THE LEARNING HEALTH SYSTEM SERIES

EMERGING STRONGER
FROM COVID-19

Priorities for
Health System Transformation

National Academy of Medicine
NAM Leadership Consortium

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

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This publication has undergone peer review according to procedures established by the National Academy of Medicine (NAM). Publication by the NAM signifies that it is the product of a carefully considered process and is a contribution worthy of public attention, but does not constitute endorsement of conclusions and recommendations by the NAM. The views presented in this publication are those of individual contributors and do not represent formal consensus positions of the authors’ organizations; the NAM; or the National Academies of Sciences, Engineering, and Medicine.

International Standard Book Number-13: 978-0-309-69173-4
International Standard Book Number-10: 0-309-69173-7
Digital Object Identifier: https://doi.org/10.17226/26657
Library of Congress Catalog Number: 2022947719

Copyright 2023 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academy of Medicine. 2023. Emerging Stronger from COVID-19: Priorities for Health System Transformation. A. Anise, L. Adams, M. Ahmed, A. Bailey, P. S. Chua, C. S. Chukwurah, M. Cocchiola, A. Cupito, K. Kadakia, J. Lee, and A. Williams, editors. NAM Special Publication. Washington, DC: The National Academies Press. https://doi.org/10.17226/26657.

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EMERGING STRONGER FROM COVID-19: PRIORITIES FOR HEALTH SYSTEM TRANSFORMATION

Steering Committee and Lead Authors

AMY ABERNETHY, Verily

JEFFREY BALSER, Vanderbilt University Medical Center

CAROLYN CLANCY, Veterans Health Administration

NAKELA COOK, Patient-Centered Outcomes Research Institute

KAREN DESALVO, Google

KATE GOODRICH, Humana

ROBERT HUGHES, Missouri Foundation for Health (former)

FREDERICK ISASI, Families USA

MICHAEL LAUER, National Institutes of Health

PETER LEE, Microsoft Research

JAMES MADARA, American Medical Association

MATHAI MAMMEN, Janssen/Johnson & Johnson

MARK MCCLELLAN, Duke University

SUZANNE MIYAMOTO, American Academy of Nursing

VASANT NARASIMHAN, Novartis

MARY NAYLOR, University of Pennsylvania

RAHUL RAJKUMAR, Optum Care Solutions

JAEWON RYU, Geisinger

DAVID SKORTON, Association of American Medical Colleges

NAM Staff

Development of this publication was facilitated by contributions of the following NAM staff, under the guidance of J. Michael McGinnis, Leonard D. Schaeffer Executive Officer and Executive Director of the NAM Leadership Consortium: Collaboration for a Learning Health System:

LAURA ADAMS, Special Advisor

MAHNOOR AHMED, Associate Program Officer

AYODOLA ANISE, Deputy Director, NAM Leadership Consortium

ARIANA BAILEY, Senior Program Assistant (until August 2021)

PEAK SEN CHUA, Consultant

CHINENYE STEPHEN CHUKWURAH, Research Associate (until July 2021)

MICHAEL COCCHIOLA, Associate Program Officer (until July 2022)

ANNA CUPITO, Associate Program Officer (until July 2021)

KUSHAL KADAKIA, Consultant (until August 2021)

JENNIFER LEE, Special Advisor (until August 2022)

JENNA L. OGILVIE, Deputy Director of Communications

ASIA WILLIAMS, Associate Program Officer

REVIEWERS

The papers in this volume were reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with review procedures established by the National Academy of Medicine (NAM).

We wish to thank the following individuals for their contributions:

PREFACE

We know from Isaac Newton’s third law that forces come in pairs: for every action, there is an equal and opposite reaction. But when it comes to human catastrophe, a post-acute human tendency often sets in to diffuse the reactive forces from what ought to be their primary directionality. Without a strong resolve to keep sharp focus on the most basic lessons learned about preparedness shortfalls, the stage is set, seamlessly and senselessly, for the tragedy of the next event. In 2001, terrorism on American soil drew collective attention to the gaps in national security that made our nation vulnerable to attack. In 2004, Hurricane Katrina made clear the need for infrastructure that is resilient to natural disaster. Both responses have led to focused change, albeit imperfect, in the nation’s preparedness. On the other hand, the tragedy of mass murders, such as the 2014 shooting in Sandy Hook, have been followed by societal inaction, and left the nation unprotected from the full force of the occurrence of similar catastrophes.

To date, in mid-2022, the United States has lost more than a million people to the COVID-19 pandemic. We have been real-time witnesses to heroic frontline responses to the disease, death, inequity, and economic strife unleashed by the virus. We have also been real-time witnesses to the consequences not only of poor preparedness to contend with newly emerging health threats, but especially to the consequences of structural failures of our health system. The nation’s health system is poised at a critical junction point, with the opportunity to emerge stronger not merely in resistance to a novel infectious disease threat, but as a secure and sustained steward of the human condition over time.

