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Questions the U.S. Delegation to Davos should Bring Home to the U.S. Health System

By May 23, 2022March 1st, 2023No Comments

Questions the U.S. Delegation to the World Economic Forum should Bring Home to the U.S. Health System

At the Davos World Economic Forum this week in Switzerland, 310 government and private sector notables and heads of state will mingle to reflect on the state of world economies in the post-pandemic era. The theme, History at a Turning Point: Government Policies and Business Strategies” reflects recognition that the landscape for global enterprise is not a replicate of the past.

First, attendees will hear results of Edelman’s Trust Barometer (ETB) which gauges views of consumers in 14 countries about business, politics and government. Notably, of 14 big country economies in the ETB analysis, trust in U.S. business stands at 55%–9th among the largest world economies. And trust in U.S. government stands at 45%, 11th on the list. Unflattering at best but understandable. The U.S. tradition of free speech and unbridled criticism stoked by social media lends to low numbers.

Then, attendees will hear government officials and global CEOs opine to the future. Topics on the agenda include rebuilding global cooperation; economic rebalancing; society, equity and global health; nature, food and climate; industry transformation; and innovation, governance and cybersecurity. They’ll get an update on the Davos Alzheimer’s Collaborative (DAC) launched in 2021 to address the 55 million currently living with Alzheimer’s or other forms of dementia at a cost of $1.3 trillion and the status of efforts to expand Covid testing and therapies in developing countries of the world.

Though only 6 of the 310 attendees serve in a formal healthcare role in their organization, healthcare will figure prominently in the week’s discussions.  Access, system effectiveness and affordability impact every country’s economy.  

So, the U.S. delegation should come home with these questions for the U.S. health system:

·        Consideration: The U.S. has the most expensive system in the world but our outcomes are worse than systems that spend less. The fault lies in incentives that are flawed, a structure that’s complicated and inefficient and inadequate investment in preventive health and social determinants that can be mitigated if addressed head-on. Is the status quo sustainable? Are needed changes radical or incremental?

·        Consideration: The U.S. can learn from other systems: provider payments, education and training, medication management and prescription drug utilization, integration of non-allopathic modes of care, supply-chain contracts, between manufacturers, wholesalers and distributors, the roles of individuals, employers and government as payers, and more. Which systems provide the highest value to their citizens? On what key assumptions are their systems built?  

·        Consideration: To mitigate future pandemics and other mass population maladies, serious consideration integration of our public health programs with our health system accompanied by investments that improve the health status of communities and lower costs seem necessary. Does the U.S. system operate as Health OR Human Services or Health AND Human Services? Is there political will to transition the system to an appropriate balance of preventive and sick care?

My take

The pandemic surfaced the importance of health systems to the economies of the world. The U.S. needs to take a fresh look at our system, address its flaws and stop pretending we’re making progress when we’re not.


P.S. Saturday, NBC News broke a story about its investigation of consulting giant McKinsey’s advisory relationship with Rostec, the Russia-owned manufacturer of engines used in 2000 missiles fired  on Ukraine since invading in February. NBC alleges McKinsey was also carrying out “sensitive national security contracts” for the Defense Department and the U.S. intelligence community concurrently. McKinsey countered that its work for Rostec did not constitute a conflict of interest and stated its work was unrelated to weapons deployment by Russia. Investigators found McKinsey’s relationship with Rostec dates back to 2010 and its Defense Department contracts date back 14 years generating $875 million in advisory fees associated with 60 different contracts per USA

“McKinsey has come under scrutiny in Congress for its work with state-owned companies in China including several blacklisted by the federal government. McKinsey also faces accusations of ignoring possible conflicts of interest when it advised both opioid manufacturers (Purdue) and officials regulating opioids at the U.S. Food and Drug Administration paying a fine of $573 million to settle allegations from 49 states that its work for opioid manufacturers helped “turbocharge” sales of the drugs, contributing to a deadly addiction epidemic.“

Per the Edelman Trust Barometer presented this morning at the World Economic Forum in Davos, “when a company ceases business operations in Russia, while still protecting ex-employees based there, respondents are 31% more likely to increase their trust in that company. Conversely, for companies continuing to operate in Russia, respondents are 38% less likely to trust that company.”

Trust matters. Optics matter.

