Live Nation’s Rapino Talks Reopening and Renegotiating the Concert Business

At the end of Live Nation’s first-quarter earnings call on Thursday, CEO Michael Rapino fielded questions about the company’s finances, but mostly, as expected, about when and how the concert industry might begin to reopen from coronavirus lockdown.
Not surprisingly, the company’s earnings report revealed challenges, even though the lockdown began in the last three weeks of the quarter: Revenues were down 20% year-on-year, concert revenue was down 25% (from $1.318 billion to $993.4 million) ticketing was down 16% and, significantly, fan attendance was down 6.2%.
And while Live Nation alone has seen some 9,000 of its concerts impacted by the coronavirus pandemic, the company’s main theme of the day has been the fact that some 90% of fans are holding onto their tickets rather than seeking a refund. The executives have not mention that the number was doubtless affected by the company’s shifting refund policy — which was solidified less than two weeks ago — but they have taken it as a resounding vote of confidence in the future of the industry and fans’ confidence that the shows are worth waiting for.
Asked for his longview on business in general, Rapino said, “In a survey we just posted, we talked to 10,000 casual and ongoing ticketbuyers and the data is pretty compelling: 90% of fans are saying ‘I can’t wait to get back to the show,’ and I think our refund rate says everything — we’re running somewhere between a 5-10 refund rate right now on a global basis, that’s much lower in Europe [which is farther ahead in the recovery process], and that’s not out of line for when we reschedule a traditional tour [under normal circumstances]. Now we’re just going to [watch] the science and see when we can back out there on a safe manner.
Asked how long the company can continue to operate with an extended shutdown, Rapino directed the question to president Joe Berchtold. “We have $870 million in available cash, $900 million untapped, so that’s $1.7 billion in untapped liquidity to start with. So we can go through this year without doing any shows at scale without any concern, even though we’re not likely to have a huge volume of shows,” he said. “And in the fourth quarter we’ll have ticket sales in some large scale for next year — we’re already seeing the NFL schedule announced today and most teams are going on sale with their tickets, so that will help drive some of our ticketing and sponsorship businesses. Getting through this year without any additional liquidity is not a concern.”
Asked how the company has dealt with the shifting nature of rescheduling concerts, Rapino replied, “We have a lot of shows, and looking at this as a glass half-full, thankfully our shows are not time-dependent: Fans wanted to see Billie Eilish in March, but they’ll wait till October or until February, because the average customer goes to two-and-a-half shows a year. The industry has never come together this well, agents, artists, buildings, promoters, managers, we’re all in the same boat, and we’re all saying, ‘How do we move availabilities?’ The only challenge we’ve had with availabilities, and part of the reason we had to [delay] the refund policy, is the sports leagues — we need to understand what’s going to happen in arenas in the fall.”
Immediately following that question, Rapino was asked how much the company has renegotiated contract terms with artists on guarantees for these rescheduled shows (as detailed by Variety last month).
“It’s been a unique time but we’re all in this together,” he replied, “and I would say artists, agents and managers have been incredibly supportive.
“The reality is,” he continued, “in ‘20 and ’21, the promoter can’t take all the risk on the business, as we historically have. We need to share some of that, especially refunds on the guarantees. So while we don’t want to get into the what and how of the deals, we absolutely are getting great latitude from the artists and agents to look at the traditional business of high guarantees and all of our risk, and to help share that risk, going into ‘20 and ’21, to get the shows back on the road and help us absorb it, and not take all of the [financial burden] of refunds, sales, sponsorship, food, beverages and unknowns for the next 6-12 months. They’re helping to share some of that risk to help us get back and scale fast, and not worry about losing money on the show.”
Finally, Rapino was asked about the strategy and timing for resuming something resembling normal touring.
“Our global diversity is our greatest strength, it always has been, and unlike sports, we have very diverse sizes of shows: We did 15,000 club and theater shows in 40 countries last year,” he said.
“So over the next six months, we’ll be starting slow and small, focusing on the basics and testing regionally. But whether it’s in Arkansas” — which he may have mentioned because a socially distanced concert is scheduled there for May 15 — “or [another] state that is safe, secure and politically fine to proceed in, we’re going to dabble in fan-less concerts with broadcasts and reduced-capacity shows, because we can make the math work,” he continued.

