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The Keckley Report

Health System Distrust contributes to Poor Health and Avoidable Cost

By September 12, 2022March 1st, 2023No Comments

This week, the celebration of Queen Elizabeth’s life will take center stage leading up to her funeral September 19. The 96-year old’s longevity, the mystique of the monarchy and Britain’s oversized role in Western culture will be table talk.

I saw it firsthand as a graduate student in the UK and have followed the evolution of its health system, the National Health Service, for almost 50 years as a student of ‘systems of health.’ Like the 14 predecessors who served the Queen Elizabeth, new British Prime Minister Liz Truss faces tough choices about the effectiveness and funding of the NHS as the country faces high inflation and economic instability. Sound familiar?

The structure of the UK and US health systems are different. Per the Organisation for Economic Co-operation and Development, the health system in the US is more expensive, more fragmented and less effective in optimizing the population’s health than the NHS and many other developed systems. Several factors explain the difference: social determinants, violence, unit prices paid for drugs, specialty care and hospitals in the U.S. and others. But a factor that gets less attention is trust in a country’s health system: Edelman’s Global Trust analyses show a direct correlation between the trust of a country’s citizens in its health system and the overall health status of its population.

The latest Edelman Survey fieldwork was conducted: February 10 – February 18, 2022 in 10 countries involving representative samples (by age, gender, ethnicity, region) of 1,000 /country. The highlights are especially telling as the UK and US health systems as the Queen’s legacy is celebrated. Highlights:

·        Since 2020, trust in their health sector has been more volatile than trust in other industries in both countries. People trust their health systems more than other sectors in their economies.

·        37% in the US rate the quality of the healthcare they can get “as less than very good” vs. 60% in the UK (#7). Brits have a different expectation about their system.

·        In the US, 70% agree “I am confident in my ability to find answers about healthcare questions and make informed decisions for myself and my family”—down 10% from January 2017 vs. 65% in the UK (down 5% 2017-2022). The US and UK populations are similar.

·        US healthcare companies are trusted less than healthcare companies in the UK.

·        Percent who have had routine check-ups in the last year, among those with lower vs. higher trust in the health ecosystem: US 58% vs. 81% (23% gap) vs. UK 22% vs. 42% (20% gap). The gaps between the two countries are similar but more consequential in the US.

·        52% say their confidence in their health system has been impaired by its handling of the pandemic: Japan #1 at 71%, UK #8 at 49% and US #9 at 48% and China #10 at 30%. Every system saw trust fall as a result of its handling of the pandemic.

·        Those with lower trust in their health systems were less likely to be vaccinated: the gap between vaccination rates comparing low trust to high system trust is widest in the US (38%) vs. UK #7 (20%). In the US, 46% of “low trust” were vaccinated vs. 84% of “high trust.” The confluence of vaccine disinformation and partisan dysfunction took a greater toll in the US than others.

These findings are significant: it’s not that Brits trust their system slightly more than we trust our system.  And it’s not the revelation that the Brits recognize the care they get thru the NHS might not measure up to ours. It’s that large numbers in our population distrust our system and poor health and avoidable costs are a direct result.

My take:  

In many healthcare organizations, trust is taken for granted. In some, it’s buoyed by well-orchestrated CRM and NPS programs and in a handful, factored into compensation for leaders.

In my experience, trust is presumed, poorly measured and too easily discounted by leaders in US healthcare companies. Its aversion to price transparency has contributed. It needs better measurement from wider sources. It needs closer study and more attention from Boards and Investors. It needs prioritization in US healthcare policy.

As the Brits bid farewell to their Queen and welcome their King, Americans like the Brits face economic challenges and big questions about our respective health systems. Trust is an issue for both.  


Jeffrey V. Lazarus et al COVID-SCORE: A global survey to assess public perceptions of government responses to COVID-19 (COVID-SCORE-10). 2020 PLoS ONE 15(10): e0240011.


Texas Judge ruling creates public health in chaos: Last Wednesday, Bottom of Forma federal judge in Texas ruled that the Affordable Care Act’s process for determining what kinds of preventive care must be fully covered by private health insurance is unconstitutional.