McKinsey & Co. worked with Russian weapons maker even as it advised Pentagon NBC News May 21, 2022

2022 Edelman Trust Barometer Special Report: The Geopolitical Business, visit #TrustBaromete


·        To consumers, the biggest problems in the U.S. are inflation (70%), affordability of healthcare (55%), violent crime (54%), gun violence (51%) and the federal deficit (51%). Covid was noted by 19%, down from 60% in June and last on the list of 12 issues probed. Pew Research April 25-May Poll)

·        76% of patients with long COVID had not been hospitalized for their initial infection 4 months after infection. (FAIR Health)

·        Hospitalizations in the U.S. have risen more than 25% in the past two weeks (CDC)

·        The number of coronavirus deaths globally dropped by 21% in the past week while cases rose in most parts of the world. (World Health Organization).

·        40% of those surveyed said they’ve already had COVID; 31% believe the pandemic is over vs. 69% who disagree. (Axios/Ipsos Coronavirus Index poll May 13-16)

·        300,000 of the one million Covid deaths could have been prevented by vaccines. (Brown School of Public Health, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health and Microsoft AI for Health)

·        32% of older adults in the U.S. who survived COVID infections had symptoms of long COVID up to four months after infection — more than double the 14% rate an earlier study found in adults ages 18 to 64. “Risk of persistent and new clinical sequelae among adults aged 65 years and older during the post-acute phase of SARS-CoV-2 infection: retrospective cohort study” BMJ Feb 9, 2022

Payment Reform, Value

Blum: Need to shift conversation about value: In a Podcast with HFMA President Joe Fifer, CMS Principal Deputy Administrator Jonathan Blum said “I think there has been a loss of confidence that continuation of direction toward more value-based care is the right course for the country. And it’s not lack of confidence within CMS but a sense there is growing fatigue and growing distrust that value-based payment systems will lead to better cost results [and] quality results…I’m personally hopeful that we can change the conversation from a business focus to a more outcome focus, more people focus, more consumer focus, more patient focus.”

HFMA’s Voices in Healthcare Finance

Consolidation, Antitrust

PBMs get attention from FTC: Last week, the Senate voted to approve Biden appointee Alvaro Bedoya to the Federal Trade Commission. Then Republican senators Chuck Grassley (IA) and Mike Braun (IN), alongside Democrat senator Ron Wyden (OR), submitted a letter to FTC chair Lina Khan earlier this week, after the commissioners remained deadlocked in a 2-2 vote in February to formally look into anti-competitive practices at the hands of PBMs.

Bipartisan trio of senators ask FTC to look at PBMs and tactics to keep insulin prices high  Endpoints May 20, 2022


Stock market continues tepid streak into 8th week: The Dow industrials recorded their eighth straight weekly loss last week–the longest such streak since 1932.  The S&P 500 and Nasdaq had their seventh straight weekly loss, their longest such streak since 2001. All three indexes finished the week down at least 2.9%. Economists at Goldman Sachs estimate a 35% probability of the U.S. economy entering a recession sometime in the next two years.

S&P 500 Pares Losses After Hitting Bear-Market Territory Wall Street Journal May 20, 2022

NABE Survey: GDP slowing: Out from the National Association for Business Economics, the median forecaster expects 2022 GDP to rise 1.8%, compared with a median projection of 2.9% in February. (GDP growth was 5.5% in 2021)

NABE Outlook Survey May 2022

Deloitte: Gen Z, Millennials worried about finances: Deloitte’s 11th Annual Global Survey of 14,808 Gen Z’ers and 8,412 millennials found…

·        46% of Gen Z and 47% of Millennials Live paycheck to paycheck and worry that they won’t be able to cover their expenses.

·        26% of Gen Z and 31% of Millennials are not confident they will be able to retire with financial comfort.

The Deloitte Global 2022 Gen Z and Millennial Survey May 10, 2022

Wall Street Journal: small business outlook dims: 57% of small-business owners expect economic conditions in the U.S. to worsen in the next year, up from 42% in April and equal to the all-time low recorded in April 2020; 12% said they expected economic conditions to improve and 28% said they would stay about the same per the May WSJ survey of 600 small businesses.

