Rae Woods:
From Advisory Board, we are bringing you a radio advisory. My name is Rachel Woods. You can call me Rae. As we reach the two year anniversary of the first surge hitting us here in the United States, I want to reflect on just how much COVID-19 has changed the healthcare industry. At the beginning of the pandemic, there were a lot of predictions about the future. You heard them from everyone, frankly you heard them from us. And today I wanted to bring my colleagues together to discuss what we got right, what we got wrong, and some of the most surprising ways that the pandemic has changed healthcare. To do that I've brought a few colleagues. There is a familiar voice, Christopher Kerns, as well as our longtime colleague, Amanda Berra. Welcome to Radio Advisory, Christopher and Amanda.

Christopher Kerns:
It's fun to be a guest again.

Amanda Berra:
Thanks for having me.

Rae Woods:
Amanda, I cannot believe I've waited this long to get you on the podcast. What is the most different for you personally, two years into the pandemic versus where we started in March 2020?

Amanda Berra:
Oh my God. Everything is different. Well, for one thing we moved. So I live somewhere different now.

Rae Woods:
Yeah. You don't live in Washington DC anymore.

Amanda Berra:
No, I don't. We're in Massachusetts now. And also, I mean, everything about work changed. I mean, I used to travel all the time for work. We all did. And now hardly ever.

Rae Woods:
Yeah.

Christopher Kerns:
Your listeners should know that Amanda and I shared an office for three years, which is one of the reasons why it is just such a pleasure to be able to do this podcast with her.

Amanda Berra:
Hey, that's nice.

Rae Woods:
Well, I'm glad I've got you both together. So like Amanda said, the pandemic changed basically everything in our lives, but I do want to try our best to focus specifically on the healthcare industry. And since we're going to be in reflecting mode, I want us to actually go back to the beginning, back to March of 2020. Back then, what were some of the prevailing assumptions about what COVID-19 would do to our industry?

Christopher Kerns:
Well, I think one of the biggest assumptions and one of the biggest fears that we had back in March of 2020 of course, was that we were going to run out of beds and that the goal was to flatten the curve, to make sure that the healthcare system wasn't overwhelmed. We also expected just about every single healthcare purchaser was going to see a major strain on their budget. But the reality is that we had the CARES Act, which really helped with the finances of the situation. And the reality is that we had a lot of excess capacity in the US healthcare system. So very few parts of the country found themselves truly overwhelmed in the way that we saw healthcare systems in other parts of the world, even the developed world.

Rae Woods:
That's right. We didn't actually see kind of the disastrous examples that we were hearing about when it came to the media, especially from a financial perspective. Christopher, in your mind, how much of that actually had to do with the fact that the federal government stepped in, gave a financial boost?

Christopher Kerns:
I think it was absolutely essential. And the main reason for that is if you remember the early days of the pandemic, there wasn't just talk of a healthcare crisis, but a solvency crisis, that we actually could see organizations running out of money because they were prohibited from doing elective surgeries. They were prohibited from doing a lot of the things that actually make providers money and provide them with their essential cashflow. The CARES Act was absolutely essential in addition to the great strides that were made by the banks and the financial institutions to keep the dollars flowing.

Rae Woods:
And I told us that we were going to focus on the healthcare industry, but I do think it's important to remember that we weren't just worried about healthcare businesses. There was a lot of fear about what this pandemic would mean for individual people's finances, right? People lost their jobs, unemployment reached record highs, and there were concern about what that meant for the uninsured. Did we actually see that play out?

Amanda Berra:
No. Hey, I'll swing at that one because I remember in what was it? The end of the year in 2020, we were putting together the like, okay, what were the big outcomes of the pandemic so far and what are all the big changes, the most significant ones? And I remember reading through the list of what we had and thinking, oh, you know what we don't have on here is uninsurance, which surely has been sweeping through the industry, given how much unemployment there was. But surprisingly there wasn't that big wave of uninsurance.

