Announcer (00:05):

Welcome to Hospitals in Focus, from the Federation of American Hospitals. Here’s your host, Chip Kahn.

Chip Kahn (00:14):

To state the obvious, it isn’t 2020 anymore, and we know a lot more today about COVID-19. Hospitals learned how to treat the novel disease with incredible speed and unprecedented cooperation across health systems. We are in a transitional phase with the pandemic at this point. New variants appear to be on the horizon, and will likely continue to come. But the general public, in at least the Western context, has moved on. Despite the public’s attitude about the pandemic, hospitals and frontline caregivers still face the new normal of COVID-19.

Joining me today are two experts, who we have been fortunate to have on Hospitals in Focus previously. Martin McKee is a Professor of European Public Health at the London School of Hygiene and Tropical Medicine, and soon-to-be President of the British Medical Association. He plays a key role in public health across the UK and Europe. We heard from him in the midst of the pandemic about the conditions overseas. Thanks so much for joining us today, Martin.

Martin McKee (01:26):

Morning.

Chip Kahn (01:27):

Our other guest is Mike Cuffe, Executive Vice President and Chief Clinical Officer for a HCA Healthcare. When we heard from Mike a few years ago, he was in charge of physician services and we talked about the HCA Healthcare graduate medical education program. Today Mike is the Medical Director for the entire system. Really appreciate you being with us today, Mike.

Mike Cuffe (01:50):

Pleasure to be with you again, Chip. Thank you.

Chip Kahn (01:52):

So appreciate both of you joining us today. I’m bringing you together today to discuss three areas. Where we are with the pandemic, what we’ve learned, and where public policy ought to be on this pandemic. To get started, from the perspective of the US and the UK, respectively, what is the current status of COVID? How are we doing today in managing treatment and prevention of the pandemic, and what are the immediate prospects of its challenge? Mike, why don’t you begin, and then Martin, chime in.

Mike Cuffe (02:24):

From a hospital perspective, we’re pretty well off right now. We’ve recently come off all time lows and while we see some of the encounters given the utility of home testing and the absence of testing in some populations, it’s a little harder to predict what the actual community burden is. Nonetheless, the clinical intensity, that is intensive care units, ventilator use, mortality is all lower. And in fact, the Omicron experience was less than half the clinical intensity of our Delta experience. And so we’re clearly improving.

I would say that this is becoming more an endemic flu-like illness, less fatal disease in the United States, for sure, with our increasing immunity, our therapeutics, but it’s not behind us. I’ll just close by saying it’s not behind us because shortages persist in nursing, in certain members of our clinical staff, due to burnout, macroeconomic workforce issues, shifts to contract nursing. And now we see inflation and labor intensity in an industry that can’t easily pass on cost increases to payers or consumers. There’s also supply chain issues, those are not behind us. They continue to shift. But I would say that the worst is behind us, but we’re not out of the woods.

Martin McKee (04:03):

The situation’s very similar across much of Europe in many ways. First of all, we have much less information about what’s going on because of the reduction in testing. So in a number of countries, we had very high volumes of testing that allowed us to track the pandemic in real time. In addition, we had high levels of sequencing, so we could identify the emergence of new variants. Now that has been scaled down dramatically, reflecting, I think a political view that we want to put the pandemic behind us. Unfortunately, the virus isn’t entirely agreeing. And I think there is a degree of concern that we will have new variants emerging. We already see that with BA.4 and BA.5, for example, in South Africa. We’re seeing them taking off when we have an expectation that as with BA.1 and BA.2, they will get to us eventually.

I think maybe the difference is that in many European health systems and UK in particular, because we have much less capacity than you have in the United States in general, we have a very large backlog of treatment. Particularly treatment of people who were not referred on time for cancer, for example. People with chronic conditions that have deteriorated. And that is putting a lot of pressure on our health systems, as well as the continuing COVID related problems. Now there’s a lot of discussion about people being in hospital with COVID or for COVID. But the reality of it is that if you’ve got a severe condition and then you have COVID on top of it, then that increases the problems.

