As state hospital association leaders assemble in Big Sky, Montana this week, the environment for hospital-friendly legislation is threatening at best:
The public’s trust in hospitals has eroded. Hospital financial performance is a mixed bag: some are profitable and many aren’t. Congress thinks hospitals need more regulation to increase price transparency, require ownership disclosure, verify community benefits that justify tax exemptions and impose restrictions on hospital private equity investments. And programs through which state and federal health policies are authorized—HHS, CMS, FTC, FDA, CMMI et al—are in limbo as a result of the June 28, 2024 Chevron ruling by the Supreme Court.
At a federal level, the American Hospital Association has successfully fended-off a significant portion of proposed cuts to key programs (DSH, rural), delayed Congressional action against facility fees and site neutral payments, influenced improvement from April’s proposed 2025 Medicare rate from 2.6% to 2.9%, advanced legislation to protect healthcare workers and streamline prior authorization business practices by insurers. In most cases, it has pursued a unified agenda alongside its Coalition (America’s Essential Hospitals, the Federation of American Hospitals, the Catholic Health Association and the Association of American Medical Colleges , Children’s Hospital Association et al) and it has invested heavily in its lobbying: $6.46 million in the second quarter 2024 (plus $4.1 million by HCA, AAMC, Tenet and others).
At the state level, the attention hospitals get is equally intense but more complicated: It starts with money and demand: Examples:
- State resources: 9 states don’t tax any income, regardless of the source (AL, FL, NV, NH, TN, SD, TX, WA, WY); 4 states don’t tax any retirement income: (IL, IA, MS, PA); 8 states tax social security benefits (CO, MN, MT, NM, RI, UT, VT, WV)
- Population health status: WalletHub used 44 measures to assess each state and the District of Columbia on healthcare cost, access, and outcomes. WalletHub weighted the three categories equally. The Top 5: MN, RI, SD, IA, NH; the bottom 5: MS, AL, WV, GA, OK
There are Blue and Red states. Some are growing and some declining. All are integrating more diverse populations and divergence between low- and high-income household financial security and spending. The health system, and its hospitals, impact all.
Healthcare spending for state employees, Medicaid and dual eligible enrollees and public health programs consume a third or more of total state spending. And actions taken in states vis a vis ballot referenda, executive orders, administrative agency rulings and legislative actions result in wide variance in the regulatory environments for hospitals. Consider:
- 32 states have passed legislation to lower health system costs
- 31 states have CON requirements (24 of these have been revised since 2021).
- 15 states have passed laws to reduce or eliminate facility fees including hospitals
- 17 have passed legislative to increase competition in healthcare
- 23 passed legislation to reduce surprise medical bills
- 9 have passed legislation to address community benefit declarations by NFP hospital and health systems.
- 9 have passed legislation to reduce insurer prior authorization obstacles.
- 13 passed legislation involving reference pricing requirements for hospitals
- 8 states passed legislation requiring minimal levels of primary care services
- 24 modified their Certificate of Need programs
- 3 states have all-payer payment policies.
- 8 states have drug price control commissions/mechanisms to limit price increases.
- And all are grappling with determinations about abortion services, drug formulary design for Medicaid, state health employee health costs, Medicaid eligibility and funding, staffing requirements in hospitals and nursing homes, rural health solvency, telehealth efficacy, insurer plan design restrictions, and scope of practice expansion for nurse practitioners, pharmacists and much more.
The advocacy environment for hospitals at the state and federal levels will be dicier going forward: the near-term macro-environment is unwelcoming for hospitals presumed to have returned to profitability after the pandemic. It’s root in four convergent issues:
- Economic Uncertainty: Last week’s BLS jobs report signaled softening of the economy and alarmed some thinking it a harbinger of a possible recession.
- Middle East Tension: the Israeli-Palestinian conflict appears headed toward a broader regional conflict involving Lebanon, Iran and others.
- Campaign 2024: hyper-partisanship coupled with disinformation on both sides lends to voter unrest: healthcare affordability, price transparency, consolidation, executive compensation and inequity are ripe targets.
- Healthcare Workforce Disenchantment (including Physicians): Hospitals directly employ half of the physician workforce and 30% of total health industry employment. Labor-management tension in hospitals is mounting.
For hospitals, effective advocacy is imperative: the reservoir of good will enjoyed for decades is evaporating. Advertising “we’re there for you” is timely as rural providers need a lifeline, and public castigation of “corporate insurers and billionaire critics” necessary to rally supporters. But beyond these, two things are clear:
- The marketplace for “hospitals” is fundamentally different than the past requiring a clearer value proposition and fresh messaging.
- And in states, hospitals will encounter unique opportunities and challenges in plotting strategies for their future. No two are alike.
Big Sky is a symbolic locale for this week’s meeting of state health executives: the Big Sky over hospitals is cloudy.
Paul
P.S. Workforce issues continue to challenge hospitals, long-term care providers and medical practices. In the first of its investigative series “The Nurse will see You Now” release last week, Bloomberg provides a provocative assessment of the growing role nurse practitioners play in the system—the wide clinical variability in their 600 training programs, emergent roles and responsibilities, and more. It’s worth reading. (See workforce section below)
Resources: See citations below
Sections in Today’s Report
- Quotables
- Congress
- Economy
- Employers
- Hospitals
- Insurers
- Physicians
- Polling
- Prescription Drugs
- Public Health
- Workforce
Quotables
Re: health system transformation: “U.S. healthcare is broken… the U.S. healthcare system requires revolutionary transformation to overcome an artificial economic model riddled with perverse incentives that reward activity and treatment over outcomes and prevention. That transformation now is upon us…The coming revolution will happen from the outside in. It will be messy. As a consequence, most industry incumbents have lost control of their destiny. For better and worse, external forces will shape their futures.
