You are about to hear a discussion I’m having on the COVID-19 pandemic with my good friend Dr. Jon Perlin, HCA Healthcare’s President of Clinical Services and Chief Medical Officer; and Dr. Larry Van Horn, a healthcare economist, professor at the Vanderbilt Owen School of Management and advisor to the White House.
We are presenting virtually to our Nashville Health Care Council Fellows Class, a group of the brightest rising executives and leaders in the healthcare space.
We are taping on Friday, March 27th. This is a rapidly evolving crisis, changing day by day. So, please continue to follow the latest recommendations by the CDC.
Jon Perlin: There seems to be a second peak done. If the first peak is, “When do people get infected?” that may not be the right ball to have your eye on. It may actually be, “How long does it take people to go from infected to sick to needing to be hospitalized to intensive care?”
Bill Frist: Today on A Second Opinion, we bring you our latest special episode in our continuing series, providing the most up to date real time coverage on the 2019 novel coronavirus. You’re about to hear a discussion I’m having on the COVID-19 pandemic with my good friend, Dr. Jon Perlin, HCA Healthcare’s president of clinical services and chief medical officer, and Dr. Larry Van Horn, a healthcare economist professor at the Vanderbilt Owen School of Management and advisor to the White House.
Bill Frist: We’re presenting virtually to our Nashville Health Care Council fellows class, a group of the brightest rising executives and leaders in the healthcare space. We’re taping on Friday, March 27th. This is a rapidly evolving crisis changing day by day, so please continue to follow the latest recommendations by the CDC. I’m your host, Senator Bill Frist. Welcome to A Second Opinion.
Larry Van Horn: I’ve got Dr. Jon Perlin here, the chief medical officer and president of HCA, on the line, ready to join us. Dr. Perlin, my friend, how are you?
Jon Perlin: Professor Van Horn, Senator Frist, great to be with you all and the Nashville Health Care Council Fellows.
Larry Van Horn: Well, you’ve been leveraging data for all kinds of purposes at HCA. Everything from your MRSA, and your sepsis, and all of that kind of activity. You are the data guy. Everybody has Dr. Perlin’s bio. Has been with HCA since 2006. Before that, he was the honorable Dr. Perlin, and was the under secretary of health in charge of the VA as the nation’s top doc. So he’s always been a great friend of the Fellows program. When we reached out and did a pivot two weeks ago, he was very kind to free up some time today to spend with all of you.
Larry Van Horn: Talking more now about organizational response. We had our conversation with Dr. Schaffner about the epidemiology and the diffusion in the case fatality rate and that. Now we want to get to the conversation of what are provider organizations having to do to meet this challenge, this pandemic in America. We’re blessed and nobody more qualified to have that conversation with than Dr. Jon Perlin, so-
Jon Perlin: Well, terrific. Just a delight and honor to be with you. Congratulations to all the fellows. What you’re learning is honestly as good as I’ve heard on any of the briefings. Had the opportunity to work pretty closely with the CDC, all other elements of HHS, FEMA, and others.
Larry Van Horn: Yeah, and I’ll start, and you guys start raising your hand, or send me texts, or just jumping in. How concerned are you about the system capacity? Are there markets where you say, “This is going to be a real issue,” and then there are markets where you’re saying, “This isn’t going to be so bad.”?
Jon Perlin: I think it’s possible that many markets, if not all markets, will eventually have activity. I think the challenge is in trying to identify where activity is going to blossom first, so that we can position equipment like ventilators and the like in those markets to meet the surge. So I wish the data were a greater leading indicator. But obviously, forecast improved, the closer you get to the event.
Jon Perlin: Maybe one note on that forecast is that we know that the incubation time for the virus is between four and a half to 11 and a half days. Which is why you may have heard people are saying, “Okay, it’ll take 12 days for the social isolation measures to come into place.” That’s true, but that’s not the whole truth.
