“We All Had the Same Warning,” but Canada’s COVID-19 Response Was Different

SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. Today’s show is about how the COVID-19 pandemic unfolded in one American hospital and how the crisis looks different across the border in Canada. My guest is Michael Apkon, the president and CEO of Tufts Medical Center in Massachusetts.

Now, Mike and I were supposed to speak in mid-March about the differences between running a hospital in the U.S. and Canada, because he used to head The Hospital for Sick Children in Toronto, and then the pandemic hit and he had more important things to do then record a podcast. So now almost six months later, we’re going to talk about these differences between health care in the U.S. and Canada, but with the additional challenge of dealing with the global pandemic.

Mike, welcome to the show.

MICHAEL APKON: Thank you. It’s a pleasure to be here with you.

SHANOOR SEERVAI: Take me back to the beginning, when you first realized that you had to prepare Tufts Medical Center for this huge crisis.

MICHAEL APKON: Well, I think really for us it started with the day that the WHO released their first warning of a potential pandemic, which I think was the third week in January or thereabouts. On that day we brought our management team together and our command center. We’re used to running a variety of emergency incident responses to whether external events like the Boston bombing or internal events like floods or equipment failures, but we knew this was going to be different. We knew this was going to be different in that we didn’t know exactly when we would face the challenge of accommodating patients with COVID-19 or how many patients or what the external environment might throw at us in terms of availability of resources.

We began to really think through all of the preparations we needed to do. We started putting together a list of supplies we wanted to make sure we had inventory of. We began to think about how we would create space within the hospital to care for infected patients versus noninfected patients. We operated that way in sort of a planning mode for several weeks, watching the worldwide number of cases grow and trying to learn from the experience in China and other parts of the world around how to care for patients with COVID-19 to begin to prepare our clinical teams. But I would say for the first few months, it was mostly a planning exercise. We tried to manage the internal anxiety of caring for patients with an infection that we hadn’t seen before, potentially putting caregivers at risk. Our main focus was making sure we were going to have the supplies and the staffing and the space necessary.

SHANOOR SEERVAI: While you were doing this, what were the other hospitals around you doing? There’s so many hospitals in Boston.

MICHAEL APKON: Yeah, that’s an interesting question. I would say for the first month or six weeks, maybe even a little bit longer, there wasn’t that much coordination among the hospitals. We were not having much conversation. I learned afterwards that everybody was going through the same planning exercise, which is no surprise. I mean, the hospitals are all very well versed in activating their incident command center and using that structure to prepare for things, so there was no surprise there. But there wasn’t a high level of coordination until we began to see the reports out of Italy of the health care system there becoming overwhelmed. I think that people were certainly shocked and surprised by what was happening in Wuhan, China, earlier, but that was sort of ground zero. So I think people maybe anticipated that by the time the virus spread, if it was going to spread around the world, that we would be able to keep it in better check.

I think the world really changed for me and for us as an organization around the end of the first or second week in March when I received a text from my wife with a link to a Twitter feed from the anesthesiologist in northern Italy, that were reporting the experience there of the hospitals and health system being totally overwhelmed by the number of patients with respiratory failure and the need to make very tough decisions about who is going to get a ventilator and who’s going to get an ICU bed. At that point it was clear that we were potentially in for a much more serious situation even than we had been planning for. We were sort of preparing for the worst, but I think not really understanding exactly how bad it might get.

SHANOOR SEERVAI: If we just back up a little bit. These tweets, what exactly did they say when your wife sent you this tweet thread?

MICHAEL APKON: The tweets describe the experience of anesthesiologists that were having to make decisions in the emergency department or out in the parking lot of hospitals, which patients might be able to get oxygen, which patients were going to be able to get mechanical ventilation in an ICU bed. And many patients, it seemed at least based on those early tweets —and I think that’s been borne out by subsequent reporting — many patients were not able to receive life-saving therapy because there simply wasn’t enough to go around given the numbers of patients that were critically ill. That was a chilling realization for me.