Rae Woods:
That's right.

Amanda Berra:
And I remember thinking like, well, we have to add this on this list then I was like, but we haven't heard anything about it. And so I felt weird about putting it down since no one had been talking about it. And then like a couple days later there was that analysis by the upshot team where they said, actually what's happening is that unemployment and uninsurance are being decoupled in the post ACA world, that many people lost their job, but did not become uninsured.

Rae Woods:
Which is a good thing.

Amanda Berra:
Yeah. Which is a great thing, right. I mean, as a judgment on the ACA the narrative then, thanks to that reporting became about, wow, the ACA's working, like combination of the individual markets picking people up and Medicaid expansion in the expansion states. More recent analysis, Urban Institute just put out something said, actually it wasn't the individual markets as much, like it's not individual plans. It was Medicaid. Those expansion states picked up a ton of enrollment.

Christopher Kerns:
And that's creating the unintended consequence of the PHE cliff, the public health emergency cliff, that during the PHE of course, states were not allowed to kick anyone off of the Medicaid rolls, even if they lost eligibility. As soon as the PHE ends states are going to have that power again. And we're likely to see a big coverage cliff. So it remains to be seen exactly what effect that's going to have over the course of 2022.

Rae Woods:
And I don't want to knock on Advisory Board here, but what you two are pointing out is that even the best of predictions that are rooted in research, that are rooted in good analysis, doesn't always mean that we're actually able to accurately predict the future. And to Amanda's point, we have seen positive impacts of either the pandemic itself or the ripple effects of this pandemic. And it's sometimes hard to remember that when you realize that you've been living through a crisis for two years. So I want to ask you, what are some of the good things that have happened that maybe you wouldn't have expected would've happened two years ago?

Christopher Kerns:
Well, one is that clinical trials are never going to be the same again. One of the things that the pharma companies really embraced was different types of technologies to be able to expand the number of people, the diversity of the population within clinical trials, and just frankly, the speed of the clinical trials that really helped us develop vaccines at a record pace. And I think going forward, we could potentially see lifesaving treatments come to market much faster than we've seen in the past, but that will likely have some adverse consequences for cost. But I think we can all agree that that's been a good thing in terms of great leap forward for clinical trials.

Rae Woods:
Amanda, what's your surprising win from the last two years?

Amanda Berra:
Health systems really turned a corner on issues that have been difficult for them for years. Like for example, how to, if you're like a big multi-hospital system, how to maybe start coming together as a system, right? This is systemness, and we've talked about before.

Rae Woods:
Do you buy that that's still happening? I mean, when I think back to the kind of early, early couple of months, I remember not just systems coming together across a geography, but partners coming together and saying, oh my gosh, we have to fight this thing together.

Amanda Berra:
Oh yeah.

Rae Woods:
But my pessimistic self says that a lot of those partnerships, a lot of those synergies have maybe disappeared.

Amanda Berra:
Well, I'll definitely give you the partnerships. Like I think that in many cases, especially like within a region or like a metropolitan area, there was like a truce called among competitors for example, when the first surge was at its height and people kind of put aside competition to work together. So that I grant you, right? There's no more of that right now. But within health systems, like your typical health system had so many different mini organizations within it forever. And they've always been talking about coming together as an integrated organization. During the pandemic, those efforts really picked up speed. And I mean new seriousness at the board level, among the general management team, because like on a very practical level, they saw things like, hey, if we were able to move staff among our facilities, that would be better.

Rae Woods:
That's right.

Amanda Berra:
And the systems that were able to do that did better. And even the systems that weren't able to do it said, you know what? This has to be an aspiration for us.

Christopher Kerns:
This is one of the reasons why, when we look at the financial performance of hospitals and health systems during the pandemic, the larger systems tended to perform better, but not across the board. It was those health systems that really did embrace the systemness elements that Amanda is talking about that performed much, much better.

