Category: Research

May
15

It’s the facility costs, folks.

Posted by Joe Paduda on Friday, May 15th, 2020 | Comments

Hospitals are drowning in red ink. In many states, workers’ comp is the lifeline.

Privately-insured patients are avoiding hospitals while those facilities have spent huge dollars to buy PPE, make modifications, and ensure they are ready for a COVID19 patient influx.

Kaufman Hall provides the graph; the blue curve shows hospital profits pre-COVID, the yellow line reflects COVID. The “0” vertical line is the breakeven point, so the graph indicates the vast majority of hospitals are losing big bucks.

Staff layoffs are all over the news, while research shows the most profitable facilities are getting disproportionally more taxpayer dollars as part of Congress’ aid packages. Rural hospitals are especially hard hit – and this comes after over 150 closed in the last 15 years.

Where are those facilities going to find the $$ they desperately need?

(your picture here)

Just in time, the fine folk at WCRI published a detailed review of outpatient hospital costs and related services. [free to members, there is a charge for non-members] I read the report (yes, the entire thing, minus the super-wonky discussion of statistical methodology). The lede was spot-on:

While the full impact of COVID-19 is currently unclear, this study will also be a useful baseline to monitor the effects on hospital payments.

The analysis is thorough, comprehensive, and easy to follow. Rui Yang PhD and Olesya Fomenko PhD have analyzed 36 states; here are a few key takeaways.

  • costs in states without fixed-amount fee schedules are at least 50% higher than in those with fixed-amount reimbursement
  • in states with fee schedules, percent of charges fee schedules are the worst offenders [my words not the authors’]
  • BUT, there are gaping loopholes in other fee schedule types that allow facilities to maximize reimbursement (looking at you, Florida)
  • many states don’t even have fee schedules, which in some cases is just as bad.

What’s a payer to do?

First, identify low cost, high quality facilities and direct your patients to them.

Second, do NOT allow physicians to schedule surgeries in high-cost facilities. The Golden Rule applies – she who has the gold rules, and you are that “she”.

Third, “cost” is the actual cost, NOT the PPO discount. Don’t be fooled – discounts tend to be higher at high-cost facilities.

More on this issue here, here, and here.

May
14

NCCI – quick hits, a deeper dive, and a critique

Posted by Joe Paduda on Thursday, May 14th, 2020 | Comments

Apologies for not getting this out sooner; wanted to wait until I heard back from NCCI on a couple items.

Quick hits

  • Insurers are enjoying record profits.
  • Frequency is down again – continuing a 30+ year downward trend.
  • Medical costs grew  – just barely.
  • Premiums dropped.

A deeper dive

The meeting planners did excellent work, the production was quite good and NCCI’s actuaries and statisticians bravely took on the role of media communicators. CEO and Chair Bill Donnell led things off, noting that the COVID19 pandemic requires agility – a talent not often associated with insurance in general or workers comp in specific (my words not his).

Bill is confident that workers’ comp is in good financial condition to deal with COVID19 – a confidence that is well founded.

For six years the industry has been quite lucrative. Investment gains and underwriting margins have driven record profits – and the profit train kept rolling in 2019.

Steady declines in frequency and relatively stable claim costs over the last five years that continued in 2019 are a big driver of record profits. (I’ve also argued that rates are way too high.)

Chief Actuary Donna Glenn reported private insurers’ reserves grew by $5 billion last year; there’s now a $10 billion reserve redundancy, so the industry has $10 billion more than it projects it needs to cover all current claims liabilities. Coming on top of billions in reserve releases in 2019 it is clear workers’ comp rates are still far too high (my words not Ms Glenn’s).

In 2019 claim frequency dropped again – by 4% – paralleling the long-term trend of 3.8% over the last three decades. According to an NCCI video, key drivers include:

  • better risk management,
  • workplace safety,
  • better training,
  • wellness,
  • automation,
  • a continued shift away from heavy manufacturing and towards a service-based economy.

