This article is part of a series on what the healthcare industry looks like one year after the novel coronavirus was declared a pandemic and life in the United States began to drastically change.
As the editor-in-chief of Health Affairs, Alan Weil has had a front-row seat to the latest in research and thoughts from key public policy experts throughout the COVID-19 pandemic.
The importance of science, collecting data and communicating all of this information to the public has never been more evident, as the country and world scrambled to learn as much about the novel coronavirus as quickly as possible.
Weil has been editor-in-chief of Health Affairs since June 2014. Prior to that, he was executive director of the National Academy for State Health Policy and has served on numerous health organizations, including the Medicaid and CHIP Payment and Access Commission, the Aspen Institute's Health Strategy Group, the Kaiser Commission on Medicaid and the Uninsured and the board of directors of the Essential Hospitals Institute.
Weil spoke with Healthcare Dive about the role of equity in health research, the staying power of telemedicine and how to effectively communicate important public health messages.
This interview has been lightly edited for clarity and brevity.
HEALTHCARE DIVE: What was the moment for you, when you realized many lives are going to change from this disease?
ALAN WEIL: Our March issue last year was on the 10th anniversary of the Affordable Care Act. We had a big event planned, an in-person event at the National Press Club. And each day as it got closer we asked ourselves, 'Are we doing this?'. And we finally concluded we shouldn't, which of course given all the lead-in, we were so disappointed.
In retrospect, it was obviously the right decision, but at the time it was a hard decision because the spread was very unknown. We didn't actually think there was that much out there, of course, now we know there's a lot more than that. You know, we could have been a superspreader event.
You mentioned that March issue. It makes me wonder, has there been some kind of research, news or anything else you feel has been overshadowed by the pandemic?
WEIL: This isn't a story, but I would say, we were very much along the path of payment reform, value-based payment, learning what works, learning that a lot — even if it works — doesn't make a huge difference, so trying to recalibrate those programs and tighten them up. And many of them have continued, but the lessons are now, in some sense, lost or frozen in time, because most of them are built on sort of a fee-for-service chassis. And when that world stops functioning, you don't have a comparison.
So you think about savings — well, savings relative to what? When the number of office visits drops by 50% and then slowly recovers, when elective surgeries just come to a screeching halt and you say, 'Well, is this intervention having any effect'. Compared to what? There's no comparison. And given how much hope — I don't share all that hope — but I think given how much hope so much of the healthcare sector puts into these value models, that loss is more than a one-year setback. Because you don't literally have to start over. But, you can't just pick back up.
What are the major lessons learned for the industry so far from this?
WEIL: The telehealth story, I think, has to be at the top of the list. The short lesson is things that you thought were impossible, now you can do them in a week. We make excuses to be resistant to change. And when you throw the excuses out the window, you can change pretty fast. Now that's not a universal truth but, I think that's an important observation. I do think that there are still reasons to have long-term skepticism about how much of that shift will remain. But, I still think you have to start there.
Certainly on the financing side, now there are all these people talking about the benefits of capitation because it would assure cash flow even when visits stop. Before this, everyone is talking about the downsides of providers taking risk. It's, 'Oh, we can't take risk.' Because it was always seen as capitation is taking risk, and fee-for-service is the steady state. Well, we just learned that fee-for-service isn't steady state, and capitation can actually be more stable than fee-for-service. Well, that's a mind-bender. That just changes how you think. Now, again, will we circle back to the old way of thinking? Sure we will. But it sure created a discontinuity in thinking about what these different models mean.
And then — these terms kind of drive me crazy — but the increasing emphasis on social determinants and social factors. We've now seen that play out with COVID itself, with everything else in healthcare increasingly. The intertwined nature of social issues and health issues, I don't think there's any going back with respect to the health sector realizing that if they're just sitting there treating diseases that have their origins in the rest of people's lives, that's just not a long-term, viable way for the health sector to work.
When it comes to telehealth, what do you think is going to be a more permanent change?
WEIL: I think the convenience. For a subset of patients and a subset of providers the notion that, 'Wow, this really works' — I think that will stick. We've published papers on disparities in utilization. So I think we have to remember that this is not equally helpful for all people. It's obviously not equally useful across all types of healthcare. But I think the sense that, if it can be done remotely, that might be the default or the preferred option. I do think that will remain for a lot of people.
