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The Keckley Report

In Campaign 2022, Healthcare Voters will Matter More

By September 6, 2022March 1st, 2023No Comments

Today begins the countdown to election day November 8: in 63 days, voters will elect 36 Governors, 30 State Attorneys General, 27 Secretaries of State, 35 US Senators, 435 US House of Representatives and State Legislators in 46 states. It’s a consequential election for the country and for its healthcare industry,


Turnout will be higher than previous mid-terms: 49.3% of the citizen voting-age population voted in 2018, the highest midterm turnout in four decades, while the 2014 election had the lowest. But polls show “likely voters” more engaged this year due to the Supreme Court’s abortion ruling and concerns about inflation. Turnout in this year’s primaries in KS, GA, WI, PA, NC and others hit record highs. While smart money still points to a Republican takeover of the House, the Senate might not follow. Consider…

·        President Biden’s favorability has climbed from 38% to 44% in the last 2 months but remains problematic to Democrats: in modern history, incumbent President approval ratings below 50% at their first mid-term lost seats to the opposition party. (Clinton 1994: 46% approval, lost 53 House and 8 Senate seats; Bush 2002: 38% approval, lost 30 House and 6 Senate seats; Obama 2010: 45% approval, lost 63 House and 6 Senate seats and Trump 2018: 41% approval, 40 House seats lost but gain of 2 in Senate). A net gain of 5 House and 1 Senate seat would flip control, but oddsmakers are hedging their bets.

·        The economy is improving, fuel and food prices are going down, but concern about the inflation and prices is increasing. Record inflation (8.5%), higher prices for food (+10.9% LTM) and gas (+36% LTM) are less concerning to voters every day as conditions seem to be improving. The Central Bank’s battle to keep inflation at 2% via interest rate hikes is of little consequence to voters unless connected directly to higher interest for loans on their cars and houses. So, the economy will be the biggest issue as is norm, but other issues including abortion, crime and immigration will influence voting relatively more.

Campaigns will avoid healthcare issues other than abortion..  Conceding that healthcare is expensive and access uneven, most midterm campaigns will default to partisan themes:

GOP Themes

·        The U.S. health system is the best in the world due to entrepreneurism and capitalism: more government control will stymy innovation and reduce consumer choice.

·        The Affordable Care Act (2010) failed to slow health cost increases and should be replaced. Competition and price transparency are keys.

Democratic Themes

·        Healthcare is a fundamental right, not a privilege.

·        Prescription drug companies and hospitals are price gauging American consumers and putting their profits ahead of patient care. Consolidation and opaque pricing are their purposeful strategies to avoid public accountability and maintain market power.

·        The health system is unfair: it routinely caters to have’s and disregards the have nots.

·        Public health is poor, deteriorating and under-funded.

Notably getting a pass in healthcare Campaign rhetoric are device manufacturers, PBMs, GPOs, health insurers and retail pharmacies as well as disruptors like Amazon, CVS, Walmart, Walgreens and others. And the industry’s most complicated issues—interoperability, data security, workforce burnout, supply chain stability, medication adherence, self-care, specialty drugs and others—will stay “inside baseball.”

That’s Campaign 2022 for healthcare: more visibility, more obfuscation, more polarization. But the issues of abortion in tandem with hospital and prescription drug prices will spark healthcare voters to play a bigger role in the outcome.

My take:

Healthcare is increasingly a fact-free zone for politicians seeking votes. The reasons are simple:

Voters do not understand the U.S. system of health. Understanding the U.S. health system is not a competency required of lawmakers who govern it nor employers and consumers who use and pay for it. Rather, most depend on their personal experiences with the hospitals, physicians, insurers and medications they use. “Good hospitals” are those that accept an individual’s insurance and are accessible; affordability matters but all are expensive. “Good doctors” are those that are accessible in person and affable; all are presumed competent. “Good insurance plans” have premiums that fit a budget and offer choices of preferred hospitals and specialists. And “good medications” are those prescribed by “good doctors” that “appear” to be safe and effective. Data comparing performance, prices, underlying costs, alternatives and comparative outcomes is not readily consumed except for less than 10% who are “sick and savvy”.

