Archive for the ‘health care’ Category

More About The Moderna Vaccine Results

Friday, May 22nd, 2020

Scientists and Wall Street analysts are now beginning to peal the onion of Moderna’s announcement about its Phase One Trial results in which it reported its vaccine candidate had produced antibodies in eight of the study’s 45 participants. Following the announcement, Moderna’s shares rose nearly 30%. A profitable day, indeed.

On Tuesday, I wrote it was way too early to get excited based on this teeny tiny study. Since then, it’s nice to see that Evercore ISI’s Umer Raffat, an analyist Institutional Investor called a Rising Star of Wall Street Research, has added context and perspective. Early Tuesday, Raffat sent a 78-page slide deck to his clients explaining why, while possibly encouraging, Moderna’s announcement  and Monday conference call should not give anyone a serious sense of hope until a lot more work is done and a lot more is known about this particular Phase One Trial.

Getting into the science weeds, Raffat focused his analysis on antibodies and T-Cells.

First, the antibodies. Raffat thinks the most impressive thing about Moderna’s data release concerns “binding” antibodies. These are antibodies that attach to SARS-CoV-2, the virus that causes COVID-19. The concern with Moderna’s announcement is that what’s really important for an effective vaccine is its ability to generate “neutralizing” antibodies that actually prevent the virus from infecting healthy cells, and Moderna provided no information about neutralizing antibodies except to say its neutralizing antibodies “were at or above convalescent serum” collected from people who recovered from COVID-19. Studies have shown that people who have recovered from COVID-19 can generate a wide range of neutralizing-antibodies in their convalescent serum. So, it is unclear just how comparable Moderna’s convalescent serum samples were to samples taken from the trial participants.

The FDA will have to determine what level of neutralizing antibodies are required for an approved vaccine. The Agency has already said that when convalescent serum is used to treat COVID-19 patients the neutralizing antibodies should be high, whatever that means.

Another issue with Moderna’s mRNA-1273 vaccine rests with T-Cells. The level of T-Cell generation is an indicator of the degree to which the immune system is attacking COVID-19. Moderna’s announcement and subsequent call did not address this. Some researchers have shown that a high level of T-Cell generation, even without high levels of neutralizing antibodies, have been found in people who have recovered from COVID-19, leading to speculation that T-Cell generation may be very important for any successful vaccine. However, when asked about this during the conference call, Moderna’s Chief Medical Officer, Tal Zaks, M.D., Ph.D., said  “You would expect that based on the fundamental scientific principles of how an mRNA vaccine works because it teaches the body’s own cells to make the protein from within the cell.”

One last point – The study participants numbered 45. Eight produced binding antibodies. Only four were sampled for neutralizing antibodies. Four.

As I wrote earlier this week, Moderna has made it to the one yard line. Ninety-nine to go.

 

 

COVID-19: Two Updates

Tuesday, May 19th, 2020

Who pays?

The last question asked in our question-filled Post of 13 May was the same as the first question asked, namely: Who’s the guy at the end of the line left holding the bill for COVID-19 workers’ compensation claim costs?

Right now, as we have written here, each state is addressing this in its own way; fifty different plans for one national crisis.Thus far, workers’ compensation is the pot out of which, in one way or another, claims are addressed. Employers do not like this.

Employers of essential workers haven’t wanted to scream too loudly about being the last in line guy, what with so many of their  workers falling ill, even dying, every day. That kind of crass insensitivity would be bad for business. But inwardly, they have to be nervous about getting stuck with the check, the cost of which, as we have documented here, could be enormous.

Employers have already taken a high hard one to the side of the head with the complete and utter devastation COVID-19 has done to their economic well being, and the requirement to pay the workers’ compensation claims which are going to avalanche over the top of them is something with which they strongly disagree. For what it’s worth, I think they have a point.

Back at the state capitals, I would venture, governors don’t really care where the money comes from, just as long as it’s not coming out of their state treasuries.

And throughout history, insurers have resisted paying for occupational disease claims. Witness the 20-year fight to avoid paying the costs of pneumoconiosis, which resulted in the Federal Coal Mine Health and Safety Act of 1969, amended four years later by the Black Lung benefits Act, which created the Black Lung Disability Trust Fund.

So, if the states don’t pay and if insurers don’t pay and if employers don’t pay, who is left?

Brothers and sisters, the federal government is left, which is another way of saying we are left. We will all share the risk and share the costs. If you cannot bring yourself to believe that, you haven’t been paying attention.

In fact, a model exists: The September 11th Victim Compensation Fund, which:

…provides compensation to individuals (or a personal representative of a deceased individual) who were present at the World Trade Center or the surrounding New York City exposure zone; the Pentagon crash site; and the Shanksville, Pennsylvania crash site, at some point between September 11, 2001, and May 30, 2002, and who have since been diagnosed with a 9/11-related illness.  The VCF is not limited to first responders.  Compensation is also available to those who worked or volunteered in construction, clean-up, and debris removal; as well as people who lived, worked, or went to school in the exposure zone.

