Key Issues for Hospitals: Operational and Financial Implications of COVID-19

Insight by Charles Rhyee and Joshua Jennings, M.D.

Charles Rhyee, Cowen’s Health Care Distribution & Technology and Managed Care analyst and Joshua Jennings, M.D., Cowen’s Medical Supplies & Devices analyst speak with David Reich, President & Chief Operating Officer, The Mount Sinai Hospital and Mount Sinai Queens.

Discussion centers on health system preparedness for COVID-19 in the NYC area and its implications more broadly across the U.S.; the current state of COVID-19 testing and expectations for the near-future; operational challenges in an environment where COVID-19 related admissions could be increasing; and potential financial implications of an increase in COVID-19 related admissions.

Press play below to hear the full discussion.


Announcer:                      Welcome to Cowen Insights, a special look at the coronavirus and its effects on sectors across the economy, as well as the policy arena. You will hear the latest insights from leading experts about where things stand and what’s around the corner.

Charles Rhyee:                This [00:00:30] panel will really look at key issues for hospitals discussing operational and financial implications of COVID-19. Joining me today is my colleague, Josh Jennings, senior analyst covering medical devices and myself, I’m the senior research analyst at Cowen covering healthcare services. To speak on the issue, we’re very pleased and honored to have with us Dr. David Reich, who is the president and chief operating officer of the Mount Sinai Hospital at Mount Sinai in Queens.

                                         [00:01:00] David, thank you so much for joining us today. I really appreciate your time, obviously, during this very difficult period and, obviously, easy to say unprecedented times. Maybe to start, you can give us sort of your impression so far of what’s happening here, particularly maybe in New York City and speak a little bit to Mount Sinai’s preparations and positioning here to deal with the issue.

David Reich:                    Well, I thank you for inviting me to join you today. I [00:01:30] think that the best thing is for me to represent sort of not just the Mount Sinai Hospital view, but also the view of the Mount Sinai Health System as a whole. We are a health system of eight hospitals. Mount Sinai Hospital is the largest in the tertiary quaternary academic health center of the health system.

                                         Just to start at a very global level, Mount Sinai has really moved away in many respects from normal operations over [00:02:00] the past two weeks in a process of preparing ourselves for what is, as you’ve properly stated, an unprecedented public health emergency. We have, for example, in all of our hospitals, created isolation units where we have changed rooms that were not previously negative pressure into negative pressure, extensive training with our team to protect them using personal protective equipment, which is unfortunately also an issue of great concern because [00:02:30] of the shortages involved.

                                         We’re also in the process of racing towards a large scale ability to test for the virus itself, although for mild disease and those not admitted to a hospital, that is not really necessary because it does not actually change the medical care of those patients. But it is important for us with patients who are hospitalized now because many hospitals in the New York area, and other areas that are affected [00:03:00] by COVID-19, have a so-called patients under investigation or patients under monitoring. I can give a little bit more detail on those later, but what it means is people in whom there are clinical conditions, including respiratory illness, that are suggestive of COVID-19 disease, but cannot be confirmed without viral testing, which has been something that Mount Sinai has been able to do on a limited basis since last Saturday, but we’re hoping to ramp up more [00:03:30] to a scale where we could be able to do several hundred tests a day starting tomorrow.

                                         I think that maybe is a good introductory statement. Then I’m sure there are many things I haven’t covered, but maybe we’ll start there and ask areas where you’d like me to expand.

Charles Rhyee:                Excellent. Thanks for that, David. Yeah, maybe there starting with capacity for testing. You talk about how you have been conducting viral testing to date, what kind of tests you’ve [00:04:00] been using, maybe who you’ve been partnering with to help you in that. It sounds like you are able to now shortly scale up that process. Maybe talk a little bit about that and whether that’s in-house testing, self-developed yourself or you’re working with others to help you with that?

David Reich:                    The platforms that we used initially were, first of all, that starting, I believe, around March 2nd, the New York City Public Health Laboratory was able to provide [00:04:30] testing. Of course, the issue there is that there are many tests they needed to perform so results may not be coming back for many days, which, of course, leads to that problem of patients in that intermediate category of suspected disease that we cannot deescalate from the strict isolation techniques that were necessary.

                                         Then we were blessed because we have a virology laboratory by a team that’s working on universal flu vaccine and they had already developed an assay to measure [00:05:00] the virus. We’ve brought that technique over. It’s somewhat similar to the CDC technique. We also received a Thermo Fisher machine, which is the same machine used in the CDC. We had to build in seven days time what’s called a BSL-2 isolation unit within our clinical laboratories because of the risk of handling live virus. We were able to begin that assay [00:05:30] on this previous Saturday, but this … I’m sorry, the Saturday preceding this one. This weekend, we received kits from Roche. Many large health systems, many large laboratories in the world have Roche platforms, including ours is the 6800, which could in theory do hundreds of tests per day. We validated that test over the weekend, but it is, of course, [00:06:00] a complex thing to corroborate all the interfaces to our electronic health record and the sort of the middleware that can communicate with the laboratory information systems. We’re hopefully completing that work tonight.