So we’ve got the backlog and the challenge of clearing the queue. We are also still struggling with relatively high levels of staff illness with COVID. And there’s a tension in some employers, not in the health sector, fortunately, are actually arguing that their staff should come to work with COVID. Of course, we’re saying that’s a really bad idea, but we definitely don’t want it in the health system. But you can lose a critical individual, an anesthesiologist or a surgeon or a specialist nurse, and then the whole team is essentially out because you don’t have that scope to substitute.

We also have a problem with burnout. We have had a lot of burnout during the pandemic, and a lot of people have left the workforce, particularly a problem in the care sector. There, people can get jobs elsewhere, so they’re going into the retail sector. Particular problem in the United Kingdom because we have very severe staff shortages across the board because of the catastrophic decision to leave the European Union. So that’s having problems in that people who might work in the care sector and who therefore provide the care that allows patients to be discharged from hospital, so there’s a knock-on effect, they are finding jobs in retail or hospitality or where elsewhere.

We’re also seeing that hospitals are finding difficulty in working at the same capacity because of the need to increase infection control, have greater spacing, have clean and dirty areas and so on. Which is reducing what is often already relatively limited capacity compared to what you have in the United States.

Chip Kahn (07:09):

Gosh, let’s take a little bit deeper dive, I think, with both of you. Maybe start with Mike, because you have laid out the side effects of it. Do you see these as continuing to affect healthcare for a while? And then let me add to that another question, which is Long COVID. So even if we are normalizing the treatment of COVID itself, what factor for the healthcare system, which you’ve described a lot of side effects that could continue into the future, will Long COVID necessarily play in this? And then, Martin, if you could take that too.

Mike Cuffe (07:46):

Chip, this is an interesting space. I think it is as difficult to predict the cross of the emergence of new variants against the continued likely periodic surges that any type of coronavirus like this may exhibit against some of these macroeconomic forces. We have the pent up demand, as Professor McKee mentioned, but not nearly as much as the UK backlog. And in the face of the inflationary pressures in this country, that’s complicated. So I do think that Long COVID is something that’s more of a to be determined. I don’t think we understand the extent of it, the scope of it, or the long term effects for any one patient or the population well enough at present. So that needs to be a focus of study, getting to your other point about policies ahead.

In terms of the lessons learned, I think there are many and powerful. And we would do well to stay on our toes and stay prepared, whether it be seasonal surges of our existing variants or the continued emergence of new variants. I do not think that this is fully behind us.

Martin McKee (08:59):

Yeah. Again, there are many unknowns here. The United Kingdom is actually quite fortunate in that we do have an ongoing surveillance system, which is monitoring the prevalence of Long COVID. So we do know that currently about 1.7 million out of a population of 65 million, so that’s about 2.5% of the population which is a lot, are suffering from persisting problems. Now, of course, there’s the spectrum of conditions and symptoms that fit into the very broad definition of Long COVID. But in addition to that, I think we are seeing the other sequelae of COVID. There’s now I think quite good evidence that there’s been an increase in new onset type one diabetes, which will pose challenges going forward. There are people who have developed thrombosis, strokes, heart attacks, renal infarctions, and so on, going forward. Now that doesn’t fit within the typical definition of Long COVID, but it does leave a disability.

And we’re seeing more and more discussion of the macroeconomic impact of this. So the Financial Times, for example, has been covering the challenges that employers are facing with long-term sickness, absence, coupled with a whole series of other issues, which are impacting labor supply. Including the way in which people during the pandemic have begun to question whether they still want to work in the same way, commuting for hours to work and often feeling unappreciated and so on. So we’ve had in many countries, quite a significant premature departure from the labor force. So that’s really quite a challenge to look forward to there.

