California Health Care's Response To The Pandemic

Good evening, everyone.

Welcome to TheCommonwealth Club.

I'm Mark Zitter, chair of the Zetema Project, a member of theClub's Board of Governors and your moderator for today.

This is anotherprogram in the Club's special virtual series on the coronavirus in associationwith the Zetema Project.

Next Friday April 24 at 2 p.

m.

Pacific we'll hostpandemic healthcare inequities and how they affect everyone, with the CEOs ofZuckerberg San Francisco General Hospital Martin Luther King jr.

community hospital and La Care Health Plan on May 4th at noon pacific we willhear Kaiser Family Foundation CEO drew Altman discuss u.

s.

healthcare and the2020 election in the era of corona virus please visit regularly at theCommonwealth Club sorry at Commonwealth Club org to stay informed on otherprograms on koban 19 out of their topics as well by the way these presentationsare free this program is generously supported by the Chan Zuckerberginitiative and a collaborative of local funders and donors we are grateful fortheir support and we encourage you to follow their example you can go to ourhome page and make a donation to support the series at the nonprofit Commonwealthclub which we proudly say is the nation's oldest and largest publicaffairs forum now it's my pleasure to introduce today's featured guests dr.

Bashar eschew care is senior vice president and chief health officer atKaiser Permanente a member of the National Executive team reportingdirectly to kaisers chief executive officer dr.

should care oversees theorganization's efforts focused on addressing the social health of its 12.

2million members and the 68 million people who live in the communities itserves his work includes the creation of the nation's largest social healthnetwork integrated with Kaiser Permanente's health care services tomeet the housing food and transportation needs of its members I'm also delightedto welcome dr.

Sandra Hernandez the president and CEO of the CaliforniaHealthcare Foundation an 800 million dollar foundationfocused on improving the healthcare system for all Californians particularlythose with low incomes earlier in her career she co-chaired San Francisco'suniversal health care Council which designed healthy San Francisco the firsttime a local government in the United States attempted to provide health carefor all of its constituents and a third panelist is Peter Lee the firstexecutive director for covered California the state's health benefitexchange covered California is the largest and many experts say the mostsuccessful state-based Obama care marketplace in the United Statespreviously mr.

Lee had various healthcare roles in the Obamaadministration and was executive director of both the Pacific BusinessGroup on health and the center for healthcare rights now for our audienceviewing via YouTube we invite you to submit questions for our panelists youcan do so by adding questions to the comments the club staff will forwardthem to me and I will try to integrate as many as possible into the program andjust before you get started I want to say that today is April 17th 2020 that'simportant for those listening later it be a podcast or the radio because thingsare moving so very quickly I just learned that yesterday just yesterdaythe u.

s.

