Politico broke its story at 8:32 pm last Monday: “Supreme Court has voted to overturn abortion rights, draft opinion shows.” Reporters Josh Gerstein and Alexander Ward’s article spread like wildfire subordinating coverage of the Ukrainian conflict and inflation through the week.
Their reporting was based on a leaked copy of the February 10, 98-page draft of Supreme Court Justice Samuel Alito’s opinion on behalf of the court’s 5 conservative justices calling Roe v. Wade “egregiously wrong from the start.”
Per Gerstein-Ward, “The draft opinion is a full-throated, unflinching repudiation of the 1973 decision which guaranteed federal constitutional protections of abortion rights and a subsequent 1992 decision — Planned Parenthood v. Casey — that largely maintained the right. “
If the Alito draft is adopted, it would rule in favor of Mississippi in the closely watched case over that state’s attempt to ban most abortions after 15 weeks of pregnancy. This ruling would overturn a decision by the New Orleans-based 5th Circuit Court of Appeals that found the Mississippi law ran afoul of Supreme Court precedent by seeking to effectively ban abortions before viability
The final ruling is expected next month but the immediate implications for the healthcare industry are significant:
· In each state, legislative committees will be scrambling to evaluate their current abortion laws: if Roe is overturned as expected, each state must pass/re-authorize its laws be addressing access to abortion services, the state’s specifications for fetal personhood (viability) and medication abortions including access through tele-pharmacies, penalties/punishment for violators of its law including civil/criminal prosecution of patients and providers, and how medical migrants who cross state lines for abortion services will be served (or not). Each state will review, update/modify and pass its own law. In at least 20 states, it is expected to be illegal and virtually inaccessible and in 11 others less accessible.
· Hotlines to OB-GYN practices, FQHCs and hospitals will be jammed by curious consumers seeking clarity and anxious women seeking abortions. Messaging to patients by physicians and hospitals will be a priority. In tandem, messaging from insurers and employers to enrollees about coverage be necessary. Employers like Amazon, CitiGroup and others have already noticed their employees about their policy changes given the likelihood Roe is overturned. And clarity about coverage policies, prices, payment options and terms of access will be required of all providers.
· And this week, the Senate’s Democrats have vowed to pass a law to protect Roe though unlikely to pass due to their lack of the 60-votes needed to pass. Nonetheless, it’s a declaration of war for the moral high ground on abortion pitting Democrats who want to “own” the abortion rights and women’s health” against Republicans who want to own fetal personhood and the sanctity of life.
Longer term, this SCOTUS decision will have profound impact beyond abortion services:
· It is sure to be a critical issue in Campaign 2022 this November embedded in the larger issues of women’s health, access to contraception and the affordability of healthcare. It’s a vote-getter: opinions about abortion are strongly held for and against. Currently, the majority of women having abortions are mothers already and 3 in 4 live at/below the poverty level, so bigger issues involving social determinants of health, health coverage in state Medicaid programs, access to prenatal care and income disparities across the entire system are part of the narrative.
· The FDA’s procedures for assuring the safety, efficacy and effectiveness of abortion medications will be more closely scrutinized since medication abortions represent a growing percentage of all abortions (54%). The bigger context for telehealth services and scope of prescribing by advanced practice nurses and pharmacists will also get wider attention.
· Coverage specifications and denial policies in health plans offered by employers and insurers will require compliance with individual state laws re: abortion services including those offered out of state.
· The strict interpretation of the constitution will be scrutinized since the lack of specific reference to abortion is central to Justice Alito’s justification for overturning Roe. Alito wrote: “Until the latter part of the 20th century, there was no support in American law for a constitutional right to obtain an abortion. Zero. None. No state constitutional provision had recognized such a right.” Interpretation of the constitution is a range of other health-related issues will become more frequent in lower court challenges.
My take:
Regardless of this SCOTUS ruling, women will seek out abortion services. Abortion is a topic that requires every healthcare organization—payers, providers, drug and device manufacturers, HIT et al—to weigh in.
The healthcare industry considers the questions of when life begins, when life ends and how life is lived happily and safely. It should be circumspect and proactive in its response to this ruling.
Paul
Resources
Josh Gerstein, Alexander Ward Supreme Court has voted to overturn abortion rights, draft opinion shows Politico May 2, 2022 www.politico.com/news/2022/05/02/supreme-court-abortion-draft-opinion
Midwest Abortion Providers Scramble to Prepare for a Post-Roe World New Yorker May 7, 2022
Medication Abortion Now Accounts for More Than Half of All US Abortions Guttmacher Institute February 24, 2022 /www.guttmacher.org/article/2022/02/medication-abortion-now-accounts-more-half-all-us-abortions
“Another Risk in Overturning Roe” New Yorker February 22, 2022 www.newyorker.com/news/daily-comment/midwest-abortion-providers-scramble-to-prepare-for-a-post-roe-world
Physicians
Study: EHR use associated with additional documentation: Cambridge Health Alliance researchers assessed the burden of medical documentation on US office-based physicians vis a vis their 2019 National Electronic Health Records Survey. Results:
· Across primary care, surgical, and medical specialties, 64.1% of respondents reported satisfaction with the EHR; 64.5% found documentation to be easy. However, 58.1% disagreed that the time spent documenting was appropriate and did not reduce time spent with patients, and 84.7% agreed that documentation solely for billing purposes increased total documentation time.
