Image by John Ritter

Back in January, the leadership at Massachusetts General Hospital, including President Dr. Peter Slavin (MBA 1990) (pictured above, right), took note of a virus that was spreading in China. They decided to activate the hospital’s emergency preparedness group, which had been deployed after the Boston Marathon bombing, as well as during world wars, previous pandemics, and other disasters. With that structure in place, the hospital was able to make the “crisp decisions that are required in warlike times,” says Slavin. That in turn allowed MGH—which treated more COVID-19 patients than any other hospital in the state—to bend without breaking under the pressure of the pandemic.

Professor Robert Huckman is an economist and health care researcher who serves as unit head for Technology and Operations Management at HBS and chairs the MBA Required Curriculum and the HBS Health Care Initiative. He teaches the second-year course Transforming Health Care Delivery, as well as executive education programs for a number of hospitals. He serves on the advisory board for RubiconMD, which provides telehealth services, and is an uncompensated trustee of the Brigham and Women’s Physicians Organization.

Slavin and Huckman joined the HBS Alumni Bulletin to discuss the ways in which MGH was able to redeploy resources to meet the surge of patients, and how the delivery of health care might be forever changed as a result.

One area where we’ve seen a tremendous shift is in the use of telemedicine. At MGH these virtual visits skyrocketed, allowing patients and doctors to reduce the risk of spreading the virus. How did that change come about so suddenly, after years of existing on the fringes?

Robert Huckman: What we’ve seen is at least a temporary easing of regulations by the federal Centers for Medicare and Medicaid Services. So now a patient can go into a telemedicine visit without a previously established relationship with a provider, who can bill for that time in a way that more closely reflects what they would have received for an in-person office visit. That hasn’t existed in the past.

THE WAY FORWARD

See more from the online-only June Bulletin’s coverage of the path ahead for education, health care, management, and the hotel and restaurant industries.

Return to June Bulletin

THE WAY FORWARD

See more from the online-only June Bulletin’s coverage of the path ahead for education, health care, management, and the hotel and restaurant industries.

Return to June Bulletin

We’ve also seen an easing of the requirements around the state-level licensure of physicians. In the past, if you wanted to interpret an image as a teleradiologist, for example, you typically had to be licensed in the state in which that image was generated. But the easing of state-level licensure has largely allowed physicians who are licensed in one state to practice in another. The easing of that regulation has, in turn, allowed telemedicine to become a more feasible approach across the nation and has more urgently enabled providers to move to other geographies to offer support during the surge.

My guess is that some, perhaps even all, of this easing of regulation is temporary. But to the extent that it remains in place going forward, I am interested to see how existing delivery systems take advantage of new approaches for interacting with patients. Historically, telemedicine has been seen by many health care systems as a source of competition; my hope is that more systems will start to think about telemedicine as a service that could be used to complement the in-person care they already provide.

Peter Slavin: The regulatory steps you mentioned—the licensing, the payments—have definitely helped, but I think telemedicine would have exploded even without those because it’s just so obvious that we needed something like this to continue to care for people, particularly vulnerable patients, during a period of time when having them come into the hospital brings unnecessary risk.

I should say that, in addition to my day job as president of Mass General, I also serve on the board of American Well, which is a Boston-based telemedicine company, so my comments come from two vantage points. I think telemedicine has been like a plane heading down a runway for a long time and not getting the lift that it needed to take off. In a matter of weeks, it is now soaring.

At Mass General a couple of months ago, less than 1 percent of our outpatient care was delivered via telemedicine, despite the fact that we had been pushing it heavily. It’s now 83 percent of our outpatient care for doctor-to-patient encounters. We can’t put this genie back in the bottle.

But the doctor-to-patient interaction is only one facet of telemedicine. We’re also using it for doctor-to-doctor communication. We’ve had a telestroke program for a number of years, where doctors in an emergency room can consult with our neurologists, share images, and get a stroke neurologist’s opinion about how to handle a patient in that community emergency department.

We’re also using it within the walls of the hospital. We have deployed 1,500 iPads in COVID-positive patient rooms, which doctors and nurses use to communicate with patients. It decreases the number of times our staff have to go into the room and the amount of personal protective equipment that we’re using. The patients also use them to communicate with their families, who can’t come into the hospital. That’s a new form of telemedicine that we really hadn’t thought of until this pandemic was upon us.

We’ve seen real disparity in patient outcomes with this disease. How is the hospital responding to this, and what can we learn from it?

PS: This pandemic has really underscored the importance of the social determinants of health. There’s no doubt that people in lower socioeconomic groups are much more vulnerable than others. When we started admitting patients with COVID-19, it was quickly noted that about 40 percent of them were Spanish-speaking, which is much more than our baseline. We looked up the zip codes of our patients and realized that they were disproportionately coming from Chelsea, Revere, and East Boston.

I think in this case the social determinants include living in crowded housing conditions, where the ventilation and air quality are not as good and which seems to make people more vulnerable to this disease. These are also individuals who have to go to work where they’re not able to socially distance, and they’re using public transportation to get there.

We have worked tirelessly with the leadership of those communities to try to mitigate the illness. We’ve distributed care kits with health information, surgical masks, and hand sanitizer to every household in the city of Chelsea. We’re staffing a hotel that the cities of Chelsea and Revere have rented for people who need to be quarantined, and we’re providing medical and nursing care there. We are doing a lot of testing in these communities where there seems to be active community spread. We’re doing everything we can to try to minimize the impact, but I also think it’s incumbent upon us to do everything we can to address those social determinants as aggressively as we can.

