April 27, 2020

FAST CHANGING LEGISLATIVE ENVIRONMENT

April 27, 2020

Similar to other initiatives expressed in major battle-like terminology, governmental responses to the coronavirus pandemic have been stated as declaration of a war on COVID-19. Legislators and government administrators throughout the U.S. have been working assiduously to mount an effective series of initiatives to combat and repel this deadly disease.

Although not having a particulary strong record for crafting legislation when control of the two congressional chambers is divided between the political parties, especially during an election year, the year 2020 is monumental in significant ways. Many pieces of legislation can languish for months and even years prior to being passed. The existence of a pandemic can change the timetable quite dramatically.

As of late April, the Trump Administration and Congress were busy negotiating the next stage of economic recovery legislation. The purpose of the bill is to provide additional funds for the Paycheck Protection Program for small businesses and nonprofits since the money supply was exhausted on April 16. Once enacted, companies that continue paying their employees will be eligible to receive forgivable loans underwritten by the federal government. House and Senate Democrats are in favor of directing some funding to minority-owned and rural businesses, and to add more for hospitals and enhanced COVID-19 testing capacity. Not as large as the $2 trillion CARES Act that became law in late March, the new infusion of funding would represent a sorely needed stimulus to an economy that is sagging from this disease.

This legislation proceeded at a rapid pace albeit being accompanied by serious disagreements regarding its contents. One controversial provision revolved around the issue of diagnostic testing. Democrats favor establishment of a national strategy for testing while Republicans are more inclined to place authority for making decisions at the state level.

The Senate on April 21 unanimously passed a $484 billion package that renews funding for a small- business loan program, boosts aid for hospitals, and expands testing for COVID-19. The bill then went to the House for approval. The aid deal includes more than $320 billion for the Paycheck Protection Program for small businesses, $60 billion for the small-business disaster fund, $75 billion for hospitals and $25 billion to increase COVID-19 testing. President Donald Trump then signed the legislation (H.R. 266) into law (P.L. 116-139) on April 24, 2020. As pandemic events continue to unfold. It remains possible that efforts will be made on Capitol Hill to add more money to deal with the effects of this disease.

Until recently, an increased pace of globalization has characterized economies around the world. A pandemic helps to change the focus by making it necessary for nations to ensure that individuals are protected within their respective borders. Immigration and travel policies become more restrictive. Manufacturing of essential medicines for domestic use no longer can be viewed as a luxury that is left to other nations to provide. COVID-19 has heightened a perceived threat that the U.S. has become too dependent on letting other countries be the main suppliers of health products needed here. Bipartisan interest is being renewed in S. 1317, the American Mineral Securities Act, as a way of enhancing production of dozens of minerals, including rare earth elements used in pharmaceuticals and medical devices. The bill would require nationwide assessments of more than 50 minerals and boost the U.S. workforce needed to produce the substances.

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STUDENT UNCERTAINTY ABOUT RE-ENROLLING IN FALL 2020

Kristen Truong

April 27, 2020

Now that colleges and universities across the nation have closed their doors for the current semester, a question worth pondering is what can be expected to happen in the Fall and will all students return to campus if able to do so? A national survey commissioned by the American Council on Education (ACE) and the American Association of Collegiate Registrars and Admissions Officers (AACRAO) administered to more than 2,000 currently enrolled U.S. college students finds that nearly one in five are uncertain about their plans for re-enrolling in the fall, or definitely are not going at all. Eighty-two percent of students say, however, that they will be able to complete all or most of their spring coursework as planned, while just 5% indicated they will not be able to complete any courses as planned.

Some 12% are uncertain or no longer plan to enroll at all. An additional 3% say they are planning to enroll in the fall to make up classes not completed in the spring due to COVID-19, meaning it is not clear they are planning to re-enroll fully. Finally, 3% say they were not planning to enroll previously and that has not changed. Hence, students who are uncertain or definitely not returning present a mixed picture for institutions already suffering significant financial losses due to the pan- demic and adding to an uncertain portrait of what fall enrollment might look like. An Infographic containing more information can be obtained here.

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PRESIDENT’S CORNER

Kristen Truong

April 27, 2020

BY ASAHP PRESIDENT PHYLLIS KING

CONTINUITY, CONNECTIVITY, AND CONVERGENCE

We have been thrust into the digitization of healthcare. The pandemic has fast-forwarded our adoption of technologies to serve the healthcare industry in almost every way. The convergence of technology, digitalization, additive manufacturing, machine learning and 3D modeling is here. Innovations as a result of these changes will significantly impact the patient experience, businesses, and the

modeling of education to prepare the next generation healthcare workforce.

The question for higher education is how fast can we understand, adapt, anticipate and project patient care needs and healthcare innovations to prepare our students and meet the needs of this new world? Digital literacy has become a necessity. Data-informed decision-making offers us a superior advantage. Collaborations and partnerships are critical.

ASAHP supports, informs, guides, leads, and works with you to advance education, practice, and research, and influence policies through partnerships. Let’s work together to shape our future. ASAHP is adapting to a more virtual reality and virtual forms of engagement with members to be more responsive to members. Join a community of learning and conversations on our website (click here to join).

More frequent webinar offerings on important topics to the health professions are being developed. The first webinar on “Clinical Education in the Time of COVID-19” received an overwhelmingly positive response with 245 participants from 96 institutions. The webinar is posted on the ASAHP website in case you were not able to attend. We will continue to bring you the latest news and information via multiple communication channels. Join us when you can.

STUDENT UNCERTAINTY ABOUT RE-ENROLLING IN FALL 2020

Now that colleges and universities across the nation have closed their doors for the current semester, a question worth pondering is what can be expected to happen in the Fall and will all students return to campus if able to do so? A national survey commissioned by the American Council on Education (ACE) and the American Association of Collegiate Registrars and Admissions Officers (AACRAO) administered to more than 2,000 currently enrolled U.S. college students finds that nearly one in five are uncertain about their plans for re-enrolling in the fall, or definitely are not going at all. Eighty-two percent of students say, however, that they will be able to complete all or most of their spring coursework as planned, while just 5% indicated they will not be able to complete any courses as planned.

