Jul
31

COVID update – vaccines, denier death, and prognostications

Lots of news COVID-related this week…

Three vaccines seem to be the most promising; all are entering Phase 3 trials with tens of thousands of test subjects involved.  Moderna and Pfizer look to be the furthest along, with AstraZenica/Oxford University’s vaccine also showing some promise.

Before we pop the champagne, remember…

  • trials are just that – they are used to assess safety, effectiveness (how much protection the vaccine provides) durability (how long the vaccine provides immunity)
  • the history of vaccine development is not exactly encouraging, and
  • once a vaccine is proven, we’ll need tens of millions of needles, syringes, vials, and a delivery system to ensure it all gets to the people who need it most.

There’s another problem with these trials – too few people of color are involved – far too few. That’s really troubling, as Black and Latinx people are suffering much more than Caucasians.

So, keep doing smart stuff until you get vaccinated. Fortunately, more of us are now accepting that masks make a big difference.

The death of former GOP Presidential candidate Herman Cain from coronavirus and the infection of Texas Rep. Louie Gohmert (R) may be changing minds; these two gentlemen dismissed the news about COVID19 and refused to wear masks.

Mr Cain is wearing the red tag.

Meanwhile, I’ve been engaging with NCCI and experts from the Insurance Information Institute in an effort to better understand the financial impact of COVID on workers’ comp. Stay tuned for more; key takeaway so far is that NCCI and III are focused on potential costs of COVID itself; they have not done any work assessing the impact of the sharp decline in claims.

There’s also a lot of talk about how bad COVID may be for profitability, a position I’m still struggling with.

What does this mean for you?

Wear a mask. 


Jul
20

What COVID really costs.

Last week Fair Health released an analysis of charges and payments for COVID-related medical care. Here are the key findings based on data from January through May.

  • Median estimated allowed payment for hospital care was $24,012 for people 51-60 years old
  • HOWEVER – costs varied significantly around the country, especially in the western US
  • 30% of people diagnosed with COVID19 were 51-60
  • However, the average age appears to be dropping by about 15 years
  • 54% of those diagnosed were male, 46% female
  • About 6% of diagnoses were made via telehealth
  • Patients’ past medical conditions weigh heavily on outcomes; the most common comorbidity involved kidney disease.

What does this mean for you?

  1. The median cost of hospital care for COVID patients isn’t that much.
  2. Patients with significant comorbidities will suffer more, require more treatment, and thus incur more costs.
  3. Another study found almost all patients hospitalized for COVID had comorbidities.
  4. While “only” one in 20 diagnoses were made via a telehealth visit, it is highly likely that percentage will (or already has) increase(d).
  5. Remember – this is based on data through the end of May; you can be sure things have evolved since then. For example, a best guess is 10-20% of those diagnosed with COVID end up hospitalized – but that is a guess, and does not account for undiagnosed cases (which may be several times higher than those diagnosed).

 


Jul
17

COVID Quick Hits Vol. 2

Lots of COVID news this week – here’s the latest.

The bad.

One out of every hundred Americans has been infected with COVID19.

Almost one out of every 25 people infected have died.

People of color are far worse off than white folks.

This racial disparity is pretty much everywhere, in every state, although it is particularly bad in Kansas where Black people account for 6% of the population and 22% of deaths; Michigan – 14% of the population, 41% of deaths; and Missouri – 12% and 36%.

Testing here in the US is still waaaaay behind where it should be. Results often take so long they are all but useless.

Hydroxychloroquine is useless. Or worse.

Despite being touted by the President and others who should have known better, more and more research is proving the drug:

Fortunately the FDA revoked its emergency use authorization for the drug; unfortunately idiots with no science background continue to tout it.

I have written extensively about this over the last four months; here’s

The good

We DO know masks really make a difference.

Fast, cheap, and accurate tests are coming – and they can’t get here soon enough. The paper-strip tests will cost less than $5 and give instant results. While that’s still costly, it is a lot less expensive than the current lab-based tests.

Therapeutic medications appear to be helping treat folks who are infected.

Monoclonal antibodies (taken from the blood of those already infected and maybe from mice) appear to help prevent the disease and treat those who get infected.

