Keckley Poll: Which Institution is Best Positioned to Solve the Health System’s Flaws?

In The Keckley Poll conducted November 13-16, 2023 among 817 U.S. adults, 69% agreed that “the health system is fundamentally flawed and needs major change.” This view is held even more among working age adults, women and those in good/fair health and less by seniors and those in poor health.

“I believe the U.S. health system is fundamentally flawed and needs major change.”

%	Total	18-24	25-34	35-44	45-54	55-64	65+	Male	Female	Good Health	Fair Health	Poor Health
Strongly Agree	33	30.9	38.7	40.4	36.6	32.5	16.3	30.8	34.2	31.7	33.2	44.4
Agree	36	34.0	36.0	30.8	38.6	39.7	34.6	34.2	37.1	36.3	36.4	14.8
Mixed Feelings	24	29.9	18.7	19.9	20.0	22.2	35.9	25.4	23.1	24.0	23.3	37.0
Disagree	6	3.1	5.3	7.5	4.1	5.6	11.8	8.6	4.4	6.7	6.3	3.7
Strongly Disagree	1	2.1	1.3	1.4	0.7	0.0	1.3	1.0	1,7	1.3	0.8	0.0

 

Asked “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?”, a majority aren’t sure about which institutions are more likely to lead. While physicians and hospitals enjoy an advantage over others, none is viewed as THE problem-solver for the health system’s issues.

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?

%	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 Co.’s	21.3	50.9	27.8

 

Hospitals are more trusted than health insurers in every cohort, but they do not enjoy “a great deal of trust and confidence” majority in any group:

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

%	Total	18-24	25-34	35-44	45-54	55-64	65+	Males	Females	Good Health	Fair Health	Poor Health
A great deal	18.4	28.9	19.3	26.7	16.6	10.3	11.1	21.0	15.7	19.9	16.2	7.4
Some	43.2	47.4	44.7	36.3	44.8	37.3	49.0	40.3	45.9	46.0	36.4	51.9
Not much/None	38.4	23.7	36.0	37.0	38.6	52.4	39.9	38.6	38.3	34.1	47.4	40.7

 

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

%	Total	18-24	25-34	35-44	45-54	55-64	65+	Males	Females	Good Health	Fair Health	Poor Health
A great deal	27.4	32.0	31.3	34.2	24.8	17.5	24.8	32.5	22.1	30.4	22.5	14.8
Some	51.9	55.7	52.7	46.6	51.0	53.2	53.6	47.9	56.0	51.8	51.8	55.6
Not much/None	20.7	12.4	16.0	19.2	24.1	29.4	21.6	19.6	21.9	25.7	25.7	29.6

 

My take:

These data confirm a public view that the status quo is unsatisfactory to the vast majority of Americans. While each of the 5 institutions asserts its unique role and value proposition in the scheme of U.S. healthcare, none stands out for its differentiated commitment to the greater good.

As 2024 nears, healthcare will be more prominent in political rhetoric: for the most part, that’s noise. As the Keckley Poll found, 76% think “Most politicians avoid healthcare issues because solutions are complicated and they fear losing votes.” Key Senate committees i.e., Health Education, Labor and Pensions (HELP) and Finance are investigating delicate matters like the tax exemptions enjoyed by not-for-profit health systems and role PBMs play in drug pricing, so media coverage of the industry will be a steady drumbeat and the long-term destination of the health system will get scant attention.

Lacking fresh solutions, new voices and honest insight, the health system will devolve into two-tiers: a private system of a la carte programs and services accessible to those who can afford them and a large public system for the rest.

This polling suggests it’s time for the industry to consider the public we serve instead of ourselves. Some do it better than others today, but lacking a systemic strategy engaging all sectors to address the health and wellbeing of the entire population affordably, incrementalism will continue, sectarianism will escalate and the system effectiveness will erode. And none of the major institutions is prepared to lead that process.