Some 12% are uncertain or no longer plan to enroll at all. An additional 3% say they are planning to enroll in the fall to make up classes not completed in the spring due to COVID-19, meaning it is not clear they are planning to re-enroll fully. Finally, 3% say they were not planning to enroll previously and that has not changed. Hence, students who are uncertain or definitely not returning present a mixed picture for institutions already suffering significant financial losses due to the pandemic and adding to an uncertain portrait of what fall enrollment might look like. An Infographic containing more information can be obtained here.

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CALLING ALL CARS AND HEALTH DETECTIVES

Kristen Truong

April 27, 2020

If the novel COVID-19 pandemic happened to be considered a crime scene, then at some point health detectives, also known as epidemiologists, would be called to investigate. Apart from the heroic efforts of respiratory therapists, dietitians, physical therapists, and other health professionals, such as physicians and nurses who are on the front lines administering care to patients, the efforts of epidemiologists will be necessary to explain what happened at key stages of this disease and the subsequent havoc that it wreaked.

It is worth noting that the eminent biologist J.B.S. Haldane in 1963 (Journal of Genetics) described important stages of acceptance in the advancement of science:

Stage 1: This is worthless nonsense.
Stage 2: This is an interesting, but perverse point of view.
Stage 3: This is true, but quite unimportant.
Stage 4: I always said so.

Since the dawn of recorded history, humans have been confronted with infectious disease outbreaks that have ravaged the population. Throughout the millennia, it has been common for mistakes to be made in understanding the true nature of invading agents and how best to treat their dire effects. The situation this time is quite similar. Errors have been made in several nations regarding whether COVID-19 was deemed to be a problem of deadly significance and whether constructive responses were and are being made in a timely manner.

Some epidemiology models are developed on the basis of collecting data involving four key building blocks: Susceptibility, Exposure, Infection, and Recovery (SEIR). Data in each category can undergo changes on a daily basis. A report from the CDC on April 8, 2020 sheds light on the susceptibility aspect of COVID-19 by providing age-stratified, disease–associated hospitalization rates for patients in March 2020. Among patients hospitalized: 74.5% are aged ≥50 years; 54.4% are male, and among adult patients with data on underlying conditions, 89.3% have one or more of them with the most common being hypertension (49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes mellitus (28.3%), and cardiovascular disease (27.8%). Moreover, among patients where race/ethnicity data were available, 33.1% are non-Hispanic black.

Linking data from the S component of an epidemiology model to both the E and the I portions creates an opportunity to employ some prevention measures to reduce exposure and the likelihood of infection (e.g., social distancing). For the R part of the SEIR model, a serological test may prove that an antibody response occurred after infection of a patient. Still unknown is whether individuals who test positive will remain immune either to infection or reinfection. Also, if the virus mutates, will those antibodies produce a comparable level of protection? Someday, epidemiologists will have answers for all these questions. It also will be interesting to see if any pundits eventually migrated from Haldane’s Stage 1 to Stage 4.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Kristen Truong

March 25, 2020

Trends In Alcohol-Induced Deaths In The United States, 2000-2016

According to a paper appearing on February 21, 2020 in JAMA Network Open, a total of 425,045 alcohol-induced deaths were identified from 2000 to 2016. The rate of such deaths increased substantially among men and women and accelerated recently. The largest increases by race/ethnicity were observed among American Indian and Alaska Native men, American Indian and Alaska Native women, and white women. Despite initial declines among black women, black men, and Latino men, increases occurred later in the study period. Among American Indian and Alaska Native individuals, increases throughout the age range were observed, with the largest absolute increase occurring for ages 45 to 49 years among men and for ages 50 to 54 among women. This study found large increases in alcohol-induced death rates across age and racial/ethnic subgroups of the US population, which have accelerated over recent years. Large increases in these deaths among younger age groups may be associated with future increases in alcohol-related disease.

Attention-Deficit/Hyperactivity Disorder And Learning Disabilities Among U.S. Children Aged 3–17 Years

According to data released in March 2020 from the National Health Interview Survey, in 2016–2018, nearly 14% of children aged 3–17 years were reported as ever having been diagnosed with either attention-deficit/hyperactivity disorder (ADHD) or a learning disability. Non-Hispanic black children were the most likely to be diagnosed (16.9%). Among children aged 3–10 years, non-Hispanic black children were more likely to have ever been diagnosed with ADHD or a learning disability compared with non-Hispanic white or Hispanic children. Diagnosis of ADHD or a learning disability differed by federal poverty level for children in all racial and ethnic groups. Diagnosis of ADHD or a learning disability differed by parental education among non-Hispanic white children only. Attention-deficit/hyperactivity disorder (ADHD) and learning disabilities are the most commonly diagnosed neurodevelopmental disorders in children and often coexist.

HEALTH TECHNOLOGY CORNER

Lab-On-Chip Ultrasonic Platform For Real-Time And Nondestructive Assessment Of Extracellular Matrix Stiffness

According to an article published in Issue 4, 2020 of the journal Lab on a Chip, similarly to how a picked lock gives away that someone has broken into a building, the stiffening of a structure surrounding cells in the human body can indicate that cancer is invading other tissue. Monitoring changes to this structure, called the extracellular matrix, would give researchers another way to study the progression of disease. Detecting changes to the extracellular matrix is hard to do, however, without damaging it. Purdue University engineers have built a device that would allow disease specialists to load an extracellular matrix sample onto a platform and detect its stiffness through sound waves. Researchers first demonstrated the device as a proof-of-concept with cancer cells contained in hydrogel, which is a material with a consistency similar to an extracellular matrix. The team now is studying the device's effectiveness on collagen extracellular matrices.

Brain Reading Technology And Development Of Brainwave-Controlled Devices

Researchers at the Francis Crick Institute, Stanford University, and University College London have developed a new method to record brain activity at scale accurately. A manuscript appearing on March 20, 2020 in the journal Science Advances indicates that the technique could lead to new medical devices to help amputees, patients with paralysis, or individuals with neurological conditions, such as motor neurone disease. The system consists of a bundle of microwires mated to large-scale microelectrode arrays, such as camera chips. This system has excellent recording performance, demonstrated via single unit and local-field potential recordings in isolated retina and in the motor cortex or striatum of awake moving mice. The modular design enables a variety of microwire types and sizes to be integrated with different types of pixel arrays, connecting the rapid progress of commercial multiplexing, digitization, and data acquisition hardware together with a three-dimensional neural interface.

