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    Transcript for Accelerating Transformation in Times of Crisis

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    David Skorton: Hello, and welcome to today's episode of "Beyond the White Coat." I'm David Skorton, president and CEO of the Association of American Medical Colleges. American's health system has been running on all cylinders, to address the COVID-19 pandemic from every angle. Public health officials are tracking the spread of disease. Scientists are racing to find treatments and cures. And all sectors of business and industry are stepping up to produce the supplies and equipment that health care providers need to in the fight. 
    The selflessness and bravery we have seen from doctors, nurses, EMTs, and other health professionals at our hospitals has been nothing short of awe-inspiring, as they worked tirelessly to save lives, often with limited supplies and limited protective equipment. There is so much to be proud of. And yet, this pandemic has laid bare so many fault lines in our health care system, so many areas where we can and we must do better, as a community of academic medicine and as a nation. One example is the stark health inequities that the virus has exposed. Another is how our employer-based health insurance system unravels quickly at a time of massive job losses and increases the number of individuals who are vulnerable to catastrophic costs and coverage gaps. 
    At the same time, the pandemic is providing opportunities to make important and, many would say, long-overdue changes, such as supercharging telehealth, letting physicians work more easily across state lines, widening scope of practice for nurse practitioners and physician assistants, and getting researchers to work together much more collaboratively. That's what I'm gonna talk about today, with our distinguished guest, Mark Laret, president and CEO of UCSF Health. Mark has more than three decades of experience as a health care executive and is a universally respected national leader in health care reform. He is chair of the board of directors of Canopy Health, and past chair of the board of directors of the Association of American Medical Colleges, the Council of Teaching Hospitals and Health Systems, and the California Hospital Association. 
    Mark, thank you very much for all you do and for joining us, today, on "Beyond the White Coat." 

    Mark Laret: Hey, David, it's my pleasure, and I'm thinking, because I'm not a clinician, that we should call it "Beyond the Suit Coat" today.

    David Skorton[Laughs] That's great – I love that. Well, you know, the West Coast, where you are such a leader, was hit very early by the coronavirus. And in fact, we learned, just in the last couple of days, that perhaps the first cases were not too far from UCSF, in the early part of February. So I wanna, first and foremost, check in and ask, how are you and your colleagues doing? You have been fighting a long, long fight already. 

    Mark Laret: Well, David, I think we were very fortunate that our leadership, Mayor London Breed, declared a shelter-in-place early, actually, on March 16th, 4 days before Governor Gavin Newsom did. And that, by doing it on March 16th, the day before Saint Patrick's Day, I think we saved, actually, a lot of lives. It's been a definite success story in flattening the curve, something we're very pleased with. In fact, I think in San Francisco, we're still under 1,400 total cases. And at UCSF, our census today is 16 COVID patients, which is almost embarrassingly small compared to some of the challenges many of our colleagues around the country are having. 

    David Skorton: Now, Mark, you've been quite selfless and, in my view, forward-looking about saying that, you know, really, we shouldn't think about success in this pandemic from the point of view of an executive of a large health system as you are. We should not look at success as making ourselves whole financially. On the other hand, tell listeners a little bit more about what financial stresses you're under with basically no or almost no elective procedures, OR is empty, things like that, what has been the effect, in dollars and cents, for UCSF? 

    Mark Laret: In the latter half of March, our revenue was down about $4 million a day. So, in the month of March, in total, we lost $60 million. We're looking at somewhere close to $120 million loss, maybe $140 million, even, in April. And depending on how things go, as we're trying to be able to bring more patients back in, given that we do have empty beds, we have capacity, that we would hope that we could mitigate that a bit. But I know in talking to my colleagues around the country, hundreds of millions of dollars of revenue have been lost, been a terrible impact on our clinical faculty, who rely on clinical activity to generate a large portion of their incomes. And that will also have an impact on the rest of our academic enterprise, given that we use clinical dollars to support so much of our education and research programs, as well. 

    You know, because of the early stay-at-home orders, California is one of several states that have been talking about what it would take to so-called reopen their societies. And how might that work, given the things that you've mentioned, given the vulnerable populations in the vicinity of UCSF and the city in general, just like D.C., a big homeless population, and so on? And also, how about the dearth of testing capacity, what is your feeling and what is the role of academic medicine in helping to inform and make the decisions about reopening more of an evidence-based decision rather than an emotional or a political decision? 

    Mark Laret: Well, I, again, couldn't agree with you more, David, that that's a role that we must play. So, even today, there's so much discussion about serologic tests to determine whether an individual has had exposure. But there is not a clear understanding that a positive antibody does not mean immunity, necessarily. Maybe it does; we don't know. There is so much concern about getting tested, asymptomatic patients or even employees being tested, but what does that really mean, if someone's asymptomatic, that maybe they're symptomatic tomorrow, maybe they're shedding today? So, I think this is really a challenging period, and while we've flattened the curve in California, it's pretty clear we're going to be in for a long bumpy road. 
    The data on coronavirus vaccines in animals has a pretty checkered history; hopefully, we'll break through that. Maybe we'll find a treatment, which is the biggest hope. But this is going to be a challenge for us, for a long time, I think, even though we'll be doing some reopenings, but we're concerned this has the look of a long-haul episode. 

