On Tuesday, December 8 HC3 hosted a Transformation Series State of the State conversation focused on cost drivers. Ashish Jha, MD, MPH – Dean of the Brown School of Public Health and Professor of Health Services, Policy and Practice – provided the keynote address on ways to improve the quality and cost of health. Following his presentation, Lynn Hanessian, Chief Strategist at Edelman, moderated a fireside chat.
Ashish K. Jha, M.D., M.P.H., Dean of the School of Public Health and Professor of Health Services, Policy and Practice Brown University School of Public Health
A practicing physician, Ashish K. Jha, M.D., M.P.H., is recognized globally as an expert on pandemic preparedness and response as well as on health policy research and practice. He has led groundbreaking research on Ebola and is now on the frontlines of the COVID-19 response, leading national and international analyses of key issues and advising state and federal policy makers.
Dr. Jha has published more than two hundred original research publications in prestigious journals such as the New England Journal of Medicine and the BMJ and is a frequent contributor to a range of public media. He has extensively researched how to improve the quality and reduce the cost of health care, focusing on the impact of public health policy nationally and around the globe.
On September 1, Dr. Jha started his role as the Dean of the School of Public Health at Brown University. Before that, Dr. Jha was a faculty member at the Harvard T.H. Chan School of Public Health since 2004 and Harvard Medical School since 2005. He was the Faculty Director of the Harvard Global Health Institute from 2014 until September 2020. From 2018 to 2020, he served as the Dean for Global Strategy at the Harvard T.H. Chan School of Public Health. A general internist previously with the West Roxbury VA in Massachusetts, Dr. Jha will continue his practice at the Providence VA Medical Center.
Dr. Jha was born in Pursaulia, Bihar, India in 1970. He moved to Toronto, Canada in 1979 and then to the United States in 1983. In 1992, Dr. Jha graduated Magna Cum Laude from Columbia University with a B.A. in economics. He received his M.D. from Harvard Medical School in 1997 and then trained as a resident in Internal Medicine at the University of California, San Francisco. He returned to Boston to complete his fellowship in General Medicine from Brigham and Women’s Hospital and Harvard Medical School. In 2004, he completed his Master of Public Health degree at the Harvard T.H. Chan School of Public Health. He was elected to the National Academy of Medicine in 2013.
Lynn Hanessian, Chief Strategist, Health, Edelman
Lynn Hanessian is the Chief Strategist for Edelman. In her position, she brings together industry, content, and media expertise to craft campaigns to achieve the business objectives of her clients. Her focus in on health and science engagement initiatives reaching a wide range of audiences. Lynn has a deep background in health, medical, and science strategic positioning and communication working with biotech, pharmaceutical and device companies, health technology companies, health systems, medical societies, and patient advocacy groups. Multi-stakeholder engagements are foundational to her approach to addressing health and science challenges.
With a degree in economics from the University of Chicago, Lynn is persistently focused on improving health outcomes worthy of the extraordinary resources invested in the delivery of health care in the U.S., especially those that can overcome the persistent health disparities affecting many communities.
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Dr. Jha equated the COVID-19 pandemic to a nine-inning baseball game. If we look at an 18-month timeline – January 1, 2020 – June 30, 2021 – Dr. Jha predicts December 2020 and January 2021 are going to be worse than people expect on our current trajectory, whereas April and May could be much improved. There could be a 10-20 percent vaccination rate by the end of February. But right now, we are currently in the bottom of the sixth/beginning the seventh inning: most of the work is behind us, but there is still a lot of work to do and hardships to get through. The biggest issue is the “buckling of the health care system under pressure.”
Most disease outbreaks happen through species jumps from animals to humans, meat consumption is rising, and inevitably more pandemics are likely. Future pandemics will be exacerbated by increased economic growth. The 2003 SARS outbreak was very different than what we are seeing in 2020. Globalization continues to increase the likelihood of pandemics like COVID-19, and this should be a wake-up call. Once this pandemic is over, we cannot go back to business as usual. Dr Jha predicts that we may very well see another pandemic originate from Africa and India due to their extreme economic growth and because both places are susceptible to more disease exchange and spread.
So, how do we think about the health care system in terms of how we can survive future pandemics? The health care sector has been devastated by the pandemic, which is sort of ironic. Instead of bolstering resources, much of the health care providers in the U.S. went into a state of duress. Throughout the pandemic hospitals have been under extreme pressure from loss of elective care. The payment systems in place were not built to survive. However, our health care system, with all of its challenges, has performed admirably during the pandemic in treating patients with COVID-19. Chances of surviving the virus today are 50-70 percent higher than in March.
Global pandemics effect how we view different parts of the health care system and teach about the system’s resiliency. The 1918 pandemic in the U.S. changed the system of care then, and the same thing will and should happen now. As we move forward, there will be demand for higher quality metrics and more affordable care for all Americans. There will also continue to be an increase in mergers because of the financial strain. Medicare-for-all is not likely in the near future, but through a bolstering of the ACA, it is possible for us to see increased access through policy efforts.
Moderated Discussion Lynn Hanessian: How does the political climate affect attitudes about our healthcare system and expanding access to care?