Judge Reed O’Connor of the United States District Court for the Northern District of Texas, concluded that the U.S. Preventive Services Task Force — a volunteer panel of experts that recommends what kinds of preventive care must be covered under the law — violated the Constitution because its members are not appointed by the president or confirmed by the Senate, yet its recommendations become binding. The ruling also took explicit aim at the H.I.V. drug regimen known as pre-exposure prophylaxis, or PrEP, saying the law’s requirement that it be fully covered violated the religious freedom of a plaintiff in the case, Braidwood Management.

The Affordable Care Act requires insurers and group health plans to cover more than 100 preventive health services recommended by the volunteer task force, with no cost to patients. The Department of Health and Human Services estimates that in 2020, 151.6 million people had access to free preventive care under the law.

“Texas Judge’s Ruling Puts Free Preventive Care in Jeopardy” New York Times September 7 2022

Healthcare Investing

WSJ: primary care gaining investor attention:

It’s no secret America has one of the least-efficient healthcare systems in the world, far outspending other wealthy countries for poorer results. The high cost of everything from medical procedures to cancer drugs often gets much of the blame. But just as bad are the incentives baked into it. Most wealthy countries have government-controlled health systems that encourage doctors to keep costs down by directing patients to less invasive approaches at first. America’s works the opposite way. In the U.S., everyone from your primary-care doctor to your cardiologist has an incentive to make you consume as much healthcare as possible, from the prescription drug you could do without to the expensive surgical procedure you might be able to avoid through physical therapy.

But the incentives might be starting to change, ever so gradually, creating an opportunity for a host of companies. Among them are those helping doctors make the shift, like Privia Health Group Inc. PRVA -3.73%▼ and Agilon Health Inc. AGL -2.56%▼ Others, like Oak Street Health Inc., Cano Health Inc. and CareMax Inc., also invest and operate medical centers that focus on value-based care.”

David Wainer Profit From America’s Healthcare Bloat Wall Street Journal September 4,

JP Morgan: Last Thursday, Morgan Health announced a $20 million investment in digital health firm LetsGetChecked, a platform facilitating at-home to diagnostic and genetic testing, virtual appointments, and prescription drug delivery.  Previously, Morgan Health announced $105 million investments Vera Whole Health, Centivo and Embold Health. 

JP Morgan invests $20M in digital health company

Study: outcomes after private equity ASC acquisition unchanged: Researchers analyzed changes in outcomes associated with the acquisition of 91 ambulatory surgery centers (ASCs) by private equity entities. Findings:

 “There was no statistically significant observed change in the probability of an unplanned hospital visit, total costs, or total encounters after acquisition by private equity relative to acquisition by non–private equity entities. When we compared private equity–acquired ASCs with matched ASCs that were never acquired, we also found no statistically significant relative change in the probability of an unplanned hospital visit, total costs, or total encounters.”

Bruch et al Private Equity Acquisitions Of Ambulatory Surgical Centers Were Not Associated With Quality, Cost, Or Volume Changes Health Affairs September 2022

Carlyle announces deal: Last week, Carlyle Group announced the formation of Atmas Health, an acquisition platform for assets in med-tech and products, life sciences tools and diagnostics sectors led by 3 health execs: Kieran Gallahue, former chairman and CEO of CareFusion, Jim Hinrichs, former CFO of Alere former CFO of CareFusion from 2010 to 2015. Jim Prutow, a former partner at PwC, specializing in M&A diligence.

Carlyle Announces Formation of Atmas Health in Partnership with World-Class Healthcare Executives September 7, 2022


Walmart-United to collaborate on value-based services for seniors: Last Wednesday, Walmart Inc. and UnitedHealth Group announced a 10-year, wide-ranging collaboration focused initially on senior care services in15 Walmart Health locations in Florida and Georgia before expanding over time. The duo will leverage Optum technology and its Medicare Advantage plan in Georgia, together with Walmart Health’s Virtual Care platform.

The Walmart, UnitedHealth Group deal: Another big retail, health care partnership September 7, 2022


HHS begins transition from PHE: The Department of Health and Human Services hosted a stakeholder meeting last week on the commercialization process for vaccines and therapeutics as the end of the Public Health Emergency is anticipated.

Key expectation: The federal government anticipates its supply of various therapeutics to be gradually depleted throughout 2023. When stockpiles run dry, it’ll transition these products into the private market:

·        Vaccines: Most Americans will probably still get their vaccines for free, because insurers usually cover them without cost-sharing. The price of the vaccines will, however, be reflected in premiums, and patients could be on the hook for vaccine-related costs if they use an out-of-network provider.