Paul

PS: In the sections that follow, there are references to events of the past week that illustrate a recurring theme prominent in healthcare i.e.  profit vs. public good. The 5-day drama around the dismissal and reinstatement of OpenAI President and CEO Sam Altman by its Board boiled down to a Board dispute pitting opposing views about the technology’s value for its shareholders vs. the public good it might enable. The lawsuit brought by private equity investor Welsh Carson against the FTC challenging its claim that the US Anesthesia Partners roll-up is covered in media as a monopolistic gambit pits private equity against the government’s role as the protector of competition. And publicity about UnitedHealth’s NaviHealth prior authorization platform paints an unflattering view of utilization management tools devised by ‘greedy investors’ to keep needed care from patients to maximize their profits. Increasingly, healthcare is painted as profit vs. the public good in media coverage. It’s a delicate balancing act for every Board: how to access capital for growth, compensate leaders and deliver recognizable value to end users—consumers, patients, enrollees and communities while fulfilling mission and purpose with integrity. In this era of social media and heightened scrutiny, promises, platitudes, affiliation and brands will be in the spotlight. A clear strategy that advances each organization’s effort to balance solvency and public good is imperative. The public’s paying attention.

Quotable

Re: 2024 economic forecast predictions: “Economists at Goldman might think growth and inflation will stay hot whereas those at UBS think both will slow down sharply. But Bank of America expects comparative stagflation, combining only a modest reduction in inflation with a pretty sharp drop in growth (and therefore little movement in the Fed’s policy rates). Morgan Stanley expects the opposite: a version of the “immaculate disinflation” world in which inflation can come back to target without growth dropping below trend much at all.

That each of the outcomes bank economists describe feels eminently plausible is a testament to the sheer level of uncertainty out there. Almost everyone has been surprised in turn by how hot inflation was, the speed of rate rises required to quell it and then the resilience of the economy.”

How will America’s economy fare in 2024? Don’t ask a forecaster The consensus is there is no consensus” The Economist November 23, 2023 https://www.economist.com/finance-and-economics/2023

Re: primary care compensation: “The U.S. faces a serious shortage of primary care physicians for many reasons, but one, in particular, is inescapable: compensation…The earnings differential between primary care and other specialists is also not lost on them. Average annual compensation for doctors who focus on primary care — family medicine, internists, and pediatricians — ranges from an average of about $250,000 to $275,000, according to Medscape‘s annual physician compensation report . Many specialists make more than twice as much: Plastic surgeons top the compensation list at $619,000 annually, followed by orthopedists ($573,000) and cardiologists ($507,000) …

Still, it’s a misperception that student debt always drives the decision about whether to go into primary care, said Len Marquez, senior director of government relations and legislative advocacy at the Association of American Medical Colleges…

In recent years, the Centers for Medicare & Medicaid Services…expanded the office visit services for which providers can bill to manage their patients, including adding non-procedural billing codes for providing transitional care, chronic care management, and advance care planning…

The American College of Surgeons and 18 other specialty groups published a statement  describing the new code as “unnecessary.” They oppose its implementation because it would primarily benefit primary care providers who, they say, already have the flexibility to bill more for more complex visits.

But the real issue is that, under federal law, changes to Medicare physician payments must preserve budget neutrality — a zero-sum arrangement in which payment increases for primary care providers mean payment decreases elsewhere…”

Michelle Andrews “Compensation Is Key to Fixing Primary Care Shortage” MedPage November 24, 2023 Money talks https://www.medpagetoday.com/special-reports/features