Rae Woods:
We'll be right back with more Radio Advisory after this short break. You're doing a good job at kind of pushing my pessimistic thinking and also pointing out that some of the things that have surprised us good or bad aren't necessarily set in stone. Right. We don't necessarily think that we are going to follow at current course and speed on any of the things that have happened in the last two years, systemness being one of them. And that's actually where I want to go next. Are there things that you are watching that you're not sure where the dominoes are going to fall or you're not sure if the trajectory is going to continue, let's say two years from now, like it has today.

Christopher Kerns:
I think the big question going forward is how virtual care will be delivered in the future. At the beginning of the pandemic, of course, tons and tons of primary care and specialty care was delivered virtually. And that hit a peak and it came back down, but it's still well above where it was pre pandemic, especially when you look at behavioral health. The thing that was interesting to us though, was virtual care was not delivered by the big national virtual providers. I mean, it was to a certain extent, but by and large, the vast majority of the digital health that was delivered over the course of the past two years has been by local providers.

Rae Woods:
Christopher, would you ever have guessed that when virtual care would have its big moment, it would've been the local docs, it would've been your primary care physician that would be the one that's delivering it and not a doctor on demand or something that's delivered by the payers.

Christopher Kerns:
No, I never would've thought that because very few organizations had HIPAA compliant platforms to make that happen, but the PHE really allowed them to use non HIPAA compliant platforms. So that allowed them to really do a test case for how digital care could be delivered in a lot of different ways. So I think that's one of the reasons why we were surprised. We didn't expect that flexibility to be given. It was given and now we know that it works.

Rae Woods:
And I think your question now is very interesting, because it's not how much virtual care will be delivered in the future, it's who's going to deliver it. Is it going to stick with the local providers or is it going to go to a tech company or a payer?

Christopher Kerns:
That's right. And the local providers have a lot of built-in advantages. But the reality is that the national digital health providers are closing a lot of those gaps. So it really remains to be seen who's going to win here.

Amanda Berra:
You know what's interesting about this discussion that you guys are having to me is I feel like, there's like a assumption in it that what we're talking about is primary care, right, digital primary care, which is where like a lot of the disrupters are playing. But to me, one of the interesting effects of the pandemic has been because all of a sudden, every possible type of care had to be virtual if possible, when nobody could come in person. Now there's a lot more sophistication in the industry about using digital in all kinds of different clinical services, including the specialty end of the world.

Rae Woods:
That's right.

Amanda Berra:
And more complex care, which is like an interesting design problem for specialists and hospital systems to think about whether and how to weave in digital on the more complex end of the spectrum that I just don't think they were thinking about at all before.

Rae Woods:
Absolutely not. And as we roll the tape forward and think about maybe the next two years, what I want to push our listeners to do is to first of all, accept the fact that the future isn't necessarily set in stone. We wouldn't have guessed that local providers would be delivering virtual care. We wouldn't have expected that specialty providers would've had to deliver virtual care also, but there are some kind of unintended consequences to any of the things that we've been focused on that I want to make sure that our listeners are working to address. Virtual care, reminds me of one of them. And that's that despite all of the good things that have come out of more connective tissue from the digital landscape, is that it's also created a lot more fragmentation.

Christopher Kerns:
Digital health and home based care have created a great deal of fragmentation in the ways in which care can be delivered. And the real question is will these extra choices be a good thing, net-net by looking at the amount of channels that are available to patients? Or will the increased fragmentation cause more challenges down the road, especially for chronically ill patients? So I think it's a really good point that you're making.

Rae Woods:
I mean, if we're talking about surprises, I also wouldn't have thought that behavioral health would be in the spotlight that it is now. And again, that is a good thing, but the downside is what is it going to mean in terms of fragmentation?

Christopher Kerns:
And I think this is something that we really should be watching over the course of this year, because if there's one area that we could potentially see some real bipartisan efforts in major healthcare legislation, it could be potentially around behavioral health and funding mental health. So this is something to watch.