· Overall, physicians spent a mean of 1.77 hours daily completing documentation outside office hours. Physicians who used EHRs spent a mean of 1.84 h/d documenting outside office hours, significantly more than the 1.10 h/d among those who did not use EHRs
Gaffney et al Medical Documentation Burden Among US Office-Based Physicians in 2019A National Study JAMA Intern Medicine March 28, 2022;182(5):564-566. doi:10.1001/jamainternmed.2022.0372
Technology
Wearables gaining traction in US health: A round-up by researchers in Denmark of more than 120 studies of personal-activity trackers, which included healthy people and those with various health conditions, concluded that wearing the devices makes people move more. The improvements are modest: about 1,200 more steps (around 800 meters/half a mile) daily, 49 more minutes of vigorous exercise per week and 10 minutes less sedentary time per day. But physical activity is so important that even small changes can matter a lot. Studies that have followed people for 4-10 years have found that increasing steps by an extra 1,000 per day reduces mortality by between 6% and 36%, with the biggest impact among those who are most sedentary.
Wearable devices are connecting health care to daily life The Economist May 7, 2022 www.economist.com/technology-quarterly/2022
Quantified self: “Smartwatches and -rings, fitness trackers and a rapidly growing array of electronically enhanced straps, patches and other “wearables” can record over 7,500 physiological and behavioral variables. Some of them are more useful than others, obviously, but, as our Technology Quarterly in this issue explains, machine learning can filter a torrent of data to reveal a continuous, quantified picture of you and your health…. But health-care professionals also have a vital role. Health care is a conservative industry—and rightly so, given the stakes. Yet it risks slowing the uptake of digital medicine not for legitimate concerns about safety, but because of the inertia of regulators, standards bodies, insurers and medical schools…It is a long and daunting list. But the pay-off, in money and well-being, is likely to be huge. Time to roll up sleeves and prepare health care for the era of the quantified self.”
Wearable technology promises to revolutionize health care The Economist May 5, 2022 www.economist.com/leaders/2022/05/05/wearable-technology-promises-to-revolutionise-health-care
Prescription Drugs
Study: FDA uses expert panels less: Per the analysis, the agency convened expert advisory panels for just 6% of the new medicines approved last year, a drop from 55% seen in 2010. During the same time period, the agency endorsed a drug about once a year that an advisory committee voted against approving. Moreover, the study found the FDA has often posed questions to its panels that are inconsistently worded and have varied considerably in substance.
Daval et al Unwanted Advice? Frequency, Characteristics, And Outcomes Of Negative Advisory Committee Votes For FDA-Approved Drugs Health Affairs May 2022 www.healthaffairs.org
Emergent issue: safety in digital pharmacy sector: Major brick-and-mortar pharmacy chains have stopped filling prescriptions for ADHD drug Adderall and other controlled stimulants sent in by telehealth providers including Cerebral, True Pill et al an online mental health company.
Investing
Rock Health: digital funding slowed in 1Q2022: “Funding for digital health companies in 2022’s first quarter totaled $6 billion, a drop from $7.3 billion in 2021’s fourth quarter and $6.7 billion the first quarter of 2021. While the first quarter of the year has tended to be the lowest quarter of the year, Rock Health suggests the first-quarter number could be a sign of a correction in digital health funding after funding levels more than tripled from 2019 to 2021. An increase in later stage private funding rounds (Series D and beyond) suggests a longer path to public market exits, perhaps because the special purpose acquisition company (SPAC) market has cooled. “
Q1 2022 Digital Health Funding: Staying the Course in Choppy Waters Rock Health Weekly April 4, 2022 https://rockhealth.com/rock-weekly
Pitchbook: Healthcare deals reach 18.5% of total PE in 1Q: Healthcare deals increased their share of private equity deal value relative to other sectors in the first quarter of 2022, growing to 18.5% for the quarter, compared to a range of roughly 14-17% over the previous five years. Deals focused on value-based care for kidney patients and Medicare Advantage members, respectively, were highlights in the quarter, according to Pitchbook. The company’s analysts also point to the planned spinout of GE Healthcare by General Electric later this year as a catalyst for more deals.