                                         But the point is everyone is racing to try to establish more testing because the problem, of course, is that personal protective equipment is used on everyone where you have uncertainty clinically. But once again, I would just reemphasize [00:06:30] that it is not really a value to have that information for the worried well or those with mild symptoms. For that purpose starting really about 10 days ago, we began sending samples on our patients who are ambulatory, had mild symptoms and we sent them home. We used our corporate partner Labcorp. I know that Quest also does this sort of work. We did have a lot of trouble, frankly, sourcing reagent [00:07:00] materials for the in-house testing that we started already. I think Roche will be challenged in terms of sourcing enough viral tests for the needs of the nation.

Charles Rhyee:                In regards to that, what has been the communication from Roche in terms of being able to provide you a steady supply of reagents to perform tests?

David Reich:                    Well, there’s an ongoing conversation. I think that once we’re [00:07:30] up to a rapid turnaround and a much more automated accessioning and processing of samples, that’s when we’ll have serious conversations with Roche about what are our true daily burn rate is on the reagent kits. But, they were very kind. They give us enough kits for at least I’d say a week and a half as an initial delivery over the weekend. Of course, it takes [00:08:00] time to validate. Now, as I mentioned, it takes time to ramp up with all the information systems, but I’m fairly confident that they will probably be able to keep up with the demand that we have, keeping in mind that public health authorities really are not recommending that we test the worried well or those with mild symptoms.

Charles Rhyee:                Can you talk about some of that triage process as patients are coming into the Mount Sinai system? How are you identifying [00:08:30] who you suspect to be worried well versus those you want to get tested right away? Are you following sort of the CDC guideline on the checklist or have you guys modified that in any ways?

David Reich:                    We follow the guidance of the New York State Department of Health and New York City Department of Health and Mental Hygiene, which is fairly consistent with the CDC guidelines, but there’s always a slight wrinkle in terms of slight variations among the [00:09:00] three. But since we’re regulated more directly by the state and city, we tend to follow their guidance. But the fact is that, just to reiterate, the highest priority is for those who have inpatient hospitalization where the information is necessary to determine where they are for clinical care, especially since isolation units are very difficult to manage.

                                         But, we’re very happy to be able to tell ambulatory patients whether they’re [00:09:30] COVID positive or not. Certainly in this era now of social isolation, it almost becomes, well, actually, just in my view of this, is it’s actually less important because if you’re COVID negative today and you go outside and you don’t observe the principles of social isolation, you could be COVID positive tomorrow. Just because you’re negative at any particular point does not take away the need for social isolation. Now, of course, if there is [00:10:00] an outbreak in a family, et cetera, then I think it becomes important as you move on to later phases as you’ve seen in other nations where they have completed the mitigation through social isolation and then they have aggressive quarantining of clusters of outbreaks.

                                         I’m a cardiac anesthesiologist, not an epidemiologist, but I’m trying to follow this very closely. But realistically, [00:10:30] again, testing people with mild symptoms or no symptoms for COVID-19 as this time does not really provide a public health advantage to us in New York City. It certainly, I think, can help people manage at home. But now the guidance has come out, for example, for healthcare workers as of today, that if someone has a mild illness, and even if it’s not diagnosed in any particular way, if they have been home for seven days and they have three days of no fever without taking [00:11:00] any fever medications, like the Tylenols or the Motrins or things of that nature, then they are asked to return to work. Sometimes, of course, returning to work wearing a mask, but we cannot afford to lose the healthcare workforce at this time. It’s fairly clear that once there’s no fever for three days, that we’re not dealing with people who are a threat to the other healthcare workers.

                                         The corollary of that is that all healthcare [00:11:30] workers are now being asked to sort of … I’m sorry, not sort of, being asked to monitor their temperature. Different employers may take this in different approaches, but we are working towards the concept of should we do a symptom and sort of a safety check with people as they start their shift.

Charles Rhyee:                The need for healthcare workers is vitally important in this period. Even though we are anticipating this type of [00:12:00] rise in cases related to COVID-19, maybe speak to sort of what you are seeing in the population, in your patient population, maybe the city more broadly. At the same time, it’s our understanding, we’ve had a little bit of a slight resurgence back into flu. Has this been a complicating factor as you’ve been trying to deal with in identifying and taking care of patients potentially who have COVID-19?

David Reich:                    Well, it’s a very challenging situation in that [00:12:30] this is the worst flu season with the highest mortality since the H1N1, so-called swine flu outbreak, I believe around 2008. Don’t quote me on the exact date. Approximately 20,000 plus people have died in this nation of regular flu. Unfortunately, many people don’t get the flu vaccine. The combination of influenza and influenza-like illnesses has been a huge burden on health systems in this season. Usually that doesn’t wane until [00:13:00] later into April, beginning of May. That’s why we have that huge problem with patients under investigation because we don’t really understand or know what’s going to happen with those individuals clinically until we can differentiate the standard influenza and influenza-like illness, which many of our healthcare workers of course are immune to from the new disease, which presumably very few people [00:13:30] have immunity. While there is probably community spread as this point, the number of individuals with immunity is still vanishingly low.

