Is your bedroom the new hospital?

In his book “Home Game: an Accidental Guide to Fatherhood,” author Michael Lewis tells the story of his infant son’s admission to the hospital for a lung infection with respiratory syncytial virus, commonly known as “RSV.” His son requires oxygen during his stay but gets no other treatment: no antibiotics, no steroids, no ventilator. Michael speculates that the only reason his kid was admitted was so that nurses and doctors could check on him daily in case he got worse and needed to be intubated. And so, feeling the burn of a lost night’s sleep for both himself and his son, Michael stages a minor protest to allow his son to rest. He meets every potential visitor to the room at the door and demands to know their purpose. Nurses are mostly let in. But if the visitor is a resident or medical student “checking in,” for example, he gives them an update on his son’s respiratory rate and oxygen level and shoos them away. After a couple days his son improves and is discharged home.

As of the writing of this blog post roughly 130,000 Americans are hospitalized with COVID-19, up from ~96,000 at the beginning of December, resulting in more than a third of America’s hospitals operating at at least 90 percent capacity. Some of those inpatients are like Michael Lewis’s son: they’ve been admitted because of frailty or a combination of risk factors (age, other diseases, etc.) that put them at higher risk of death, and the primary treatments they are receiving are oxygen and steroid medications that could theoretically be delivered at home.

Like telemedicine, our very idea of the purpose of hospitalization may be morphing under the pressure of a viral pandemic, prompting changes that have been smoldering for decades. CMS is exploring ways to increase hospital capacity during the COVID-19 surge. We can’t solve this problem by building new hospitals. That takes time (at least outside of China), and hospital beds are needed in relatively small numbers in the US (compared to places like Germany) when viral pandemics aren’t raging uncontrollably. CMS is instead encouraging hospitals to be more aggressive in deciding who can be cared for at home in a program they call, unimaginatively, the “Acute Hospital Care At Home” program, a waiver allowing qualifying health systems to provide hospital-level care at patients’ homes for more than 60 conditions, including common reasons for admission like asthma, congestive heart failure, and pneumonia. You can’t be “admitted” to your own bedroom via telemedicine; you have to be transferred from an in-person emergency department or traditional inpatient hospital bed after an in-person evaluation by a physician. And surgical care clearly needs to be done in the traditional setting, at least for now.

Some companies, having anticipated this need, are marketing equipment or even using artificial intelligence-based systems for monitoring “hospitalized” patients at home. And it seems to work. “Hospital at home” may be marginally better than traditional hospitalization: a study in the Annals of Internal Medicine showed that with one home hospital program, only 7% of patients had to be readmitted to the hospital within 30 days of discharge, compared to 23% of inpatients in traditional care, and the average cost of care of home was 38% lower than care in the hospital.

So the next time you’re on your way to the hospital (heaven forbid), be sure to keep your choice in the back of your mind before you hit the door: would you rather be cared for in the hospital, or would you rather convalesce in the comfort of your own bed?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Is it time to re-think sick leave?

When I was a medical resident, saucy attending physicians, wanting to impress on us the importance of our work, said things like “If we’re not rounding with you, we better be rounding on you,” meaning that in order to justify missing hospital rounds we better be sick enough to need hospitalization ourselves. So it was no surprise that I once saw a residency classmate work through a night call shift with obvious symptoms of acute influenza.

In the COVID-19 era, working with patients through a febrile illness seems as dated as smoking indoors or driving without a seatbelt. But America remains one of the few developed countries that does not guarantee universal access to paid sick leave for all workers. Twenty-seven percent of all US employees and 17 percent of all US full-time employees cannot take paid sick leave. Congress tried to address this, albeit temporarily, with the Families First Coronavirus Response Act (FFCRA), which was passed on April 1, 2020 and expired on December 31, 2020. 

As a reminder, FFCRA said that employers with up to 500 employees must cover, with exceptions:

• Up to 80 hours paid sick leave at usual pay if the employee was quarantined and/or experiencing COVID-19 symptoms

• Up to 80 hours paid sick leave at two-thirds usual pay if the employee was caring for someone else in quarantine

• Up to 10 weeks of paid expanded family and medical leave at two-thirds usual pay if the employee was unable to work due to caring for a child whose school or child care provider was closed or unavailable for reasons related to COVID-19

About a quarter of US companies affected by the law used it in its lifespan; employers with 500 or more employees already overwhelmingly offer paid sick leave. FFCRA’s passage set up a “natural experiment” (we’ve talked about these before): in some states like Kansas without pre-existing laws around sick leave, workers gained the right to take paid sick leave. These were treated by researchers as the “treatment group.” Their change in COVID-19 rates were compared to changes in workers in twelve states and the District of Columbia who already had access to paid sick leave before FFCRA, the “control group.” Investigators were able to use baseline levels of infection in the few weeks before passage of the law as a baseline. 

The results? States where employees gained new access to paid sick leave had a “statistically significant decrease of approximately 400 fewer confirmed new cases per state per day relative to the pre-FFCRA period and to states that had already enacted sick pay mandates before enactment of the FFCRA.” The authors estimate that this translated into about one prevented case per day per 1,300 newly covered workers.

Given COVID-19’s roughly 2% mortality rate, 400 cases fewer per day could equals as many as eight lives per state per day saved by a simple administrative decision. This is completely in line with previous research showing that paid sick leave induces employees with contagious infections like influenza to take sick leave, thus reducing influenza activity during non-COVID-19 times.

Besides the obvious humanistic angle, is this cost effective? After all, COVID-19 hospitalizations are expensive. I tried to muddle through some math to see how much each saved life cost, but I don’t trust my numbers. So instead I’ll ask you: if you’re an employer with fewer than 500 employees, how did FFCRA affect you and your bottom line?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.