With more than one-third of U.S. adults now fully vaccinated against COVID-19, there's growing optimism on many fronts. A majority of states have either lifted health-related restrictions or have announced target dates for doing so.
Already, many clinicians and health policy experts are thinking about what the post-pandemic world will look like.
COVID-19 demonstrated that even in a behemoth industry like health care, change can come quickly when it's necessary. Patients understandably avoided hospitals and clinics because of the risk of viral exposure — leading to quick opportunities for innovation.
For example, the use of telemedicine skyrocketed, and many think it's an innovation that's here to stay. Patients like the convenience — and for many conditions, it's an effective alternative to an in-person visit.
Dr. Shantanu Nundy, for one, is optimistic about the future of health care in the U.S. He is a primary care physician practicing just outside Washington, D.C., and the chief medical officer at Accolade, a company that helps people navigate the health care system.
Nundy has bold views, based on his current roles as well as prior positions with the Human Diagnosis Project, a crowd-sourcing platform for collaboration on challenging medical cases, and as a senior health specialist for the World Bank, where his work took him to Africa, Asia and South America.
He spoke with Shots about his new book, Care After Covid: What the Pandemic Revealed Is Broken in Healthcare and How to Reinvent It.
This interview has been edited for length and clarity.
You seem pretty optimistic about changes to U.S. health care because of the pandemic. What changes or new practices do you think are most likely to stick around?
I am optimistic. Health care has changed more in the past year than during any similar period in modern U.S. history. And it changed for the better.
Doctors and other front-line workers finally started meeting patients where they are: in the community (e.g., at drive-through testing and mass vaccination sites), at home (e.g., with house calls and even hospital-level care at home), and on their devices. Doctors and patients connected in new ways: In my clinic, which serves low-income patients in the Washington, D.C., area, I was given an iPhone for the first time for video and audio visits and found myself messaging with patients between visits to refill medications or follow up on their symptoms.
Some of these changes will reverse as things get back to normal, but what won't change is the fundamental culture shifts. The pandemic magnified long-standing cracks in the foundation of the U.S. health care system and exposed those cracks to populations that had never witnessed them before. All of us — not just patients with chronic diseases or patients who live at the margin — have the shared experience of trying to find a test or vaccine, of navigating the byzantine healthcare system on our own.
The crisis also exposed just how inequitable the health care system is for Black and brown communities. The numbers don't lie — these populations died of COVID-19 at a rate much higher than their white counterparts. I'm hopeful these shared experiences and revelations have created the empathy and impetus to demand change.
Your book envisions a care framework that will be "distributed, digitally enabled, and decentralized." Let's take them one at a time. What do you mean by "distributed care?"
"Distributed care" refers to the notion that care should happen where health happens, at home and in the community. We need to redistribute care from clinics and hospitals to homes, pharmacies and grocery stores, barbershops and churches, workplaces and online, where patients are on-the-go. This doesn't mean we should eliminate traditional health care settings. Hospitals and clinics will continue to play a major role in health care delivery, but for most people, these will become secondary, rather than primary, sources of care.
The most obvious upside to distributed care is that it's more affordable. Without the overhead costs of expensive medical facilities, costs decrease. It also has the potential to be more effective and equitable. Our health is largely driven by our behaviors and our environment. By delivering it where we live and work, care can better address the root causes of poor health, including social isolation, poor nutrition, physical inactivity, and mental and emotional distress. Distributed care can also reach communities too far from the nearest clinic or hospital — or who are too distrustful to even step foot in one.
We already have digitally enabled care to some extent: We use apps, our medical records are electronic, and many of us have now used telemedicine to connect with clinicians. What is your vision of the future of "digitally enabled care?"
"Digitally enabled" refers to the idea that the right role of technology in health care is simply to increase the care in healthcare. ... For a glimpse of what's possible, I'll share my mom's experience during the pandemic. For 25 years, she struggled with Type 2 diabetes (and for the past 10 years, has been on insulin). But faced with all the reports of patients with diabetes having higher rates of COVID-19 complications, she signed up for a virtual diabetes service that was completely different than anything she had tried in the past two decades.
She was shipped a free glucose meter and weighing scale to send her data to her new diabetes care team. She downloaded a mobile app where she did video visits with her doctor — more frequently than she ever had in person — and 24/7 access to a health coach that she sometimes messaged with multiple times per day in the first few weeks of the program. She also was connected with another patient — a gentleman in Chicago who, like my mom, followed an Indian vegetarian diet — to exchange recipes with. The result: Within weeks, my mom lost over 10 pounds and safely got off of insulin. Nearly a year later, she still is.
How do you envision future care that is decentralized? Will U.S. health care become more of a do-it-yourself industry?
"Decentralized care" refers to a model where decisions about care are in the hands of those closest to it, including doctors and patients.
But health care is highly centralized and heavily regulated, and what doctors can do often comes down to what we can charge insurance companies for.
One example: I had a patient who was in and out of the hospital for heart failure. After one of these hospitalizations, I saw her in-clinic and learned that she didn't have a scale and couldn't afford one. Daily weigh-ins are critical for patients like her, as a few pounds gained can be an indicator of impending heart failure. So, I handed her a $20 bill from my pocket for a scale, and she was never admitted to the hospital again. If our health care system was decentralized, I would be able to get my patients the $20 piece of equipment they need instead of racking up thousands of dollars in expensive medical tests and hospitalizations.
With all of the innovation you foresee, will there be actual market-based competitive pricing reform, or will all of the whistles and bells just drive health care costs inexorably upward?
The type of innovation we need most is true "disruptive innovation." This is a term that gets thrown around liberally, but the real definition refers to products or services that dramatically lower prices and increase quality, much more so than those currently available.
I see two steps we must take to get there: First, we need to stop nibbling around the edges. Often, our solution to, say, Type 2 diabetes, is training doctors in better management or approving a drug that is 1% better (and 200 times more expensive) than what we have now. A truly disruptive innovation is what my mom used: a digitally enabled service that reversed her diabetes and got her off of insulin completely.
Second, we need to get out of our own way. Early on in the pandemic, when we finally allowed patients to test themselves for COVID-19, we still required a doctor to sign off on the test. Patients filled out a questionnaire and a doctor then needed to scan through dozens of forms an hour to approve or reject the test applications (these were almost always approved). That's crazy! Now, we've finally let doctors off the hook, and patients can walk into a CVS or Walgreens to pick up a rapid COVID-19 test over the counter.
What are some ways that your future vision could go off the rails and lead us toward a care system that is less open, less transparent or less patient-centered?
The biggest threat is the continued monopolization of health care. In many parts of the country, there are only one or two large health systems and a few options for health insurance. This drives up prices with little to no benefit for patients or doctors.
Will the lessons of COVID-19 make us more prepared, and our health care system more adept for the next global challenge?
Absolutely. The pandemic has created medicine's greatest generation. By shepherding this country through the crisis, an entire generation of doctors, nurses, pharmacists and administrators learned an entirely new set of skills: public communication, front-line innovation, data-driven decision-making.
An outside force — a new virus — accelerated much-needed change in health care, but the work is just beginning. The future of care is now on us.