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REPORTING OF RACE AND ETHNICITY IN THE MEDICAL LITERATURE

Kristen Truong

March 25, 2020

Far beyond mere academic interest, the collection of race and ethnicity data is an important way to identify and ultimately address disparities in access to treatment and inequalities in health care provision. The extent to which race and ethnicity, a multifaceted concept, is reported in the medical literature is extremely variable, according to an article published in the March 2020 issue of the Journal of Clinical Epidemiology. Investigators sought to determine objectively the quality of reporting of race and ethnicity in original medical research papers. A retrospective bibliometric analysis was used. Two independent investigators analyzed original articles investigating race and ethnicity, published between 2007 and 2018, in the 10 top-ranking academic journals in each of the following categories: general medicine, surgery, and oncology.

Among 995 original articles reporting race and ethnicity in the top 10 ranking medical academic journals, only 4.52% provided a formal definition of race and ethnicity and only 10.25% described the method used to classify individuals as to race and ethnicity. Eighty-one different race and ethnicity classifications were identified, but they often were imprecise and open to interpretation. A reasonable question is what, if anything, does this information add to what already is known? The adherence of leading medical academic journals to International Committee of Medical Journal Editors (ICMJE) and also the American Medical Association (AMA) Manual of Style guidelines was poor (still poor when considering previous studies). Pertinent questions are what is the implication and what should change now? The investigators conclude that there is significant room for improvement in the collection, reporting, and publishing of data describing ethnicity and race. Given that many national and international agencies, including the National Institutes of Health, require extensive data sets to identify and ultimately prevent health disparities, the lack of adequate reporting of race and ethnicity in the medical literature presents a significant and clinically relevant problem.

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TEETH, EARLY-LIFE ADVERSITY, AND MENTAL HEALTH RISK

Kristen Truong

March 25, 2020

Exposure to early-life adversity is one of the biggest risk factors for both mental and physical health problems across the lifespan. A need for objective measures that are noninvasive, inexpensive, and able to provide more accurate information about the presence and timing of childhood adversity has been recognized. If such a measure existed, its public health implications would be profound. For the first time, clinicians would be able with confidence to identify children on a population-wide scale who experienced childhood adversity during sensitive periods in development and therefore are at future risk for developing a psychiatric or other disorder. A manuscript appearing in the March 2020 issue of the journal Biological Psychiatry advances the proposition that teeth potentially could serve as a promising and actionable new tool capable of achieving key primary prevention goals. To support this claim, researchers first summarized empirical work from dentistry, anthropology, and archaeology on human tooth development and show how these fields collectively have studied human and animal teeth for decades, using teeth as time capsules that preserve a permanent, time-resolved record of life experiences in the physical environment.

Specifically, the investigators articulate how teeth have been examined in these fields as biological fossils in which the history of an individual’s early-life experiences is permanently imprinted, acknowledging that this line of research is related to, but distinct from, studies of oral health. They then integrate these insights with knowledge about the role of psychosocial adversity in shaping psychopathology risk to present a working conceptual model, which proposes that teeth may be an understudied yet suggestive new tool to identify individuals at risk for mental health problems following early-life psychosocial stress exposure. They end by presenting a research agenda and discussion of future directions for rigorously testing this possibility and with a call to action for interdisciplinary research to meet the urgent need for new biomarkers of adversity and psychiatric outcomes.

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AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

Kristen Truong

March 25, 2020

Characteristics And Health Status Of Informal Unpaid Caregivers: 2015-2017

The Centers for Disease Control and Prevention (CDC) has released a report, Characteristics and Health Status of Informal Unpaid Caregivers. In 2015, an estimated 17.7 million U.S. persons were informal caregivers who provided substantial services through in-home, unpaid assistance to their family members and friends. Caregiving can have many benefits, such as enhancing the bond between caregiver and recipient, but it also can place an emotional and physical strain on caregivers, leading to higher rates of depression, lower quality of life, and poorer overall health. Based on three years of Behavioral Risk Factors Surveillance System (BRFSS) data across 44 states, the findings indicate that approximately 20% of respondents were caregivers, and nearly 20% of these caregivers reported fair or poor health. Demographic characteristics and health status of unpaid caregivers, along with implications of the findings are discussed. Unpaid family and friend caregivers are paramount to the care of older adults, as well as the health system more generally. Unfortunately, caregivers are often under-supported and consequently may suffer adverse health effects. The report can be obtained here.

2020 Alzheimer’s Disease Facts And Figures

2020 Alzheimer’s Disease Facts and Figures is a statistical resource for U.S. data related to Alzheimer’s disease, the most common cause of dementia. This disease is the most common cause of dementia, accounting for an estimated 60% to 80% of cases. Recent large autopsy studies show that more than half of individuals with Alzheimer's dementia have Alzheimer's disease brain changes (pathology) as well as the brain changes of one or more other causes of dementia, such as cerebrovascular disease or Lewy body disease. This condition is called mixed pathologies, and if recognized during life is called mixed dementia. Difficulty remembering recent conversations, names or events is often an early clinical symptom. Apathy and depression also often are early symptoms. Later symptoms include impaired communication, disorientation, confusion, poor judgment, behavioral changes and, ultimately, difficulty speaking, swallowing, and walking. Background and context for interpretation of the data are contained in the Overview. Additional sections address prevalence; mortality and morbidity; caregiving; and use and costs of health care and services. A Special Report examines primary care physicians’ experiences, exposure, training, and attitudes in providing dementia care and steps that can be taken to ensure their future readiness for a growing number of Americans living with Alzheimer’s and other dementias. The report can be obtained here.

Critical Analysis Of Existing And Emerging Patient Safety Practices

Despite sustained national attention and notable successful interventions in recent years, patient safety remains a significant problem in the United States. Harms such as adverse drug events, healthcare-associated infections (HAIs), falls, and obstetric adverse events are responsible for thousands of deaths and hundreds of thousands of injuries each year. An estimate is that in 2017, there were 86 hospital-acquired conditions per 1,000 hospital discharges, a figure that has fallen steadily in recent years, but remains alarmingly high. The Making Healthcare Safer III report by the Agency for Healthcare Research and Quality (AHRQ) addresses this continuing problem by supporting the implementation of patient safety practices where appropriate, advancing a framework for patient safety transformation, and considering the contextual factors that can lead to successful use of patient safety interventions. Forty-seven practices are reviewed that target patient safety improvement in hospitals, primary care practices, long-term care facilities, and other healthcare settings. The practices are categorized among 17 chapters that represent harm areas including medication management and diagnostic errors. The practices include clinical decision support and those designed to prevent medication errors and reduce opioid misuse and overdose. The report can be obtained here.

