COVID-19; Changing the Face of Healthcare

Introduction: 

On Dec 31, 2019, Chinese health officials informed the World Health Organization (WHO) about a mysterious pneumonia that affected 41 people in Wuhan city, Hubei province China. This was later identified on June 7, 2020 by Chinese scientists as a new type of coronavirus. COVID-19 is the name given to the disease which reflects the year it started and SARS-CoV-2 is the name given to the virus which reflects the second wave of CoV virus family to infect humans and cause Severe Acute Respiratory (SARS).? Scientists speculate that “patient zero” had contracted the virus from an animal at the local wet market in Wuhan city back in Nov. 17, 2019.?

The whistle blower, Doctor Li Wenliang was the first to warn a group of fellow doctors about a possible outbreak of an illness that resembled SARS, sadly he died on Feb 7, 2020 at age 33 due to contracting the virus from an infected patient.  Currently, Covid-19 disease became a pandemic throughout the globe and drastically changed our daily lives in fundamental ways which probably would need a few years to return to some form of normalcy. 2,3,?

History of the SARS-CoV-Virus 

The SARS-CoV-1 virus was first identified in 2003 when an epidemic of SARS affected 26 countries and resulted in more than 8098 cases with 774 deaths worldwide and eight deaths in the US. Despite lacking scientific evidence, SARS-CoV-1 virus is thought to be an animal virus from uncertain animal reservoir; most likely bats, that spread to other animals and later infected humans in the Guangdong province of southern China in 2002.1 However, the coronavirus was first identified in the late 1960s by a group of scientists who named it “coronavirus” (corona signifying the crown-like appearance of the surface projections) and was officially accepted as a new genus of viruses. The coronavirus is a large family of viruses which may cause illness in animals and humans.  Though usually there is no transmission between animals and humans, this might not have been the case in SARS-CoV-2 virus. In humans, several coronaviruses are known to cause respiratory infections ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS).?

Transmission & Symptoms 

 Currently, the transmission of SARS-CoV-2 virus is primarily from human-to-human. While this occurred in the health care setting for SARS-CoV-1 virus, the SARS-CoV-2 virus spread is through community transmission. The hope is with the implementation of appropriate infection control practices, we will eventually bring the global outbreak to an end.1 The most common symptoms of COVID-19 virus are fever, tiredness, and dry cough. Some people may have aches and pains, nasal congestion, runny nose, sore throat or diarrhea. These symptoms are mostly mild and begin gradually. Some people can become infected and not develop any symptoms, however, they continue to transmit the disease to other. Most people (about 80%) recover from the disease without requiring medical attention. Around 1 out of every 6 people who get coronavirus become seriously ill and develop difficulty breathing needing a ventilator to survive.? 

Traditional Mental Model Approach in Healthcare 

Healthcare in the United States is provided by both public and private organizations with no universal healthcare program. 58% of community hospitals in the United States are non-profit, 21% are government owned, and 21% are for-profit. There are currently 152 VA Medical Centers and approximately 1,400 community-based outpatient VA clinics in the US. In 2017, the United States spent $10,224 on healthcare per capita, which is roughly double the average amount spent on health per person in comparable countries at $5,280 (Exhibit-2). The US spends 17.9% on health care as percentage of its GDP that same year. Unlike other developed countries which depend on a large degree of direct government intervention, negotiation or rate-setting to achieve lower-priced medical treatment for all of their citizens, the US believes that this is not politically acceptable! Medicare is not allowed to negotiate prices, but instead it decreases reimbursement rates. However, the system reacts to the lower reimbursement rates by billing for created services that are not needed which results in higher general expense for simple medical services and procedures.1?,1?

