Keckley Poll: The Public is Fed Up with the Health System…so what else is New?

In the 4Q 2023 Keckley Poll*, signals about the public’s perception of the U.S. health system are clear:

• The majority think the system is heading in the wrong direction and needs fundamental change. They believe it puts its profits above patient care.
• Trust and confidence in the health system’s major institutions is low: none enjoys “a great deal” of trust from a majority. And few expect politicians to address the system’s issues because it’s too complicated/politically risky.

These are the topline findings of polling conducted last week by Centiment for The Keckley Report. The high-level data are below. Subsequent analyses will explore comparisons across demographic subgroups as well as insurance and health status but there’s clear direction to consumer concern about how the health system is performing.

• 69% think the system is fundamentally flawed and in need of major change vs. 7% who think otherwise.
• 60% believe it puts its profits above patient care vs. 13% who disagree.
• 74% think price controls are needed vs. 7% who disagree.
• 76% think politicians avoid dealing with healthcare issues because they’re complex and politically risky vs/ 6% who think they tackle them head-on.
• And no major institution in the system enjoys “a great deal” of trust and confidence in the public’s view of their ability to “develop a plan for the U.S. health system that maximizes what it has done well and corrects its major flaws.” Hospitals and physicians hold a slight edge over the federal government, retail health and health insurers but none enjoys a solid majority of public support as the system problem solver.

% Agree with each statement	Strongly Agree	Agree	Mixed Feelings	Disagree	Strongly Disagree
The U.S. health system is heading in the right direction.	11	17	43	13	13
I believe the U.S. health system is fundamentally flawed and needs major change.	33	36	24	6	1
The U.S. health system puts its profits above patient care.	30	30	27	9	4
I believe the federal government should impose price controls for hospital services, prescription drugs and insurance premiums.	39	35	19	4	3
I believe the tax exemption given not-for-profit hospitals is justified by the community benefits they provide.	18	37	34	7	3
Having health insurance that’s affordable and comprehensive is essential to financial security	46	37	13	2	1
The majority of physicians care more about caring for their patients more than their income.	17	32	38	12	5
I am confident in my ability to navigate the U.S. system when I have a problem.	14	38	32	11	5
Most politicians avoid healthcare issues because solutions are complicated and they fear losing votes.	33	43	18	4	2

 

How much trust and confidence do you have in … to develop a plan for the U.S. health system that maximizes what it has done well and corrects its major flaws?

% Trust and Confidence	A great deal	Some	Not much/none
Insurance Companies	18.4	43.2	38.4
Hospitals	27.4	51.9	20.7
Physicians	32.5	52.9	13.6
Federal Government	14.2	42.4	43.5
National Retail Health Companies	21.3	50.9	27.8

 

My take

These findings are consistent with studies by Gallup, Pew and the Kaiser Family Foundation that have shown erosion of public trust in the system. Like those, the root cause seems related to how the business of healthcare is conducted. Since its not widely understood nor taught in K thru 12 or college curricula, public opinion is shaped by individual experiences—good and bad—and media coverage, more often negative than positive.

Thus, the data above are not surprising: the public is fed up with the health system, holds all its major players responsible and lacks confidence any one sector will solve its issues appropriately. They’ve concluded its more about money than mission and purpose.

Pew, Gallup and Kaiser Family Foundation have chronicled the decline in institutional trust that’s eroded faith in the political system, big business, organized religion, the Supreme Court and health system. They attribute their demise to the impact of media coverage and changes in the public’s expectations about its use of time, money and values. In coming Keckley Reports, we’ll explore these more deeply comparing those who are unhealthy vs those who are well, those who have health insurance vs. those without, those of household means vs. those lacking, and others.

But what’s clear is this: public opinion about the health system is negative lending to calls for change that are systemic: predictable, understandable, accessible, transparent prices across the board; proof of quality and guarantees of outcomes; access that’s simple and hassle-free and affordability. No single sector in healthcare can deliver these: a collective solution is the only answer.