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DEVELOPMENTS IN HIGHER EDUCATION

Kristen Truong

March 25, 2020

As the month of March 2020 draws to a close, the nation is experiencing an unprecedented array of governmental and non-governmental proactive and reactive initiatives to mitigate the impact of COVID-19. Closing K-12 to postgraduate education activities will exert a wide variety of strains on students and their families. For example, a health professional who also happens to be a single parent with children is placed in the unenviable position of trying to juggle the responsibility of going to work every day to provide care for patients while also contending with the challenge of assuming family life duties for offspring who are at home because of school closings.

Portions of the education sector are being affected in different ways. Classroom teachers throughout the nation have to figure out how best to furnish a comparable level of education for their students who now are at home rather than on school grounds. Children who depend on school nutrition programs for food need to have effective alternative ways of being fed satisfactorily. Colleges and universities fortunate enough to possess hefty endowments may not have any immediate concerns of having to make refund payments to students for dormitories that have been closed and classes that have been suspended indefinitely. The same is not true, however, for institutions with little in the way of financial reserves and that rely heavily on tuition income. A related concern is that the high cost of operating intercollegiate athletic programs for students cannot be offset by post-season tournament revenues derived from television and ticket sales.

Governmental Assistance For Education In Response To The Spread Of The Coronavirus

Phase 2 of a federal stimulus package in the form of the Families First Coronavirus Response Act (P.L. 116-127) expands paid family and medical leave for child care due to school and day care closings for both private and public employers with less than 500 employees. Recognizing that more assistance is needed, legislators continue to seek agreement on how to address related situations that include: (1) Continuation of school lunch programming; (2) Allow the secretary of education to defer student loan payments, principal, and interest for three months without penalty to the student, with an additional three months’ deferment available if necessary; (3) Ensure that students at eligible institutions whose semesters were ended due to the emergency do not have to return their Title IV aid or have the distributed aid count towards their loan limits; and (4) Allow institutions to issue work-study payments to a student who is unable to work due to work-place closures and grant institutions the ability to transfer unused work-study funds for supplemental grants.

Under a change announced on March 20, borrowers can suspend payments for two months by contacting their servicers and enrolling in “forbearance.” No interest would accrue during that time. The plan would apply to all loans made directly by the federal government and to a portion of those made by private lenders and guaranteed by the government under a program that ended in 2010. However, loans made under the federal guarantee program that are held by commercial institutions won’t qualify. Approximately 43 million Americans owe roughly $1.5 trillion in federal student loans. The typical family spends $179 a month on payments, according to a July 2019 report by the JPMorgan Chase Institute.

Accreditation In The Context of Disease Transmission Increases

The congressional legislative hopper contains bills aimed at improving accreditation. The necessity of focusing on initiatives that bear directly on controlling the spread of disease means that for the immediate future such legislation will not move forward. Examples are: H.R. 5768, the Accreditation Reform Act to amend the Higher Education Act of 1965 to protect students and taxpayers by modernizing evaluation and increasing transparency in the accreditation system, and for other purposes; and H.R. 5171 to authorize the National Advisory Committee on Institutional Quality and Integrity permanently. Currently, it must be reauthorized each time the Higher Education Act is extended or reauthorized. Meanwhile, Education Secretary Betsy DeVos announced finalization of a package of regulations on college accreditation that are designed to erase any distinction between regional and national accrediting agencies. If the original schedule is adhered to, they will be effective this coming July 1. Aimed at promoting innovation in higher education, consumer advocates have expressed concerns that new regulations will enable low-quality institutions to shop for friendly accreditors more easily, thereby allowing them to access federal funding.

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HEALTH REFORM DEVELOPMENTS

Kristen Truong

March 25, 2020

Across the decades, policymakers have strived assiduously to produce improvements pertaining to the metaphorical three-legged stool of health care quality, access, and cost. The Patient Protection and Affordable Care Act of 2010 came into effect in March of that year. It represented a highly comprehensive approach of dealing with a wide range of defects and deficiencies in health care that continued to persist in the first decade of the 21st century.

Until several weeks ago, efforts to reform health care have proceeded in incremental and uncoordinated ways. The sudden appearance of a new communicable disease in the form of a pandemic has resulted in an explosion of new initiatives launched through a combination of coordinated federal and state interventions. Such new efforts continue at a rapid pace, but they do so in a time of considerable uncertainty. Some essential issues that continue to call for a clear resolution involve the following considerations: the best way of slowing the spread of infection, accurately determining how many individuals continue to circulate freely as their infection goes undetected, understanding how long the current appearance of the disease will last, and even if it apparently disappears, what the likelihood is that it could resurface later in the year. Also, if an appropriate vaccine becomes available, it remains to be seen whether it will result in any untoward hazardous side effects.

Role Of The Health Workforce And Challenges It Faces

A steady accumulation of new cases of COVID-19 in both the U.S. and in other countries that occurs as diagnostic testing for the presence of this disease increases, means that much greater stress is being placed on the capacity of the network of health care services to deal with this situation. Apart from the basic question of whether there are sufficient numbers of many kinds of health professionals in appropriate venues, such as hospitals to meet patient demands for care, there is the matter of the increased risk of disease exposure these personnel must confront when providing treatment. Not all of these individuals have the protective equipment needed to prevent infection. Logistically, more effort is needed to increase the supply chain and ensure that effective masks and hazard protection clothing are distributed rapidly. Otherwise, a serious problem becomes even more threatening if front line health care practitioners are sidelined because they also become seriously ill.

The Left Hand Giveth While The Right Hand Taketh Away

Many actions taken with the best of intentions, unfortunately often are accompanied by unintended negative consequences. For example, according to the Congressional Research Service, the current COVID-19 outbreak may pose significant challenges for the United States’ blood supply. Mitigation strategies to prevent the spread of this disease, such as closures of schools and workplaces, have led to blood drive cancellations, resulting in a critical blood supply shortage in the Pacific Northwest (specifically, western Washington and Oregon). School closures, event cancellations, and other mitigation strategies in other areas of the country may provide challenges for maintaining a sufficient blood supply. The management and distribution of the supply in this nation is coordinated largely by private organizations (e.g., Red Cross), with some oversight by the Department of Health and Human Services (HHS). Congress may need to consider how best to address critical shortages, such as through HHS or the U.S. Food and Drug Administration’s (FDA) authority over blood safety and donation guidance.