The healthcare system around the globe has been a clinician centric care model where unlike most businesses the healthcare customer, for the most part, is not in a position of power. There is also a monopoly on healthcare where once the customer makes a choice, he or she are stuck with their doctors or healthcare networks. Patients depend on the experts, the healthcare providers who are the power brokers for advice and solutions for their illnesses. The same model applies to countries for the most part, as citizens in different countries depend on the guidance and wisdom of their imposed or elected leaders to help protect public health. Marketing for healthcare services differs based on where you are, the population density in that area and the number of medical staff per capita. The more healthcare providers in one area, the bigger the competition and market share wars. In the US, more marketing and promotions concentrate on obtaining new patients rather than maintaining old ones, however, due to the competitive nature of the healthcare industry, new marketing platforms e.g. social media, new technologies e.g. AI, and add to that the emergence of the novel coronavirus, healthcare marketing is changing. 

In recent years, there has been a shift in the US to a patient-centered system which strives to provide a personal patient-clinician relationships where clinicians lead teams that collectively take responsibility for patient care, treat the patient as a “whole-person” to meet all of the patient’s needs, coordinated care across the healthcare system and community, focus on quality of care and outcomes, improve access ,and align payments based on quality of care.1? This model can only be partially, if at all, applied to this critical situation during the coronavirus crisis where clinicians, especially in hospital settings, have to make decisions in a matter of seconds to save the patient life. 

On a larger scale, the medical traditional model in the US and most of the world has been a firefighting crisis after crisis model rather than a proactive one despite all advancements in the detection and containment of viruses and diseases in general. In the recent scare of the Ebola virus, eleven people were treated for Ebola in the United States during the 2014-2016 epidemic outbreak in West Africa. CDC’s reactions included activating its Emergency Operations Center in July 2014 to help coordinate technical assistance and disease control activities with its partners. CDC personnel were also deployed to West Africa to assist with the response efforts.1? 

As for pandemics, the model dictated by the International Health Regulations (IHR, 2005) governs the international response to public health risks that can pose a potential worldwide impact. The member states (196) and non-member parties are obligated to detect, assess, notify, and report events that may create a “public health emergencies of international concern” (PHEICs) to WHO. Reportable events include all cases of smallpox, wild-type polio, SARS, and human influenza caused by a new subtype. Those member states are also obligated to develop core capabilities for public health surveillance and response. Once WHO determines that the event at hand is a PHEIC, it would facilitate information sharing and broadcasting, and may declare a pandemic. In 2013, WHO released new interim guidance for pandemic influenza risk management with four pandemic phases: Interpandemic, Alert, Pandemic, and Transition (Exhibit-3).21,22,23  

The last two paragraphs reflect the fact that we have had experience dealing with contagious diseases and pandemics. So, what went wrong? Did the Global community forget to sound the alarm? China did inform WHO on Dec 31,2019 about a mysterious pneumonia that affected 41 of its citizens, seven days later China identified a new type of coronavirus. On Jan 30, 2020, following protocol as the world was learning about this new virus, the WHO declared a global public-health emergency. Despite all this, one can argue that the warning about the severity of this outbreak was not loud enough and more importantly, was far too slow and thus too late. Part of why we failed as a global community is the fact that we are still learning about this very aggressive and highly contagious virus. However, based on our past experiences with contagious disease outbreaks, especially influenza, we knew the necessary steps to prevent this scale of spread and we have failed in applying them effectively. On the other hand, the world is more connected than it has ever been, and people can move around the globe in a faster manner.  Despite all this, we should have been more prepared to deal with this pandemic especially as a global healthcare community. 

Novel Coronavirus Disease and the Global Dynamic

Developing countries usually rely on the developed ones to pave the way and provide the model to how to deal and contain such a virus. Experts were concerned about an aggressive spread of COVID-19 disease in developing countries’ urban slums, where people have little access to proper hygienic measures, social distancing is a huge challenge due to the population density in some areas, and little to no access to healthcare facilities which are ill equipped and lack staffing.  

Ideally, a country like the US top healthcare organizations would usually instruct others on how to slow the spread of the coronavirus and provide them with medical guidelines. However, with most developed countries struggling, the US is no exception, to stay afloat and keep their healthcare systems’ capacity in check, they are not playing the expected big role in providing guidance, medical materials supplies, and on-the-ground technical assistance to the developing countries.