The wheels are already in motion. Last week, a bipartisan group in the House unveiled the Pandemic Heroes Compensation Act, a plan to compensate essential workers who fall sick or die from COVID-19. The Act is modeled on the September 11th Victim Compensation Act.

Senate democrats are also proposing legislation. Like everything else in D.C. these days, the road from here to eventual victim compensation will be tortuous, but I cannot see any other way of paying for this national catastrophe other than with a national program. Can you?

The Moderna results

For a number of years, I chaired the Board of a BIOTECH pre-clinical Contract Research Organization (CRO). We took compounds, whose makers hoped would become the next blockbuster drugs, and tested them in mice, rats, guinea pigs, rabbits, pigs and non-human primates (that’s right, monkeys). In the biotech business, everyone knows everyone else, and we certainly knew a lot of scientists trying to develop vaccines.

Yesterday, the Boston pharmaceutical company Moderna reported a vaccine it was developing for COVID-19 produced antibodies in humans. In vaccine development, this is the beginning of a Phase One trial, and its purpose is to confirm the vaccine is not toxic. Moderna’s Phase One trial is composed of 45 participants, eight of whom  Moderna says produced the antibodies. We know nothing of the other 37.

While encouraging, you won’t find respected scientists getting too excited yet. They know what Moderna has done is to take the ball out of the end zone and reach the one yard line. Nintey-nine to go.

Two things are exciting, however. First, Moderna was able to get to this point at light speed. What Moderna did in about 70 days usually takes three to four years. That is over the moon fast, but the other ninety-nine yards are going to be increasingly more arduous. Second, there are more than 100 other groups around the world, both pharmaceutical and academic, who are also going hell bent for leather to develop the vaccine that will eradicate COVID-19. Although I have every confidence one of these groups, maybe Moderna,  will cross the goal line at the other end of the field, it will take a miracle on the order of the Raising of Lazarus for this to happen before mid to late 2021.

Until then: Constant vigilance. Complacency will kill you. Really. Please keep this in mind as all the beaches and parks open this coming Memorial Day weekend. It will be highly tempting to revert to former form.

 

How Are States Handling Workers’ Compensation During COVID-19?

Monday, May 11th, 2020

Last week we wrote about Governor Gavin Newsom’s Executive Order implementing a workers’ compensation rebuttable presumption for all essential workers who contract COVID-19 in California.

To review, a rebuttable presumption means an essential worker who contracts COVID-19 does not have to prove work-relatedness. The burden is on the employer to prove the disease was not caused by work.

Writing that other states have also taken action, I noted those actions varied widely across the country. But the monumentality of COVID-19 requires more on this topic. Just what are other states doing? Specifically.

Thirty-nine have either done nothing or have legislation pending. That is, they have taken no action via Executive Order, as Newsom did, or have yet to enact legislation. The District of Columbia is also in this group. Neither, have any of these states declared COVID-19 an occupational disease, although it obviously can be one.

The other 12 states have taken the following actions:

Akaska: On 9 April, Alaska Governor Mike Dunleavy signed legislation declaring a rebuttable presumption for first responders and other health care workers.

Arkansas: On 21 April Governor Asa Hutchinson issued an Executive Order creating a rebuttable presumption for first responders, other health care workers and National Guard personnel assigned to COVID-19 duties.

Florida: The state published a Memorandum saying first responders and health care workers “would be eligible for workers’ compensation benefits under Florida law.” Given the torment COVID-19 is causing throughout society, this is pretty wimpy, don’t you think?

Illinois: On 16 April, Governor J. B. Pritzker issued an Executive Order declaring a rebuttable presumption for first responders and other health care workers. Then, under intense pressure from the business and insurance communities, Pritzker, whose family owns the Hyatt hotel chain, rescinded the order. Obviously, a stand-up guy. So, I guess you could say Illinois now belongs in the camp of the other 38 states that have done nothing.

Kentucky: On 9 April, Governor Andy Beshear issued an Executive Order similar to Newsom’s, creating a rebuttable presumption for all essential workers who contract COVID-19. The business community isn’t happy, but, unlike Pritzker, Beshear has not changed his position.

Michigan: On 30 March, the Workers’ Disability Compensation Agency declared an Emergency Rule creating a rebuttable presumption for all First Response Employees, a term, as Michigan defines it, that includes just about everyone in health care.

Minnesota: On 7 April, Governor Tim Walz signed legislation establishing a rebuttable presumption for first responders, health care workers, correctional officers and child care workers.

Missouri: The Department of Labor and Industrial Relations issued an emergency rule, effective 22 April, declaring a rebuttable presumption for first responders, but, not, perplexingly, for other health care workers exposed to COVID-19. First responders are defined as “a law enforcement officer, firefighter or an emergency medical technician (EMT).”

New Mexico: On 23 April Governor Michelle Lujan Grisham issued an Executive Order creating a rebuttable presumption for state-employed first responders and volunteers to the health care system fighting the disease. Private sector employees are not covered.