saw 40 591 deaths due to Kobe of 19 which is the highest figure yetaccording to Johns Hopkins University that is sobering but California hasfared better than many states and much better than the worst initial estimatesso let's see we can learn from these three California health care leaders orsure I want to start with you you're a medical doctor but much of yourbackground is in public health and you are Kaiser Permanente's chief healthofficer I think many of us think more about the medical side of all thisbecause we have personal relationships with doctors and hospitals when we thinkmore about that then public health which is more abstract and distant but I canargue that we really have a medical crisis that was precipitated at least inpart because the failure of our public health efforts so give me your expertisehow much of this copán 19 problem is a public health problem rather than amedical system problem and how can kaiser as a medicalorganization address all the challenges that lie be you know including butbeyond the traditional medical issues well thank you so much for hosting memark it's great to be with you seem dry and and peter and thank you for thecommonwealth club for hosting this this event and let me start by saying thispandemic is everyone's problem it is a medical problem it is a public healthproblem it's a problem that's creating significant strain on our economy it's aproblem that's creating significant strain on long society and so let mestart just briefly by talking for a minute about the medical system and iwant to use that as an opportunity to give a big shout out to the tens ofthousands of Kaiser Permanente health care workers who are on the front lineour doctors nurses respiratory therapists and other workforce who areout there taking care of our members and of our communities and as well as otherhealth care workers across the country and the globe um and to your point thisis a medical problem because we want to be able to step up and surge and be ableto take care of the increase of number of people who are getting infected withgo ahead with the virus and having to deal with Gove in nineteen at the sametime we have to be thinking very carefully and working very closely withthe public health community because if you think about it a pandemic starts andas an outbreak and the way the public health community takes care of anoutbreak is by doing going to the roots of what public health is all about inthis country and in the world it's about identifying people who are infected veryquickly isolating those who are infected quarantine those who are exposed anddoing contact tracing to identify more and more people who've been exposed andhopefully I being able to isolate more of those who are infected that's reallythe core of what the public health community's effort is about and thenwhen that fails when you start having more and more community spreadthat's where really the health care system really needs to step up becausewhen you have these types of spread in the community that you can't containanymore and you really need to do all types of measures to slow the spread andthe community so you can give time for your health care system to step up andbe able to accommodate more people in the case of copán 19 be able to haveenough ICU beds ventilators and all of that all of that other stuff meanwhilethe public health community is doing all these this amazing work on socialdistancing efforts closing schools shelters and plays cancelling events toreally slow that spread so it's really about the public health community andthe medical community's working side by side but also mark it is about theprivate sector stepping up for more PPE availability it's about researchersidentifying vaccines and treatment modalities it's about public policymaking the right policies to mitigate the impact on people so it really takesa village it's everybody's problem and everybody needs to be working and by himhand in hand to address this issue and Kaiser Permanente is the big gorilla inCalifornia certainly particularly in Northern California but with major otherareas as well and it's primarily a medical organization but you're kind ofin charge of the public health side so what's how skies are managing that mixbetween public health and medical care well the way I think of KaiserPermanente I look at us as a health organization we deliver health care butwe're also we also think about the overall picture of health in ourcommunities and we've been now in existence for 75 plus years and we'vehad the same mission since we were born as an organization which is about makingsure that we're improving the health and well-being of our members and those inour communities and the fact that we have an integrated care delivery systemallows us to really step up and be able to take care of our members and thecommunities where those members live in a way that no other fee-for-servicehealth system could do that and that's I think thesignificant added value that we bring to the table as an organization we've beenbuilt if you want on the concept of really stepping up and pay attention toprevention and now Public Health is really the ultimate prevention if youwant and the fact that we are in this fight with others in the community withthe public health sector the private sector is a testament to our commitmentto be able to making a difference sure so what skies have been able to dobecause of its unique model that would be harder for that's part of others todo related to this pandemic well a mark in response to the guidance that we'veseen about shelter in place our organization stepped up and it reallystepped up our telehealth capabilities and we've done telehealth services for awhile now but we've really stopped the buzz up significantly so now almost 80%of the care that's happening in an outpatient setting at Kaiser Permanenteis happening pretty much virtually no every day we're doing over 65, 000virtual visits for our members so that our members can still stay at home staysafe respect the social distancing practices including over 14, 000 videovisits every day so that's one of the ways that we're supporting our membersbecause we know our members need care and the ability for us to deliver thatgift virtually becomes critically important same thing for our pharmacyour Mahlon pharmacies are significantly and have increased and again this isgreat for our members respect social distancing great for the environment bythe way as well and now more and more people are receiving their mail theirpharmacy through mails in like most other healthcare system we've deferredmany of our elective procedures down the line and that's mostly to protect thosemembers from having to be in the hospital but also freeing up thehospital beds freeing up our personal protective equipment to be used to takecare of patients have been diagnosed with Gove in nineteen and many many morebut that's kinda the gist of it if you want moreright thanks senator I want to go to you you have kind of an your job you have abird's-eye view of things going on throughout California health care whatis unique about California that's relevant to this pandemic both good andbad well first mark nice to be with you andwith all my colleagues today um you know I everything Bashar said I I think isquite true what what I think has been quite unique though about California isreally how bold and how data-driven the infrastructure has been to communicatethe need to do something as Extreme as community contained I mean it's beenmore than a hundred years since community containment as a public healthtool has been used at this scale and today a month into that eighty fivepercent of Californians by and large are supportive of all the actions that havebeen taken to date notwithstanding the fact that koban 19 has been incrediblydisruptive for all kinds of reasons that are well known no treatment no vaccineand it's a virus that's so fascinating because it has this