Originally published to Becker’s Hospital Review
The COVID-19 pandemic started nearly eleven months ago and has resulted in worldwide human suffering, an economic meltdown, and increased healthcare inequities and disparities. It has also contributed to a highly contentious American presidential election and the social justice demonstrations throughout the United States. Since the discovery of the virus, no aspect of the American lifestyle has been spared from dramatic changes. 2020 is likely to go down in history — along with 1860, 1929 and 1968 — as one of the watershed years of the Great American Experiment. This once-in-a-generation pandemic has impacted the global population with a similar magnitude as past world wars.
With encouraging news about potential vaccines emerging over the past few weeks, we have reached an inflection point. There is an immediate need to be realistic about the next phase of this pandemic while planning for the recovery of the nation. This recovery must help those negatively affected by the pandemic — those who have lost their jobs or loved ones, our exhausted healthcare workers, as well as our pandemic-fatigued population in general. The nation is at its most vulnerable stage.
In early May, our team at Neeka Health built and published simulations of a multi-parametric and real-time dynamic COVID-19 model. As the pandemic has continued to spread across the United States, our team has been diligently updating the model to incorporate mitigation strategies and generate ongoing simulations. In our first article, our model, which predicted a second peak of COVID cases, was directionally accurate, based on the policy information available at the time. Based on actual enacted policies and mitigation strategies over the last several months, in fact, a second wave did emerge starting in November. We show forward looking simulations with different scenarios (Figure 1 is the base case, with low restrictions enacted and Figure 2 is an alternative scenario with enhanced risk mitigation strategies). With vaccines being approved at a rapid pace, it appears that our initial estimation of April 2021 for general deployment of vaccines will hold true.
Figure 1 – Base Case: Continued Low Level COVID Restrictions Simulation analysis built in December 2020 for the United States, assuming 0.6% mortality rate, acute care rate of 1.2%, hospitalization rate of 2.4%, the first wave ended on July 1, 2020, and a vaccine available in April 2021 and administered in 6 months’ time
The base case assumes that relative mask wearing, social distancing, and travel restrictions (and adoption) remain constant from December 2020 through the end of 20201. This results in approximately 753,000 deaths by the end of 2021.
Figure 2 – Alternate Scenario: Improved pre-2020 Holiday COVID Restrictions Simulation analysis built in December 2020 for the United States, assuming 0.6% mortality rate, acute care rate of 1.2%, hospitalization rate of 2.4%, the first wave ended on July 1, 2020, and a vaccine available in April 2021 and administered in 6 months’ time
The second scenario assumes that relative mask wearing, social distancing, and travel adoption will increase in December 2020 preceding the holidays before returning to pre-Thanksgiving 2020 level for all of 2021. This relatively short term change in COVID precautions and enhanced risk mitigation strategies results in approximately 143,000 fewer deaths than the base case.
In this article we will focus on phases 2 and 3 of the pandemic, which we believe will likely unfold over the next 12 to 15 months. We will review the COVID-19 mitigation tactics for healthcare leaders in the context of the pandemic phases and discuss the public policy, economic (general and healthcare specific), and human toll implications that will follow. We anticipate dire COVID consequences for the healthcare system over the next few months and continuing severe challenges over the next year.
Phases of the Pandemic
Based on scenario analysis and COVID-19 research, as well as research on previous pandemics, our team has proposed four distinct phases of the pandemic:
- Initial Onset: The initial detection of the virus to the time of FDA approval of a vaccine
- Pre-Deployment: The time between the approval of the vaccine and initiation of vaccination broadly to the general population
- Deployment: The time from when the vaccine is being supplied to the general population until we reach “herd immunity” or significant population resistance
- Long Haul: The extended effects of COVID-19 on healthcare providers, patients, and society at large
We have been living through Initial Onset (or Phase 1) throughout 2020. Since onset, COVID cases have seen multiple peaks and a recent dramatic increase in cases.