North Dakota: On 25 March, Governor Doug Burgum issued an Executive Order creating a rebuttable presumption for all first responders and health care workers. On 16 April, he issued another one to cover funeral directors.

Utah: On 22 April, enacted legislation creating a rebuttable presumption for all first responders.

Washington: On 5 March, Governor Jay Inslee issued an Executive Order  creating a rebuttable presumption for first responders and other health care workers. The order also applies if the workers are merely quarantined.

The majority of states not listed here have some kind of legislation filed awaiting legislative action. But as anyone who has ever wandered the halls of a state capital watching the sausage being made knows, it doesn’t mean a thing until the Governor in the corner office signs it.

Time is wasting.

 

Pandemics: Are We Smart Enough To Learn From Them?

Friday, May 8th, 2020

“As the world becomes more of a global village, infectious disease could by natural transmission become more threatening in the United States. Here monitoring is lax because of a mistaken belief that the threat of infectious disease has been almost wiped out by antibiotics.” American Medical Association conference on infectious disease, 2001, from Norman F. Cantor, In the wake of the plague, 2001, Harper Collins.

Pandemics and the Roman Empire: From glory to gory

History’s first pandemic, the Antonine Plague, struck in AD 165 at the height of the Roman empire, the time Edward Gibbon described as when “the condition of the human race was most happy and prosperous.” Nobody knew, but the Roman Climate Optimum (RCO) was approaching its end. The RCO was an extremely propitious climatological period (BC 400 – AD 250) that allowed the empire to keep all its ~70 million people well fed and relatively healthy, which led to the development of the greatest army the world had ever seen, and would not see again for more than a thousand years. The Antonine Plague, named for the family of Emperor Pius Antoninus, killed at least seven million of the empire’s people, more than 10% of the population.

The greatest physician of the age was Galen (born AD 129). He treated and cured a number of distinguished Romans and extensively documented the spread of the disease in his masterpiece, The Method of Medicine. He said, “Hippocrates showed the path; I made it passable.” Galen didn’t know what caused the Antonine Plague, but he did know that it spread quickly in densely packed pockets of humanity and less quickly when people stayed away from each other.

The Roman Empire survived the Antonine Plague, its imperial fibers frayed, but not broken. The empire recovered its strength. Relative good health returned. Until AD 249, that is, when the Plague of Cyprian ambushed the empire. The Plague, named for the Christian Bishop from Carthage whose writings document the event, was probably smallpox. The Plague of Cyprian lasted 20 years and, at its height, killed about 5,000 people per day in Rome.

Once again, the empire recovered, but now it was weaker with reduced resources. Moreover, the RCO was steadily ending and climate was beginning to turn unfavorable. Egypt, the empire’s breadbasket, began to experience drought, something that had never happened during the RCO. This time, the empire dissolved into anarchy and saw the emergence of the “barracks emperors,” who righted the ship of state once more – for a time. But now, disease was always just over the horizon.

In AD 378, the Roman army suffered its worst defeat ever at Adrianople where 20,000 soldiers were killed, a terrible loss of life, but tiny compared to plague deaths. In 410, the Visigoths sacked the city, the first time an enemy army had ever been inside the the Roman walls. Rome was heading inexorably toward its ruin.

In AD 541, the Justinian Plague landed the knockout punch for the Roman Empire. This greatest of pandemics, until then, anyway, was the pandemic of yersinia pestis, the agent that causes bubonic plague, and it lingered off and on for 200 years. That was when Rome descended into a high-end, Byzantine rump state, its former glory a distant memory. Roman records show the city inhabited by one million people during the time of Marcus Aurelius in AD 165, now housed about 20,000. The world would not see another million person city until London at the end of the 17th century.

Where did all the disease come from? Until the Antonine Plague, Rome had never been struck on such a grand scale. Today, experts believe it hitched a ride with people who travelled more and more in a vast empire. For example, the Justinian Plague is thought to have originated in China, making its way to Rome through trade. Just like today.

The Romans didn’t have the scientifically designed medical therapies to combat infectious disease. But even then mitigation efforts were aimed at running from the disease, creating separation, wherever it manifested. For example, in AD 452 Attila the Hun was plundering all of Italy on his way to Rome, whose soldiers were powerless against him. But then, confounding the Romans, he stopped, decamped and headed for the high ground of the Alps. Why? To get away from the anopheles mosquito. Malaria was suddenly killing his men and his horses. Which proves germs were better at killing than soldiers.

The Black Death of the Middle Ages

In the 14th century, bubonic plague (and probably anthrax, too) struck again causing the greatest pandemic the world has ever seen. The population of England was reduced by ~50% and did not recover until about 1800.

At that time, Edward III, King of England, Wales and one-third of France, was poised to add Spain to his conquests by marrying his 15-year-old daughter, Princess Joan, to Spain’s Prince Pedro. The marriage would change the face of Europe and give Edward control over most of the continent. The year was 1348, and bubonic plague struck as Joan and her large entourage were crossing the channel. They landed at Bordeaux, where the plague was suddenly and viciously cutting down the population leaving bodies stacked in the streets. The stench was terrible. People dealt with it by walking around covering their noses with handkerchiefs drenched in perfume. The 14th century’s version of face masks.