It’s more than a PR problem. More effective messaging is a start but not enough. The public’s fed up with the status quo and frustrated by its benign neglect of systemness solutions. So what else is new?

Paul

PS Today is President Biden’s 81^st birthday. Political pundits think he’ll face 78-year-old Donald Trump in the ‘24 election. Per Pew, consumers think the political system is ineffective and corrupt: the majority favor terms limits and cessation of the electoral college. They’re tuning out politics and political parties and endorsing alternatives. Instructive for U.S. healthcare? Possibly. Time will tell. The Affordable Care Act was divisive and supported by barely half of the population in 2010 when passed; now it enjoys majority support and crickets from the GOP that voted its repeal in Congress more than 50 times. So, the naming of Paragon Health Institute (PHI) Advisor Drew Keyes as Senior Health Policy leader for the Speaker of House Mike Johnson is telling. PHI favors conservative causes supportive of less regulation, competition, free markets and transparency in healthcare. How the Speaker advances legislation beyond his caucus will send important signals to consumers. Per this poll, some will pay attention, most won’t because they distrust the political system’s willingness to address healthcare issues honestly Stay tuned.

*The 4Q 2023 Keckley Poll is based on survey responses from 817 adults collected November 14-16, 2023. The sample is stratified by age, sex, household income, insurance and health status.

Quotable

Re: CBO health spending estimate, spending reforms: “The CBO’s estimates of $25 trillion in federal health subsidies over the next decade translates into needing about a $1.9 trillion reduction in spending…

To lower the cost growth in federal programs, policy makers should focus on realigning incentives with a view toward maximizing value and reducing distortions. Congress could start where there is bipartisan agreement. For Medicare, reduce hospital payments for services that can be effectively and safely provided in physicians’ offices to the physician office amount. For Medicaid, reduce states’ ability to use financing gimmicks to inappropriately raise federal costs and target funds to politically connected providers..

On the ACA, Congress should recognize that it has not lived up to its promise…Thus, extending the enhanced subsidies after they expire in 2025 should be a non-starter. Congress should instead look to reform the subsidy structure, such as by directly subsidizing low-income people for their health care needs rather than subsidizing health insurance companies, funding the ACA’s cost-sharing reduction program and prohibiting silver-loading. Congress should permit and expand alternative coverage arrangements and build on the Trump administration’s individual coverage health reimbursement arrangements that permit employers to use tax-preferred dollars to reimburse individual market coverage. Finally, Congress should build on the price transparency rules so that US consumers and employers can be more effective shoppers of coverage and care.”

Brian Blasé “CBO Report Highlights Need For Change Of Direction In Health Policy” Health Affairs Forefront November 15, 2023 10.1377/forefront.20231114.230202 Note: Paragon Health Institute Is An Influential Healthcare Think Tank In Dc Known For Market-Driven Policy Reforms Including Price Transparency Et Al.  Blasé Is Its President And CEO. Among Its Advisors: Drew Keyes Named Last Week as Speaker Johnson’s Chief Health Policy Deputy. 

Re: downstream impact of obesity medication access on overall Medicare costs: “People struggling with obesity have found hope in new injectable drugs. Clinical trial participants using semaglutide (Wegovy) safely lost 15% or more  of their body weight, with similar results for other injectable glucagon-like peptide-1 receptor agonist (GLP-1) medications like tirzepatide (Zepbound). Since more than 40%  of adults in the U.S. are obese, another third are overweight, and the disease kills 300,000 Americans  annually, these therapeutics have immense potential to improve the nation’s health… The key to drug price declines is robust competition among producers. Competition comes for nearly every drug eventually, and particularly the small molecule treatments we take as pills.

We believe the signs suggest that if Medicare offered coverage, the competition in anti-obesity medications would be robust due to an expanded market, more investors in search of better drugs, and more competitors.”