The expectations are once the US takes control over its own crisis, healthcare system, and the number of patients needing an ICU level of care, the US would take lead and assist other developing countries in their fight against the COVID-19 disease. The reality so far has been different, as the US is gaining control, it is helping other developed countries such as Italy and Spain while developing countries seem not to need as much help due to many reasons including having a younger population demographics and the application of stricter measurements of social distancing and shut-downs which led to a better containment of the spread and less pressure on their poorly structured and supplied healthcare systems.  

Novel Coronavirus Disease and US Healthcare  

The initial reaction of the healthcare systems especially in the states and cities which later became epicenters for the disease, was mediocre at best due to many reasons. Some of these reasons include: denial that such a virus could reach the US on a large scale, strong confidence in the capabilities and capacities of the US healthcare system, lack of firsthand experience in the management and containment of a contagious disease of this magnitude in the US since the Spanish flu in 1918, and lack of up to date systems to recognize and address such a threat at a healthcare facility level. This led to a delay in the reaction of cities such as New York which implement a Stay at Home order on March 20, 2020 after confirming 7,102 total confirmed cases and 46 deaths in comparison with Wuhan City’s quarantine on Jan 21, 2020 when data sources report 444 confirmed cases and 17 deaths. 2?,2?,2? 

One can argue the accuracy of China’s data, however, collecting data from available research, healthcare discussions and webinars, the author found the following; first, little was known about how to manage this novel virus or the disease it caused especially during the early stages. Thus, new waves of patients will have a better chance surviving Covid-19 disease than early ones as the medical community continues to come up with new treatment protocols to manage it.  Second, patients who came to the ER early in this pandemic with flu-like symptoms were sent back home without any testing because the availability of the coronavirus test did not exist and therefore doctors could not prescribe it. Third, as more testing became available on a smaller scale, it could only be prescribed for those with severe symptoms. Sometimes, by the time the results came back, the patient was either on a ventilator or had already expired. Lastly, the capacity to absorb 150-200 severely ill patients in the emergency room within a few hours with 10-15 ER medical staffers at most, was not established nor were there preparedness plans to address this level of patient influx. Consequently, when one combines all these reasons, early waves of patients’ outcomes were grim.  

Coronavirus has changed our healthcare system and from the author’s perspective, it changed certain aspects of it for the best. Some of the bureaucracy that limited the healthcare staff abilities to concentrate on quality of care and forced them to be concerned mainly with billing codes, as an example, and limited their ability to treat just because they crossed state boarders, had come down in order for the system to work as a whole rather than individual hospitals and individual states. As seen in the US government organizations timeline reaction, many lines had to be crossed, for example, the US Department of Health and Human Services (HHS) temporarily suspended a regulation that prevents doctors from practicing across state lines, the Centers for Medicare & Medicaid Services (CMS) agreed to expand telehealth benefits for Medicare beneficiaries and recently increased its reimbursement rates for such services, and some VA hospitals opened its doors to serve non-veteran coronavirus patients to assist the hard-hit states and Federal Emergency Management Agency (FEMA) in their response to the coronavirus.?,1?   

The Global Collaboration; Junctional Thinking 

There has been great collaboration between nations during this crisis. The global healthcare community has been slow in its reaction due to the sudden influx of cases that overwhelmed many countries and their healthcare systems. Slowly, hard-hit countries, their hospitals and healthcare networks, started to share their findings on the different approaches they took to address the crisis. Lessons learned in Italy and other hard-hit European countries have been shared with the US healthcare system and communities. Chinese scientist has published their small-scale studies in western journals, an uncommon occurrence, to share their findings and help the international medical community.   

