Q&A: Dr. Bob Wachter and Andy Slavitt on the Past, Present, and Future of COVID-19 and the Transformation of Healthcare

On August 11, 2022, Bob Wachter, MD, spoke with author and public health expert Andy Slavitt, who served as a senior advisor to the White House’s pandemic response team under President Biden, to discuss the latest issues in public health and the response to COVID-19 in the United States. This discussion was part of the Executive Advisory Board meeting hosted by TDC Group. Dr. Wachter is professor and chair of the Department of Medicine at the University of California, San Francisco, and a member of the Board of Governors of The Doctors Company, part of TDC Group.

This interview has been edited for length and clarity. Watch the full interview:

Dr. Wachter: You had COVID recently. You dodged it for two and a half years, and you tested positive a couple of weeks ago. What did you learn from the experience of having it that you didn't know?

Andy Slavitt: A couple things. One is that BA.5 can find a hole in all our stories. The variants are getting more clever, if you could put human terms on these variants. It makes it incredibly hard unless you're going to live a completely risk-free existence, which, except in the most extreme cases, I don't recommend.

The second is, with all of the biotechnology advances that have occurred over the last couple of years, it is very different to have COVID-19 today than it was two years ago. We're talking about bounce-backs. We're talking about very narrow optimization fields as opposed to a couple of years ago when we were talking about overcrowded hospitals and the like.

Dr. Wachter: You’re still being careful, at least you were until you got it. Do you think that's a waste of time and energy at this point? A lot of people, maybe most of you are going to indoor places without masks and think it’s not even worth trying to dodge COVID-19 at this point. What are your thoughts on that?

Andy Slavitt: One of the best things we can do is to adopt a posture that there's no wrong answers for individuals. If you're putting someone else at risk and you're being reckless, I think that's wrong. We have to take a step back and stop sneering, stop with the dirty looks and stop saying, “She's wearing a mask. He's not wearing a mask.” Let it go. But we've got to let people protect themselves the way they see fit.

Dr. Bob Wachter: Do you feel the same way about vaccinations in terms of people casting judgment and trying to push people to get a booster?

Andy Slavitt: The best thing to do is get people the information they needed while directing them to reliable sources they trust and allowing them to hear from experts. That is often a doctor, a pharmacist or someone else in their life. If someone chooses to get the facts and they get true, reliable information and they choose still not to get vaccinated, that's not something that we can force on people.

I think it's important that everybody gets those facts. I do think it's important that in certain situations where you're going to be exposing other people, targeted-vaccine mandates are appropriate at that level. There are three groups of people that I think are called out as being unwilling to get vaccinated for one reason or another. Primarily, though, it's driven by age. Show me a 90-year-old, I'll show you someone vaccinated. Show me a five-year-old, I'll show you someone who's probably not vaccinated. There's a certain logic to that.

Dr. Bob Wachter: Let's move to the present. There are new boosters coming soon, better boosters. Where do you think all that's going?

Andy Slavitt: We're going to release boosters probably at best once a year, and if the formula is better than the last one. It’s incumbent upon us to be as clear about the incremental benefits to each population of getting these new vaccines. A certain segment of the public feels like they were overpromised. We've saved five or six million lives across the globe with vaccinations. We've dramatically decreased hospitalizations. We've done all these wonderful things, but that's not how these vaccines were originally billed to people, and that's not how people hear them. There are a lot of people that are going to look at that and say, “Why should I do it?”

Dr. Bob Wachter: “It’s not that great.”

Andy Slavitt: Hopefully within a year or two, we will see the next breakthrough, which is probably a nasal vaccine, which can prevent you from getting the infection in the first place and be more easily administered. We’ve got 12 nasal vaccines in some stages of the trial. If we do find something that works, you don't need medical professionals to do it. In the meantime, I think we're going to be sort of in this incremental battle with the variance. I don't see the death rate climbing significantly. I don't see hospitalizations climbing massively significantly, but I also don't see it getting a whole lot better until something else changes.

Dr. Bob Wachter: My last COVID question. We haven't talked about long COVID. When my wife got it, my feeling was, “I'm not really worried about dying anymore with four vaccine shots in me, but I am worried about long COVID.” Your chances of dying of it if you're fully vaccinated (boosted), is quite low. How do you think about long COVID in your own personal behavior and as a policy issue?

Andy Slavitt: The best evidence, and the most hopeful, is that a lot of these are lung cases clear up in six months to a year, which is a long time. You see continued clearing. And that's because in part, the vagus nerve system essentially, which is most affected in a lot of these long COVID cases. It takes the longest part of the body to adjust.

The data would say that the chances if you're vaccinated of getting long COVID is about 5%, which is a lot. But the other hopeful sign is that we now have clinics set up. Mount Sinai has a great clinic. There's a bunch of other clinics being set up because we do know how to provide some treatment. From a policy standpoint, we do need to think more about the chronic elements of this disease, not the acute.

Dr. Bob Wachter: Let’s switch to the rest of healthcare. Value-based payment has been just around the corner for about 30 years, and I recently saw some data on how little of physician income and frankly, hospital income is really based on value. What do you think the future is and why has it been so slow?

Andy Slavitt: I think the best thing you can do with these payment models is reinforce the good practice and good behavior and say, “Hey, if you're doing these things right and well and you're taking care of patients and more prevention, we will pay you more for that if you're investing resources in those things.” But it's not a panacea. And healthcare's biggest problem is we've had a series of 20 or 30 silver bullets in the last couple of decades. In the real world, you must respect the fact that there is something sacrosanct at the level of where care exists. If you think you're going to be a marionette and say, “We're going to change the way payment works and therefore transform everything, it doesn't quite work.” And I think what evidence shows is that people who have been practicing integrated team-based care and have been since before these payment models exist, when the payment models came in, they make more money. But it's not because they've changed things.

Dr. Bob Wachter: When you heard about the Amazon purchase of One Medical, what went through your mind? Big deal? Not a big deal?

Andy Slavitt: I think we need more competitors in healthcare. I think we need more innovation in healthcare. I know, there's a lot of people cheered when Apple lost hundreds of millions of dollars when they invested in healthcare. People cheer when Google does.

We need disruptors to be successful. I spend a lot of my time my time funding companies that are trying to innovate in underserved communities and completely transform care delivery, and I feel like that's a good force that we need. If we talk only about policy in this country, and we see the world only through that lens, we get very rigid, slow plotting movements. So why not take advantage of what we do uniquely well in this country? And that's innovation from companies like Amazon who understand different ways people are driven, new ways to bring costs down and new ways manage a supply chain, whether it's in prescription drugs or in primary care. That's good. We need to shake things up.

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