Goldman, Kolchinsky “Want Lower Obesity Drug Costs? Medicare Holds the Key” Medpage November17, 2023 www.medpage.com

Re: home birth safety: “Home births represent just 1.4%of the more than 3.6 million babies born in the United States, according to 2021 data from the Centers for Disease Control and Prevention. But they have increased by 35% over five years, while hospital births slightly declined over that 2017-2021 period. White mothers account for 85% of planned home births, according to demographic data, but Black and Hispanic people also are increasingly choosing to deliver at home amid a maternal mortality crisis that has disproportionately affected them.

Many women say they choose home births to feel empowered and have more control over their own bodies; others because they want to avoid such medical interventions as Caesarean sections and inductions. The pandemic also fueled a deeper distrust of doctors and hospitals.

Most home births in the country are attended by certified professional midwives such as Carr, who provide care through pregnancy, labor and delivery, and the postpartum period. They generally have no hospital privileges and learn mainly through apprenticeships. Many believe that giving birth is a natural part of life that needs little, if any, medical intervention. They are distinct from certified nurse midwives, who are registered nurses with graduate degrees, and certified midwives, who have graduate degrees but no nursing license; midwives in both of these categories also provide primary care.

Overall, full-term infants in the United States are more than twice as likely to die after planned home births attended by midwives as those delivered in hospitals by any providers, according to a Post analysis of CDC data over five years.

Thirty-six states and D.C. have laws allowing certified professional midwives to seek licensure, but the rules governing their practice vary widely. Some states ban midwives from attending riskier breech or twin births, but others, including Texas, have no such restrictions. Midwives in Delaware and Louisiana, for example, must check the fetal heart rate at certain times during labor, while in other states, including Maryland, there is no such requirement. State laws even differ on what medications midwives can administer.”

Amy Brittain “A home birth midwife faces scrutiny after a baby dies. It’s not the first time” Washington Post November 14, 2023 https://www.washingtonpost.com/investigations/interactive/2023/home-birth-midwife-karen-carr

Re: Stark Law, physicians: “Today, hospitals are eating up practices all around us … and guess what? They don’t play by our rules,”

Mohammad Ibrahim, DO, in the AMA House of Delegates debate about Stark Law Changes November 14, 2023 Calls to Support Stark Law Reforms Blocked by AMA Delegates MedPage https://www.medpagetoday.com/meetingcoverage/ama

Re: administrative complexity: “Data obtained under the Centers for Medicare & Medicaid Services transparency rules show that there are 317,987 health plans in the US market, roughly 1 plan for every 1000 people in the country. In the worst-case scenario, each plan can have its own set of covered benefits, its own documentation standards, its own payment processes, and payment rules. Faced with this daunting reality, it’s remarkable that any physician receives any insurance payment for their service…

Complexity is not just a characterization of health insurers. There are 599, 204 unique codes to describe health care products and services. Each code requires the health plan to establish a pricing model for the service with the provider (or pharmacy). The complexity of the coding system means that clinicians must justify assignment of billing codes, and this allows health insurers to question the justification…

All this complexity comes together in the staggering result that there are 57 billion negotiated prices in the US market, or 94, 335 for each service code.

Seen in aggregate, it’s hard to justify this complexity and lack of standardization of the health insurance model in the US. This is not a question of how health care is financed, but a question of transaction processes underlying the market. Transaction costs in the US are 10 times those in the Netherlands, which has a private multipayer health care system.^”

Achieving this level of standardization will be difficult. In Washington, DC, there is no single organization overseeing the health care market that could be the catalyst for the needed market reform. The good news is that addressing the fundamental challenges of the transaction platform for health care could be an issue with support from both political parties. It’s time for the physician community to advocate for these fundamental reforms to the market, to save our sanity, and to protect our patients from the chaos that is the health care market.”