U.S. healthcare is at an inflection point. The delivery of healthcare services will change more in the next 10 years than in the last 100. Ultimately, this is good news for American consumers who can expect better care services at lower costs with greater convenience. The coming healthcare revolution, however, will eviscerate incumbents that cling to inefficient and ineffective business practices.”
David Johnson, 4Sight Health
Re: not-for-profit hospital systems, executive compensation: “The health economy has amazingly not taken much more of the overall economy since 2010. It went from 13% to 17% of GDP between 2000 and 2010 but has amazingly stayed around there–only popping up during the Covid recession and then heading down again. But the amount of money flowing into health care has stayed at a constant rate. And the American people continue to hate their experience with the health system.
They’re aren’t many selfless heroes. Payers, providers, doctors, pharma, equipment suppliers are all doing well…Over the last 30 years America’s venerable community and parochial hospitals merged into large health systems, mostly to be able to stick it to insurers and employers on price. Blake Madden put out a chart of 91 health systems with more than $1bn in revenue this week and there are about 22 with over $10bn in revenue and a bunch more above $5bn. You don’t need me to remind you that many of those systems are guilty with extreme prejudice of monopolistic price gouging, screwing over their clinicians, suing poor people, managing huge hedge funds, and paying dozens of executives like they’re playing for the soon to be ex-Oakland A’s. A few got LA Dodgers’ style money. “
Re: not-for-profit health systems tax exemptions: “One owns a for-profit insurer, a venture capital company, and for-profit hospitals in Italy and Kazakhstan; it has just acquired its fourth for-profit hospital in Ireland. Another owns one of the largest for-profit hospitals in London, is partnering to build a massive training facility for a professional basketball team, and has launched and financed 80 for-profit start-ups. Another partners with a wellness spa where rooms cost $4,000 a night and co-invests with leading private equity firms.
Do these sound like charities?
These diversified businesses are, in fact, some of the country’s largest nonprofit hospital systems. And they have somehow managed to keep myriad for-profit enterprises under their nonprofit umbrella — a status that means they pay little or no taxes, float bonds at preferred rates, and gain numerous other financial advantages.
Through legal maneuvering, regulatory neglect, and a large dollop of lobbying, they have remained tax-exempt charities, classified as 501(c)(3)s…
Bottom of Form
Hospitals get their tax breaks for providing “charity care and community benefit.” But how much charity care is enough and, more important, what sort of activities count as “community benefit” and how to value them? IRS guidance released this year remains fuzzy on the issue.”
Academics who study the subject have consistently found the value of many hospitals’ good work pales in comparison with the value of their tax breaks. Studies have shown that generally nonprofit and for-profit hospitals spend about the same portion of their expenses on the charity care component…”
Attorneys general, who regulate charity at the state level, could also get involved. But, in practice, “there is zero accountability,” West said. “Most nonprofits live in fear of the AG. Not hospitals.
Today’s big hospital systems do miraculous, lifesaving stuff. But they are not channeling Mother Teresa. Maybe it’s time to end the community benefit charade for those that exploit it, and have these big businesses pay at least some tax. Communities could then use those dollars in ways that directly benefit residents’ health.”
Why Many Nonprofit (Wink, Wink) Hospitals Are Rolling in Money – KFF Health News
Re: physician employment by hospitals: “The hundreds of thousands of doctors that hospitals hired over the last decade or so aren’t quite as good of a deal anymore, hospital allies say, and policymakers’ responses to that consolidation could make the arrangement straight-up unsustainable.
Why it matters: There are plenty of economists who shed no tears at the idea of hospitals making less money, especially at taxpayers’ and patients’ benefit. But if a substantial number of hospital CEOs decide it doesn’t make sense anymore to employ so many doctors, it could really shake up the health care landscape. Research has shown that health care costs go up when hospitals acquire physicians, which translates to higher hospital revenues, which is part of why they’re attractive to health systems in the first place…
State of play: More than half of doctors are employed by hospitals or health systems, at least according to one study, a drastic increase from when hospitals only employed a quarter of doctors in 2012.
- Another 22.5% of doctors are employed by insurers, private equity or other “corporate entities,” as the Physicians Advocacy Institute-Avalere study puts it. Altogether, nearly 80% of America’s physicians are employed by someone else.
- But hospitals and their allies have been warning that the cost of employing physicians is much higher than the direct revenue they bring to the hospital — to the tune of a nearly $300,000 annual deficit per physician, according to Kaufman Hall, a hospital-friendly consulting firm. That deficit was only $177,000 in 2018, according to the firm.
- That number generally excludes what I’ll refer to as indirect revenue brought in by hospital-employed doctors, such as facility fees that hospitals charge in addition to the doctors’ fees or revenue brought in from referrals for other services.
Reality check: That downstream revenue still almost certainly offsets what hospitals “lose” on employing physicians, economists say — or else they wouldn’t continue to do it…And while national hospital groups are sounding the alarm about hospital finances, the reality is there’s wide variation in how hospitals are performing — with plenty of them doing just fine.