That evening I went home and sort of did the calculations in my mind around with the death rate of 1 percent and how many people might have to be infected to get to herd immunity and how many people that meant dying. It’s millions of people in the United States, and then the number beyond that of people that would need critical care. I just knew that there wasn’t going to be enough to go around if something didn’t change.

We regrouped as a leadership team pretty quickly, and we sort of laid out what the situation was. We believed from the very beginning that it was important to be transparent with our staff. We knew that people were anxious about the risks to themselves and to their family, the risks that they might bring an infection home to people at risk. We weren’t sure whether we were going to have sufficient personal protective equipment to keep people safe, and we weren’t sure what the demand was going to be on them in terms of their time and effort and energy. But we were honest with them from the very beginning. We recognized that we had a responsibility to the patients that needed us. We were trying to balance that against the responsibility that we had to keep our staff safe and to have as humane conditions as we could muster to have them work in. And we also knew that we had a broader responsibility to society at large to play a leadership role in showing what government needed to do in terms of introducing the concepts of social distancing and those kinds of things.

We acted very quickly. We were among the first hospitals in the country to stop our, what I guess I would call discretionary or schedulable activity. I hate to call it elective because there’s so little in health care that’s truly elective. We stopped our routine ambulatory surgeries and our routine office visits. We did that within two days of those tweets coming out of Italy. We did it because we understood very quickly from our infection prevention specialists that the most effective strategy that we had was reducing the interaction between people that you couldn’t test that might be harboring the infection. And we already knew at that point in Massachusetts, that we had reasonably widespread community spread and no meaningful ability to test at any appreciable level.

We normally run 50 ICU beds in total roughly across the organization, and at the peak, we had 100 ICU patients. So we had to double the size of our ICU. We had our Pediatric Intensive Care Unit caring for adults with COVID. We had people from our operating rooms staffing the ICUs. We had to create all kinds of new roles to help train and monitor people in the use of personal protective equipment to keep people safe. We had to introduce new staffing in our public safety workforce to try to manage the flow of people through the organization, and the introduction of symptom checking and things like that. We needed the time to develop those plans and to get people up to speed, and so stopping the activity that we had was part of that.

That happened all within two days of the reports coming out of Italy.

SHANOOR SEERVAI: Let’s talk a little bit about testing, because I remember at the beginning that was a huge problem: shortage of tests. How did you handle that?

MICHAEL APKON: When we think about testing, it’s important to really recognize that worldwide we all had the same warning. We all saw the same reports coming out of the WHO. We all saw indications as early as last December, December 19th, that there was a risk of a pandemic. We all had the same access to a genotype and all the information needed to develop the PCR test, we all had access to the same reagents. We began working to introduce testing at Tufts Medical Center in January, late January, and by March, we were one of the first centers in Massachusetts . . . a number of centers introduced their tests within days of each other and we were one of those centers.

I had an interesting experience. The day before we went live with our testing, I called my former colleagues from Canada because we had limited testing capacity still, and we wanted to understand how they were triaging the use of testing to have the most beneficial social impact. One of the things I was just struck by was they were sharing with me that they had been up and running with widespread testing for weeks. And this was the end of the second week in March or thereabouts. At that point in time, there were paramedics in Ontario that would go out to people’s homes to test on demand. They were doing so much of that kind of testing that they had opened up drive-through testing. I talked to one physician from my former hospital that had needed testing, went for drive-through testing and had a result that afternoon. And we were just beginning to introduce testing where we weren’t sure whether we had enough capacity for our staff and for the patients that we were caring for, let alone widespread testing.

As recently as four weeks ago . . . I have a home out of state, and I was traveling there for a weekend and actually needed to get tested myself. I wasn’t feeling well. It was a week before I got the results back from a commercial laboratory. And that’s now in July.

There’s been a varied experience around the world with testing. I will say that the testing was a game-changer. The ability to know which staff were sick and to help them quarantine, the ability to know which patients coming in were sick helped calm the fears of our staff and helped us better manage patients. It took us a lot longer in the States to get up to a level of testing that I think other parts of the world have had for a while.