Schulman et al “AI Alone Will Not Reduce the Administrative Burden of Health Care” JAMA.  November 16, 2023. doi:10.1001/jama.2023.23809

Re: physician co-pay responsibility: “As health insurers require patients to pay a larger share of health care bills, many physicians do not feel comfortable or adequately equipped to be the collection point for cost-sharing between insurers and patients. In response, the AMA has established new policy supporting the removal of physicians from the middle of cost-sharing between insurers and patients and require insurers to collect deductibles, copays or coinsurance from patients. Delegates voted to adopt policy instructing the AMA to ‘support requiring health insurers to collect patient cost-sharing and pay physicians their full allowable amount for health care services provided, unless physicians opt-out to collect such cost-sharing on their own.’”

AMA Website November 13, 2023 based on House of Delegates deliberation www.ama.org

Re: private equity in healthcare: “Some scholars believe that private equity serves as a divining rod for failures in our current health care market. Investors, they believe, are simply exploiting the system’s weaknesses for profit. In this sense, the growth of private equity is a symptom, not the cause, of our health system’s failure to meet the needs of Americans.”

Private Equity’s Role in Health Care Commonwealth Fund November 17, 2023 Private Equity’s Role in Health Care | Commonwealth Fund

Re: covid misinformation: “We analyzed 50 papers published between January 1, 2020, and February 24, 2023, to understand which interventions, if any, were helpful in mitigating COVID-19 misinformation. We found evidence supporting accuracy prompts, debunks, media literacy tips, warning labels, and overlays in mitigating either the spread of or belief in COVID-19 misinformation. However, by mapping the different characteristics of each study, we found levels of variation that weaken the current evidence base. For example, only 18% of studies included public health–related measures, such as intent to vaccinate, and the misinformation that interventions were tested against ranged considerably from conspiracy theories (vaccines include microchips) to unproven claims (gargling with saltwater prevents COVID-19). To more clearly discern the impact of various interventions and make evidence actionable for public health, the field urgently needs to include more public health experts in intervention design and to develop a health misinformation typology; agreed-upon outcome measures; and more global, more longitudinal, more video-based, and more platform-diverse studies.”

Smith et al A Systematic Review Of COVID-19 Misinformation Interventions: Lessons Learned Health Affairs November 15, 2023 https://doi.org/10.1377/hlthaff.2023.00717

Re: State employee health plans: “The growth in average family premiums in employer-sponsored insurance has steadily outpaced inflation and workers’ earnings. Family premiums are now almost $24,000 per year. Many employers have tried to shift more of these costs onto workers and their families through higher deductibles, with the result that 43%  of people with employer-sponsored coverage say it is very or somewhat difficult to afford their health care, and more than one-third of them struggle with medical debt..

Our survey finds that, while many SEHPs continue to focus on reducing health care use, a number of SEHP administrators are demonstrating that it is possible to design and implement strategies that reduce provider price inflation while also minimizing pushback from important internal and external stakeholders. To the extent that some of these strategies change provider behavior or engage other health care purchasers, improvements in quality or cost savings can have ripple effects across the market for commercial insurance. As these efforts garner more experience and data, other SEHPs, as well as private-sector purchasers and policy makers, can learn, and potentially benefit from, these initiatives.”

Commonwealth In An Era Of Premium And Provider Price Increases, State Employee Health Plans Target Key Cost Drivers NOVEMBER 16, 202310.1377/forefront.20231115.722201

 Polling

Pew: Public opinion about the political system: From its July 2023 polling: “Just 4% of U.S. adults say the political system is working extremely or very well; another 23% say it is working somewhat well. About six-in-ten (63%) express not too much or no confidence at all in the future of the U.S. political system.

Positive views of many governmental and political institutions are at historic lows. Just 16% of the public say they trust the federal government always or most of the time. While trust has hovered near historic lows for the better part of the last 20 years, today it stands among the lowest levels dating back nearly seven decades. And more Americans have an unfavorable than favorable opinion of the Supreme Court – the first time that has occurred in polling going back to the late 1980s.