PE Investors Home In on Value-Based Healthcare Deals in Q1 Pitchbook www.pitchbook.com
Pitchbook: investing outlook in 2022 cautious: “The private markets were largely able to slough off the economic destruction caused by the pandemic because areas like travel, hospitality, and hospital systems are not major components of most portfolios. Even last year’s rise of the Delta and Omicron COVID-19 variants are barely visible in the lagged data, but inflation, rising interest rates, and continued global supply issues will not be so easy to dodge in 2022.” Related insights:
· Venture, private equity IRR slow: In 4Q 2021, private capital IRR increased 4.0%; 1-yr: +37.9%, 3-yr: +18.3%, 5-yr: +16.6%, 10 yr.: +14.2%.
· Venture capital outperformed other classes in 1-yr (+59.9%), 3-yr (+30.5%) and 5-yr (+23.2%) and tied with private equity for 10-yr IRR (+17.0%).
Context: The Nasdaq closed down 13.3% and the S&P 500 was down 8.7%.
Pitchbook The Research Pitch May 7, 2022 www.pitchbook.com; Pitchbook Global Markets Outlook April 2022 www.pitchbook.com
Hospitals
Kaufman Hall: hospital finances improved in March: While repercussions of the surge persist, hospitals saw some early signs of relief as outpatient volumes and revenues returned and expenses eased with fewer high acuity patients. Findings:
· The 7-day moving average of new cases decreased 53.3% from March 1 to 25,559 on March 31.1 The 7-day moving average of new daily admissions dropped 64.9% over the same period, to 1,506 by month’s end.
· Actual hospital margins were negative for a third consecutive month: The median YTD Operating Margin Index was -2.43% in March, up from -3.99% in February. (an improvement of 32.7%).
· Nonlabor Expense per Adjusted Discharge rose 6.4% compared to March 2021 and 2.7% compared to the pandemic’s first month. Non-Operating Inflation registered at 8.5% year-over-year in March, its highest rate since 1981.
NATIONAL HOSPITAL FLASH REPORT Kaufman Hall April 2022 www. flashreportmember.kaufmanhall.com
Modern Healthcare: Not-for-profit hospitals lean on investment income to cover losses:
· St. Louis-based Ascension recorded a $640.1 million operating loss on $19 billion in revenue through the first nine months of its 2022 fiscal year, according to the 142-hospital system’s earnings statement released Friday. Nearly $900 million in non-operating income, $736.4 million of which was attributable to investment income, more than offset those losses. That was down from nearly $4.5 billion in non-operating gains in the same prior-year period.
· Providence, the 52-hospital health system based in Renton, Washington, accrued more than $1.2 billion in non-operating income in 2021, covering its $714 million operating loss. That was up from $1 billion of 2020 non-operating income.
· Advocate Aurora Health, which has 27 hospitals in Illinois and Wisconsin, posted a $1.33 billion windfall in non-operating income in 2021, up from $395.1 million in 2020. Advocate Aurora had $593.5 million in operating income in 2021.
· Rochester, Minnesota-based Mayo Clinic’s cash and investments exceeded $18 billion at the end of 2021, an increase of $3.6 billion from the end of 2020.
· Kaiser Permanente, a large integrated health system based in Oakland, California, benefited from similarly strong investment gains in 2021. While Kaiser had a banner year with $8.1 billion in net income on $93.1 billion in revenue, its operating margin was a slim 0.7%.
Kacik Large not-for-profit health systems are recording investment income windfalls that are offsetting significant operating losses. Modern Healthcare May 2, 2022 www.modernhealthcare.com
Study: Hospital acquisition by private equity associated with lower mortality: In this cross-sectional study of more than 21 million Medicare beneficiaries with 5 different acute medical conditions who were hospitalized at short-term acute care hospitals, PE acquisition was associated with significantly lower inpatient mortality (−1.1 %) and lower 30-day mortality (−1.4%) among patients admitted with acute myocardial infarction. However, PE acquisition was not associated with significant differences in other dimensions of quality and spending or with differences across other medical conditions. “PE acquisition had no substantial association with the patient-level outcomes examined, although it was associated with a moderate improvement in mortality among Medicare beneficiaries hospitalized with AMI.”
Cerullo et al Association Between Hospital Private Equity Acquisition and Outcomes of Acute Medical Conditions Among Medicare Beneficiaries JAMA Network Open. 2022;5(4):e229581. doi:10.1001/jamanetworkopen.2022.9581
Care Management
Studies: self-monitoring for preeclampsia, hypertension BP effective: “In this randomized clinical trial that included 2441 pregnant individuals at increased risk for preeclampsia, self-monitoring of BP with telemonitoring compared with usual care resulted in a mean time to clinic-based detection of hypertension of 104 vs 106 days, a difference that was not statistically significant…Among pregnant individuals at higher risk of preeclampsia, blood pressure self-monitoring with telemonitoring, compared with usual care, did not lead to significantly earlier clinic-based detection of hypertension.”