Ashish Jha, MD, MPH: Across the political spectrum, there is a broad coalition of people who believe in expanded access. There is obviously some disagreement about how to make that happen. There will likely be a lot of adjustments to the ACA, such as, subsidies, improved access to navigators and exchanges, and Medicaid expansion. There is no certainty for universal coverage, but definitely hope.
(L) What do you see from a policy perspective around hospital organizations and mergers? What will this look like/what has changed about the role they play in rural communities?
(A) Health care policies have not shifted dramatically between administrations historically, but I expect more leeway around rural health systems and affiliations to come. The Federal Trade Commission (FTC) has been reasonably nonpartisan in health care (bush vs Obama for example). There will be continued scrutiny when there are multiple large health systems in a single geographic area that want to merge. The question is: do they have to merge to fix their issues, or are there other solutions? We should expect the merger movement to really pick up in the next year or two. “There will be a lot more of people getting into other people’s businesses.” Most industry players were happy with the ACA, not entirely but they were not against updates and changes. All players want more insurance, and they should want it. Coverage will continue to be addressed, what we are not sure of is the cost implications.
(L) How have regulatory relaxations for digital health and telehealth played a role in addressing disparities, and how will they change post-pandemic?
(A) 2020 and this pandemic has permanently affected life moving forward. Regarding policies going back to pre-pandemic: pandemics are a one-way path; there is no 2019 in the future. “You can’t put this back in the bottle.” We are not going to go back to pre-pandemic policies because these solutions are working, and people like them. What happened in the digital health space was a long time coming, but it was accelerated by the pandemic. However, there are some limitations. For example, not everyone has access to the technology needed to reach these services. For a lot of people, it doesn’t work well enough, so we have to create new models that are hybrids of in-person and virtual care. Expansion will be vita for under-served communities.
(L) Will we see a bigger environmental change, particularly in individual responsibility (i.e., less meat consumption)?
(A) Meat consumption is growing across the world, especially in other parts of the world like India and China. For example, in China meat is a sign of wealth and prosperity. It is unlikely this will change anytime soon.
(L) What is it going to take to change the minds of the 40 percent of the population who are reluctant to take the vaccine?
(A) The 40 percent who are reluctant to take the vaccine vary in reasons for why they are reluctant. First, we need to get 70-80 percent of the population vaccinated. Second, we need to understand what is making people hesitant and address these reasons. Many people are worried that the vaccine development went too quickly and that we cut corners. We should explain to people that this vaccine has gone through all of the same testing requirements as every other vaccine. We have not cut any corners. It will help a lot when people start seeing many other people around them getting vaccinated, prompting more people to get the vaccine as well. We also need powerful messengers, which means finding trusted voices within communities to become advocates. For anti-vaccine people, I am not optimistic, though we should still try to engage them.
(L) What is the future for outpatient care? Primary care?
(A) Walgreens and CVS are the future of outpatient care models. They will continue to try to break the norms of patients going to their primary care providers. We are likely to see more offerings and services built out with offerings like a sports physical. They are going to try to build out their services and keep expanding into what has traditionally been the primary care space. It is going to be a very dynamic market play. I expect to continue to see more mergers and more payment model reform likely on the primary care side.
(L) A 10 percent reduction in the Medicare Physician Fee Schedules (MPFS) is due to kick-in on January 1. What do you expect to see in access to care, especially in at-risk communities?
(A) The physician community is speaking out and will continue to speak out against this. We will continue to see mobilization around this issue and others like it, because of the balancing act providers need to generate to achieve an optimal payment mix. Truly understanding what the best payer for a provider is difficult. And the end of the day, frontline workers have been out there during the pandemic, so to then cut 10 percent of their possible income is just not going to be good optics.
(L) Will Medicare Advantage and similar programs continue to accelerate?
(A) Medicare advantage has grown a lot in the last 5-10 years. It will continue to grow a lot, because there is nothing out there that will stop it. Medicare Advantage will start to single out and target assistance for those who suffers from food scarcity and other social determinants of health.
(L) Do you think we are now better equipped for something even worse?
(A) There were many failures in our COVID-19 response. Big investments will also continue to be made in testing for COVID-19. Ubiquitous testing will be online by July, in large part due to federal efforts, and there will be a push to cultivate a public health core for contact tracing. Other efforts could include establishing a national guard-like system whereby people who have other jobs but could be called up to help during times of emergency.
We have to be much more equipped for an even worse scenario because the risk is still there. We’re even more worried about viruses that have a 10 percent mortality rate, which could kill millions of Americans, or even a virus that we have never even heard of or seen that would be very difficult to deal with.
(L) Are there key aspects of healthcare policy that can be unified in this polarized political climate?
(A) Middle ground is easier to find in health care. There is typically bipartisan support for health care workers, like doctors and nurses, or hospitals in people’s areas. Doctors and nurses have been targeted unfairly during this pandemic. The broad swath of middle ground folks who want to rebuild the system has even become eroded during the pandemic. However, there is a good amount of people who fall somewhat in the middle who want to rebuild our health care system. There is an opportunity to bring people together, but it will require strong leadership.