Then more generally, I think what we are seeing is this change in working patterns, which will have consequences going forward. There’s an issue of education, children that have missed out in education and a generation going forward there. So I think as we look forward to what the post-pandemic world will look like, there’s an awful lot of uncertainty. And then you add into it, of course, for us in Europe, we have to remember that there is a land war going on in Europe at the moment. And leaving aside the tragedy of the consequences of the Russian re-invasion of Ukraine, the human tragedy we see on our screens, that is diverting the attention of policy makers and ministers from many of the domestic problems that need to be sorted out too.

Chip Kahn (11:24):

Looking up apart for a moment, as you’re describing, we are moving along with all of this baggage. The Chinese government has chosen to take a different approach to the current wave of COVID and to really clamp down on it. Something that, politically I guess, would be an impossibility in the West. What do you think of their response, and what are its implications? Maybe start with Martin.

Martin McKee (11:53):

So I think … I was one of those who argued from the very beginning that there should have been a much more robust response. We published a paper recently suggesting that if the United Kingdom had locked down a week earlier, just a week earlier, then we probably would’ve saved about half of the lives that were lost in the first wave. That said, of course, the countries that have done that have had challenges in sustaining that. And I would be hesitant about blaming them because, of course, the problem they faced is that other countries didn’t. So they’re getting cases imported from the countries that failed. But I think I would contrast China, Hong Kong in particular, with say New Zealand, which followed a similar … we can call it zero COVID, call it maximum suppression approach.

And what New Zealand did was to use that time to maximize uptake of vaccination, get a very high uptake of vaccination among older people. Whereas in China, in Hong Kong, they didn’t do that and the uptake was much lower. So that when Omicron did come in with being highly transmissible, then you saw a very high death rate. Now we do need to remember with Omicron that it’s often described as being much milder, but that was because it was relatively mild in South Africa, where there was a very high level of background immunity. And what we saw in Hong Kong, where we’ve got very good data, is that it was not mild in a population that didn’t have that degree of immunity. We also know, in fact, in the United Kingdom that the cumulative deaths from Omicron are now about the same as they were with the Delta wave, because it’s lasted for a bit longer.

So I think the situation in China is that there was a missed opportunity to increase the vaccination rate, and had they done that then I don’t think they would be in the situation they are now. But now I think this has become both a domestic and a geopolitical issue. It’s a domestic issue because it is challenging the authority of the party. And it’s a geopolitical issue because it’s having a major impact on supply chains, with consequences for us all.

Chip Kahn (13:52):

Mike, do you have anything to add in terms of your view about China?

Mike Cuffe (13:55):

Well, so I couldn’t agree with professor McKee more. These approaches are achievable in the short term. In many ways, if you went all the way back to spring of 2020, one could have anticipated an approach like that would never go in the United States, but we also wouldn’t have just opened up and let it happen. And so it feels as though many countries landed where one would’ve expected them to land, whether they had the ability to shut down and do control measures, or whether or not they would take some middle of the road stance. But as he said, everyone needed to use that time to engender immunity within their population, or immunity and the presence of therapeutics. And for China, that was probably a missed opportunity.

My siblings live in Beijing and what they’re experiencing now is difficult. And the risk of instability, both domestic and geopolitical due to the supply chain issues, looms large for them and for us. So while it was achievable short term, the ultimate goal here is to achieve enough population of immunity to make this more … it’ll never be a background issue. But more of a background issue that one can live with than they have in front of them still.

Chip Kahn (15:15):

So looking at COVID, despite the tragedy in the United States, over a million deaths and double digit deaths, obviously in the millions across the globe, generally, there were in a sense two miracles, at least from my view. One was the vaccines, and the other was the rapid adaptation of various treatments. None perfect, but millions and millions were saved despite the fact that so many were lost.

Martin, from your standpoint, in terms of hospitals, do you see from your side of the ocean, the approach to care and operations being affected by this process of learning so rapidly and adapting to COVID?

Martin McKee (16:03):

Absolutely. And I’ve been very critical of many aspects of the response in the United Kingdom, but we did a number of things really well. The genomic sequencing, for example. And I think our testing, our surveillance program. But the one thing I think we did especially well in which people can learn from is the recovery trial. So it meant that virtually every patient who was admitted to hospital with COVID was given the opportunity to enter into a clinical trial. And that allowed us to test a whole lot of punitive treatments. It allowed us to show, for example, that chloroquine was ineffective. It demonstrated the benefit of steroids, and it has helped us really to understand what works and what didn’t work.

