Thousands of clinicians, clinical leaders, and health executives from organizations that are directly involved in care delivery form the NEJM Catalyst Insights Council. They are in some ways the voice of NEJM Catalyst. In early April, as Covid-19 began to take hold in the United States, we surveyed Council members on their organizations’ preparation and response. We asked how well the needs of clinicians and medical staff, as well as patients, were being met. We tested organizational leadership and communications about Covid-19, both internal and external. And we asked these health care professionals what the future of care delivery would look like.
The survey respondents were largely sanguine about their ability to care for patients with Covid-19 illness — a few trouble spots notwithstanding — and satisfied with their organizations’ readiness. But in prognosticating about care delivery, the Insights Council members say the status quo must go. They are eloquent in calling for better preparation for future pandemics, more telehealth and virtual care, and payment reform. Rather than railing against one another, these clinicians, clinical leaders, and health executives are mainly on the same page. A common theme is a call for a true population health — because, after all, we are all in this together.
How will the future of health care delivery be different after this pandemic?
Clinician responses:
1) It will be financially devastating for many Health systems 2) we will have lost several physicians and nurses when we are already short 3) telemedicine will increase significantly 4) there all be universal recognition that we cannot exist without a vigorous public Health system including pandemic preparedness 5) there will be financial and tax incentives to bring back production of critical medications and PPE back to this country.
— Clinician at a large nonprofit health system in the Midwest
Fearful that humanistic connection will decline.
— Clinician at a small for-profit clinic in the West
All respiratory infections will be pre-screened and tested in the parking lot. It has gone on far too long that we have allowed actively coughing, sneezing and contagious patients to mix with our uninfected patients in our building.
— Clinician at a small for-profit clinic in the Midwest
Clinicians and nurses are feeling a sense of expendability when being directed by ignorant administrators with little clinical understanding. Subsequently I suspect a large number will leave due to burnout post pandemic.
— Clinician at a small nonprofit teaching hospital in the Northeast
Hiding from an invisible enemy is not effective as it will be waiting when you must leave hiding. Widespread unfocused isolation is economically and socially very damaging, unsustainable, and will ultimately fail. It will fail unless, as we hope, the COVID-19 wanes in the summer like the flu. But hope is not a real strategy. To fight this enemy we must find it with widespread timely testing, rapidly do thorough contact follow up with testing, and then do focused isolation.
— Clinician at a nonprofit clinic in the South
Hopefully we will be able to stockpile more conventional PPE and have at least some more specialized PPE such as PAPR. We will have many protocols already in place after this. We will have more people cross-trained. We will keep track of aging clinicians and staff and those with co-morbidities so as to substitute for them. We will have documentation in place so that residents cannot weasel out of seeing patients.
— Clinician at a small for-profit clinic in the South
I hope that healthcare does not progress to even more what I call hands-off medicine. Even before COVID-19, a doctor told my mother that she would not be touching her due to germs. This was my mother’s first visit at 89 years old to a new primary care physician. I was mortified. I am concerned that doctors don’t engage in their patients’ illness anymore or really even engage their patients at all. I am concerned that after this pandemic, that problem will magnify. I hope not.
— Clinician at a small for-profit clinic in the West
It’s all about prevention, baby.
— Clinician at a midsized nonprofit community hospital in the Midwest
Not sure there will be an after this pandemic for a long while. Flattening the curve means extending the duration of the curve, and hopefully reducing the area under it. But we just can’t know. Preparation never seems necessary until it’s necessary. Ethics of ventilator allocation exercise will have been considerably advanced in theory and preparation.
— Clinician at a large nonprofit community hospital in the Northeast
Not sure. Analysis of all the data after the pandemic resolves must be done to determine what happened and what works and what does not work to effectively respond to future events. Maintenance of personal and population health must be balanced with the ability of society to continue to function. What that balance is we do not yet know.
— Clinician at a large nonprofit clinic in the South
Of course, one would hope that the future would be different, but I am fearful that the change for the better will have to come from higher up. We were totally unprepared for pandemic, and I am convinced that the government will do nothing.
— Clinician at a small for-profit physician organization in the Northeast
People will be more comfortable with telehealth. Beyond that I doubt that anything will change. We were ill prepared for this pandemic and downplayed it even though we had enough warning.
— Clinician at a large nonprofit community hospital in the West
Should be better organized and have a national plan of logistics for distribution of needed supplies, including ventilators. We basically have 50+ medical systems that are scrambling and bidding for supplies.
— Clinician at a large nonprofit teaching hospital in the South
Telehealth has arrived.