A growing share of the public dislikes both political parties. Nearly three-in-ten (28%) express unfavorable views of both parties, the highest share in three decades of polling. And a comparable share of adults (25%) does not feel well-represented by either party.

Candidate choices are underwhelming. As the presidential campaign heats up, 63% of Americans say they are dissatisfied with the candidates who have emerged so far. Setting aside the presidential campaign, there has been a downward trend in views of the quality of all political candidates. Just 26% rate the quality of political candidates as very or somewhat good, down about 20 percentage points since 2018.

Majorities back age and term limits and eliminating the Electoral College. Reflecting the public’s frustration with the federal government and political leaders, large shares of Americans support various changes to the political system, including for such long-standing proposals as establishing term limits for members of Congress and scrapping the Electoral College. Age limits – for both federal elected officials and members of the Supreme Court – draw broad support. But there is little appetite in the public for increasing the size of the U.S. House or modifying the allocation of Senate seats.”

Americans’ Dismal Views of the Nation’s Politics Pew Research Center September 10, 2023 https://www.pewresearch.org/politics/2023/09/19/americans-dismal-views-of-the-nations-politics

Survey: mental illness, substance abuse prevalence: Per the 2022 Substance Abuse and Mental Health Services Administration (SAMHSA) 2022 NSDUH report released last Monday based on self-reported data:

• Among people aged 12 or older in 2022, 59.8% (or 168.7 million people) used tobacco products, vaped nicotine, used alcohol, or used an illicit drug in the past month (also defined as “current use”), including 48.7% (or 137.4 million people) who drank alcohol, 18.1% (or 50.9 million people) who used tobacco products, 8.3% (or 23.5 million people) who vaped nicotine, and 16.5% (or 46.6 million people) who used an illicit drug.
• In 2022, 70.3 million people aged 12 or older (or 24.9%) used illicit drugs in the past year. Marijuana was the most used illicit drug, with 22.0% of people aged 12 or older (or 61.9 million people) using it in the past year.
• In 2022, 48.7 million people aged 12 or older (or 17.3%) had a substance use disorder (SUD) in the past year, including 29.5 million who had an alcohol use disorder (AUD), 27.2 million who had a drug use disorder (DUD), and 8.0 million people who had both an AUD and a DUD.
• In 2022, almost 1 in 4 adults aged 18 or older had any mental illness (AMI) in the past year (59.3 million or 23.1%).
• Among adolescents aged 12 to 17 in 2022, 19.5% (or 4.8 million people) had a past year major depressive episode (MDE).
• 1 in 20 adults aged 18 or older had serious thoughts of suicide in the past year (13.2 million or 5.2%), 1.5% (or 3.8 million people) made a suicide plan, and 0.6% (or 1.6 million people) attempted suicide in the past year. Over 1 in 8 adolescents aged 12 to 17 had serious thoughts of suicide in the past year (13.4% or 3.4 million adolescents), 1 in 15 made any suicide plans (6.5% or 1.7 million adolescents), and nearly 1 in 25 (3.7% or 953,000 adolescents) attempted suicide in the past year.

2022 National Survey on Drug Use and Health November 13, 2023 https://www.hhs.gov/

Carta Healthcare: Trust of Artificial Intelligence (AI):  Healthcare based on an online survey of 1,027 U.S. consumers between August 18 and August 29, 2023:

• 38% say they trust AI
• 57% feel they have a good understanding of AI and how it’s used in healthcare.
• 47% feel that if they were to learn about it, they would be more likely to trust it.
• 65% reported that if they were to have an explanation of the use in AI from their healthcare providers, it would make them more comfortable with its use.