Axios Future of Health Care “”1 big thing: How hospital doctor deals could go south August 3, 2024
McKinsey senior partner Sajal Kohli on today’s consumer and brand loyalty in a recent episode of The McKinsey Podcast
Re: clinical evidence:” Respect for the scientific process and a diversity of views; open discourse and debate based in principles of ethics, evidence, and scientific inquiry and integrity; and an understanding of evidence gaps, uncertainty, and how to communicate them are important values in the advancement of science and the practice of medicine…
Complicated decisions should be based on wide and public debate. Suggestions during the COVID-19 pandemic in social media postings “that nuanced questions have universally correct answers” were not helpful. Perhaps revisiting 1921 would have lent some wisdom, when, on the heels of influenza pandemic, JAMA published an article on the scientific method. The article stressed that science is a process of verification and described “the cultivation of a strong and vigorous skepticism as the most valuable attribute of a scientist… Never was there a time when such skepticism was needed more than at present” One hundred years later, in another pandemic era and beyond, never is it needed more—again.”
Congress
2Q 2024 health lobby spending: The analysis by Fierce Healthcare identified lobbying spending for the top 30 healthcare organizations in the second quarter., 2024: The top 10:
- American Hospital Association (AHA) $6.46 million.
- AARP (formerly the American Association of Retired Persons) $5.46 million
- American Medical Association (AMA) $5.32 million
- Pharmaceutical Care Management Association 3.83 million.
- Oracle also ranked in the top five, spending $3.3 million.
- CVS and its subsidiaries $2.79 million.
- America’s Health Insurance Plans $2.66 million
- Cigna $2.60 million
- UnitedHealth Group $1.91 million
- Elevance $1.83 million
Healthcare advocates spent millions this quarter for policy change. Here are the top 30 spenders Fierce Healthcare July 26, 2024
Economy
BLS July 2024 Survey Results: Highlights:
- Household Survey Data: The unemployment rate rose by 0.2 percentage point to 4.3% in July, and the number of unemployed people increased by 352,000 to 7.2 million. These measures are higher than a year earlier, when the jobless rate was 3.5%, and the number of unemployed people was 5.9 million.
- Establishment Survey Data: Total nonfarm payroll employment edged up by 114,000 in July, below the average monthly gain of 215,000 over the prior 12 months. In July, employment continued to trend up in health care, in construction, and in transportation and warehousing, while information lost jobs. Health care added 55,000 jobs in July, similar to the average monthly gain of 63,000 over the prior 12 months. In July, employment rose in home health care services (+22,000), hospitals (+20,000), and nursing and residential care facilities (+9,000).
Employment Situation Summary – 2024 M07 Results (bls.gov)
Analysis: Jordan Keckley, CPA, MFA: “…the unemployment rate is by definition a lagging indicator, and is highly contingent on labor force flows which always cause it to increase non linearly late cycle. Absent an understanding of how it’s calculated and what influences labor force flows, the unemployment rate in isolation tells you basically nothing…. key takeaways:
- Growth in Private Education & Health Services (which is primarily healthcare) as well as Government jobs have been masking weakness in the labor market for quite some time now. The quality of job growth has been poor at best because there isn’t broad participation across all industries.
- Unemployment components suggest that Job losers not on layoff (i.e. permanent job losers) is starting to materially increase which is a textbook recessionary signal. To be clear, Job losers on layoff are individuals who are temporarily out of work, but expect to be hired back.
That’s a long-winded way of saying the unemployment rate will move higher from here because layoffs are picking up. It’s much more productive to simply analyze the year over year change in the stock of jobs (by industry) to see where growth is slowing (if at all).
Jordan Keckley CPA (33) Post | LinkedIn
Analysis: Axios: “There’s a bit of a “boy who cried recession” phenomenon now. The fact that many forecasters made incorrect recession predictions two years ago is fueling complacency about the possibility that a serious downturn will arrive soon.
Reality check: Subtle but worrying signs in economic data over the past several weeks have shown cracks in what has been a robust post-pandemic expansion. The July jobs numbers, out yesterday, were the least subtle and most worrisome of them all.
What we’re watching: Whether interest-rate cuts that the Fed is nearly certain to commence at its mid-September policy meeting will be enough to arrest the emerging economic weakening before it goes too far.”
Axios AM August 3, 2024
JP Morgan Report: Household preparedness for emergency expenses: “We find that most households have sufficient liquidity to weather moderate expense shocks, and that sources of liquidity beyond cash savings are the key to many households’ ability to weather an emergency expense. Overall, 8% of our sample is unable to cover a $400 expense shock by any combination of cash on hand, disposable income, or use of short-term credit. Additional findings:
- 77% of low-income households can cover an unexpected $400 expense, though many must cover it with disposable income or short-term credit.
- 43% of low-income households unable to weather small expense shocks might be able to pay them with access to additional credit.
- White and Asian households, middle-aged households, and multi-person households are better able to cover an unexpected expense than their counterparts.
How vulnerable are Americans to unexpected expenses? | JPMorganChase
Food prices: “Americans in the past two years spent more of their income on food than they have in three decades. Food prices have become a hot-button issue on the campaign trail as U.S. presidential candidates and other politicians debate economic issues ahead of November elections…. Last fiscal year, each of the 10 largest U.S. restaurant chains by market value posted a profit that met or surpassed 2019 levels…
Big food manufacturers booked similar results…Gross margins for many food makers are at or near prepandemic levels….