A study published last week shows anti-viral drug remdesivir was associated with “improved recovery and a 62 percent reduced risk for death compared with standard care.”

Black people did even better as did those not on a ventilator.

The unknown

We do NOT know if or when a vaccine will be developed and produced in sufficient quantity to inoculate enough of us.

If you’re buying into the White House’s happy talk about a vaccine, take a lesson from the Administration’s early cheerleading for hydroxychloroquine – they were completely wrong. Wait for the science, and ignore the politicians.

What does this mean for you?

Science.  It’s all about the science. 

 

 


Jul
15

Hope-driven Hype

There’s a lot of hope – in my house just as in your’s – that we will have a safe, effective and durable COVID19 vaccine in 2020.

Hope is not a strategy, nor should it guide our personal or professional behavior and planning.

Consider this.

Vaccine development

  • the record for the fastest vaccine ever brought to market was 4 years for Merck’s mumps vaccine
  • We’ve been trying unsuccessfully to get an HIV vaccine since the 1980s
  • over the last quarter-century, a total of 7 vaccines for new pathogens have been successfully developed and rolled out globally.
  • From the CEO of Merck, the world’s largest vaccine company:
    There are a lot of examples of vaccines in the past that have stimulated the immune system, but ultimately didn’t confer protection. And unfortunately, there are some cases where it stimulated the immune system and not only it didn’t confer protection, but actually helped the virus invade the cell because it was incomplete in terms of its immunogenic properties. [emphasis added]

Merck CEO Kenneth Frazier

Vaccine delivery

COVID19 is a global pandemic; many countries have no where near the healthcare infrastructure the US has, are conducting far fewer tests, and don’t have the money to pay for expensive treatment or widespread immunization. Right now, even the US is in deep trouble with almost a quarter of the world’s recorded infections and over 130,000 deaths in six months – more than twice the number of Americans that died from opioid overdoses last year…

And;

  • some vaccines require boosters or are a two-shot series;
  • some must be given every year while others convey lifetime protection;
  • some require refrigeration and special handling;
  • this will likely require hundreds of millions of bottles, caps, syringes, needles or other delivery mechanisms;
  • all must be kept sterile until use;

Let us not forget there is a substantial number of people who reject immunizations for reasons of their own.

I’ll balance this with a note that the COVID19 vaccine effort is unprecedented; there are about 160 vaccine efforts now underway. Thousands of brilliant minds are using incredibly powerful computing systems to figure this out. They are using different delivery mechanisms, trying old vaccines, experimenting with RNA-based technology, working to stimulate the immune system all in an effort to stop or blunt the impact of COVID19 infections.

It’s possible we’ll have a proven vaccine proven to be safe, effective, and durable by the end of the year. It’s also unlikely.

Whenever it arrives, make sure you are alive and well enough to be vaccinated.

What does this mean for you?

Until then, wear the mask and don’t do stupid stuff.


Jul
8

Help me understand…

We are in the midst of a national pandemic, where:

Yes, Congress has appropriated funds to help cover the costs of COVID19 treatment, but those funds are likely woefully insufficient – especially now that the infection rate is exploding. Oh, and the Administration notes that its program to reimburse providers for treating uninsured COVID-19 patients is “subject to available funding.”

As hospital costs alone for these patients could be between $13.9 billion to $41.8 billion, that’s a huge caveat.

Into this disaster, the White House and Republicans are seeking to overturn the Affordable Care Act, which would:

  • end Medicaid expansion,
  • allow insurers to deny coverage,
    • based on pre-existing conditions,
    • for adult dependents up to age 26
  • allow insurers to charge whatever they want,
  • and allow insurers to limit payment or refuse coverage for any type of medical care they want.

So, 3 million of us now have been infected with COVID-19. Those unfortunates now have a pre-existing condition, which would – if the ACA is overturned – mean health insurers would be able to reject them and/or raise their premiums as much as the insurers want.

Let’s not forget many of the rest of us also have pre-existing conditions; personally I had cataract surgery years ago and several orthopedic injuries which would subject me to limits on coverage.