Jon Perlin: The vast majority of people… Bill Schaffner probably said this. Particularly younger individuals will be either asymptomatic, or have mild respiratory symptoms, or just something that’s sort of flu-like that doesn’t hospitalize. Some percentage will go on to more severe disease. Some with more severe disease, particularly with underlying conditions, or older individuals will deteriorate to the point that they need to be hospitalized, some intensive care, and some needing a ventilator.
Jon Perlin: That longer period, there seems to be a second peak done. If the first peak is, “When do people get infected?” that may not be the right ball to have your eye on. It may actually be, “How long does it take people to go from infected to sick to needing to be hospitalized to intensive care?” That may be longer out there. So we’re just beginning to get those data. I think our best learning is going to come from places like Northern California, Seattle, and now New York, where some of those data may help us understand what’s going to happen when and where.
Jon Perlin: But that said, in New York, they’re right in the throes of that. Right now they’re still meeting the needs with ventilators they have. Whether it rises to the level that Governor Cuomo is worried about in terms of needing 40,000 ventilators or the like, I’m not sure. But our best models will be built on what happens.
Jon Perlin: One other feature that we’re trying to program into our predictive models is the urban density. There are a couple things that haven’t been talked about. Maybe Bill alluded to it. But if you look at a worldwide band, there appears to be lower activities in warmer climates. There’s still a lot of debate about that. But if that’s true, then maybe there is some suppression of activity as we get into the spring. No one knows. That’s one potential factor.
Jon Perlin: Second factor is the urban density. New York is the perfect culture, obviously, because you have extraordinary density and you also have reliance on an infrastructure like subway that puts people inevitably together even to fulfill the essential services. There are a couple of natural experiments, unfortunately, going on. I’m probably not in a better place to answer the question than anybody else on this call this morning.
Larry Van Horn: Comments, questions, things you’d like to hear Dr. Perlin speak to.
Jeffrey: Yeah. Can you talk a little bit about what you guys are either willing to or able to do from a treatment perspective, and are you willing to enable to move ahead of FDA recommendations institutionally across your footprint?
Jeffrey: The reason I ask is clearly, there’s a number of things being discussed right now in terms of mitigating antivirals. Hydroxychloroquine plus Zithromax is a popular, slightly controversial topic out there. There’s a variety of others that are IV-based. Is there something that you all are proactively looking at? Are you waiting for data on?
Jon Perlin: Yeah. Thanks, Jeffrey. That’s a fantastic question. First, we try to make our practices consistent with FDA and the CDC. That said, under the circumstances, there’s a lot of interest and… The plain truth is that medications are prescribed off-label all the time.
Jon Perlin: We actually have to date, had about in the aggregate about 6,000 persons under investigation, and in the aggregate about 3,000 confirmed COVID cases. About 600 and some have been hospitalized. I’m just looking at some data this morning that across the organization, we had 300 plus who have actually been treated with hydroxychloroquine or chloroquine plus or minus azithromycin. We are actually working with epidemiologists, CDC and others, to actually do very quick analytics on that, because we think these data are so critically important.
Jon Perlin: We’ve got use of remdesivir under compassionate use. And we’re approached by a number of other organizations as to potential trials. Some of those trails are extraordinarily complex. There’s one that would involve plasmapheresis or harvesting the serum from infected individuals and extracting components for treatment of other individuals. That may not be practical at scale, particularly at this time, or even feasible in terms of conduct at small scale.
Jon Perlin: But going into our data is part of the advantage of a large coordinated system and why the CDC, and HHS, et cetera are so interested, is the ability to aggregate these data. For 10 years, we’ve put everything into a data warehouse. We’re looking not only at those, but our goal is to look at the incidental features. Are there certain drugs that’s been rumored that NSAIDs are worse than Tylenol? It’s been suggested that hypertensive patients on ACE inhibitors may fare worse. We can actually look at the validity of some of those things, and we think we can make some pretty good contributions very, very quickly along those lines.