Re: vertical integration in prescription drugs: “We are writing regarding vertical integration in the health care industry and its role in raising already sky-high prescription drug costs. In particular, we are concerned by a recent report suggesting that large insurance companies – including Cigna, CVS Aetna, and UnitedHealth – are hiking drug prices at their vertically integrated specialty pharmacies to evade the Medical Loss Ratio (MLR), a statutory requirement for health insurers to spend at least 80 or 85 percent of health care premium dollars on medical claims. We therefore request that the Health and Human Services Office of the Inspector General (HHS OIG) investigate the extent of this potential MLR gaming and its harm on patients and taxpayers. Last month, the Wall Street Journal published a report revealing significant markups of generic drugs at specialty pharmacies owned by CVS Aetna, Cigna, and UnitedHealth. In each case, prices for these products were far higher at vertically integrated specialty pharmacies than they were at Cost Plus, the independent pharmacy the Wall Street Journal used as a baseline. Cigna, CVS Aetna, and UnitedHealth charged 27.4, 24.2, and 3.5 times more, respectively, than Cost Plus across a selection of 19 drugs. These findings are alarming…One key factor driving these high prices appears to be the fact that insurers own other key links in the drug supply chain: pharmacy benefit managers (PBMs) and pharmacies. Cigna, United Health, and CVS Aetna each own or are affiliated with the country’s three largest PBMs, which in theory negotiate drug prices with pharmaceutical manufacturers on behalf of insurers and set prices at the pharmacy. However, when those same insurers and their vertically integrated PBMs also own their own specialty pharmacies, they can profit handsomely. That’s because insurers are not just the payers at the end of the transaction; instead, through their PBMs and pharmacies, they are also the recipients of those funds. According to the Journal, “PBMs try to pay as little as possible for drugs distributed through independent retail pharmacies. But when their own pharmacies dispense prescriptions, PBMs profit from the higher prices.”

Letter to Inspector General from Sens. Warren, Braum requesting investigation November 22, 2023 2023.11.21 Letter to HHS OIG regarding MLR evasion.pdf (senate.gov)

Re: Financial burden in U.S. Households: “Our main contribution, however, is perhaps not in adding to the already large literature on burdens, medical debt, and barriers to needed care. Rather, it is our analysis of the joint distribution of these three dimensions of health care financial strain. In part because relatively few adults lived in families with multiple financial problems, the total number of adults affected by at least one type of strain was large, ranging from 27.0% to 45.4% in our preferred and broader measures, respectively. Moreover, although financial strain was most prevalent among lower-income families, even adults in families with incomes more than four times the federal poverty level were at risk, with 15.8% facing at least one of the three problems (34.9% using the broader measures). Our findings in this regard, although intrinsically of a general nature and not specific to any one policy, nevertheless offer a useful overall perspective on the US system for financing health care, and they can help provide context for the urgency felt across the country for change that addresses all dimensions of health care financial strain.”

Didem M. Bernard, Thomas M. Selden, and Zhengyi Fang “The Joint Distribution Of High Out-Of-Pocket Burdens, Medical Debt, And Financial Barriers To Needed Care” Health Affairs November 2023 The Joint Distribution Of High Out-Of-Pocket Burdens, Medical Debt, And Financial Barriers To Needed Care | Health Affairs

Re: OpenAI leadership dispute: “Five very weird days passed before it seemed that Sam Altman would stay at OpenAI after all. On November 17th the board of the maker of ChatGPT suddenly booted out its chief executive. On the 19th it looked as if Mr. Altman would move to Microsoft, OpenAI’s largest investor. But employees at the startup rose up in revolt, with almost all of them, including one of the board’s original conspirators, threatening to leave were Mr. Altman not reinstated. Between frantic meetings, the top brass tweeted heart emojis and fond messages to each other. By the 21st, things had come full circle…

The chief lesson is the folly of policing technologies using corporate structures. As the potential of generative ai became clear, the contradictions in OpenAI’s structure were exposed. A single outfit cannot strike the best balance between advancing ai, attracting talent and investment, assessing ai’s threats and keeping humanity safe. Conflicts of interest in Silicon Valley are hardly rare. Even if the people at OpenAI were as brilliant as they think they are, the task would be beyond them…

Fortunately for humanity, there are bodies that have a much more convincing claim to represent its interests: elected governments. By drafting regulation, they can set the boundaries within which companies like OpenAI must operate. And, as a flurry of activity in the past month shows, they are paying attention to ai. That is just as well. ai technology is too important to be left to the latest corporate intrigue. ”

The fallout from the weirdness at OpenAI the Economist November 22, 2023 https://www.economist.com/leaders/2023/11/22/the-fallout-from-the-weirdness-at-openai

Re: medical spa investing: “Private equity interest in the delivery of Botox injections, laser hair removal and specialized facials across the US is growing rapidly as the medspa industry matures and investors recognize those services have become habits for many consumers.