·        Tests: likely an out-of-pocket expense for over-the-counter tests.

·        Treatments: COVID therapeutics like Pfizer’s antiviral Paxlovid will “be like any other treatment. If you’re hospitalized or getting a prescription drug, it’s going to be subject to a deductible, coinsurance.

Understanding Coverage Considerations for COVID-19 Vaccines and Treatments HHS August 31, 2022 Understanding Coverage Considerations for COVID-19 Vaccines and Treatments | ASPE (

CDC: Daily Covid deaths averaging 320: The U.S. averaged about 320 new Covid-19 deaths each day vs. above 400 before the Labor Day holiday weekend– far below pandemic peaks, including levels above 2,500 a day during the Omicron wave early this year. Key insights:

·        Roughly 85% of people who died from Covid-19 through mid-August this summer were 65 or older

·        Flu deaths range from roughly 15,000 to 70,000 a year vs. most recent seven-day average for Covid-19 deaths over a year would add up to 116,000.

·        Covid-19 is on pace to be the third-leading cause of death for the third straight year, said Dr. Robert Anderson, chief of the mortality statistics branch at the. Since 2020, it has trailed only heart disease and cancer, significantly reducing life expectancy.

CDC’s National Center for Health Statistics

Cool Tools:

Behavioral Health Workforce Tracker: A team of researchers from the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University created a data mapping tool for analyzing national database on the behavioral health workforce.” Behavioral Health Workforce Tracker.

The database includes around 1.2 million behavioral health providers — some 600,000 psychiatrists, addiction medicine specialists, psychologists, counselors, and therapists, as well as 400,000 primary care physicians and advanced practice providers who prescribe medication for mental health.

Behavioral Health Workforce

McKinsey United States of Health Dashboard: An interactive dashboard of in-depth public health indicators for each state compared to national comparisons.

McKinsey Public Health

Trilliant Similarity Index: Trilliant Health, a healthcare-focused predictive analytics and market research firm announced its Similarity Index, which produces similarity scores for hospitals to relevant peers based on factors like financial results, CMS quality metrics, patient mix and market share. Its interactive data visualization tool allows users to isolate variables for specific hospital comparisons.

Trilliant Similarity Index

Apple Medication Reminder Watch: Half of Americans with chronic illnesses stop taking medications within a year of the initial prescription, according to the Centers for Disease Control and Prevention. One cited reason: forgetfulness. Apple Inc. AAPL 1.88%▲ is the latest company to address the problem, with a new Medications tool in the Health app update that arrives Monday with iOS 16. The reminder feature marks Apple’s latest push into personal-health management, following earlier iPhone or Apple Watch features such as the walking-steadiness score, fall- detection system and notifications for irregular heart rhythm.

Apple’s Medications Reminder Is Coming in iOS 16. Here’s How to Use It. WSJ September 12, 2022


Trinity Health completes acquisition of MercyOne from Common Spirit: The deal adds 18 medical centers, 23 affiliated hospitals and more than 2,000 physicians and advanced practice clinicians to the Trinity system’s wide scope of operations in 25 states. MercyOne was founded in 1998 through a collaboration between Catholic Health Initiatives, now Common Spirit, and Trinity Health, has annual revenues of $3 billion. 

Trinity Health Completes Acquisition of MercyOne Health System Trinity Health September 1, 2022


Inflation dips slightly: The core personal consumption expenditures price index that excludes the volatile food and energy sectors has trended lower, falling to 4.6% in July from 5.3% in February.  But transportation, recreation, accommodation and food services prices, which rose the most last year, surged more than 6% in July  contributing 1.3 percentage points (or 31%) to overall core PCE services inflation and might go higher. A leading theme in August was the decline in the price of gasoline. A gallon of unleaded dropped to $3.84 at the end of August from $4.22 at the end of July, a 9% decline, according to the AAA. Other findings:

·        Housing and medical services have significant weighting (around 15% and 18%, respectively) in calculating PCE, and are still seeing fast-rising prices. 

·        Rent and the homeowners’ equivalent to rent surged to 5.9% in July, from 2% in May 2021, contributing 1.4 percentage points (or 32%) to core PCE services inflation and reflecting with a lag, surging house prices since mid-2020.  The economists forecast housing can add another 35 basis points to headline PCE inflation and 40 basis points to core PCE inflation this year before easing in mid-2023 as these prices continue catching up to record home prices. 