The welcoming committee advised the Princess and her party to get far away from the plague. But the English thought they knew better and settled into Chateau de l’Ombriere, overlooking the Mediterranean and dead smack in the middle of the disease. Within weeks, they were all dead except for one English minister who brought the news back to Edward.

And so the bite of a flea altered the course of history.

The Spanish Flu of 1918/1919

And in the early 20th century we were visited by the Spanish Flu, which carried off 50 million souls worldwide. We told the story of the Spanish Flu here, early in our waltz with COVID-19.

Americans then did what Americans are doing now: they kept apart, stayed home to avoid contact, and wore masks when they moved around in society. At least most of them did, just as most are doing now.

Those Americans had to wait 20 years for a vaccine that only 40% of us now take, and thousands still die every year from the flu.

Conclusion

You may say, “Why is this history, interesting though it may be, even being mentioned? Here in 2020, we’re 2,000 years removed from ancient Rome; 650 years from the death of Princess Joan, and the Spanish Flu was 100 years ago. Why bring this stuff up now?” After all, the combination of more energy, more food, sanitary reform, germ theory, antibiotics and all around jet-propelled science have led to a population boom unlike anything else in the history of the planet. People are living longer and better. So, why look to ancient history in the midst of COVID-19?

Social distancing is nothing new. Throughout history, when societies were confronted with infectious disease on a grand scale, people tried to evacuate the area. Some of them could, most could not. They had no knowledge of the value of hand washing, and hand shaking was as common then as it is now, or at least as it was ten weeks ago, so disease transmittal was rampant.

But beyond all that, although blind luck and more than a little mismanagement contributed to the decline and fall of Rome, infectious disease and climatological degradation were the driving forces. And the Romans were blindsided by both. In the Black Death period, aristocratic hubris and tremendous poverty throughout the population’s underbelly led to death on a massive scale. During the Spanish Flu, many in the U.S. ignored warnings and directives to be “socially distant.” Many chose not to mask in public. Many protested government edicts to contain the spread of the disease. And many died.

Here, during COVID-19, we’ve had:

  • Gross mismanagement from the top, as well as in some of the states;
  • Aristocratic hubris on a massive scale;
  • Profound economic inequality and, consequently, disease in large sections of our urban communities; and,
  • Misguided protesters who endanger themselves and others as they gather together clamoring for the freedom to do just that.

Science and our seeming societal sophistication have led many of us, too many, to believe we actually can plant cut flowers and watch our garden grow.

In the words of that great American philosopher, Pogo, “We have met the enemy, and he is us.”

More COVID-19 Quick Takes

Thursday, May 7th, 2020

Workers’ compensation and the disease

COVID-19 is presenting some interesting and perplexing issues for workers’ compensation. Among them are:

  1. Claims adjusters and Nurse Case Managers are far more familiar with injury claims than disease claims. Occupational disease claims are fuzzy, and work-relatedness is often difficult to determine. A broken arm on the shop floor is ever so much more cut and dried. Yesterday, Governor Gavin Newsom made this moot for California by signing an Executive Order that will make it easier for essential workers who contract COVID-19 to obtain workers’ compensations benefits. His order is in effect for 60 days and is retroactive to 19 March. Note Bene – his order establishes a rebuttable presumption and covers all workers deemed essential during the crisis; e.g., grocery workers, among others, as well as first responders and all health care workers. A rebuttable presumption means an essential worker who contracts COVID-19 does not have to prove work-relatedness. The burden is on the employer to prove the disease could not have been caused by work. California is one of a number of states that have taken action addressing workers’ compensation coverage for essential workers.
  2. But not all states have taken action in the same way. In fact, approaches vary considerably. Two issues treated differently among the states are: first, whether to establish a rebuttable presumption as described above; and, second, just who is essential. Some states say that while a number of occupations have been determined to be “essential” during COVID-19 (see Grocery Workers, above), only first responders and health care workers are essential enough to qualify for workers’ compensation if they come down with the disease. Labor unions say this is an issue of fairness, but since when has workers’ compensation been equally fair in all states? Consider loss of function awards, which vary tremendously across the nation.
  3. NCCI has jumped into the COVID 19 what if debate and projected various loss cost scenarios for the workers’ compensation insurance industry. All scenarios show increased losses, and some of the them are downright grim. In the worst case, 50% of all workers are infected and 60% of all claims are paid, in which case losses increase $81.5 billion, or 250% more than current total loss costs. Ouch! In the best case NCCI presents, there is no rebuttable presumption, only first responders and health care workers are eligible for workers’ compensation benefits, only 5% of them become infected, and only 60% of the claims are paid, which results in an increase in loss costs of $2 billion. The best case scenario is is not going to happen. See 1, above.
  4. And what about the poor employers and insurers who are going to foot the bill? Specifically, what about experience modification? One can almost say COVID-19 comes under the heading: An Act Of God. But the claims are going to be paid, so how does a confused insurer account for that in  the premium it’s going to drop on the head of John Q. Employer with a loud and painful thud?

