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COVID-19 Updates with Dr. David Shulkin

March 23, 2020

In response to the COVID-19 pandemic, our team will be interviewing experts from across the ecosystem to bring the HLTH community timely facts and updates. 

HLTH Team: What are your short and long term projections on how COVID-19 will progress in the United States?

Dr. David Shulkin: That’s a good question because we are really operating without complete data. The fact that we did not have testing available on a widespread scale and still are not seeing testing accessible to large numbers of patients who are exhibiting symptoms means that we don’t have complete data about the level of community spread. It looks like in terms of the reporting that we are on track with what is more like the European experience, maybe specifically the Italian experience, where we are seeing the doubling of cases every three to four days and that would indicate that we are looking at a peak incidences in the United States in approximately 10-12 weeks and a number that looks like a total cases of about 250,000 and that would be assuming that our containment practice such as social distancing and hygiene and quarantining where necessary in geographic locations are effective. If there is not evidence of effective reduction in the incidence of new cases through our efforts in social isolation, we could see a far more aggressive epidemiologic curve than that. It is my feeling right now, with incomplete data, that we are probably looking much more at the scenario I described earlier.  

HLTH Team: What do you feel is the biggest misconception out there right now concerning the virus, perhaps in the media?

Dr. David Shulkin: I think the media is doing a good job of trying to report on data that is credible and accurate. I think the internet and the rumor mill and social media in general too often is  creating false information that is out there. 

The number one misconception is that people that are asymptomatic are not likely to be spreading the virus or carrying the virus. Number two that young people are protected against the virus. I think we need to take a look at what is happening in Italy and France and see that that is no longer the case. I think even in the United States experience so far we are seeing people under the age of 60 with severe hospitalizations and very extreme demonstration of the impact of this disease. People on respirators, people requiring life support who are far younger than what people had previously thought. 

HLTH Team: In your opinion, what have been the biggest missteps by the Federal Government in their response so far? 

Dr. David Shulkin: To me I think that every day that there wasn’t and continues not to be very aggressive preparedness and planning is a missed opportunity that will end up extending both the impact and the consequences of this virus. When there became evidence of a serious outbreak in China in mid-December there was a lot of time that was lost between then and when it started to be taken seriously as an emergency in the US. There was a misconception at the top of our government that this was something that could be stopped by stopping airline travel between countries. They felt that this was an international problem, not a US problem and that reflected a lack of understanding on how these pandemics occur and that infectious agents in these modern ages really have no boundaries. We could have jumped on this a lot earlier than we did. The fact that we were not prepared for diagnostic testing I think we will turn out to be the single biggest misstep. A country like South Korea that is far smaller in population than us has tested close to 300,000 people and we’re probably closer to 30,000 tests having been done at this point really shows that other countries were really more prepared on the diagnostic front. 

HLTH Team: Where do you feel the Federal Government has succeeded in handling this outbreak? What appropriate steps have been taken?

Dr. David Shulkin: While I think the federal government may have had a slow start, I do believe we are now dealing with this as a top priority. They are bringing in help from the private sector, coordinating with our local and state governments, they are moving aside regulations that have been barriers to getting people the type of treatment that they need, in particular with telehealth. Government is also looking into waving barriers to vaccine development and antiviral therapies. I believe that the government is now communicating in a credible fashion and doing many of the things that need to be done so I do give them credit for that. However, it just took longer for us than I would have liked to have gotten here. 

HLTH Team: You mentioned telehealth and this plays into the next question - how can we close the gap in inequities to receiving care? Please touch on how we can provide assistance to people who are underinsured or who have no insurance, and assistance to people in more rural or remote areas with not as many hospitals or clinics around. 

Dr. David Shulkin: Addressing inequities and disparities is essential. The recent bill that went through the house and senate and that the president signed does have an important component on that with making testing available without charge and I think that’s a good first step but it’s not at all clear how you would get the test without having to also get charged for a facility fee from a hospital, a physician fee, some of the ancillary testing that would go along with it such as chest x-rays, lab equipment, etc. so I do believe that financial access to care is still going to be a barrier for people seeking the right type of healthcare that’s needed. The bill that passed was not nearly as comprehensive as I think it is needed to to eliminate those disparities. 

