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What Is Flattening the Curve?
I had a mini debate/discussion with my neighbor yesterday.
I mentioned that the original goal of lockdown was to flatten the curve.
His response: what is flattening the curve?
I didn’t respond because he had to leave and I didn’t have the energy to explain something. I also didn’t think I could have a productive conversation with someone who doesn’t understand “flatten the curve.” What’s the point?
Published in General
When the curve flattening was first announced, I thought it was probably a bad idea but an understandable one: no one knew just what we were facing, and so an excess of caution could be justified. The goal, clearly, was to avoid overwhelming our critical care capabilities. This made a lot of sense, back when we thought (were led to believe) that we’d have a ventilator shortage and that ventilators were actually a practical treatment option.
(My own opinion, as I wrote here, was that we should spend a few hundred billion helping old people self-isolate, and leave the rest of us free to work.)
I’ve gradually revised my criteria for justifying extreme concern. It used to be the danger of running out of ventilators and ICU beds. Given what we’ve learned about this disease, I now consider running out of hospital beds and staff to monitor to be the critical consideration: as long as we have hospital capacity, or can create hospital capacity, we should leave people free to make their own decisions. Only when we face the plausible prospect of people dying in hospital hallways because we are out of beds should we even consider imposing restrictions.
I am not concerned about how many get this virus, nor even about how many die of it. We know it’s a serious, flu-like illness, and we know it’s likely to be with us for a few years, if not forever. It’s killed a bunch of people — like a bad flu — and it’s going to kill a bunch more. Life’s dangerous. Who’d have thought.
As to hospital capacity, I understand that one Tucson hospital is now admitting all suspected Covid cases to ICU while it waits for the test results. I think the numbers have been grossly inflated for economic reasons. Hospitals have been hit hard by the cancelling of elective surgery. They are now admitting patients as revenue enhancers. This is a well known phenomenon.
Yes they were the defective masks. I am not sure if the order was re-produced correctly and then sent over to the governor or not. But if the exchange was a cash refund, we might not, to quote Janet Reno, “ever ever know.”
For some cohorts, the flu is worse than covid. For children age 0 – 19, influenza is more dangerous than covid.
For ages 20 – 70, covid is comparable to influenza.
Age >= 70, covid is similar or more dangerous than influenza.
Flattening the curve has reduced hospital capacity (the irony).
No one benefits from hospitals losing money.
Even the Mayo Clinic in Minnesota projects huge financial losses this year.
Regarding ICU, in Texas, at least 25% of ICU patients are non-covid patients who happened to test positive but that was not the reason for their visit.
One reason why hospitalizations and ICU patients are up is that non-covid patients are starting to seek hospital care.
The lockdown in March and April was a mistake but understandable.
But continuing such a policy in May, June and now July is nonsense
You are probably wrong on this-
1)the hospital you mention may not have the proper kinds of rooms for transmissible respiratory diseases other than ICUs. You need negative pressure rooms to safely treat them (or else endanger your staff and other patients). Many hospital rooms are POSITIVE pressure (such as operating rooms). Furthermore, you need adequate space to put on and TAKE OFF protective medical gear when treating COVID patients-complete with washing or disinfecting stations, special trash receptacles and loads of protective gear. Most ICUS are not setup for this-at the hospital I work at we have retrofitted many rooms with negative pressure ventilation systems, increased air flow and added filters to clean the air. This has been done in multiple ICUs as well as our pulmonary floor. We previously had a very limited number of negative pressure rooms. But it isn’t standard practice to have large numbers of negative pressure rooms and space to handle PPE.
2) As I stated earlier taking care of the sick elderly patients is NOT a revenue enhancer-you lose money on every medicare and medicaid patient you treat. If you can devise a way to make a profit on medicare patients I can promise that hospitals will fight to pay you a 8 figure salary per annum.
3) medicare pays by diagnosis- so if you put people in the ICU for, say, a bruise-you won’t get paid more-you will just lose more money b/c of the added cost of treating them. The Feds aren’t dumb enough to just pay for whatever gold plated care you try to provide. The Blues aren’t dumb enough either-they often have agreements with hospitals to pay a flat fee for certain diagnosis so that they aren’t hostage to extraordinary expenses.
Or you need wings or floors that can be sealed off from the rest of the hospital and dedicated to Wuhan-positive patients, and staff who have already been exposed and and recovered and who are, quite likely, resistant or immune. By now, I suspect that there are quite a lot of the latter.