Healthcare policy issues of significance to voters are complicated. Voters care about healthcare issues that impact their lives directly. Access to medical care, out of pocket costs, and user experiences are understood by voters. Opinions about abortion are a case in point: it’s more than PRO CHOICE VS. PRO LIFE for voters. The Dobbs decision (Dobbs v. Jackson Health June 24, 2022) was not against abortion. Rather, it was a decision that the federal government has no role in abortion policy and therefore the issue is to be adjudicated by individual states. Per the Wall Street Journal’s August 17-25 poll results released this week, 60% of registered voters think abortion should be legal in all or most cases, up from 55% in March. Another 29% said it should be illegal, except in cases of rape, incest and when the woman’s life is endangered, compared with 30% in March. And 6% said it should be illegal in all cases, down from 11% in March. Clearly complicated. Clearly not a binary choice. Clearly a wedge issue that will drives votes, especially this year and especially among women. But it’s understood better than most issues in healthcare.

Trusted sources are less trusted.  Gallup’s Institutional Confidence monitoring since 1973 reflects a disturbing trend: less confidence in the medical system in parallel with eroding confidence in the federal government, Congress, media, public education, the Supreme Court, organized religion and Big Business. Case in point: Covid vaccines. While the majority of physicians, the CDC and health agencies promote their necessity, a fourth of U.S. adults don’t believe CDC warnings and a majority suspect drug companies of profiteering at the expense of the public’s health. Social media and well-orchestrated disinformation campaigns have successfully eroded the public’s trust in our health system.

In 63 days, the table will be reset for the 118th Congress that convenes January 3, 2023 and for state legislatures and Governors’ offices nationwide. For healthcare, the results will be immediately felt at the state and federal levels. Stay tuned.


PS: A Guest Column last week by two business coalition leaders is particularly relevant to healthcare’s role in the economy and its interactions with employers. Excerpts are included in the section below. For America’s business leaders, the health system’s not delivering value commensurate with its cost. Worth reading.


Commentary: Employer coalition leaders challenge pandemic subsidies for hospitals: In a blistering Guest Column, leaders of 2 employer coalitions blame hospital prices, lack of transparency for increased costs. Excerpts:

 “Despite a recent taxpayer-subsidized boon, the hospital industry spent the last several months lobbying for additional federal dollars amid warnings about the continued spread of Covid-19 and inflation’s impact on the nation’s health care system. Those efforts bore fruit: Medicare recently granted hospitals the largest price increase since 1998….

“Covid-19 funding deals marked the continuation of a pre-pandemic trend that has seen larger systems swallow up smaller players in pursuit of greater market share, reduced competition, and higher profits. Despite industry claims to the contrary, this kind of consolidation extracts a significant cost from employers, who provide health benefits to more than half of all Americans, and their workers. Hospital mergers increase the average prices of hospital services by 6% to 18%, with no demonstrated improvements in quality or access to care. What’s more, hospital growth crowds out resources for the type of care known to support health and well-being, namely, primary care, behavioral care, and community health….the prices hospitals charge have soared 600% since 1990, and hospital services now represent the largest share of total health care costs, at about 37% of the total for privately insured Americans…

“Employers and private insurers pay, on average, 224% of what Medicare would have paid for the same service at the same facility, despite new data showing that hospitals require payments that represent just 127% of Medicare to cover their expenses…

“The truth is that large urban hospitals and wealthy health systems have more than enough money…Those paying the bills can no longer accept a health care system that exploits workers and employers and endangers the country’s future in pursuit of a fatally flawed status quo.”

Elizabeth Mitchell is the president and CEO of Purchaser Business Group on Health; Mike Thompson is the president and CEO of the National Alliance of Healthcare Purchaser Coalitions.

Elizabeth Mitchell, Mike Thompson As hospitals raise their prices, U.S. workers and businesses suffer Aug. 31, 2022

EBRI, CFPB: Co-pays up for employees in private coverage, medical debt growing: A recent Employee Benefit Research Institute study shows that Individuals enrolled in employer-sponsored health plans saw average deductibles grow 336% from $650 in 2002 to $1,945 in 2020. Out-of-pocket payments rose to 19% of all U.S. healthcare expenditures by people with employer-sponsored health insurance in 2021, up from 17.4% in 2013.

Those have contributed to the $88 billion of medical debt on the credit records of 43 million Americans, according to a report published this year by the Consumer Financial Protection Bureau. Illinois residents owe about $2.5 billion of that debt, the ninth-highest in the nation behind states like Texas, California and Florida.