For decades, the U.S. health system has fallen far short of its potential to produce individual and population health. In contrast to health care spending that exceeds that of any Organisation for Economic Co-operation and Development (OECD) nation, the U.S. experiences lower life expectancies, higher suicide rates, higher chronic disease burdens, higher obesity rates, and higher hospitalization rates from preventable causes than any of its peers. The inequities, lack of community

engagement, misaligned resources and incentives, untapped digital potential, and slow rate of evidence mobilization that belie these trends were also at the root of the nation’s experience with COVID-19. To fully realize health system effectiveness, efficiency, equity, and continuous learning that will translate to better and more holistic health and well-being, leaders from across the U.S. health system must take action to leverage both the learnings and the transformational opportunities that have accompanied the pandemic’s devastation.

Cognizant of the potential near-term and long-term importance of understanding in detail the features, impacts, and responses within and between various health sectors during the pandemic, the National Academy of Medicine’s (NAM’s) Leadership Consortium, comprised of the leadership of organizations from all major health system sectors, has undertaken a sector-by-sector review of the U.S. health system. The papers contained within assess the weaknesses that existed prior to COVID-19, how each sector has responded to the pandemic, and the opportunities that exist for health system strengthening and transformation. The resulting sectoral impact assessments are presented here in Emerging Stronger from COVID-19: Priorities for Health System Transformation. Each assessment team has been led by members of the NAM Leadership Consortium. Emerging Stronger is comprised of nine chapters that summarize the findings, opportunities, and collaborative options for sectoral transformation, followed by a chapter on cross-sector priorities for change, including:

1. Patients, Families, and Communities
2. Clinicians and Professional Societies
3. Care Systems
4. Digital Health
5. Public Health
6. Health Care Payers
7. Health Product Manufacturers and Innovators
8. Biomedical Research
9. Quality, Safety, and Standards Organizations
10. Health System Transformation: Common Priorities Across Sectors

The summary insights, drawn from the shared perspectives of the sector authors, underscore three deeply rooted common features leading to the core problems within each sector:

1. Systemic fragmentation,
2. Perverse incentives, and
3. Structural inequities.

Accordingly, the authors note the importance of forceful collaborative engagement of transformational opportunities for stakeholders setting priorities for organizations in each of their sectors:

1. Financing that is linked, integrated, seamless, and focused on outcomes for people and populations;
2. Digital interoperability and shared data;
3. Culture and accountability focused on outcomes most important to people and their communities;
4. Learning that is real world, continuous, and timely; and
5. Public health integrity as an explicit responsibility of every organization.

Taken together, the assessments in Emerging Stronger provide a unique and comprehensive review of the U.S. health system’s experience throughout the pandemic, as well as a roadmap toward a healthier future. It integrates the deep and growing knowledge base of the NAM with the expertise of leaders engaging the pandemic in real-time, offering both information and inspiration for aligned action on key opportunities. In this respect, we extend our deep appreciation to the members of the NAM Leadership Consortium, the project Steering Committee composed of the lead authors of each sector assessment, their collaborating colleagues from the field, the expert reviewers of each of the papers, and the superb NAM staff who coordinated and facilitated their work.

As Americans, innovation, improvement, and invention is our shared birthright. This publication underscores the imperative and the promise of applying the full strength of the nation for system-wide transformation as we apply the clarity of the lessons learned to create a health system that is effective, efficient, equitable—and continuously learning.

CONTENTS

Acronyms and Abbreviations

1 Patients, Families, and Communities COVID-19 Impact Assessment: Lessons Learned and Compelling Needs

Frederick Isasi, JD, MPH; Mary D. Naylor, PhD, RN; David Skorton, MD; David C. Grabowski, PhD; Sandra Hernández, MD; and Valerie Montgomery Rice, MD

2 Clinicians and Professional Societies COVID-19 Impact Assessment: Lessons Learned and Compelling Needs

James Madara, MD; Suzanne Miyamoto, PhD, RN; Jason E. Farley, PhD, MPH, ANP-BC; Michelle Gong, MD, MS; Millicent Gorham, PhD(Hon), MBA; Holly Humphrey, MD, MACP; Mira Irons, MD; Ateev Mehrotra, MD, MPH; Jack Resneck, Jr., MD; Cynda Rushton, PhD, MSN, RN; and Tait Shanafelt, MD

3 Care Systems COVID-19 Impact Assessment: Lessons Learned and Compelling Needs

Jeffrey Balser, MD, PhD; Jaewon Ryu, MD, JD; Michelle Hood, MHA; Gary Kaplan, MD; Jonathan Perlin, MD, PhD; and Bruce Siegel, MD, MPH