SHANOOR SEERVAI: Why did it take so long? What did your colleagues in Toronto think when you told them that you were just beginning to test in March?

MICHAEL APKON: Yeah. I think my colleagues from Toronto, from Canada, look at what’s happened here and can’t quite make sense of a number of aspects of it. We have not had a coordinated response to testing. It’s been a number of commercial laboratories, a number of academic medical centers, more recently many other hospitals that have acquired the machinery to do the testing, but there has not been a coordinated response. Whereas in Canada there were provincewide and even countrywide responses to ensure widespread access to testing. They really focused on the entire logistics from collecting the swabs, to getting the swabs analyzed, to getting results back and feeding that into a public health infrastructure that was more ready and able to respond to a pandemic than what we see in this country where we have underinvested, I’d say in general, in public health, it’s much more fragmented at the municipal level with a moderate amount of state coordination and no federal coordination.

In Canada there is a social compact about people caring for each other. It shows up in the fact that there’s universal health insurance and that there is very little disparity in what people have access to in Canada. There’s plenty of health care disparities for other reasons; economic reasons and other things. But in terms of access to health care, people all have access to exactly the same health care. In the U.S. it doesn’t play out that way. The health care system here is much more fragmented. There really is nobody running the health care system here. It really is more of the market in many ways.

The other thing that Canada didn’t have to contend with was the financial impact. The hospitals in Toronto, you’re not going to see a significant deterioration in their financial condition. The government has a certain appropriation for health care. They have a certain allocation methodology. But as some care became less necessary and other care became more necessary, the net costs stayed roughly the same and dollars got shifted around.

In the states, the experience was very different. Hospitals saw a significant deterioration in their patient service revenue. The insurance companies that collected premiums saw windfall profits in the second quarter of the calendar year, because they didn’t have to pay for much, and were still collecting premiums. And for a system that believes it relies heavily on the market, we relied pretty heavily on government to step in and save the day with a variety of programs to either advance us funds or to provide grants, or to increase the payment for caring for patients with COVID to keep us in some way whole.

SHANOOR SEERVAI: Let’s talk about that a little bit. What happened at your hospital? You mentioned earlier that a lot of your scheduled activity had to be halted, which meant that a lot of your revenue was halted. So where did the money come from?

MICHAEL APKON: First we made a number of very difficult decisions. We furloughed 650 or so staff members, which was probably the hardest decision we made. We looked very carefully at how we could manage other expenses in the short term. We are fortunate to have a healthy balance sheet, so we have money in reserve and relied heavily on that for the first several months. The government grants that we got from the state of Massachusetts and from the federal government under the CARES Act helped a lot. The advances that we got from the Centers for Medicare and Medicaid Services for future services, they provided a significant amount of advanced funding that they expect to get paid back, but that put money on the balance sheet that allowed us to ensure that we would always be able to make payroll and pay our bills.

We have worked very hard on recovering our activity and are nearly back to normal in most areas of the hospital. We’re still seeing about a third less activity in our emergency department than normal, and some parts of our ambulatory operations are still nowhere near back to normal, but most of the hospital is back to a normal level of activity.

So we had about a three-month period where our revenue was significantly below normal. A lot of that gap has been filled by federal funding.

SHANOOR SEERVAI: It’s so interesting that federal funding is what is coming to the rescue in this country that is so opposed to universal coverage and so opposed to government interference, as some call it, in health care.

MICHAEL APKON: I mean, isn’t that ironic? We sort of believe that we live or die by the free market, but at the end of the day what I’ve come to appreciate is, markets don’t address the need that investors aren’t willing to pay for. Markets don’t do well in addressing the needs of the poor that can’t buy health care. They don’t do well with delivering care in settings that are economically not as viable, like the rural parts of the country. They don’t do well in driving mass investment for collective good that doesn’t have any real return to investors like facing a pandemic, keeping hospitals solvent during a pandemic so that they can be available when the pandemic’s over.

That’s what we rely on government for. We rely on government to manage the constraints around the market so that it does things like prevent the market from not ensuring patients with preexisting conditions, so we use regulation to manage the market. But we also rely very heavily on government to step in and keep the system functioning. I think there’s a lesson there in the importance of government, which really in many ways, saved the system over the last several months.