Update on Long Term Care Facilities

I’ve addressed LTCFs here, here  and here, pointing out that there is no coordinated national reporting of LTCF COVID-19 cases or deaths. “One would think this cries out for federal data tracking conducted in a consistent manner across the nation.” Doesn’t seem to have happened yet.

The logical entity to track this is the Centers for Disease Control and Prevention (CDC), and maybe it is. But, then again, maybe it isn’t, because it won’t say. Yesterday, two Senate Democrats — Ron Wyden of Oregon and Bob Casey of Pennsylvania — called on the Trump administration to close this gap and commit to a timeline to release the information.

“There have been no signs that the Trump administration has an effective plan to address the tragedy that is taking place in America’s nursing homes,” they said in a joint statement.

It’s logical to assume that a disproportionate number of deaths would occur in LTCFs. The vulnerable elderly, many, perhaps most, with a number of comorbid underlying conditions, are packed together and present a breeding ground for the virus. Early on, this should have been apparent to the CDC. Why its talented scientists didn’t dive into this from Day 1 is beyond me.

We’ll continue to follow this.

Are We Learning From History, Or Repeating It?

Throughout history, infectious diseases have crippled societies. They have stymied progress and, in the best cases delayed, in the worst reversed, economic development and prosperity.

How have societies handled infectious disease pandemics throughout history, and are our actions in the midst of COVID-19 any better?

It’s true that our science puts us a quantum leap ahead of historical societies in terms of searching for therapies and a vaccine. Oh, the vaccine will happen, but between now and then are we dealing with our current infectious disease problem better than our ancestors?

Actually, no. Societies have long known that when a killing disease strikes on a grand scale the best thing to do is stay far away from other people. Quite literally, head for the hills. Trouble was, that wasn’t always possible due to urban densities and economic privation. Today, densely packed areas, especially cities, are the immediate hot spots, the poor and African Americans are disproportionately infected, and our mitigation efforts are the same as time immemorial.

Tomorrow, we’ll take a look at the history of pandemics, their societal effects and how we can learn from them as we move through and, we fervently hope, leave behind the scourge of COVID-19.

 

 

Direct Care Workers: Health Care’s Essential Underbelly

Wednesday, April 29th, 2020

First, an update

Yesterday, we wrote about Long Term Care Facilities (LTCF) and the sad COVID-19 experience of Massachusetts’ nursing homes. As of this morning, 303 of the Commonwealth’s 386 nursing homes have had at least 2 cases, for a total of 10,031 cases statewide. Fifty-six percent, or 1,632, of all the Commonwealth’s COVID-19 deaths have happened to nursing home residents or staff.

Governor Charley Baker is a former CEO of Harvard Pilgrim health Care, one of the Commonwealth’s leading HMO  health care plans. So, it’s a given that Baker knows health care. But, even with that background, he, like all our governors, has been living through the tortures of Tantalus as they attempt to work with the administration in all things COVID-19.

Today, the governor announced he’s sending $130 million to help nursing homes deal with the crisis. He’s also enlisting 120 nurses to respond lickety split to nursing home emergencies. Moreover, his administration will be auditing LTCFs for compliance with new care criteria including mandatory testing of staff and residents, a 28 point infectious disease checklist, and PPE requirements. This is all good, but one hopes reality is not that this particular horse has escaped the barn and is now grazing four pastures over.

And what about those caregivers?

They call it “Direct Care.” The care that Certified Nursing Assistants (CNAs), home health aides, and personal care attendants provide America’s elderly and disabled. You’ll find them in nursing homes, residential care homes, hospitals, and plain, ordinary, everyday homes, the kind you and I live in. And they are essential workers.

All told, there are more than 1.3 million of them in the U.S., and the Bureau of Labor Statistics (BLS) projects the direct care industry will grow more than any other over the next decade, with a compound annual growth rate of 4.0. And they are essential workers.

They are also the least compensated workers, by far, in the health care sector. Here’s a graph from the BLS to illustrate the point:

The direct care workers are the pink dots. The isolated pink dot on the lower right refers to Certified Nurse Assistants. According to the Paraprofessional Health Institute (PHI):

The median hourly wage for home care workers in the U.S. is $10.49—a wage that, when adjusted for inflation, has remained virtually stagnant for the last 10 years. In turn, the median annual income for home care workers, most of whom work part-time or only during part of the year, is $13,800.[1]

Twenty-three percent of direct care workers live below the federal poverty line (FPL), as opposed to 7% of the rest of the population (which is abominable in its own right). Some of them might be caring for your parents or grandparents right now. Yes, they are essential workers.

Fifty-two percent of home care workers and 39 percent of nursing assistants rely on some form of public support, such as food and nutrition aid, Medicaid, or cash assistance. Moreover, because of low pay and irregular hours, it’s difficult for direct care workers to qualify or pay for employer-based or individual health coverage. Neither can they afford to stop working during COVID-19. They need the money, such as it is – and they are essential workers.

