March 19, 2020
Photo by Jeffrey Kuperman
This episode is part of a limited series of conversations with people who are being forced to make difficult decisions in a rapidly evolving situation with many unknowns.
If you have a story you’d like to share, you can email us at firstname.lastname@example.org.
Listen to the conversation below or scroll down for the transcript and more information.
Dan Gorenstein: A quick note before the show. Tradeoffs need your help. We’re putting out a survey today because we want know more about you and the stories you think we should be doing. This survey has been in the works for a while, and now with coronavirus, hearing from you is even more important as we move through this critical time for our health care system and our country. Taking 5 to 10 minutes to do our survey will help us serve you best in these important months ahead and help ensure Tradeoffs sticks around for a second season. You can find the survey at tradeoffs.org/survey.
Okay, on with the show.
Chris Chen: My wife and I, we have our date nights once a week. When you start to reduce and you start to cut corners and you’re not having your date nights, you realize you’re just not as connected. It’s going to be the same thing with our patients.
DG: It’s Thursday, March 19. I’m Dan Gorenstein.
This week on Tradeoffs, we’ve been having conversations with people making difficult choices under the new normal of COVID-19.
Today, from the Annenberg Studio at the University of Pennsylvania, we hear from Chris Chen, CEO of ChenMed.
CC: We take care of the old, the poor and the sick. We provide them with a concierge high-touch care model in which we see patients typically about once a month. And our goal is to substantially reduce their hospitalization rates thereby reducing the total cost of care.
DG: ChenMed is a primary care provider for more than 50,000 Medicare Advantage patients across eight states. Rather than being paid for every service, they get a lump sum for each patient and decide how best to spend it to keep that patient healthy.
CC: Our population is on average, age is about 72 to 74 years old and about 74% of our patients have five or more major chronic conditions. And so our population represents possibly the highest risk population for the COVID-19. And that really encourages us to take this extraordinarily seriously.
DG: When you talk about being a high-touch model, let’s just define that term, high touch. What does that actually look like day to day, pre-COVID 19?
CC: So the typical primary care doctor will take care of anywhere from 2,300-3,000 patients for one primary care doctor. In our patient model, our doctors typically take care of about 400 patients. We also will offer patients door-to-doctor private transportation. We will offer them onsite pharmacy services, onsite specialty services, even holistic care such as acupuncture.
DG: And so now, Chris, here you are. For 30-plus years, you’ve been telling patients when you have a problem, don’t go to the hospital, don’t go to the emergency room, come to the doctor’s office. And now that COVID-19 is here, you’re saying actually don’t come to the doctor’s office. This is a huge shift.
CC: It’s a little bit less than what you think. We tell patients when you get in trouble, call us first and we will figure out what to do. That hasn’t changed. The differences on our end, whereas 80% of the time we would have said, “Hey, come in,” we’re going to say the exact opposite, “Wait, we will come to you.” Maybe we have to bring by a sterilized iPad so we can do a video conversation so we can see what you look like. We need our patients to be healthy, happy and at home. So we are no longer a clinic based model during COVID 19.
DG: What choice or decision are you trying to make as a team to ensure as many patients as possible are getting care at their homes, which is ultimately a much safer place to be right now?
CC: So, our teams, they may need to do shopping for our patients in order to help them stay home. They may need to get on the phone just to have what we call happiness calls. Our patients, they are already very lonely and they used to use our centers as one of the best outlets to get over loneliness. They can play bingo, do tai chi, do salsa classes. Their doctors hug them and and the staff, you know, love on them. And they’re not going to have that now. And so we’re going to have to figure out how to do that virtually.
DG: Chris told me he expects this pivot to virtual will play out differently for different patients. He expects the company will end up developing two approaches: one for the less vulnerable, people like one of his patients, a woman he’s calling Mrs. Rogers.
CC: She lives in south Florida. She’s 69 years old. She’s got hypertension, diabetes and she’s got atrial fibrillation, but in general she’s a pretty stable patient. She’s very active. So here’s the big tradeoff for her as we pivot to virtual: She’s not going to have her tai chi classes. She’s going to get socially distanced. We’re going to start having calls with her, but I’m not going to be able to see her and see what she looks like. And I don’t know for how long. It could be for two months. It could be for longer. We’re not going to feel as connected with with Mrs. Rogers. We know that. So we’re going to have to look for resourceful ways to try and stay as connected.
DG: Meanwhile another of Chris’ patients, a man he calls Mr. Smith, has more advanced heart failure, severe diabetes and poor kidney function. He’s a lot more vulnerable than Mrs. Rogers.
CC: We have to go to his house. We would normally see Mr. Smith, we see him once a week. We’re probably gonna have to go to his house every other week and going forward, we’re going to have to get him on the phone once, maybe twice a week. But for Mr. Smith, we gotta be there.
DG: Are you concerned that some of your patients do not have the resources, the disposable income, to be able to take care of themselves in this new way? Do you think that in some way, you guys are going to end up having to spend some money on these people in a way that you haven’t in the past?
CC: So we were concerned about their financial barriers to care or barriers to health prior to the COVID-19. So, yes, we are very concerned. We’re going to have to spend more money.
DG: What are you going to have to spend money on?
CC: We may have to spend money on groceries. I’m hearing about large toilet paper shortages. Our seniors can’t not have toilet paper. So we’re going to have to solve for simple things like that. We can’t have them hunting around town looking for toilet paper.
DG: What’s a difficult choice you anticipate you and your staff are going to have to make over the coming weeks as our hospitals see more and more COVID-19 patients?
CC: COVID-19 is highly contagious. And so it’ll be in the air in these hospitals. And so if we are not able to keep Mr. Smith healthy, happy and at home, we have a choice to make. Do we do what we can to create some sort of hospital environment at home that keeps him minimally exposed to COVID-19, or do we send him to a hospital that is going to be extremely infectious with COVID-19 and run the risk of him getting COVID-19? So these are all substantially difficult decisions that have ethical implications. We understand that there is a limited number of beds in this country. We understand that the disease is highly contagious, and it really depends on our ability to contain that disease. We are going to watch this very closely. We hope that we don’t have to make those type of tradeoff discussions, but we know that we’re going to have to.
DG: Chris Chen, thank you very much for taking the time to talk to us.
CC: Thank you.
DG: We’ll be bringing you more stories in the coming weeks from people dealing with hard decisions.
I’m Dan Gorenstein and this is Tradeoffs.
Additional Resources & Credits
COVID-19 Information and Updates
Seniors and COVID-19
Q&A: How to care for the elderly without putting them at risk of coronavirus (Shafaq Zia, STAT, 2020)
Seniors are the most vulnerable to coronavirus. You can help protect them. (Lateshia Beachum, Washington Post, 2020)
How to Protect Older People From the Coronavirus (Katie Hafner, New York Times, 2020)
Stores designate shopping time for seniors vulnerable amid coronavirus: Safeway, Whole Foods, Target and more (Kelly Tyko, USA Today, 2020)
For millions of low-income seniors, coronavirus is a food-security issue (Annelies Goger, Brookings, 2020)
Music in this episode by Miscellaneous, courtesy of Badman Recording.