SHANOOR SEERVAI: You mentioned that markets don’t work or markets don’t function to serve the poor. If we actually think about it, those are the people who’ve been worse impacted by COVID in the U.S. and there was no cushion.

MICHAEL APKON: There is no cushion. And moreover, I think it is possible, and I think there’ll be lots of research into this in the coming months or years, but I also think it’s possible that the financial burden to getting care may have amplified the pace of the pandemic in the early days. We know that things like copays or out-of-pocket expenses are barriers for people to seek care. And when people don’t seek care and they walk around with infections that are spreadable, infections spread faster.

I was talking to a former colleague from Sick Kids last night, and he was saying, “The one thing that they were quite confident about is nobody avoided care because they were worried about paying because people don’t pay for care in Canada.” They don’t pay a copay. They don’t pay a doctor’s bill. They don’t pay a hospital bill.

Finances, while they still can be a barrier to people buying their medications, in all honesty, I mean, there’s challenges with that in Canada to be sure, people don’t avoid going to the emergency department for worry about the out-of-pocket expense, and they do in this country. And exactly the people that are the most at risk for the infection, people that were taking mass transportation to work, that had to go to work whether they were sick or not, that have jobs that put them in large crowds and things like that, those same people are more likely to be underinsured or to be uninsured, and the financial barriers to their seeking care could well have been a contributor in the early days with what we saw here.

SHANOOR SEERVAI: So now it’s September and we are far from out of the pandemic. Looking back over these past few months, what you’ve learned about the way that Canada responded to the crisis, your own experience, how should hospitals in the U.S. be prepared going forward?

MICHAEL APKON: I guess a few thoughts about that. One is I think we have learned the benefit of coordination and acting as a system. The fact that we can’t predict exactly where the hot spots of infection are going to be, where the demand might be, the hospitals that have the most critical care capability are actually not the hospitals that are exactly where people live or where the initial hotspots of infection activity were. And our ability to work as a system within our integrated health systems and then across our different systems within the state’s ecosystem, I think was a profound success factor. I think figuring out how to do that even more effectively, how to leverage technology better, I think that is a big learning for us.

I think the other thing that we have learned is how much of health care can be done in different ways. The amount of in-person health care that we’ve been able to substitute telemedicine effectively for is pretty staggering. I think we’ve seen a five-year journey to implement telemedicine in a more widespread way that’s played out over a couple of months, and I don’t think there’s any going back.

We’ve innovated new care models at Tufts. We partnered with a company called Medically Home to be able to use the home as a substitute for the hospital for patients that need to finish their convalescence or even avoid hospitalization altogether. I think we’ve proven out the ability to safely manage patients in ways that create capacity, are maybe lower-cost, and probably create a more healing environment, and I don’t think there’s any going back in that regard.

I think there’s still a lot to be learned around the coordination of things like testing and the testing logistics. I think we still have a patchwork approach with a number of different organizations that are providing testing without a good link between the collection of samples, the analysis of those samples, and the return of results with the use of those results in a public health sense, as well as a clinical sense. I think there’s still things that we could learn from other parts of the world and how they are doing that.

I think the other piece that we really have to wrestle with is the way health care is financed in this country and the staggering impact that this has had on hospitals and health systems financially. We’ve been able to weather the storm. There are a number of hospitals, particularly rural hospitals and smaller hospitals that are on their own, that may not make it financially when we come out the other side of this. And similarly, there’ll be physicians and physician offices, physician practices that won’t be able to sustain themselves financially. I think it’s really going to call the question around how do we create a financing of the health care system that doesn’t introduce barriers to patients seeking care, and that creates some sustainability that allows us to balance public health needs with the financial interests of enterprises that deliver health care and the need to have good accessible care in general.

SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. I produce this show along with Joshua Tallman for the Commonwealth Fund. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for our art and design, Oona Palumbo for mixing and editing, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources.

That’s it for The Dose. Thanks for listening.