Food executives have said they haven’t gouged consumers and are working to keep prices as low as possible… Still, more than 70% of consumers believe that restaurants, supermarkets and food manufacturers are overcharging……Some food executives and analysts have warned that wooing consumers back will be a slow process or require more investments than companies anticipate.”
After Years of Raising Prices, Food Companies Hit Consumers’ Limits – WSJ
Employers
Gallagher Report: Employer strategy: Per Gallagher’s 2024 U.S. Physical & Emotional Wellbeing Report based on responses from 3552 organizations:
- 52% say they effectively manage healthcare costs.
- 92%, of the more than 3,500 organizations said they’ve experienced health plan premium increases during their most recent renewal and one-quarter experienced double-digit increases.
- 80%, offer more than one medical plan, with consumer-directed health plans with health savings accounts among the fastest-growing plan type. With about 56% offering the lower-cost consumer-directed plans with HSAs, up by 16% from 2020; a quarter of these organizations, 24%, enroll more employees in their CDHP with an HSA than any other plan.
- 14% use designated centers of excellence for specific medical procedures. Incentives include lower out-of-pocket costs, travel accommodations to the site of care, or both.
- 70% noted concerns about the impact of stress and burnout on their employees; 42% say their managers are well equipped to refer employees to mental health support services.
Gallagher’s 2024 U.S. Physical & Emotional Wellbeing Report https://www.ajg.com/us/2024-us-workforce-trends-report-physical-and-emotional-wellbeing-report/
Class Action lawsuit against Wells Fargo over prescription drug costs: A lawsuit filed in federal court in Minnesota last Tuesday alleges that Wells Fargo, the country’s fourth-largest bank, wasted money in its health plan causing workers to pay far more for medications—a violation of the Employee Retirement Income Security Act (ERISA), which mandates that companies manage employee health and retirement plans prudently.
This is at least the second lawsuit from workers alleging they paid more than they should have for medications because their employers struck bad deals with the companies that oversee drug benefits for health plans, known as pharmacy benefit managers. In February, a Johnson & Johnson worker made similar claims against the drugmaker in a New Jersey federal court.
Hospitals
Strata: Hospital operating expenses 2Q 2024: Highlights from the June data include:
- Median operating margins July2023-June 2024: Health systems from +.6% to +2.3%; Hospitals from +1.1% to +4.9%
- Inpatient admissions July2023-June 2024: +3.6% to +4.9%.
- Total expense is up 4.8% and inpatient revenue is up 5.7% from prior year.
- Labor expenses were up 5.2% increase from prior year. Patient volumes were down across most measures in June, with outpatient visits seeing some of the biggest declines, down 4.2% year-over-year and 10.2% month-over-month. Median physician expenses remained high at $1.08 million for the quarter, up 16.3% from the second quarter of 2023.
“This report uses data from Comparative Analytics and Strata’s StrataSphere® database. Comparative Analytics offers access to near real-time data drawn from more than 135,000 physicians from over 10,000 practices and 139 specialty categories, and from 500+ unique departments across more than 1,600 hospitals.”
PK Note: The Strata methodology differs from the more widely-recognized Vizient Kaufman Hall approach. In Its most recent Flash Report, released July 9, 2024 it reported a 3.8% operating margin for hospitals in May 2024 vs.1.9% for June 2023. “The National Hospital Flash Report uses both actual and budget data over the last three years, sampled from more than 1,300 hospitals on a recurring monthly basis from Syntellis Performance Solutions, now part of Strata.” Axios refers to Kaufman Hall as a “hospital-friendly” data source.
Median hospital labor expenses up 5.2%https://www.stratadecision.com/monthly-healthcare-industry-financial-benchmarks/ July 30, 2024
National Hospital Flash Report: May 2024 Metrics | Kaufman Hall
Study: Private equity-acquired hospitals: Researchers compared 242 acute care hospitals acquired for the first time by PE between 2005 and 2018 to 870 matched control hospitals not acquired by PE. had, on average, similar earnings and operating margins as their non-PE-acquired counterparts, but carried a lot less debt and owned more of their assets.
“As a share of total revenue, PE hospitals had, on average, similar earnings and operating margins before acquisition as their non-PE counterparts. However, PE hospitals carried substantially less debt before acquisition—equity ratio of 0.97 vs 0.43—meaning that PE hospitals owned about 50 percentage points more of their assets than did control hospitals.
Among the 100 hospitals acquired on or after 2010, PE hospitals had similar rates of in-hospital mortality and hospital-acquired conditions before acquisition
PE hospitals were, on average, not worse off financially or clinically than comparable non-PE hospitals before acquisition. On the contrary, PE hospitals carried less debt and owned more of their inherent value before acquisition, likely representing more financial stability…. These findings do not support the notion that PE investments generally target struggling hospitals and instead support broader evidence that PE firms target successful entities for acquisition.”
Financial and Clinical Characteristics of Hospitals Targeted by Private Equity Firms JAMA Intern Med. Published online July 29, 2024. doi:10.1001/jamainternmed.2024.3319
Study: Hospital acquisition by private equity: The assets of 156 acquired hospitals decreased by a mean of 15% in the 2 years after acquisition while the assets of 1,560 non-acquired control hospitals increased by 9.2% during that timeframe, reported researchers led by Elizabeth Schrier, MD, of the University of California San Francisco.