Medical Debt Burden in the United States, Consumer Financial Protection Bureau February 2022


August jobs report: labor market loosening: Per the labor department Friday, employers added 315,000 jobs last month, down from 526,000 in the July. The jobless rate rose to 3.7% from a half-century low of 3.5% the prior month reflecting more workers entering the labor force (62.4% in August vs. 62.1% in July) as participation among women ages 25 to 54 jumped to the highest level since 2000. Healthcare added an estimated 48,200 jobs in August and 412,000 jobs in the past year.

US Department of Labor www.bls.govs

Care Management, Telehealth

Study: Telehealth useful in drug addiction therapy: In this cohort study including 175 778 beneficiaries, receipt of OUD-related telehealth services during the COVID-19 pandemic was associated with improved MOUD retention and lower odds of medically treated overdose. Emergency authorities to expand telehealth utilization and provide MOUD flexibilities during the COVID-19 pandemic were used among Medicare beneficiaries and were associated with improved MOUD retention and lower odds of medically treated overdose, lending support for permanent adoption.

Jones et al Receipt of Telehealth Services, Receipt and Retention of Medications for Opioid Use Disorder, and Medically Treated Overdose Among Medicare Beneficiaries Before and During the COVID-19 Pandemic JAMA Psychiatry. Published online August 31, 2022. doi:10.1001/jamapsychiatry.2022.2284

Study: hospital, pharmacy prices drive spending increases in cost-control states: In the  6 states  (CT,NJ, NV, OR, RI, WA) participating in the Peterson-Milbank Program for Sustainable Health Care Costs which have per capita cost growth targets, Bailit consulting found…

·        Health Care Spending Growth Has Been Highest In The Commercial Markets (Nationally, between 2008 and 2020, per capita commercial spending grew 46.8%, compared to 28.2% and 21.2% for Medicare and Medicaid, respectively, despite a decrease in commercial growth in 2020)

·        Hospital Spending and Pharmacy Have Been Major Drivers of Spending Growth

·        Price Increases—Not Increased Service Use—Have Generally Been the Cause of High Rates of Hospital and Pharmacy Spending Growth

Michael Bailit What Is Driving Health Care Spending Upward In States With Cost Growth Targets? Health Affairs August 9, 2022

Population, Demographics

Life expectancy drops (again): Per the CDC’s latest report:

·        Among the 50 states and D.C., Hawaii had the highest life expectancy at birth, 80.7 years in 2020, and
Mississippi had the lowest, 71.9 years.

·        From 2019 to 2020, life expectancy declined for all 50 states and D.C., from 0.2 years for Hawaii to 3.0 years for New York.

·        In 2020, life expectancy at age 65 ranged from 16.1 years in Mississippi to 21.0 years in Hawaii.

·        Life expectancy at birth was higher for females in all states and D.C. The difference in life expectancy between females and males ranged from 3.9 years in Utah to 7.0 years in D.C.

In a related study comparing life expectancy in 19 peer countries, the average decline was 0.4-year decrease in life expectancy between 2019 and 2020 and a 0.28-year increase between 2020 and 2021, with a net loss of 0.3 years over the two-year period


National Vital Statistics US State Life Tables August 23, 2022


CMS ACO Report: Savings of $1.66 trillion reported: In 2021 results released last week for the Medicare Shared Savings Program aka accountable care organization (ACO) model:

·        11 million seniors were engaged in ACOs thru 475 ACOs

·        Medicare $1.66 billion after accounting for shared savings payments

·        98% of ACOs hit quality objectives, 81 % achieved savings to Medicare with 56% achieving shared savings.

Serious Mental Illness Health Affairs August 2022

Related study: ACOs spending lower for serious mental illness: Using national Medicare data from the period 2009–17, researchers evaluated changes in spending and use associated with enrollment in the Medicare Shared Savings Program (MSSP) among beneficiaries with serious mental illness (SMI). After five years, participation in MSSP ACOs was associated with small savings for beneficiaries with SMI (−$233 per person per year) in total health care spending, primarily related to savings from chronic medical conditions (excluding mental health; −$227 per person per year) and not from savings related to mental health services (−$6 per person per year). Savings were driven by reductions in acute and post-acute care for medical conditions. “Further work is needed to ensure that Medicare ACOs invest in strategies to reduce potentially unnecessary care related to mental health disorders and to improve health outcomes.”


