Health care’s shaky recovery – We face the reality of inequity

BY TODD ARCHBOLD, LSW, MBA

Reprinted with permission from Minnesota Medical Association – Minnesota Medicine

The early snowfall across Minnesota was a reminder that the seasons will continue to change, and each day the sun will continue to rise and set. When everything around us feels uncertain, everything that is important becomes clear.

A report published by the Commonwealth Fund illustrates the disruptions felt by our health care systems throughout the first several months of the pandemic. According to this report, by mid-April, overall outpatient visits were down nearly 60 percent while telehealth visits were up 14 percent (behavioral health visits are up 41 percent). The regulations that have allowed for increased access to telehealth services are largely being extended through 2021 (it is important to note there is no single governing body over telehealth; decisions are made by individual insurance companies, often at the plan level). Larger health systems have leveraged telehealth platforms at 2 to 2.5 times that of smaller practices with fewer than five providers. The report also shows that in many areas, health care has returned to relative pre-pandemic levels. Most health systems suffered a devastating financial impact during the spring months that will be felt for the foreseeable future.

Our health care systems are slowly rebuilding and stabilizing—but are now suffering morally as we face the damning realities of health care inequities in our communities, the failure of our idealized national and global collaboration efforts, the fundamental flaws in payer-provider relationships that has led to many American’s being under-insured or simply the estimated 14.6 million people who may have lost their job-connected health insurance. The biggest threat facing our health systems today is our struggle to retain the critical staff needed to care for a variety of sick patients. The capacities of our hospitals are not limited by space or beds, but rather by the number of necessary staff.

The level of collaboration and coordination within our Minnesota health care systems is unprecedented, though our institutions are not infallible. For the first time during the pandemic, we have now seen the rural COVID-19 infection rates rival the numbers in our greater metropolitan areas, reaching levels that continually threaten hospital capacities across the state. As the threat of reaching ICU bed capacity initially rose last May, the Critical Care Coordination Center (C4) was established as a collaborative effort between the Statewide Healthcare Coordination Center (SHCC) and M Health Fairview Systems Operation Center (SOC). This system is responsible for managing ICU bed placement and patient transfers across the state of Minnesota in response to the COVID-19 pandemic. Throughout November and December, we saw record-breaking numbers reaching thousands of new COVID-19 cases identified each day, occupying on average well over 20 percent of our overall hospital beds in Minnesota. Nationally, the number of hospitalizations doubled in this same timeframe, totaling over 100,000 in early December, a number that would have far surpassed capacity just months earlier. The surge in COVID-19 patients requiring hospitalization poses a risk to other types of patients and our ability to meet their medical needs. In addition, the need for mental health services and support within our communities continues to increase as well.

In the meantime, our communities have grown comfortable yet weary of the continually changing landscape. Gov. Tim Walz has continued to adjust the Stay Safe MN plan just before the holidays, resurrecting previous restrictions on restaurants and bars, fitness centers, youth sports and social gatherings. According to MDH data, these types of settings have contributed nearly 71 percent of COVID-19 outbreaks. Many workplaces are committing to indefinite work-from-home structures, and most school districts have returned to distance learning models in light of rising infection rates. Data from a variety of early coronavirus studies in schools show that infection rates in schools mirror that of the communities they live in—suggesting that schools have not become the “super-spreaders” that many feared. One of the largest studies, done at Brown University, analyzed data from 47 states encompassing 200,000 students and 63,000 staff. The report showed an infection rate of 0.13 percent among students and 0.24 percent among staff who had returned to school.

It has become clear in recent months that the biggest factor impacting the recovery of our health care systems is the collective behavior of individuals in our communities. We demonstrated an ability to slow the spread of infection last spring with strict shelter-in-place orders, mitigating the surge that we felt was inevitable. We then spent the summer months monitoring ripples and trends in infection rates that could be correlated to community activities. Now, with the risk factors mounting with colder weather, we are relying on the public to adhere to masking mandates, follow the Stay Safe MN orders and quarantine when sick in order to prevent catastrophe. Increasing infection rates pose a threat to our institutions and all the essential workers we rely on, and lead to even stricter restrictions in our communities. While these restrictions are proven to slow the spread of the coronavirus, they come with their own cost to our economy, unemployment, mental health and more.

The accelerated success of global vaccine trials now offers hope during our darkest time and the race is on to deliver vaccines to our critical health care workers and our at-risk populations. Experts expect that the general public will have access to a vaccine as early as March, and we anticipate an impactful level of herd immunity by fall. Many questions remain about the effects of the vaccine (such as its longevity, if a vaccinated person can still be infectious, etc.) as well as how well the public will comply. The mass distribution of a vaccine is the tipping point we have been waiting for—and ultimately the one thing that will allow our health care systems to begin to normalize. The tables have turned on our health care systems in that our medical experts are now on the end of the bullwhip, and have become the last line of defense.

The challenges we have faced throughout 2020 are the same threats that have plagued humankind for centuries. However, there are extraordinary circumstances that that define the current challenges, perhaps as an example of overdetermination, including the politicizing of the coronavirus pandemic, the polarization of societies’ understanding of systemic racism, the unusual confluence of weather systems causing record West Coast wildfires and the failure of regulatory enforcement that is supposed to keep our international ports safe. And, leading up to and after election day November 3, an intense battle over voter rights in America, and the fallout of unfounded accusations of voter fraud and lawsuits long after the election. One can’t help but wonder why these problems persist in our modern world—at the cost of trillions of dollars and precious human life.

The lyrics in John Lennon’s humanistic 1971 song “Imagine” seem absurdly altruistic as we grapple with systemic variation of opportunity. One example of macro-level approach at addressing disparities are the steps taken by the American Psychiatric Association. Jeffrey Geller, MD, MPH, president of the APA, is now months into a comprehensive reckoning of structural racism in psychiatry through a series of writings and public townhall meetings. We are building a roadmap for equity and inclusion while working to meaningfully engage with our oppressed communities—beyond the walls of our clinics and hospitals. In this regard, we must continue take risks and be vulnerable.

While our health systems and communities are far from stable, it behooves us to appreciate the dramatic improvement in our understanding of COVID-19, how it is spread and advancements in effective treatments and medication trials.

Todd Archbold, LSW, MBA, is chief executive officer, PrairieCare and PrairieCare Medical Group.