Hospital Assets Before and After Private Equity Acquisition July 30, 2024 https://jamanetwork.com/journals/jama/article-abstract/2821826
Court challenge: Hospitals v. CMS Payments: Last Monday (July 29), the American Hospital Association, Federation of American Hospitals, America’s Essential Hospitals and the Association of American Medical Colleges filed an amicus brief in the U.S. Court of Appeals for the District of Columbia in support of hospitals’ continued right to seek immediate review of any Centers for Medicare & Medicaid Services determination: Excerpts:
“This case concerns whether providers may seek review of CMS determinations immediately, or instead must wait months or years to ask CMS to correct a mistake. Amici have a strong interest in the answer to that question (p.15)
The determination at issue here epitomizes the actions Congress intended to make immediately reviewable. Plaintiffs challenge CMS’s June 2009 decision to count Medicare Part C enrollees toward hospitals’ Part A populations in calculating the Medicare fractions for Fiscal Year (FY) 2007… “(p. 16-17)
UNITED STATES COURT OF APPEALS FOR THE DISTRICT OF COLUMBIA CIRCUIT BATTLE C REEK HEALTH SYSTEM, et al., Plaintiffs-Appellees, v. XAVIER B ECERRA, S ECRETARY OF THE UNITED S TATES DEPARTMENT OF HEALTH AND HUMAN S ERVICES, Defendant-Appellant
Updated CMS Star Ratings 2024: The Centers for Medicare and Medicaid Services’ (CMS) 2024 hospital star ratings, released July 31, showed more hospitals than last year performed poorly. “That may be, in part, because the data submitted by hospitals was from April 2019 through March 2023 and excluded facilities’ performance on quality metrics from the first half of 2020.” Highlights
- Across peer groups and facility types, nearly 10% of the 2,834 hospitals CMS rated received one star, 21% got two stars, 29% got three stars, 27% earned four stars and 13% got five stars.
- The number of hospitals that scored one star increased by nearly 30 facilities compared with 2023; 100 fewer hospitals received five stars.
- Critical access hospitals and acute care facilities had 24 and 81 fewer five-star ratings, respectively. More Veterans Administration hospitals — 35% versus 32% in 2023 — received five stars.
- Compared with last year, 227 fewer hospitals were rated. In part, the dip is due to hospitals being unable to report on enough measures for CMS to calculate a star rating.
- Overall, 51% of hospitals kept the same star rating this year. In large part that’s because most facilities are acute care hospitals and they maintained their 2023-star rating.
Hospitals | Provider Data Catalog (cms.gov)
Coalition Report: ED Use in 2021: Based on KNG Consulting’ analysis of the 2021 National Hospital Ambulatory Care Survey:
- Children accounted for 21% of ED visits in 2021. Most of these visits (55% or 15.3 million) occurred after-hours.
- Of the 136 million ED visits in 2021, 18.1 million occurred in rural areas.
- 3 million ED visits were related to trauma.
- Two-thirds of overdose and poisoning-related ED visits occurred after-hours in 2021
Coalition to Strengthen America’s Healthcare | Join Us (strengthenhealthcare.org)
Insurers
United-HCA standoff in TX, CO, SC & NH: “The country’s biggest private health insurer, UnitedHealthcare, and its biggest hospital chain, HCA Healthcare, are in a dispute with huge potential consequences. If they can’t strike a deal on prices by Sept. 1, 38 hospitals and their affiliated physician groups and surgery centers across four states — Texas, Colorado, South Carolina, and New Hampshire — would become out-of-network for UnitedHealthcare members.”
UnitedHealth and HCA clash over hospital chain’s rates in ‘battle of the giants’ STATNews August 2, 2024
Physicians
AMIA Survey: Physician views about clinical documentation: Percentage of physicians who agree with statement:
- The amount of time and effort I spend documenting patient care is appropriate: 12.5%
- I finish work later than desired or need to do work at home because of excessive documentation tasks: 83.1%
- Recently, there has been a noticeable decrease in the time or effort or both needed for me to complete my documentation tasks: 13.7%
- The effort or time required for me to complete documentation tasks impedes patient care: 80%
- I find it easy to document patient care using the electronic health record: 21.9%
American Medical Informatics Association (AMIA), Trend Burden Pulse Survey, June 2024
Polling
Study: Trust in physicians and hospitals during pandemic: To assess how public trust in hospitals and physicians changed during the pandemic, 24 surveys were conducted between April 1, 2020, and January 31, 2024, involving 443,455 unique respondents aged 18 years or older residing in the US. Findings:
- “Overall, the proportion of adults reporting a lot of trust for physicians and hospitals decreased from 71.5% in April 2020 to 40.1% in January 2024.
- In regression models, features associated with lower trust as of spring and summer 2023 included being 25 to 64 years of age, female gender, lower educational level, lower income, Black race, and living in a rural setting. These associations persisted even after controlling for partisanship. “
This survey study of US adults suggests that trust in physicians and hospitals decreased during the COVID-19 pandemic. As lower levels of trust were associated with lesser likelihood of pursuing vaccination, restoring trust may represent a public health imperative.”