Infographic link via BusinessWire, Carta Healthcare survey results indicate that education around AI may improve consumer trust, October 12, 2023

McKinsey: social needs survey: McKinsey surveyed 5010 US adults Unmet HRSNs are very common;

• 45% of all consumers reported experiencing an unmet HRSN on a regular basis and the majority have multiple unmet needs. Childcare (among those with children), material status (the ability to pay for utilities or purchase basic goods), and social support (feeling lonely, not having someone to count on, or missing having someone to talk to) were the three most reported needs, with nearly one-third of consumers experiencing each of these.
• Consumers with multiple HRSNs were more likely than other groups to report seeking support from family or friends, yet 20% do not seek support.
• Consumers want health systems, health insurance companies, and employers to better understand their needs.

Consumers’ perceptions of their health-related social needs McKinsey November 14, 2023 https://www.mckinsey.com/industries/healthcare/our-insights/consumers-perceptions-of-their-health-related-social-needs

Regulatory

Study: pharmacists in primary care: Researchers devised an intervention of asynchronous automated orders; a centralized approach using pharmacists to discuss and prescribe statins without a doctor’s visit. This led to most orders cosigned (73.7%) and a referral to a centralized pharmacy initiated, after which the most frequent outcomes were a patient starting a target-dose statin (28%) or a patient declining the statin (19%).

The proportion of individuals who were ultimately prescribed any statin reached 31.6% out of all eligible patients, a significant improvement over usual care’s 15.2%. Similarly, there was an increase in prescriptions of appropriate-dose statins (24.8% vs 7.7%.

Statins Reach More Patients with Pharmacist’s Orders: Asynchronous automated order approach boosts statin prescribing MedPage Today November 14, 2023 https://www.medpagetoday.com/

Hospitals

Moody’s 2024 Nonprofit hospitals’ outlook improvement expected: Moody’s Investors Service has upgraded the 2024 nonprofit hospital sector financial outlook to stable, from negative:

• Nonprofit hospitals are expected to experience a financial recovery in 2024 as patient volumes — particularly for outpatient care — increase.
• Nonprofit hospitals , anticipate a 10% to 20% increase in median operating cash flow next year.
• Median operating expense growth will slow but baseline expenses will “remain structurally higher” and require “diligent cost controls”

Nonprofit hospitals upgraded to ‘stable’ outlook: Moody’s Healthcare Dive November 9, 2023

Study: hospital pricing: “Using commercial claims from the Health Care Cost Institute (HCCI) and hospital data from the Healthcare Cost Report Information System (HCRIS) from 2017 to 2019, we compared in-network prices (inpatient or outpatient facility plus physician fees) for common services offered by quaternary and nonquaternary hospitals… Chosen for their high frequency and relative homogeneity, we defined common services as uncomplicated inpatient admissions for hip replacement, knee replacement, pneumonia, and diabetes, as well as outpatient lower joint magnetic resonance imaging, pulmonary spirometry, screening colonoscopy, and screening mammography.” Findings:

“Within the same geographic market, quaternary hospitals negotiated higher commercial prices than nonquaternary hospitals for several common inpatient admissions and outpatient studies… Whether price premiums for common services performed by quaternary hospitals cross-subsidize specialized services, enable other valuable activities, or deliver meaningful quality benefits remain questions for future study. Yet to the extent that price premiums reflect market power and bargaining leverage against insurers derived from offering quaternary services, additional regulation and/or policies that promote competition may be appropriate.”

Yan et al “Prices for Common Services at Quaternary vs Nonquaternary Hospitals” JAMA November 16, 2023. doi:10.1001/jama.2023.17249

Care Management

Study: mental health care management in ACOs: “Accountable care organizations (ACOs) have become Medicare’s dominant care model because policy makers believe that ACOs will improve the quality and efficiency of care for chronic conditions. Depression and anxiety disorders are the most prevalent and undertreated chronic mental health conditions in Medicare. Yet it is unknown whether ACOs influence treatment and outcomes for these conditions. To explore these questions, this longitudinal study used data from the 2016–19 Medicare Current Beneficiary Survey, linked to validated depression and anxiety symptom instruments, among diagnosed and undiagnosed fee-for-service Medicare patients with these conditions.” Conclusion: Among patients not enrolled in ACOs at baseline, those who newly enrolled in ACOs in the following year were 24 percent less likely to have their depression or anxiety treated during the year than patients who remained unenrolled in ACOs, and they saw no relative improvements at twelve months in their depression and anxiety symptoms. Better-designed incentives are needed to motivate Medicare ACOs to improve mental health treatment.