Was this reaction by the medical community enough? Some might argue that it was that of a drowning person clutching at a straw to stay afloat especially during the early stages of dealing with this crisis. We, as citizens, expected more from our governments and medical systems especially in the developed countries. The bottom line is that, although many countries did not have preparedness systems in place nor the needed information to make the right decisions, some reacted faster based on old experiences and thus achieved better outcomes than others. For example, while some developed countries were watching the news unfold in Asia and then later were more focused on increasing the capacity of their healthcare systems, other countries such as Germany, as per the Business Insider and the Guardian, recognized the similarity in the symptoms to SARS-CoV-1 and realized the need for a test kit. Germany was able to make its first test kit in January before even China had one and before Germany recorded its first case. Another country that stayed in the driver’s seat and did well in managing the spread of Covid-19 disease was South Korea where it worked hard on testing and contact tracing of its citizens to stay ahead of the spread.2?,3?  

US Healthcare Marketing and Coronavirus  

Main healthcare marketing trends tend to concentrate on a direct-to-consumer marketing model. Clinics and different healthcare networks would usually market the advantages of using their systems and facilities directly to the patient which could include: hours of operation (including weekends), ease of access to their sites, a suite of specialties, amount of services done at one location, medical chart availability to all providers within their network, digital superiority, and ability to manage many diagnoses and diseases. New models concentrate on building the brands using the emotional connections as patients usually come seeking help when they or their loved ones are most vulnerable. Many recognize the importance of an improved patient experience to go beyond the old image of green (in some countries) or white sterilized cold walls of a medical facility.

Not only did the coronavirus changed some of these healthcare marketing approaches to some degree, it also sprung new ones. Commercials for healthcare networks on the local news channels these days include showing a patient who overcame the Covid-19 disease being wheeled out of the hospital as healthcare staff clapped for him just to be hugged by his wife for the first time since his admission. This implies how much the healthcare staff cares at that facility and also conveys a subliminal message of a superior clinical and medical abilities to manage patients with the Covid-19 disease. Some examples of how the social media marketing platform was used by healthcare networks during this crisis include tips on how to deal with the coronavirus, videos on how to improve one’s health and how to stay active, and a live stream podcast on Facebook to update the public on the coronavirus.2?,2?

Patients seeking the outpatient clinics and urgent care centers, especially the ones who know they are considered a higher risk, were more attracted to clinics which implemented stricter rules and regulations earlier or used telehealth to manage patients without exposing them to the possibility of contracting the coronavirus. This became a marketing angle and a competitive advantage for these clinics, and those who implemented these early enough attracted new patients and kept the loyalty of their current ones. 

Many new competitive marketing approaches will emerge once testing becomes more accessible and new effective management protocols are established. Facilities advertising efforts would emphasize how fast testing results are obtained and the effectiveness of the available testing (false positive and false negative results) at their facilities, and how the hospitals or clinics would manage Covid-19 using a specific protocol which was established by a famous university, CDC, or clinic such as the Mayo Clinic. Another future marketing tactic would be emphasizing the ability to prevent coronavirus spread from a Covid-19 patient to a non-Covid-19 patient who is at the hospital due to either an unrelated illness or to undergo an elective procedure once these are allowed.  

Access to testing is still either limited or difficult to be obtained, but from a marketing point of view the way that the limited testing is being done, even though it is out of necessity to divert pressure away from hospitals, is sending a message to the customer to stay away from hospitals and network facilities. This affected the customers confidence negatively and informed them that hospitals do not have the capacity to treat them. Due to this and fears of contracting the coronavirus at a medical setting, new commercials and educational messages have been communicated to the public recently to seek medical attention if they are experiencing a medical emergency due to a non-Covid-19 disease or symptom such as chest pain or signs of a stroke.  

The Future of the Global Healthcare: New Mental Model for Global Executives

The new Mental Model for the Healthcare System is here, it will need refining, but the coronavirus drew the outlines for this model. Need is the mother of invention and our need to save people from this disease forced us to adapt and adopt a reform to the global healthcare system which was desperately needed. Collectively, the author believes there is no going back, however, there will always be people fighting change, but they will represent small pockets of nations or leaders around the globe.  

