The U.S. healthcare system has been engaged in a historic challenge, and it has responded with heroic efforts by providers, support staff, the supply chain, payers and government at all levels. However, not all of this system has worked well, and experiments and innovations have occurred spontaneously to meet patients’ needs. Once the pandemic moves into a phase of chronic disease management, action will be taken to clarify the roles of the federal, state and local governments.
However, other health policies may also need changes. Creative healthcare leaders have responded to the crisis with innovations in care delivery, and some of these changes that are successful might be adopted as standard practice with new health polices in the future. These include revisions to the role of testing by public health agencies and the private sector, the healthcare supply chain, innovations in payment and creative use of the healthcare workforce.
Public Health: The Testing Challenge
The U.S. healthcare system has a long history of a continuous focus on improving clinical quality. A key characteristic is that clinical diagnostic tools and therapies need to be proven efficacious. The result is a sophisticated but complex and slow system of moving new technologies into clinical practice. This issue was on graphic display in the dissemination of the COVID-19 testing program. The primary testing for new potential epidemics is done by the Centers for Disease Control and Prevention with replication carried out by state and local public health laboratories. Due to errors in the initial test kits sent to state and local labs, national testing was delayed three weeks. In addition, the rapid clinical onset of COVID-19 and the Food and Drug Administration approval process slowed academic, hospital-based and commercial laboratories in the development of rapid testing capabilities to support clinical care and broader public health surveillance and contact tracing.
A future healthcare system will use the tools of continuous process improvement to identify bottlenecks in test development and create more speed and agility. The roles of federal and public agencies and the private delivery and lab sector will also go through significant change.
Supply Chain
The shortage of personal protective equipment and ventilators needed to treat patients with COVID-19 exposed another dangerous feature of the plan for successfully confronting pandemics. The current supply chains’ focus on just-in-time inventory systems did not provide significant safety stock for the historic spike in demand for these materials. Although the U.S. Department of Health and Human Services manages a Strategic National Stockpile of drugs and supplies ready for deployment in the case of national emergencies, it has clearly proved to be inadequate. In addition, there is no central coordinating federal agency responsible for developing an inventory data collection, forecasting and distribution system for these critical supplies.
It is likely that an improved future healthcare system will include a new federally managed and funded system to make these straightforward improvements. Any new system will have significant implications for group purchasing organizations and the potential for increasing their costs.
Payment and Financing
The financial health of hospitals has been challenged due to the need for rapid expansion of inpatient and intensive care unit facilities, and the loss of elective admissions. Fortunately, the Coronavirus Aid, Relief and Economic Security Act provides some immediate funding for hospitals, but its administration and rulemaking is still evolving. Other funding in the bill supports community health centers, drug development, the Department of Veterans Affairs and the CDC.
An important Medicare payment policy improvement is the full payment of telemedicine services, and many private payers have followed. In addition, many Affordable Care Act marketplaces have re-opened to provide workers with the opportunity to acquire insurance, even if they did not do so during the regular open enrollment period.
It is likely that telemedicine payments will continue, and that a long-term surge-financing system for hospitals will be developed. More market consolidation is likely to occur as some financially weak health systems are absorbed into more stable organizations.
Workforce
The need to staff new inpatient and ICU beds has encouraged the creative use of the existing workforce supplemented by clinicians working in new roles, students stepping in and retirees returning to work. For example, the Society for Critical Care Medicine has developed a model for a 96-bed ICU with one highly trained critical care physician supervising a small number (4–8) of experienced critical care practitioners, supplemented with physicians and nurses experienced in other areas of critical care.
These experiments could pave the way for more flexibility in job roles, scope of practice and specialization in the future.
The system’s many flaws have been part of the political dialogue for years, but the basic expertise and commitment of all professionals in healthcare has once again been demonstrated across the healthcare continuum. This will be one of the lasting impacts of this pandemic.
Daniel B. McLaughlin is director, Center for Innovation in the Business of Health Care, University of St. Thomas, Minneapolis, and an ACHE Faculty Associate (dbmclaughlin@stthomas.edu).
Tiered Staffing Strategy for Pandemic
The COVID-19 pandemic has had a significant impact on several aspects of healthcare, including the workforce.