Figueroa et al ACO Participation Associated With Decreased Spending For Medicare Beneficiaries With

MedPAC warns of Medicare funding shortfall: Last Thursday, members of the Medicare Payment Advisory Commission (MedPAC) heard a presentation by MedPAC senior analyst Rachel Burton, MPP, describing Medicare’s overall financial situation. Highlights:

·        ‘Within the Medicare program itself, Medicare Advantage spending per beneficiary starting in 2013 has increased faster — at 3% annually — than traditional Medicare, which has risen 2.3% on average. Medicare Part D drug spending during the same period increased an average of 1.9% annually.

·        These increases are occurring even as the number of workers paying into Medicare through their taxes continues to drop: in 1970 there were more than 4.5 workers paying taxes per one Medicare beneficiary by 2021, that number had dropped to 2.9.

·        To help the Medicare Hospital Trust Fund remain solvent for another 25 years, the government could raise the percentage of the salary workers pay in from today’s 2.9% to 3.66%, or decrease Medicare Part A spending by 16.9%, or $69 billion per year.’

MedPAC Members Concerned About Medicare’s Finances Medpage September 1, 2022


Kaufman Hall Hospitals experience worst margins since beginning of pandemic: Per Kaufman Hall’s August Hospital Flash Report, hospitals and health systems saw decreases in outpatient revenue and operating room time and increases in inpatient lengths of stay from June to July. Highlights:

·        Margins: The median Kaufman Hall Year-To-Date (YTD) Operating Margin Index reflecting actual margins was -0.98% through July; median % change in Operating Margin was -63.9% from last month and -73.6% from July 2021 and Operating EBITDA Margin was -45.2% month-over-month, and -49% from July 2021.

·        Volumes: Operating Room Minutes dropped 10.3% from June and dipped 7.7% year-over-year (YOY); length of Stay (LOS) rose 2% from June and was up 3.4% compared to July 2021; patient days rose 2.8% from June to July but were down 2.6% from July 2021 levels; adjusted discharges dropped 2.8% month-over-month and were down by 4.2% compared to July 2021; emergency Department (ED) Visits rose 2.6% from June to July and were up slightly YOY — by 0.7%.

·        Revenues: Gross Operating Revenue was down 3.6% from June and up 1.2% YOY. It is up 5.5% YTD. Outpatient (OP) Revenue dropped 4.8% from June levels but rose 0.6% YOY. It is up 7.1% YTD. Inpatient (IP) Revenue dropped 0.7% from the previous month and is down 1.5% from July 2021. It is up 3.6% YTD.

·        Expenses: Total Expenses dipped 0.4% from June to July and rose 7.6% from July 2021; Inflation and labor shortages contributed to total costs climbing 9.6% YTD; Labor Expense per Adjusted Discharge rose 3.5% from June and is up 13.9% YTD; Full-Time Employees Per Adjusted Occupied Bed (FTEs per AOB) is up 7.2% from June; Total Expense per Adjusted Discharge is up 2% from June.

Kaufman Hall National Hospital Flash Report August


Pitchbook: serial entrepreneur experience increases valuations: Per Pitchbook, entrepreneurial experiences result in deal sizes and pre-money valuations 2x-4x larger than their counterparts. Related findings:

·        “…seed-stage serial entrepreneur-led startups achieve median valuations that were 1.9x higher than those of their novice counterparts. Median valuation variances between serial and novice entrepreneurs further increased to 2.5x at the early stage and 3.7x at the late stage. •

·        “Across all venture stages, serial entrepreneur-led startups capture roughly 2.5x more participation from the top 100 investors than their novice peers.

·        “.. serial entrepreneurs own roughly 3% less of their businesses than their novice counterparts.”

Serial Entrepreneurs Raise More Capital, but at What Cost? Pitchbook September 1, 2022


Per the CDC, FDA as of September 3::

·        total cases 94,546,190

·        total deaths1,043,401

·        In the last two weeks:1,219,559 confirmed cases (-12%)

·        1 in 268 people infected

·        7,033 reported deaths (+7%)

·        In its meeting August 31, the U.S. Food and Drug Administration authorized updated versions of the two available mRNA boosters (bivalent vaccines) for use in people 12 years of age and older.