Charles Rhyee:                Yeah, no, we’re trying to understand a little bit as we now try to prepare in anticipation for potentially an influx in patients that need to be admitted into the hospital, can you talk about from a workflow standpoint some of the things that you’re doing?

David Reich:                    Two major things that we’ve done, and really everyone has done, in the hospitals in New [00:14:00] York. Number one is that we took over space that had been a geriatric practice and sort of an urgent care that we labeled express care for various administrative reasons. We took that space, which has about, it’s probably about 25 or 30 exam rooms. We turned it into an annex of our emergency department. As people enter the emergency department, anyone was respiratory symptoms, patients that is and their companions, were asked to put on a mask and they were immediately screened.

                                         If they are in the respiratory [00:14:30] symptom pathway, which could be COVID-19, they were then escorted to this annex area, this ambulatory area. Anyone too sick to walk, of course, was taken into the main emergency department into an isolation area or an isolation room. Then, these individuals who went over to the annex were assessed by our practitioners. They were tested, if necessary, for COVID-19 or other problems that they might have. Then, frankly, they were sent home [00:15:00] with instructions to call back if symptoms worsened. Because the real concern is not people with mild upper respiratory illness, but those who develop shortness of breath or severe pneumonia. That’s one workflow.

                                         The second thing was creating within the hospital clusters of rooms, in our case, many, many rooms at this point, that are isolation units so that we [00:15:30] were able to obtain fans with HEPA filters. We took out some of the window panels in the rooms and used a plywood cutout and basically turned the rooms into negative pressure rooms so that any air in the hallway is sucked into the room so that if there is any aerosolization or there are droplets, normally droplets wouldn’t persist for more than six feet. It’s perfectly fine to have [00:16:00] somebody who just has plain COVID-19 disease in a private room with the door closed.

                                         But in the case of patients who are more ill or those who might be receiving certain medical procedures like a noninvasive ventilation or high-flow nasal oxygen or those who are on mechanical ventilators and intubated, then there can be so-called aerosolizing procedures, things like suctioning or nebulizers. In those cases, [00:16:30] it’s much better to have all of those patients in negative pressure rooms. We had to create those facilities by emptying out our hospital of other patients and most recently, curtailing non-urgent surgery. Elective is a strange word because there are people with cancer that if put off for a month or two, it may be a fatal decision to delay because that tumor could metastasize. That’s, [00:17:00] for example, one issue.

                                         Or there are people with heart disease that is relatively well advanced that might need procedures in our cath lab or our cardiac ORs. If we put them off for two months, it could be fatal for them. We have to decide what’s a true emergency, like an appendectomy where you have to do it within 24 hours and things that are urgent enough that you really should not stop them. But we’re curtailed our schedule dramatically, as many other hospitals has done [00:17:30] around the nation, so that the beds that are occupied in both critical care and regular beds that are occupied by those patients, are available for us to compress the rest of our enterprise because these people are still sick. People still need medical and pediatric and transplant and other care. We can’t stop all of that.

Charles Rhyee:                Good segue to my colleague, Josh. I have two questions in the inbox that are kind of related to what you just spoke to. You talked about taking over rooms to create these negative pressure rooms. Can you talk about [00:18:00] what percent increase in these kinds of new potential critical care kind of settings or expansions of your ICU kind of critical care unit kind of area, is that’s maybe a percent of your total capacity? Was it like a 10% increase, a 20% increase? Maybe you can give some type of …

David Reich:                    I have diverted at this point about 40% of our total ICU capacity, really by tomorrow morning towards isolation areas. It’s [00:18:30] not all filled yet, but we expect it to be filled in the days and weeks to come.

Charles Rhyee:                That’s helpful. Then secondly, at the moment, how many patients would you say are currently in the Mount Sinai system for flu versus COVID-19?

David Reich:                    I can’t really give you that number. I mean, there are always a fair number of people in medicine at that time. But, let’s put it this way. Of the patients in whom we’ve been able to obtain results [00:19:00] from viral testing, only about, so far, only about 20% of those patients have had COVID-19. The remainder has had some other respiratory illness, but that’s now. That could be different in a few weeks.

Charles Rhyee:                Great. Josh, why don’t you jump in here.

Josh Jennings:                 Oh, thanks Charles. Thanks, David, for spending time with us today. Just on the elective procedure, I guess, postponement and cancellation policy you guys put in place, maybe we could just start about just how that [00:19:30] decision was made. Were you guys following a mandate from American College of Surgeons or the Surgeon General? Was that something that’s been in the works by your team over the last couple of weeks?

David Reich:                    Well, I’d say that all of us who have been following this disease as it’s worked its way through, sadly through China and South Korea and Iran and Italy, the pattern is fairly clear that there comes a point that even with mitigating or mitigation [00:20:00] in the form of social isolation and all the other things that we see that may blunt the curve, there’s a point where the health system becomes overwhelmed with patients requiring critical care. At some point, you have to wind down aspects of normal operations to make room for this spike that is coming.