·        Another source of likely further upward pressure on PCE inflation is health care services, led by wage growth among hospital workers. The economists expect health care will contribute 70 basis points to year-over-year core PCE inflation in the coming year, 32 basis points more than in second quarter 2022, all else equal. 

“Fed officials meet Sept. 20-21 and have suggested they are leaning toward raising their benchmark short-term interest rate by 0.75 percentage point to combat inflation by restraining economic demand. A soft inflation reading would make it easier to slow the pace of rate increases in the months ahead.”

Inflation Showed Signs of Easing in Several Industries in August Wall Street Journal September 12, 2022

Healthcare services, equipment and pharma outperform overall stock market performance: Overall market at close September 9, 2022:

S&P 500 closed week +3.65% for week but -14.66% YTD vs. healthcare industry overall +3.49%/-8.47%, healthcare services +5.12%/-9.76%, digital health +3.60%/-29.37%, healthcare equipment +5.42%/-18.66%, pharma +3.27%/-6.90%, biotech 4.52%/-21.83%

Standard and Poor’s

Value-based Care

CMS: ACO savings down form 2020: Medicare’s Shared Savings Program (MSSP) saved CMS $1.66 billion in 2021— the fifth consecutive year of overall savings for the program but a decline from 2020, when ACOs saved Medicare $1.9 billion.

·        The 475 participating ACOs provided service to 11,000,000 Medicare patients; 99% of met quality standards and 58% earned performance payments from CMS, worth a total of $1.9 billion.

·        21.9% of 2021 Medicare savings bonuses went to ten ACOs:

o   Palm Beach Accountable Care Organization — $61.9 Million

o   Baylor Scott & White Quality Alliance ─ $61 Million

o   Privia Quality Network (VA, MD, DC) ─ $41.6 Million

o   Caravan Health Collaborative ACO ─ $35.3 Million

o   Steward National Care Network ─ $34.4 Million

o   Advocate Physician Partners Accountable Care ─ $27.8 Million

o   USMM Accountable Care Partners ─ $25.8 Million

o   Keystone ACO ─ $25.6 Million

o   Banner Health Network ─ $25.5 Million

o   Mercy Health Select ─ $25.3 Million

Quotable: At NAACOS Fall Conference last Thursday, CMS’ Director Chiquita Brooks-LaSure on value-based care: “That kind of language (value-based care) only resonates with a certain part of the health care system. People don’t know what that means. Beneficiaries have no idea what that means. And if they do have a sense, usually it’s a negative reaction. That means you’re going to cut my benefits. And so I think that we need to talk about accountable care in a very different way.”


Study: Comprehensive Primary Care Plus (CPC+) produces modest results: Researchers analyzed claims and enrollment data for commercial plans from the period 2013–20 from two large insurers in Michigan. Findings:

CPC+ was not associated with changes in total spending (−$44.70 per year) or overall quality performance (−0.1%). “We conclude that CPC+ did not improve spending or quality for private-plan enrollees in Michigan, even before accounting for payouts to providers. This analysis adds to existing evidence that CPC+ may cost payers money in the short term, without concomitant improvements to care quality.”

Markovitz et al Comprehensive Primary Care Plus Did Not Improve Quality Or Lower Spending For The Privately Insured Health Affairs September 2022

MGMA Study: Value-based contracts modest part of practice income: Per the analysis of practice changes since the pandemic by the Medical Group Management Association, revenue from value-based contracts accounted for 6.74% of revenue in primary care specialties, 5.54% in surgical specialties, and 14.74% in nonsurgical specialties. Across all practices, the median revenue amount from value-based contracts was $30,922 per full time equivalent provider. Related findings:

·        More than a third (35%) of medical groups reported they increased the share of compensation tied to quality in the past two years, while 62% said they have the same share compared to 2019. Only 2% of respondents said they have decreased the percentage of compensation tied to quality.

·        Appointment availability for new patients increased by two days, from 6.1 days in 2020 to 8.1 days in 2021.

·        No-show rates held steady, appointment cancelations also increased across nonsurgical and surgical specialties, jumping from 8.3% in 2020 to 17.7% in 2021, and from 7.0% to 8.4%, respectively. Primary care experienced a slight decline in cancelations from 8.3% to 8.0%.