“There are a lot of great artists that can sell out an arena, but they’ll do higher-end theaters or clubs. So you’re gonna see us [gradually reopening] in different countries, whether it’s Finland, Asia, Hong Kong — certain markets are farther ahead [in the recovery process]. Over the summer there will be testing happening, whether it’s fan-less concerts, which offer great broadcast opportunities and are really important for our sponsorship business; drive-in concerts, which we’re going to test and roll out and we’re having some success with; or reduced-capacity festival concerts, which could be outdoors in a theater on a large stadium floor, where there’s enough room to be safe.
“We think in the Fall, if there are no second hotspots, you’ll see markets around the world [reopening] — Europe, specifically, has talked about opening up 5,000-plus [gatherings] in September. And on the venue side, we’re dealing with federal, the White House, every government body you can imagine, and we’ve got a great task force around what we have to do with the venue to make you safe.
“So I think in the Fall you’ll see more experimenting and more shows happening in a theater setting, into some arenas. And then our goal is really to be on sale in the third and fourth quarters for 2021 at full scale.”
Live Nation’s Michael Rapino Talks Reopening and Renegotiating the Concert Business

Critics Castigate Mayor De Blasio’s New ‘Testing and Tracing Corps’

Mayor Bill de Blasio’s launch of the city’s new Testing and Tracing Program is alarming both the political and public health establishments.
The mayor said the program will ramp up to 50,000 coronavirus tests a day and build a corps of 5,000 to 10,000 contact tracers in the coming months.
But he’s drawing fire for putting the nation’s largest public hospital system, NYC Health + Hospitals, in charge of the large-scale initiative, rather than the nation’s preeminent municipal health department.
“It fits the sheer operational scope and capacity of Health and Hospitals,” de Blasio said during the announcement on Friday. “They provide health care directly to people, and so they understand what it means to put together a process that’s going to be not just testing a lot of people and tracing a lot people, but then ensuring a lot of people get to their hotels, get the health care they need, all the pieces.”

He said officials from the city Department of Health and Mental Hygiene would be “deeply integrated into this effort” and would be “coordinated … under the rubric of Health and  Hospitals.”
Criticism, though, has been swift and strong.
“This plan raises a lot of alarm bells,” City Council Speaker Corey Johnson wrote in a news release. “Contact tracing is a core function of the Department of Health and Mental Hygiene, and has been for years. This is a distraction when we need to be focused on battling this virus.”
Johnson said the Council would hold a hearing in the coming weeks “to get to the bottom of this and chart the best path forward.”
Other Council Members and their counterparts in the state legislature were even more harsh.
“It is startling that months into the worst public health crisis our City has ever faced, the de Blasio administration is undertaking a bureaucratic reshuffling that creates new and unnecessary obstacles for the critical, complicated and sensitive work of contact tracing,” wrote the chairs of the City Council, State Assembly and State Senate committees on health and hospitals, in a rare joint letter.
“There is no doubt that DOHMH should be the lead here,” wrote Council members Carlina Rivera and Mark Levine, Assemblyman Richard Gottfried, and Senator Gustavo Rivera. “This is what the agency is built for and its expertise and a century and a half of experience in contact tracing cannot be duplicated. We call on Mayor de Blasio to reconsider this decision and to ensure that the vital work of contact tracing is under the unified leadership of our world-class health department.”
City Comptroller Scott Stringer also released a letter asking for the mayor to reconsider.
“Tasking H+H with leading the City’s ‘Test and Trace Corps’ is both contrary to historical precedent and to the established expertise already housed within DOHMH,” Stringer wrote. “At a time when H+H should be focused on providing medical care, especially if infections spike in coming months, operating a new program could further strain their administrative and managerial capacity.”