capability oftransmitting infection without people having any symptoms whatsoever so it isa very challenging virus in the public health realm and as a state which isvery diverse we're 40 million people or 58 different counties were incrediblyethnic diverse we have very large low-income population but the otherthing you have to say about California is as you look at it it has been thelead in the implementation of ACA which I'm sure Peter will talk more about butalso in Medicaid expansion so we don't yet have everybody covered but I dothink the fact that the vast majority of our population has insurance coverage isa significant advantage for us we have a mechanism to communicate andcommunication is so important transparency around what kind ofdecisions you're making and why what kind ofsacrifices you're asking people to make and why is really critically importantespecially in the early days of managing the pandemic of this nature so I wouldsay that as the first and the second would be in the sharp alluded to thisthe extraordinary outpouring of people who have stepped up to take whateverkind of medical training they have to come and be able to support the deliverysystem to do the surge planning necessary to make sure we didn't havepeople who needed ventilators and ICU beds and couldn't get them that wasreally the biggest goal and to see the mobilisation of the state people whocame out of retirement volunteers tremendous public/private partnerships Ithink that is a very much a statement about how California operates and it'sone of the reasons I think people look at California and say what have you doneright and I would say thus far quite a few things right thanks we've got kindof a big picture view and a more detailed view because the CaliforniaHealth Care Foundation has been conducting a couple of ongoing pollsrelated to the epidemic one aimed at residents the other at physicians solet's start with the the general public what have you found about the people interms of that are being tested how many have had tests telling you think theyneed testing how many are unable to get tests and is that number getting wellchanging I hope getting better if it's changing at all yeah so we did a coupleof rapid polls we did it pretty much as a baseline to understand how we wereprogressing with testing because of course testing is so important again aspart of the tools and the toolbox to contain a pandemic you really want toknow who's infected how much incidence of infection do you have really try tounderstand case fatality so understanding testing is such animportant part of the public health toolkit so we did a quick poll to try tounderstand how many people have been tested and how many people tried to gettested that weren't able to and what we've seen is firstPaul it was very low about 1% and two weeks later it was about 2% of peoplehad been tested interestingly enough we don't have a big demand of people whowant to be tested who have not been able to and that really is a again atestament to really good communication in messaging where we were trying toprioritize the use of tests as they became available keep in mind that in amonth a month it's time we went from having about two fda-approved tests totoday having more than 30 in a month so testing is becoming more widelyavailable and we've got it first in the healthcare workforce and emergency roomsand people have symptoms like it and that's actually where you want to usetesting when you have it original and so the polling from residents would suggestthat it's growing more people are being tested over time but it also suggeststhat the test that we do have are being used in the right place and then theother piece really it has to do with affordability and people having a senseof you know are you afraid to go and get care if you need care because of costsand of course that runs high anyways people believe that health care is veryexpensive co-pays are expensive notwithstanding all the great work thatPeter has done in covered California and using subsidies and the like so whatyou've seen though is the slight uptick in people's concern about if I go in toget care am I going to get a bill that I'm not going to be able to to pay or tocover and there there's a lot of confusion around the Care Act and whatit covers and what it does and then what hospitals are going to do in thistesting 3 and so that message is very complicated to slow down for individualsbut I think overall there's an uptick in anxiety anyways and when you've got thekind of unemployment and a displacement of workers that concern you can imagineit's going to continue to rise and it has a great thanks now California is both thenation's wealthiest state and also has but I think believe the highest povertyrate which sounds counterintuitive but we proved in California you can somehowmanage that and I know that a lot of what your foundation looks at is how theaccess and the care quality for for lower income Californians looks soBeshara mentioned that many many or most visits disappoint are being donetelephonically or over video resume or Skype or I think what are you findingabout changes in physician visits in that regard and you see a difference inthe change between you know all Californians and low-income Californiansyeah I think I completely agree with Bashar I mean Kaiser has been doing alot of virtual care for a very long time arguably the leader in the field butthere's been a lot of obstacles to the expansion of telemedicine including notallowing it to be paid at current rates a lot of payment and disincentives a lotof regulatory obstacles and what you've seen with this pandemic in my view issimply the telemedicine and telehealth sheetingsout of everybody converted to telemedicine telehealth as quickly asthey possibly could technically important to do for all the reasons thesheriff said that I would not repeat but essentially for safety of the workforcefor people to be able to maintain shelter at home and the CMS has widelyopened up Medicare reimbursement for telehealth now the Department of HealthCare Services in California has done the same the Department of Insurance hasdone the same so what you've seen is now that people are going to be compensatedfor it we're seeing what the tremendous capability there is for that andimportant to realize for people who are low income if you're low income and youhave a child with some chronic disease and you live in some rural county innorth Northern California and you need to get to UCSF to see a specialist to beable to have telehealth and telemedicine work for you and not have to take a dayoff and not have to drive your car and that's it put your kid in the car manyou creates tremendous capabilities forpeople who are very low income and fundamentally shifts where we'reproviding care we're now providing care in communities in people's homes intheir living rooms and that really from a overall affordability of the systemmeans when we currently spend a lot of dollars building facilities we reallyshould be thinking about how do we use our workforce fully and use telemedicineas a vehicle to reach people including people who are very lonely yeah nothat's great well thanks Peter I want to turn to you obviously covered Californiabeing a large a large payer of a group that covers a lot of Californians I knowthat as a result of this pandemic you've reopened enrollment to serve residentswho have recently become unemployed or have different needs or whatever so youtell us who's eligible who isn't how affordable is the coverage and what'sthe deadline for people to get this coverage great so thank you very much Igot a thrill to be here with my colleagues and also with theCommonwealth Club a couple things that Sandra noted they're so important tonote about what's different about California today in the pandemic one ofthe things is that eight years ago California said we're gonna use all thetools of the Affordable Care Act which a lot of that