During Phase 1, there has been a noted disparity in mortality rates between nations with stricter lockdowns compared to more relaxed risk mitigation strategies. Much has been written about the pros and cons and broader effects of lockdowns, but, from a medical perspective, the stricter the lockdown (government mandated or individual choice driven), the greater the ability to control transmission. We have seen during Phase 1 that quarantining, social distancing, and mask wearing work. However, these measures require national adoption to be maximally effective and, given our porous state borders, the current approach to implementation is infeasible. We take it as a given that a strict national lockdown is not a viable option and thus healthcare providers must prepare for what will happen as a consequence.
The Pre-Deployment Phase (or Phase 2) represents the time between the approval of the vaccine – right now — and initiation of vaccination to the general population several months from now. Leveraging pre-existing technology, unprecedented collaboration, government support, and global commitment, mRNA-based vaccines have been developed and are being approved on an unprecedented timeline. U.S. approval is anticipated imminently. Given the logistical complexities of transporting the vaccine, it is unlikely that the vaccination for the general population will be available prior to April 2021. While certain cohorts will be vaccinated earlier, as we explain below, the Pre-Deployment Phase may be the darkest quarter of the pandemic for our healthcare system.
The Deployment Phase (or Phase 3) is set to start around April 2021 (in Q2), during which the vaccine will be distributed to the general population. While there are numerous estimates for how long it will take the U.S. to deploy the vaccine, our team is estimating it may take up to a full year to reach to achieve herd immunity. This estimate is based on various well-documented barriers that vaccine developers and distributors will face. These are:
- Manufacturing: There is only so much manufacturing capacity. Given the global need for the vaccine, manufacturers such as Pfizer have already stated the additional doses will not be available to the U.S. until June causing a range of deployment issues in Q2 and Q3 of 2021.
- Distribution: Doses of the vaccine also require strict transportation and storage plans, such as, cold temperature requirements down to minus 70°C. To ensure that the vaccine is rapidly and efficiently delivered to distribution sites, this will be particularly challenging in rural regions, likely requiring centralized urban distribution hubs.
- Booster requirements: Both the Moderna and Pfizer vaccine specifically requires an initial vaccine followed by a booster within a specific dedicated time window, which will require logistics, community engagement, access, and tracking.
- Compliance: Compliance will require significant educational and logistical effort that will take time and resources, especially for the portion of the population opposed to vaccination or without immediate access, such as homeless and indigenous populations.
Unless every aspect of deployment goes exactly as planned (a highly unlikely scenario), we estimate this phase will take much longer than some of the more optimistic predictions. Figure 3 demonstrates our timeline estimation, which was reproduced from our original publication in May.
Figure 3. Projected Potential Vaccine Deployment Timeline
The Long Haul Phase (or Phase 4) is associated with an improving mortality rate among those experiencing multi-organ chronic conditions, such as lung, heart, muscle, neurological, immune, and other system issues. This will likely be a generational event and represents the lasting impact of the pandemic on the nation, similar to other conditions such as Tuberculosis. Phase 4 will be discussed in a subsequent article.
Phase 2 – Pre-Deployment
As the current peak of COVID cases taxes our systems, the United States is rapidly transitioning into a vital period where the protection of our depleted healthcare system and its exhausted healthcare workers must be paramount. In this period of transition over the next several months, a careful calculation needs to be made: Will an overconsumption of our fixed healthcare resources occur prior to adequate vaccine deployment? Our modeling predicts that significant healthcare resource depletion will occur prior to the end of 2020, resulting in the potential that patients will be turned away from emergency rooms due to lack of beds and healthcare professionals. This trend can be observed emerging in Kansas, Missouri and other Midwestern states, where rural institutions incapable of handling COVID patients are sending them to larger, urban centers.