NYC Health and Hospital offer walk-in COVID-19 testing Steve Sanchez/Pacific Press/Shutterstock

The mayor’s decision to tap Health + Hospitals officials to lead the effort has rankled members of the city’s Health Department, according to a New York Times story. The department has traditionally handled contact tracing for diseases such as tuberculosis, H.I.V. and Ebola. De Blasio has reportedly butted heads with Health Department officials, who were said to have wanted him to treat the crisis with more urgency in the early weeks.
On Friday, the city health commissioner, Dr. Oxiris Barbot, who has normally attended the mayor’s press briefings through video conference, was absent. Asked about why she was not there, de Blasio said Friday’s briefing topics did not pertain to her.
Pressed on why he was choosing the public hospital system over his closest health experts, the mayor said that testing and tracing represented a vastly larger undertaking that would require more resources and the ability to execute contracts more quickly than a traditional agency.
“Health and Hospitals, also, because of its nature as an independent agency, is able to move very quickly—major contracts, make things happen in terms of personnel operations faster than traditional mayoral agencies,” de Blasio said.
Stringer said the mayor currently has all the emergency authority he needs to fast-track contracts via the Health Department.
Public health experts said they were gobsmacked.
Health and Hospitals, staff and leadership, and have phenomenal infectious disease doctors and epidemiologists that think about diagnosing and treating patients,” said Lorna Thorpe, professor of epidemiology at NYU and the city’s former Deputy Commissioner of Health. “But when I think about what’s needed for contact tracing, it’s the Health Department that thinks about the role of community transmission; that has the relationships with the state, the CDC, other health departments; that has the playbooks on how to do contact tracing; that has the best practices already baked into their DNA.”
She said it’s a little bit like putting officials from a veterinary hospital in charge of a zoo.
“Clearly, they both know a lot about animals, and there’s a tremendous amount of overlap in expertise between the two,” she said. “But running a hospital and running a zoo are two pretty different things. So, I’m just not clear why the decision was made for this transition of responsibility.”
Denis Nash, an epidemiology professor at the CUNY Graduate School of Public Health and Health Policy, said he thought putting the hospital system in charge would slow down deployment of contact tracing, because they lack infrastructure and experience.
“It’s incredibly important to get this off the ground and get it off the ground fast,” Nash said. “And I can’t see how anyone could ever do it as quickly or as well as the New York City Health Department.”
Nash said he was concerned about the people from Health + Hospitals being put in charge, Dr. Ted Long, the system’s Vice President of Ambulatory Care; Dr. Andrew Wallach, who plays a similar role at Bellevue Hospital; and Jackie Bray, the director of the Mayor’s Office to Protect Tenants
“As someone who’s been doing public health in this city for four decades, I have no idea who they are,” Nash said. “They may be great administrators or health care providers and leaders in the health care system. But putting people with no public health experience in charge of this effort is just really wrongheaded. I worry that it’s another one of these huge missteps by our mayor.”
Asked about reports that Health Department officials were unhappy with the move, de Blasio said, in effect, that’s their problem.
“My job is not to ensure people’s happiness,” he said. “This is about effectiveness. It’s about serving people. This is about fighting a pandemic. I’m not going to get overly focused on anyone’s personal opinions in the midst of that.”
https://gothamist.com/news/critics-castigate-mayor-de-blasios-new-testing-and-tracing-corps

Med Schools Bringing Back Students, Flooded With Applicants

Severely disrupted by the COVID-19 pandemic, medical schools are gearing up to reopen in the near future.
At a press conference on Friday, officials of the Association of American Medical Colleges (AAMC) provided updates. Two thirds of the 155 accredited US medical schools recently provided the AAMC with information on their plans to reopen, said Alison Whelan, MD, chief medical education officer of the association.
In mid-March, nearly all medical schools removed students from direct patient care in order to flatten the COVID-19 curve and conserve personal protective equipment (PPE). Students have continued to take courses online, but that alone falls short of the requirements for graduation.
Of the medical colleges that informed the AAMC of their plans, 15% plan to restore students to clinical care by the end of May, 55% by the end of June, and 77% by the end of July. Fifteen percent of the schools are finalizing their plans, Whelan said.
“Returning students to direct patient contact, like reopening communities, is a delicate balancing act,” she noted. “Schools want to get students back to patient-centered learning, so they can continue progress toward on-time graduation in 2021 and 2022. But critical considerations, including patient safety and not triggering a second surge, must be taken into account.”
Medical colleges must also ensure that there are opportunities for meaningful learning, Whelan said. “In areas where there are a lot of COVID patients, the physicians who typically supervise these medical students may have zero time and zero capacity to teach. In those areas where elective surgeries and routine office visits are severely restricted, there may be very few patients to learn from.”