The telehealth regulations that were waved will be helpful. The fact that providers are not able to wave medicare copays and cost shares is a very important step and I’m glad to see that. We are also seeing some commercial payers waving all costs for telehealth. But, if you do not have insurance and you do not already have access, as 30 millions Americans do not, it is not clear how you would access telehealth at this point. And for many people who do have insurance, it’s not clear to them how they would access telehealth. So while I think that while we’re moving aggressively and doing the right things, again more time would have helped to prepare for this. It’s pretty common sense that in an infectious pandemic, we do not want people rushing to doctors' offices and emergency rooms in hospitals, you want them to get testing where they can remain self-quarantined or isolated. 

HLTH Team: And do you think this is resulting in people not getting tested or not taking the appropriate steps who are showing symptoms because they fear receiving a bill afterwards? 

Dr. David Shulkin: I do not think that people that should be getting medical care are getting the type they need right now and this could be for a number of reasons. 

I think first people are fearful about leaving their homes and going to a setting where they may get exposed to other people that have COVID-19. 

Secondly, the cost aspect is considerable. People do not know what type of liabilities they may occur by going to seek medical help at a time where they have great uncertainties about their own personal economics. People having either been laid off or furloughed, or their businesses no longer viable during this crisis, I think everyone is very concerned about their own personal economics. 

Third, people simply don’t know where to go. A lot of people are now calling their doctors, and their doctors themselves have closed their offices. Hospitals are telling people not to come in unless they are very, very ill. I’m certainly familiar with patients who have had high fevers and coughs who have gone to seek care and have been told that they are not sick enough to get a test and have been sent away without any real instructions other than if you get much sicker, then come back to us. So unfortunately, we’re in the point where there are so many barriers to people seeking the right type of healthcare resources. 

HLTH Team: So switching gears a little bit, bridging on your experience at the VA, what steps do you think we can take to better protect our elderly, more vulnerable populations?

Dr. David Shulkin: I believe that our elderly and medically vulnerable populations are certainly at the greatest risk and if you take a look at how many of our senior citizens are cared for, they are cared for in long-term care facilities, nursing homes and institutional settings. And those people tend to be extremely vulnerable to an infectious outbreak, because there is often more than one patient in a room.  Staff go between patients often with hands on contact in many situations. So, ideally we'd like to find a way to begin to start social distancing many of our most vulnerable patients that is going to mean doing things that in the past we just never thought of. For example, taking advantage of empty hotel rooms. The President mentioned today that there was an offer to use empty cruise ships which each have individual rooms on those. And I think that we are going to need to begin to protect our senior citizens and those that are vulnerable in ways like that where we can help get them out of group settings and certainly out of shared rooms and provide the type of social distancing that may be necessary. Now that is logistically extremely complex, it is also very costly, and I certainly hope that this doesn’t become necessary on a wide scale, but as we saw in washington state where there were many deaths in one senior citizen housing facility, they did obtain a local hotel to be able to get people out of that environment and so just like we are planning our hospitals for surge capacity, i believe all of these facilities need to be having plans to act upon and implement quickly should they be required to do so.

HLTH Team: And for seniors that are self-isolating at home, by themselves in some situations, how do you think the industry could address isolation, loneliness, maybe some mental health issues stemming from this crisis?

Dr. David Shulkin: I do believe that the long-term unintended consequences of social isolation and preventing people from doing their normal daily activities will ultimately end up having greater negative consequences than actually the virus itself. What we do know from past pandemics is that social isolation is associated with increased anxiety, depression, and in past pandemics we've seen up to 30% of those who have been isolated experiencing symptoms of post traumatic stress. And those tend to last for quite long periods of time. So whatever we can do to recognize that we’re asking literally hundreds of millions of Americans to change what they've been doing, and restrict their activities, we should anticipate that without intensive social contact, and trying to retain as normal a life as possible, that we will see these consequences. So I think simple things like reaching out to people that you know that are isolated on the phone or on video. Encouraging social contact on the media and other technologies to keep people engaged. Getting out where you can safely exercise and to walk, being able to engage with tech communities where social distancing is safe. I think all these are things that are important and I also believe that innovation and invention is often done at times where it's needed the most. We're going to find new ways to connect with other people that frankly haven't been necessary in the past. Americans and people around the world are beginning to learn that their life is different and there will be ways of adapting to that new circumstance that I believe will be helpful to all of us.

HLTH Team: What do you think they could do to contribute to the solution? 

Dr. David Shulkin: There are a couple of things that come to mind. 

