May 3 2021

Dr. Shantanu Nundy on Care After Covid

By Accolade

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The Covid-19 pandemic transformed many aspects of American life – none more than the healthcare experience. In his new book,  Care After Covid , Accolade CMO Dr. Shantanu Nundy explains why U.S. healthcare needs to maintain many of the changes it made in the past year – and use them as the foundation for further transformation. 

We sat down with Dr. Nundy to learn more about the book, the most heartening changes he’s seen in the past year working as a physician, and how a year of transformative changes has left him optimistic for the future of U.S. healthcare.

Did the Covid pandemic really teach healthcare providers anything about the flaws in U.S. healthcare? Or did it just stress cracks that were already visible to people who were paying attention?

It is certainly true that Covid didn’t create the flaws in healthcare. But for many including myself, it was a magnifying glass, making visible what up until now was not always obvious. 

We also need to acknowledge the emotional component of this increased awareness. It’s one thing to know about something cognitively and a whole other thing to experience it. Nearly all of us have had the experience during the past year of trying to find a test or a vaccine, figure out whether we’re sick enough to go to the doctor or not, and being deeply worried about the unacceptable inequities faced by members of our community. That matters.

Where did the U.S. healthcare system succeed in adapting during the pandemic, and where did it fail?

When most people think about the healthcare system, pretty much the last word they would use to describe it is “agile” or “responsive”. And yet the healthcare system changed more in the past year than it has in any similar period of time in its modern history. Nearly overnight, clinics like mine went from 0 to 80 percent virtual overnight. For the first time in my career, I saw patients over FaceTime or WhatsApp. We pitched tents in the parking lots to do drive-thru testing. We used data from our electronic health records to identify and outreach the highest risk patients to get the Covid-19 vaccine. So there was a lot of success. 

The failures largely reflected the longstanding failures of the healthcare system. We’re relatively good at acute care like heart attacks, strokes, and helping people with Covid-19. But where we fall down is primary care, chronic care, mental health and prevention. That’s even more true for communities of color, rural communities, individuals living in poverty, and the elderly. 

What surprised you the most about how healthcare transformed during the Covid pandemic?

How quickly and how deeply we adapted. It’s notable that prior to the pandemic, we had been trying to increase adoption of virtual care and telemedicine for decades now and seeing very minimal uptake each year. Healthcare is hard to change and sometimes with good reason. But necessity is the mother of invention and, enabled by a few policy changes, it’s been astounding how fast and how far we’ve moved into virtual healthcare. 

And as a result of that movement, I think a lot of smart people in the healthcare system are looking at right now and saying “Wow. What else does this mean we could get done?”

At the risk of asking you to sum up the entirety of  Care After Covid  in a few sentences – what lessons does our healthcare system need to take from this pandemic? What do we need to start doing, or do more of, or stop doing altogether?

  That  is  a tough question! To me the biggest lessons are:

  • Care doesn’t need to happen in a clinic or a hospital.

Much of care can be effectively and safely delivered outside of a healthcare setting, and doing so makes care more accessible, affordable and equitable. Testing for viral respiratory illnesses should always be done in a drive-thru setting, for instance. Many follow up visits to the doctor can be done over video call. In the last year, we’ve learned a lot about how much care can be done by patients themselves at home. 

  • The right role of data and technology in healthcare is to increase the care in healthcare. 

When I got a clinic iPhone for the first time in my career to do virtual visits, I found myself messaging with my patients between visits more to see if they got the medication I prescribed or just to check in on them. Technology in healthcare is at its best when it is being used to extend and support the trusting, empathetic relationships that are central to quality care. 

  • We need to trust frontline workers and patients with more resources and authorities to make their own care decisions.

Early in the pandemic I wrote an op-ed that patients should be able to test themselves at home. The piece went viral because the general public and doctors loved the idea. But when I went to policymakers, they pushed back hard. Won’t patients over-test themselves? Will they administer the test correctly? How will they know what the test result means? Their concerns reflected a deep paternalism. Today I’m excited that any patient can walk into a pharmacy and over the counter get a Covid-19 test to administer at home with results in 15 minutes for $14. $14! Compared that to missing a half day of work to go to the doctor, the cost of the visit, and then the cost of the test. That’s transformative.

  What’s the message you hope that other healthcare professionals take from  Care After Covid

Lead don’t follow! Because healthcare and medicine are so complex, people sometimes are worried about rocking the boat too hard. But intuitively, they know certain things don’t make sense. Like why we do ask people who are sick to come up to us instead of go to them? And why do we then have them wait in a waiting room where they risk exposing other people to their sickness and themselves get exposed to others? During the pandemic we threw out a lot of those assumptions

In many respects employers and companies were the bright spot in our pandemic response. They were amongst the first to shift to remote, they filled the essential public health gap in contact tracing, they launched mental health programs and spun up emergency daycare services and gave PTO to support employees in getting the Covid-19 vaccine. 

What I hope more employers and companies realize is that there aren’t good reasons for a lot of things we see in healthcare. We do those things because that’s just the way it is. But as the pandemic also showed us it doesn’t have to be. With courage, ingenuity and expertise we can reinvent a new healthcare system that makes sense for everyday people and get our companies and our country on the right track.

How do healthcare providers identify things that worked and make them ‘the way we do things’ instead of just ‘the way we did things that one weird year?’

There’s an old saying: “Don’t let a good crisis go to waste”. This is exactly where we stand right now. Very soon things will get back to “normal” in a lot of ways. And I for one can’t wait for that! But there are a lot of things in the healthcare system that changed for the better this past year, and we need to ensure we don’t backslide on those changes. 

I think the most powerful way we can sustain those changes is for us to demand it. By “us” I mean all of us. Employers pay for a substantial amount of the healthcare we receive in this country. If you go to a restaurant and they mess up the order you pay for, what do you do? You kindly ask that they make it again or refund your money. 

Patients are the whole reason we are here, and as patients we need to demand more from the healthcare system. It’s not okay to be told that we don’t know how much a medicine costs or that no you can’t have a copy of your medical records.

With Covid, we got lucky in a way. An outside force moved the system forward. Now it’s up to us to keep that movement going.

What are the hazards of moving to a healthcare model that depends more on being able to connect virtually with care providers? 

One of my deep beliefs is that we need to start with the patient. We need to design solutions for the patient, with the patient, in service to the patient. In this case, that means understanding that virtual isn’t the solution for everyone or for everything. Some people prefer or need in-person care and that’s OK. 

This is why to me the shift is not to virtual care, but to what I’m calling “distributed care”. Distributed care is the notion that care should happen where health happens – at home and in the community. For many people, virtual care is a powerful tool to ensure that care starts there because it’s meeting many of us where we are these days which is on our phones and online. But it isn’t for everyone.

In addition, in designing solutions, we need to think holistically, because post-pandemic digital access will increasingly mean health access. As part of healthcare, we need to start investing in expanding broadband and device access and increase digital literacy. When I built a mobile phone-based text messaging system for helping people with their diabetes on the South Side of Chicago, many of the older patients we had didn’t know how to text when we got started. But we taught them and many told us at the end of the program that knowing now how to text with their grandkids was one of the things they were most grateful for from the program. It’s really amazing sometimes how making changes to how people access healthcare can improve their lives in ways we never expected.