The following is a transcript of the podcast episode:
Rachael Robertson: Hey everybody. Welcome to MedPod Today, the podcast series where 鶹ý reporters share deeper insight into the week's biggest healthcare stories. I'm your host, Rachael Robertson. Today we're talking with Kristina Fiore about several new updates on COVID. Then Cheryl Clark will tell us about some issues with Medicare Advantage advertising. Lastly, Joyce Frieden shares an update on the loaded term 'excited delirium' – and why medical professionals aren't using it anymore. But first, let's get into all things COVID.
Things have been relatively quiet on the COVID front, but some interesting science has come out over the last few weeks. This includes new information about changes in peak viral load relative to symptoms and how long kids are contagious. And of course, the latest COVID variant. Kristina Fiore is here to tell us about all of these developments.
So Kristina, one of the COVID updates generating buzz is a paper in Clinical Infectious Diseases on COVID viral load. Why has this research generated so much discussion among experts?
Kristina Fiore: Hey, Rachael. I had been seeing quite a bit of chatter on MedTwitter, if I can call it that, about this paper, because it suggests that COVID viral load peaks on day 4 of symptoms now, which is quite different from the beginning of the pandemic, when it generally peaked on the first day of symptoms. So as you can imagine, that may have some implications for rapid tests. You may have COVID, but you won't test positive until several days into your symptoms now.
Paul Sax, the editor in chief of Clinical Infectious Diseases, told us that people may want to be a bit more cautious about isolating and not socializing when they start to feel symptoms now. Because even though testing negative on a rapid test suggests you're less likely to be contagious, these new data show that viral load will only increase over the next few days.
Robertson: Hmm, got it. You've also done some reporting on how kids spread COVID. What do the new data say?
Fiore: Yeah, so a small study of 76 kids appearing in JAMA Pediatrics showed that the median duration of infectivity was 3 days. But other studies have shown that adults are typically infectious for about 5 days. So strangely, kids seem to spread fewer germs here, which is just a little weird.
The researchers were able to swab these kids at home 5 times over a 10-day period, and then see if they could grow virus from those samples. By day 5, they had culturable virus in only about 18% of samples. The study co-author, Dr. Eran Bendavid of Stanford, told me that school guidelines might want to take this into account, because he said, "By 3 days, the majority of children are going to be non-infectious. By 5 days, it's going to be a relatively small portion."
And interestingly, they didn't see any difference in infectiousness whether kids had been vaccinated or not. That's consistent in studies with adults, which also found no difference by vaccination status.
Robertson: It's so counterintuitive that kids are less infectious. What about the variants? Where do we stand? There seems to be a new COVID variant popping up every few weeks.
Fiore: Right. So in the CDC variant tracker, a new variant called HV.1 is estimated to be making up about 20% of cases. And that puts it right behind the top and much more established variant of EG.5, which accounts for about 24% of cases.
I spoke with Dr. Shishi Luo. She's the head of infectious diseases at Helix, which is involved with SARS-CoV-2 genetic sequencing, and she said the prevalence of HV.1 is similar in outpatients and in hospitalized patients, so there's no cause for concern at this time. In fact, Dr. Luo was saying that researchers are kind of in a different place with variant monitoring these days. They're not doing neutralization assays for every new variant that takes hold. Instead, they're waiting to see if there's an increase in the prevalence of a particular variant in hospitalizations, because that would indeed signal some kind of increased severity. And that has much more real-world utility than lab data, she said. She also actually called for monitoring all respiratory viruses to help hospitals improve their preparedness and resourcing.
Robertson: Thank you for the COVID rundown, Kristina.
Fiore: Thanks, Rachael.
Robertson: Anyone who's turned on a TV over the last week or so can hear the often shrill ads urging seniors to call the number on your screen to get additional Medicare benefits. Now some members of Congress are losing their patience with sales pitches they say mislead beneficiaries into Medicare Advantage plans that don't meet their healthcare needs. Cheryl Clark is here to tell us more.
Cheryl, let's start with the basics. What issues are Senators raising about these ads?
Cheryl Clark: Well, Rachael, for nearly 2 hours, members of the Senate Finance Committee last week criticized a wide range of problems with these ads. For starters, the ads emphasize 'extra benefits' like debit cards, free transportation, or free meals rather than the out-of-pocket co-pays you have to pay if you get sick. And a big theme was that the telephone numbers displayed on these ads direct callers to agents who may be just selling the callers' information. And while there are some agents and brokers who are honest -- probably a lot of agents who are honest -- another theme was that these agents are not obligated to put the beneficiary's healthcare needs above their own financial interest. One of the witnesses of the hearing said agents are sometimes paid $1,300 – and more sometimes – in bonuses for enrolling a beneficiary in a Medicare Advantage plan for just one year.
Robertson: I can see how that can add up to quite a bit of money. What other kinds of issues were raised at this meeting?