The measure is one part of a broader confidence index that in May posted its largest year-over-year drop since the Covid-related shutdowns of April and May 2020. Despite rising prices, the portion of small businesses that expects revenue to increase in the coming year fell to 61%, down from 79% in May 2020.

Small Businesses Lose Confidence in U.S. Economy Wall Street Journal May 22, 2022

Altarum: GDP growth higher than health spending increases: Per Altarum’s latest report:

·        National health spending in March 2022 grew by 4.8%, year over year. In the absence of federal government support in 2021 and a lesser amount in 2022, health spending would have grown by 6.8%.

·        For the first quarter of 2022, national health spending was 4.9% above its first quarter 2021 level and would have been 7.1% higher in the absence of federal government support.

·        GDP in March 2022 was 9.7% higher than in March 2021. For the first quarter of 2022, it was 10.6% higher than in the first quarter of 2021. Both rates are significantly higher than health spending growth, even in the absence of federal support.

·        Growth in the overall Health Care Price Index (HCPI) fell slightly in April, rising only 1.9% year over year, less than the 2.3% growth of a month prior and well below economywide inflation.

·        Among major health care categories, physician services and prescription drug prices increased the least in March (0.4% and 1.7% year over year respectively), while home health care and nursing home care prices increased the fastest at 2.4% and 2.3%.

·        Growth in prices paid by Medicare for health care services fell noticeably in April, from 1.1% to 0.2%, while private insurance price growth increased to 3.2% year over year. This represents the largest gap between the two since the by-payer series began in 2014.

May 2022 Health Sector Economic Indicators Briefs May 17, 2022


RAND study: commercial rates for hospitals twice Medicare rates: Key findings of RAND’s analysis of rates for 3100 hospitals:

  • In 2020, across all hospital inpatient and outpatient services (including both facility and related professional charges), employers and private insurers paid 224% of what Medicare would have paid for the same services at the same facilities–down from the 247% figure reported for 2018.

  • Some states (Hawaii, Arkansas, and Washington) had relative prices below 175% of Medicare prices, while other states (Florida, West Virginia, and South Carolina) had relative prices that were at or above 310% of Medicare prices.

  • Prices for common outpatient services performed in ambulatory surgery centers (ASCs) averaged 162% of Medicare payments, but if paid using Medicare, payment rates for hospital outpatient departments (HOPDs) would have averaged 117% of Medicare.

  • Although relative prices are lower for ASC claims priced according to HOPD rules, HOPD prices are higher than ASC prices.

  • Very little variation in prices is explained by each hospital’s share of patients covered by Medicare or Medicaid; a larger portion of price variation is explained by hospital market power.

  • Prices for COVID-19 hospitalization were similar to prices for overall inpatient admissions and averaged 241% of Medicare

Whaley, Christopher M., Brian Briscombe, Rose Kerber, Brenna O’Neill, and Aaron Kofner, Prices Paid to Hospitals by Private Health Plans: Findings from Round 4 of an Employer-Led Transparency Initiative. Santa Monica, CA: RAND Corporation, 2022.

Leapfrog: A third of hospitals get A for safety: In its recent Hospital Safety Grade report assessing safety in 3000 U.S. hospitals across 30 measures:.

  • 33% of hospitals received an “A”

  • 24% received a “B”

  • 36% received a “C”

  • 7% received a “D”

  • Less than 1% received an “F”

Leapfrog Hospital Safety Grade

Study: Hospital CEO turnover: Per Challenger, Gray & Christmas May 18 report: 

·        Nearly 520 CEOs across all industries left between Jan. 1 and the end of April—up 18% since 2021. 

·        36 hospital CEOs exited their roles in the first four months of this year–up from the 20 hospital chiefs who resigned in the same period last year.

Challenger, Gray and Christmas

Advocate Aurora Health, Atrium Health to Merge: On May 11, officials from the two systems announced their intent to merge creating a not-for-profit health system with 67 hospitals in six states (Illinois, Wisconsin, North Carolina, South Carolina, Georgia and Alabama). The system will operate under the Advocate Health name and serve 5.5 million patients annually. Key stats:

·        1,000 sites of care and 67 hospitals that employ 7,600 physicians (including 2600 primary care) and 150,000.

·        Revenues of more than $27.1 billion.