RH: Peter’s list of all the social determinants that need to be addressed in the context of this crisis underscores a big limitation of our current system of health insurance, which is based on covering a predictable set of needs for surgical procedures, office visits, and hospitalizations across a given population. It’s not built for catastrophic events such as COVID-19 that require, for instance, community outreach to minimize the risk of transmission or extensive efforts to retrofit facilities. These are expensive activities, and we need a financial model for them. I’m assuming that like every other provider, Mass General is feeling the burden of that right now.

PS: I would say two things about that: First, in most countries, it’s the government that addresses the social determinants of health. The social spending in this country pales in comparison to most other Western democracies, and that’s at the heart of why these social determinants are so powerful here.

The other thing I would say is, and I’ve been meaning to get this off my chest for a few weeks, where are the health insurers in all of this? They’ve done a few things, like pay for COVID tests and waive deductibles, but they’re continuing to get premium payments from employers, and my guess is that the cost of the health care that they’re paying for their subscribers has gone down by 50 percent in the last month or so. It seems irresponsible for the private insurance industry to realize a windfall at a time when providers are hemorrhaging financially and mounting this war against COVID.

RH: There have been some suggestions that insurers should look back at their historical hospital spending and transfer a commensurate amount of money to hospitals during this crisis. There are different health care needs right now, and it is appropriate for health insurers to think about how they can contribute to offsetting the financial costs of those unique needs.

PS: Right. And as unemployment grows, the number of subscribers that private insurers will have is likely to go down. Even so, the difference between premium and medical expense has probably widened dramatically in the last two months. It’ll be interesting to see how much their balance sheets have swelled when they start reporting their financial results.

Let’s talk about the medical workforce, where we’ve seen medical students being called up early and doctors coming out of retirement to meet the demand in hospitals. How well has the workforce flexed and how will it transition back?

PS: The adaptability during the past two months has been breathtaking. We have redeployed hundreds of physicians to new roles within the hospital, and they have accepted those roles willingly. In fact, the people that we haven’t redeployed are frustrated that they aren’t able to contribute more. Our chief of orthopedics is serving as a scribe in one of our respiratory illness clinics. We have radiology residents who were medical interns a year ago working again as medical trainees on some of our COVID units. The adaptability of the workforce during this period is extraordinary and has been made possible by the fact that we canceled all elective procedures.

One of the puzzles we’re beginning to think about is how to transition the workforce back. How do we continue to have the staff we need to care for the COVID patients as we repatriate some of the staff that are necessary for the elective procedures that we’ll hopefully be doing in the not-too-distant future? How do we balance that from a capacity standpoint, a PPE standpoint, and also a staffing standpoint? That is one of the biggest management challenges that health care organizations around the world are facing.

RH: And every organization outside of health care is watching how hospitals like MGH think through this return to elective care. Educational institutions, large firms, any place with a large campus will benefit from the knowledge that MGH gains in thinking about the entry of visitors onto its grounds. What are the requirements for testing? How frequently would employees need to be tested? These are just two of the many questions that still need to be answered.

PS: I’m pretty proud of the method we’ve used to allow people to come to work every day. We developed a phone-based app that enables people to input any symptoms they’re experiencing. Then they either get a clearance pass that shows up on their phone or they’re told to get in touch with their doctor. We’ve closed all of the entrances to the hospital but two, and you have to show your pass to get in, plus there are stations for hand sanitizer and surgical masks.

The other thing I want to say is that we in the health care industry are really worried about one thing: If every other industry starts to buy PPE, it’s going to put enormous pressure on those limited supplies. I think that has to factor into governments’ decisions about what to open up.

RH: Absolutely. The stress on so many resources that we might consider to be commodity products—surgical masks, hand sanitizer, gowns, and other forms of PPE—exposed a broader challenge facing our economy. We haven’t really thought about how to do high-volume production of certain commodity items in the private sector. In part that’s because manufacturing those products doesn’t represent a very attractive profit-making opportunity under normal circumstances. In a crisis, however, we find that making those commodities becomes the focus of many firms that were making other products.

PS: As you well know, one thing that’s been drilled into the head of every business in the world, including health care businesses, is this notion of just-in-time inventory, and we’ve all worked hard to keep our inventories low to minimize our supply costs. In retrospect, the health care industry has paid a huge price for that. In the long term, it makes sense for inventories to be held at the federal, state, and individual provider levels so that we don’t come up short in disasters like this.

RH: In the area of operations, where we teach cases about the Toyota production system and lean manufacturing, we also discuss the complementary need for pooling inventory across sites and even firms. Right now, we are seeing companies and health systems bidding against one another and states bidding against the federal government for these precious resources. It exposes the fact we need to think about effective pooling mechanisms that would allow for these supplies to be held regionally. In a well-functioning system, one would hope not that each hospital tries to build massive stockpiles to ensure against an event, but that hospitals would work together and be able to draw upon shared stockpiles of key materials.

Looking ahead to the other side of the surge, where do you see space for optimism in the future of health care delivery?

PS: The speed and ferocity with which the scientific community has gone after this virus has been breathtaking. The fact that we knew the genetic sequence of it within a few weeks, the fact that there are vaccine candidates being tried in humans, that perhaps we’ll see a drug that is effective against it—the power of biomedical research in the year 2020 gives me a lot of hope that we will come up with innovations that make our future brighter than it otherwise would have been.

RH: Historically, we have spent far too much time talking about how constrained the health care system is when it comes to engaging in local innovation. I think this crisis has freed up those constraints to some degree. Innovations like the use of iPads to help communicate with patients in hospital rooms need to remain in use after this pandemic has passed. Unfortunately, this virus has resulted in the tragic loss of many lives and a lot of suffering. My hope, though, is that the system can learn from this crisis to create innovations in process and technology that could fundamentally improve care delivery in the future.

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