Hockenberry et al “No Improvement in Mental Health Treatment or Patient-Reported Outcomes at Medicare ACOs for Depression and Anxiety Disorders” Health Affairs NOVEMBER 2023  https://doi.org/10.1377/hlthaff.2023.00345

Health Spending

Altarum Health Sector Economic Indicators: November 2023 highlights:

• Health spending has outpaced GDP growth for past 8 months:
• In September 2023, national health spending grew by 5.7%, year over year, and represents 17.2% of GDP.
• Nominal GDP in September 2023 was 6.6% higher than in September 2022, and grew 0.9 percentage points faster than health spending.
• Neglecting government subsidies, spending on personal health care in September increased by 8.0%, year over year, and by 7.7% when subsidies are included, exceeding the GDP growth rate for the eighth consecutive month.
• Neglecting government subsidies, year-over-year spending on prescription drugs (11.8%) grew fastest in September, while spending on home health care increased the least (5.5%) among major categories.
• Personal health care spending growth (neglecting government subsidies) continues to be dominated by growth in utilization rather than price increases.

November 2023 Health Sector Economic Indicators Briefs | Altarum

Study: 340B prescribing, fulfillment trends: Researchers analyzed trends in the proportion of Medicare Part D claims that are prescribed by 340B-affiliated clinicians and filled in 340B pharmacies based on 2013 to 2020 claims data from a 5% random sample of Medicare Part D beneficiaries and 6292 nine-digit national drug codes. Findings:

The proportion of prescriptions written by a 340B-affiliated clinician doubled from 9.4% in 2013 to 19.3% in 2020. The capture of 340B prescriptions by 340B pharmacies, defined as the proportion of claims prescribed by 340B-affiliated clinicians that were filled by 340B pharmacies, increased from 18.4% in 2013 to 49.9% in 2020. As a result, the total proportion of 340B claims in Part D increased from 1.7% in 2013 to 9.6% in 2020. Rates of 340B prescribing and capture increased consistently across therapeutic classes. In 2020, the antiviral therapeutic class was the class with the largest proportion of 340B claims (16.1%), followed by targeted antineoplastics (15.7%).

Dickson et al “Trends in Proportion of Medicare Part D Claims Subject to 340B Discounts, 2013-2020” JAMA Health Forum November 17, 2023;4(11):e234091. doi:10.1001/jamahealthforum.2023.4091

Sullivan Cotter: APP Compensation: “While 2022 saw higher-than-normal growth in primary care and hospital-based specialties, the 2023 results show larger increases for primary care, medical and surgical specialties (each at 5%) and modest growth for hospital-based specialties (2.5%) for both base and total cash compensation (TCC).

Although this year’s increases are more in line with historical APP compensation increases, the 3-year trends reflect a continuing market demand for these clinicians. Median TCC for nurse practitioners and physician assistants rose 13.0% for primary care, 10.2% for medical, 9.4% for surgical, and 10.9% for hospital-based specialties from 2020-2023.

Consistent with the past several years, the demand for anesthesiology providers remains high, which continues to put upward pressure on compensation. Certified Registered Nurse Anesthetists (CRNAs) saw a 9.6% increase in median TCC in 2023. In looking at the 3-year trends for CRNAs, median TCC rose 15.6% from 2020-2023, and median hourly rates increased from $89.62 in 2020 to $102.91 in 2023.”

2023 Advanced Practice Provider Compensation and Productivity Survey