·        2.2 million managed lives across 15 Accountable Care Organizations (ACOs), four Clinically Integrated Networks (CINs) and nearly 60 value-based contracts

·        Medical education programs with nearly 2,000 residents and fellows in 172 programs

In the announcement, leaders noted key value accelerators justify the deal: clinical pre-eminence and safety, health equity, affordability, next-generation workforce, learning and discovery, and environmental sustainability. They also pledged $2 billion to “disrupt the root causes of health inequities across both rural and urban underserved communities, their commitment to achieve carbon neutrality by 2030 and a pledge to create more than 20,000 new jobs across the communities they serve.”

Advocate Aurora Health May 11, 2022

AHA urges DOJ action on Medicare Advantage Denials: The letter from AHA General Counsel Melinda Hatton to Brian M. Boynton, Acting DOJ Assistant Attorney General, Civil Division urged the establishment of a Medicare Advantage Fraud Task Force to conduct False Claims Act investigations into commercial health insurance companies that are found to routinely deny patients access to services and deny payments to health care providers.

Background: an HHS-OIG investigation found that 13% of prior authorization denials and 18% of payment denials actually met Medicare coverage rules and should have been granted.

AHA to Department of Justice Re: False Claims Act investigations AHA May 19, 2022

Private Equity

Humana Joins Welsh, Carson, Anderson & Stowe in Primary Care Joint Venture. May 16, Humana and investment firm Welsh, Carson, Anderson & Stowe (WCAS) announced a joint venture to invest $1.2 billion to develop 100 primary care clinics for Medicare members in the next 3 years. The two organizations have an existing collaboration to invest up to $800 million to open 67 clinics by early 2023. WCAS will own a majority stake in the joint venture, with clinics operating under the Humana’s CenterWell Senior Primary Care brand. 

Humana’s CenterWell Senior Primary Care and Welsh, Carson, Anderson & Stowe Announce Second Joint Venture to Develop and Operate Value-Based Primary Care Clinics for Medicare Patients May 16, 2022–Stowe-Announce-Second-Joint-Venture-to-Develop-and-Operate-Value-Based-Primary-Care-Clinics-for-Medicare-Patients

DOJ official calls out private equity: Jonathan Kanter, the DOJ’s top antitrust official, believes that buyout firms have inappropriately escaped regulatory scrutiny, in an interview with The Financial Times. “Sometimes [the motive of a private equity firm is] designed to hollow out or roll up an industry and essentially cash out,” Kanter said. “That business model is often very much at odds with the law, and very much at odds with the competition we’re trying to protect.” Kanter argues that some PE funds could be in violation of the Clayton Antitrust Act of 1914, if they have reps on the boards of competing companies—a legal pursuit heretofore not applied to financial sponsors.

Crackdown on buyout deals coming, warns top US antitrust enforcer Financial Times

KPMG: 1,145 private equity deals involving health systems, physician practices, nursing homes and disability care in 2021: Highlights:

·        11% of U.S. nursing homes and 4% of hospitals are now owned by private equity firms—1 60% jump since 2019.

·        Private equity investors spent $18.3 billion for these types of providers in 2021—down from $35.1 billion in 2018.

·        As of the end of March, there were 171 deals in 2022, down from 255 in the first quarter of 2021 and 216 in the same period in 2020.

·        There were 198 health IT deals in 2021, up from 157 the year before.

·        Humana Inc., for one, announced plans this week to open about 100 value-based primary care clinics for Medicare patients through a partnership with the private equity firm Welsh, Carson, Anderson & Stowe.

KPMG Advisory Services May 19, 2022

As Biden Signals Crackdown on Private Equity in Nursing Homes, Exclusive Analysis Shows PE Health Care Provider Deals Hit a High in 2021

Veritas role in monetizing GE data: “STAT spent months investigating how a constellation of businesses plotted to take GE’s database and turn it into a far more intimate — and valuable — picture of the patients whose secrets it held. The beneficiaries were some of the world’s largest health data brokers, including Quintiles, now known as IQVIA, and the owners of MarketScan, a widely used repository of insurance claims on more than 270 million Americans. In February, a long trail of transactions involving GE’s data and software resulted in a windfall for the New York private equity firm Veritas Capital, which acquired and then sold GE’s medical records business as part of a larger deal worth $17 billion.”