Most PE firms in the space are rolling up existing clinics under one management company, the classic buy-and-build strategy that PE firms use to create efficiencies of scale. Deals that provide capital to support roll-ups that are already in progress have been especially in vogue.

This year has seen the most growth deals in aesthetic dermatology to date, with at least eight announced in 2023, according to PitchBook data. While that deal count is still in the single digits, it’s a marked increase from 2020, when PE made only one growth equity investment in the space.

Emily Burleson “Private equity raises bets on Botox-dealing medspas” Pitchbook November 21, 2023 https://pitchbook.com/news/articles/private-equity-medspa-aesthetic-dermatology-deals-botox

Re: Welsh Carson lawsuit against the FTC re: U.S. anesthesia partners: “A decade ago, a Welsh Carson fund helped finance a local group of physicians to create defendant U.S. Anesthesia Partners, Inc. (“USAP”). Over the years, USAP grew into a company that expands access to quality anesthesia services across Texas and other states. Part of USAP’s approach was to attract and combine with other quality practices—a strategy used by countless other companies in many other industries. Its growth has allowed USAP to invest in technology, quality, and infrastructure to provide comprehensive 24/7 anesthesia services to hospitals both large and small, including those with patient populations that previously had access only to lower quality anesthesia services or struggled to access such services at all. And USAP serves these patient needs at prices that, accounting for inflation, have basically stayed flat since inception. None of this seems to matter to the FTC. This lawsuit focuses on supposed harm to the healthcare insurance industry, dominated by four insurers: Aetna, United, Cigna, and Blue Cross. Nothing in the Complaint alleges that USAP’s success has harmed patient care, much less that Welsh Carson investments have done so. Nor does the Complaint assert that any of the respected Texas hospitals (which rely on USAP for access to high-quality care for underserved populations) has been hurt by the supposed anticompetitive acts. Instead, the FTC complains that the big four Case 4:23-cv-03560 Document 100 Filed on 11/20/23 in TXSD Page 9 of 45 2 insurance companies—which routinely kick out healthcare providers from coverage during pricing negotiations—now are allegedly less able to leverage their bargaining power against USAP. Beyond that, the Complaint just looks backward and cites no specific current or imminent violation by the Welsh Carson entities.  That is fatal to its claims.”

Complaint filed against the FTC by Welsh Carson Welsh Carson MTD FTC 20231120.pdf (thomsonreuters.com) November 20, 2023

Re: Medicare physician payments: “Our current predicament is tied to the fact that Medicare physician payments haven’t even come close to keeping up with inflation over more than 20 years. Since 2001, Medicare physician payments have lagged 26% behind inflation while hospital and other health industry payments have kept pace, according to American Medical Association data . Over the same period, the CPI for physician services in U.S. cities increased by 65%.”

Rick Snyder “The Broken Medicare System Is Forcing Physicians Out” Medpage November 20, 2023https://www.medpagetoday.com/opinion/second-opinions

Re: NaviHealth, United prior authorization dispute: “The black box of the AI has become a blanket excuse for denials… The product was a revelation to insurers, giving them a way to mathematically track patients’ progress and hold providers accountable for meeting therapy goals.  By summer 2015, NaviHealth was managing post-acute care for more than 2 million people whose insurance plans had contracted with the company.   It was also working with 75 hospitals and clinics seeking to more carefully manage contracts in which they shared financial responsibility for holding down costs. At the time, spending on post-acute care accounted for $200 billion annually.

That same year, Scully sold NaviHealth to the conglomerate Cardinal Health for $410 million — roughly eight times the investment. In 2018, another private equity firm, Clayton, Dubilier & Rice, upped the ante and paid $1.3 billion to take over NaviHealth. Then in 2020, UnitedHealth — the largest Medicare Advantage insurer in the country — decided to make the hot commodity its own, buying NaviHealth in a deal valued at $2.5 billion.”