Rae Woods:
Frankly, if I'm honest with myself, the fact that we're talking about disparities in care in any way, whether we're talking about it in the virtual space or in the behavioral health space is surprising in and of itself.

Christopher Kerns:
I mean, think about it for a generation we had defunded behavioral health and now it is the primary focus of potentially major healthcare legislation. That in and of itself is a monumental seat change.

Amanda Berra:
To me when I've been present at conversations among a lot of different kinds of healthcare players, where there's this unanimous ground swell of support for figuring out behavioral health, the thing that really strikes me about it and like why I think it's so bipartisan is that every single human is touched by behavioral health issues, right? It's not just like an abstract kind of like a policy question that you're motivated to solve. Because you're a systems thinker. Everybody has experience themselves or their family members, people they know, the failures of the, kind of lack of solutions in behavioral health. And they've seen how consequential it is. So it's like a very emotional thing for pretty much every individual I know to try to get to solution.

Christopher Kerns:
And the pandemic gave us a test case for what a universal trigger can do. So we've all had the same stimulus to look at what behavioral health needs to be.

Rae Woods:
Christopher, I really like your point about this fact that we all went through the same kind of stress test and from a clinical aspect, we can think of the fact that so many Americans, so many people had to deal with the same medical issue, COVID-19. But we know that outcomes weren't actually the same, despite us all facing the same disease.

Amanda Berra:
I mean, there've always been disparities like health equity problems in healthcare, but they were just so stark coming out of COVID-19, which is tragic. Right. But the fact that they were so obvious has actually spurred changes in the technical kind of like definition of clinical quality and how quality is measured, and reported, and like paid for such that actually clinical quality is about to become a different thing in the near future. All of a sudden the whole industry has woken up to this idea that, if you take those exact same metrics and stratify them by who the patients are, so like race, age, ethnicity, language, gender, and so forth, all of a sudden you're going to see that the fall rate isn't the same at any given hospital for who the patients are, which is obviously unacceptable. And so suddenly you get like Medicare, for example, saying, wow, we could be stratifying all these commonly reported quality metrics by who the patient are. We're going to expose major disparities at the point of care. We're going to make all hospitals do this and then make it a condition of getting paid or a trigger for getting penalized. That means the definition of clinical quality is going to be different than it was before the pandemic. I think that's amazing and positive.

Rae Woods:
We're kind of all over the place. And there's a good reason for that. It's because there have been a lot of really surprising things that have happened in our industry that not enough people are talking about. The fact that the safety net actually worked. The fact that the question around virtual care isn't how much care is being delivered virtually, but who is currently winning in the race to provide digital care to consumers. It's surprising in some ways that we have a real moment to achieve mental health and behavioral health services in mass. It's an open question of whether or not that's going to make disparities better or worse. And to Amanda's point, we're actually at a moment where we might be changing the definition of clinical quality and for good reason. Here's my question back to you. If there are going to be things that continue to surprise us in the future, are there big kind of structural things that you're watching that will tell us what shifts might be coming next?

Christopher Kerns:
Well, the revolutions that you've talked about, whether it's talking about clinical trials, and the impact on drug costs, or the spotlight on outcomes equity and the changes that need to be made to address that, or healthcare resilience in the face of the pandemic, or the need for greater mental health reimbursement and funding. What we're seeing is a new set of priorities across the healthcare delivery system. That's likely going to require some form of legislative push. Exactly what form that's going to take is anyone's guess at this point. But the reality is we know that there is going to have to be some major healthcare legislation just to shore up Medicare. And what I would be watching for is how does Medicare solvency contribute to this perfect storm of new priorities? That's what I'm going to be watching for in the health policy space.

Rae Woods:
And Christopher, we should probably have a separate conversation about exactly what we think health policy is going to do for this industry in the next year.

Christopher Kerns:
Maybe we can even have a new podcast out.

Rae Woods:
All right, let's do it. Amanda, what big things are you watching?