is around coverage expansionthe biggest thing is expanding the Medicaid program but also developingcovered California to be a marketplace for people that needed a financial legup could get private plans now this has been never as important today when somany millions of people are not only economically insecure but insecure aboutthe health status so we actually opened our doors wide open even though as anormal course of business if you lose your job and lose insurance we're openyear-round otherwise we have a special open enrollment period but we decided tohave what's called a special enrollment period for kovin because there are somepeople that might have been uninsured three months ago and you know be verygood help but now be worried about the pandemic and want to sign up we want toget him in the door because it's a public health measure you want peoplethat are at risk to get coverage they go see thatprimary care doctor they get tested it's also equity the right thing to doso we've now been opened about three weeks into a special enrollment periodthat we've decided in California we'll go all the way through at least the endof June and this is one of the things I appreciate about the state of Californiayes governor nuisance would have done an incredible job of from months ago sayingwe're gonna look at the facts look at the evidence and act based on thosefacts and evidence we know sadly this pandemic won't be gone in June it'llchange course change shape so our having a special enrollmentperiod at least through June is part of the California approach then what do wesee almost 60, 000 people sign up forcoverage through us but we know many times that signing up for Medicaidmedical in California so it really is back to Sanders point California byputting investments in a delivery system and in coverage it's not quite everybodyundocks aren't all covered but we have in California a different world thanpeople are seen in much of the country where you have 20% uninsured and peoplethat are losing jobs in Texas and Florida are not only losing income butthey're now being thrown out into the world being very insecure about thehealth times so everybody in a sense is eligible at some level and some peopleactually get subsidies correct so a little bit about affordability yeah soit the one of the great things about the Affordable Care Act is your financialhelp is tiered based on your income you make less money you get more financialhelp if you're very low income you get met account which is free and now inCalifornia one third of Californians under the age of 65 agree médicale theseare good plans they're kaisers in the program we got Blue Shield er managedcare plans that have local initiatives range of options that are providingreally good care then a covered California you make more than say thirtythousand a year you may get virtually all of your health care premium paid bya subsidy but we actually added in California this year a state subsidy oneof the things the Affordable Care Act did was say if400 percent of poverty which is about $100, 000 for a family of four you makeone penny more than that you won't get any financial help that's none of thefederal law governor Newsom of the legislature said you know now it's wehad older Californians across the state paying twenty thirty percent of theirincome for health insurance premium we expanded this year with middle classsubsidies so now you can make up to six hundred percent of poverty that's onehundred and fifty thousand a year for a family of four and get state financialhelp depend on your age and what health care is gonna cost you and this reallycomes back to the philosophy this state has had which is we want to leave no onebehind and it really is a commitment that is pretty much across the politicalspectrum Oh Health Care's are right we want everyone to have health care andnot have financial burdens or impediments to you getting coverage oraccess to care and I really want to build on one of the things Sandra saidis it's a very important point that telehealth it's a wonderful system butunder the general system for telehealth and we've been tracking telehealth forthe 11 plans we contract with for seven years all of them offer telehealth butfor some there's co-pays some there's not co-pays so those differ a lot andfor a doctor whether or not they get paid the same Barry's incredibly whatwe've got in California and this is to the credit of our insurance regulatorsDepartment amount of healthcare is to say during this pandemic you health planmust pay every doctor for that telev isn't the same as if that visit were inperson now why is that important now if you're kaiser you're paid to serve apopulation it makes financial and health care sense to do telehealth but ifyou're in a small group or a large group that relies on fee-for-service and youaren't paid for a television many of those practices are dying right now theyare struggling because they're having huge drops of paid service people aren'tgetting the doors and our state said access isn't just about premiums it'sabout how you pay providers and giving them a reason that doctors will haveopen doors for telehealth great thanks and that leads me anotherquestion I'll ask for sure and that is that a lot of groups are a lot of careis being deferred right so fortunately Kaiser if you're doing good telehealthyou're not deferring that many primary care visits or as many as you wouldotherwise but you're still just deferring elective procedures in thehospital right which are substantial so maybe I should ask you generally aboutyour plan for reopening facilities when that's a kind of what you've called thesuppression phases of pandemic and I'm particularly curious are you expecting asurge and demand for people who delay these elective procedures well thank youfor for bringing up this question it was such an important question I think ourmessage is our message to our members has always been throughout the shelterand place orders we're here for you we're going to try to accommodate asmuch as you need by telehealth you can call us you can schedule avideoconference with us you can come to see us if you need to in one of ourfacilities but like most other health care systems in this country we did theFIR elective procedures down the line just so that we make sure we're readywhen we have a surge and an uptick and number of people having covered 19 whoneed that hospital bed who need that ventilator in the ICU um and honestlyalso for our health care workers who might need that personal protectiveequipment to use to deal with patients with kovat and so we're trying toaccommodate as much as we can through telehealth at this point some throughin-person visits um and the plan now is thinking throughtogether with the states and with other healthcare systems in the country in thecommunity and the public health community what would it look like tomove to the next phase of dealing with the pandemic you know I think mark whatwe know about pandemic we've learned from previous pandemics and you knowusually an outbreak starts and you want to focus on containing it clearly wecouldn't contain this this this outbreak before it became a pandemic thecommunity spread became so so high we have to shift into mitigation stageswe put the non-pharmaceutical interventions by advancing socialdistancing we call those schools that all these measures that are so criticaland we given ourselves the country or our healthcare system an opportunity tostep up and be able to respond to the increased demand now what we're seeingall these measures exactly to what Sanders described of actually paying offand particularly here in California we're seeing this flattening of thecurve if you want which is a great time for our healthcare system to be able torespond but also a great sign for people living that living in this countryparticularly here in California now as the rate of new infections starts goingdown then we need to shift our thinking