                                         We are in the phase of preparing for that because we are in the early part of that [00:20:30] curve compared with the other nations. But I believe that many health systems in the nation have been quite astute in following the patterns here and trying to do their best to be ready sort of for the onslaught of a very large number of very ill patients.

Josh Jennings:                 Thanks for that. Then just in terms of the last number of weeks or even a month, have you seen patients start to cancel elective procedures out of fear of COVID-19 [00:21:00] or have your physicians or surgeons been cautious of scheduling with the procedures prior to the announcement that you guys made this week?

David Reich:                    Not really. Honestly, our OR schedule, elective and urgent and emergency, was pretty much at normal par until we curtailed it starting yesterday and severely today. I’m a cardiac anesthesiologist. I’ve worked with surgeons for three and a half decades. There are a few interesting personalities [00:21:30] here and there that need a reality check, but by and large, we’ve had tremendous acceptance by the medical community of the needs to adapt to the public health emergency.

Josh Jennings:                 Great. I think it would be helpful, and this may be a difficult question, there’s a lot of moving parts I imagine. But just in terms of buckets of procedures that most of them will be canceled versus procedures that will continue to move forward in this era of [00:22:00] hyper-caution and cancellation/postponement of “elective” procedures. There are life-threatening cases that, obviously, move forward, but are there distinct buckets that you consider purely elective, maybe a knee replacement or a hip replacement that’s non-traumatic? If there’s any way we could sort of walk through some of those buckets as you see it in your mind. Then we can, just a couple of thoughts on that topic.

David Reich:                    Yeah, well, I’ll be honest. Pretty much there’s very little in the way of orthopedic surgery that [00:22:30] is truly urgent or emergency. I mean, there are infected joints which have to be done. There are other infectious conditions related to orthopedics that are important to do in an urgent basis, but orthopedic surgery, by and large, is a specialty where you can defer surgical procedures. But I think that it’s case by case. I mean, orthopedics also has [00:23:00] tumor cases. It’s less so than, for example, urology or GI surgery where you have a say a lesion which could be cancer, liver surgery. We really have to look at each individual service line. The chairs of the departments look at the surgeon’s volume case by case. We have to basically set up an oversight [00:23:30] group that can provide guidance because not all of these decisions are black and white.

Josh Jennings:                 Understood. I guess, it sounds like the department head and maybe a committee will adjudicate these decisions. Is there any strict, I guess, guidelines or is this going to be kind of case by case, department by department adjudicating decisions and making sure that elective procedures that aren’t [crosstalk 00:23:57]-

David Reich:                    Well, it’s black and white and gray. The gray needs some guidance. [00:24:00] Then there’s the obvious stuff where our administrative team that runs the perioperative area is very easily able to say, “No, we’re not doing that case during their public health emergency. Don’t schedule it.”

Josh Jennings:                 Excellent. Just thinking about the orthopedic category, maybe we just run through one other, I guess, vertical within the medical devices industry, which is cardiology or cardiac surgery. Are there any, I guess, outside of acute MI, are [00:24:30] any buckets that you would consider essential or need urgent or immediate care that would not be postponed or canceled. I guess, more specifically, thinking about transcatheter aortic valve replacement. Is that just going to be a patient by patient decision based on the [crosstalk 00:24:47]-

David Reich:                    Well, many of the TAVRs, the transcutaneous aortic valves, have to go because these are patients with critical aortic stenosis. Their life span would be measured in months if they don’t receive the therapy. [00:25:00] We certainly would receive with those. Obviously, the most critical of the patients who are having a so-called STEMI, the ST elevation MI, that continues. The stroke interventions continue. The interventions for brain tumors that are compressing and causing symptoms. I think it’s fairly obvious to most physicians what must be done, but I understand that for this group that it wouldn’t necessarily [00:25:30] be known based upon that. But within every specialty, there is always a subset of cases that are emergency in nature. For example, a hip fracture is still, we were talking about orthopedics before. Hip fractures have to be done.

Josh Jennings:                 Excellent. Just thinking in terms of just maybe a high-level thinking about, I guess, the declines in procedure volumes that you guys are anticipating, any back of the envelope, I guess, forecasting that you guys are assuming over the next [00:26:00] month? I know it’s hard to determine how long this crisis will be in play, but how big of a [crosstalk 00:26:04]-

David Reich:                    Yeah, maybe a 70% decrease.

Josh Jennings:                 70% decrease.

David Reich:                    But, that’s just a guess.

Josh Jennings:                 Sure.

David Reich:                    It’s certainly more than 50%, but it’s less than 90%, is what I would say.