Study: children capable of Covid self-testing: Researchers evaluated the ability of school-aged children to self-collect nasal swabs for SARS-CoV-2 testing compared with collection by health care workers. Note: Children were given instructional material consisting of a short instructional video and a handout with written and visual steps for self-swab collection. Participants first provided a self-collected nasal swab. Health care workers then collected a second specimen.

·        “After hearing and seeing simple instructional materials, children and adolescents aged 4 to 14 years self-collected nasal swabs that closely agreed on SARS-CoV-2 detection with swabs collected by health care workers.”

Waggoner et al Concordance of SARS-CoV-2 Results in Self-collected Nasal Swabs vs Swabs Collected by Health Care Workers in Children and Adolescents JAMA. Published online August 26, 2022. doi:10.1001/jama.2022.14877


Medicaid-CHIP coverage likely to dip despite PHE subsidy extension: Enrollment could decrease by as much as 15.4 million: 8.2 million enrollees ineligible for Medicaid after the PHE, 6.8 million due to churn despite remaining eligible for the program and 383,000 who fall into the coverage gap (reside in a non-expansion state. Only 2.7 million of those losing Medicaid or CHIP coverage would qualify for advanced premium tax credits per the HHS Assistant Secretary for Planning and Evaluation’s (ASPE) analysis.


Groups challenge copay adjustment by insurers: Last Tuesday, 3 patient advocacy groups–the HIV+Hepatitis Policy Institute, the Diabetes Leadership Council, and the Diabetes Patient Advocacy Coalition—filed suit against HHS and CMS challenging a regulation that prevents patients from including drugmaker discounts including copay coupons. The groups claim health insurers and pharmacy benefit managers have harmful policies that prevent those savings from actually reaching the patients. The policy at issue originally put in place by the Trump administration in 2021 allows insurers to avoid counting the discounted drug prices toward the deductible or out-of-pocket cap in their health plan, a policy known as copay adjustment. The lawsuit claims the rule is not only arbitrary and capricious, but illegal under the Administrative Procedure Act.

Tara Bannow In a new lawsuit, pharma-backed patient groups fight federal rule around copay coupons Stat News Aug. 30, 2022

Humana Completes CenterWell Home Health acquisition: Four years after the initial acquisition of Kindred at Home, Humana Inc. (NYSE: HUM) completed its rebranding efforts: Kindred at Home is officially CenterWell Home Health. CenterWell Home Health will operate in 350 locations 38 states.

Humana September 1, 2022


Amazon: Friday, the Federal Trade Commission requested for additional information about Amazon’s $3.9 billion acquisition of the primary health organization One Medical and One Medical’s parent, San Francisco-based 1Life Healthcare Inc. One Medical offers a concierge-type medical service with roughly 190 medical offices in 25 markets. Last week, the e-commerce giant said it would shutter its own hybrid virtual in-home care service called Amazon Care, a One Medical competitor, because it wasn’t meeting customers’ needs.

CVS: CVS Health Corp. CVS -0.49%▼ is in advanced talks to acquire the home-healthcare company Signify Health Inc. SGFY 1.34%▲ for around $8 billion beating out Inc. and UnitedHealth Group Inc.

Walgreens Walgreens Boots Alliance completed its previously announced $330 million acquisition of majority ownership (55%) of home health benefit management firm CareCentrix. Last year, the company invested $5.2 billion to become majority owner of primary-care startup VillageMD and spent $970 million to acquire a controlling interest in Shields Health Solutions, an integrated pharmacy care provider.


MGMA: Medical practices gradually increasing value-based care participation: Major findings from the MGMA DataDive Practice Operations survey:

·        The highest value-based payment (VBP) among nonsurgical specialties (14.74%), followed by primary care (6.74%), and then surgical specialties (5.54%).

·        Across all practices, the median revenue amount from value-based contracts was $30,922 per FTE provider.

·        42% of providers tie physician compensation to an element of quality (up from 26% in 2016), and most providers (45%) use both in-house analysts and vendors/software to handle quality metrics.


Private equity acquisition of practices results in higher revenue, more patients per practice: Researchers examined changes in prices and utilization associated with private equity acquisitions of dermatology, gastroenterology, and ophthalmology practices from 2016 to 2020. “For dermatology, we focused on biopsy procedures, pathology services, and E&M visits; for gastroenterology, on procedures related to removal of polyps, tumors, and lesions, esophagogastroduodenoscopy, and E&M visits; and for ophthalmology, on cataract extractions, diagnostic imaging, and eye examinations. “Findings:

·        Compared with the 2874 control practices, the 578 PE-acquired physician practices exhibited an average increase of $71 (+20.2%) charged per claim and $23 (+11.0%) in the allowed amount per claim.