Gallup-West Health on Affordability: “The percentage of U.S. adults readily able to access and afford quality healthcare when they need it has dropped six percentage points since 2022 to 55%, the lowest since West Health and Gallup began tracking healthcare affordability in 2021.
Although adults aged 50 and older are more likely than those younger than 50 to be “cost secure” — meaning they have had no recent problems affording care or medicine and can easily access care — their scores have fallen faster and further over the past two years. The percentages of cost secure adults aged 50 to 64 and 65 and older have both dropped eight points since 2022, to 55% and 71%, respectively. At the same time, the percentage of younger adults has slipped five points, from 52% to 47%.”
The West Health-Gallup Healthcare Affordability Index is part of the West Health‑Gallup 2024 Survey on Aging in America, conducted by web and mail from Nov. 13, 2023, to Jan. 8, 2024, with 5,149 adults aged 18 and older, living in all 50 U.S. states and the District of Columbia.
In U.S., Affording Healthcare More of a Struggle Since 2022 July 17, 2024 https://news.gallup.com/poll/646994/affording-healthcare-struggle-2022.aspx
Gallup-Walton Family Foundation Survey: Mental health status: The poll of 1,625 kids and their parents or guardians was conducted March 13-20, 2024. Highlights:
- In the last 24 hours, 23% felt sadness, 38% anxiety, 45% stress, and 94% happiness.
- Negative feelings were more common among girls and teenagers between 16-18 years old and least common among Black youths.
- The most common ways kids reported making themselves feel better were listening to music (58%), playing video games (45%), connecting with friends (45%) or talking about their feelings (39%).
- Social media was lower on the list of coping mechanisms: 31% said they went on YouTube, and 20% more generally to platforms.
- Both 13- to 15-year-olds and 16- to 18-year-olds were likely to say they wanted their parent to “give them space.” Fewer than a third across age groups wanted advice.
Gallup Survey Details Gen Z Struggles with Stress, Anxiety and “Need to be Perfect” (waltonfamilyfoundation.org) July 30, 2024
U of MI Aging Survey: Per its National Poll on Healthy Aging based on survey responses from 3300 adults 50+ conducted in February-March, 2024:
- The health-related issues poll respondents were most commonly very concerned about for older adults in their communities included: cost of medical care (56%), cost of home care, assisted living, or nursing home care (56%), and cost of prescription medications (54%).
- Women were more likely than men to be very concerned about financial scams and fraud (59% vs. 47%) for older adults in their communities.
- Discrimination by age was very concerning for 42% of Black, 32% of Hispanic, and 18% of White older adults
16th Annual J.D. Power 2024 U.S. Pharmacy Study key findings:
Brick-and-mortar pharmacies lose ground to mail order: “Even the top-performing brick-and-mortar pharmacies saw overall satisfaction scores decline more than 10 points this year, while satisfaction scores for mail order pharmacies have increased 6 points, on average.”
Retail pharmacists excel on communication but do not foster trust: Brick-and-mortar pharmacies are excelling in pharmacists’ communication with customers, with 89% of them indicating that their pharmacist’s explanation was understood—a significant positive change from 2023. That said, just 51% say prescriptions were filled quickly, and only 51% say their pharmacist is trustworthy.
The 2024 study is based on responses from 13,505 pharmacy customers who filled a prescription within the past 12 months and was fielded from September 2023 through May 2024
2024 U.S. Pharmacy Study | J.D. Power (jdpower.com)
Prescription Drugs
Status: community pharmacies: “Community pharmacies are facing an existential crisis. According to the National Community Pharmacists Association, there are 2,200 fewer retail pharmacies in the country than there were in 2020. Walgreens, CVS, and Rite Aid have all announced closures . Many pharmacists are pushing to unionize as they struggle to protect patient health in challenging work environments.
A recent MedPage Today Perspectives piece criticized community retail pharmacies for being “transactional” and not attending to patients’ needs. And media attention more broadly over the last year or so has highlighted issues with pharmacies, from medication access delays to dosing errors. But this coverage often fails to tell the whole story. Much of the problem is out of the hands of community pharmacies; there are much larger systemic issues that trickle down and complicate the work we do. “
Community Pharmacy Gets an Unfairly Bad Rap | MedPage Today
Generic drug supply chain: “The generic drug business has become a hostile environment for American companies. Prices for the often-critical medicines have dropped so low that it has become difficult for U.S. manufacturers to compete with companies overseas.
One after another, generic-drug makers have gone bankrupt or moved their operations overseas or cut the number of products they offer. The number of facilities making generic drugs in their final form in the U.S. has dropped by roughly 20% since 2018, to 243….
Drug shortages have become common. Today, 300 medicines are in short supply…For years, U.S. plants produced pills that Americans relied on to relieve everything from headaches to heartburn. Yet their prices kept rising, triggering cost-control efforts like the authorization of lower-priced, or generic, versions of drugs that lost patent protection.
Pharmaceutical manufacturing plants started popping up overseas. Because their labor and other costs were less than U.S. factories, they could sell generic medicines at lower prices.”
America Is Running Out of Generic Drugmakers. Another One Is on the Brink. – WSJ
Industry response to IRA: “A market rotation is playing out across large pharmaceutical companies… the industry seems to be weathering regulatory storms well.
One of the biggest concerns for pharmaceutical companies in recent years has been drug-pricing pressure stemming from the Inflation Reduction Act (IRA), which for the first time empowered Medicare to directly negotiate how much it pays for some high-price therapies.