Jon Perlin: So we’ll be learning, and we hope we can get the science nailed down so that we can be more successful as a country and frankly, for humanity on the basis of data. There are very few places that have the ability to bring these data together. We have both an awesome task, but we feel an awesome responsibility to be able to accelerate learning. That fundamentally, Larry’s heard me say this before, the privilege of scale isn’t being big. The privilege of scale isn’t just being able to move ventilators to where you need them. That’s all good. Privilege of scale is the ability to accelerate learning.
Marten: Hi, Dr. Perlin. Question for you around maybe more more of the economics of your situation at HCA. If you look at the industry today, we heard a comment earlier about how disruptive the current situation is to the business of healthcare. How do you see sort of the size and scale of HCA weathering this storm versus smaller hospitals? Do you anticipate there will be an accelerated M&A later this year as some hospitals won’t be able to make it?
Jon Perlin: Yeah, so first, Marten, it’s great to see you. Full disclosure, I had the pleasure of working with Marten when he was at Digital Reasoning.
Jon Perlin: To your question, this is a tough time for hospitals. You’ve got decreased revenues on the one hand, and you’ve got increased expenses on the other. You want the infrastructure to be intact, and you’ve got a very intense patient load. That is a challenging prospect. We’re appreciative the administration recognizes that, and the legislation making its way through Congress, it’s recognized as well.
Jon Perlin: You mentioned that this is rough weather, rough seas. Better to be on a large boat in rough seas than a small, less stable boat. So I do worry about the infrastructure. I think the real lesson is actually, what changes after this? How do we think more effectively about how robust our healthcare infrastructure is, generally in terms of surge capacity? How do we think about the integration of our healthcare and our public health?
Jon Perlin: With respect to the M&A and that sort of thing, I’m the wrong person to speculate on that. Again, this group would have insights. But what I can tell you is as a member of MedPAC and as former American Hospital Association chair, if you just look at hospitals at large, we’ve got a third that have negative operating margins. You’ve got a third that have such low margins that they’re generally in violation of their bond covenants. And you’ve got a third that are healthier. That means that there are two-thirds that are really tenuous. I can tell you that it’s stressful on a large ship and a rough sea. It’s, I’m sure, extraordinarily stressful for the others.
Jon Perlin: It’s also stressful in every other way. I mean, think about the individuals who are out there on the front lines. They see a varying range of experience around the world, where in some countries like Italy, there have been very high rates of healthcare worker infection. In other countries, it’s been much lower. Fortunately in the United States, it’s actually been very, very low.
Jon Perlin: The point I make here is that the other thing that if you let an industry sort of decay to a certain point, you have potential not only health threats, but security threats. We see a complete dependence on one source of masks. Supply chain that’s both vendor and geographically consolidated. So I hope in the near term that we make thoughtful investments in healthcare to keep it viable through this issue. But I think we need to have a longer conversation about the viability over the long haul.
Jon Perlin: One thing that has been alluded to, but I don’t know whether it was called out specifically, what do we think the timeline for this is? I mean, I think realistically, I’m operating with I’m calling eight and eight, is that we have eight weeks of more accelerated activity. Hopefully, the social distancing, if applied effectively, will ameliorate the height of that peak. But we’ve probably got eight months of simmering, particularly if the climate issue is a bit of a red herring and not really true.
Jon Perlin: Difference… People always ask, “Why isn’t the flu peters out, this is thought to continue on?” It has to do with the distance the particles are transmitted, the proximity that’s… Increased proximity in winter months. These particles travel further than the flu particles. So we hope that indeed some of that early climate data, weather data is accurate.
Jon Perlin: So imagine then you’ve got eight weeks of more accelerated activities. Including those eight weeks, eight months of kind of simmering activity. Then you come the fall, rinse and repeat. That’s why the most important thing that we should be investing on is not only, to Jeffrey’s question, what are the therapies, but what might be available in terms of vaccine and other strategies.
Larry Van Horn: Very good. Mark, do you want to ask your question?