·        The PE-acquired practices increased their numbers of unique patients seen by 25.8% compared with control practices, driven by a 37.9% increase in visits by new patients.

·        In aggregate, their volume of encounters increased by 16.3% compared with the control group, with a 9.4% increase in the share of office visits for established patients that were billed as longer than 30 minutes.

·        No statistically significant changes in patient risk scores were found between PE-acquired practices and controls. Within specialties, we found modest differences along selected outcomes.

“… private equity acquisition of physician practices in dermatology, gastroenterology, and ophthalmology were associated with differential increases in allowed amount and charges per claim, volume of encounters, and new patients seen, as well as some changes in billing and coding.”

Singh et al Association of Private Equity Acquisition of Physician Practices With Changes in Health Care Spending and Utilization JAMA Health Forum September 2, 2022;3(9):e222886. doi:10.1001/jamahealthforum.2022.2886

Study: Medical scribe use does not enhance medical record closures: Medical record closure time is used as an indicator of physician documentation burden, a quality improvement measure, as well as one reflection of efficiency and burnout risk. This study evaluated medical record closure outcomes before and after the use of medical scribes. Findings:

“Physicians using scribes had suboptimal medical record closure practices at baseline compared with colleagues who never used scribes. While scribe assignment did not significantly improve these metrics, significant reductions occurred in encounters that did not use a scribe compared with those where a scribe was used. This suggests that the use of scribes may not be a solution to clinical documentation burdens. “

Florig et al Medical Record Closure Practices of Physicians Before and After the Use of Medical Scribes JAMA. September 1, 2022. doi:10.1001/jama.2022.13558

ONC Report: 12% of office-based physicians electronically exchanged patient health information with public health agencies in 2019. Per the report from the Office of the National Coordinator for Health IT:

  • Electronic exchange capabilities were higher in 2019 among primary care physicians than those in other specialties.

  • The most common data electronically exchanged with public health agencies was immunization information.

  • Primary care physicians engaged in interoperability and those using certified health IT were more likely to electronically share data with public health agencies.

  • Physicians using electronic health records systems from health IT developers with large market share had the highest rates of data exchange with the agencies.

Interoperability Among Office-Based Physicians in 2019 ONC July 2022

Commentary: Drivers of Physician Burnout need Attention: In a MedPage Opinion, Rafid Rahman, MD, argues that physician burnout is harmful to patient care: “We need to focus on improving the organizational drivers of burnout… workload, autonomy and control, and loss of meaning in work. To address these, organizations can provide physicians resources to streamline EHR workflow, use advanced practice providers to allow physicians to work consistently at the top-of-license, give physicians clarity and decision-making capacity in their schedules, and allow physician leadership roles to be sustainable and fulfilling.”

Physicians Are Getting the Wrong Dose of Medicine MedPage August 7, 2022

Study: in-home vs. remote physician visits have comparable results: Researchers compared remote and in-home physician care for infection, heart failure, chronic obstructive pulmonary disease, and asthma, between August 3, 2019, and March 26, 2020; follow-up ended April 26, 2020. Findings:

·        Mean adjusted adverse event count was 6.8 per 100 patients for remote care patient’s vs 3.9 per 100 patients for control patients, for a difference of 2.8 supporting noninferiority.

·        For remote care vs control patients, the mean adjusted Picker Patient Experience Questionnaire 15 score difference was −0.22 supporting noninferiority.

·        The mean adjusted 30-day readmission absolute rate difference was 2.28% which was inconclusive. Of patients in the remote group, 16 (19.0%) required in-home visits beyond the first visit.

“In this study, remote physician visits were noninferior to in-home physician visits during home hospital care for adverse events and patient experience, although in-home physician care was necessary to support many patients receiving remote care. Our findings may allow for a more efficient, scalable home hospital approach but require further research.”

Levine et al Remote vs In-home Physician Visits for Hospital-Level Care at Home A Randomized Clinical Trial JAMA Network Open August 30, 2022;5(8):e2229067. doi:10.1001/jamanetworkopen 2022.29067