The VA Health System Within A Nonexistent System

Calling U.S. health care a system is a misnomer. Rather than a single unified entity, it is a collection of various systems that include government providers (e.g., Veterans Health Administration and Medicare) and non-governmental providers (e.g., private sector employers and private insurance). At a time of COVID-19 crisis, the Veterans Administration is of special interest. Because of their age, patients who served in Vietnam, Korea, and World War II are an important part of a demographic group designated as being at high risk for this disease. The VA currently administers the provision of health care services for more than nine million beneficiaries. Having served their nation in time of need, every effort should be made to ensure that these individuals receive the kind of care they need in this period of crisis.

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RISING TO THE OCCASION

Kristen Truong

March 25, 2020

Ordinarily during a presidential election year, significant legislative proposals grind to a halt. The party controlling the White House would like to be able to enact laws that bolster its reputation in ways that strengthen the rationale for voters to retain it in office. Opponents in the other party are less inclined to aid in achievement of that goal. Instead, it is much more to their advantage to portray the incumbents as being ineffective and give the electorate good reasons for removing current officials from office.

A good crisis can act as a circuitbreaker that disrupts this pattern of doing business and it arrived in the form of a declaration by the World Health Organization that a pandemic is underway accompanied by the establishment of a national emergency by the Trump Admiistration regarding the outbreak of COVID-19. These developments have set in motion some extraordinary responses in the form of legislation aimed at providing nostrums for the perceived health and economic threats posed by this disease. The following description of the steps being taken may be considered partial as of the date this section of the newsletter is being written because each passing day stimulates the arrival of new responses to the challenges arising from the spread of communicable disease.

In phase one of providing financial assistance, the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (P.L. 116-123), which passed with near unanimous support in both the House and Senate, was signed into law by the President on March 6, 2020. The bill provides $8.3 billion in emergency funding for federal agencies to respond to the coronavirus outbreak. Of that amount, $6.7 billion is designated for the domestic response and $1.6 billion for the international response. The next major step taken was completion of the second supplemental legislative package aimed at seeking to contain and combat the COVID-19 pandemic. The president signed the Families First Coronavirus Response Act H.R. 6201 (P.L. 116-127) on March 18. The House had passed the bill on both a 363-40 vote on March 14 and a subsequent March 16 unanimous vote to add technical corrections. The Senate then passed the measure on a vote of 90-8 on March 18.

The scope of these initiatives is vast insofar as recognition is being accorded to major disruptions caused by health care facilities in the U.S. possibly being overwhelmed by the demand for services and economic dislocations that result from workers becoming unemployed, along with the production of essential goods and services being curtailed. The kinds of situations either addressed by existing initiatives or being contemplated for future action include: unemployment insurance; enhanced paid leave and sick leave; direct financial payments to individuals; federally guaranteed loans to employers; loans to distressed industries, such as airlines; and increased funding for medical supplies and equipment.

P.L. 116-127 makes it possible for group and individual health insurance plans to cover approved diagnostic tests as well as office visits, treatment at urgent care clinics, telehealth, and emergency room visits that result in orders for coronavirus diagnostic testing, insofar as the services received during the visit relate to testing or determining the need for testing. Plans will not be able to impose cost-sharing or subject enrollees to prior authorization or other medical management requirements.

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PRESIDENT’S CORNER

Kristen Truong

March 25, 2020

BY ASAHP PRESIDENT PHYLLIS KING

We are living in an unprecedented reality that is likely to have a transformational effect on aspects of our lives, especially higher education. No doubt everyone has had to demonstrate adaptability and creativity to address changes under challenging conditions. The pandemic has altered our routine lifestyles to one of disruption, social distancing and isolation. Use of technology has provided us with a means of continuity in operations and communications. This is a time to model resilience, persistence, strategic thinking, leadership and teamwork, as we all work together to recover.

The Higher Logic platform is a member benefit of ASAHP where you can share online your questions, concerns, announcements, best practices, and many other items (click here for the ASAHP Community). I encourage you to join this community and reach out to others sharing similar experiences. Show your support and learn from one another collectively how to handle challenging times and build a road to recovery. ASAHP is here for you.

The Association has been instrumental in providing resources for institutions of higher education. The following examples indicate efforts aimed at continuing to monitor COVID-19:

Interim Guidance for Administrators of US Institutions of Higher Education (IHE) to Plan, Prepare, and Respond to Coronavirus Disease 2019 (COVID-19)

Interim Guidance: Get Your Mass Gatherings or Large Community Events Ready for Coro- navirus Disease 2019 (COVID-19)

CDC Coronavirus Information

Harvard Medical School Coronavirus Resource Center

Department of Education Coronavirus Information and Resources for Schools and School Personnel

Federal Student Aid Guidance

Federal Student Aid FAQ

Inside Higher Ed Article - March 6, 2020

Inside Higher Ed Coronavirus Coverage

World Health Organization Coronavirus Information

White House Coronavirus Guidelines for America

Kaiser Family Foundation Tracking

HRSA Coronavirus Resources

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SOME REFLECTIONS ON A PANDEMIC

Kristen Truong

March 25, 2020

The early part of the 1600s was characterized by the plague in Europe. Vaccinations were unknown, so health authorities had to rely on other forms of conventional wisdom. Health officer Cristofano di Giulio of Prato in Italy wrote a manuscript back then with the title Libro della Sanità, in which he provided a summary of what he believed a public health officer ought to know in time of plague.

He asserted that it has been proven by experience that to respond to an epidemic, first of all it is necessary to resort to the majesty of God and in the intercession of the Holy Virgin and of the Saints. Then it is necessary to observe with every possible diligence the following rules: (1) disinfect with sulphur and perfumes all homes or rooms wherein there has been death or sickness; (2) separate at once the sick from the healthy as soon as the case of illness is discovered; (3) burn and take away at once those objects such as have been used by the deceased or by the sick; and (4) shut up straight away all houses wherein there have been infected patients and keep them closed for at least 22 days so that those who are segregated inside the houses will not carry the infection to other individuals.