Last year, the U.S. government named the first 10 drugs that will be subject to the negotiations, taking aim at some of the most widely used medicines in America. But what has been unclear is just how steep a discount the government would seek.
Management teams will continue to bemoan the law’s alleged impact on innovation. But a close reading of industry earnings calls this month suggests executives are telegraphing to investors that the impact won’t be so bad…
Besides allowing Medicare to negotiate prices, another provision limiting what people on Part D plans pay out of pocket for medications at $2,000 annually starting in 2025 is also expected to negatively affect some manufacturers, because it forces them to offer more discounts once patient spending reaches a certain threshold….
Obesity hype aside, Big Pharma once again looks like good value for your money.”
Big Pharma Rallies and Moves Past Obesity – WSJ
Public Health
State Public Health Issues: Association of State and Territorial Health Officials (ASTHO) www.astho.org
- Workforce:
- Mental Health:
- Overdose Prevention and Substance Misuse:
- Sexually Transmitted Infections (STI) Prevention:
- Data Systems Modernization and Privacy: Po
- Preventing the Spread of Infectious Disease:.
- Access to Evidence-Based Reproductive Health Services and Family and Child Health:
- Optimal Health for All:
- Environmental Health:.
- Tobacco and Nicotine
Association of State and Territorial Health Officials (ASTHO) www.astho.org
SAMHSA Report: Mental health, substance abuse stats: Last Tuesday (July 30), HHS’ Substance Abuse and Mental Health Services Administration (SAMHSA) released the results of its 2023 National Survey on Drug Use and Health (NSDUH). Highlights:
- Mental Health: Among adults aged 18 or older in 2023, 22.8% (or 58.7 million people) had any mental illness (AMI) in the past year.4.5 million youth (ages 12 to 17) had a major depressive episode in the past year, of which nearly 1 in 5 also had a substance use disorder. Among adults aged 18 or older in 2023, 5.0% (or 12.8 million people) had serious thoughts of suicide, 1.4% (or 3.7 million people) made a suicide plan, and 0.6% (or 1.5 million people) attempted suicide in the past year.
- Substance Use: In 2023, 3.1% of people (8.9 million) misused opioids in the past year, which is similar to 2022 and 2021 (3.2% and 8.9 million, 3.4% and 9.4 million respectively).Among the 134.7 million people aged 12 or older who currently used alcohol in 2023, 61.4 million people (or 45.6%) had engaged in binge drinking in the past month. Marijuana was the most commonly used illicit drug, with 21.8% of people aged 12 or older (or 61.8 million people) using it in the past year.
- Services and Recovery:9% of adolescents aged 12 to 17 (or 8.3 million people) received mental health treatment in the past year, an increase of more than 500,000 from 2022. 23.0% of adults aged 18 or older (or 59.2 million people) received mental health treatment in the past year, an increase of 3.4 million from 2022.
Mental Health, substance abusehttps://www.hhs.gov/about/news/2024/07/30/samhsa-releases-annual-national-survey-drug-use-and-health.
Report: American Cancer Society Disease Prevalence: The ACS study used data from 23.7 million patients dating back to 1920 through 1990 to classify people based on their birth year. Highlights:
- Adults in their 30s, 40s and 50s are more likely than previous generations to develop 17 different types of cancers, including breast, liver and pancreatic cancers.
- Previous research has indicated alarming increases in certain cancers among younger adults, such as colorectal cancer.
- Of 34 cancers examined, half had increased incidence among younger adults
- Incidence of eight different cancers increased with each successive age cohort after 1920.
- In particular, adults born in the 1990 cohort were 2-3 times more likely to get cancers of the small intestines, kidney and pancreas (as well as the liver and bile duct in women) compared with those in born in the 1955 cohort at the same age.
- In the case of five cancers — liver and endometrial in females, as well as gallbladder, testicular and colorectal cancers — young adults were more likely to die compared with prior generations.
WalletHub Healthiest State Rankings 2024: Here are the 10 best and worst states for healthcare in 2024 in order:
- Best:Minnesota, Rhode Island, South Dakota, Iowa, New Hampshire, Massachusetts, Utah, Vermont, Maine, Colorado
- Worst: Mississippi, Alabama, West Virginia, Georgia, Oklahoma, Alaska, Texas, Arkansas, Louisiana, Florida
Additional notes:
- Minnesota (ranked No. 1 overall) placed second in cost rank, sixth in access and 11th in outcomes.
- Iowa (ranked No. 4 overall) placed first in cost, 30th in access and 12th in outcomes.
- Rhode Island (ranked. No. 2 overall) placed first in access, 17th in cost and 6th in outcomes.
- Utah (ranked No. 7 overall) paced first in outcomes, 20th in cost and 34th in access.
Best & Worst States for Health Care (wallethub.com) July 29, 2024
Note: Per WalletHub: the Average Credit Card Debt/person is $6,501 and $10,479/household. In 1Q 2024, total credit card debt is $1.26 trillion—down 14% from 1Q 2023. “The average American household’s credit card balance has increased by more than 79% since 1990, after adjusting for inflation.”
Average Credit Card Debt in 2024 & Historical Balances (wallethub.com) August 2, 2024
Mental health in America Report: Prevalence of mental health issues: On Monday, July 29, Mental Health America (MHA) released its annual report on the state of mental health in the U.S. Highlights:
- 23% of adults experienced a mental illness in the past year, nearly 60 million Americans.