Covid-19 disease has pushed the medical community locally and globally to a new “Together Health” culture in many ways. Another aspect to this togetherness was due to the fact that it did not discriminate, it infected people from all ethnicities, healthcare workers, and world leaders alike, e.g. Boris Johnson testing positive for Covid-19 disease and getting admitted to the ICU. Healthcare staff became part of the hardest hit patient population due to the level of “virus load”, or the amount of exposure, which worsened their outcomes. It also eliminated bureaucratic constraints on all levels and cleared lines of communication between countries, some of these constraints were impossible to overcome prior to this pandemic. The driver in the healthcare system returned to its original goal of achieving the greater good for all, this led to standardizing processes, sharing of knowledge and resources on an unprecedent scale, and dedicating efforts to succeed as a global healthcare system and not specific hospital, network, state, or country.  

We have witnessed a rapid redesign of the “Health Delivery System” in clinics and hospitals. There had to be either a strategic separation of services to limit the spread, e.g. foregoing elective surgeries for the meantime, or a strategic sharing of services or specialties for the same reasons. It challenged the ability to connect with patients and thus telehealth became an essential part of the delivery system. It also changed the command structure due to greater need for a different kind of leadership that concentrated on collaboration between hospitals and systems in order to be more affective. New models to share specialists, such as epidemiologists and infection disease doctors, between hospitals and healthcare systems became a norm. It changed the priorities and goals for “Hospital Incident Command System” during emergencies, which now included ensuring supplies such as PPE and testing kits, planning for potential surge of patients with Covid-19 disease, supporting healthcare caregivers on unprecedent levels, growing digital health capabilities, advocating for regulatory relief to enable best care practices, and implementing epidemiological models.  The hope is that these strategic changes and new models would improve the preparedness and readiness for that next surge of Covid-19 patients or the next pandemic.31,32 

Future plans are to go back to the root cause for why Healthcare System was established in the first place, which is to prevent disease and improve the quality of life. We need to continue to build on what we learned so far, especially the need for lighter more flexible systems that are based on collaborations. We have to reduce bureaucracy and the many layers of management and expand public health and community health roles. We need an up-to-date emergency preparedness with appropriate funding especially for pandemics. Expand telehealth, home care, and specialty clinic services with more virtual and work-at-home positions. Secure the uninsured and widen government sponsored health care systems with an increased involvement in community health planning. Finally, an effective global communication and collaboration where warning sirens would be loud and clear to prevent the next pandemic. All this translates into an agile healthcare system that continues to evolve, one that can meet patients’ needs and continue to provide them with choices. What sets providers apart during this time is their ability to change rapidly how and even where they render care and how they implement procedures to adapt to new realities. It also reflected the importance of a qualified staff who is showing up despite the circumstances. In the end we are one system, from the nurse’s aide to the doctor and from the garbage collector to the governor. We all need to play our roles effectively and protect the safety and health of all of us. 

Final Reflection 

Being part of the healthcare system for more than a decade and working at a hospital for 5 years, I can assure you that we practiced code black drills as a hospital many times, however, we did them for a possible terrorist attack on the US and not a pandemic. I worked at a hospital in Bergen county, NJ and never in my wildest dreams I thought I would hear that my rehabilitation department got torn down to make more rooms for patients with Covid-19 disease or that my fellow collogues are helping nursing staff in their daily chores instead of providing rehabilitation services due to shortages as medical staff got sick and some even passed away from Covid-19 disease.  

This pandemic, despite its severity, will not wipe out the human race. However, we might not be this lucky next time! How did we preform so far? On the grounds, early messages to warn the different communities were conflicting and possibly non-existence in some. We as a developed nation were in denial and listening recently to some people, I want to say that we still are, even after we passed the 90 thousand deaths nationwide recently. However, just to be fair, there are more unknowns than knowns about this novel virus.  Government officials and medical representatives have tried to keep us informed but three months later the messages continue to be confusing at times. 

I dedicate this article to my family, friends, and community members who work in the healthcare field. Thank you and stay safe. 

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This is a personal article. Any views or opinions represented in this body of work are personal and belong solely to the writer and not represent those of people, institutions or organizations that the owner may or may not be associated with in professional or personal capacity, unless explicitly stated. Any views or opinions are not intended to malign any religion, ethnic group, club, organization, company, political party, or individual.

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