Amanda Berra:
Well, one thing we haven't really talked about has been workforce, which is like amazing because otherwise I feel like every conversation anyone has about healthcare these days, you have to talk about the huge workforce crisis in healthcare. And the fact that, especially at sort of like the nurse level, there just aren't the people in this massive workforce shortage there. I am definitely watching that because I don't know, among health systems, this is not just like a human resources executive type challenge. And it's not just a chief nurse executive type challenge. This is like the strategy executive and the board and the CEO. And like, everybody's thinking about how the organization itself, which translates to the whole delivery system in the United States and beyond, may need to evolve to be something different to continue to function in a workforce constrained environment. Like we're going to need to use technology different. We're going to need to have teams that are designed differently. We're going to need to use roles creatively. Like they're all really thinking out of box.

Rae Woods:
We're going to need to use technology to actually support these people in a real way.

Amanda Berra:
Yeah. I mean, not just, you say labors substitution in like kind of a wonky way and people start getting upset because they think that means that human clinicians are going to get replaced by robots. When really I think, what the real kind of like leadership level discussion is more like, how can we boost everybody to top of license, right? We need to make much more efficient use of the constrained workforce that we have. And that could lead to some amazing things. I mean the healthcare system and working within it can be very clunky. Could that be less clunky? That would be better.

Rae Woods:
So we need to watch what's happening in a policy space. We absolutely need to keep an eye to what's happening with the workforce because that's going to impact our ability to do basically anything. I want to get to my final question for both of you. If the future is still unwritten and frankly, if the future is hard to predict, given the fact that we've had so many surprises, how do you want our listeners to take action? What do you want them to focus on right now?

Christopher Kerns:
Don't take anything for granted. If there are positive benefits to the changes that have come out of the last couple of years, none of them are set in stone.

Rae Woods:
That's right.

Christopher Kerns:
All of the things that we have seen that have positively benefited our industry, whether that is systemness, or the deployment of digital health, or any number of innovations that we've seen come out of the last couple of years, none of those are guaranteed to last. And never underestimate this industry's ability to backslide quite frankly. So if we want to be able to maintain a lot of these innovations into the future, it's going to require stakeholders working together to make sure they become permanent.

Amanda Berra:
Christopher, you know how in many years of working together sometimes like you're the negative half of the coin and I'm the positive half of the coin. I'm going to pick up what you said and just say, same facts, but different interpretation, which is like, this is a moment where everybody's waking up to the fact that you can do things differently. And all of the individual people who are running health systems and working in the healthcare industry are realizing that things don't have to be this way, right, meaning the way that they've been before.

Amanda Berra:
So I actually think this is a moment when some of the changes that have gotten an initial step are definitely going to continue. Like for example, the changing definition of clinical quality, nobody's going to put that genie back in the bottle. It's more an opportunity to like take it as far as it can go. Like, let's see what we can do when we think creatively. I mean, healthcare, people who work in healthcare, especially in the clinical jobs have been kind of beaten down by this. It's inspirational to think about, all the things you could do in a sort of like an innovation way to build a better system in the future.

Christopher Kerns:
It's like that moment in Wizard of Oz when the door opens and everything's in color.

Amanda Berra:
Yeah.

Rae Woods:
If that's not an action step, I don't know what is.

Amanda Berra:
You open the door and everything's in color. That's the action step.

Rae Woods:
Well, thanks for coming on Radio Advisory.

Christopher Kerns:
This was fun, Rae. Thanks for having us.

Amanda Berra:
Thanks for inviting us.

Rae Woods:
Amanda and Christopher are right. Because we can't always accurately predict the future, it means that people like you, our listeners have the power to shape what happens next. In fact, I believe that the decisions that you make this year might even be more important than the decisions that you made way back in March of 2020. And frankly, I'm looking forward to seeing the ways that you surprise us in the coming months and the coming years. And remember as always, we're here to help.