Internships on Track, In-Person Instruction on Hold

Whether or not medical schools will resume classroom instruction in the fall will depend on the local severity of the pandemic, as well as on state and national guidelines, Whelan noted. “If there are recommendations for social distancing, they won’t be bringing students back into large classrooms.”

Moreover, she said, there’s no immediate need for in-person instruction “because the medical schools have been very successful with online learning. So they’ll go back when they think it’s safe, but there’s not a huge urgency for that because virtual and online distance learning has been found to be effective.”
Asked whether medical school graduates will start their internships on July 1, as usual, Whelan said, “The expectation in the medical community is that these new students do need to enter their residency programs in a timely fashion.”
To make that happen, she said, a workgroup that includes the AAMC has been discussing key issues, such as the transportation of students to hospitals in other areas and whether they need to be quarantined before they start.
Meanwhile, students from more than 20 medical schools have been given the opportunity to graduate early in order to join the fight against COVID-19. “The vast majority of those students are working in their local hospitals and were granted special licenses for supervised practice,” Whelan said.

Grim Present, Bright Future

Despite the gloom and doom enveloping physicians at present, the AAMC has seen signs that many idealistic young people are still eager to go into medicine.
On May 6, when the AAMC opened up MCAT registration, which had been postponed in March and April because of stay-at-home orders, 62,000 people registered online, up from 10,000-12,000 on the first day of registration last year, said Gabrielle Campbell, chief services officer of the AAMC.
The system initially crashed under the load but was fixed in a few hours. All 62,000 applicants successfully registered and were able to choose the time and place for their tests.

The registration for the American Medical College Application Service, which initiates applications to medical schools, began on March 4. In the first 3 days, Campbell said, there was a 50% increase in the number of people who started their applications compared with the same period last year.
“This doesn’t necessarily mean more people will be applying in this application year, but we’re cautiously optimistic about it,” she said.
David Skorton, MD, president and CEO of the AAMC, likewise said, “We’re very encouraged by students’ strong interest in registering for the MCAT exam. We’re starting to see hints of strong interest in people entering the field overall, even though it’s quite early in the medical school application process. That is a great sign if that preliminary trend continues, because our country needs more doctors.”

How Hospitals Will Reopen

Medical education, of course, is inseparable from hospitals, specifically the academic medical centers where most students and residents are trained. Treating patients with COVID-19 is currently taking center stage in most hospitals, and many states have ordered healthcare facilities and physicians to delay elective or nonurgent procedures.
However, the Centers for Medicare and Medicaid Services in mid-April issued recommendations for reopening facilities to provide nonemergent care to patients without symptoms of COVID-19. A number of states have also relaxed their prohibitions to some extent.
At the AAMC briefing, Janis Orlowski, MD, chief healthcare officer of the association, said, “As we talk to medical leaders, we’re hearing that some urgent cases have become more emergent. Those are the first cases we’ll start to see in the hospitals.”
However, she noted, hospital leaders have said in conference calls that they plan to reopen their institutions slowly. For example, Indiana University Health is planning to increase the number of patients in its hospitals by no more than 25%. “They will stop at that point and reassess before opening up further,” Orlowski said.
Among the concerns on the minds of hospital executives, she said, are the local burden of the disease, whether there is adequate testing and PPE, and whether there are enough ICU beds available “in case they have to pivot. Hospitals have to be prepared to pivot as needed if there’s a local or national surge [of COVID-19].”
https://www.medscape.com/viewarticle/930256#vp_1

FDA OKs new use of AstraZeneca and Merck’s Lynparza

AstraZeneca (NYSE:AZN) and collaboration partner Merck (NYSE:MRK) announce the FDA nod for the use of Lynparza (olaparib), combined with bevacizumab (Roche’s Avastin), as first-line maintenance treatment of adult patients with advanced epithelial ovarian, fallopian tube or primary peritoneal cancer who are in complete or partial response to first-line platinum-based chemo and whose cancer is associated with homologous recombination deficiency-positive status defined by either a deleterious or suspected deleterious BRCA mutation, and/or genomic instability.

The approval is the sixth in the U.S. for the PARP inhibitor.

https://seekingalpha.com/news/3572389-fda-oks-new-use-of-astrazeneca-and-mercks-lynparza

FDA approves Quidel’s antigen test

Quidel (NASDAQ:QDEL) lands emergency use authorization from the FDA for a new antigen test that could help rapidly screen people for COVID-19.