— Clinician at a large nonprofit teaching hospital in the Northeast
The high levels of pre-existent burnout present before the pandemic will grow. The clinicians will find a collective voice in demanding that their well-being be adequately addressed.
— Clinician at a small nonprofit health system in the Northeast
The industry will need to manufacture and stock pile much more protective equipment and patient supportive care equipment. We will need to change origin of the supply chain. That is, we need to be less dependent on a global supply chain due to the ease of its disruption during a pandemic. We need to plan for other types of crises and pandemics that may not be airborne. Which may require different types of protection and supportive equipment. There will be a greater shift to virtual care for routine medicine.
— Clinician at a for-profit physician organization in the West
There are at least two disasters unfolding in the health care system. The public health emergency is first, and will be a catalyst for changes. The next is a coverage disaster. 28 million uninsured (before the layoffs) will be subject to HUGE bills. (A CBS News piece today covered a patient with a $9000 bill for an ER visit for COVID testing). This is the tip of a really big iceberg. The epidemic/pandemic will create a huge need to cover 100% of the population and do so in an affordable way.
— Clinician at a small nonprofit community hospital in the Northeast
Will have to go back to basics of clinical work. The private sector preparedness LAGGED way behind the public sector in NYC. Will need to curtail the expenditures on branding and transformation into spas. PRESS GANEY, NPS, HCAHPS NEED TO GO — clinicians are not there to please and appease, but to do clinical work that matters to cure, preserve quality of life and mitigate suffering. Clinicians involved in the frontline should be rewarded for the extra risks taken every day of this battle.
— Clinician at a nonprofit teaching hospital in the Northeast
We’ll realize just how much care can be delivered virtually; we’ll rely more on patients / clients to own the management of the conditions with which they live; we’ll see provider turn-over as some (primary care?) clinicians realize how psychologically, physically and spiritually unsatisfying practicing in the American non-system of care delivery had become.
— Clinician at a small nonprofit clinic in the West
We will be increasingly pressured to put the good of society above the good of the individual. There will be more pressure to depersonalize medicine through tele-medicine and algorithmic care. We will know a lot more about managing viral respiratory illnesses. I would hope that more supply chain production will come home. Many Politicians and epidemiologists seem to see this as an opportunity to change the nature of our society and government.
— Clinician at a for-profit hospital in the South
Clinical Leader responses:
Delivery will be more diverse and efficient. As we determine that telemedicine is as effective as face to face encounters, and documentation requirements need not be so onerous, I expect we will adopt these practices in not pandemic times.
— Service line manager at a large nonprofit teaching hospital in the South
Better stockpiles of supplies. Better planning for healthcare workers being sick. Better communication with patients and families. Use telehealth and video visits more in primary care. Medicare needs to start paying for these visits like regular office visits.
— Department chair at a midsized nonprofit teaching hospital in the South
Collapse of health care financing and delivery is probable, unless decision is made quickly for utilitarian and difficult ICU decisions as data appears to be emerging of near futility of ventilator support of elderly.
— Department chair at a small for-profit clinic in the West
Fate of independent rural hospital uncertain.
— Chief Medical Officer at a small nonprofit community hospital in the West
I hope there will be more effective federal coordination of supply chain issues, quarantine and testing.
— Fellowship director at a medical school program in the South
I like to think in innumerable ways, but: 1. Perhaps we will cease to underfund public health infrastructure. 2. Better resources directed toward emergency readiness. 3. A more realistic approach to the delivery of care with broader acceptance (both from payors and providers) for innovative and virtual care delivery. 4. I have been a physician for > 25 years; I am a big proponent of the value of the physical exam, but I am being forced to re-think that!
— Department chair at a nonprofit university in the Northeast
I would start by answering a question with a question. Of the regulations that were lifted during this time — how many are truly necessary? If we can practice medicine safely during this time, are those regulations benefiting patients at all? Clearly virtual medicine will become more accessible. Being forced to this format has propelled some reluctant providers into an additional practice skill. On this note, providers should be offered training in how best to accomplish virtual medicine, including risk.
— Manager at a government organization in the South
I’m concerned many smaller independent hospitals will close as will clinics in marginal reimbursement areas. With the financial hit fewer hospitals will be able to invest in equipment and will lose staff.
— Service chief at a small nonprofit health system in the Northeast
Improved efficiencies and coordination. Tools like Microsoft Teams. Virtual visits have now been widely utilized due to this burning platform on which we now stand.
