By 6:30 on Sunday evening, I was filled to overflowing with Super Bowl hype. How many times can you hear the “G.O.A.T.” versus the “best of these times” line before you are ready to throw something at the television? The only recurrent line that has drawn more ire at my house over the last month is the media phrase “shots in arms.” My wife hates this new cliché. It offends her in ways I don’t quite understand, but the phrase elicits the same negative response from her that “boots on the ground” triggers. She will yell at the television, “Not shots in arms but vaccinations.” Likewise, I was done with “the greatest of all times” versus the “best of these times.” I was just eager to see an interesting game. I was rooting for the Bucs. I always affiliate with the underdog, and I had been miffed by the way Belichick and Kraft had dismissed Brady after twenty years of loyal service and six Super Bowl wins.
If you don’t know by now that the “G.O.A.T.” blew away “the best of these times,” you must really have no interest in current events and only get your information from history books because every front page and every news broadcast on Monday featured Brady’s smiling face. My favorite shots showed Brady, the family man, as he held his young daughter in the crook of his left arm while he held up the Vince Lombardi trophy in his right hand as his sons looked up at him in awe.
Until the Super Bowl, I had limited my sports watching to the replays on the evening news and the Internet transmission of my granddaughter’s high school volleyball and basketball games that have been my one identified benefit of the pandemic. Her basketball season came to an abrupt stop last week when her team was forced out of the regional tournament because one of their players came down with COVID. That was a bummer, but I am looking forward to next year when she will be playing volleyball for Bowdin. I must admit, that although I had sworn off all sports because it was annoying to see the lack of precautions to prevent COVID transmission, I felt a real “need” to see the Mahomes/Brady encounter.
Despite my enthusiasm for the game, I was overcome by the media hype. Most articles went on and on in awe about how a man of 43 could perform as well as Brady had performed over the last seven games before the Super Bowl. Tony Romo, who was a better than average quarterback for fourteen years and has been retired for several years, was one of the announcers for the game. He is several years younger than Brady. He appeared several times a day on CBS talking about the miracle of Brady’s ability to perform at an advanced age and hyping the match up of Brady versus Mahomes. I fell for his sales job.
Brady was born on August 7, 1977. If Brady had retired five years ago with Peyton Manning who was born March 24, 1976, they might be entering the Hall of Fame together this year. Manning won the Super Bowl for only the second time in the last year he played. On the day that Manning enters the Hall, Brady will be preparing for another season and anticipating his eighth Super Bowl win. He has now won more Super Bowls than any team in the NFL and at least three since common sense would have suggested that he retire. How has he done it?
Today’s header is a clue to the answer to my question. It is a picture of Brady in his daily workout routine. Brady is famous for being the first at work and the last to be satisfied with his own preparation. He is all about preparation. He is about continuous improvement through the focused study of outcomes and a routine of thoughtful strategies designed to make him better. He rarely makes excuses. A failure is usually regarded as evidence that more work is needed. And, he seems to believe in blending his skills with those of others in what can only be called teamwork. It is said that the majority of American football fans can’t stand him. I don’t think it is because he was accused in 2015 of letting air out of footballs to gain an advantage he did not need. It seems more likely to me that his lack of popularity outside of New England, and now the West Coast of Florida, is because his enormous success underlines and calls into question our usual acceptance of our own personal limits. Brady has a message for all of us and for healthcare. Ironically, the message is identical to the Boy Scout motto, “Be prepared.” When it comes down to looking at what has happened to us as a nation and asking what we should have learned, it is hard to escape the conclusion that we were not prepared for what hit us.
If you read last Friday’s letter, you know that over the next several notes I am going to be reviewing the November 17, 2020 post of “The Commonwealth Fund Task Force on Payment and Delivery System Reform: Six Policy Imperatives to Improve Quality, Advance Equity, and Increase Affordability.” I think that Tom Brady should have a lot to add to the first imperative which is to “Increase health care delivery systems’ preparedness for health disasters.” Brady is all about preparedness.