How a complex web of businesses turned private health records from GE into a lucrative portrait of patients StatNews May 23, 2022

Infant Formula, Nutrition

Administration responds to infant formula shortage: After factory contamination and stalled production led to nationwide shortages, the administration initiated two remedies: the Defense Production Act and Operation Fly Formula that directs the Department of Health and Human Services and the Agriculture Department to use defense commercial aircraft to pick up U.S.-approved, overseas infant formula “so it can get to store shelves faster. In related comments, the administration has warned infant formula manufacturers and retailers against price gauging during the shortage.

Update: A shipment of 35 tons of baby formula arrived Sunday in Indiana on a US military aircraft from Germany providing formula for 9,000 babies and 18,000 toddlers for one week. The administration says the total amount of formula in the first round of Operation Fly equals up to 1.5 million doses of eight-ounce bottles.

Related: The FDA and Abbott reached a deal last week to reopen shuttered infant formula plant in Sturgis, Mich. which was shut down in February due to a bacterial outbreak at the facility.

Related: Abbott Laboratories Chief Executive Robert Ford apologized Saturday for his company’s role in the nationwide shortage of baby formula and promised production will ramp up again in June.

FACT SHEET: President Biden Announces New Actions to Address Infant Formula Shortage White House May 18, 2022 www.

Abbott CEO Apologizes for Company’s Role in Baby Formula Shortage Wall Steet Journal May 22, 2022

FDA considering new food label: The Food and Drug Administration is testing designs of a label that food manufacturers could voluntarily put on the front of packages indicating that a product is “healthy.” The FDA itself is in the process of updating its definition, which dates back to 1994. Other concerns are that such a label could be of dubious value, used too liberally by food makers, or seen by consumers as a product endorsement by the FDA.

US Food and Drug Administration

McKinsey: shopping for food has changed since pandemic: According to McKinsey consumer insights:

·        Total e-commerce sales have grown nearly 60% since the beginning of the pandemic and consumers are making fewer trips: they are 20% more likely to go to just one grocery store a week. As such, consumers are increasingly seeking out one-stop shops and have expressed an interest in buying everything in one place even more frequently in 2022.

·        The food-at-home market, which had been slowly losing share to food away from home before 2020, has surged 8.7%, four times its historical growth rate. The move to food at home coincides with a growing emphasis on healthier eating.

The state of grocery in North America McKinsey May 18, 2022

Care Management

Study: US gets C- for end-of-life care: A 2021 survey of more than 1,200 caregivers around the world identified several key factors that are associated with good deaths. Researchers at the Duke-NUS Medical School in Singapore selected the 13 most-cited elements of a good death and asked 181 palliative care physicians in 81 countries to grade their countries’ health systems based on these elements. The United Kingdom came out on top. Other countries that got an A for end-of-life care include Ireland, Taiwan, Australia, South Korea, and Costa Rica. According to the report, “Best Places to Die,” the U.S. got a grade of C-minus, coming in 43rd of the 81 countries surveyed.

One million reasons to reimagine end-of-life care StatNews May 16, 2022

Study: rural cancer survival lags urban: Researchers compared differences in 5-year survival rates between rural and urban cancer patients. Findings:

Rural and non-Hispanic Black patients for all cancer types often had shorter survival. From 1975 to 2016, the 5-year lung cancer survival rate was shorter for non-Hispanic Black rural patients in 1975 at 48%, while increasing to 57% for both non-Hispanic Black urban and rural patients in 2011, but still the shortest among all cancer types.

Lewis-Thames et al Racial and Ethnic Differences in Rural-Urban Trends in 5-Year Survival of Patients With Lung, Prostate, Breast, and Colorectal Cancers: 1975-2011 Surveillance, Epidemiology, and End Results (SEER)JAMA Network Open May 19, 2022;5(5):e2212246. doi:10.1001/jamanetworkopen.2022.12246

KFF: States expanding maternity coverage in Medicaid programs: Per KFF’s analysis of actions taken starting July 2021 in 41 states:

·        More than half of states have taken recent steps toward lengthening the postpartum coverage period beyond 60 days, including some states that haven’t opted to extend Medicaid benefits to all adults under the Affordable Care Act.

·        More than half the states cover home births under Medicaid — an option that’s gained more attention during the COVID-19 pandemic.