Mark: My question is, is there any initial read on your hydroxychloroquine data? You said 300 people were on therapy. There’ve been two deaths in Davidson County, which is two too many. But one would infer that these patients must have done fairly well. Any wet read on whether that’s working or what the discharge rates are for those 300 people?
Jon Perlin: Yeah. Well, here’s the good news. Thank you for your question. Also, best to Secretary Principi, just a wonderful person. We’ve had very few deaths across the system, even amongst very sick patients.
Jon Perlin: What I can tell you among the hospitalized patients, 50% are in the intensive care unit. Among the hospitalized patients, half of those in intensive care are on ventilators.
Jon Perlin: So you’ve now got a base of cumulatively, close to 600 patients. Half of whom had been in intensive care, and a quarter of that 600 who’ve been on ventilators. Across the entire system, I need to go check the data, but the death rate has been extraordinarily low.
Jon Perlin: One of the questions that’s out there is, “Okay, let’s…” One question is, “Does chloroquine, or hydroxychloroquine, or either plus azithromycin, or remdesivir, do these work?” The other question is, “If they work, when is the optimal time?” It may be that if given too late, you’re not going to have a good outcome. It may be that there are issues with giving it too early. Those are dynamics we have to understand. But we’ve been very fortunate. Hopefully, we’ll keep up the trajectory. But fortunately, we don’t have a surfeit of mortality, but it’s also one of the reasons we need to take our data, as large as it is, and put it together with other people’s data, because we need to understand the characteristics of people who didn’t fare as well.
Mark: Dr. Perlin, as a follow up, are you guys using IV ascorbic acid in your protocols? Or do you know if that’s being used?
Jon Perlin: We looked to that to some degree with sepsis, and there’ve been a number of good studies. I don’t know. I can’t tell you that they’re being used in this situation outside of perhaps some incidental use of particular clinicians or clinical teams. One of the things that I think bears further science, interestingly, is the role… There seems to be suggestion of a relationship with vitamin D deficiency and greater susceptibility to worse outcomes. More to watch on that.
Larry Van Horn: Jon, you made the point that you don’t think Nashville is doing a very good job social distancing.
Jon Perlin: No, I made a point that we’re not doing a good job of social distancing. [Inaudible] our community.
Larry Van Horn: What do you see the path here is? Do you see a state of the world where we should be socially distancing or even more for months?
Jon Perlin: Here’s the irony is that our country is made up of rugged individuals. We’re just not good at taking dictums from above and abiding by it. But it’s not like a little bit pregnant. You’re either socially distanced or you’re not.
Jon Perlin: The irony is that if we did this really well for a shorter period of time, that probably would be the most effective way to stop. And if we did it early enough while we simultaneously ramp the testing, then like Germany, we could have the capacity to isolate those individuals who are carriers, socially distance them, and not the entire population.
Jon Perlin: For what it’s worth, Bill Gates recorded an absolutely phenomenal TED Talk interview. It’s about an hour long, but it reviews a lot of this very, very well. He makes the points that if one approach that’s not sort of in the American psyche is the challenge of social distance. Work through what happens if you don’t social distance and have an extraordinarily intense and widespread disease burden with excess mortality. Because you think people are really going to be in the mood to buy new homes, or invest, or do all those things. Will that really gear up the economy? So I think we have a political, and sort of sociological, and scientific argument that has a number of components of it.
Jon Perlin: I think what we do need to do is find a satisficing approach. My fear is that we’re going to end up with a general sense that, “Well, social distancing doesn’t work. We tried that.” Well, if you go back to the unicast data, I think the second order question is, “Where didn’t it work, and why didn’t it work?” Let’s grab our lessons there. This is one of those points where we really got to go to the science, go to the data, and make great decisions.
Larry Van Horn: Bill, you got some comments?
Bill Frist: No, it’s just ironic. Jon and I, what, three weeks ago were at a conference together, did a panel. Over that weekend, the world really changed. Was it three weeks ago, Jonathan?