    David Skorton: Well, you know, it just shows how a center like yours, and, if I may say, other academic health centers, are really on the front lines in multiple, multiple different ways in a pandemic like this. Of course, you're on the front line in terms of patient care, absolutely. You're on the front lines in terms of education, not only undergraduate medical education but graduate medical education. You're on the front lines in terms of research, tests, and treatments, and vaccines, and just an understanding of the epidemiology of pandemics. So, I think that role is enormous, and any other thoughts you have about the role of academic medicine in this kind of a pandemic would be most welcome. 

    Mark Laret: Well, I think, as you look across the country, it's been the academic medical centers that have stood up and provided the voices around the epidemiology to get the facts out into the community. So, our clinical lab people – and by the way, this is National Clinical Laboratories Professionals Week – they have been remarkable in the work that they've done in developing new tests and so forth for our caregivers across the spectrum. But I think – I come back to the point about fragmentation: I think the academic medical centers can be the locus of information in our community, should be the locus of information in our local communities. We see it here when we're talking to our affiliated community hospitals and physician groups, they don't know how to treat a pregnant COVID patient. They're not quite sure what the changes should be in infection control standards. 
    And they're not tied in to any of the issues around how to get PPE or ventilators or even swabs, which is the challenge of our moment. So, I think we have a tremendous responsibility and opportunity, there. So, the other thing I would just say is that I think we need to be advocates, now more than ever, for a knitted-together organized public health infrastructure in this country. The people who work in public health have worked tirelessly, for decades, trying to get resources, trying to get attention, and maybe now today, the academic health centers, academic medicine, writ large, joins hand-in-glove with that public health team across this country and we do something profound, here, that maybe has never been done before. 

    David Skorton: Well, I couldn't agree with you more, to throw it back at you, I think it's very, very, very important. And maybe that's a good way for us to segue into a little conversation about the ways that the pandemic has transformed the practice of medicine. Some of this forward-looking, -thinking that you've been famous for, for decades, has really made me think, and many of us think, what is our future? This pandemic has shown us that perhaps business will never be as usual again. Perhaps it shouldn't be. Perhaps this is a time to take the lessons that we've learned, the profound lessons, for how faults that existed in our health care system have been made immensely worse by the pandemic. 
    Once we've conquered the pandemic, which we certainly will, maybe it's time to go back and fix the health care system. Tell us a bit more about your thoughts about that, Mark. 

    Mark Laret: Yeah, thank you, David. You know, who would've thought that, two months ago, 2% of our outpatient visits would be via telehealth, and today they're over 50%. 100% of our behavioral health visits are telehealth today. Who would've thought that some of the rules around not being able to do telehealth across state lines would be broken down? Let me start what I think would be the worst outcome of this crisis for us, and that is for us to just try to go back to where we were before. Not that we did a bad job, in academic medicine; we've done an amazing job, on so many levels. 
    But you pointed out in your introduction that we still have a pretty shameful record on health equity in this country. Our cost issues have not gone away; in fact, they may be worse today than ever before. And it's hard to imagine that, after this pandemic and after the trillions of dollars of additional deficit spending that the country will do, that at some moment, we're going to be faced with the usual issues that we must significantly reduce the cost of health care in this country. So when I look at those issues, I think this is our moment to change, and to lead the change. And frankly, we would be alone if we didn't change, because you see every other industry having to rethink many of their fundamental premises of how they operate. 
    But I think this is our moment to say, as I've emphasized earlier, we need to be more focused on the care of our communities than on the care of ourselves. That we need to be taking a much bigger picture about population health, where I think, you know, we've had our toes in the water, some more than others, but we haven't owned that in a significant way. At the end of the day, I think what we should have our legacy be, in academic medicine – this is me speaking – it's not about how big our endowment is at this institution or that institution, or even our rankings or any of those other things. But it's, we should be measured in how well we took advantage of this moment, to change the trajectory of health care in our communities across this country. 

    David Skorton: Well, you're starting it off by being public about it, something, I will tell you, not only do I appreciate but a lot of people will appreciate that. Now, you mentioned something about the cost of health care, and if it's not an embarrassment, it's at least something that is disappointing. That after all these years and all of the conversations and decades, really, and health economists and others who have thought about this, that we're still in the situation where costs and prices are rising. And one thing I wanted to ask you about, a very specific thing for the more general topics, is about reimbursement for care in this country. And I'm gonna take it on myself, look back to the days when I was running an echocardiography laboratory, and also seeing patients in general. 
    At that time, I was also running a general internal medicine clinic at the same time. I would go to the general internal medicine clinic and see a patient get a certain reimbursement. Then I would go across the street to the echo lab, spend perhaps the same amount of time, and get an order of magnitude different reimbursement. And those kinds of things always sort of stuck in my mind a little bit, "Is this the best way to work things?" Is it time for us to reconsider the reimbursement system? 
    We've talked a lot about value-based reimbursement. Is it time for us to be more assertive about moving away from volume-based reimbursement? For example, should we be salarying academic physicians, as some institutions already do? 