·        Coverage for services outside of medical settings is mixed, with most states paying for home visits but limiting coverage for educational classes and home-base lactation consultations.

·        Very few states offer any coverage for fertility assistance services.

·        11 states are considering adding doula services as a covered benefit. 

·        8 states have initiatives to address substance use or mental health services for pregnant or postpartum beneficiaries.

Medicaid Coverage of Pregnancy-Related Services: Findings from a 2021 State Survey Kaiser Family Foundation May 19, 2022

Study: ED visit telephone follow-up effective: Researchers assessed the association of a 2-day post-discharge telephone call with metrics of perceived quality of care measured at 14 days and also with rates of ED return at both 72 hours and 7 days after the index visit, as well as subsequent return visits resulting in hospital admissions. Findings:

·        Rates of ED return within 7 days of the initial index visit were significantly lower among those who received a call at 2 days than those who did not receive a call (7.6% vs 10.3%).

·        Patients who received a 2-day call were more likely than those who did not receive a call to have followed up with a health care clinician (67.9% vs 66.3%), understood their health issues (77.5% vs 74.9% and have received their discharge medications (87.0% vs 83.6%) although none of these differences between the 2 groups were statistically significant.

Fruhan, Bills Association of a Callback Program With Emergency Department Revisit Rates Among Patients Seeking Emergency Care JAMA Network Open May 20, 2022;5(5):e2213154. doi:10.1001/jamanetworkopen.2022.13154


McKinsey survey: consumer pessimism growing: Per the third edition of McKinsey’s American Opportunity Survey:

“Across almost every demographic group and metric, Americans are more pessimistic than they were in two surveys conducted in 2021. The McKinsey Economic Opportunity Index—a scale that gauges Americans’ perceptions of past, present, and future economic opportunity—showed a 5% decrease in optimism in March–April 2022 compared with a smaller survey six months ago and a 3% drop from a survey a year ago.”

·        In both rural areas and cities, and across almost every demographic, income level, and age group, more respondents than last year believe America is doing a poor job of providing opportunities for all people.

·        People aged 25–34 are the most positive age cohort and the only one to report being more optimistic about their opportunities than a year ago.

Fidelity survey: retirees underestimate their long-term health costs, lack understanding of Medicare: Findings:

A March survey of 2,022 adults 58-76 years of age commissioned by Fidelity found that most are unaware of their cost of healthcare in retirement, estimating that a couple retiring this year will spend $41,000 on healthcare expenses in retirement — $274,000 less than Fidelity’s estimate and up 5% from 2021 ($300,000) and double from the $160,000 baseline estimate in 2002. Additionally, 68% think associated costs will remain under $25,000. Other findings: 

·        57% of respondents incorrectly think a person can elect to enroll in Medicare at age 62 and receive reduced benefits.

·        41% assume incorrectly that there are out-of-pocket caps for Medicare coverage. In reality, retirees must enroll in Medigap to limit their out-of-pocket expenses.

·        40% believe incorrectly that Medicare will pay for them to stay in a nursing home when they can no longer take of themselves. 

Fidelity’s 21st Annual Retiree Health Care Cost Estimate May 10, 2022

Study: Medical debt not associated with pandemic severity: Using TransUnion data, researchers found no statistically significant association between the percentage change in medical debt and the measures of pandemic severity. They also found that increases in medical debt being were associated with decreases in elective medical procedures.

Guttman-Kenney et al Trends in Medical Debt During the COVID-19 Pandemic JAMA Health Forum May 20, 2022 doi:10.1001/jamahealthforum.2022.1031


PAI-Avalere study: 108,700 physicians shifted to employment from 2019 to 2021: Key findings:

·        58,200 physicians joined hospitals and 50,500 joined corporate entities.

·        83,000 (76%) became employees since the COVID-19 pandemic.

·        In 2021, the number of employed physicians increased from 69.3% to 73.9%, leaving just 25.9% of physicians in private practice.

·        From 2019 through 2021, hospitals and health systems saw a 9% growth in physician practice acquisitions; corporate entities saw an 86%growth.

·        Hospitals and corporate entities, including private equity firms and insurers, now own 52.1 % of physician practices — hospitals own 26.4% and other corporate entities own 27.2 %.

Physicians Advocacy Institute