What’s even worse is the White House and Republicans have no alternative, no replacement plan, no solution or stopgap.

Nope, they want to blow up the current system and replace it with…nothing.

What does this mean for you?

Nothing good.

 


Jun
30

The long haul

This isn’t going to be “over” for at least a year. Probably longer. Long enough that all of us must focus not on preparing for the end of the pandemic, but adapting to it and accepting that tomorrow will look just like today.

Allow me to make the case.

The only thing that will bring back “normal” life is “vaccinating” all of us. Period. That will happen – either by herd immunity (at least 2/3rds of us get infected and survive, so the virus can’t find enough carriers to keep the pandemic going) or by development, production, and use of a vaccine.

But…”Immunity” isn’t binary – think of it as a continuum rather than an on/off switch. Many vaccines reduce the severity of an illness rather than preventing it entirely. This means that COVID19 may well be with us for a long time, although its impact will be reduced.

Here are the issues. (caveat – there’s much we don’t know for certain, the following is culled from the most credible sources I could locate)

Stopping COVID19’s spread requires enough of us to have immunity that the virus can’t find hosts.  That immunity can come from antibodies created by our immune system reacting to an infection, or a vaccine. Antibodies are blood proteins produced in response to and counteracting a specific antigen – in this case COVID19.

Herd immunity

For myriad reasons, few countries have been able to stop COVID19’s spread. (New Zealand is an outlier, Taiwan and Vietnam have had notable success).  At the other end of the spectrum are Russia, the US and Brazil where the disease continues to spread rapidly.

There’s some research that suggests people who have had relatively mild cases of COVID19 don’t produce a lot of antibodies, thus may be vulnerable to future infections. Other research suggests antibodies may be pretty effective.

Another study found COVID19 patients’ antibody levels remained stable two months post-infection (that was when they were tested, it is possible levels remain high over a longer period).

Eventually, herd immunity will reduce the ability of COVID19 to spread, and likely reduce the severity of the illness – or prevent it entirely – among those who’ve been previously infected

Vaccines

There’s been much wildly optimistic and wholly unrealistic happy talk about a vaccine this fall. Is this possible?

Sure – about as possible that my beloved Chicago White Sox go undefeated and win the World Series.

  • The average development time for vaccines is about ten years. Lots of vaccines take even longer.
  • The fastest vaccine development  – for mumps – took four years (but that was way back in 1967, and we’ve got a lot smarter since then and technology is a gazillion times better) But, humans are still humans, and biology moves at its own pace, so there are inherent limits in the testing process
  • Despite 17 years of effort, we’ve never successfully developed a vaccine for a coronavirus.
  • If we don’t have a vaccine by this time next year, it won’t make much difference as COVID19’s spread will push us closer to herd immunity.
  • Once a vaccine is developed, hundreds of millions of doses and needles must be manufactured and an entire delivery infrastructure implemented. Good news here, the Feds are investing hundreds of millions in manufacturing potential vaccines, the idea being they will be ready to go IF they are found to be effective and safe.

If you want to track vaccine development, this link is pretty useful.

Takeaway

One of my favorite movie quotes is from Shawshank Redemption;  just after he learns his release from prison is not going to happen, Andy tells Red “I guess it comes down to a simple choice…get busy living, or get busy dying.”

Some will rail against the unfairness of it all, accuse others of all manner of sins, pine for the “old days”, and otherwise waste precious time and energy uselessly bemoaning our fate.

Which will keep them imprisoned behind walls of their own making. Others will accept the new reality, not resigning themselves to it but rather adapting, creating, building and eventually thriving.

 


May
19

COVID update – hope for the best, plan for the worst.

I’ve stayed away from most of the COVID stuff because Tom Lynch at WorkersCompInsider has been… as the kids say…crushing it.

Yesterday’s news that Moderna, a new company in Massachusetts reported very early results from tests of a potential vaccine was welcome indeed. The experimental vaccine appeared to help increase resistance** to COVID19 in a handful of people without undue harm.

It was also extremely preliminary.

The trial actually involved 45 people, but the press reports were based on results from 8. That’s less than a fifth of those involved…as one wag put it, “The drug trial sample size seems to be as big as 2 full of people.”

