4A5PModel – Value Addition

Anna Karenina and The COVID-19 Puzzle Part 2 : The Dance of the Stakeholders

“Healthcare is a 5 stakeholder game often with little shared perspective or incentive”

The COVID 19 crisis is not a simple medical problem. It is a complex crisis of logistics, healthcare capacities and stakeholder alignment.

The Capacities represented by the 4A’s are : Access to infrastructure & treatments, Adoption of treatments by the medical community, Awareness among patients and Affordability of the care by patients. (See Anna Karenina and The COVID-19 Puzzle)

What makes it very interesting is that these 4A’s have to do with 5 very powerful stakeholders – Patients, Physicians, Providers, Payers and Policymakers – who are responsible for creating these capacities. And they, more often than not, don’t have their objectives and incentives aligned!

Let’s look at the roles of these stakeholders in the context of the 4A’s discussed earlier.

Providers :

Key Concern: Will I make money for my shareholders?

These are the stakeholders who provide access to infrastructure and supplies for patient care. In the COVID-19 situation these are healthcare institutions as well as pharmaceutical & Medtech companies providing hospital & ICU beds, quarantine lodgings, ventilators, Personal Protective Equipment (PPE), test kits and (as and when we discover them) vaccines, treatments and the like.

This set of stakeholders has one characteristic – they are businesses. And generally they don’t focus on public health other than as a social responsibility activity. They do not build capacity for extremely unlikely events like the COVID-19 crisis nor do they invest R&D dollars to create capacity for the next pandemic. That then becomes the responsibility of another key stakeholder : The Politician

Politicians (Policymaker) :

Key Concern: Will people vote for me during the next election?

Unlike physicians who looks after patients, the politicians’ customers are all people (read voters). The Policymakers are important in healthcare as they set the rules of the game – who can provide healthcare? how many doctors can be educated? can we import manpower from other countries? Which drugs and medical devices can be allowed into the country? How much should the patient pay for treatment? And many other such decisions.

In a pandemic, this becomes the most important stakeholder as people can become patients in days! If that happens all planning falls apart and all healthcare capacity becomes inadequate. We have seen this in the COVID-19 crisis.

Unfortunately usually this is the least educated stakeholder when it comes to medical science. And their primary focus is on looking good & maximizing votes and less on patient health. Therein lies one of the biggest sources of friction and expensive delay.

Some countries are fortunate. These are Countries where the funding and management of healthcare is largely public and quick alignment is possible between policymakers and physicians and quick shared decision making saves vital time. China, South Korea, Singapore, New Zealand, Japan acted relatively fast and implemented measures to redirect capacity faster than others where things are left to private enterprise

Physicians :

Key Concern : How do I treat my patients successfully?

Healthcare practitioners are the key human resources for healthcare. Infection control personnel, nurses, intensivists, support staff are the key defense at the frontline to manage and isolate patients. Again this resource is limited and cannot be built overnight. On the contrary this can be severely depleted in a pandemic if Healthcare workers start getting infected.

Unfortunately in its drive towards productivity and high value surgical procedures, most hospitals today are not built to manage infectious patients. The surgeons are largely those focused on cancer, cardiac, general and orthopedic surgery and physicians are specialized to manage NCDs (Non-Communicable Diseases). In fact most of us were so confident that the era of communicable disease is over that perhaps the physician with the least power or clout in healthcare institutions was the Infectious Disease specialist. I doubt that many high caliber aspiring medical students put communicable disease or public health as their first choice. A serious leadership issue in a pandemic!

Patients :

Key Concern : How do I get better soon without going bankrupt?

The third – and the real “consumer” of healthcare – is the Patient. A lot of healthcare depends on the patients’ behaviour:

Do they adopt the right preventive measures? Do they accept the sick role? Do they seek help from a doctor? Do they follow advice? Does the GP refer them to the correct Specialist?

Each one of these represents a variable that determines the flow of patients to the healthcare system and determines whether or not the system can cope with the demand. In the COVID-19 pandemic this is the most important stakeholder. If they listen and behave according to guidelines – hand washing, social distancing, reporting sick early, quarantining in a disciplined way – the patient flow is low and the healthcare capacity is not overwhelmed. “Flattening the curve” is essentially the attempt to space out sickness so that the healthcare system can cope and provide time by which treatments can be found.

This is once again a stakeholder where the Policymakers can have a big impact. If they take timely actions and send the right messages the patient flow can be managed. If not the pandemic becomes a pandemonium!

This is the place where most countries who have low numbers have directed their initial efforts – with good results. The have “flattened the demand curve” and provided relief to the first two capacities. But they must remember that unless we have a cure, the moment we let things open up – like many states in the US are planning to do shortly – we will again see a rise of patient numbers and overwhelm the first two A’s.

Payers :

Key Concern : How do I fund the healthcare costs?

The fifth stakeholder – and often the most important one – is the payer.

This is a difficult role since no one knows how long the pandemic will last! And its is doubly complicated as the pandemic adversely affects the economy further reducing the ability to pay.

It is quite clear that the COVID-19 pandemic is a complex problem of capacities, multiple stakeholders with often conflicting objectives, lack of clear/effective treatment or prevention measures and a race against time.

This is a not a time for passing the buck or assigning blame. This is time for joint efforts and concerted Global leadership to prevent mankind and economies from collapse.