During this period of limited vaccine availability, the only viable option for the nation is to continue implementing strategies of risk mitigation to protect our healthcare resources. Thus far, these strategies have been implemented on a state-by-state basis in the form of lockdowns and partial mitigation mandates, limiting their effectiveness based on continued allowance for travel. While a large scale nationwide lockdown will not occur through government mandate, it may nevertheless, functionally occur without federal mandate. For instance, state governments may impose strict lockdowns if healthcare resources are depleted due to surging COVID cases.
If hospital beds or providers become completely exhausted and people are sent home to self-treat and subsequently die with COVID, we could see an inflection point whereby current policies, economics, individual behavioral changes, and health implications could force policymakers to drastically change their approach. If the U.S. reaches this inflection point, there are several significant implications of policy, economy, and the health of the nation’s population.
If healthcare resources are exhausted, emergency rooms will, functionally speaking, no longer be able to admit new patients. We have already seen this happen during the early days of COVID in New York state hospitals, where nursing homes were directed to take in more stable COVID patients to alleviate bed congestion. This was followed by California and New Jersey creating policies that incentivized nursing homes to admit COVID patients. With the recent rise in cases, hospitals around the United States are quickly filling their remaining beds. Once occupied, hospital systems will be forced to turn away new patients and procedures, which, in addition to having drastic consequences for patients, will continue to burden healthcare systems’ already distressed finances.
Under this scenario, new patients may need to self-manage their treatment as outpatients – most likely with steroids and other therapeutics. While some of these therapeutics (e.g., steroid protocols, monoclonal antibodies) have been shown to improve mortality rates and reduce duration, they have also resulted in more carriers and greater systemic burden. Entire households could become infected, potentially increasing total mortality.
As COVID cases begin to rise and fall disparately, states will once again implement risk mitigation strategies that may lack cohesion or social equity. As we discussed in May, state-by-state guidelines do not sufficiently control the spread of COVID. With historically popular travel dates happening now, super spreader events will most likely follow. Already, we are seeing packed airports, bars, and restaurants across the U.S.
With respect to non-COVID patients, the system’s capacity or ability to provide high quality care will be challenged. Patients requiring urgent and emergent care, such as cardiac and neurological related conditions, will continue to present to the emergency department (ED). This will further strain EDs that are dealing with COVID patients. If this occurs, the net result will be more advanced diseases (across the spectrum), increasing acuity, and increasing resource requirements.
While aggregate consumer-spending has not been impacted by the pandemic so far and has actually led to growth in sales for some companies, there are signs indicating a slowing of that growth. A major economic issue is parity — COVID has disparately impacted certain households and income groups more than others. We have seen a significant increase in the number of Americans filing first-time unemployment requests over the last several weeks. The number of Americans relying on foodbanks has increased significantly. The net effect of COVID and COVID-related policies is a further widening of economic disparities.
We are seeing and likely will continue to see a disparate impact across economic sectors. The technology sector has enjoyed unprecedented growth since the pandemic began and this will likely continue. Large companies with strong cash positions have effectively weathered the crisis and some have even shown bottom line improvements through labor force reductions and shedding of facilities through work-at-home policies. However, small business and medium-sized companies that constitute the backbone of the everyday American economy have preferentially suffered the brunt of the pandemic and will need to continue in survival mode throughout Phase 2 and into Phase 3.
Our research predicts that the healthcare economy will experience negative economic impacts during Phase 2 caused by an inundation of patients, higher utilization of the ED for primary care and elective and non-urgent care, payer mix shifts, labor shortages, increased burden of chronic COVID long haul patients, and supply chain disruptions. For instance, healthcare institutions make a significant portion of their annual profits from elective surgeries that may well be prohibited by CMS guidelines or practically due to COVID surges. The fourth quarter is historically an exceptionally active period for these high-margin procedures, as patients seek to optimize insurance deductibles. Hospital providers’ bottom lines will be impacted if these patients do not have access to such procedures due to bed availability. Additionally, there may be payer mix shifts resulting from the surge of emergent versus elective patients. This means decreased revenues for hospitals which had already operated on thin margins prior to the pandemic, as shown in Figure 4.