The double asterisk after “resistance” is because the experiment involved taking a blood sample from those 8 people, putting it in petri dishes with the virus, and measuring the antibodies ability to “kill” the virus. That is waaaaaay different from conveying immunity in the human body.

Perhaps coincidentally, the person charged with leading Operation Warp Speed, the White House initiative to develop a vaccine, has 156,000 shares of stock in Moderna, the vaccine research firm in question. And the company had just been awarded almost a half billion dollars in taxpayer money to help fund research.

I get that we are all looking for any hint of good news, and we all desperately hope Moderna’s vaccine:

  • is effective and preventing COVID;
  • is safe for humans;
  • can be manufactured in huge quantities quickly and cheaply.

But vaccine development is full of fits and starts, blind alleys and dead ends, promising early results leading to disappointing failures.

Fewer than one in ten vaccine candidates reach production. Vaccines typically take 10 – 15 years to develop. “And while biotechnology underlying this drug has existed for nearly 30 years, it has never yielded a working vaccine for any human disease” (quote from NatGeo).

Yet we’ve never seen the might of the entire world’s vaccine expertise focused on a single problem, an unprecedented level of effort that – hopefully – will produce an unprecedented result.

Meanwhile, the virus has killed over 90,000 of our friends, parents, neighbors and grandparents so far, while infecting over 1.5 million of us. Thousands more will die, even if the vaccine is everything we hope it is.

People and organizations who focus on what they can control – reducing the risk of infection – will come out of this far better off than those who ignore the risks that remain real and deadly.

What does this mean for you?

Hope for the best and plan for the worst.

 

 

 

 

A useful discussion of how some companies are handling this crisis is here.


Apr
30

COVID catch-up

In  less than 4 months, COVID19 has killed more of us than died in the Vietnam war’s 11 years. Some have stated this is a “great success story.”

Healthcare providers may not see this as such a great success, as COVID is crushing healthcare financials.

Research suggests almost 13 million workers have lost their health insurance due to the repercussions of COVID19. Multiplying that by 2 approximates the total number of employees plus dependents that lost coverage – 26 million.

Many will seek Medicaid coverage, but eligibility varies widely (and wildly) by state. People who don’t have coverage and contract the disease and need facility care should have their bills covered by the Feds – either at Medicare rates or via Medicaid.  Either way, reimbursement is likely half or less what their private insurer would have paid.

Anthem just informed us they expect the percentage of people covered by governmental healthcare plans to increase. The $100 billion+ health insurer saw its financial results for Q1 improve; my guess is the drop in elective procedures was a big factor.

All of this to say that COVID appears to be accelerating a trend towards a public option for health benefits – or perhaps a much bigger role for governmental programs in health insurance.

Hospital financials are getting hammered as elective procedures are way down, and many folks with all kinds of ailments are staying away for fear of coronavirus exposure. (chart from Kaufman Hall)

With receivables drying up to dust, facilities are going to redouble their efforts to collect every nickel they can from everyone they can.

Workers’ comp payers – you are hereby warned.

Willis Towers Watson has been publishing their perspectives on all things COVID19, from the impact on the LGBTQ community to a helpful discussion of paying premiums when cash is tight.

An early piece focused on employers’ considerations re workers’ comp liability for COVID19 claims. One item in particular stuck out – large employers with excess coverage should read their current communicable disease coverage details very carefully.  Friend and colleague Karen Caterino was kind enough to paraphrase for me:

For large employers purchasing excess, a multi-claimant disease incident carries the possibility of creating catastrophic financial loss.  If the transmission of a covered communicable disease is a series of incidents versus a single accident, the difference in retained loss could be significant.  A majority of work comp deductible agreements include a provision stating that the deductible applies per employee for occupational disease.  Some insurers are likely to suggest the statute requires they follow the assumption that occupational disease, by its very nature, is a series of occurrences for multiple claimant losses.

This is especially important for supermarket chains, who by now should know that paid sick leave may be the most effective risk management tool to prevent employee and patron exposure. There are many stories like this one detailing how quick, thoughtful action kept food coming while drastically reducing employee exposure.