Josh Jennings:                 Understood. Maybe thinking about, I guess, the recovery, again, forward-looking question. But just, are there any triggers that we should be looking for in terms of when elective procedures could come back? [00:26:30] I mean, is there anything specific to the COVID crisis or outbreak in terms of trends where …

David Reich:                    Yeah, I think that if you look at the data that came out of China and Korea, not yet, unfortunately, out of Italy, at some point, there’s a decline in new cases. When the number of new cases is declining, the number of recovering patients is rising and the occupancy of critical care beds is diminishing, that’s when you see [00:27:00] that there might be an improvement. But I have to also just be students of history here in that the 1918 flu pandemic, the so-called Spanish flu, had a rise in the spring, and then it declined over the summer. Then in the fall, 50 million people died. Obviously, it’s a very different time, over 100 years ago without oxygen therapy, modern hospitalization, ventilators, et cetera.

                                         But, if you look at the pattern [00:27:30] of a virus that has no immunity, and certainly it does not seem that warm weather just kills it, certainly they’re having cases in Australia and it’s their summer. There’s no guarantee that there’ll be a seasonal variation, but there is the potential that there could be a second major … I don’t know what the proper term is. I was going to say outbreak, but it’s probably not epidemiologically correct since that’s not my specialty, but a second major wave of [00:28:00] infections could follow in later months. A vaccine, as we’ve all heard, is over 12 months away. I’m sure that this will be probably the most rapid vaccine development cycle ever, but there are limitations to creating safe and effective vaccine production that cannot be sped up.

Josh Jennings:                 Understood, thank you for that. I mean, just thinking about that type of decline in elective procedure volumes. [00:28:30] I mean, how long can this run before, I guess Mount Sinai from a revenue generation perspective, can sustain missing out on those profitable procedures?

David Reich:                    It’s a huge issue. Our health system will probably sustain a major loss this year. It’s unlikely that we would be able. If you look at the average health system in the nation, I think [00:29:00] the margin is around 1%. That margin is based largely upon procedural medicine, which would include more than just surgery. It also includes interventional radiology. It includes oncology care. It includes, well, I think I’ve already mentioned transplantation. When you create a circumstance where these service lines operate at a fraction of their normal capacity, it would, obviously, [00:29:30] put the majority of health systems into a deficit situation.

Josh Jennings:                 Gotcha. Then just thinking again, forward-looking, assuming that there is control. I mean, how do you see procedure volumes, I guess, rebounding? I mean, how long would it take from, I guess, starting to ramp back up till you get back to, I guess, the efficient kind of workflow or procedure numbers that you were [00:30:00] experiencing in the back end of 2019? Is that a six-month, twelve-month process?

David Reich:                    Well, yeah. I mean, if you could flip a switch and everything were fine, then people would ramp back up in days. But the problem here is that the workforce may be problematic. There may be people who are ill or they may have taken other jobs. It’s hard for me to say. You may have to do training and work to replace some of the people and the supply chains [00:30:30] for some of the equipment, drugs, implantables that we need may be constrained by a shutdown of the economies for several months. It’s really we’re in unknown territory here in terms of what it would take to ramp back up.

                                         I imagined that it would be ramping back up in a few months and that the world economy would do its best to come back. But if there is global recession or global depression, then it may be very difficult to reinitiate that. [00:31:00] People might lose jobs and might lose their insurance. They may not have the wherewithal in our health system as it currently stands in the US, to actually pay for these procedures. There are a lot of unknowns here.

Josh Jennings:                 Understood. Just thinking about the potential of a second wave, I mean, just the prospect of that, does that impact any decision making to start to ramp up, say if things get under control like the Spanish [00:31:30] flu did by the summertime? Does it cause any hesitation and decision-making to ramp [procedures 00:31:38] back up with the prospect of a second wave out there?

David Reich:                    I just think it’s just total conjecture. I mean, it is a possibility that we might look better in July, August and sort of started to come back a little bit, but then we get a second wave. It’s just unknown. I can’t predict that. But I’m just saying that there is that example of the 1918 [00:32:00] flu pandemic to consider as a sobering lesson that just because we see a decline in the cases, doesn’t mean that when we relax the restrictions on travel and social isolation, that we won’t see a rebound.

Josh Jennings:                 Okay, just two last quick ones. First, just on your capital budgets, operating budgets. Are there investments that you’re now deprioritizing or postponing [00:32:30] on the capital side? I know a lot of device manufacturers that are selling robots. Then there’s also other supplies and capital that you may need in terms of beds or ventilators, even IV fluids and inpatient supplies. Anything that you guys are prioritizing or postponing?

David Reich:                    Well, I mean, I’ll take the advantage of talking to a, I don’t know, a large audience or a small audience, but to the audience that if anybody [00:33:00] has connections that can get us ventilators in the next two weeks or personal protective equipment supplies, such as masks of any type, please call me. But, the issue here is that right now we are acquiring as much equipment as we can to prepare for what other nations have experienced with COVID-19, which is a massive requirement for intensive care supplies and equipment and staff and preparing our staff for that. Then [00:33:30] the corollary of that is there’s going to be much less call for us to go for things like surgical robots. There’ll be less demand for joint replacement materials and cardiac valves and things of that nature.