Intuitively it makes sense that these factors have helped lower claims frequency. However, the video didn’t provide any data or identify any specific research supporting these assertions. I would have expected NCCI  – at its core a research organization – would include references to studies that supported the video’s claims.

I asked NCCI for the research that supported these assertions – as usual Cristine Pike and her colleagues were very responsive; additional research is here and here. However the citations provided didn’t conclusively demonstrate these factors were the cause of frequency declines – and didn’t mention most of the drivers cited in the video.

Donna Glenn, NCCI’s new chief actuary, provided an update on the State of the Line. Lots of good news…

On a per-claim basis, for private carriers, medical severity ticked up 3 points for lost time claims, a very modest change. Combining the 4% decrease in frequency with the 3% increase in severity likely yields no appreciable change in overall workers’ comp medical spend (my assumption, not NCCI’s).

NCCI projects claims incurred in 2019 will ultimately result in a 99% combined ratio reflecting continued underwriting profitability for private carrier business.

Thus it’s not surprising that premiums for state funds and private carriers dropped by $1.6 billion to $47 billion [a 2.6% drop] in 2019 as rates trended down.

Bob Hartwig did provide some context, citing Willis Towers Watson ‘s May 2020 analysis as the basis for projections on changes in workers’ comp premiums motor vehicle accidents and the like

My complaint.

NCCI has extensive access to workers’ compensation data. Given that the world has dramatically changed from 2019 to today and all of us are desperate for information, a discussion of changes in claim counts and types of claims would have been extremely helpful. I get that data is scant and spotty, but generalities and qualitative statements aren’t nearly as helpful as data. I asked NCCI about this; here’s the response:

NCCI has spoken to a number of carriers about their COVID-19 claim experience.  However, I would be very careful about making assumptions based on these conversations.  Until more time has passed and we can get information from a significant portion of the market, we would not be sharing any observations on COVID-19 claim activity.

Here’s where I’m perplexed. The discussion of frequency drivers attributed declines to a host of factors without citing specific research, data, or studies. That’s an assumption.

NCCI could have – and in my view should have – provided data on Q1 2020 claim counts by claim type (cause). That would not have been an assumption, but rather initial reporting of concrete data.

Given potential moves by governors and legislators to make COVID19 illness a covered condition and the lack of certainty about where this is headed, I can understand why NCCI – and other research organizations – don’t want to provide any data that might encourage politicians to look to workers’ comp to cover the costs of COVID19.

What does this mean for you?

The more we know and the sooner we know it, the better.

May
8

COVID19 catch up

Posted by Joe Paduda on Friday, May 8th, 2020 | Comments

Three key takeaways from this week’s COVID19 news.

Do we KNOW how bad things are, who’s dying, and Remdesivir.

  1.  Do we know how many are infected, the death rate, and the number hospitalized/in the ICU/on ventilators?

No.

We are three plus months into the crisis and if anything, the picture is muddier than it was a month ago. From the highly-credible COVID Tracking Project;

it is impossible to assemble anything resembling the real statistics for hospitalizations, ICU admissions, or ventilator usage across the United States.

Also from the Project:

the CDC does offer a national-level account of “specimens tested,” this data is incomplete and lagging, and it uses a different unit (specimens tested) for total tests than for positive results (which are counted in people). This makes it impossible to accurately match testing totals with positive tests to infer a complete picture of COVID-19 testing, even at the national level…a simple count of identified COVID-19 cases doesn’t show the true location or comparative severity of outbreaks. Simple case counts show where people are being tested, not where people are sick. [emphasis added]

Yep, the greatest country on Earth can’t even capture and accurately report infections, hospitalizations, and deaths…you should be pounding your head against the wall.

Or maybe just scream in frustration…

2. Who’s dying.

In the New York City, it’s mostly older folks.

From Statista…

Alas, our nation’s leaders still do NOT KNOW how many of our loved ones in nursing homes have been killed by COVID19. 

Almost three weeks after CMS Administrator Seema Verna took to the podium to announce HHS would begin publishing the numbers, we’ve seen nothing.