For the challenges, we've published over the years a number of papers showing that telemedicine is not a cost saver. I think a lot of people think of it as, well you don't have the cost of the office, but the evidence is actually not so clear. And, there are a lot of follow-up visits from telemedicine visits. And that increased accessibility — which is a good thing — also means people use a visit when they might not need a visit. And so, there are all these downstream implications of the growth that I don't think we fully know.
It's one thing when telehealth is the only option, but when it's one of two, if you could do this or you could do that, then I think it's more complicated.
In terms of health equity, what about healthcare research, what does that community need to do to improve?
WEIL: Oh man, that's like a whole hour-long conversation.
We're trying to start that journey, where we're trying to look at data and methods to be sure that we're not excluding important knowledge just because it comes from research traditions or data sources that we're not as familiar with. It's very commonplace in a quantitative analysis to sort of throw race and ethnicity in as an explanatory variable in a regression, without really thinking about why it's there or what it represents. And I think we're going to see people saying, 'Wait a minute, controlling for race' — which is the statistical term — 'we need to disentangle what that really means and how doing that affects our understanding of results.'
Certainly this is not new, but just like in clinical trials, you get a report that shows the average effect — this medication improves survival rates by a year. Well, that's an average. Some people may have five years, some may have zero effect. And I think we're increasingly understanding that those averages can mask systematic differences between different populations. And so if you're just looking at the averages, you're missing who does this work for and who does it not work for, who does it help and who does it harm.
Paying more attention to the distribution of results and not just the average level of results, I think that's going to become increasingly important.
What about Health Affairs, specifically? Have you looked back at whom you publish, for example?
WEIL: Yeah, we're undertaking a whole initiative in this area. We've never collected data on our authors, with respect to their race, ethnicity, gender, disability — we've just never done those things. And in fact there are lots of questions about how to collect it and from whom to collect it and what are you doing with it and should people feel comfortable giving us that information. But, you can't solve a problem that you don't know the scale of, so I think whatever those limitations are, we're still going to just need to move forward, as well as we can.
One of the first priorities of the new equity director that I've hired is, we need to go to particularly academic institutions that don't tend to publish with us and that are doing really important work and try to understand why. The fact is, if you're a graduate student at Harvard, in one of the health policy programs, you have a faculty mentor who's published with us, you are working with data that we've published before, you're using methods that we publish. And you may even have grant support to write a paper for us. And all those things line up and you get in Health Affairs, and that's terrific. You could be doing just as good work at an organization where you don't have the mentor, you're not using datasets we're familiar with, you certainly don't have the institutional support to write a paper. And we would just never even know of your work. And that's on us. So we're going to try to break that apart a little bit and try to understand better what those barriers are.
What have we learned about how best to communicate public health messages to people as the pandemic continues?
WEIL: The first thing I think we've learned is that it's very hard to unscramble the omelet. For those who have been told for an extended period that this isn't really a problem, that it's no worse than the flu — pick your framing — it's very hard to change those views because they've been repeated, those messages have been told over and over.
I think we're having some sophistication, which I really appreciate, with the term vaccine hesitancy. It has sort of been, some people look down their nose at people and say, 'What's wrong with you?'. And it comes a lot out of discredited science around autism. I think now, there's a greater appreciation that people's hesitation is rational and appropriate, and that you're not going to convince people to overcome that hesitation by telling them that they're wrong or stupid. You're going to listen to what their concerns are and try to help them through those. I think that's really positive. That's a positive development in healthcare in general.
The phrase that physicians use of a non-compliant patient, it's just very belittling of the person and it suggests that their reasons for behaving the way they are are wrong and my reasons for wanting you to behave a different way are right. And from a public health perspective, that just is not a recipe for success. So I think we're getting a little more sophisticated.
Obviously time isn't helpful in the sense that, the sooner people are vaccinated, the better. But time is helpful in that people will, just like in the early days of COVID there were large numbers of people who didn't know anyone who'd had it, so it was easy to imagine it was a hoax or not very serious because, if it were so serious, I would know someone — I think increasingly people are all going to know people who've been vaccinated, and they're fine. And they didn't become deathly ill and the pain of the immunization passed in a couple of days.
So I think that will be helpful. But I do think the first lesson is the key one, which is that it's very hard to reverse the degree to which a large number of people have been told that this is not really what it is.