Public Health

Study: Supplemental Nutrition Assistance Program (SNAP) churn significant: Researchers examined the rate of churning among Massachusetts’ SNAP participants with young children between 2014 and 2019. Findings:

In 2019, a total of 9752 recertification events occurred among 9735 households (3841 [39.4%] Hispanic, 2138 [21.9%] non-Hispanic Black, and 3533 [36.2%] White) with at least 1 child younger than 6 years participating in SNAP. Of these households, 3984 (40.9%) experienced SNAP churning for a period of 1 to 30 days because of missed recertification forms in any given month. Churning was more common among Hispanic households (by 3.9%)) than non-Hispanic White households and more common among households with more than 1 child younger than 6 years (by 5.6%) compared with smaller households.

Kenney et al Simplification of Supplemental Nutrition Assistance Program Recertification Processes and Association With Uninterrupted Access to Benefits Among Participants With Young Children JAMA Netw Open.  September 6, 2022;5(9):e2230150. doi:10.1001/jamanetworkopen.2022.30150

Study: social media exposure increases tobacco use: Researchers analyzed the association between exposure to tobacco content on social media and lifetime tobacco use, past 30-day tobacco use, and susceptibility to use tobacco among never users. Findings:

·       Participants who were exposed to tobacco content on social media, compared with those who were not exposed, had greater odds of reporting lifetime tobacco use (OR, 2.18), past 30-day tobacco use (OR, 2.19) and susceptibility to use tobacco among never users (OR, 2.08).

·       Subgroup analyses showed similar associations for tobacco promotions, active engagement, passive engagement, lifetime exposure to tobacco content, exposure to tobacco content on more than 2 platforms, and exposure to tobacco content among adolescents and young adults.

Donaldson et al Association Between Exposure to Tobacco Content on Social Media and Tobacco Use Systematic Review and Meta-analysis JAMA Pediatrics July 11, 2022. 2022;176(9):878-885. doi:10.1001/jamapediatrics.2022.2223

Mental Health

Study: increased use of mental health nurse practitioners among Medicare enrollees: Using Medicare claims for a 100% sample of fee-for-service beneficiaries (average age, 61 years) who had an office visit for either a psychiatrist or a PMHNP during the period 2011–19, researchers examined how the supply and use of psychiatrists and psychiatric mental health nurse practitioners (PMHNPs) changed over time. Findings:

·        From 2011 to 2019 the number of PMHNPs treating Medicare beneficiaries grew 162%, compared with a 6% relative decrease in the number of psychiatrists doing so. During the same period, total annual mental health office visits per 100 beneficiaries decreased 11.5% from 27.4 to 24.2, the net result of a 29.0% drop in psychiatrist visits being offset by a 111.3% increase in PMHNP visits.

·        The proportion of all mental health prescriber visits provided by PMHNPs increased from 12.5% to 29.8% during 2011–19, exceeding 50% in rural, full-scope-of-practice regions.

Cai et al Trends In Mental Health Care Delivery By Psychiatrists And Nurse Practitioners In Medicare, 2011–19 Health Affairs September 2022


Study: cost of low value variation significant due to unit costs, not utilization volume: Researchers analyzed administrative claims data for 2009-2019 from Optum Labs Data Warehouse for low-value care (LVC) and associated spending. Findings:

·        LVC remained prevalent among commercially insured and Medicare Advantage enrollees. The aggregated prevalence of 23 low-value services was 1,920 per 100,000 eligible enrollees, which amounted to $3.7 billion in wasteful expenditures during the study period.

·        State-level variation in spending was greater than variation in utilization, and much of the variation in spending was driven by differences in average procedure prices. If the average price for 23 low-value services among the top 10 states in spending were set to the national average, their spending would decrease by 19.8% (from $735,000 to $590,000 per 100,000 eligible enrollees).

Do et al State-Level Variation In Low-Value Care For Commercially Insured And Medicare Advantage Populations Health Affairs September 2022

Campaign 2022

Abortion referenda in 6 states: In November, measures will appear on the ballot in California, Kentucky, Michigan, Montana, and Vermont. Votes on these ballot measures follow the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, which held that the U.S. Constitution does not confer a right to abortion. In August, Kansas voters rejected one of the six measures that provided that nothing in the state constitution created a right to abortion or required government funding for abortion. Turnout on the amendment was 49%, and the number of votes cast exceeded those in the state’s U.S. Senate and gubernatorial primaries on Aug. 2.

Ballotpedia September 12, 2022