to start thinking about how do wesuppress this pandemic that's kind of like the third phase if you want of thepain that means so you have the containment you hit once containmentfail you go into mitigation once mitigation pays off and you seeflattening of the curve and the number of cases go down then you have to shiftinto suppressing this virus down the line and that goes back to the same corePublic Health principles of doing broad testing and the ability to isolate thosewho are infected quarantine those who are exposed and doing a lot of contacttracing and at the same time as we start doing that we have to be thinkingtogether with the rest of the healthcare system what would it take to reopen ifyou want the healthcare system what would it take to make sure that we stillhave as a community enough capacity in case we've seen more surges the realityis we're likely going to see more surges down the line we're hoping they're notgoing to be nearly as severe as the first round but we will potentially seesurges so we want to make sure before we reopen the healthcare system as acountry in here in California and each one of our communities that we'vemaintained the capacity to be able to surge up very quickly and be able toaccept and deal with patients who are dealing with ghovat 19 we're gonna needthose those extra ventilators extra ICU bedsand we want to make sure that we have good solid plan and supplies of personalprotective equipment because we do want to make sure that we're protecting ourfrontline workers and unless we have these plans and systems in place andreally solid it's gonna be hard for us to be successful at suppressing thispandemic in this next phase right tom mark if I could just jump in here youyou asked a question about Kaiser and it's a big delivery system with a lot offacilities and Peter mentioned the impact on some of the smaller medicalgroups but there's another part of our delivery system that we shouldn't losesight of which are rural hospitals who are standalone hospitals don't have alot of reserve and those facilities are very much at risk really being lost aspart of this pandemic they don't have the flexibility of having numerousfacilities where you can move beds and use different sort of sources indifferent places in your facilities they don't tend to have those kinds ofreserves and so even as hospitals that have big delivery systems and and arepart of a big system as they think about how to come back online and do thingsthat are quote-unquote elective although elective today is might bechemotherapy it might be the coronary procedure it might be about replacementit's not elective in the sense of plastic surgery so I do think one of thethings we have to do when we get into a more normative state of our deliverysystem is assess really won't be lost in capacity particularly for parts of ourstate that doesn't have good access today and I worry in particular aboutsmall rural hospitals being able to survive this economic downturn and theimpact on their hospitals in those communities yeah that's important pointalthough I think some neural communities are seeing a lower incidence of coma 19not all are but that could be just because it'll get there laterright and because we don't have as much testing there yetright so yeah social distancing and we've had great compliance with that andthat's work but as we began to loosen that which inevitably will happen thoseare the kinds of things I think we need to continue to monitor very closelycrazy yeah and the mark I can't agree more with what Sandra this is such animportant piece and and on top of that I also worry about a few vulnerable groupsand our communities I'm particularly concerned about what's happening inshelters what's happening for our homeless population who are strugglingand how to deal with this pandemic on top of the stress and struggles ofliving on the streets and and I also worry about the skilled nursingfacilities and nursing homes that are really you know they they have the mostvulnerable in our communities and we have to be able to support thesefacilities support them with PPE and others and other protocols and others tomake sure that we are able to suppress the pandemic because there's no waywe're gonna be able to suppress the pandemic if we're not paying attentionto those who are most vulnerable and I appreciate um Sandra's referral to thehospitals and in rural communities I think we also need to pay attentionclose attention to the homeless population the skilled nursingfacilities and others as key part of suppressing this pandemic yeah thanks Ithink California did well and being out front and having one of the I guess theearliest state to shelter in place fully in the Bay Area was even a little bitahead of that so I think that's helped us a great deal and next week's programwill focus on the more vulnerable among us and also how that affects everybodybecause of course it doesn't really matter who gets sick if somebody'sgetting sick and isn't getting treated they can infect everyone regardless ofwho they are and whether you whether you're covered for insurance orsomething but I did want to go back to something that you were talking aboutfor sure and that is let's say that I'm a well don't have to be a Kaiserremember let's say I have an elective and Sandra maybe it's work I couldcalled a non urgent procedure something that can wait right okay and now a monthand a half from now I'm able to I'm able to go back in okayI assume everybody who a month and a half from now would have needed toproceed you're still gonna need a pen right plus all the people who've beenwaiting for a while so you have this big bolus at the same time which are you cancomment on this I may be things are different maybe you need to space outpatients or physically or by distance maybe need to test everybody and thattakes more time maybe you have fewer staff members to do it so is it possiblewe're gonna have more demand and less supply at the same time in a few monthswell this is exactly where we're spending a lot of time right now as anorganization is trying to look at what the next few weeks and few months aregonna look like and and that's gonna have to be built on what are we learningfrom our modeling that we're seeing how honestly it's gonna really depend onwhat's gonna happen to this curve are we really kind of keeping that curve flatare we crushing that curve are we gonna see spikes down the line so it's gonnarequire a lot of really detailed planning with the idea that you'd wantto really be able to catch up eventually on everything that you have deferred soa lot of planning is happening along those lines right now obviously veryimportant and I know that at this point according the University of Washingtondata California has hit or just maybe past its peak for this round and we hopewe hope that's true and I know that along the way we've been trying to getenough equipment PPE and so forth in how is Kaiser doing with having sufficientPPE today and over the next month of herself yeah so we do have theappropriate PPE that we need to protect our workforce and just like many otherhealthcare systems across the country we've modified our protocols so that wecan preserve those personal protective equipment as much as we can we've workedvery closely with the CDC on their guidelines we've translated theirguidelines on day to day and operations for our health system and so and we areactively engaged in making sure that our supply chain is as aggressive aspossible in obtaining more and more personal protective equipment you know Iwant to use this opportunity to highlight some of the innovationsthat we've seen around personal protective equipment you know in one ofour regions and KP Washington we've partnered with a a Seattle area Westlanddistillery for example to create sanitizers distillery made sanitizersand we've got 25 or so gallons or even more of sanitizers that way here in theBay Area one of our pediatrician dr.