3. Finally, Remdesivir is NOT a cure – far from it.

The results of a study conducted by NIAID on about 1,000 patients found it does shorten the course of COVID19 – by four (4) days – in some patients. Manufacturer Gilead hasn’t said what remdesivir will cost, but indications are about $4,000 per patient.

NIAID’s study found the anti-viral drug:

  • has been shown to be safe in humans,
  • is given intravenously (it is injected into the blood stream),
  • the course of treatment is 5 – 10 days,
  • has to be administered in a hospital, and
  • the vast majority of patients who recover at home will NOT get the drug.

Perhaps the most important impact will be shortening the course of COVID19 (although that didn’t happen in all patients who got the drug). This will free up more bed-days in facilities and allow them to treat more patients.

Note an earlier study in China did not find remdesivir was effective in treating COVID19. From the study: “Remdesivir use was not associated with a difference in time to clinical improvement”

Lastly, who will actually get the drug depends on luck – some hospitals will get it, others will not, with no rhyme or reason.

For my work comp readers, over at Workers’ Comp Insider Tom Lynch has a quick summary of COVID19 and its impact on workers’ comp.

What does this mean for you?

We should expect way more from our elected officials. 

May
4

RIMS, opioids, and awards to drug distributors’ risk managers

Posted by Joe Paduda on Monday, May 4th, 2020 | Comments

Last month RIMS announced its annual awards; one of the recipients is the risk manager for Cardinal Health, another has a similar role at McKesson.

Awarding awards for excellence in risk management to two individuals at companies with huge liabilities for the opioid crisis, and failing to discuss that liability in press releases is pretty shocking.

Both companies are embroiled in ongoing and likely very expensive litigation regarding their responsibility for the opioid crisis. Cardinal just announced a $4.9 billion loss for the first quarter of 2020, attributing the hit entirely to opioid litigation (the company estimated the cost of litigation at $5.6 billion.

West Virginia is one of the states devastated by rampant overuse of opioids; Pulitzer Prize-winning reporter Eric Eyre just published a book detailing his investigation into Cardinal’s role in the opioid crisis.

According to Eyre, Cardinal “saturated the state with hydrocodone and oxycodone — a combined 240 million pills between 2007 and 2012. That amounted to 130 pain pills for every resident.” All told, distributors shipped 780 million pills into West Virginia over that time.

Cardinal, McKesson, and Amerisource Bergen are the largest drug wholesalers in the nation, acting as the middlemen between manufacturers and retail and mail order pharmacies. While all three contend they are just part of the supply chain, they are required to monitor and report shipments of controlled substances – including opioids, a responsibility that is at the center of the litigation.

(This is not to say the three distributors bear all the responsibility for the crisis – far from it. State health officials, the DEA, FDA, prescribing physicians, opioid manufacturers and others all share in that responsibility.)

From the Washington Post:

McKesson, Cardinal Health and AmerisourceBergen, were in and out of court. They paid lots of fines but kept on trucking. In 2018, their chief executives gave sworn testimony before the House of Representatives Committee on Energy and Commerce: All denied contributing to the opioid crisis. Later that year, the committee released the results of an 18-month study. It found that distributors failed to conduct proper oversight of pharmacies by not questioning suspicious activity and not properly monitoring the quantity of painkillers shipped. [emphasis added]

Earlier this year, McKesson agreed to pay investors $175 million to settle claims that “directors failed to maintain adequate internal systems for spotting suspicious opioid shipments…”  According to Bloomberg, U.S. District Judge Claudia Wilken in Oakland, California said the suit raised:

“legitimate questions about whether directors ignored “multiple red flags” about opioid shipments even after agreeing to step up compliance oversight as a result of a deal with the government.

The settlement, produced in part by a series of mediation sessions, calls for McKesson to add two new independent directors to its board, to beef up compliance training for directors and improvements in internal systems designed to red-flag suspicious orders, according to court filings.”

McKesson is the also the subject of a criminal probe launched by Federal prosecutors in Brooklyn, NY. 

So, the world’s leading risk management organization conferred prestigious awards on risk management professionals at two companies that have massive financial liability – and I would argue ethical responsibility – for what can only be described as a massive risk management failure. And one is the subject of a Federal criminal probe.