Physicians suggested that patients should be treated at a distance with the barber-surgeon of the lazaretto (i.e., a pest house for isolating persons believed to have the disease or to be incubating it), shouting from the window the quality, sex, condition of the patient, and the stage of illness. A cautious physician then would shout back the cure from a safe distance. Another belief was that even though a patient had recovered, convalescents remained infectious for some time.

Unfortunately, related public health measures failed to produce salutary outcomes. Orders for the mass slaughter of dogs and cats, in the belief that the coats of these animals harbored the plague bearing miasma, made life easier for rats, the creatures eventually discovered to be more closely associated with disease outbreaks. Oddly enough, resorting to the majesty of God often led to crowded religious processions and packed houses of worship, which aided in the rapid transmission of infection.

1960 Nobel Prize winner Sir Macfarlane Burnet stated in 1962 that “One can think of the middle of the 20th century as the end of one of the most important social revolutions in history, the virtual elimination of the era of infectious diseases as a significant factor in social life.” Since then, the appearance of Zika, Ebola, SARS, MERS, and other devastating communicable diseases has shown that his prediction was issued prematurely. Enormous progress over the past four centuries has been made in medical laboratory procedures, hospital care, health devices, communication capabilities, and the highly sophisticated education and training of health professionals. These developments will have a decisive bearing on how successful efforts will be in eliminating the COVID-19 threat.

For the present, however, it is reasonably safe to assume that household pets are in no immediate danger of being slaughtered and physicians will not find it necessary to stand across the street from homes and holler instructions through bullhorns to their beleaguered patients.

Return to March 2020 TRENDS

QUANTIFYING HEALTH SYSTEMS’ INVESTMENTS IN SOCIAL DETERMINANTS OF HEALTH

John Colbert

February 25, 2020

Trends Archives

Social determinants (e.g., conditions in which individuals are born, grow, work, live, and age) are seen as accounting for substantially more of the variation in health outcomes than medical care does while interest in addressing these determinants has increased markedly in recent years. According to a study reported in the February 2020 issue of the journal Health Affairs, the past decade has involved a growing recognition of the importance of social determinants of health for health outcomes. Meanwhile, the degree to which health systems in the U.S. are investing directly in community programs to address social determinants of health as opposed to screening and referral is uncertain.

Researchers conducting this investigation searched for all public announcements of new programs involving direct financial investments in social determinants of health by U.S. health systems from January 1, 2017, to November 30, 2019. They identified 78 unique programs involving 57 health systems that collectively included 917 hospitals. The programs involved at least $2.5 billion of health system funds, of which $1.6 billion in 52 programs was committed specifically to housing-focused interventions. Additional focus areas were employment (28 programs, $1.1 billion), education (14 programs, $476.4 million), food security (25 programs, $294.2 million), social and community context (13 programs, $253.1 million), and transportation (six programs, $32 million). These figures demonstrate that health systems are making sizable investments in social determinants of health. To cite one example, housing-related programs included strategies, such as direct building of affordable housing, often with a fraction set aside for homeless patients or those with high use of health care; funding for health system employees to purchase local homes to revitalize neighborhoods; and eviction prevention and housing stabilization programs.

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THE ROAD TO IMMORTALITY IS PAVED WITH EPONYMS

John Colbert

February 25, 2020

Trends Archives

The health sphere represents fertile ground for the production of eponyms. Prominent examples are Salk vaccine, Alzheimer’s disease, Parkinson’s disease, and Obamacare. Perpetual glory appears to be associated with having one’s name used in such ways and the website Whonamedit.com provides thousands of examples of medical eponyms. Is the practice of employing them a constructive use of nomenclature or has it become more timeworn than beneficial? This kind of question is addressed in a manuscript that appeared in the February 11, 2020 issue of the journal Neurology in which a study is described that assesses historical trends of medical eponym use in neurology literature, and knowledge and attitudes among current trainees related to eponyms. The yearly prevalence of eponyms among neurologist-authored publications ranged from 15% and 25%, with a mean of 21%. The total number of unique eponyms appearing in titles and abstracts increased from 693 in 1988 to 1,076 in 2013, representing 1.8% average annual growth.

Worth noting is that medical eponyms represent a polarizing issue among clinicians, including neurologists. Impassioned calls for the abandonment of eponyms in the published literature and in clinical use have appeared regularly in the literature for decades. Supporters explain that eponyms are concise and memorable, providing an effective shorthand to communicate precisely in clinical settings. Eponyms also may represent an essential thread of medical history, an oral tradition transmitted to successive generations of students through teaching rounds. An opposing perspective is that eponyms can be viewed as lacking accuracy and being characterized by inconsistent usage, frequent misattribution of credit, and occasional recognition of individuals with unethical research practices, such as Nazi-affiliated physicians. Study findings indicate that residents with at least one year of neurology training reported familiarity with significantly more eponyms than those before neurology training (p < 0.001). For familiar eponyms, most residents either were unaware of an alternative descriptor or preferred using the eponym. Despite recognizing both the benefits and drawbacks of eponyms, the vast majority of trainees stated that historical precedent, pervasiveness, and ease of use would drive the continued use of eponyms in neurology. For the nonce, it seems reasonable to predict that this path to immortality will remain open.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

February 25, 2020

Trends Archives

2020 Patient Data Breach Barometer

In 2019, the healthcare industry continued to be plagued by data breaches involving sensitive patient information, with public reports of hacking jumping a staggering 48.6% from 2018. This number of reported hacking incidents is a reminder of how vulnerable patient data remain. An analysis by Protenus is based on 572 health data breaches reported to the U.S. Department of Health and Human Services (HHS), the media, or some other source during 2019. For the 481 incidents where data exist, breaches had an impact on 41,404,022 patients, which is likely to be a huge underestimate. Two incidents for which there were no data affected 500 dental practices and clinics and could affect significant volumes of patient records. The number of breaches went from 503 in 2018 to 572 in 2019, along with a substantial increase in the number of affected records. In 2019, the total number of affected records almost tripled when compared to 2018 data (i.e., 15,085,302 affected records).