Sofia 2 is described as utilizing the original Sofia fluorescent chemistry design while improving upon the graphical user interface and optics system to provide an accurate, objective and automated result in 15 minutes.

The FDA says the antigen tests can be produced at lower prices than PCR tests and potentially be scaled up to test millions of Americans a day, although there is a warning that they also have a higher chance of false negatives.

Shares of QDEL have doubled over the last 90 days.

https://seekingalpha.com/news/3572388-fda-approves-quidels-antigen-test

Study Backs Cytokine Targeting for COVID-19 Therapy

Survival rates were significantly higher, though mechanical ventilation-free survival did not differ between hospitalized COVID-19 patients treated with high-dose anakinra (Kineret), an interleukin-1 receptor antagonist, and patients receiving only standard treatment, a small retrospective study in Italy found.
While cumulative survival at 21 days was significantly higher for COVID-19 patients in the anakinra group versus historical controls receiving only standard care (90% vs 56%, respectively, P=0.009), the difference in mechanical ventilation-free survival was non-significant between groups (72% vs 50%, P=0.15), reported Giulio Cavalli, MD, of Vita-Salute San Raffaele University in Milan, and colleagues, writing in The Lancet Rheumatology. The study may have been underpowered for the latter outcome, with 29 patients receiving anakinra and 16 controls.
The authors emphasized that treatment with high-dose anakinra, which is used to treat autoinflammatory disorders such as rheumatoid arthritis, was “safe and associated with clinical improvement in 72% of patients,” including improvements in respiratory function and reductions in C-reactive protein, a marker of inflammation.
“Our study is the first to suggest that a high dose of the arthritis drug anakinra may be able to block the overreaction of the immune system caused by COVID-19,” Cavalli said in a statement.
Indeed, the authors cited a previous phase III trial that found anakinra in sepsis “showed significant survival benefit in patients with hyperinflammation.” They added that compared with other cytokine-blocking agents, “anakinra has a remarkable record of safety and a short half-life, which allows prompt discontinuation.”
An accompanying editorial by Kate Kernan, MD, and Scott Canna, MD, both of Children’s Hospital of Pittsburgh, noted prior research indicating associations between inflammatory biomarkers and development of ARDS and death in COVID-19 patients.
“These and other emerging data rightly focus more attention on the host inflammatory response and might herald a shift in how we approach the host-virus relationship,” Kernan and Canna wrote.
They also noted that the higher 21-day survival rate was “accompanied by a more rapid and complete improvement in C-reactive protein” in the anakinra group, characterized as “remarkable in a condition with 30-50% mortality in patients who develop clinical ARDS.”
And while the editorialists noted that both ferritin and C-reactive protein values were higher in this cohort than in other hospitalized adults with COVID, they “correlated better with the risk of mortality, and, thus, might help identify a subset of patients who are most likely to benefit from anti-inflammatory treatments.”
Cavalli and colleagues examined consecutive adult patients with COVID-19, moderate-to-severe acute respiratory distress syndrome (ARDS), and hyperinflammation managed with non-invasive ventilation outside of the intensive care unit. Standard treatment was 200 mg hydroxychloroquine twice daily and 400 mg lopinavir and 100 mg ritonavir twice daily. Patients in the anakinra group received high-dose anakinra 5 mg/kg twice daily.

From March 17 to March 27, high-dose anakinra was given to 29 patients on top of standard treatment. Median patient age was 62, over 80% were men, and over 85% had severe ARDS. They were compared with a historical cohort of 16 patients who did not receive anakinra. Seven other patients received low-dose subcutaneous anakinra, but their treatment was stopped after 7 days due to lack of improvement.
After 21 days, 21 patients in the high-dose anakinra group had improvements in respiratory function compared with 10 of 16 historical controls. Five patients versus one patient required mechanical ventilation, respectively, and three patients in the anakinra group versus seven in the comparison group died.
Notably, in the anakinra group, 13 were discharged from the hospital, while three no longer needed supplemental oxygen, three were receiving low-flow supplemental oxygen, and two no longer had ARDS. In the comparison group, seven were discharged from the hospital and one was still receiving low-flow supplemental oxygen.
Treatment was continued for adverse events in seven patients after a median of 9 days, with four having bacteremia, specifically Staphylococcus epidermidis, while three had increases in serum liver enzymes. Two patients in the comparison group had bacteremia and five had increases in liver enzymes, as well.
Three patients in the anakinra group and two in the comparison group had thromboembolism attributed to COVID-19 pathogenic events.
Noting the many limitations to the study, including its small size, its retrospective nature, use of historical controls, and restriction to a single center, Kernan and Canna said the findings should be interpreted as “exploratory” but still merit further research.
“In view of the biological plausibility of anakinra, the pharmacokinetic and safety profile of the drug, and a growing body of positive experience in autoinflammation and cytokine storm, these data are promising and support [prioritizing] this approach in the planning and [enrollment] of [randomized] controlled trials,” the editorialists wrote.
https://www.medpagetoday.com/infectiousdisease/covid19/86407