Rosen together with her friend Reginasac calls partnered together to design a prototype for a face shield that endedup partnering with with Apple and created lots of face shields assupporting our the protection of our workforce and others across the countrywe've partnered with Microsoft and UPS and the American Hospital organizationAmerican Hospital Association and we've launched a new effort called a neweffort to really match people and organizations who want to donate PPEwith hospitals who have the most need for PPE and and we launched this effortearlier this week so I think we're seeing lots of theingenuity if you want and the innovation of what this country can bring andpeople in this country can bring and we have to continue to double down on thisand as we continue to fight this pandemic okay thanks for seeing any kindof cooperation and and the spirit that Sandra was talking about worked on thePPE issue it's just important to realize that all countries are looking for PPEand it's not just hospitals to need PPE now right you need prisons need to haveit you need to have it you know we were talking about doing isolation after wedo contact tracing you put people in isolation if they can't isolate at homeyou're going to have to put them somewhere again you'll need masks to beable to do that so the PPE demand is an enormous one and it's not just inhospitals where we're going to need to have it in order to continue to containthis virus yeah it's a great point hoped we've ramped up or are ramping upsufficient at least we'll be able to meet that togoing forward I should say that for anybody who just joined us you'relistening to the Commonwealth Club where we're discussing a code 19 pandemic withKaiser Permanente senior vice president and chief health officer four-star shoecare California Healthcare Foundation CEO Sandra Hernandez and coveredCalifornia executive director Peter Lee and Peter are going to jump to you hereI read an analysis by covered California which found that commercial healthinsurance costs related to this pandemic could range from anywhere between thirtyfour billion and two hundred and fifty billion this year but Ida quartersphysician practices and even hospitals as we've heard are seeing such a drop inoverall demand that many are laying off staff which really is unprecedented sowhy wouldn't there be a net savings to the healthcare system with more spent onpublic but so much less spent than everything else in California werenational yeah great question it doesn't relate to your question about drop inother demands we did this study 300 years ago as in in March time changesvery quickly and in the high medium and low the high estimates were what mighthappen if the efforts to flatten the curve didn't work good news is they workbut if they hadn't worked we could easily have been spending nationally inthe commercial market two hundred fifty billion dollars which would be 20percent increase over what we would have spent otherwise 20 percent we're stillgonna spend a lot on COBIT likely in the mid-range which might be in theneighborhood of a hundred billion dollars in direct spending on Kovach nowif that were only added to our healthcare expense that would be about a10 percent add-on that wasn't planned or budgeted for it's absolutely clear thereare huge reductions in care and we've been talking to a lot of our plansincluding Kaiser but others about how much of a drop and we're seeing drops upfrom ten fifteen twenty five percent of what the cost would have been otherwisebecause not occurring he has an elective procedure if people not going and alsothings that right now none of us might understand such as fewer strokes fewerheart attacks are elected you don't think but in someareas they're seeing fewer we don't really know and we're doing a lot ofwork right now with our health plans to project what isthis gonna look like for the balance of 2020 and for 2021 because right nowevery plan across America is starting to think about what will this be in 2021what do we need a prize for and will 2021 be a year where we've got continuedcovin that we're dealing with with smaller ups and downs and a bolus ofcare unprovided in 2020 coming back or is it gonna be similar they inserted astandard year for issues of cancer diabetes etc these are very bigquestions and I think part of our job at covering California is to not think wegot the right answers but make sure we're answering asking the rightquestions and we know there's a lot of uncertainty we need to narrow thatuncertain as much as possible okay and you have been quite outspoken and urgenta federal government take some action to prevent large spikes and premiums nextyear of course there's lots of uncertainty but many people may not beaware how far in advance a lot of those premiums have to be set so you used towork in the federal government what would you tell the federal government todo well it two things I mean punt they is it's striking that California andabout a dozen other states declared special enrollment periods the firstthing forget planning for down the down the road we need to make sure peoplethat are insecure and need potential access care can get in today the federalgovernment which actually runs marketplaces for 35 states has notdeclared a special enrollment period I still don't understand that I mean thatstarts on the federal level opening the doors for people that don't haveinsurance it's good for public health it's good economics because most ofpeople coming in will not get Kovac they're worried well bringing them intogood economics as well as good public health so that's number one number twowe really should be going back to almost part of the original Affordable Care Actwhat's called reinsurance these are programs that actually help theindividual market cover big costs that aren't planned for it's a core design ofthe four Care Act there was time limited but thatwould give health plan certainty in planning for 2021 to say that we'regonna cover a portion of your cost and because of that you could lower premiumsfor everybody the third thing I commend the federal policymakers knew is whatCalifornia started on the path of doing this last year expanding subsidies Iwant to be clear affordability even with the subsidies their lower-income peoplestill struggle and middle income people are left out the fourth thing that Inote and this is something Sandra alluded to which is so important youknow we often talk about covered California the individual market andmédicale remember half of Californians and half of Americans I get theircoverage through their employer now a lot of that coverage is really goodcoverage rich covered wide benefits but about a third of the people withemployer based coverage I get two things that really are not good equations forgood health number one they're in high deductible plans they have bigdeductibles which means they are scared to go to the doctor because I think theygot the whole bill we don't want people to be scared from going to the doctor wewant someone if they're worried about having Kovach to see a doctor to get acheck you got a high deductible plan you're discouraged from getting care theother thing that's a problem with the employer base design just they aren'tadjusted for income someone making $20, 000 working in the same company assomeone making $300, 000 gets the same premium support to buy health carethat's just cuckoo math and bad public health so these are some of the policiesneed to be addressed that aren't just individual market issues theirdysfunction at a healthcare system that doesn't recognize that income mattersand getting people into care means removing financial barriers thatshouldn't be there in the first place all right we'll see if this makes animpact on a long-term health care system sooner I'll go back to you for a momentyou know we hear a lot about the availability of testing and we've talkedabout PBE and so forth and the Trump administration has said that there's alot some critics say that it's not you actually went out and asked doctors inCalifornia do you have enough tests for yourselves or other healthcarecolleagues and do you have enough PPE so what are the doctors directly on thefrontlines st.