And I think going forward, other countries should be thinking about how they can have the infrastructure in place so that they can implement very rapidly clinical trials that have as broad a recruitment as possible, and are not just … The problem we often have with clinical trials. They have a very small, highly selected group of people who are included, who don’t have comorbidities or aren’t older or whatever. We need to be as inclusive as possible. And we need to get the IRB work done in advance as far as we can. We need to get the approval, regulatory approvals done in advance, and we need to be prepared to hit the ground running.

The other area where I think we’ve really learned a lot is the importance of having learning collaboratives. So at the beginning, COVID was seen as another, effectively, an infectious pneumonia. The perceived challenge at the beginning was how do we get enough ventilators? We rapidly learned that this was a complex multi-system disease with implications on almost every system in body. And that involved bringing together cardiologists and respiratory physicians and neurologists and physiotherapists and all sorts of other people, so that they could share their experience, do trials where appropriate, and disseminate the learning that was taking place. So the importance of placing people in a prone position and working out when it was appropriate to initiate mechanical ventilation and so on and so forth.

So those mechanisms are now being institutionalized so that we will have an opportunity to learn across specialties. Because the problem is that often, specialists go to their own conferences, they talk to themselves, in all specialties. And we don’t have as many mechanisms for that cross fertilization of ideas.

Mike Cuffe (18:35):

So there’s a paradox here, Chip. And the paradox, I think, was the success that HCA had, and the demonstration that scale matters in response. So as you know, Sam Hazen, our CEO led us on what was initially a very conservative approach to simply protect our people and protect our organization. Doing so meant creating capacity, financial capacity, clinical capacity. And we didn’t furlough or layoff staff, which was uncommon among US hospitals. And we were able to return $6 billion in federal Cares Act dollars to the government.

The bottom line for us, and our prime lesson, was that scale mattered. Scale mattered in the supply chain, in our ability to move things around our system and find alternatives. It mattered at market levels and state levels and flexing our staffing. It mattered, as Professor McKee said, around learning networks. We set up a scaled lab, a scaled clinical guidance, interpreting the masses of data that was coming from varied reputable and non reputable sources, and set up learning networks for our labs, our leaders, our intensivists, our physicians. And even scale in our collective financial resiliency was important.

The paradox is that scale in US healthcare is rare. US healthcare on the provider side is still very fragmented. And yet, we look back and think about what that offered us at times of pressure like this. And as I think about the de-risking of the supply chain, you can de-risk a supply chain in anticipation of pandemic, but also war, trade agreements, transportation, inflation, the presence of raw materials. That’s an interesting paradox for US policy makers moving forward. And I think one of the lessons is, if not implicit scale as we have in US healthcare, or we at least have five to 6% of scale on the provider side, some sort of virtual networks in scale as the UK was able to set up, is vital in the face of whatever the next challenge is.

Chip Kahn (20:54):

So Mike, you’re heading us in the direction of policy, and I’d like to go there to finally close out our discussion. So considering where we are today with the pandemic … and let me say, without worrying about the specific obstacles of the politics of COVID, which are obviously monumental. What do you both see as the public policies that ought to be implemented, both in terms of dealing with the ongoing pandemic, as well as preparing for the next one?

And in the answer … and I’ll ask Martin to go first. I’d really like you to blue sky for our audience and talk about, if you were king, what, what you would do. Because obviously the obstacles complicate everything, but I’d like them to get a clear view from both of you of where you think we should be going.