Jon Perlin: Hard to believe. It seems like a lifetime ago.
Bill Frist: Yeah, so things have really changed. I think just listing really over the last couple hours and really finishing, Jonathan, what you were saying, the idea of testing and the importance of testing, both with PCR up front and then eventually the serologic testing here is really important. I think there’s not enough emphasis being placed on that. It’s the one thing that I keep coming back to that can be done.
Bill Frist: I mean, we’re going to social distance now. I think the American people are getting tired of it. I worry about that getting tired of it will be this sort of bursting through this flattening of the curve that we have achieved today. I don’t know if there’s much we can do about that. There’ll be pockets where things flare up. Some testing has put in, it’ll flare up, and then the mayor will close down on it.
Bill Frist: But I worry about that. I think that all of us should be thinking a lot more about the reagents, where to get the reagents, the type of testing, introduce serologic testing. It’s not out there. It’s not what a lot of the hospitals in New York and… We were just talking about St. Thomas and others, where the PPE is a focus. But I think all of us should leave this conversation understanding the importance of testing and that we’ve failed as a country and have continued to fail over the last four weeks [inaudible] made no progress whatsoever. That’s all for me.
Jon Perlin: You make fantastic points. Thank you for your advocacy in terms of the social distancing. I know you’ve been encouraging that. Clearly, there are deficiencies in our approach in terms of the lab testing and the need to really amp that up right now.
Jon Perlin: The thing that intrigues me is how do events like this change things for the fellows. The eye is of course on the ball, which is COVID. But it’s interesting to me to think about what happens when we put this behind us at some point? Well, what’s changed? I used to think, “But my kid’s using telehealth. Not so much my 95-year-old dad using telehealth.” He’s totally down with that. In fact, he’d rather have the iPad visit than go somewhere. That’s forever changed.
Jon Perlin: I’m the board chair of the National Quality Forum. We’ve had a conversation about what would improve quality in the future. There were some things that were thought to be a bridge too far, such as some interstate licensure. Well, in support of the telehealth, that’s already happened. So there are a number of things that are immutably changed. Scope of practice for non-physicians, as an example.
Jon Perlin: What are the lessons that we are compelled to respond to after we come out of this? What are the opportunities that are created by virtue of the disruption? It’s said sometimes, don’t let a crisis go to waste. I’m always amazed at the accelerated innovation. In our organization there’s been just extraordinary acceleration of innovation, such as the data I’ve shown you. But putting all that together, what does it mean for how we operate on the other side of this? What are the new challenges, what are the remaining challenges? But the bright light for me is, “What are the really extraordinary opportunities?” I think that’s a pretty exciting prospect.
Bill Frist: Jon, thank you a million for taking time to be with us today. It’s usually helpful in that systems approach and big data approach, we have so much to learn from. And that sharing of data with our government, clearly important.
Bill Frist: We kept coming back over the course of today or the last two hours to the importance of data. With Larry’s model and working with the federal government and the amount of data that you at HCA can collect and share with others, and then our lack of data to make these policy decisions. We talked a little bit early, very early on about the policy decisions that are being made, and our policy makers are looking for data. How far to go with sheltering, how far to go with shutting things down, recognizing there’s an economic cost. The policy makers have to make these decisions in that very imprecise world.
Bill Frist: It takes a lot of patience, I think, on the American people part. We need to congratulate the American people, because they’ve accomplished what I’d never thought they’d be able to do, and that is uniformly step up and shelter and do the appropriate physical social distancing and adopting to new technologies. So we need to congratulate them as well. But Jonathan, this was a perfect capstone to our conversation today.
Jon Perlin: Well, honored to be with you. I have a feeling I’m going to be using Zoom skills a lot in the future, so thank you for helping accelerate my Zoom capacity.
Bill Frist: Yeah, good. Thank you very much. Thank you very much. Thank you.
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