Self-reported Marijuana Use In Electronic Cigarettes Among U.S. Youth

The National Youth Tobacco Survey (NYTS) is a cross-sectional, school-based study conducted annually using a stratified, three-stage cluster sampling design to produce a nationally representative sample of middle school (grades 6-8) and high school (grades 9-12) students in the U.S. They were asked about whether they ever have used marijuana in an e-cigarette. As reported in the February 4, 2020 issue of the Journal of the American Medical Association, the study identified a significant increase in self-reported ever marijuana use in e-cigarettes from 2017 to 2018 among U.S. students. Prevalence estimates reported for all students (14.7%) and current e-cigarette users (53.5%) in 2018 also were much higher than those reported in 2016 (8.9% and 39.5%, respectively). The increase in marijuana use in e-cigarettes could be attributable to the increase of sales of pod-mod–style e-cigarette products, access to marijuana through informal sources (e.g., friends, family members, illicit dealers), and reduced perception among adolescents of the harms of marijuana use.

HEALTH TECHNOLOGY CORNER

Light-Adapted Electroretinogram Differences In Autism Spectrum Disorder

A new eye scan could help identify autism in children years earlier than currently possible. This non-invasive device uses a hand-held instrument to locate a pattern of subtle electrical signals in the retina that are different in children on the autism spectrum. According to a manuscript published on February 7, 2020 in the Journal of Autism and Developmental Disorders, the retina is an accessible model of neural connectivity in the brain where specific retinal signaling pathways can be probed and measured with an electroretinogram (ERG). Light-adapted (LA) electroretinograms (ERGs) of individuals with autism spectrum disorder (ASD) were compared to control subjects in a multicenter study of children. The results show that the LA-ERG is a potential marker for neurodevelopmental conditions, such as ASD in children. These potential biomarkers for ASD also could allow for early detection of other disorders, such as attention deficit hyperactivity disorder (ADHD).

Evolving Magnetically Levitated Plasma Proteins Detect Opioid Use Disorder As A Model Disease

As reported on January 29, 2020 in the journal Advanced Healthcare Materials, new research from the University of British Columbia, Harvard Medical School, and Michigan State University suggests that levitating human plasma may lead to faster, more reliable, portable, and simpler disease detection. The researchers used a stream of electricity that acted like a magnet and separated protein from blood plasma, which is the clear, liquid portion that remains after red blood cells, white blood cells, platelets, and other cellular components are removed. The basic notion is that as plasma proteins are different densities, when separated the proteins levitate at different heights, and therefore become identifiable. An evaluation of these types of proteins and how they group together can produce a picture that identifies whether a patient has the possibility of contracting a disease or becoming addicted to drugs, such as opioids.

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HEALTH REFORM DEVELOPMENTS

John Colbert

February 25, 2020

Trends Archives

Debates by candidates seeking to be the Democratic party’s nominee to run against President Donald Trump in the upcoming election indicate that health care is a major policy issue that cries out for significant improvement. Proposals range from eliminating private forms of insurance coverage available through employers to protection offered solely by the federal government to a single-payer government operated program that also includes options for other forms of coverage. The latter choice recognizes that some beneficiaries may prefer having insurance provided by an employer rather than being compelled to participate in a governmental program.

Recent findings from the National Health Interview Survey help to highlight why some form of remediation is considered desirable. An estimated 14.2% of U.S. residents said they or a family member had problems paying medical bills in 2018, down from 19.7% in 2011, according to a report issued in February 2020 from the Centers for Disease Control and Prevention. The percentage of individuals in families having problems paying medical bills was higher among females (14.7%), children (16.2%), and non-Hispanic black persons (20.6%) compared with males, adults, and other racial and ethnic groups, respectively. Among persons under age 65, those who were uninsured were more likely than those with Medicaid or private coverage to have problems paying medical bills.

The Challenge Of Financing The Costs Of Health Care

National spending on healthcare is projected to grow 5.5% between 2018 and 2027, according to the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary's annual report that was issued in February last year. This growth would outpace average projected GDP growth by 0.8%. The forecast means the healthcare segment of the U.S. economy would climb to 19.4% by 2027, up from 17.9% in just two years. Medicare for All is one proposal being touted as a way of addressing the challenge of financing the cost of health care. Differences exist among advocates of this approach regarding whether it will be necessary to impose additional taxes. Individuals in favor of higher taxation believe that the amount beneficiaries must pay will be offset by eliminating other expenses associated with deductibles, co-payments and co-insurance.

A concern is that even if Medicare for All ever becomes the law of the land, there is no guarantee that it will be implemented and sustained as originally planned. The Affordable Care Act furnishes compelling evidence of the kinds of unintended alterations that can occur once a significantly large national endeavor leaves the launching pad. An original element of the ACA pertained to Community Living Services and Supports (CLASS) as a means of meeting the costs of long-term care. Seventeen months after the law was enacted, however, the HHS Secretary announced that CLASS would be abandoned because it was unsound financially. Reforming the federal tax code in 2017 resulted in repeal of the individual mandate to purchase health insurance or pay a penalty for failing to do so. In December 2019, legislation was enacted to eliminate three mechanisms designed to pay for the ACA: the so-called “Cadillac Tax”, the “Health Insurer Tax”, and the “Medical Device Tax.”

Curbing Waste In The Provision Of Health Care Services

A review of 54 unique peer-reviewed publications, government-based reports, and reports from the gray literature described in the October 15, 2019 issue of the Journal of the American Medical Association yielded the following estimated ranges of total annual cost of waste: (1) failure of care delivery, $102.4 billion to $165.7 billion, (2) pricing failure, $230.7 billion to $240.5 billion, (3) fraud and abuse, $58.5 billion to $83.9 billion, and (4) administrative complexity, $265.6 billion. The estimated annual savings from measures to eliminate waste were as follows: (1) failure of care delivery, $44.4 billion to $97.3 billion, (2) pricing failure, $81.4 billion to $91.2 billion, and (3) fraud and abuse, $22.8 billion to $30.8 billion. No studies were identified that focused on interventions targeting administrative complexity. The estimated total annual costs of waste, including items not listed here, were $760 billion to $935 billion and savings from interventions that address waste were $191 billion to $286 billion.

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PULLING BACK THE CURTAIN

John Colbert

February 25, 2020

Trends Archives

Two events that are prominent in the nation’s annual political pageant enable voters to obtain a glimpse of the kinds of policies that may be concealed behind the curtain. One is the President’s State of the Union Address, which makes it possible to boast of past achievements and describe in broad terms anticipated future legislative initiatives. While members of the President’s party cheer vigorously at each utterance, Congressional members of the opposition party typically are more reticent. The second noteworthy event is the release by the Administration of its federal budget for the next fiscal year. Stock full of details on how money should be allocated, it’s relatively easy to determine which budgetary elements are destined to undergo some exceptionally rough legislative sledding based on who cheered wildly at the State of the Union address and who remained silent.