Figure 4. Nonprofit hospital margins prior to the COVID Pandemic (2018)
After 11 months of dealing with the pandemic, healthcare workers and providers are exhausted and relying on dwindling resources. This will increase the expense of providing COVID care. Until more definitive treatment for COVID is established and broadly available, patients will occupy hospital beds without specific treatments and therapeutics. The lack of specific treatments and therapeutics has resulted in COVID patients requiring expensive critical care resulting in higher costs, leaving fewer resources for emergent non-COVID patients. Hospital systems are being stressed and unstressed at varying times, with small and rural systems being hit hardest.
The health implications of COVID cannot be understated. Almost 300,000 people have already died from the pandemic and this number will only grow in Phase 2. As a result of increased spread coupled with reduced access to healthcare resources, we anticipate that the declining effective mortality rate from improved treatments seen in Phase 1 may start to increase. It is anticipated that the need to self-manage due to limited ED accessibility and intensive care capacity issues will lead to a peak in the mortality rate in Phase 2. Furthermore, greater spread will lead to more survivors struggling to cope with long term effects, about which our understanding is limited.
Americans are experiencing an event that has profoundly shaken the mental health and wellness of many. Our healthcare workers are physically exhausted and mentally drained as they deal with Post Traumatic Stress Disorder and burnout. Many people are yearning for the end of online schooling and work-from-home. There will be an urgent and sustained need for mental health and wellness, as well as factors impacting Social Determinants of Health (SDoH). While these were emerging considerations pre-pandemic, our team is hopeful that COVID will become a catalyst for a stronger focus on SDoH and mental wellness over the next decade.
Phase 3 – Deployment Phase
The pandemic will not be “over” once general vaccine deployment happens. Americans will continue to need to practice social isolation and risk mitigation strategies until we reach herd immunity. Based on our team’s modeling and experience researching other pandemics, we expect it may take up to another year to sufficiently vaccinate the general population due to the transportation, cold storage, booster requirements, compliance, access and supply barriers outlined above. Phase 3 will present critically important policy, economic, and health-related implications for which hospital providers should prepare.
Critical policy decisions will need to be made with respect to manufacturing of the vaccine, deployment of the vaccine, and mitigation strategies while people wait for vaccination. It will require that U.S. policymakers “play a perfect game” to create herd immunity by this time next year.
Manufacturing vaccines have already begun for a limited supply (100 million doses each) as part of Operation Warp Speed. The program promises a rapid delivery of the Pfizer vaccine which requires two doses and will only cover 50 million people (or approximately 15% of the population). If the other two contenders are also approved (mRNA-1273 by Moderna and AZD1222 by AstraZeneca), it is likely the U.S. will just have enough vaccines to inoculate two-thirds of the population.
However, this assumes that none of the vaccines have issues. For instance, the vaccines were tested in record breaking trial timelines and side effects may be found during more protracted deployment. Things can and do go wrong over time. There have been reports hacking the cold supply transportation and issues raised regarding the rigor of the AstraZeneca trial data.
Deployment of at least 220 million vaccines across the U.S. will not be simple. In the best of times, deploying this many vaccines would be a logistical challenge, let alone in a stressed and resource depleted national healthcare system.
Based on the current administration’s approach, vaccines will be deployed by private retail pharmacies rather than national emergency organizations such as FEMA or the National Guard. Some experts have questioned whether this approach can move quickly enough. If the new administration transitions to a national approach, it will take time to retool and implement the strategy as well as to get bipartisan buy-in, not only among politicians but a heavily divided population.
The final major policy hurdle is societal compliance with the mitigation strategies required to get us through Phase 3. As we have seen throughout 2020, Americans are not particularly compliant when they are told to social distance, wear masks, and stay at home. Vaccine compliance also means people are willing to take the vaccine. Current polls show 42% of the population is opposed to vaccine compliance.