I contacted RIMS to inquire about the decision criteria used by the individuals to select the award recipients, stating:

I’m curious as to the decision criteria employed by the award committee that resulted in awards to these two executives. While their accomplishments are impressive and their achievements notable, I’d like to understand how the opioid settlement issue factored into the award decision.

RIMS Communications Director Josh Salter was kind enough to provide an initial response:

RIMS awards are reviewed and selected by volunteers. This group of risk professionals is charged with vetting all submissions and then, using their experience in the profession, making a decision based on the applicant’s accomplishments. While the volunteer group changes from year to year, I will share this information with them.

I asked Mr Salter if he would facilitate a discussion with any members of the committee and offered to keep the names of those members confidential; to date and after multiple requests I have not received a response. [I’m certainly willing to hear from Mr Salter and committee members]

Eyre’s editor, Ned Chilton, coined the term “sustained outrage” to define what he saw as an essential responsibility of news organizations, a demand that media keep the focus on injustices instead of reporting on a calamity and moving on. I’ve been reporting on the opioid crisis since 2005; over the last two years my passion and drive has burned out.

That’s my fault.

I struggle to understand how RIMS could confer prestigious awards for “risk management” on individuals at two huge companies that bear significant responsibility for the opioid crisis – and not even mention the opioid issue in publicity around the awards. This is not to impugn the professionalism, ethics, or abilities of the individuals recognized by RIMS, rather to ask a very uncomfortable question, one RIMS needs to address.

What does this mean for you?

We cannot let crisis fatigue take our focus off opioids.

[PS – kudos to Tristar’s Mary Ann Lubeskie for her ongoing and tireless efforts to keep opioids front and center… you can follow her at @maryannlubeskie on Twitter]

 

 

 

Apr
30

COVID catch-up

Posted by Joe Paduda on Thursday, April 30th, 2020 | Comments

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
29

When can we re-open?

Posted by Joe Paduda on Wednesday, April 29th, 2020 | Comments

That depends on when we:
a) can reliably tell people if they’ve been infected, and
b) know that those who have been infected are immune.
Let’s take these in order.
How do you know you’ve been infected with coronavirus?
Outside of the obvious – a positive test that shows the actual presence of the coronavirus, there has been much talk of “antibody” or “serology” tests. You may have seen articles like this one reporting that many more of us have been infected with the virus than we thought.

Not so fast…that assumes the tests used to verify exposure are accurate, ergo, the core issue is “are these antibody tests accurate?”

First, there are over 120 antibody tests on the market – few if any vetted by the FDA to determine if the tests are accurate. And some have been shown to be pretty inaccurate, including $20 million worth of tests the UK bought from a Chinese supplier.

Credible research indicates some tests are accurate – and some aren’t.  A study conducted by UC-San Francisco and Cal Berkeley on a dozen of the tests indicates there are an alarming number of false positives – tests that show patients DO have antibodies, when in fact the patients don’t.  That means the tests indicated the patients were infected – when they may well not have been.

Here’s the key statement from the cite below: “a large proportion of those testing positive on an antibody test may not actually have had COVID-19 [emphasis added]” – and thus could be infected – and infect others – in the future.

The good news is the FDA has decided it will begin to “test the tests”; yet another example of the FDA’s new operating principle “Better late than never.

Second, there is no consensus as to the immunity of individuals previously infected with coronavirus to a re-infection. 

This from the actual study report cited above:

Importantly, we still do not know the extent to which positive results by serology reflect a protective immune response. Future functional studies are critical to determine whether specific antibody responses predict virus neutralization and protection against re-infection. Until this is established, conventional antibody assays should not be used as predictors of future infection risk [emphasis added]

What does this mean for you?

Until we know who’s been infected and if they are immune, “opening up” will be a crap shoot.

Scientific rigor is critical, and you MUST read critically. 

Apr
22

COVID19 Update – what we KNOW now

Posted by Joe Paduda on Wednesday, April 22nd, 2020 | Comments

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?