How Medicare Advantage plans use AI to cut off care for seniors (statnews.com) March 13, 2023 Bob Herman, Casey Ross STAT News www.statnews.com

Polling

Annenberg: seasonal respiratory concern Per the Annenberg Policy Center survey of 1599 adults October 5-12, 2023:

• RSV concern: 35% worry that they or someone in their family will get RSV in the next three months, up from 32% in January 2023. About two-thirds (65%) are not worried.
• Covid-19 concern: 35% are worried that they or someone in their family will get Covid-19 in the next three months, up from 21% in August 2023 but similar to last winter (36% in January 2023). About two-thirds (65%) are not worried.
• Flu concern: 39% are worried that they or someone in their family will contract the seasonal flu in the next three months, statistically unchanged from January 2023. Six in 10 people (61%) are not worried.
• Complications: Nearly 1 in 3 people (31%) say they personally know someone who believes they are suffering long-term health complications as a result of getting infected with Covid-19. One in 6 (17%) say they personally know someone who believes they are suffering long-term health complications as a result of getting infected with Covid-19.
• Flu shots: 21% said they had received the flu shot this season, compared with 26% in mid-October 2022 and 38% in the second week of November 2021.

“Over a Third of Americans Worry About Getting the Flu, RSV, or Covid-19” Annenberg Public Policy Center November 20, 2023 https://www.annenbergpublicpolicycenter.org/over-a-third-of-americans-worry-about-getting-the-flu-rsv-or-covid-19

WSJ-NORC Poll: abortion access: The poll, conducted for WSJ by NORC at the University of Chicago, surveyed 1,163 registered voters from Oct. 19-24. Findings:

• 55% of respondents say it should be possible for a pregnant woman to obtain a legal abortionif she wants it for any reason.
• 77% of Democrats in say they support access to abortion for any reason, up from 52% in 2016. Among Republicans, that share is one-third.
• “Nearly nine in 10 poll respondents support abortion access in the event of rape or incest, or when a woman’s health is seriously endangered by the pregnancy.”

“Support for Abortion Access is Near Record, WSJ-NORC Poll Finds”  WSJ November 20, 2023 https://www.wsj.com/politics/policy/support-for-abortion-access-is-near-record-wsj-norc-poll-finds

KFF Covid-19 November 2023 Poll: Half not inclined to get vaccination: The survey was conducted October 31- November 7, 2023, online and by telephone among a nationally representative sample of 1,301 U.S. adults in English (1,222) and in Spanish (79). Highlights:

“As the public heads into the fourth holiday season with the virus, about half of adults say they do not plan to get the latest vaccine which became publicly available nearly two months ago. This includes three in ten of those who were previously vaccinated. A quarter of the public say that while they have not gotten the latest vaccine, they intend to do so.

That leaves about two in ten adults reporting having gotten the latest COVID-19 vaccine. Consistent with demographic differences across other COVID-related behaviors, uptake of the new vaccine is highest among those ages 65 and older (34%) and Democrats (32%). Smaller shares of younger adults ages 18-29 (18%), Republicans (11%) and independents (16%) report getting the latest vaccine. Similar shares across racial and ethnic groups say they have gotten the updated vaccine, including 26% of Black adults, 20% of Hispanic adults, and 19% of White adults. However, when combining the shares who have gotten the shot and those who intend to get it, Black adults (59%) and Hispanic adults (59%) both outpace White adults (42%).”

Sparks et al “KFF COVID-19 Vaccine Monitor November 2023: With COVID Concerns Lagging, Most People Have Not Gotten Latest Vaccine And Half Say They Are Not Taking Precautions This Holiday Season” KFF November 17, 2023  https://www.kff.org/coronavirus-covid-19/poll-finding/vaccine-monitor-november-2023-with-covid-concerns-lagging-most-people-have-not-gotten-latest-vaccine

Physicians

Study: SDOH and physician access: Researchers analyzed whether social determinants of health (SDOH) were associated with cardiologist involvement in the management of adults hospitalized for Heart Failure between 2009 and 2017. Findings:

“This cohort study found that adults with low household income were 11% less likely than adults with higher incomes to have a cardiologist involved in their care during a hospitalization for HF. These findings suggest that socioeconomic status may bias the care provided to patients hospitalized for HF.”