Urge to Build More Intensive Care Unit Beds and Ventilators: Intuitive but Errant

Throughout the coronavirus 2019 (COVID-19) crisis, much attention has been devoted to the fraught question of how to allocate intensive care unit (ICU) beds and mechanical ventilators if the supply of these resources is insufficient to provide them to all patients considered to be in need. Contemplating such tragic choices naturally conjures thoughts that we might have avoided these dilemmas by rapidly manufacturing new beds and ventilators at the first sign of a looming pandemic, or by rapidly converting existing beds and machines such that they could be used to expand the supply of critical care resources. These ideas stem from the natural human heuristic and conventional clinical ethos to mount unstinting effort toward saving the lives of those who fall ill. These views are also psychologically reinforced by the instinct to deploy aggressive medical technology to win the “war” against the pandemic.

Indeed, the instinct to save the lives of the desperately ill, which exemplifies the “rule of rescue” (1), is so intuitively powerful as to make it hard for humans to even consider competing approaches. No one would condone a response to the COVID-19 pandemic that did not include using the nation’s full supply of critical care resources. However, the drive to build even more beds and ventilators will do more to assuage public anxiety and outrage than to reduce overall mortality, owing to both the poor outcomes among patients with COVID-19 receiving mechanical ventilation and the diversion of clinical workforces.

We argue that supply-side investments in critical care in the midst of the pandemic would not substantially improve population health in the short term and would worsen it in the long term. As psychologically disruptive as it may be to consider not expanding the critical care supply, such expansions would magnify the already considerable skew of U.S. health care toward intensive care. We further argue that even modest improvements in public health measures, such as physical distancing (which might be promoted by infomercials featuring sports or movie stars) and training more health care workers to become expert in serious illness communication, would be more effective than investments in critical care for improving short-term population health.

Before COVID-19, the United States had more ICU beds and ventilators per capita than nearly any other country (2). Indeed, an assessment of ICU occupancy and ventilator use revealed that during noncrisis times, the United States has a glut of critical care resources. In any given hour, only two thirds of ICU beds are occupied and only one third are occupied by patients receiving mechanical ventilation (3). Although these numbers have been starkly different during the COVID-19 crisis, they highlight our substantial existing capacity to care for those most likely to benefit from critical care.

As a result of this extant capacity, adding ventilators and ICU beds would make critical care delivery less efficient. Indeed, many studies have shown that when ICU beds are tight, critical care is increasingly allocated to patients who benefit from it, without increasing overall mortality (4–6). Building more beds and ventilators would offset these efficiencies of scarcity, increasing the already high mortality rates observed among patients with COVID-19 who require mechanical ventilation (7). Although the total number of survivors might increase to an extent, so too would the burden of chronic critical illness.

The second reason that building more ICU beds and ventilators will not deliver the hoped-for life savings is that they are not the scarcest resources during the current pandemic. Most projections indicate that ward beds and healthy critical care clinicians will be more scarce than ICU beds or ventilators (8). Thus, expansions to the ventilator supply may carry adverse consequences for population health by requiring the redeployment of non–critical care clinicians and beds, such that non–critically ill patients may become critically ill and even die.

Such workforce redeployment reveals a third reason to doubt the benefits of increasing critical care capacity: the adverse consequences for clinician effectiveness and well-being. Although building beds and ventilators may prevent the moral distress that certain clinicians would otherwise feel in having to make life-or-death choices about allocation, redeployment would likely increase burnout among clinicians who are unaccustomed to working in critical care environments. Asking physicians who have not contemplated a ventilator since medical school to manage the sickest ventilated patients, particularly without adequate personal protective equipment, could adversely affect the long-term health of the clinical workforce.