Posted by Joe Paduda on Thursday, April 16th, 2020 | Comments

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.
Apr
14

COVID19 – what’s the real death count?

Posted by Joe Paduda on Tuesday, April 14th, 2020 | Comments

As of this morning 23,459 US deaths have been attributed to COVID19.

That number is almost certainly too low.

The words “have been attributed” were carefully chosen – note I did NOT write “COVID19 killed 23,459 people” or “23,459 people died of COVID19 or “there were 23,459 COVID19 deaths.”

Briefly, that’s because:

a) patients presenting at a hospital with breathing problems, a fever, and a bad headache are often not tested as COVID19 is assumed;

b) severe COVID cases typically lead to heart attack, Acute or Severe Respiratory Distress Syndrome or other problems, and the cause of death [more on this below] may be attributed to a heart attack/ARDS/SRDS and not to COVID;

c) many hospitalized victims also have other health problems; diabetes, high blood pressure, asthma, COPD, cardiac issues.  These co-morbidities greatly increase the risk of death and, absent a positive test for COVID19, may be given as the cause of death; and

d) cause of death (COD) can be a judgment call, and multiple CODs can be reported on the “death certificate”.

Here are the facts.

The CDC finally published guidelines for assigning cause of death for COVID19 earlier this month. Needless to say, a lot of people had died from COVID19 before these guidelines came out, so that’s issue One; Issue Two – as noted above, there can be multiple “causes of death”.

For physicians confronted with a deceased patient, determining and assigning a  cause or causes of death is often complicated and uncertain. For example, COVID19 leads to much greater stress on the heart as it tries to pump more blood to get more oxygen out of damaged lungs. According to the CDC, when that old, tired, sick heart gives out:

The immediate cause of death [in this case the heart attack], which is the disease or condition that directly preceded death and is not necessarily the underlying cause of death (UCOD) [in this case COVID19], should be reported on line a.  The conditions that led to the immediate cause of death  should be reported in a logical sequence in terms of time and etiology below it [on the cause of death statement]. [italics added]

Last week, CDC spokesman Scott Pauley said, “It’s likely that COVID-19 related deaths may not be included on a death certificate [italics added] or COVID-19 might be a factor related to an individual’s death but not the main cause.”

Issue Three – no test, no diagnosis (in some cases) From ABCNews last week

“There is no swabbing of deceased individuals anymore and unless the medical examiner has knowledge of a confirmed coronavirus test, then they aren’t being marked down as having coronavirus,” said [New York City Councilman Mark] Levine, whose committee has oversight for the Office of the Chief Medical Examiner.

Issue Four – A related issue is most of the victims of COVID19 are elderly; older people who contract COVID19 are much more likely to die than younger folk.

Of course, older people have more health problems than younger folks, so there are more “potential” causes of death – cancer, heart disease, stroke, hypertension, COPD, kidney failure and the like. Thus there are more opportunities for the pathologist to attribute non-COVID causes as one of the causes of death – which would further skew the numbers.

There are compelling data from New York City indicating COVID19 may be involved in many more deaths than have been attributed to the virus;

The FDNY reported a nearly 400 percent increase in “cardiac arrest” home deaths in late March and early April, [emphasis added] a spike that officials say is almost certainly driven by COVID-19, whether they were formally diagnosed or not.

Between March 20 and April 5, the department recorded nearly 2,200 such deaths, versus 450 in the same period last year,

Then there’s the issue (Five, to those still counting) that there are a LOT of “extra” deaths that can’t be directly tied to COVID19 as that specific cause of death, however these “extra deaths” happened during the COVID19 crisis.

This from Judy Melinek M.D., a forensic pathologist:

To quote Dr. Ed Donoghue, a forensic pathology colleague at the Georgia Bureau of Investigation, “No matter how these deaths are currently being attributed, after this pandemic terminates, an excellent approximation of the true fatality rate of COVID-19 deaths can be made by the calculation of the excess mortality for the period. This calculation was very helpful during the 1995 Chicago heat wave. Almost certainly, because of the scarcity of testing and other reasons, we will find that the number of COVID-19 deaths has been grossly underestimated.”

