to go out of business within 60 days if they had to put four or five million dollarsper hospital in place.

What happens six months from now? And there's not a government in the world that can plug all those dikes.

I mean every practice needs money, right? Every provider needs a salary.

Every hospital is hemorrhaging money.

And so I don't know where, I don't know how you fix this except for to go to that to cost-based reimbursement on hospitals and pay every physicianin the country a salary.

But Dick, I think thatwithout that happening, I think the workforce will revolt and it won't come from the government.

It's gonna come from the people and it's gonna come from our workforce that is just saying, enough is enough.

We need a rational system, otherwise I'm not gonna be there for you.

– And building on sortof the workforce issues, could somebody comment onsort of physician extenders or bringing other peopleinto the workforce? We've really limited ourselves.

I don't know Steve Lockhart, if that's an area thatyou guys are looking at, but this idea of nursepractitioners or other folks that we're also reading that we have a, especially in California, a very low use of using our retailpharmacies as testing sites.

It feels like there'sa lot of underutilized, both workforce capacity, people not at top of license or licenses that have a lot ofroom that couldn't be moved.

And then also sites of care that aren't potentially being utilized.

Steve, would you mind commentingon that for the audience? – Sure well, I thinkcertainly at Sutter Health, we have been moving in that direction to use we call it bestpractice clinicians, nurse practitioners, physicians, assistants, others to work in these sort of group models in order to extend care.

The notion of a singleprimary care physician going through and seeing20, 25 patients a day, it's just the model doesn'twork for the physician and it doesn't really work for the patient because they don't really get the extended care that they need.

They don't get the diversity of services that you can get withthis team based approach.

And so physician extenders or these advanced practiceclinicians, if you will, truly have a lot to offerin addition to just being an adjunct to the physician.

There actually areprofessionals who can contribute in a very substansive wayto the patient's care.

I would say also as we've seen in terms of communities ofcolor where we tried to go in and be much more community based, and of course now Jane andthen the work that she does it's very much a community based as a large provider organization.

We also have that needto be able to tap in and feel the pulse within the community.

Certainly in those situations, the ability to get into the community with these best practice clinicians or even the Promatores model or community health care workers or whatever you want to callthem is extremely important.

We have an African American asthma program going to address as an issue, divert our conversation there except to say that beingable to do home visits, being able to have someone whois a racially can coordinate, hopefully sensitive tobe able to with people is so important.

So having this extendercommunity is important and I think you'vementioned something else, which in the world of COVIDwill be extremely important.

It's how do we get all of this testing? How do we do all this contact tracing? How do we do all of this withour existing infrastructure? We cannot, right? So the pharmacist there willbe needs to do these things.

School nurses and justthere are a number of people who can learn and be trained.

Are there ways we can take, again, these community health care workers.

A lot of these things arenot not issues that require and these PhDs are ends or others.

They need training.

And in fact, if youdon't have the training, even if you are a physician or a nurse, you probably are notgonna do a very good job.

So I think we can train and that's part ofDick's public health plea is that's part of a public health network, not the network that we have currently, but it's really about buildinga public health network of people who have avariety of levels of skills and training and canprovide the requisite skills to the healthcare team.

– Well, thinking of usingour dental providers that are on temporary reductionto do some of this testing.

– And for both of you, are you seeing access to testing beyond symptomatic population? That's another questionthat's getting asked here about whether we're still limiting testing to symptomatic folks and when and how the true expansion of asymptomatic and then obviously antibody testing comes.

But either Jane or Steve, ifyou could just quickly comment Lynn, maybe if you've gotinsights in the world, how pervasive is testing.

We see all the stats andthe news and the media, but it's unclear.

I think many people, what is the reality of testing right now? – We have noticed in rural America, – I say, I'm gonna say we don't have zero, but we don't have enough.

And I think that moving fromsymptomatic to asymptomatic is where we need to go.

But the real problem isthat you don't wanna use and waste valuable resourcetesting asymptomatic patients if you're not really using itfor a containment strategy, for contact tracingand that sort of thing.

If it's just being usedfor social purposes or because you want to beable to mark or advertise that you're doing testing or that you're making people feel better.

There has to be some intellectual honesty and how that testing is carried out.

And I think when theantibody front as well, I think we're a littlebit out over our skis in terms of being able to really interpret some of the results and also in terms of more importantly some of the testing that's being done.

We had something like90 versions of the test the FDA has allowed and mostof them are not accurate.

So there are the right ways to do things.

I think we just have tomake sure that in our rush to be speedy or to getthe next best thing, that we're not being careful.

We have to be sure thatwe're careful enough and we do this in a step wise way.

So I firmly believe in antibody testing.

I think there's a lotthat we can do with it for convalescent plasma, for epidemiologic purposes and so on.

But we really need to havevalid tests that are specific, that are sensitive andwe also need to have a lot more PCR tests for usto do the type of, again, I come back to Dick.

I'm looking at him on the monitor here and know that I'm sure he would say that from a public health perspective, we have to be able tohave large volume testing with a lot of differentpeople providing it so that we can do this surveillance, this contact tracing and isolation.

– And Jane.

– PPE is still hit and miss and we still are anxiousabout that on a daily basis, we're taking inventory ofwhat do we have in hand.

Right now we're doing it using dental PPE so we redirected it.