— Service chief at a large nonprofit community hospital in the South
Increased telemedicine, increased patient understanding of population needs and hospital/ government review, increased adoption of healthcare backup staff (hopefully!).
— Program director at a small nonprofit hospital in the South
Maybe we’ll actually understand that running hospitals at 105% capacity all the time is a really bad idea.
— Department chair at a nonprofit teaching hospital in the South
Need universal healthcare. Rural areas need protection. Fearful about physician burnout. Worried about good staff leaving. Hopefully more telemedicine. Need more disaster planning. Can’t run healthcare like a business. I hope we still have healthcare providers at every level.
— Service chief at a small nonprofit community hospital in the Northeast
Now that patients are used to virtual visits, I think they will ask for them more. Care delivery will move to more on-demand with less need for continuity except in certain populations. Everyone will wash their hands more!
— Director of a small for-profit physician organization in the West
Preparedness in terms of capacity for critical care, ventilators, PPE will need to be reassessed and addressed. Financial challenges to affiliated hospitals (rural hospitals are in danger of running out of money in a matter of weeks). Lack of coordination at federal level seems glaringly evident.
— Service chief at a midsized nonprofit health system in the Midwest
Telemedicine will be more common between provider and patient. It appears that many fee-for-service practices are struggling and likely many of them will go out of business. Value based capitated models will get a lift from this and will be more prevalent. More Medicare patients will be looking for value in their health care and will be drawn towards Medicare advantage. I would like to think that more primary care in fee-for service will be paid on a prospective payment model rather than an episodic model.
— Chief Medical Officer at a small for-profit physician organization in the South
The pandemic has clearly shown many weaknesses in our healthcare system. I am not optimistic that much will change with a care system driven by money and politics. We have good documentation of a failing healthcare system compared to other countries without the will to substantially change. Our political system has a short memory and will shift to managing the recession after the pandemic is effectively controlled.
— Chief Medical Officer at a nonprofit clinic in the West
The virtualization genie will not go back in the bottle. Also, more meetings will have a virtual component.
— Department chair at a large for-profit medical school program in the Northeast
This is an inflection point. Telehealth, population health issues will both emerge. Influenza, car accidents, smoking, and all sorts of other public health impacts will be looked at differently. An understanding of the choices we make as a community will emerge; tradeoffs in lifestyle inform health. A renewed sense of purpose and meaning will infuse medicine. Discussion over how we manage (or don’t manage) healthcare will rise in importance; similarly for who has healthcare.
— Service line manager at a large nonprofit teaching hospital in the West
Virus care forever. Screen everyone at every visit.
— Director at a large nonprofit medical school program in the South
Executive Responses:
Will elevate the role of clinician leadership (especially physician). Dramatic driver of telehealth. Will lay bare the obvious inequities in health care based on race and SES status. Hopefully (though not holding my breath on this one) will elevate the importance of public health and pandemic preparedness.
— Vice President at a large nonprofit teaching hospital in the Midwest
Expose lack of coordination between health systems and health departments as a major issue requiring investment. Expose telemedicine payment requiring 2-way video as discriminatory to patients with limited technology resources and health care organizations who care for such patients. Expose vulnerability of health care organizations to visit based fee for service revenue for cash flow.
— Director at a large nonprofit health system in the Northeast
Government preparedness. Manufacturing of critical supplies in the US. Manufacturing of essential drugs in the US. Transparency of Federal Govt. National Taskforce on Health Pandemic. International collaboration on management and innovation.
— Vice President at a small nonprofit health system in the South
Hopefully we will have a more unified national disaster preparedness plan and a universal health care system where getting the right care doesn’t depend on your income, race, socioeconomic status, language, gender/sexual orientation, immigration status. And hopefully we will understand better how to protect healthcare workers.
— Vice President at a nonprofit clinic in the Northeast
I honestly don’t know.
— Executive at a midsized nonprofit community hospital in the West
IMPETUS FOR UNIVERSAL HEALTHCARE.
— Executive at a small nonprofit long-term care facility in the Northeast
It is my hope that allocation of all health care resources will be more fair and efficient. The corporate practice of medicine that has been exposed during this crisis by profiting off of opportunity, while putting health care staff and patients at risk has to be abolished or severely limited. Drug companies, insurance companies, and health care supply chain manufacturers need to be regulated, and executive compensation in all health care related industries slashed.
— Executive at a small for-profit clinic in the Northeast
It will not change. Our protocols keep everything clean and disinfected. We continue with what we always have done.
— Director at a for-profit clinic in the West
More telemedicine. More consolidation and corporatization as smaller private practices are hurt by lost volumes. More governmental insurance for a broader spectrum of the population.