Okay, counterclaims.  There are any number of specious claims about rampant over-counting of deaths as COVID; I have yet to see any from any credible source backed by credible data. This is perhaps the best overall discussion of claims that COVID deaths are overcounted; it is thorough and detailed.

Here are just a couple debunked claims…

For those interested – The international picture

From the BBC – “it might seem simple enough: if a patient dies while infected with Covid-19, they died of Covid-19.” Perhaps – but they may have died from a car accident, or might have an underlying health condition such as COPD or asthma or heart disease. The UK counts ANYONE who dies and has tested positive for COVID as a COVID death. Even if they died in a car accident.

A related issue – reports from Italy indicate there are a lot more people dying of all causes than usual, and many of those “extra” deaths aren’t attributed to COVID. “Only 12 per cent of death certificates have shown a direct causality from coronavirus,” said the scientific adviser to Italy’s minister of health last week. [source here]

What does this mean for you?

Two things:

We do not KNOW how many deaths are directly or indirectly due to COVID19.  But medical experts, physicians, epidemiologists, and medical examiners believe it is significantly higher than the published total.

There are truckloads of BS on the interwebs about COVID; ignore anything not based on solid research from credible people with scientific and/or clinical training and experience.

Apr
13

COVID infections – what’s the real number?

Posted by Joe Paduda on Monday, April 13th, 2020 | Comments

Ten days ago I wrote:

Ignore anyone who says there will be this many infections and this many deaths – their “models” are based on data that is likely wildly inaccurate and [based on] assumptions that differ wildly.

Not much has changed.

Today we’ll dive into “official” infection rates and why they may be way less than the actual infection rates. (for those wanting a lot more detail, try this.)

How many of us are infected?

According to testing results, in the US about 550,000 people have tested positive for coronavirus.  However, some researchers suggest as many of 12 million may have been infected, with the vast majority showing no or mild symptoms. (original source is Reason magazine, an avowedly libertarian publication)

DO NOT take that as gospel or dismiss it outright; the researchers relied on data from testing from China as well as other sources; some have questioned the reliability of data and testing kits from China. Other scientists have employed mathematical modeling to calculate actual infection rates; their findings indicate we’re identifying about 2/3rds of COVID19 cases.

Remember, all projections rely on data that are woefully inadequate. Reality is we do NOT know how many of us are infected, because here in the US (and in many other countries) the rollout and ramp up of testing has been far too slow. As you can see, after an initial increase, in the US we’ve been averaging less than 150,000 tests per day for more than two weeks.

data from CovidTracking project; source here (btw, this is a highly credible entity with full transparency re data sources)

From the research reported by Reason:

Credible research indicates Insufficient and delayed testing may explain…Germany, which has detected an estimated 15.6% of infections compared to only 3.5% in Italy or 1.7% in Spain. Detection rates [the percentage of people who are actually infected that are tested and counted as infected] are even lower in the United States (1.6%) and the United Kingdom (1.2%)…As of March 31, [research article authors] Vollmer and Bommer calculate confirmed cases represented just 3.5 percent of infections in Italy, 2.6 percent in France, 1.7 percent in Spain, 1.6 percent in the United States, and 1.2 percent in the U.K. [emphasis added]

In other words, the true number of infections was between 29 and 83 times as high as the official tallies in those countries [emphasis added]

The countries with the highest estimated detection rates were South Korea (nearly 50 percent), Norway (38 percent), Japan (25 percent), and Germany (16 percent)…The estimated prevalence of infection ranged from 0.1 percent in India and Japan to more than 13 percent in Turkey; it was 3.6 percent in the United States.[emphasis added]

To be clear, the researchers made several assumptions, some based on other researchers’ work. And, Vollmer and Bommer’s findings are quite different from Rao and Krantz’s.

What does this mean for you?

Net – we do not KNOW how Americans are infected…but it is definitely more than a half-million.

We will not KNOW until testing using a statistically-credible sample size and methodology has been done and reported.