Clark: Well, there's ghost networks. Several speakers mentioned that there seemed to be no oversight of the provider networks the plans are supposed to offer. Transparency about the providers in these networks is essential so beneficiaries can know if visits to their doctors are covered or out-of-network – which they're going to have to pay for. In some cases, patients have reported that their doctor doesn't work at the specified location, or isn't seeing new patients, or isn't actually contracted to be in the network at all.
Robertson: So based on your reporting, what do you think is going to happen next? Is Congress going to take further action?
Clark: Well, who knows. These criticisms of Medicare Advantage marketing tactics have been around for a long time. And CMS, which is supposed to oversee these ads and plan adequacy, has promised to do better. Senator Ron Wyden of Oregon said CMS officials told him 300 of these Medicare Advantage ads didn't pass CMS' muster. Yet, we're still seeing some of these same pitches, like the Joe Namath ad that advises people to call an 800 number. He says, "Millions have called. You should too."
A key issue that we're talking about with seniors is that many of them have debilitating health issues that keep them from comprehending many of the fine points of each complicated plan. With sometimes 100 plans to choose from in some counties, it's really unreasonable to expect all seniors to know which one is the best for them. And some of the Senators noted that well, 31 million people have Medicare Advantage plans now.
Some healthcare systems are becoming fed up with the plans' strategies of denying services to reduce costs. They're just saying 'no' to contracting with MA plans in 2024, forcing large numbers of seniors to drop the plans and go back to traditional Medicare. We'll see if that happens. And if it does, ultimately, it will force the plans to change their ways – if regulators don't do it for them first.
Robertson: Thank you so much, Cheryl.
Clark: Thank you, Rachael.
Robertson: Lastly, we have an update on terminology that another professional group has deemed outdated and imprecise. Earlier this month, the American College of Emergency Physicians, or ACEP, voted to ban the use of the term 'excited delirium.' Joyce Frieden is here in the studio to tell us more about this decision and why it matters.
So Joyce, let's start with what exactly is 'excited delirium'? Is that a legit term?
Frieden: Well, it's a term used frequently by law enforcement officers to describe a suspect who's acting very agitated and is considered a danger to themselves and those around them. The problem is that it's not really an official medical diagnosis, but instead has sometimes been used as a reason for police officers to use lethal or near-lethal force.
One notorious example of 'excited delirium' being given as a reason for law enforcement to resort to violent measures is the case of George Floyd, a 46-year-old Minneapolis man who died after being asphyxiated for more than seven and a half minutes by a member of the police force there. Reuben Strayer, an emergency physician at Maimonides Medical Center in New York City, told me that, "Clinicians don't want to have this diagnostic entity; it's a diagnosis that doesn't exist."
Robertson: Wow, it sounds like the term has a really loaded and dangerous history. How did the emergency physicians group come to make this change?
Frieden: Well, ACEP originally published a paper in 2009 that said 'excited delirium' was a distinctive syndrome. They also said that although there wasn't a diagnostic test for it, it could be identified by its 'clinical features,' including sweating, agitation, unusual physical strength, and police non-compliance.
But in 2021, the college published another white paper which referred to the controversy over the name, and said it would no longer use the term 'excited delirium,' and instead would refer to 'hyperactive delirium with severe agitation.' And then this year at its annual meeting, the college formally voted to remove the term 'excited delirium' from use, a decision which was affirmed by its board of directors. This is significant because the emergency physicians were the last major medical group to make this change. The American Psychiatric Association made this change in 2020 and the American Medical Association followed suit in 2021. And just recently, California passed a law prohibiting use of the term on death certificates.
Robertson: Hmm. What do you think might change now that all of these different groups aren't using the term anymore?
Frieden: The hope is that now that this term has been abolished, the focus will be more on it being a medical condition that can be managed and not just a tool for law enforcement. Michele Heisler, the medical director of Physicians for Human Rights, called this a "major win for police accountability, justice, and public safety." Heisler also said that because no major medical associations will use 'excited delirium' anymore, "law enforcement, clinicians, medical examiners, and the courts should never use this outdated, baseless term to explain deaths in custody or inform first-responder training."
Robertson: Wow, thank you so much for that update, Joyce. We are looking forward to having you on the podcast again.
Frieden: Thanks, Rachael.
Robertson: And that's it for today. If you like what you heard, leave us a review wherever you listen to podcasts, and hit subscribe if you haven't already. Subscribing (on , , or wherever you listen) helps us bring you the news you need from people you can trust. Thank you so much for listening. See you again in 2 weeks.
This episode was hosted and produced by me, Rachael Robertson. Sound engineering by Greg Laub. Our guests were 鶹ý reporters Kristina Fiore, Cheryl Clark, and Joyce Frieden. Links to their stories are in the show notes. MedPod Today is a production of 鶹ý. For more information about the show, check out medpagetoday.com/podcasts.