you know we particularly wanted to understand what our safety netproviders were experiencing and so it's really important in our very first pollour safety net providers were concerned about being able to get access to PPEremember this was a you know it was sort of a fend for yourself non coordinatedapproach to PPE and and so you know one Hospital system leaders said to me theyhad 520 vendors that they were trying to procure pinkey in from and so in thesafety net providers and in our federally qualified health centers forexample they're competing in that kind of marketplace so in the first poll thatwas certainly a concern and what we saw nicely were from pole to pole that isover the last two that we did is that that stress about PPE is starting to geta little better among our safety net providers which of course is a reallyimportant sign because we're asking people to go take care of patients invery unusual circumstances with very high stress and then not really surewhether you're going to have the PPE that you need to be able to provide toyour workforce so some improvement in that but certainly the smallerpurchasers competing with bigger purchasers in a very chaotic environmentand hospitals that had PPE for example up to a month supply are now into twoand three days and waiting for these vendors to come through so I do thinkour safety net providers are always at a disadvantage there even while they'regoing and serving the populations they've always served so over I wouldsay improvement well what's good I about two weeks ago got a call from a friendof mine who lives in China and said by the way you need 95 masks I said yes sohe said well you know I got a friend who's got some time I said well how manygot I'd say like a dust and he said oh I can get you know thousands well my wifeworks as you know Sandra at the county hospital in AucklandHighland Hospital and I know that her us well needed some so I put her hospitalin touch with them I felt pretty good about it for a moment and I thought waita minute what am i doing managing the International supply chain this doesn'tseem like the way that that the health care system should work no but the pricegouging that was associated with that I mean people used to buy these masks forten cents and now they're paying six dollars for our masksI mean that's just an extraordinary cost that we're seeing that's being builtinto this disrupted supply chain yeah yeah you know I think that one of thechallenges of anybody who works in public health is to notify and informthe public sufficiently so that they are sufficiently concerned about the threatbut not get them so scared they panic and riot or just overreact overall and Iwas thinking about that when I looked at the most recent data from your surveyand found it very concerning but not completely dire is that a faircharacterization of what you're finding you know I think it's I think what Iwould say and Peter alluded to this and I would echo it I think that theCalifornia what you have seen is that people have been very patient patientwould be the word I would use and that is to say they understand this virusdoes can take people into an ICU and get them ventilated in a very fast way andthat there is no herd immunity and we don't have any vaccine you don't yethave any treatment but what I do think has been very well done is by the Newsomadministration and an amazing team of people that he has around which is theyare looking at the modeling and the modeling is only as good as the data youput in it so getting really good data communicating really well with thecounties very important because that's where things are actually happening andthen really being very clear about why you're making the decisions that you'remaking and I think that that has really borne out quite well so that people arenot and think about it what in Californiadoes eighty-five percent the population ever do or agree upon I mean it's reallyquite extraordinary and I think that is both a sense of hope we when he did hisHealthCorps on the first day 25, 000 people came and said here I'll help I'llcome back from retirement or I'm a paramedic I'll come and do this and soit has been really I think an amazingly good communication effort and inpandemics what you need to do is be honest you need to be factual you needto be consistent and you need to be totally transparent and I think that'swhat's gone well in California as well as the be willing to make bold decisionsto use the tools of Public Health as drastic as they are to not see the kindof thing that we were trying to avert and so you know the challenge now markwill be as with prevention always is well you don't see people say well thennothing happened well that's exactly what you want right was for nothing tohappen and so what you don't want is people to go well you know there arepeople dying the hospitals aren't overloaded and so what's the big dealand so that's the risk so what I say is the smart people have been very patientthe communication has been very transparent and decisions have been madebased on data and when you're in a pandemic even if you don't have all thefacts you have to tell people the facts you don't have but you also have to tellpeople while you're making the decisions that you are and I think that theCalifornia leadership has done an extraordinary job of all great thanksbut I won't you spend a lot of time worrying ofcourse for the Kobe 19 about the impact on the lungs and people dying and soforth um but some that maybe gets less attention his mental health and it's mysister's a therapist on East Coast and she said her business is way up she'snot happy about that but its way up um what are you seeing at Kaiser aboutmental health and what can we do during this time to help support mental healthwhich typically is underserved even in the best of times yeah so thank you forbringing up this question and even from our own internal survey for our ownmembers we're realizing that there is an uptick in people's having to deal withthe mental health implications of this pandemic and and we're seeing that andpolls across the country and so at the Kaiser Permanente what we've done iswe've transitioned the overwhelming majority of our mental health servicesto be calm on virtual so we're almost 90 percent of our counseling services aredelivered through telehealth at this point we've also made available on ourKP app or the kp.

