A Special Look at “How Covid Crashed the System” by David Nash, MD, MBA and Charles Wohlforth

Is it time to review the past 2+ years of the COVID-19 pandemic? When I learned that my Dean Emeritus, David Nash, MD, MBA, and coauthor Charles Wohlforth were about to publish a book doing just that, I reacted first with weariness from COVID-19 over-saturation. I think all Americans—truly all world citizens—probably feel likewise!

With COVID-19 abated but still present (344 Americans are dying daily of the virus today), the story is not yet over.¹ David Nash and Charles Wohlforth suggest the time is now, and recently published How Covid Crashed the System: A Guide to Fixing American Health Care, an extensive analysis of COVID-19’s challenge to our American health care system.

It is a tall undertaking given the complexity of people and systems. From attempts to achieve health care safety that matches the safety record of the airline industry, to aligning payment models that reward achievement of population health instead of more medical care. The book is a big, thought-provoking, and easily readable story of our once-in-a-lifetime pandemic. There is urgency, too, because the next pandemic is not likely to wait 100 years.

The authors systematically examine failure, but also recognize some innovations spurred by critical necessity. It is just as important to recognize and work to sustain these innovative aspects of our “new normal” as to perform post-mortems on our dismal performance through the pandemic.

The crisis calls out, the authors argue, for us to promote the “system-ness” of our national health care. We have, in fact, thousands of health care systems, and despite a huge investment in technologies, lack an integrated approach to managing our population health. COVID-19 helped to change that.

Because of the pandemic, medical knowledge developed rapidly the past two years and new treatments and approaches received quick, widespread adoption across most of our hospitals. For example, the benefit of prone positioning, the turning face-down of the critical patient with COVID-19 who verges on respiratory failure, was one of many interventions considered for COVID-19 patients, especially when ventilators became scarce.² Prone positioning worked, and we saw quick adoption of the practice over a matter of months across our intensive care units.

A theme running throughout the book is that health care delivery and public health must be viewed as two parts of one whole. Our country often neglects public health in favor of medicine; a profit-driven health care model does not support it. Where is the profit in public health? Public health does not make any money, no matter how many people it keeps well. While health care is responsible for, at most, 15% of variation in premature death, the impact of investment in public health is much greater—$14 to $88 are saved for every $1 invested.³ The 1964 Surgeon General’s report about the dangers of smoking saved 8 million lives in 15 years and was responsible for 30% of the substantiated increase in life expectancy of the 40-year-old during those decades.⁴ I wonder if tobacco companies would have foiled that change in today’s social media-saturated partisan environment.

How Covid Crashed the System first analyzes what went wrong, considering failures of leadership, how American culture made us vulnerable, COVID-19 and racism, public health, and the crisis in the hospital. Hospitals and practices funded by the fee-for-service model collapsed, while insurance companies banked payment from policyholders and posted windfall profits. Part 2 explores how to address this paradox through the promise of financial incentive alignment through vertically integrated systems (“payviders”). The retraining of doctors, thoughtful adoption of technology, empowerment of employers who fund almost half of Americans’ health care, and the continuing role of models that advance quality and safety are also proposed. The challenges are great. Only comprehensive assessment of our past two years, and a theoretical roadmap for the future, can offer us a more successful path through our next national crisis. How Covid Crashed the System offers both.

Stay tuned for a video interview discussing How Covid Crashed the System with Dr Nash!

References:

1. Centers for Disease Control and Prevention. COVID data tracker weekly review. September 30, 2022. Accessed October 4, 2022. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html
2. Guérin C, Reignier J, Richard JC, et al; PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013; 368(23):2159-2168. doi:10.1056/NEJMoa1214103
3. Masters R, Anwar E, Collins B, Cookson R, Capewell S. Return on investment in public health interventions: a systematic review. J Epidemiol Public Health Rev. 2017;71:827-834. doi:10.1136/jech-2016-208141
4. Holford TR, Meza R, Warner KE, et al. Tobacco Control and the Reduction in Smoking-Related Premature Deaths in the United States, 1964-2012. JAMA. 2014;311(2):164–171. doi:10.1001/jama.2013.285112