4 Digital Health COVID-19 Impact Assessment: Lessons Learned and Compelling Needs

Peter Lee, PhD; Amy Abernethy, MD, PhD; David Shaywitz, MD, PhD; Adi V. Gundlapalli, MD, PhD, MS; Jim Weinstein, DO; P. Murali Doraiswamy, MBBS, FRCP; Kevin Schulman, MD; and Subha Madhavan, PhD

5 Public Health COVID-19 Impact Assessment: Lessons Learned and Compelling Needs

Karen DeSalvo, MD, MPH, MSc; Bob Hughes, PhD; Mary Bassett, MD, MPH; Georges Benjamin, MD; Michael Fraser, PhD, CAE; Sandro Galea, MD, MPH, DrPH; J. Nadine Gracia, MD, MSCE; and Jeffrey Howard, MD, MBA, MPH

6 Health Care Payers COVID-19 Impact Assessment: Lessons Learned and Compelling Needs

Mark McClellan, MD, PhD; Rahul Rajkumar, MD, JD; Marion Couch, MD, MBA; Diane Holder, MS; Peter Long, PhD; Rhonda Medows, MD; Amol Navathe, MD, PhD; Mai Pham, MD, MPH; Lewis Sandy, MD, MBA; William Shrank, MD, MSHS; and Mark Smith, MD, MBA

7 Health Product Manufacturers and Innovators COVID-19 Impact Assessment: Lessons Learned and Compelling Needs

Mathai Mammen, MD, PhD; Vasant Narasimhan, MD, MPP; Richard Kuntz, MD, MSc; Freda Lewis-Hall, MD; Mojdeh Poul, MBA, MEng; and Adam H. Schechter

8 Biomedical Research COVID-19 Impact Assessment: Lessons Learned and Compelling Needs

Nakela L. Cook, MD, MPH; and Michael S. Lauer, MD

9 Quality, Safety, and Standards Organizations COVID-19 Impact Assessment: Lessons Learned and Compelling Needs

Carolyn Clancy, MD; Kate Goodrich, MD, MHS; Jean Moody-Williams, RN, MPP; Karen Dorsey Sheares, MD, PhD; Margaret O’Kane, MS, MHS; Stephen Cha, MD, MHS; and Shantanu Agrawal, MD

10 Health System Transformation: Common Priorities Across Sectors

Amy Abernethy, MD, PhD; Jeffrey Balser, MD, PhD; Carolyn Clancy, MD; Karen DeSalvo, MD, MPH, MSc; Kate Goodrich, MD, MHS; Robert Hughes, PhD; Frederick Isasi, JD, MPH; Peter Lee, PhD; James Madara, MD; Mathai Mammen, MD, PhD; Mark McClellan, MD, PhD; Suzanne Miyamoto, PhD, RN; Vasant Narasimhan, MD, MPP; Mary Naylor, PhD, RN; Rahul Rajkumar, MD, JD; Jaewon Ryu, MD, JD; and David Skorton, MD

BOXES, FIGURES, AND TABLES

BOXES

1-1 Stories of Lived Experience: Impact of Being a Frontline Employee During COVID-19

1-2 Stories of Lived Experience: Impact of Isolating to Prevent Transmission to Family Members

1-3 Stories of Lived Experience: Challenges Faced by Elizabeth de Garcia and Her Family in Navigating the Health System During the COVID-19 Pandemic

1-4 Stories of Lived Experience: Challenges Faced by Joe Merlino and His Family in Navigating the Health System During the COVID-19 Pandemic

1-5 Stories of Lived Experience: Impact of Suicide on Loved Ones

1-6 Stories of Lived Experience: Health Care Disparities During COVID-19

1-7 Stories of Lived Experience: Communicating Science to the Public

1-8 Stories of Lived Experience: Perceptions of the Pandemic Response

1-9 Stories of Lived Experience: Challenges with Communicating COVID-19 Messaging

1-10 Stories of Lived Experience: Community Collaboration and Resilience in Support of Individuals During COVID-19

1-11 Considerations for Facilitating Active, Continued, and Meaningful Community and Health Care Engagement with Patients and Families

1-12 Considerations for Building and Restoring Trust Through Improved Communication, Trusted Sources, and Translation of Scientific Practices

1-13 Considerations for Prioritizing Investment in Solutions Designed to Advance Health Equity

1-14 Considerations for Realigning Care Approaches to Meet and Engage the Health-Related Needs of People and Their Families, and Strengthen Community Capacity

1-15 Considerations for Examining Critical Intersections and Implementing Aligned Solutions Between Patients, Families, and Communities and Other Sectors