    Mark Laret: Well, you're gonna find a very supportive ear on that, because I don't think there is an answer to the reimbursement issue as we know it. Who reimburses us anyway? Commercial employers? Well, we can see what's going on with them. If there isn't a major hit to the number of uninsured in this country, it will be shocking. Is it Medicaid, states, and the federal government? Well, we know what's gonna happen to state. Certainly, in California, we're extremely dependent on state income tax; there isn't gonna be nearly the amount as normal, so Medicaid's gonna hurt. 
    So, I think we just have to have in our minds that no longer is the answer getting more to do the same, or getting everybody to pay us at the highest levels, but for us to think in the terms that you just talked about. Population health: how do we start to take ownership of a population and keep them healthy? Yes, we're still going to need the tertiary-quaternary centers that we're so strong at in academic medicine, but I also think we need to think through how we organize ourselves. One of the reasons that we've been successful in academic medicine has also been one of our greatest weaknesses. 
    We have trained outstanding physicians in a certain model. We have been exceptionally successful in our research enterprises, with a certain model. And when there's any question about how do we go forward, we always say, "You need to pay us more, so we can continue more with these exceptionally successful models." And, look, UCSF is always in the front of the line with every other academic center, we're trying to get every loose buck that we can find. But we, I think, need to privately step back and say to ourselves, "You know what, it's time for us to think differently." There must be ways that we can do our education programs more efficiently. 
    There must be ways that we can reduce the subsidy that's required on every NIH grant dollar – there must be. We have to find them, because, frankly, there just aren't going to be enough dollars otherwise. So, to me, population health is the greatest hope. There are downsides to it, to be sure, but we have to put some serious energy into that. I just don't think we, to this point, have really done it across the board to the extent that we could. 

    David Skorton: Well, you know, I won't be the only one across the nation to say this, but I, for one, would certainly follow your lead in the conversation, follow your lead in asking the difficult questions, and follow your lead in doing a what-if kind of analysis, "What if we tried it this way or that way?" There's this old saying about how you don't wanna waste a crisis, which always struck me, you know, sort of two ways. It's a truism. It's also a little hard to listen to when you're in the middle of a crisis. 
    But nonetheless, I guess I would say, in great, great support of what you're talking about, if we're not gonna have these more profound fundamental thoughts now, when are we gonna have 'em? Because I feel, in a certain way, our back was pretty close to against to the wall in certain parts of this country, in academic medicine, and it really makes you sort of rethink things. You know, Mark, you've talked so much about the many things that academic medicine has done to be on the front lines of this crisis, patient care, of course, education of those throughout the continuum of medical education. We've talked about the importance of working with communities. 
    And what about research? I mean, isn't that a front line in this battle just as much, the research labs where the next treatments will come from? We don't have any specific treatments; we're giving supportive care. Where the vaccines will come from, where an epidemiological understanding of pandemic dynamics will come from, talk to us a little bit about that as one of the front lines of the battle. 

    Mark Laret: Oh, it's so important, and we've seen it here at UCSF, whether it's our epidemiologists who are running the models and advising the state, it's our scientists developing new laboratory tests. It's our whole scientific community at UCSF who, by and large, have stepped back from their normal research efforts, to focus together and collaboratively on approaches to dealing with COVID. It's incredibly moving to see this group of people make that commitment. And it's hard not to believe that the greatest accomplishments, the greatest steps forward in treating and vaccinating against this disease aren't gonna come out of the academic medical centers. 

    David Skorton: Well, you know, I'm so gratefully, personally and also being in this sector as a leader, I'm so grateful to the people who are on the front lines. I'm not really on the front lines. I'm a cheerleader trying to organize some things in the policy domain, but I think about those who are on the front lines of actual health care, literally taking their lives in their hands, those who are working with infectious materials in the labs, and so on and so forth. So, I just want you to know that if you could carry back, on my behalf and the behalf of the AAMC, and, if you'll excuse it, on behalf of a grateful country, that the front-line workers in academic medicine are really standing between us and the abyss, and I, for one, very much appreciate it. 
    And, Mark, I very much appreciate what you do, every day. 

    Mark Laret: Thank you, David. You know, I think we have the seeds of change within us, and we only need to look at our front-line caregivers, as you've pointed out. A week-and-a-half ago, we sent 20 people to New York City; this afternoon, we're sending 21 nurses and doctors to the Navajo Nation. These people have a heart, they have a vision, a belief in health equity, and we selected those individuals from hundreds of people who applied. So, we don't have to look far to find greatness inside academic medicine, and it's really in our people. 

    David Skorton: Well, I wanna thank Mark for joining me today and for giving us just tremendous insight, not only into the impact of COVID-19, and not just about what's happening at UCSF, or even San Francisco, or even California, but how it's changing, or perhaps should change, the practice of medicine. We welcome your feedback and suggestions. For future episode topics, you can share your thoughts via the AAMC's social media channels, using the hashtag #beyondthewhitecoatpodcast. I'll see you next time for another episode of "Beyond the White Coat." Thank you.  

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