                                         I don’t know if I can answer it better than that, except to say that when you look at it, obviously, elective or truly elective surgery plummets and the supplies that are associated with that and that critical care supplies, [00:34:00] to the extent that we can get them because of the interruption of the global supply chain, I mean, those would be a benefit. Anything from, we’re going through massive amounts of hand sanitizer, personal protective equipment. We need ventilators. We need staff that are able to take care of patients in a critical care state. Then, hopefully, we have as a nation, intervened early enough with social isolation to mitigate the [00:34:30] growth of that curve of critically ill people so that it will allow the rest of the health system to still take care of all those sick people out there that need medical care.

Josh Jennings:                 Got it. Then lastly on just you guys I think are a big participant, a lot of principal investigators in clinical trials. Have you suspended clinical trials at your center? Is that happening broadly across New York? Is that what I understand?

David Reich:                    Yeah, the NIH just put out guidelines [00:35:00] today. I didn’t read them. I just it saw come through my email streams. But our dean has specifically, along with other deans in this area, wound down most of the trials where it requires that our staff interact directly with patients. I think that there are certain things that continue. For example, if there are people who are receiving cancer trials and they’re in the midst of therapy and the patients are asymptomatic and have not developed COVID-19, those will continue. [00:35:30] But I would imagine that will be more difficult to enroll people because with social isolation and less willingness of people to move and probably less diagnosis of conditions related to the fact that people aren’t seeing their physicians, that would probably decline as well, even in the therapeutic trials that are ongoing.

Josh Jennings:                 Thanks a ton for taking all these questions. I’ll hand it back over to Charles.

Charles Rhyee:                Thanks, Josh. A number of questions [00:36:00] here that’s kind of come in, David. First, this kind of goes back to earlier on when you were talking about getting the testing kit from Roche, with the supplies. Do you think that this new capability will shorten the turnaround time for you? Maybe rephrasing it, what was the turnaround time for testing last week perhaps? Then, what do you expect to turnaround time for your testing now?

David Reich:                    Yeah, on a platform like Roche or a platform [00:36:30] like GenMark, you will have results in four to six hours, but that doesn’t mean you get results to the patient in four to six hours because there’s a batching process in terms of you load up a machine and then, of course, it runs and then you have to result. There’s sometimes quality control issues, but I would say generally a machine with a process time of about four hours. There are more rapid tests that have come out for COVID, but most [00:37:00] viral testing requires a process called polymerase chain reaction to sort of grow the amount of RNA that’s in the virus to a level that can be analyzed. Most of those are going to take around the four-hour range.

Charles Rhyee:                Okay, that’s great. Overall, what do you think your throughput will likely be? What was it kind of in the last week or two? What do you expect it will be in the coming days?

David Reich:                    Well, I believe we’ll be able to do several hundred, [00:37:30] but that will satisfy the needs of our health system to be able to understand as patients come in with respiratory illness, is it a true COVID? I mean, will we be able to, and of course, patients who are coming let’s say through our emergency department with severe symptoms, or more severe symptoms, and that will be important. We may be able to give better instructions to people that come through our emergency department and are sent home in terms of [00:38:00] what’s appropriate for isolation and whether their contacts need to be also observed. Of course, if they’re negative, then it may imply not.

                                         But I think the whole point here is as long as there’s widespread, or if there’s community spread of the virus, that it doesn’t necessarily give anyone relief, other than psychological relief that they don’t have it today, because if they don’t have immunity, they could walk out of their apartment and go shopping in the grocery [00:38:30] store and get it tomorrow. Really it’s a strange situation here because people are wanting and demanding it for psychological wellbeing, but it doesn’t actually provide any protection to know that in a particular day.

                                         They may reach a point in the future, if you follow what happens in China and is happening in South Korea, where with strict social isolation and aggressive control of outbreaks that can be contained within smaller [00:39:00] geographical areas, that that may be effective. That seems to be the Chinese approach. We don’t know yet. It’s still early in this disease to know whether that’s going to work and if they reopen factories and build up their production again, if they will engender a second wave. I think that’s the big question.

Charles Rhyee:                Great. That’s helpful. Another question I’ve got here, is this a whack-a-mole virus until a vaccine is developed? Given how contagious this virus is, [00:39:30] much more than SARS, how do we put out the spreading? It seems like maybe you touched on that a little bit, but …

David Reich:                    Well, I think that what you’ve seen in all of these nations, what’s happened in China and South Korea and Italy, now it’s really spreading throughout Europe and even now heading California, is basically these concepts of modified curfews. If you just prevent people from interacting with one another and they stay six feet away from one another, [00:40:00] then they don’t have the opportunity to spread. You’re interrupting the chain of transmission and reducing the number of people that each infected person subsequently infects.

                                         I always forget the epidemiologic name for that, but there is a specific number of people that can be infected by a particular person, but it doesn’t mostly work. It’s just an average because there can be people that are so-called superspreaders. We have no idea [00:40:30] in this disease, which is a brand new disease, how many people are asymptomatic but spreading it. That’s why the social isolation makes the most sense at this time. I invite everyone to follow the statements of Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, because if there’s anyone in the world who speaks to the scientific truth, it is that gentlemen. Like I said, don’t listen to the cardiac anesthesiologist. I’ve tried to be a quick study on this, [00:41:00] but it’s not my specialty. People who study epidemics are the people you should be listening to.