Zhang et al “Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure” JAMA Network Open November 20,2023;6(11): e2344070. doi:10.1001/jamanetworkopen.2023.44070

Study: EHR use by PCPs: Researchers analyzed variation in EHR use across 307 PCPs in 31 primary care clinics at Massachusetts General Hospital and Brigham and Women’s Hospital during 2021. Findings:

“On a per-visit basis, PCPs spent a median (IQR) of 36.2 (28.9-45.7) total minutes on the EHR, 6.2 (3.1-11.5) minutes of pajama time, and 7.8 (5.5-10.7) minutes on the electronic inbox. When comparing PCP time expenditure by clinic, median (IQR) total EHR time, median (IQR) pajama time, and median (IQR) electronic inbox time ranged from 23.5 (20.7-53.1) to 47.9 (30.6-70.7) minutes per visit, 1.7 (0.7-10.5) to 13.1 (7.7-28.2) minutes per visit, and 4.7 (4.1-5.2) to 10.8 (8.9-15.2) minutes per visit, respectively. In a multivariable model with an outcome of total per-visit EHR time per visit, an above median percentage of teamwork on orders was associated with 3.81 (95% CI, 0.49-7.13) minutes per visit fewer and having a clinic pharmacy technician was associated with 7.87 (95% CI, 2.03-13.72) minutes per visit fewer. Practicing in a community health center was associated with fewer minutes of total EHR time per visit (5.40 [95% CI, 0.06-10.74] minutes).”

Rotenstein et al “System-Level Factors and Time Spent on Electronic Health Records by Primary Care Physicians” JAMA Network Open November 22, 2023;6(11): e2344713. doi:10.1001/jamanetworkopen.2023.44713

Study: MIPS program effectiveness with surgeons: “Most surgical health care professionals in MIPS received bonus payment adjustments in 2021 and performance varied by specialty. The estimated increase in Part B payments for surgeons was $1341. Despite Medicare raising thresholds, almost all physicians continue to score highly in MIPS, making it challenging for the program to meaningfully discern quality care. Importantly, incentives for surgeons are modest and may not outweigh the time and financial costs required to participate in the program, particularly for those practicing in disadvantaged care settings who may lack the necessary resources.”

Maganty et al “Financial Implications of the Merit-Based Incentive Payment System for Surgical Health Care Professionals” JAMA Surgery November 22, 2023. doi:10.1001/jamasurg.2023.5638

Public Health

McKinsey: Global poverty: Of the 8.1 billion global population.

• 4.7 billion people, or 58% of the global population, live below the economic empowerment line—the point in which individuals can meet their essential needs and begin to achieve security. 730 million (9%) live in extreme poverty.
• Upward of 2.3 billion people worldwide lacked access to adequate food in 2020, according to the UN Food and Agriculture Organization.

Food for thought on Thanksgiving Day McKinsey November 23, 2023 ://www.mckinsey.com/featured-insights/themes/food-for-thought-on-thanksgiving-day

CDC: Youth Cancer Mortality rate decline: Data from the National Vital Statistics System NCHS Data Brief No. 484, November 2023:

• From 2001 to 2021, the cancer death rate for youth ages 0–19 years in the United States declined 24%, from 2.75 to 2.10 per 100,000.
• Declines between 2001 and 2011 in cancer death rates occurred for all age groups (0–4, 5–9, 10–14, and 15–19 years), but only rates among those ages 0–4 and 5–9 declined through 2021.
• Declines between 2001 and 2011 in cancer death rates occurred for Black non-Hispanic, White non-Hispanic (subsequently, White), and Hispanic youth, but only rates for White youth continued to decline through 2021.
• Brain cancer was the most common cancer-causing death in youth in 2021, with a rate (0.59) that was 23% higher than the rate for leukemia (0.48) and more than twice that of bone and articular cartilage cancer (0.25).

Curtin SC, Anderson RN. Declines in cancer death rates among youth: United States, 2001–2021. NCHS Data Brief, no 484. Hyattsville, MD: National Center for Health Statistics. 2023. DOI: https://dx.doi.org/10.15620/cdc:134499