NCCI has a helpful compendium of states‘ COVID19-related legislative and regulatory initiatives along with COVID19 FAQs.

And yes, surgical masks are quite effective at reducing viral transmission; thanks to Glenn Pransky MD for tipping me off to this research.

Finally, this is a terrific summary of what we know and don’t about how COVID19 affects the human body. It’s long, very well-written, and perfect for a lunch-time read. Spoiler alert – a lot of treatment these days is based not on extensive research but on what docs think works based on prior experience and communication with other clinicians.

From the physician author:

In the absence of data from randomized, prospective trials, we search for answers on colleagues’ Twitter accounts, in interviews with Chinese or Italian physicians, and in our patients’ charts.

What does this mean for you?

Wear a mask, and physically isolate, because we can’t take much more of this “success.”


Apr
22

COVID19 Update – what we KNOW now

Social distancing works.  Hydroxychloroquine doesn’t. Remdesivir might.  A lot of “tests” may be wrong…Just because you’ve had COVID you may not be immune to future infection.  And COVID19 may lead to long term health problems.

Social distancing works. 

A study showed social distancing significantly reduces infection risk:

estimated that current social distancing measures will reduce the average contact rate among individuals by 38% “Social distancing saves lives but comes at large costs to society due to reduced economic activity… the economic benefits of lives saved substantially outweigh the value of the projected losses to the U.S. economy.”

Hydroxychloroquine and variations thereof are no cure.

It’s becoming increasingly clear that Hydroxychloroquine and its various versions are no COVID19 cure. One study (that has NOT been peer-reviewed) showed more veterans with COVID19 that took the drug died than those that didn’t. Another study found no difference in outcomes for patients that took the drug and those that didn’t. The drug can have deadly side effects. [my March 27 post has a lengthy and citation-filled discussion of the drug and the faulty “research” used to promote it]

Remdesivir

Preliminary data from an analysis of multiple studies shows 2/3rds of patients with severe COVID19 treated with anti-viral drug Remdesivir had “promising” outcomes.

One study in Chicago had positive results as researchers saw “high fevers fall “quite quickly” in remdesivir-treated patients and patients weaning “off ventilators a day after starting therapy.”

This is PRELIMINARY; much work still needs to be done. Additional clinical trials are underway, with one posting results by the end of this month.

Remdesivir is an injectable and to date has only been administered in hospitals.

If you’ve had COVID, are you immune?

We do NOT know. There is no evidence that those who have contracted the disease have immunity from a subsequent infection.  Serology tests look for antibodies in the blood, proteins whose function is to find and kill coronaviruses.

Usually those who have had a disease gain some immunity; that’s the idea behind vaccines. However, there is a report out of China that some patients previously infected tested positive after they were ostensibly “cured”.

There are concerns that tests are inaccurate, that they may show false positives (you aren’t infected but the test results say you are) and false negatives (you are infected, but the test results show you aren’t).

One theory is the antibody tests are hitting on non-COVID19 viruses (like those that cause the common cold) and thus giving false results.

Long term health issues associated with COVID19

There’s growing evidence that people with severe cases of COVID19 may have long-term pulmonary deficits due to compromised lungs.  The most vulnerable are – as you’d expect – older folks, those with pre-existing conditions, and compromised immune systems

A study out of China found about a third of patients that had recovered from severe COVID19 had brain stem issues that manifested as dizziness, headache, seizures and other issues.

Another study found that a fifth of severe COVID19 patients had significant heart issues. Blood clots are also a common problem, one that can be deadly.

PTSD and other mental health problems are also reported – no surprise there.

There have been reports of significant kidney problems, however an earlier study in China found no acute (short term) kidney damage.

What’s clear is we are just starting to grasp the potential long-term health effects of COVID19 – and we will learn a lot more in the coming months.

There is a lot of mis- and dis-information out there, from “cures” to the assertion that 5G towers cause COVID19 to Chinese claims that COVID is a U.S.-caused disease to “evidence” that the virus escaped from a Chinese bio-research lab to ridiculous claims by “scientists’ that all the health problems are caused by an overactive immune system.