Charles Rhyee:                What is the treatment protocol for those with acute respiratory distress to mitigate the progress of COVID-19 in them? How quickly is the experience of individual patients recovering?

David Reich:                    Well, if you look at the data, the average patient spends at least nine days in an intensive care unit. Now, of course, that can be a shorter stay if, unfortunately if they succumb, [00:41:30] if they expire. But that seems to be the average from China and Europe so far. Then they would probably spend an equal number of days in the hospital after that recovering from the severe illness. Right now, the treatment is if someone develops severe illness, it’s oxygen therapy. Then noninvasive and invasive forms of ventilation. Whether they use BiPAP-type machines, which are noninvasive ventilation and mechanical [00:42:00] ventilators with endotracheal breathing tubes. That is my specialty. I know a lot about that. That’s the supportive care.

                                         Then some of the most severe cases will need to be ventilated in the prone position, meaning that they’re face down. Other, more severe patients, will receive support by a process called ECMO or extra corporeal membrane oxygenation. Think of it as a heart lung machine that supports and replaces the function of the lungs for a period of days with the hope that [00:42:30] the individuals will recover. In general, people who are placed on ECMO for this type of problem, which is referred medically to as ARDS, acute respiratory distress syndrome, about 50% of them will survive the ECMO. There’s that.

                                         Then there are drug trials, which are beginning. Some people have tried hydroxychloroquine, which is sort of you might think of as an anti-inflammatory of sorts. There is remdesivir, [00:43:00] which is the Gilead drug, which is an antiviral. Those trials are just beginning. That may be effective. We are also working towards some research testing that we’d like to move over into the clinical sphere to look at the inflammatory response, because so many people believe that the patients who do worse are those who develop a medical condition referred to as cytokine storm. There may be interventions such as interleukin six inhibitors that may [00:43:30] improve outcome, but these all will have to be tried clinically. The Chinese data, it was too soon for them to really stand up a lot of trials. I’m just not sure if the Italians would have the wherewithal considering the massive crisis that occurred in their system.

                                         Also, we are working towards the development of an antibody assay. Once again, we’re blessed that we have a research lab. There is a 90-year-old concept or therapy [00:44:00] that’s been around for a very long time called convalescent plasma. Where you take people who have recently recovered from an illness and you ask them to donate their plasma, not the red blood cells, but the plasma itself. The blood is taken out of the body, spun, and then the red cells are returned to the patient. The plasma is stored in a blood bank and frozen and treated usually with heat to inactivate potential other illness-causing entities or pathogens. If [00:44:30] you do it in the right patients at the right time, the antibody boost may slow the progression of the disease.

                                         That’s another thing that people are looking into. Just on a call today with our New York Blood Center to see if we could arrange a protocol like that in New York. It’s another option, but there are just a lot of unknowns again, but all of us involved are racing to set [00:45:00] up all of these processes because we know that we have only a limited period of time until we have a massive influx of very sick people.

Charles Rhyee:                It goes back to some of your comments around ventilators. Can you talk about your ventilator capacity expansion? Then secondly, reports of ventilation potentially exasperate risk of secondary infection. I guess if people need support on ventilators, does that open them up to further risks?

David Reich:                    [00:45:30] Well, the people who are on ventilators for a long period of time may have other infections develop. Of course, people with COVID-19 may have so-called coinfections where bacteria will take advantage of the weakened state of the lungs to also coinfect the patient. But, it’s not that the ventilator per se causes this. It’s more that the patients who require ventilation for a long time are in a weakened state.

                                         But, I think that the capacity issue is a very serious one. You see the feds and [00:46:00] the state governments having discussions back and forth and Trump saying to the states, “Find your own ventilators.” It’s a very scary situation for those of us in healthcare. Frankly, I’ve been working every angle. I’ve been an anesthesiologist for three and a half decades and I have connections in that community and I’ve worked through our board of trustees, some of whom have interest in these companies to see what I can do to just find and divert [00:46:30] as many ventilators to Mount Sinai as possible. My goal would be to more than double our ventilator capacity for the health system in the next two weeks. Will I be able to do that? We’ll see. I mean, we’re assembling a hodgepodge of ventilators and cutting purchase orders without the usual oversight process. Our chief financial officer probably is turning pale, but that’s the nature of what it takes to prepare for a crisis like this.

Charles Rhyee:                The President in his remarks over the last few days, in the last couple of weeks also, has highlighted [00:47:00] the potential for telehealth to be helping combat COVID-19. Can you talk about sort of Mount Sinai’s virtual care capabilities today? Is this something, if it’s not kind of aggressively being pursued, something that you are looking to aggressively expand upon or will look to in the future?