Fourth, every dollar spent building more ICU beds and ventilators would save more lives if instead spent on more testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), contact tracing, and personal protective equipment, or on promoting adherence to physical distancing. Indeed, using the COVID-19 Hospital Impact Model for Epidemics (8), we projected that even a doubling of the ventilator supply would not save as many lives as a 40% decrease in physical contact. And the sooner in a region’s epidemic trajectory such policies were implemented, the greater the benefit of distancing, and the less the benefit of ventilator production.

Other, less obvious initiatives might also yield greater benefits to short-term population health. For example, palliative care clinicians and others with excellent skills in serious illness communication and symptom management are among the scarcest of all health care resources (9). Thus, COVID-19 leads us to utilize our preexisting glut of critical care resources, but it also magnifies the preexisting shortage of palliative care clinicians. Although expanding the palliative care workforce will not save lives, it may offer a societal investment superior to that of critical care expansion, given the resultant benefits in quality of life for patients and their family caregivers.

Finally, in a nation in which nearly 1% of gross domestic product is already allocated to critical care, further growth should be approached with extreme reticence. History suggests that any COVID-19–induced expansions to the critical care supply may unfortunately be hard to reverse once the pandemic ends. Supply-induced demand—or, “if you build it, they will come”—was a hallmark of U.S. critical care well before COVID-19 (10). Having experienced this pandemic, we will find it difficult to shrink the critical care supply for fear of being underprepared for the next pandemic.

Our natural moral reasoning precludes us from withholding available critical care, even from patients with remote chances of benefiting from it, and the same reasoning motivates us to expand critical care during times of need. But even if building more ICU beds and ventilators neither crowded out opportunities for other more effective initiatives nor exacerbated critical care excesses in the future, it would ultimately represent the triumph of deeply human instincts over optimal policy.

References

1. Jonsen AR. Bentham in a box: technology assessment and health care allocation. Law Med Health Care. 1986;14:172-4. [PMID: 3645228]
2. Wunsch H, Angus DC, Harrison DA, et al. Variation in critical care services across North America and Western Europe. Crit Care Med. 2008;36:2787-93, e1-9. [PMID: 18766102] doi:10.1097/CCM.0b013e318186aec8
3. Wunsch H, Wagner J, Herlim M, et al. ICU occupancy and mechanical ventilator use in the United States. Crit Care Med. 2013;41:2712-9. [PMID: 23963122] doi:10.1097/CCM.0b013e318298a139
4. Wagner J, Gabler NB, Ratcliffe SJ, et al. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159:447-55. [PMID: 24081285] doi:10.7326/0003-4819-159-7-201310010-00004
5. Wagner J, Halpern SD. Deferred admission to the intensive care unit: rationing critical care or expediting care transitions? Arch Intern Med. 2012;172:474-6. [PMID: 22412077] doi:10.1001/archinternmed.2012.114
6. Anesi GL, Admon AJ, Halpern SD, et al. Understanding irresponsible use of intensive care unit resources in the USA. Lancet Respir Med. 2019;7:605-612. [PMID: 31122898] doi:10.1016/S2213-2600(19)30088-8
7. Richardson S, Hirsch JS, Narasimhan M, et al; Northwell COVID-19 Research Consortium. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020. [PMID: 32320003] doi:10.1001/jama.2020.6775
8. Weissman GE, Crane-Droesch A, Chivers C, et al. Locally informed simulation to predict hospital capacity needs during the COVID-19 pandemic. Ann Intern Med. 2020. [PMID: 32259197] doi:10.7326/M20-1260
9. Courtright KR, Cassel JB, Halpern SD. A research agenda for high-value palliative care. Ann Intern Med. 2018;168:71-72. [PMID: 29132161] doi:10.7326/M17-2164
10. Gooch RA, Kahn JM. ICU bed supply, utilization, and health care spending: an example of demand elasticity. JAMA. 2014;311:567-8. [PMID: 24408679] doi:10.1001/jama.2013.283800

    https://annals.org/aim/fullarticle/2766004/urge-build-more-intensive-care-unit-beds-ventilators-intuitive-errant