“In this randomized clinical trial that included 850 pregnant individuals with chronic hypertension or gestational hypertension, use of self-monitoring of blood pressure with telemonitoring resulted in an adjusted mean difference in clinic-based systolic blood pressure, compared with usual care alone, of 0.03 mm Hg for chronic hypertension and −0.03 mm Hg for gestational hypertension. Neither difference was statistically significant…Among pregnant individuals with chronic or gestational hypertension, blood pressure self-monitoring with telemonitoring, compared with usual care, did not lead to significantly improved clinic-based blood pressure control.”
Tucker et al Effect of Self-monitoring of Blood Pressure on Diagnosis of Hypertension During Higher-Risk Pregnancy the BUMP 1 Randomized Clinical Trial JAMA May 3, 2022;327(17):1656-1665. doi:10.1001/jama.2022.4712
Chappell et al Effect of Self-monitoring of Blood Pressure on Blood Pressure Control in Pregnant Individuals With Chronic or Gestational Hypertension The BUMP 2 Randomized Clinical Trial JAMA May 3, 2022;327(17):1666-1678. doi:10.1001/jama.2022.4726
Pandemic
WHO: Covid death toll 13.3-16.6 million: Last Thursday, the World Health Organization increased its estimate of global pandemic deaths to 15 million –double its official death toll of 6 million. Most of the fatalities were in Southeast Asia, Europe and the Americas. Earlier, scientists at the Institute of Health Metrics and Evaluation at the University of Washington guessed there were more than 18 million COVID deaths from January 2020 to December 2021 in a recent study published in the journal Lancet, and a team led by Canadian researchers estimated there were more than 3 million uncounted coronavirus deaths in India alone.
14.9 million excess deaths associated with the COVID-19 pandemic in 2020 and 2021 World Health Organization May 5, 2022 www.who.int/news/item/05-05-2022-14.9-million-excess-deaths-were-associated-with-the-covid-19-pandemic
Nutrition
Senators introduce nutrition bill: On April 26, Senator Dick Durbin (D-IL) and Senator Mike Braun (R-IN) introduced the Dietary Supplement Listing Act of 2022, which, if passed, will enhance the U.S. Food and Drug Administration’s ability to ensure the safety of all dietary supplements by requiring all dietary supplement manufacturers to submit basic information to the agency—including the product name, a list of ingredients, and a copy of the label—before marketing the products to consumers.
Nutrition and diet Bills www, GovTrack.us
Study: vegetarian diet impact on children’s health: A total of 8907 children, including 248 vegetarian at baseline, participated. Result: “Evidence of clinically meaningful differences in growth or biochemical measures of nutrition for children with vegetarian diet was not found. However, vegetarian diet was associated with higher odds of underweight.”
Elliott et al Vegetarian Diet, Growth, and Nutrition in Early Childhood: A Longitudinal Cohort Study Pediatrics May 2, 2022 https://publications.aap.org
Nursing Homes
Study: union representation in nursing homes associated with better Covid protections for residents, workers: Since March, 2020, of the 996,233 who have died from the pandemic, 150,026 were residents of nursing homes. In addition, 2,362 nursing home staff have succumbed to the virus. Researchers examined whether unions for nursing home staff were associated with lower resident COVID-19 mortality rates and worker COVID-19 infection rates compared with rates in nonunion nursing homes. Findings: unions were associated with 10.8% lower resident COVID-19 mortality rates, as well as 6.8% lower worker COVID-19 infection rates.
Dean et al Worker Infection Rates From COVID-19 Lower In Union Than Nonunion US Nursing Homes, 2020–21 Health Affairs April 20, 2022 No Access https://doi.org/10.1377/hlthaff.2021.01687
The Economy
Bureau of Labor April jobs report: healthcare still down from pre-pandemic: The latest BLS report:
· The economy created 428,000 nonfarm payrolls through April exceeding the 391,000-job projection from economists.
· Average monthly job creation over the previous three months reached 523,000 in April, Insider calculated.
· In the 26 months since the pandemic recession began, the US has recouped about 95% of the jobs it lost vs. 6 years for the 2008 recession.
· Healthcare employers added 34,300 jobs in April, up from 23,300 in March and 229,000 in LTM. While the industry is still down 250,000 positions, about 1.5%, from February 2020, healthcare employment is the highest it has been since the COVID-19 pandemic began in March 2020. In April, physician practices added 9,800 jobs, home health providers added 7,800, hospitals added 4,500 hires, but are still down nearly 100,000 jobs since COVID-19 arrived March 2020.
Bureau of Labor www.bls.gov