This is exactly why one needs to be very careful when reading about drugs, cures, tests, results, and infection rates...almost no one had heard of COVID just 120 days ago, all research is just getting started, and we are all learning as we go. And fear-mongers and charlatans love a crisis and get off on scaring people while they get their 15 minutes of fame.

Oh, and YouTube is NOT a reliable or credible primary source for scientific information.


Apr
16

COVID19 – how does it do its damage?

This week we’re attempting to figure out how much of an impact COVID19 will have on the country in general and workers’ comp in specific. That requires:

  • estimating the number of people infected;
  • determining how deadly it is;
  • assessing our ability to contain it;
  • evaluating other health effects of the disease; and
  • knowing if and where and how much liability will be assigned to workers’ comp.
This last is best left for later; there are obvious implications for workers’ compensation, however until there’s more clarity around the industry’s liability for COVID19 we won’t be able to even guess what that liability ultimately might be. Of note, several states have asserted WC will be presumed responsible for patients working in pubic safety, healthcare, and some retail establishments who become infected with coronavirus.
The work comp COVID19 coverage situation is fluid and evolving rapidly; Nancy Grover’s piece in workerscompensation.com provides excellent insights on the current status of state coverage from knowledgeable professionals and is well worth a read.  I’m sure Nancy and her experts will keep us informed.

Health effects

Big caveat here – as one of the articles cited below notes and as is true for pretty much everything you read about COVID19 (including this post), physicians interviewed “are speculating with much less data than is normally needed to reach solid clinical conclusions.” COVID19 is so new and so little is known that there’s very little credible research. What we’re relying on are ‘reports from the battlefield”, information from the front lines that’s coming in real time, not careful, methodological, rigorous research using controls.

Another caveat, from the LATimes –

Patients with disorders that affect the heart, liver, blood and lungs face a higher risk of becoming very sick with COVID-19 in the first place. That makes it difficult to distinguish COVID-19 after-effects from the problems that made patients vulnerable to begin with — especially so early in the game.

But for now, this is all we have. The faster we collect and assimilate information, the more able we will be to respond quickly and with the right solutions.

Broadly speaking, the physiological effects seem to vary widely between victims; women seem to fend off the virus better then men; and people with pre-existing conditions, especially hypertension, appear to be at particularly high risk. The recovery process, which at first seemed pretty straightforward (lungs get better after intubation) even for those on ventilators, appears to be more complicated and take longer than originally thought.

We are only now seeing indications that COVID19 may have long-term health effects, and its reach extends beyond just the lungs.  From an extensive piece this morning in the Washington Post:

coronavirus kills by inflaming and clogging the tiny air sacs in the lungs…clinicians around the world are seeing evidence that suggests the virus also may be causing heart inflammation, acute kidney disease, neurological malfunction, blood clots, intestinal damage and liver problems.

One study indicated some patients with relatively mild cases appeared to have significant warning signs of long-term health effects – in this instance impaired liver function.  Another study noted cardiac issues post-discharge, and a nephrologist at Yale’s School of Medicine reported that almost half of “the people hospitalized because of covid-19 have blood or protein in their urine, indicating early damage to their kidneys…”

How can this be happening?
The coronavirus attacks by attaching to the ACE2 receptor on cell surfaces. These receptors are on cells in the lungs and other organs as well. From the WaPo:
there is increasing suspicion that it is using the same doorway [ACE2 receptors] to enter other cells. The gastrointestinal tract, for instance, contains 100 times more of these receptors than other parts of the body, and its surface area is enormous.
In particularly bad cases, severe inflammation can occur, causing significant problems throughout the body. This has its own set of challenges as it appears to be driven by a hyper-active immune response. There appear to be some treatment approaches that are having positive results using lessons learned from prior viral outbreaks.
Again, this is so new that many treatments are being developed and tried on the fly as doctors scramble to learn what works and what doesn’t on which kind of patients exhibiting what signs and symptoms.
What does this mean for you?
As awful as this is, the more cases that physicians encounter, the greater the knowledge gained.
With much of our medical establishment and resident brain power focused on COVID19 and caring for its victims, things will improve.