Solutions Related to the Covid-19 Pandemic
by Ellis M Knight MD, MBA
INTRODUCTION
Much has been written about the challenges to the American healthcare system during the recent Covid-19 pandemic. Many are now banking on the availability of a vaccine in the near future to alleviate the stress on the system, hospitals in particular.
This article will outline both short and long-term operational changes that have proven beneficial and should be immediately considered for implementation by hospital and healthcare system leaders. The short term solutions are most important to consider since an effective, widely distributed, and safely administered vaccine will likely take several months, if not years, to materialize.
SHORT-TERM SOLUTIONS
Smoothing elective surgical or procedural schedules:
Elective cases compete with unplanned medical and surgical admissions for bed space in the hospital. In times of higher than usual demand for inpatient beds, such as during the Covid-19 pandemic, elective cases can either be moved to the ambulatory setting, postponed, cancelled altogether, or smoothed out over the workweek.1 The smoothing of elective cases is preferable to other options in that it will allow activity in this sector to continue and not disrupt or block admission of patients from other areas. This smoothing effort has already been done successfully in many medical centers, pre-Covid-19, and the benefits of implementing this methodology are likely to be much greater in the midst of the current pandemic.2
Another argument for elective schedule smoothing is that multiple studies have demonstrated the morbidity and mortality risks of allowing peaks to occur in elective admissions. These peaks should be avoided for the safety of the patients and the wellbeing of the staff who are required to care for them in a safe and efficient fashion.
Finally, many elective surgical cases have been postponed or cancelled.3 Further delays for some of these surgeries now pose a threat to the patients affected by worsening and progressive conditions for which surgery may now be urgently needed. These cases should be culled out from the larger pool of truly elective cases and prioritized for scheduling. There is now software that can assist in this process and hospitals and other healthcare organizations should strongly consider implementing this technology.4
Split pooled testing for Covid-19
The federal government appears to be cutting back on funding and availability of coronavirus testing. Hospitals will likely find that they need to pick up the slack when private labs curtail testing activities due to lack of adequate funding for this work. Hospital labs should therefore understand and implement a pooled testing protocol that allows for more accuracy, a lower number of testing episodes, and lower costs.
Pooled testing has been recognized as a viable alternative to individual testing since World War II when Dorfman introduced the concept. Application of Dorfman’s protocol to testing for Covid-19 however, is fraught with a critical problem — high false negative rates. A modification of Dorfman’s algorithm, known as split-pooled testing, is available and would release nearly fifty percent less infected patients into the population than individual testing and ninety percent less than the utilization of Dorfman’s protocol. In addition, the number of tests required to screen a population of five million patients, using split-pooled testing, would be ten times less than using individual testing and more than two times less than when using the Doorman protocol.5
LONG-TERM SOLUTIONS
Accelerate the move from Volume to Value Reimbursement
One of the best long-term solutions to improve the US healthcare system in the midst of the Global pandemic would be to accelerate the move from a volume-based reimbursement model (FFS) to a model where the delivery of high value, defined as quality per unit of cost, is preferentially reimbursed and the perverse incentives inherent in the FFS model are avoided.
While the movement from volume to value was underway prior to Covid, many organizations and payers were hesitant to move forward in this regard. The Covid Pandemic now seems to be accelerating the move in healthcare financing toward a more rational value-based model — one that rewards quality, to include the appropriate attention to preventive and population health measures along with the efficient allocation of resources within this highly wasteful system.6
CONCLUSION
There are solutions, both short and long term, that can improve the healthcare system’s ability to withstand the extreme challenges of the Covid-19 pandemic. Time, however, is wasting and these solutions should be implemented as quickly as possible to avoid further calamity.
1. Wu K, Smith CR, Lembcke BT, Ferreira TBD. Elective Surgery during the Covid-19 Pandemic. New England Journal of Medicine. 2020;383(18):1787–1790. doi:10.1056/nejmclde2028735
2. Krol J, Long M. Optimizing Patient Flow Advanced Strategies for Managing Variability to Enhance Access, Quality, and Safety. In: Litvak E, ed. 2nd ed. ; 2018:39–67. Accessed August 27, 2020. http://www.jointcommission.org.
3. 8 hospitals postponing elective procedures amid the COVID-19 resurgence. Accessed October 31, 2020. https://www.beckershospitalreview.com/patient-flow/8-hospitals-postponing-elective-procedures-amid-covid-19-resurgence.html?origin=BHRE&utm_source=BHRE&utm_medium=email&oly_enc_id=1094E1345067D3V
4. Cordata: Case Accelerator — Identify Surgery-Ready Patients. Accessed November 16, 2020. https://www.cordatahealth.com/case-accelerator/
5. The Right Kind of Pooled Testing for the Novel Coronavirus: First, Do No Harm. Accessed November 16, 2020. https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2020.305945
6. Coronavirus Pandemic Impacts Value-Based Contracts. Accessed November 16, 2020. https://revcycleintelligence.com/news/coronavirus-pandemic-impacts-value-based-contracts