The Commonwealth Fund task force’s report begins by saying that we were not prepared for the challenges that the COVID-19 pandemic brought to us. Worse yet, our feeble responses to the challenge of COVID-19 revealed the inequities that we had allowed to exist in our system of care for years and years. The task force points out that we must take steps “to prepare for, and to respond to, any national health-related crisis.”
They show evidence of a Bradyesque thought process for preparedness:
Without better policies and systems in place to ready our delivery systems against national disasters, Task Force recommendations to improve quality, advance equity, and lower costs will be ineffective. We identified three key areas for federal policymakers to ensure health care delivery systems are prepared to partner effectively with their public health counterparts: [1] improved digital systems for communication and data collection; [2] updated workforce policies that allow for flexibility in care delivery; and [3] development of a refined national crisis response strategy.
The task force is looking into the mirror for all of us and it does not like what it sees. I found their description of what they saw to be a powerful prelude to some far-reaching and transforming suggestions. They continue:
Our nation’s disorganized and often uncoordinated response to the pandemic has also pulled back the curtain on the structural racism present in our society and our health care system, including its devastating impact on access to care and health outcomes for people of color.
Achieving and sustaining a more equitable, higher-quality, and less costly health care delivery system will require a paradigm shift toward a culture of national preparedness.
Perhaps we need a coach. The task force is willing to outline a workout plan. They make one more introductory statement regarding preparedness to meet the next challenge that will surely come.
…the Task Force recognizes that disaster preparedness must also include shoring up our public health system…
We did not need to be as ill-prepared as we were. Experience with H1N1 and Ebola had convinced the Obama administration that we were imminently vulnerable to a pandemic. In the post for June 6, 2020, entitled “Pandemic Fatigue and Folles” I outlined the stepwise destruction of the program of preparedness that had begun in the Obama years and was dismantled by the Trump administration. Obama had elevated the assurance and direction of preparedness to the level of the National Security Council. Trump was not interested in planning to meet any challenge and directed that the machinery for preparedness be dismantled. It is never a good exercise to ask “What if only…?” questions. We can’t go back in time, but I have to wonder just what our experience with COVID-19 would have been if Hillary had won.
The first preparedness suggestion of the task force is a call for a long-overdue health IT update. We need a system that allows the various databases in healthcare to easily talk with each other. It is amazing that the computers at hospital A can’t talk to hospital B, and neither hospital can easily pass information to the state and the state does not have an easy flow of data to the CDC. There are many places in the country where the IT infrastructure does not allow patients to be connected to the system. There is great complexity to this recommendation and the investments required to make it happen will be large, but it is clear that we did not have a trustworthy system of data collection and information distribution when we really needed one. To not invest in building what we need before the next challenge would be an invitation to the next disaster. We should think about the defense of the nation against disease with the same vigor that we apply to foreign foes and internal terrorists and give the resources and respect to those we choose to protect us from diseases that we give to those who protect us from human aggressors.
Buying more IT capability will be much easier than it will be to implement the second suggestion of the task force, updated workforce policies that allow for flexibility in care delivery. Why will it be harder? It will be a harder job than the IT task because it will require that we change many of the attitudes and control points that underlie our system of care. It is hard to give up the status quo and the individual and local autonomy that has created the dysfunctional system of care that has been unable to adequately respond to this pandemic and will fail again unless changes are made. The task force makes several specific suggestions that begin with “Congress should” which indicates that it will take the power of laws to overcome the inertia of the status quo. Those suggestions that begin with “HHS should or CMS should” can proceed through administrative channels.
- Congress should fully fund provisions in the Affordable Care Act (ACA) that require HHS to train more experts with advanced degrees in public health epidemiology and emergency preparedness and response.
- Congress should develop and fund a national preparedness training program for community health workers and other nonclinical frontline personnel to ensure they are ready and able to respond to health-related emergencies through outreach, public education, and public health surveillance activities.
- HHS should facilitate the development of interstate compacts enabling health professionals to practice across professional and geographic boundaries during national emergencies.