Martin McKee (21:45):

Well, I don’t really have to blue sky because I was a commissioner on the Pan-European commission on health and sustainable development reporting to WHO. And I was the lead author of the evidence review for it. So we’ve spent much of the last year and a half thinking about these things. And we have a whole series of proposals that are going forward through WHO, G-20, and elsewhere. So I won’t go into all the detail, but essentially we start off from the need to prevent the emergence of a future pandemic. And that means addressing the issue of one health, the interrelationship between the health of humans, animals, and the environment. And it goes through to ensuring that we have greater commitment to investing in health. And that involves looking at the OECDs accounting rules and so on. And it looks at the global health architecture, a whole series of proposals there. Also recognizing that one of the challenges will be reducing the vulnerability of the population as well as the resilience of the health system.

So I would say that there’s a lot of thinking that’s gone on in there. But let me just bring it back to the more prosaic and say that I think that one of the priorities for us all will be to think back to our predecessors in public health in the 19th century, who recognize the importance of clean water. And for us, I think we need to look at the importance of clean air, because we now have growing evidence that … of course, we now know that COVID is transmitted by airborne means. But looking at the greater use of masks in situations where there are reasons to think they will be helpful. Filtration, ventilation in particular, looking at the design of our buildings. So essentially I think we’re looking at a clean air revolution going forward, which will have benefits which go beyond COVID, to all of the respiratory pathogens that are transmitted in this way.

Mike Cuffe (23:37):

I don’t think we should overlook the miracles, as you said, of vaccine therapeutics and the sharing that happened. Both sharing that arose spontaneously around shared learnings, as well as shared supplies. I do think there were some mistakes that have led to important aspects of policies. One, allowing local leaders to manage capacity and volume. It was an odd time in March of 2020 when we shut down broadly in anticipation of surges that didn’t materialize at that time. Instead, allowing people to collaborate with competitors and self-manage elective cases to create local surge capacity, I think is a wiser step.

Clearly, there was opportunity in this country for better collaboration of federal agencies. Many of whom were pushing out separate rules and expectations that were different, particularly around workforce safety. I do think it would be helpful, given all the pressures we’re facing, to evaluate more prospectively care models that could be acceptable and potentially more efficient during public health emergencies. I think about New York in the heat of those early days.

And then, I will say, the supply chain needs to be a better pressure tested. We have seen what a perfectly optimized supply chain that’s just-in-time looks like, and it doesn’t respond well to perturbations and war and pandemics and things like that. So de-risking the supply chain is important. And then finally, I’ll just say again, scale whether virtual or actual. Scale and the preparation and pressure testing of that scale, I think was one of the important lessons for us in the United States. We were able to execute internally, but we were able to collaborate broadly. And as they did in the UK, that became very powerful. But it was not something that was naturally set up to act that way, it was spontaneous.

Chip Kahn (25:34):

Well, boy, this has been just a terrific conversation. I so appreciate both of your expertise and openness, and the experience that you all have had going through this situation. Hopefully there is some light at the end of the tunnel, but looks awfully dim right now.

So with that, I’ll say, thanks, Martin, and thanks, Mike. And we’ll wrap it up.

Martin McKee (25:56):

Thank you very much.

Mike Cuffe (25:57):

Thanks, Chip. Have a great day.

Announcer (26:04):

Thanks for listening to Hospitals In Focus, from the Federation of American Hospitals. Learn more at fah.org. Follow the Federation on social media, @FAHhospitals, and follow Chip @chipkahn. Please rate, review, and subscribe to Hospitals in Focus. Join us next time for more in-depth conversations with healthcare leaders.

Dr. Michael Cuffe, Executive Vice President, Chief Clinical Officer, HCA Healthcare

Dr. Michael Cuffe is executive vice president and chief clinical officer for Nashville, Tennessee-based, HCA Healthcare, one of the nation’s leading providers of healthcare services. In his role, Dr. Cuffe is broadly responsible for the company’s clinical and physician agenda including clinical quality, nursing, clinical informatics, care transformation, urgent care operations, graduate medical education, laboratory services, and more than 13,000 employed and managed physicians.