org website and additional virtual resources to supportpeople dealing with stress and dealing with anxiety being able to deal with thesocial isolation so there are multiple digital tools that we've made availableto our members free of charge and we have to step up as a country becausethis is going to be the mental health implications of this pandemic is goingto be pretty significant and I think now we're all making sure that we're notcatching Cove at 19 but as this pandemic settles down and we get it suppressedit's gonna be really important that we pay attention for the mental healthneeds of people in this country overall yeah Center I believe you also surveyedCalifornia's about ending a worsening of mental health it is getting a little bitworse pull over poll it sounds a little worse among women interestingly if youif you break up the poll by respondents male and female there seems to beincreasing stress among women and you can understand that because you have alot of women who are homeschooling their kids they don't have childcare if theycan work they're working from home and juggling those kinds andcircumstances and if you're very low-income and you're a woman or agrandmother and whoever was making any money in the household is now not youcan imagine that those financial pressures are going to add to to thestress that we're seeing in the polls and it doesn't surprise me that we'reseeing it more so in women and men and it is something I think we aredefinitely going to want to continue to attract a little bit over this periodwell fortunately something I've heard pretty consistently is that zoom orSkype or video mental health visits seem to work as at least as well as thephysical health visits tell us like is something that the California HealthCare Foundation we've been trying to do telemedicine telehealth for many yearsand in the past it was very much focused on trying to get access to specialiststhat are a few in part between of which psychiatry is certainly one and sotelepsychiatry is something that has been around for a while againconstrained by fee for service and regulatory and what gets paid and whatdoesn't and so absolutely and there are you know apps that are people are usingto be able to do it but but I think it's also important to recognize as you saidearlier in the program work we have a large population of low income peopleand as long as the economics are so distorted by virtue of what we have todo from that I'll imagine that stress even the dogs are getting more stressedbut it is it is a it is a real concern that as the economic pressures continueto grow and paychecks stop and jobs will not come back like the flip of a switchand so I do think the demand for psychiatry and for social work and formental health support is going to continue to grow and the good thing isthat telepsychic is a good solution to that yeah greatPeter I have a question for you but first you have to tell us the name ofyour dog Gilly right over my shoulder there and I should have left it in overthe room but she's been good up till now he's been pretty good that's okay youknow you you mentioned you some things about the government andbenefit design and do you maybe imply but didn't say outright the Californianumber California does require benefit designs that make sure that when peoplehave deductibles it they don't discourage them from getting basic drugsor going to the doctor's office so that's something you have you don't havea health plan you've got a marketplace of health plans you can influence thosehealth plans what so I assume that's we assumed that that's probably had a goodgood impact on your on your members and on the plans members umhow else can you or have you tried to influence consumer behavior during thispandemic through benefit design or other way well first I want to describe whatyou know tube is your sort of filter of the market but most people listeningprobably aren't is that for most people when you have a deductibleit's a deductible means you need to pay that bill entirely up to $1, 000 $2, 000before insurance kicks in what we have a covered California for virtually all ofour plans and they're identical benefit designs whether you buy with Kaiser orBlue Shield or anthem or health identical so consumers aren't shoppingbased on benefit designs they don't understand but everyone the designingsays for most of the products the deductibles don't apply for outpatientcare which means you want to go see a doctor for us mental health visit yourprimary care doc its first dollar coverage it's not a barrier that's nothow standard designs are in the employer world it's not how most othermarketplaces work it's the right kind of design so a couple things that we'vebeen doing it number one and this is where I sort of think that we got itright seven years ago so like California's Care Foundation has beenlooking at Tahoe for quite a while we've been pushing our plans now telehealthand the fact that not just Kaiser but every one of our other ten health plansnow has thousands of thousands of televisions happening every day isbecause of work done years ago being ready for a pandemic is it as a publichealth issue it's a benefit design issue it's a delivery system issue was havingthe right networks and I feel very good about what our plans are doing every oneof them in reaching out to support their Docs not as well integrated as Kaiserwithout a doubt but reaching out to make sure they can get telehealth they'vebeen providing tools to their doctors to support carevirtually they've been reaching out to patients know they've got access whetheryou're an integrated system or not integrate but the other piece that Iknow that we've been doing which is again right now you know we have atsunami of concern around around Kovac but the one that's following beyond thatwhich has got to last longer is the economic impacts this recession sosomething we've been doing to that end is we have sadly millions ofunemployment checks going out in California starting this month everysingle one of those checks is going to come with an envelope that talks aboutcovered California and how to get insurance coverage and this is again ourstate has been ready to turn a dime not just to make sure the first responderswhether it's a doctor or a nurse has good protective equipment on but also wehad the infrastructure so that people lose insurance they've got a place to goand so we've been going thinking of both of those tracks but it's part of thingsthat don't happen overnight you aren't ready to stay overnight for a pandemicrather you have systems infrastructure in place that can then be ramped up andif they're ramped up well you have better responses we've seen here inCalifornia right well thanks that but you also want to say kudos to youbecause I know you've been involved with covered California for the start and ourstate has done a lot of things right with that marketplace that really hasn'tpaid off thank you for that I'm sorry to say that we've now reached a point inour program or this time for only one last question but since there's three ofyou I want you each a shot at it a short shot at it but here's the question whatis one lesson good or bad that other states can learn from California'sexperience with this pandemic and Bashar we're gonna start with you I have to sayI think for me to see our public health officers and the Bay Area stepping up soearly before anybody else in the country make those decisions and put thesedistancing measures in place to see them step up the six of them and the Bay Areaand say based on the data that we have based on what we know needs to happenhere's what needs to happen and the courage to do that makes me a proudproud resident in there in the Bay Area here and as a former health officer tosee that work happening with this courage just made me so proud being partof a state thank you all right thanks very much Sandra we'llhave you go next well you know mark maybe I'll end with a when I I've you isso incredibly unique about California which is that we have a very robustnot-for-profit sector we have a very robust philanthropic sectorBeshara talked about the leadership in our in our public health departments andjust that may be a preamble to your next programSanta Clara was an early hotspot and has a very large homeless population andtoday every individual who's unsheltered in Santa Clara County has been testedand if they're tested positive they have been housed they have put sanitizers andhand-washing capabilities they've done mobile health and really you know wethink of homelessness is such an intractable situation and yet when werecognize that it's all of our best interest to make sure that we take careof our most vulnerable to me that is the statement that is most powerful aboutCalifornia the governor two days ago said he was going to put some money tomake sure the people who are undocumented but pay taxes and work herewill get some benefits in the philanthropic community matched it thisis the kind of public-private civic life that we have in California and it makesme feel good about being here and being part of the solution right thank youPeter what counter states learn from the way that California has responded andthen so a couple things one number one California sort of has a reputation asbeing a blue state but what I look at what CalPERS that has been its respondto this epidemic not as a political issue which comes back to how itresponded Affordable Care Act my organization was lost with theRepublican governor establishing a marketplace because it was the rightpolicy we have a governor in a state that has said let's not play politicslet's be driven by facts was during my evidence and as Saturday let'shave systems that support everybody in this state whether you're homelessundocumented lower income higher income and that approach it's good policy goodPublic Health and it's why we got out ahead of this epidemic because we'vebeen thinking those in those terms for ten years great thanksthat's great but before he close I want to remind you all to visit us regularlyat the Commonwealth Club dot org to stay informed about other programs in theclub's ongoing series on Koated 19 done in association with the sedima projectnext you can join us on Friday this coming Friday at 2 p.

m.

Pacific time forpandemic healthcare inequities and how they affect everyone and also on May 4that noon to hear Kaiser Family Foundation CEO drew Altman discuss US healthcare atthe 2020 election in the era of coronavirus now I want to give a bigthank you to our panelists Beshara shoe care sandra Hernandez and Peter Lee forjoining us virtually today for the Commonwealth Club program thanks also tothe Chan Zuckerberg initiative and to our other donors if you enjoyed thisprogram I encourage you to make a donation yourself we'd really appreciateit I'm mark center of the sedima projectand now this virtual program the Commonwealth Club is adjourned.

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