First is a general recognition that this type of infectious pandemic has no boundaries. So the artificial limits that we even posed upon ourselves in the healthcare segment. The differences between payers and providers, the separate systems that we have for physical health and mental health, the payment barriers that have been created, that create inequities in healthcare, the cultural differences have divided us, even the political difference that has divided us, the democrats and republicans. All of that now is really meaningless. We’re all in this together. We need to break down those artificial barriers and begin thinking about ourselves as a connected ecosystem where we begin to reach out beyond our comfort zones and offer help. The pharmaceutical industry which traditionally has been somewhat separate from the provider side, they're going to need to be an integral part of these solutions. Our supply chain manufacturers , our PROVIDER organizations, and you're beginning to see these types of barriers break down not only in congress but also in the community where people are pulling together. 

Secondly, I think its the job of a healthcare leader, no matter what segment of the industry you’re in to prepare for the worst, hope for the best, but prepare for the worst. I think our healthcare leaders around the country that I am in touch with are doing amazing jobs with that. They are doing things they have never done before, they’re clearing out their cafeterias, they're converting cafeterias to make room for additional bed capacity.They are changing their operating rooms into ICUs. they are identifying space outside in local businesses and potentially hotels if they need to be able to use them. They’re cross training their staff. They're using equipment particularly those that protect their employees in ways that it wasn't necessarily intended, but they're required at this point because of the shortages that we’re seeing. And they’re challenging their own rigid rules to see where they can make greater flexibility so that staff and patients have quick access and the flexibility that will be required in the time that we may see just a massive on-slaught of resources required. 

I think, finally, it’s important as a leader to show moral leadership and being very visible during these times of crisis, reminding people why almost all of us chose to go into healthcare. The professionalism that I see day in and day out when I work with people in healthcare settings that they’re there to help people, and they really are the heroes on the front line when they’re showing up risking their own health and that of their family by being there to help others. I think that's incredible. So I think showing recognition, showing gratitude. Reminding people that they are working under very difficult circumstances. What we know from past pandemics, up to 35-50% of healthcare workers will not be able to work or do not show up for work because they themselves are sick, or they are caring for somebody at home, or they are too fearful to come in to expose themselves to that type of risk. So, for the 50% or 60% that do remain, they are going to be under incredible stress with not only less staff but greater demands on them. And they have to be supported, and you can support them in many ways, making sure that they don't have to worry about transportation, to and from home. Making sure that they have food available for them and their families, so they don't have to worry about being in lines at supermarkets. Making sure that they do have the right type of protective equipment so that they feel the most confident about their own safety. And Making sure that they are supported and thanked for what they’re doing. Times of crisis are when leadership matters the most, so leaders can do things that frankly other people in the organization may think about, but they’re not empowered to do. So this is really where we're gonna see the real outstanding leaders step up to this type of crisis and get us through this.

About David Shulkin:

The Honorable Dr. David J. Shulkin was the ninth Secretary of the US Department of Veterans Affairs. Nominated by President Trump to serve in his Cabinet, Secretary Shulkin was confirmed by the US Senate by a vote of 100-0. Secretary Shulkin previously served as Under Secretary for Health having been appointed by President Obama and confirmed unanimously by the US Senate. Prior to coming to VA, Secretary Shulkin was a widely respected healthcare executive having served as chief executive of leading hospitals and health systems including Beth Israel in New York City and Morristown Medical Center in Northern NJ. Secretary Shulkin has also held numerous physician leadership roles including the Chief Medical Officer of the University of Pennsylvania Health System, the Hospital of the University of Pennsylvania, Temple University Hospital, and the Medical College of Pennsylvania Hospital. Secretary Shulkin has held academic positions including the Chairman of Medicine and Vice Dean at Drexel University School of Medicine. As an entrepreneur, Secretary Shulkin founded and served as the Chairman and CEO of DoctorQuality one of the first consumer orientated sources of information for quality and safety in healthcare. Secretary Shulkin is the University of Pennsylvania Leonard Davis Institute Distinguished Health Policy Fellow. He is board-certified internist. He received his medical degree from the Medical College of Pennsylvania, his internship at Yale University School of Medicine, and a residency and Fellowship in General Medicine at the University of Pittsburgh Presbyterian Medical Center. He received advanced training in outcomes research and economics as a Robert Wood Johnson Foundation Clinical Scholar at the University of Pennsylvania.