COVID-19 Converts Elective Clinical Interventions Into Discretionary


In an editorial in the Journal of the American Medical Association last October, two of Harvard’s more influential economists, David Cutler and Lawrence Summers, called COVID-19 the “$16 Trillion Virus”. This is their estimate of health expenditures and lost income through the summer of 2021 barring important mitigating medical and/or policy interventions. That astronomical sum represents 90% of the annual gross domestic product, which translates into a loss of $200,000 for a family of 4. Approximately half represents diminished income consequent to job loss and the COVID-19 induced recession. The other half is in expenditures related to premature death and long-term physical and mental health impairments. 

Cutler and Summers do not focus on the costliness of treating acute SARS-CoV-2 infections. These are economists who are keen on following the money. It turns out that during the early months of the COVID-19 pandemic when Intensive Care Units in many cities were overrun with patients requiring costly and labor-intensive care, health care expenditures in the country plummeted, as much as 50%! The decrease in healthcare expenditures reflects decreases in outpatient and inpatient utilization across the age spectrum and was particularly dramatic for those with private health insurance. Obviously, many found the need to seek medical care more discretionary than they had prior to the pandemic. Some of this behavior represents avoidance resulting from concerns that healthcare facilities were sources of infectivity. Much of it represents reframing the notion of “elective” procedures. 

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The Apocalypse Will Be Streamed


After 9 months of taking every reasonable precaution and then some  (masks, social distancing, extreme hand washing, crossing the street to avoid people who looked like idiots) I tested positive for COVID-19 a week before Christmas.

Fourteen days later, I found myself climbing out of my bunker. Coughing, blinking, and surveying the New World. 

My case was “moderate.” 

Trust me, in this case, the word “moderate” does not mean what you think it does.

A few observations follow.

(And no, this is *definitely* not what I asked for for Christmas.)

In my case, “moderate” meant 7 days of 101 plus degree fevers, shortness of breath, plunging O2 Sat levels and a bunch of weird ass symptoms. Including – but not limited to – coughing up blood, circulation issues, acid-like changes in taste + perception.

I live in Los Angeles, which turns out to be the not very well made but impossible to escape sequel to COVID in the spring in New York.

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The Missing Variable: Doctors


The United States spends more on healthcare than comparable nations, with a spending gap that has markedly increased over the last forty years.  However, this additional spending has not translated into better health outcomes for Americans, with the U.S. lagging behind other similar nations.  While health policy experts and economists have written volumes analyzing the deficit between U.S. spending and health quality measures, one variable is always missing: the impact of nonphysician practitioners on U.S. healthcare.

Over the last fifty years, non-physician practitioners like nurse practitioners and physician assistants have increasingly assumed roles traditionally filled by physicians.  Originally created in 1965 by physicians, these professions were specifically designed to bring primary medical care to underserved areas. Anticipating an impending physician shortage, the U.S. government strongly supported the growth of both professions, and by 1987, the federal government had spent $100 million on nurse practitioner training programs and passed legislation mandating that nonphysician practitioners comprise at last fifty percent of medical professionals in rural clinics. 

In 2010, the Affordable Care Act further expanded the role of nurse practitioners, creating nurse-led clinics. By 2020, nearly half the states in the Union have granted nurse practitioners the right to practice independently without physician supervision, with North Dakota recently becoming the first state to grant physician assistants the same privilege. 

In 2013, the U.S. ranked 24th of 28 countries in the number of practicing physicians, with only 2.56 physicians for every 1,000 people.

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