- HHS should work with national accreditation agencies like the Joint Commission to review and update their requirements for preparedness plans on the part of health care delivery organizations.
- Congress should give HHS the authority to provide emergency funding to primary care clinicians during national health emergencies, with priority given to practices in rural, underserved, or highly impacted areas.
- Congress should fund the Indian Health Service to assist preparations for national emergencies and strengthen coordination among federal, tribal, state, and local health agencies.
- CMS should allow states to make retainer payments to essential Medicaid clinicians during national emergencies through Section 1115 waivers.
- HHS and the Federal Emergency Management Agency (FEMA) should develop an emergency response plan for assessing and meeting the physical safety and behavioral health needs of health care workers and first responders, at no additional cost to them, during national health care crises.
If we go back to our comparison to Brady, the set of actions that are grouped under the second suggestion of the task force are “team building.” There was very little organization to our initial response to the pandemic because there was a total lack of clarity about the role of each “member of the team” or the responsibility of governmental powers to the team. Actions of autonomously performing “authorities” frequently canceled out or diminished the impact of efforts that could have saved lives. Finally, there was remains little consistency in how we protect those who are the “essential” players on the team.
The final suggestion of the three that form the task force’s recommendations about preparedness is to Develop, Implement, and Regularly Update a National Strategy for Disaster Response. We have seen that a strategy that New York wants must be compatible with what is happening in Iowa and in Florida. The specific recommendations sound a little wonky but you should read them. Again they begin with “Congress should” which suggests to me the need for new laws. In several instances the strategies suggested would shift responsibility from local control to a central level that will require that localities give up their autonomy. This is not unlike what happens when we are defending the nation against a foreign foe. There is no better example of why this shift is needed than to think about the amazing variability from city to city and state to state about requirements for using masks. It is obvious that there is an impact of not wearing masks in Florida on citizens as far away as California.
Congress should establish a nonpartisan, independent commission of experts, including delivery system leaders and public health experts with both operational and logistical expertise, to assess the nation’s response to the novel coronavirus pandemic and make recommendations to raise the nation’s preparedness level and the resiliency of the care delivery system. Relevant federal agencies should implement and update annually the applicable federal recommendations of the nonpartisan commission. At a minimum, the commission’s recommendations and subsequent congressional action should address:
- Local, state, and federal responsibilities during crises, including a governance structure for national response and coordination among federal agencies and between the federal government and the states.
- A transparent, real-time national inventory of necessary supplies and equipment. HHS should develop and make public an allocation strategy focused on delivery systems that ensures critical supplies are distributed on the basis of population health needs and that promotes collaboration — not competition — among states.
- Proper funding and mechanisms to support surge capacity within the acute care system.
- Systems and requirements for national, state, and local authorities to regularly collect and report data critical to managing national response to disasters in real time, including: the potential and actual impact of disasters, broken down by race, ethnicity, age, gender, zip code, disability status, pregnancy status, and facility type (whether long-term care or correctional facilities).
- Measures to address people’s behavioral health needs, including assessment, prevention, and treatment, both during and after a national disaster.
- Necessary increases in funding for the Hospital Preparedness Program to enable hospitals and health systems to implement federal, state, and local recommendations.*
Congress should authorize an emergency response fund for the CDC that would automatically appropriate funds to the agency when a national emergency is declared, the amount of which would be predetermined by Congress. Clear guidance on CDC accountability and congressional oversight would be needed, as well as a mechanism for continuing funding after the emergency’s initial phase has been addressed.
The work that the Commonwealth Fund Task Force recommends in the first of their six suggestions, “Increase health care delivery systems’ preparedness for health disasters” suggests changes that are far-reaching and will take time to enact. The fact that there is much to do, that do it will take a long time, and that the work will be resisted by those who will fear some encroachment on their powers or autonomy are not reasons to give up before beginning the work. A willingness to work toward distant but important goals is the last reference that I will make to Tom Brady. He is working toward an eighth Super Bowl victory. He has his eyes on that goal already. What is our goal? What more important goal could we establish than the goal to be ready for the next pandemic?