So that's the other partof the puzzle that we and that's where governmentcould also really help.

– Yeah.

So we're coming close to our time and so I want to just give each of you maybe a quick 20, 30 seconds if there's something elsethat you're excited about that you think is another positive or an opportunity from this, could be domestic, international.

Maybe I'll start with Dick andjust move through the group if you just one last thoughtabout what could come of this, what should we be looking for, hoping for to come out of the pandemic as it relates to the delivery system? – Yeah, we've seen the stresses, the financial stresses on thehealthcare delivery system.

They could get a lot worse.

We're facing a recession, which could go a year, two years, five years, and there's not gonna be enough money to do all the kinds ofthings we have been doing.

So what do we do? We've mentioned a lot of things already, but I want to mention four more.

One is our healthcaresystem is very siloed, very specialized.

We're finding that peoplecan work better in teams, some of which are not doctorsand nurses to do more things.

Second, we have 30 to 60% unnecessaryprocedures in healthcare.

There's documented evidence of that.

That has to be stopped.

Third, the electronic healthrecord is very expensive.

It's useful, that's true, but it's very expensive.

It takes a lot of time awayfrom doctors and others.

It takes a lot of administrative time that can be fixed very quickly and fourth, one of the biggest costs inhealth care is chronic diseases.

We don't do a good jobon chronic diseases.

We manage episodes of care, but we don't have a longtermcare for chronic diseases.

All of those things are areas where we can save a lot ofmoney, not by laying off people and becoming more efficient, but by doing things totally different and I think that's an opportunity that we can't miss at this point.

– Thanks Dick, Lynn.

– Yeah, I'd love tofollow that last point.

So one of the biggestthings I'm excited about is they waived the copaysfor chronic care management.

So we as ACOs, we talk aboutchronic care management all the time and our number one barrier to getting our patientsto sign up is the copay and it's eight dollars a month, but it's too much andthey don't understand it.

And so they waived thosecopays for the rest of the year so we're going out scorched earth to sign up all of ourchronically ill patients on chronic care management.

We're redeploying ournurses out of inpatient that have nothing to do and say, I want you to get on the phone with every single Medicare patient you got and we provided them apatient engagement app that I work with my studentsat Berkeley on and said, get them to download this app and get them to start talking to you and texting you and start figuring out how to communicate with yourchronically ill patients.

And so then we've got startedup remote patient monitoring.

Again, with those waivers of copays, we have this uniqueopportunity between now and the end of the year to totally change chronic disease management and that's what we're excited about.

We've totally reoriented our entire health systems for example.

– Exciting.

Steve Lockhart, something quick.

– Well, I think that thisis a great opportunity for us to understand thedifferential impacts of COVID-19 or any kind of healthcare disease on our most vulnerable populations and especially with respectto race and ethnicity and addresses this issue toSteve Shortell brought up about structural and systematic racism, both in our society andin our healthcare system.

It clearly exists.

It clearly has taken a toll on impact.

And in the case ofCOVID-19 it's costing lives and that is just unconscionable.

So I think it's a moralimperative for us to address that.

This is an opportunitythat cannot be wasted.

And I'm hoping that at least as people are starting tohave the conversations, people starting to ask, why are there so many moreAfrican Americans dying here? Why are there so manymore Latinos dying there? So as we have that conversation, my hope is that we willactually look to solutions rather than just describingthem as specimen the problem.

That's my hope.

– Really important, thank you.

Steve Shortell.

– We have to go way beyondhonoring the problem as Steve has just said, just two or three finalpoints, Kim I think.

One is I foresee an increased permeability between the delivery systemand those organizations, social determinants of health.

So whole person pilots aregoing on here in California.

As you know, we have some ofour faculty evaluating those.

We've talked about ideas about whole person development centers that would get at education, housing, food, transportation although the health systemscan play a role on that.

That's the first point.

The second point is I really do think we need to move this fee for services.

We need to aggregate up, as Lynn has said, where providers can accept the risk, they have the populations to do that.

And the final point, I would make, there's really an opportunity for increased investment in public health.

The infrastructure we need, the workforce we need, the training we need in ourschools of public health.

And that's been cut back our own department here in California just talked about contact tracing.

We don't have enough there, et cetera.

So perhaps we'll begin to make a greater systematic longterm investment in our public health infrastructure and the public health workforce.

– Amen.

Jane, one last thing.

– I'm hopeful that ifwe've learned anything from this pandemic is theimportance of universal coverage that everybody have access to coverage.

I'm really excited about thepotential for telehealth, for payment reform andalso for population health and the importance of socialdeterminants of health.

And just one last thing is what we've learned from this pandemic is how quickly any oneof us can be hurting for something as basic as food.

– It is profound.

Well, thank you all.

I can't imagine a better group to have this important conversation with.

So thank you to everybody.

Jane Garcia, Lynn Barr, Dick Levy, Steve Lockhart, Steve Shortell, really amazing.

Just really appreciate theinsights that you all share.

obviously this will beavailable via recording for others later.

Just wanted to thank ouraudience for joining us today and encourage them toplease look at the schedule of the upcoming Berkeley conversations as we continue to bringyou the most accurate and up to date information on COVID-19.

So thank you all verymuch for joining us today and have a great rest of the day.

Thanks everybody on the panel.

– Thank you.

– Thank you.

.