And what about direct care workers who are immigrants? Researchers from Harvard Medical School studied this in their June 2019 paper, “Care for America’s Elderly and Disabled People Relies on Immigrant Labor.” 

They wrote:

Using nationally representative data, we found that in 2017 immigrants accounted for 18.2 percent of health care workers and 23.5 percent of formal and nonformal long-term care sector workers. More than one-quarter (27.5 percent) of direct care workers and 30.3 percent of nursing home housekeeping and maintenance workers were immigrants. Although legal noncitizen immigrants accounted for 5.2 percent of the US population, they made up 9.0 percent of direct care workers. Naturalized citizens, 6.8 percent of the US population, accounted for 13.9 percent of direct care workers. In light of the current and projected shortage of health care and direct care workers, our finding that immigrants fill a disproportionate share of such jobs suggests that policies curtailing immigration will likely compromise the availability of care for elderly and disabled Americans. (emphasis added)

Nearly 15% percent (14.9%) of the foreign born workforce are college graduates, compared with 8.4% of the native born direct care workforce.

Many foreign born direct care workers are in the country with Temporary Protected Status (TPS), a status provided to nationals of certain countries, ten of them, experiencing problems that make it difficult or unsafe for their nationals to be deported there. In 2018, The Trump administration attempted to terminate the Temporary Protected Status for workers from a number of the designated countries, but courts have enjoined that for now. Nonetheless, that can’t be doing the workers’ mental health much good at the moment. And they are essential workers.

Nobody’s attacking direct care workers during COVID-19. They wouldn’t dare. After all, they are essential workers. But, if we ever get out of this healthcare fiasco, I don’t think it’s a wild stretch of the imagination to think if Donald Trump continues his  fervent anti-immigration polemic direct care workers will be marginalized even more than they already are.

They deserve better. They are essential.

 

The Long Term Care Industry: The Ice Under The COVID 19 Waterline

Tuesday, April 28th, 2020

A sneak attack no one saw coming

The nation has come to realize that Long-Term Care Facilities (LTCF) are the number one breeding ground for COVID 19. To date, the best guess is that about 30% of all deaths from the disease happen in the LTCF world. But, as USA Today discovered when its journalists tried to quantify actual numbers, no one knows for sure. The absence of any coordinated, centralized, and focused effort (by the CDC, perhaps?) to track this data is another in a long list of unfortunate and tragic failures we can lay at the doorstep of 1600 Pennsylvania Avenue.

Some states, for example, Indiana, (where 31% of all COVID 19 deaths have occurred in LTCFs,) and Massachusetts (56%), have begun to try to gather the relevant data and publish it on their COVID 19 dashboards. However, most states have yet to take this step. Massachusetts has gone so far as to list the total of the COVID 19 cases in each of the state’s LTCFs by name – the list runs to five pages, 60 facilities per page.

The story of one such facility in Massachusetts is particularly sad. The Soldiers’ Home in Holyoke labels itself as “a state-funded, fully accredited health care facility that offers veterans quality health care, hospice care, including full-time residential accommodations, an on-site dental clinic, Veterans (sic) assistance center, and a multi-service outpatient department.” The Soldiers Home has always been held in high esteem for its excellent and compassionate care of military veterans. It has been one of God’s finer waiting rooms.

But in late March COVID 19 struck, and it struck hard. Here’s how the Boston Globe described it today:

In late March, when the first resident of the Soldiers’ Home in Holyoke died from the coronavirus, 226 residents lived at the elder care facility. Just over a month later, nearly 30 percent of them have died in one of the nation’s deadliest outbreaks, and another 83 have tested positive.

With 67 deaths linked to the coronavirus, the facility has a greater reported death toll than any other nursing home in New England, New York or New Jersey, or the long-term care facility in Kirkland, Wash., the initial epicenter of the US outbreak, according to a Globe review of cases.

The impact of this disease will be with us for a long time. The wounds to the nation’s physical and mental health will not heal anytime soon. As we flatten the Coronavirus curve, it is tempting to conclude we are at the beginning of the end. Nothing could be further from the truth. This is merely the beginning of the end of the beginning.

Tomorrow, a look at the least compensated people in our healthcare system, the myriad essential workers who care for the nation’s elderly and disabled.

Still More Covid 19 Quick Takes

Monday, April 27th, 2020

The age problem

“You know you’re getting old when you stoop to tie your shoelaces and wonder what else you could do while you’re down there.” ― George Burns

Question: When will elderly people, say over the age of 70, dare to venture out of their present tightly-wrapped cocoons and back into general society?

Answer: I will go out on a very fat limb and suggest not anytime soon.

Today marks the 118th day since 31 December 2019, the day the World Health Organization (WHO) reported the first case of a “pneumonia of unknown cause” in Wuhan, China. It’s the 47th day since 11 March 2020, the day the WHO officially declared the newly named COVID 19 a pandemic. And it’s the 53rd day since 5 March 2020, the day the Workers’ Compensation Research Institute (WCRI) convened its annual conference in Boston.