2-1 Considerations for Investing in Clinician Well-Being

2-2 Considerations for Advancing Innovations in Clinician Practice

2-3 Considerations for Promoting Financial Resilience for Clinicians

2-4 Considerations for Transforming Education and Training

2-5 Considerations for Addressing Health Disparities

3-1 Considerations to Enhance the Financial Resiliency of Health Systems

3-2 Considerations to Strengthen Health System Supply Chains

3-3 Considerations for Investing in Workforce Development

3-4 Considerations for Health System Capacity Building

3-5 Considerations for Renewing Commitments and Instituting Concrete Actions for Health Equity

3-6 Considerations for Addressing Subsector-Specific Challenges

3-7 Considerations for Fostering Linkages Between Health Systems and Public Health

4-1 Definition of Digital Health

5-1 Considerations for Transforming Public Health Funding

5-2 Considerations for Affirming the Mandate for Public Health

5-3 Considerations for Promoting Structural Alignment Across the Public Health Sector

5-4 Considerations for Investing in Leadership and Workforce Development

5-5 Considerations for Modernizing Data and IT Capabilities

5-6 Considerations for Supporting Partnerships and Community Engagement

6-1 Considerations for Accelerating the Transition to Value-Based Payment

6-2 Considerations for Extending Flexibilities for Virtual Health Services and Capabilities

6-3 Considerations for Rethinking Benefit Design Using the Lens of Value-Based Insurance

6-4 Considerations for Aligning Incentives and Investments to Address Health Inequities

6-5 Considerations for Creating Mechanisms for Collective Action During Public Health Emergencies

6-6 Considerations for Coordinating Payment Reforms with Public Health Functions

10-1 Centering Health System Actions and Accountability on Individuals, Families, and Communities

10-2 Committing to the Pursuit of Equity as Core to Health System Performance

10-3 Securing the Public Health Infrastructure to Address 21st Century Population Health Challenges

10-4 Building a Robust and Integrated Digital Health and Data Sharing Infrastructure

10-5 Integrating Telehealth into Payment and Delivery Systems

10-6 Investing in Workforce Capacity and Readiness

10-7 Streamlining Innovation Pathways for Biomedical Science

10-8 Enhancing Stewardship of the Health Product Supply Chain

10-9 Restructuring Health Care Payments to Focus on Outcomes and Population Health

10-10 Fostering Communication and Collaboration Across Sectors and Stakeholders

FIGURES

1-1 Impact of the Pandemic on Patients, Families, and Communities

1-2 Experiences of Patients, Families, and Communities During COVID-19

1-3 Impact of COVID-19 on Patients, Families, and Communities’ Relationship to the Health System

2-1 The Clinician Response to COVID-19

2-2 COVID-19 Stressors for Clinicians

2-3 Priority Areas for the Clinician Sector

3-1 Landscape of U.S. Health System

3-2 Health System Functions During COVID-19

3-3 Cross-Cutting Public Health Functions for COVID-19

3-4 Priority Actions for Sector Transformation and Emergency Preparedness

4-1 Lifecycle for Continuous Management and Refinement of AI Models

5-1 Models of Public Health Governance

5-2 Frameworks for Essential Services and Foundational Capabilities in Public Health

5-3 Pre-Pandemic Challenge Areas for the Public Health Sector

5-4 Key Challenges for Local and State Health Departments During COVID-19

6-1 Overview of America’s Multi-Payer Landscape

6-2 Payer Responses to COVID-19 Challenges

6-3 Key Challenges for Payers for the Post-Pandemic Era

6-4 Opportunities for Sector-Wide Improvement

6-5 Select Examples of Clinical Use Cases for Telehealth

7-1 Profile of the Health Products Sector

7-2 Elective Procedure Volume Weekly Trends

7-3 Weekly Volumes of New Prescription (Rx) of Branded Therapeutics

7-4 Telemedicine Use Among Health Care Provider Organizations

7-5 Opportunities for Sector-Wide Transformation

9-1 Key Levers for Care Quality and Safety

9-2 Vulnerabilities in Quality and Standards Exposed by COVID-19

10-1 COVID-19 Stakeholder Sectors Legend

10-2 Overview of Sector Changes, Challenges, and Transformation Opportunities

10-3 Select Examples of Leadership and Advances During COVID-19

TABLES

1-1 Pre-Pandemic Experiences of Patients, Families, and Communities

1-2 The Disparate Impact of COVID-19 on Communities of Color

2-1 Key Challenges for the Clinician Sector

3-1 Health System Challenges During COVID-19

3-2 Drivers of Supply Chain Vulnerability

4-1 Digital Health Challenges and Opportunities Revealed in the Eight Other Sector Papers

5-1 Role of Foundational Capabilities for Public Health During the COVID-19 Response

6-1 Payer Support for the Social Determinants of Health

6-2 Payer Strategies to Support the Transition to Virtual Care

7-1 Examples of Collaborations Which Emerged During COVID-19

10-1 Select Examples of Cross-Cutting Challenges and Experiences of Sectors for COVID-19

ACRONYMS AND ABBREVIATIONS