— Vice President at a large nonprofit teaching hospital in the West
More telemedicine. Better infection control processes. More locally available testing capability (PCR etc.) Better understanding for the need for teamwork. Improved alignment between MDs, Hospitals and Community. Will weed out the true leaders. It has unleashed creativity. Should encourage more dependency on local resources, as opposed to Federal resources. Should force more entities to consider taking risk (I wish we had the premium dollars up front now...FFS collections are tanking).
— Executive at a midsized for-profit physician organization in the South
Needless to say, telemedicine will fill an increasing role in many management venues. On a very worrisome sense, will politicians use this pandemic to institute policies like an overriding of a patient or family’s wishes for upper level care? In all crisis situations, there are unintended consequences which may affect our constitutional liberties.
— Vice President at a large nonprofit teaching hospital in the Northeast
No one knows since we are at the beginning. If most resources are used, with less revenue I anticipate challenging times to recover for the individual and the health care industry. I am hoping people will learn from the need to prepare for the worst and have a plan to respond to increased demand. I worry about neglecting other patients when we focus too much on COVID-19.
— Director at a small nonprofit clinic in the South
Not much change. There is too much ingrained political resistance to any significant change.
— Vice President at a large for-profit health plan in the Midwest
Pandemic preparedness plans will be based on real experience and not merely theory.
— Vice President at a midsized for-profit teaching hospital in the Midwest
PPE will be rationed more closely. Emotional/mental health burden will be significant, perhaps resulting in more vacation time or other PTO, and perhaps greater need for mental health professionals to care for frontline healthcare providers.
— Vice President at a midsized nonprofit teaching hospital in the South
Primary care physicians will be better appreciated. If we were to keep any clinics open it would be primary care. They take care of multiple illnesses and diseases and keep people out of the hospital and ED. That’s the most important outpatient clinical need and maybe it took a pandemic to finally recognize that.
— Executive at a nonprofit physician organization in the Midwest
Telemedicine will start to take off but I’m not sure it will get to the heights people necessarily think it will. I think the financial hit being taken by the hospitals and health systems will significantly increase consolidation. If only people would get rid of the ridiculous payment model.
— Executive at a small nonprofit community hospital in the Midwest
The highest value adaptations will be adopted moving forward. There will be a bigger push for wide spread adoption of telemedicine by patients, clinicians, and organizations as long as tele-visits are fairly compensated. A model of compensation for tele-visits to consider is a combination of time driven activity-based costing + visit complexity modifier + patient complexity modifier.
— Vice President at a large nonprofit health system in the South
The importance of hospitals will be greater; utilization of tele-health; increased concern for hospitals not being squeezed; increased appreciation of doctors and nurses.
— Vice President at a large nonprofit health system in the South
The intermediate managerial workforce will likely shrink. The importance of clinical leaders and managers is being represented well in this response. There are positives emerging. We are working together in our teams with much more cadence and rhythm, exploring new avenues for collaboration and likely setting the bar for POST19.
— Vice President at a nonprofit ancillary provider in the Northeast
The long tail is very worrisome. Governmental preparedness should improve short-term but long-term memory is a problem. Telemedicine will come into its own. The effect of psychological barrier of PPE is yet to be fully realized…
— Executive at a nonprofit health system in the Northeast
NEJM Catalyst surveyed health care executives, clinical leaders, and clinicians about organizational readiness and care delivery for Covid-19. Leaders were asked about the current status of Covid-19 in their local area and patient population; preparedness of organizations when Covid-19 appeared; adequacy of organizational responses to Covid-19; the degree to which clinician and staff needs are being met by organizations; the challenge of providing safe, effective care to patients; the effectiveness of leadership teams; the quality of internal and external communications; and the use of telemedicine/virtual visits in Covid-19 care delivery. Completed surveys from 522 respondents are included in the analysis.
We’d like to acknowledge the NEJM Catalyst Insights Council. Insights Council members participate in monthly surveys with specific topics on health care delivery. These results are published as NEJM Catalyst Insights Reports, such as this one, including summary findings, key takeaways from NEJM Catalyst leaders, expert analysis, and commentary.
It is through the Insights Council’s participation and commitment to the transformation of health care delivery that we are able to provide actionable data that can help move the industry forward. To join your peers in the conversation, visit https://catalyst.nejm.org/insights-council .
What Health Care Leaders and Clinicians Say About the Covid-19 Pandemic | Catalyst non-issue content - nejm.org
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