The challenges of manufacturing, deployment, and compliance are likely to increase the time required for full vaccination which could take up to a year once the vaccine becomes available.
Phase 3 will continue to stress the current economic system. While it looks likely that a second injection of federal emergency stimulus money will occur, it may be less than what is needed to weather the storm. COVID has significantly taxed one of the largest and most fragile parts of the U.S. economy – healthcare. A second economic contraction could occur in 2021, driven by the U.S. healthcare economy.
During Phase 3, hospital focus will be on both COVID and non-COVID emergent and urgent patients. Non-COVID patients with cardiac conditions, brain conditions (bleeds, strokes, and tumors), and cancer will continue to need care. Healthcare organizations will need to understand that patients will no longer be able to wait at home for non-COVID care. Providers will need to improve their service line delivery models for cardiac, oncology, and neurosciences to decrease length of stays and reduce inpatient stays. The pre-pandemic transition to outpatient and ambulatory care will likely be accelerated. On top of that, it is possible that new venues for subacute COVID long haulers will need to be developed (as will be discussed in the next article).
During Phase 3, healthcare providers will need to pay attention to the mental health and wellness of their workforce. Front-line workers are combat-fatigued and may experience long post intra-traumatic stress syndromes for years to come. All of these factors will be a burden on the healthcare economy. We need to learn from our past and implement key sustainability strategies that have been proven to enhance individual wellness of these vulnerable populations, such as self-validation, self-efficacy, empowerment of individuals, and connectivity to communities leveraging modern digital tools.
A key consideration to protect the health of our labor force may be to mitigate the economic stress they are facing now. We might consider a specific debt forgiveness policy for the first responders based on years of service, much like the military services offer. We need to find a way to keep these exhausted front-line workers engaged in a sustainable manner and replenish the workforce through economic and quality of life incentive policies.
During Phase 3, more people will become infected. For survivors, COVID is proving to create chronic medical conditions, for example chronic pulmonary and cardiac diseases, that will persist for years to come (this will be discussed in the next article – the Long Haul Phase).
An increased focus on mental health and wellness may emerge out of the pandemic. As people have quarantined themselves and their families and lost jobs and loved ones, they are experiencing greater anxiety, depression, and addiction. Based on how these diseases manifest, increased levels of long-term mental health and wellness care requirements will continue for the foreseeable future.
While many Americans think we’ve reached the “fourth quarter” of the COVID game, in reality we are only at the beginning of the “second quarter”. We have only passed the Initial Onset Phase and are in the Pre-Deployment Phase. This represents the most dangerous phase, with a significant risk of an access-related increase in mortality rates coupled with high stress levels resulting in significant long-term harm to the population.
We will, unfortunately, be entering Phase 3 of vaccine deployment in a state of significant resource depletion while taking on the ambitious healthcare efforts needed to protect our nation. Once vaccine deployment begins, Phase 3 may take up to a year. This presents policy, health, and economic challenges that will continue to stress an already fragile society. What we do now will define important aspects of American life for decades. Phases 2 and 3 will be difficult, but we are hopeful that COVID may actually help the United States unify and forge a pluralistic path out of the crisis. We also strongly believe in American ingenuity and are hopeful we can create a more resilient, efficient and contemporary healthcare system.
In our next article, we will focus on what we call “Phase 4”, or the Long Haul Phase, which represents the lasting impact of the pandemic on the nation. Stay with us and stay healthy.
About the Author: Dr. Kassam is a pioneering neurosurgeon, CEO and Founder of Neeka Health Enterprises, and the Chief Medical Officer at the National Hockey League Alumni Association. He has developed and implemented integrated patient-centric service line delivery models. Over two decades, Dr. Kassam has emerged as a strategic thinker that can work across multiple disciplines and bring people together to make meaningful change in the service of patients.
Neeka Health, LLC. Note: All charts are subject to uncertainties associated with any modeling assumptions and not intended for financial and healthcare treatment guidance.