- 5% of adults and 13% of youths reported experiencing severe thoughts of suicide.
- One in five youths had at least one major depressive episode (MDE), over which half of them did not receive treatment. Of those that received treatment, 65 percent stated that it helped.
- In the past year, 18% of adults had a substance use disorder (SUD), of which 77% did not receive treatment.
- One in four adults with mental distress could not see a doctor due to financial concerns,
- 10% of adults and 8.5% of youths have private insurance, which doesn’t cover mental health. There are 340 people for every one mental healthcare provider in the U.S.
- Massachusetts, Connecticut, and Maine were ranked highest for overall mental health and treatment. Nevada, Arizona, and Montana were ranked lowest.
- The number of individuals who died by suicide in 2022 was the highest number ever recorded in the U.S., up after slight decreases in 2019 and 2020.
Reinert, M, Fritze, D & Nguyen, T (July 2024). “The State of Mental Health in America 2024.” Mental Health America, Alexandria VA.
KFF Report: Mental Health of young adults: The share of young adults who received mental health treatment jumped 45% from 2019 to 2022, the largest increase among any age group. More than 1 in 4 young adults (26%) received counseling and/or medication for mental health concerns in 2022, up from 18% three years earlier, according to the analysis of the most up-to-date National Health Interview Survey (NHIS) data available. That was a higher share than among adults in any other age group in 2022.
The Share of Young Adults Receiving Mental Health Treatment Jumped 45% From 2019 to 2022 (kff.org)
Maternal Mortality Rate, U.S. vs Comparable Countries per 100,000 live births (2020)
- United States: 23.8
- Canada: 8.4
- Sweden: 7.0
- Germany: 3.6
- Japan: 2.7
- Austria: 2.4
- Australia: 2.0
- Netherlands: 1.2
- Switzerland: 1.2
- Per 100,000 live births, 2020
“Within the U.S., there are significant racial disparities in maternal mortality rates. The maternal mortality rate for Black mothers is about three times the rate for White mothers — a disparity that persists across age and socioeconomic groups. Every race and ethnicity, socioeconomic, and age group in the United States sees higher maternal mortality rates than the average in comparable countries. Maternal mortality in the U.S. has risen in recent years, sparking concern from the medical community and policymakers. “
KFF, International Comparison of Health Systems, May 2024
Workforce
Bloomberg-Business Week Nurse Practitioner investigation: “The rapid proliferation of nurse practitioners programs in the U.S. is spurring concerns about the quality of training for these advanced practice providers and potential consequences for patient safety.
As happens increasingly in the US, in medical settings ranging from tranquil primary-care offices to chaotic ERs, he was seen instead by a nurse practitioner…After getting an advanced degree—typically a master’s or doctorate in nursing—and an additional license, nurse practitioners are allowed to treat patients in many of the same ways medical doctors do, including diagnosing ailments and prescribing medications…But this ongoing change also involves risks. Poorly trained NPs can pose serious dangers. In the worst cases, patients die…
More than 600 US schools graduated students with advanced nursing degrees in 2022, according to US Department of Education data. That’s triple the number of medical schools training physicians. More than 39,000 NPs graduated in the 2022 class, according to the AANP, up 50% from 2017…”
Bloomberg Businessweek investigative report “Miseducation of America’s Nurse Practitioners “released July 24.https://www.bloomberg.com/news/features/2024-07-24/is-the-nurse-practitioner-job-boom-putting-us-health-care-at-risk?leadSource=uverify%20wall&sref=tA6i1jgy
Governance: Workforce issues get increased Board attention: “The numbers underscore the extent to which talent concerns have escalated in boardrooms: The majority of U.S. public company boards now discuss workforce matters at least quarterly (58%) …That’s a significant jump from the 40% who, in 2020, said they discussed human capital regularly throughout the year. At that time, directors were already reporting an increase in board-level talent conversations, with 79% of directors saying the time their board spent discussing workforce matters had risen since 2015. The majority (69%) reported feeling that the frequency at which they were discussing the talent strategy at the time was “enough” to allow for adequate oversight.
The upswing in board focus on human capital in the past few years has been even more pronounced at larger companies. Among directors on the boards of companies with $10 billion in market cap or more, 78% report that they review human capital data quarterly vs. 22% at companies with a market capitalization of less than $300 million.”
For Many Boards, People Are the Priority – Corporate Board Member
Study: Shortages in dementia specialists: “…neurologists, geriatricians, and geriatric psychiatrists—serve a critical clinical function in diagnosing early-stage Alzheimer’s disease and determining eligibility for treatment with disease-modifying therapies. The availability of dementia specialists is limited and varies across the United States. Using data from the Area Health Resources Files, we found that the median density of dementia specialists across hospital referral regions in United States is 28.8 per 100 000 population aged 65 years and older (interquartile range 19.3-43.6). We derived thresholds of 33-45 dementia specialists per 100 000 population aged 65 years and older as the provider density necessary to care for older adults with mild cognitive impairment and dementia. Based on these thresholds, we estimated that 34%-59% of the population aged 65 years and older resided in areas with potential dementia specialist shortfalls. The extent of potential shortfalls varied by state and rurality. A better understanding of potential gaps in the availability of dementia specialists will inform policies and practices to ensure access to services for people with cognitive impairment and dementia.”