David Reich:                    Well, we had already developed our telehealth platform like pretty much every other health system in the nation. I would describe it as [00:47:30] the proverbial kick in the pants because now we really can’t bring people in for cognitive evaluation, let’s say for diabetes or for, luckily people can take blood pressure at home and things of that nature. For most medical illness, not procedural care, but for medical illness, we can do telehealth appointments. Luckily we have had some relief from the state and the federal government in that we can now do telehealth.

                                         For example, a [00:48:00] doctor licensed in New York cannot do a telehealth appointment on a patient that’s physically sitting in New Jersey unless that individual also has a New Jersey license to practice medicine. Those restrictions have been reduced at this time, during the course of the public health emergency. You will undoubtedly see a massive spike in the number of telehealth appointments because, frankly, people like to see their doctor. They want to come in and be in the [00:48:30] office and have that human interaction. Now that that’s not safe for most people, telehealth is definitely taking off. But on the other hand, frankly, it’s kind of annoying to get an extra 20 or 30 emails a day now in my feed about people who are kind of trying to, frankly, profit off the crisis by claiming that their telehealth platform would suddenly work for us.

                                         Telehealth is a very delicate thing to set up because it has to interact with your electronic health records. It has to interact [00:49:00] with your billing systems. It’s based upon relationships with the payers and there are different policies. It’s not just a simple matter of saying, “Telehealth is great. Let’s do it.” Telehealth also, you have to set up the platforms. You have to have the physicians ready and you, frankly, have to be paid for it.

Charles Rhyee:                You also mentioned that, obviously, in this period probably the health system, not just yourself, but a lot of health systems are going to be facing difficult financial issues. [00:49:30] Maybe talk specifically about testing. Copays and testing are being waived now. How does reimbursement work for you in this scenario? I think in testimony for Congress, the head of, or someone senior in the CDC seemed to be basically committing to covering out-of-pocket costs related to COVID-19 testing. Besides the cost of the test, what are the other typical out-of-pocket costs that are likely to be incurred by patients that come into the hospital with suspicion of [00:50:00] being infected?

David Reich:                    Really it’s almost you’ve seen one, you’ve seen one, and then everyone seems to have a different copay and deductible with their plans these days. Based upon what your employer has, if you’re self-insured, what particular Medicare Advantage program you might belong to, what other commercial payer policies are. It’s really not something that you can create easy global generalizations about, but if the government [00:50:30] says that we have to waive all copays and deductibles for everyone who is treated for COVID-19 disease, that would be a further reduction in revenue for health systems because the amount of out-of-pocket responsibility has grown gradually over time as the health insurance whatever policies have evolved in the last several years.

                                         I don’t think [00:51:00] I can answer it better than that, except to say that there would be expensive out of pocket copays and deductibles for many patients. It’s unclear what will happen. Of course, once again with global recession, if people lose their employment, they lose their insurance and Medicaid is a much worse payer for hospitals, then it’s very unclear what will happen, but everyone will have less money. That much I can say with a fair degree of certainty.

Charles Rhyee:                [00:51:30] Have you had discussions with payers yet or any kind of initial discussion among your team in how billing will be handled here? Particularly, how are you going to be dealing with coverage for uninsured?

David Reich:                    Well, and frankly, no. No one’s really had the time, at least in the health system leadership that I deal with. Everyone’s been obsessed with preparing for the [00:52:00] massive influx of sick patients. I don’t know if any payer really knows what this landscape looks like going forward. I just don’t think that that’s been the focus at this time.

Charles Rhyee:                I think Josh had that one last question here. Then I think we will need to wrap up.

Josh Jennings:                 Thanks, David. Thanks, Charles. I just wanted to just punch in on ambulatory surgical centers and whether or not they could serve as a maybe a release valve for some of these [00:52:30] elective procedures that are not going to be done in the hospital. Does Mount Sinai have surgery centers within the system? Then how should we be thinking about the potential for them to pick up some of the slack, if you will?

David Reich:                    I understand the thinking, but right now just speaking from my standpoint as a leader in a health system that’s going to have to deal with both staff shortages at the same time that we have a massive influx of sick [00:53:00] patients, I really would want those healthcare workers to be available and either volunteer or be hired as temporary workers to work in hospitals. I’d personally find it a little bit offensive if ambulatory surgical centers say, “We’re open for business.” First of all, I don’t think it’s wise anyway because with community spread, it just creates another situation where there’s a lack of social isolation and furthers the spread of disease.

                                         [00:53:30] But, this is a personal opinion. I’m sure others will have a different view. Certainly from a business standpoint, it would be desirable if ASCs could go on. But, I don’t approve of it personally. I think that it would not look good in a public health context for ASCs to be operating a normal business when hospitals don’t have enough people to care for patients in intensive care units and those healthcare [00:54:00] workers in ASCs are helping to make money for their doctors.

Josh Jennings:                 Understood. Thanks so much for all the time and for answering all our questions.

Charles Rhyee:                Thank you, Dr. Reich. Thank you so much for your time and good luck with everything.

David Reich:                    Thank you, all. I appreciate your giving me the opportunity to speak to the group.

Charles Rhyee:                Take care. [Thanks from everyone 00:54:20], including us.

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