John Ruser, WCRI’s President and CEO opened the conference by advising everyone to avoid shaking hands; elbow bumps were the order of the day, but social distancing was non-existent, about two feet was typical.

I mention the WCRI’s just-before-the-deluge conference because of one chart shown during it. This chart:

WCRI’s injury database shows about 40% of injured workers over the age of 60 have two or more comorbidities, which increase inexorably with age. Sort of like the way those of us who still have it have been watching the steady growth of the stuff on top of our heads over the last five or six weeks. My hair hasn’t been this long since 1980.

I thought of that chart this morning as I was beginning my new daily routine: studying various COVID 19 dashboards (more about that below). I was struck by two charts from the Commonwealth of Massachusetts that put the problem the elderly now face into stark relief. Here they are:

Massachusetts is not unique; COVID 19 does not respect state boundaries. One realizes this as one attempts to quantify the disease’s impact in the nation’s 15,600 nursing homes housing 1.4 million elderly and disabled people. A difficult task, as USA Today discovered when its journalists tried to investigated the issue (article dated 13 April):

At least 2,300 long-term care facilities in 37 states have reported positive cases of COVID-19, according to data USA TODAY obtained from state agencies. More than 3,000 residents have died.

The numbers eclipse those previously disclosed by the Centers for Disease Control and Prevention (CDC), which in late March estimated that 400 facilities had reported cases of the virus. But the new totals still represent an incomplete accounting due to the ongoing lack of widespread testing for the virus and inconsistent record-keeping from state to state. On the federal level, neither the CDC nor the Centers for Medicare and Medicaid Services is tracking the number of U.S. nursing homes with COVID-19 cases, or the number of total cases and fatalities in those facilities.

In Massachusetts, 56% of COVID 19 deaths have occurred in long-term care facilities. One would think this cries out for federal data tracking conducted in a consistent manner across the nation. One would think.

About those dashboards

Where are you getting your information on the daily spread of COVID 19? Where do you think most Americans are getting theirs? Could the answer be Twitter? Or Facebook? How about the daily White House Coronavirus Task Force briefings (Randy Rainbow beautifully summed up last Thursday’s, which was highly controversial and chock full of more than ordinary mediocrity)?

If you’re thinking of the CDC’s dashboard, you’ll find the data in a few places, not all in one, easy to navigate spot. For example, go here; or here; or here. You get the point. A lot of information, but you really have to dig.

There are national dashboards, which are organized well and highly informative. Two that I recommend are the Coronavirus Resource Center at Johns Hopkins University and the New York Times’s Coronavirus in the U.S.: Latest Map and Case Count. Updated frequently, at least daily, each is excellent. The Johns Hopkins dashboard is global in scope; the Time’s focuses on the U.S.

The Massachusetts dashboard is the best state-maintained dashboard I’ve found. Disclosure: I live in Massachusetts. However, the dashboard is truly exceptional. Take a look. Scroll through it. I think you’ll agree this should be a model for all others.

Where one gets information about COVID 19 matters, because of all the disinformation and outright lies being thrown up against the wall every day. Some of it will always stick, and this is too serious for that. The more we know about this disease, the more we ought to realize how much we really don’t know. Ignorance is not bliss. Benjamin Franklin said, “It is in the religion of ignorance that tyranny begins.”

 

The Sad Saga Of The Masks

Wednesday, April 22nd, 2020

face masks

Michael Einhorn is CEO of Dealmed, a medical supply importer and distributor for the New York, New Jersey, Connecticut Tri-State area, the hottest COVID 19 spot in the U.S (so far).

Although Dealmed buys gowns, gloves and other medical supplies from manufacturers around the world, it gets all its masks from China. Prior to the COVID 19 pandemic, Einhorn would buy medical masks for about $.50 apiece. He would then, at a cost of around $15,000, or $.05 per mask, put 300,000, or so, of them on a container ship, which would reach the U.S. a couple of weeks later, whereupon, under contract, he would sell them for between $.70 and $.80 per mask, garnering a tidy, volume driven profit.

At the beginning of January, Einhorn’s world turned upside down thanks to an unfortunate series of events.

  1. On 8 January, the CDC announced “a pneumonia of unknown cause” was spreading in Wuhan, China. This greatly alarmed Einhorn. “It was then I knew that something shocking was happening”;
  2. On 25 January, the Chinese new Year, the Year of the Rat, began. Lasting 23 days, this is the major vacation period for Chinese workers. Think Paris is August;
  3. Wuhan is the “world capital” of medical mask manufacturing. All of Dealmed’s masks come from three companies within one hour’s drive of Wuhan;
  4. On 23 January, China issued the Wuhan (Hubei province) lockdown, which lasted 76 days until 8 April; and,
  5. The Chinese government allowed mask-manufacturing to begin again in early March, but all masks stayed in China to fight its own COVID 19.

Meanwhile, back on the home front, the COVID 19 tsunami was washing over America.