But you would need reliable testing to be sure. And the same idiots that will be mandating a vaccine of some sort in December have not managed to produce a reliable test yet. Not just in the US, either.
Two problems-1) not many medical staff have caught it- the PPE worked. So you will work to death a small fraction of providers. The only MDs I know who have been infected aren’t the ones who take care of COVID patients regularly.
2) we don’t know how long immunity lasts-so even those recovered will need to take precautions. You could try to repeatedly test their antibody levels to try to assure some immunity but you’d still have the problem reliability of the test ( would you be willing to gamble your life by not wearing PPE) and also your risk increases linearly over time and the test is always post hoc. The providers will need PPE and negative pressure rooms to protect THEM even if you have wards remote from other patients. ( it’s not that I think test don’t work but if you are tested multiple times the chance of an erroneous result goes up & this plan requires a LOT of testing).
also my main point was why it was probably erroneous to assume the hospital was placing presumed COVID patients in the ICU to increase revenue.
Let me be clear. I want to avoid another shutdown, and I’m willing to accept a lot of infection and a lot of casualties toward that end.
Until we actually know the efficacy of the immune response, it seems reasonable to assume it’s comparable to that for other coronaviruses and to act accordingly. As I understand it, that’s typically a one to three year interval of resistance.
You ask “would you be willing to gamble your life by not wearing PPE?” So wear PPE, we should have plenty of it by now — and recognize that it is not a great gamble for young health care providers in any case, as the mortality for this disease isn’t particularly great in the under-50 set.
This isn’t ebola, it has a pretty dramatically age-correlated mortality, and, as you point out, wearing PPE works. This doesn’t seem like a crisis.
Covid may be a different story regarding Medicare and Medicaid reimbursements to hospitals.
Any proof-or just wild speculation +/-slander? One should not claim that hospitals are engaged in widespread fraud w/o any evidence. Edit- this is more a reply to many assertions above not you specifically-many claims of fraud/abuse w/o support in the COVID numbers.
Bumper sticker:
“Flatten the curve, not the economy.”
Then principle of admitting patients based on bed census is well established. You could be correct on the details of why ICU when the diagnosis is unknown. In my wife’s case, she was never admitted to ICU and was so ill I was not sure I would see her alive again. Her primary care internist and the hospitalist who got her through are both convinced she had Covid aborted by HCQ. Her tests, five of them, were all negative.
https://pubmed.ncbi.nlm.nih.gov/10312632/
Again-no. For Medicare patients, since you lose money on each one, admitting more only causes you to lose more money (ie the marginal revenue is less than the marginal cost). The sick COVID patients are largely Medicare patients & there is no way to make a profit on them.
Addendum-hospitals are getting new monies for the COVID crisis but it isn’t based on admissions-ie calling somebody a COVID patient doesn’t create a windfall. The money they are getting is partly the payment protection program and also money to help support hospitals expenses during the pandemic-but it isn’t a gift- some has to be repaid and some might be granted by the government AFTER an audit approves the expenditures (hopefully for the cost of things like the ICU beds we converted to be negative pressure rooms etc). Otherwise you still get paid by diagnosis & comorbidities-but again its medicare you ain’t paid enough to cover your costs. If a hospital lies and claims everyone has COVID and needed a lot of care (which you then don’t really provide so you can skim the money) you will likely be caught, fined, & imprisioned etc-fun for the CEO & CFO.
I’m guessing that reimbursements won’t be low for covid
Doesn’t Medicare gap insurance alleviate some of the cost for hospitals?
I think there is an additional payment for ICU. I have been retired for years but recall artful hospital reimbursement antics. The failure to admit my wife to ICU was probably just incompetence by the first hospitalist she saw. Who announced “I am a board certified internal medicine specialist,” as she stopped my nurse practitioner wife’s regular meds.
No- it just helps the insured- no change in hospital reimbursement
There is additional pay b/c when you are admitted to the ICU your diagnosis often changes-from say bronchitis to pneumonia with hypoxia and therefore the payment might change. But your diagnosis must be backed by comorbidities, findings & labs that support it-they just don’t pay you for sticking people in the ICU. And again, the incremental pay by Medicare is less than the added cost of ICU care so putting people in the ICU isn’t a cash bonanza.
6 minute video by Michael Levitt