Dr. Cuffe joined HCA Healthcare in October 2011 as president and CEO of Physician Services. Prior to this position, he served as vice president for Ambulatory Services and chief medical officer for Duke University Health System. He previously served as vice president of Medical Affairs for Duke University Health System, vice dean for the Duke University School of Medicine, as well as in various leadership roles in the Duke Clinical Research Institute.

Dr. Cuffe is a graduate of MIT, and received his MD and MBA degree from Duke University. He also completed his residency in internal medicine and fellowship in cardiology at Duke.

Professor Martin McKee, CBE MD DSc MSc FRCP FRCPE FRCPI FFPH MAE FMedSci, London School of Hygiene and Tropical Medicine

I qualified in medicine in Belfast, Northern Ireland, with subsequent training in internal medicine and public health. As Professor of European Public Health at the London School of Hygiene and Tropical Medicine I was founding director of the European Centre on Health of Societies in Transition, a WHO Collaborating Centre,  and which I led for over a decade. I am also research director of the European Observatory on Health Systems and Policies, a unique partnership of universities, national and regional governments, and international agencies and a Commissioner, and Chair of the Scientific Advisory Board, of the Pan European Commission on Health and Sustainable Development, reporting to WHO EURO. I will be President of the British Medical Association in 2022/23.

I am a former Chair of the UK Society for Social Medicine and Past President of the European Public Health Association. I have published over 1,300 scientific papers and 50 books and have an h-Index (Google Scholar) of 164. I was an editor of the European Journal of Public Health for 15 years and am a member of numerous editorial boards, as well as being an editorial consultant to The Lancet. I have been invited to give many endowed lectures, including the Milroy (Royal College of Physicians), Cochrane (UK Society for Social Medicine), Ferenc Bojan (EUPHA), Davidson and Dr Andrew Duncan (Royal College of Physicians Edinburgh), Salvador Lucia (UCSF), Population Health Sciences (McMaster University),  DARE (UK Faculty of Public Health), Victor Horsley (British Medical Association), Hjelt (University of Helsinki), Duncan (City of Liverpool), Thackrah (University of Leeds), Dixon (Ulster Medical Society), Sandy Macara (BMA), Neuberger (Hebrew University, Jerusalem), Litchfield (University of Oxford), Netherlands Scientific Council for Government Policy lecture, Schorstein (Barts), and Teddy Chester (University of Manchester). I sit on a number of advisory boards in Europe and North America, in both the public and private sectors and I was a trustee of the UK Public Health Association. I am a board member at UCL Partners.

I am a former chair of WHO’s European Advisory Committee on Health Research and of the Global Health Advisory Committee of George Soros’ Open Society Foundations, and a member of the European Commission’s Expert Panel on Investing in Health. I am also a Senior Fellow at the Center for Health Outcomes and Policy Research (CHOPR), University of Pennsylvania School of Nursing and a Senior International Fellow at the Population Health Research Institute, McMaster University.

I am a Fellow of the Royal Colleges of Physicians of London, Edinburgh, and Ireland and the UK Faculty of Public Health and a former chair of the UK Society for Social Medicine. My contributions to European health policy have been recognised by, among others, election to the UK Academy of Medical Sciences, the US National Academy of Medicine, and the Academia Europaea, by the award of honorary doctorates from Hungary, The  Netherlands, Sweden,  Greece, and the United Kingdom (QUB), and visiting professorships at the Universities of Zagreb and Belgrade, the London School of Economics, and Taipei Medical University. In 2003 I was awarded the Andrija Stampar medal for contributions to European public health and in 2005 was made a Commander of the Order of the British Empire (CBE) by HM Queen Elizabeth II. In 2014 I was awarded the Alwyn Smith Prize for “the most outstanding contribution to the health of the public” by the UK Faculty of Public Health and, the same year, a scientometric analysis in the journal Health Research Policy & Systems identified me as the most productive researcher in global health systems research. In its 2015 listing I was included in the Thomson Reuters list of the top 1% most cited researchers worldwide and, the same year, I was awarded the Donabedian International Award.

You can read more about me in my Lancet profile, on Wikipedia, and in BMJ Confidential