  • In early January, U. S. intelligence agencies began warning the Trump Administration that China wasn’t being honest about the scale of the crisis.
  • On 10 January, former Trump Homeland Security Advisor Tom Bossert urged action on COVID-19, saying,“We face a global health threat…a new kind of coronavirus.”
  • On 21 January,  The CDC’s Nancy Messonnier said in a congressional briefing that more cases were expected in the United States.”This is an evolving situation and again, we do expect additional cases in the United States”
  • On 28 January, former FDA Administrator Scott Gottlieb and Luciana Borio penned an op-ed in the Wall Street Journal offering a 4-point plan to prepare for COVID-19.
  • And on 29 January, both the New York Times and The Atlantic published articles detailing the woeful shortage of masks in the U.S., and reporting, in the words of the Times, “the hoarding has begun.”

Two decades ago more than 90% of America’s masks for the healthcare community were made in the USA. But then, China entered the game. China with significantly lower manufacturing costs. The result: Now U.S. firms make only 5% of the masks we need. China has cornered the market.

So, in early January, when the fecal matter impacted the whirring instrument, Michael Einhorn was catapulted overnight into a new wild west style universe where everyone in the health care community all over the world was competing with each other for a finite number of masks.

Eventually, his Chinese manufacturers were willing to once again make his masks, but at greatly elevated prices. A mask that used to cost him $.50 was now $2.00, or more. Because of the urgent need, he could no longer use container ships; they took too long. Enter Air Freight. At first, “We were paying $40,000 to $60,000 for cargoes that were one-fourth what we’d put on container ships,” he says. “Then, the cargo planes were in such short supply that the cost went to $80,000 to $90,000.” Consequently, his total costs are now in the $3.50 to $6.00 range for masks, which he sells to his health care clients for about $5.00, which is more than six times higher than pre-COVID 19.

If you didn’t know any better, you’d think Einhorn is price gouging, but he’s not. The Chinese manufacturers and the air freight companies on the other hand….

People, this did not have to happen. Our federal government, yes, the Trump administration, should have seized control of this supply chain fiasco from the beginning and put in place a comprehensive and coordinated program to secure and distribute the essential medical equipment the nation was going to need during COVID 19.

If the Trump administration had done that governors would not have to compete with each other, hospitals would not have to compete with each other, and no one would have to compete with the federal government for a single mask.

And maybe, just maybe, a lot of health care heroes who have given their lives saving others would still be with us.

 

At The Heart Of COVID 19: Fear

Thursday, April 16th, 2020

 

“One fear creates a dereliction, which brings a greater fear, and there comes a point where the fear is too great and the human spirit just gives up…” – Wolf Hall, by Hilary Mantel.

“We have to remember the enemy is the virus. Not one another.” – Michigan Gov. Gretchen Whitmer.

The protests are ramping up. Over the last two days groups demanding governors reopen state economies have gathered to protest stay at home orders.

Protesters in Michigan, Kentucky, Ohio, Utah, North Carolina and Virginia have made their presence felt and voices heard. Timed to coincide with governors’ daily press briefings on COCVID 19, to varying degrees of success they tried to drown out the gubernatorial updates.

By far, the largest protest was yesterday in Lansing, Michigan where, for five miles, thousands of vehicles blocked traffic going into or out of the city. They also blocked all traffic heading to Sparrow Hospital, which meant hospital workers were denied access to the most important jobs in the nation: Treating COVID 19 victims. And, to make a bad situation worse, many, perhaps most, of the protesters were unmasked, standing around as if they’d never heard the term, “social distance.”

Here’s a pretty alarming photo from Ohio:

And this from Michigan:

Yes, those really are automatic weapons in the hands of angry protesters. People, this is a bad combination.

What in the name of Galen is going on here?

How about fear and insecurity?

When I was a commander in Vietnam, training, and lots of it, kept my unit alive. We trained for everything imaginable, and when bad things happened, we were scared, but prepared. Running toward danger is not an intuitive response. Training takes over in those situations. Here, in the midst of COVID 19, no one has any training, and that includes most of the health care workers on the front lines fighting this entirely new disease. Everyone is making it up as they go along, and our health care workers…excuse me, our health care heroes… are learning new things every day aimed at keeping people alive.

Americans have no training or experience to guide them through the stay at home period, however long it turns out to be. And so, they fearfully worry. About themselves, their kids, their parents and grandparents, and their jobs. Many of those jobs could be gone forever, and this scares them to their core. That, along with the open-ended nature of the stay at home orders, leads to fearing the worst.

People are looking for something to believe in, some hope, someone to blame, so, when right wing rabble rousers stoke their fears…

Defusing this growing powder keg starts at the top. The nation’s governors, with some notable exceptions, have stepped up and are doing all they can to keep their citizens alive. They have to, because Donald Trump and his administration have performed so poorly during the crisis. It is unfortunate, indeed, that the president cannot help himself from fanning the flames of his base. Yesterday’s protests were replete with Trump and MAGA hats, as well as, ironically, protesters calling the stay at home orders “tyranny.”

The protests without social distancing or masks are going to result in more infections and deaths. That is a terrible thing. And so unnecessary.