Lobbyists and leaders of special interest groups pay close attention to the proposed federal budget. Each year, the plot lines in the drama are reasonably clear. Many liberals tend to fret that important discretionary social programs involving health care and education will be seriously underfunded, while proclaiming that some military programs are too bloated and either should be eliminated outright or undergo significant reductions in spending. Many conservatives view matters differently and it is rare for them to fail to acknowledge what they perceive as redundant and wasteful amounts of money allocated for ineffective social programs.

The budget sent to Congress on February 10, 2020 contained some of the following items:

The administration proposes funding $38.7 billion for the National Institutes of Health (NIH) in FY 2021, which amounts to $3 billion less money or more than a 7% cut below the FY 2020 enacted program level.
The Agency for Healthcare Research and Quality (AHRQ) would be funded as a new institute within the NIH in the amount of $257 million, representing an $82 million (24%) reduction below AHRQ’s current funding level.
On the plus side, the budget proposes a nearly $900 million increase in career and technical education funding.
The Food and Drug Administration (FDA) would obtain a small budget increase in FY 2021 ($25 million, for a total of $3.29 billion).

Apart from legislation that involves spending, bipartisan cooperation has aided in producing efforts aimed at protecting patients from surprise medical billing. House Ways and Means Committee Chairman Richard Neal (D-MA) and Ranking Member Kevin Brady (R-TX) on February 7, 2020 announced the Consumer Protections Against Surprise Medical Bills Act of 2020 while Education and Labor Committee Chairman Robert “Bobby” Scott (D-VA) and Ranking Member Virginia Foxx (R-NC) revealed their surprise billing legislation, the Ban Surprise Billing Act.

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GEOGRAPHIC INFLUENCE ON HEALTH DISPARITIES

John Colbert

February 25, 2020

Trends Archives

Individuals possess distinguishing characteristics, such as age, education, level of income, extent of health insurance coverage, and degree of health literacy that contribute to the likelihood they will experience health disparities. Where they live and work also will play an important role due to a rural-urban divide that exists. For example, an article in the January 2020 issue of the American Journal of Preventive Medicine discusses how in the U.S., rural residents have poorer health than urban residents and this disadvantage is growing. Compared with metropolitan county residents, inhabitants of the most rural counties were seven percentage points more likely to have a usual source of care (81% vs 74%), but their providers were 13 percentage points less likely to be physicians (22% vs 35%). Despite having to travel longer to reach their usual source of care providers, residents of the most rural counties were 12 percentage points less likely than metropolitan residents to have usual source of care providers with office hours on nights and weekends (27% vs 39%).

Rural counties make up approximately 80% of the land area of this nation, but they contain less than 20% of the U.S. population. The relative sparseness of the population in rural areas is one of many factors that influence the health and well- being of the inhabitants of these places. An important difference pertaining to the health workforce is that some rural counties may lack the presence of a single member of a particular health profession, such as dentistry or psychiatry. Older patients with chronic ailments often require rehabilitation care, which typically requires a team consisting at a minimum of physicians, nurses, dietitians, occupational therapists, physical therapists, and speech therapists.

Hospitals often serve as the main type of venue where such teams are located, but as Seema Verma, Administrator of the Centers for Medicare & Medicaid Services, pointed out in a presentation she made on February 12, 2020 at the National Rural Health Association’s policy institute, more than 120 rural hospitals have closed since 2010, which does not appear to be a step in the right direction of ensuring the presence of a sufficient network of health providers. Unlike students who live in big cities that have access to several academic institutions with health professions programs reachable by subway and bus, rural students lack this luxury and may live hundreds of miles from educational resources. Fortunately, telehealth services can benefit patients and online degree programs may be available to enable the pursuit of academic degrees necessary to become health professionals, but it is not the same as having face-to-face kinds of opportunities that exist in urban areas.

Health policy is in a state of flux. Some presidential candidates propose new approaches, such as Medicare for All, but it is not entirely clear what impacts possibly could materialize that affect the delivery of health care services. Changes in reimbursement patterns, for example, either could slow the pace of hospital closings in rural areas or accelerate their disappearance if financing levels prove to be less than what is necessary to enable these facilities to remain afloat financially.

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GEOGRAPHY DETERMINES WHEN A DEATH CAN BE DECLARED

John Colbert

January 24, 2020

Trends Archives

Apart from decision fatigue, there is the issue of decision confusion. An example is that it is possible for an individual to be pronounced dead in one state, but not dead in a neighboring jurisdiction. As described in an article appearing on December 24, 2019 in the Annals of Internal Medicine, this situation exists because only 36 states have incorporated the complete language of the Uniform Determination of Death Act (UDDA) into their respective definitions of death. An original goal was for all states to adopt the UDDA as the legal standard for death by neurologic criteria (DNC). Instead, there is ongoing confusion about DNC since medical standards of determination vary, public acceptance is inconsistent, and responses to family objections have ranged from continuation of organ support indefinitely to unilateral discontinuation. Unresolved problems pertain to: (1) lack of uniformity in the medical standards used to determine DNC, (2) uncertainty about whether “all functions of the entire brain, including the brainstem” entail hormonal functions, (3) the UDDA does not address whether consent is needed before a determination of DNC, and (4) the UDDA does not address religious objections to discontinuation of organ support after DNC.

In a related vein, a debate is underway in the field of Alzheimer’s disease (AD) research over the definition of the disease itself. As described in the December 11, 2019 issue of the journal Science Translational Medicine, a problem is that the terms dementia and AD have become interchangeable. Arguments in favor of using a biological versus a clinical diagnosis for AD are that: the latter is not specific for any etiology; a biological definition of AD will lead to a better understanding of the sequence of events that leads to cognitive impairment and dementia; biological markers will improve efficiency of clinical trials; and a biological definition of AD enables study of the disease from the preclinical stage through all symptomatic stages and of all disease phenotypes, not only the memory loss phenotype.

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More April 2020 TRENDS Articles

CALLING ALL CARS AND HEALTH DETECTIVES

PRESIDENT’S CORNER