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The Keckley Report

Strategy in Healthcare: Are Insiders Prepared to Shift?

By February 27, 2023March 1st, 2023No Comments

Last week was a week for big announcements in healthcare:

  • Amazon closed its $3.9 billion acquisition of primary care company One Medical.
  • UnitedHealth Group (UHG) closed its $5.4B acquisition of home-health provider LHC Group which operates in 37 states.
  • Humana announced its plan to exit the employer-sponsored insurance focus on its Medicare Advantage strategy.
  • Walgreens CEO Rosalind Brewer announced it is shifting its focus from retail drug stores to urgent care vis a vis its plan to acquire Village MD in a $9 billion deal announced in November. (Note: Village MD acquired primary care provider Summit Health-CityMD for $8.9 billion in November.
  • Already the owner of insurer Aetna, CVS this month agreed to acquire Oak Street Health Inc., a network of 169 senior-focused clinics for $10.6 billion.
  • And there was escalating buzz about generative AI applications in healthcare as speculation about Microsoft’s chatbot ChatGPT and Google’s Bard have dominated the healthtech news cycle.

Corporate strategery is about big bets. It’s about course adjustments that take advantage of market opportunities and competitor vulnerabilities. It’s about growth, scale and scope. Notwithstanding near-term risks associated with inflation and work-force shortages, and the industry’s clumsy response to price transparency mandates and alternative payment models, long-term opportunities in healthcare are attractive, especially to players like these not encumbered by a complicated regulatory environment and shrinking access to capital.

The long-term plays in healthcare are necessarily focused on scale, access and affordability. They rely on data and consumer activation. They leverage technologies that reduce labor intensity and they deploy capital to highly concentrated service centers and distributed virtual networks. And they expand clinical investments to holistic primary care services and virtual services in homes, schools and workplaces. Hospitalization is a last resort; public health and local delivery systems are fully integrated and care coordination is managed by professional services organizations that accept full risk for clinical and financial results.

It’s a major shift for the system and a major opportunity for outsiders. The implications are clear:

  • For healthcare suppliers (devices, prescription drugs, advisors, facility developers et al), it means fewer traditional customers with greater leverage in their purchasing relationships and a new set of customers with unique buying requirements.
  • For its doctors and hospitals, it means rethinking capital and operating priorities, recognition that people seek better care at lower costs and organizational structures that integrate consumer-friendly financing and delivery of services. No excuses. For outsiders, it’s the blind spot that can be exploited to move market share.
  • And for disruptors like those noted above, it’s about taking advantage of insider dysfunction, opaque pricing and risk aversion and balance sheet strength to permanently replace the status quo with affordable systems of health that serve individuals and communities.

Rosalind Brewer, Starbucks’ #2 before joining Walgreens last year, saw a need to chart a new course. She took her Board on a road-trip to a Village MD site to acclimate them to a new normal. Her strategery is not without risk but for Walgreen’s Board, it’s their destination.

Healthcare’s insiders talk good games but default to incrementalist’ strategery not because the future is an unknown. It’s because many boards are uncomfortable with ‘too much’ change or, in some cases, executive comp is geared to risk avoidance and short-term financial success. Often, excuses masquerade as reasons. That’s why outsiders are gaining ground on insiders.

Healthcare’s future is not a repeat of its past. Strategery in every organization needs a fresh look– especially among its insiders.


PS: In the sections below, quotations, citations and polling results reflect the state of play in US healthcare today. Hope you’ll take time to read them. Thanks!!


Rosalind Brewer, CEO Walgreens CEO Bets on Doctors Over Drugstores in Search for Growth WSJ February 19, 2023

Week ahead: Events of Note in Healthcare to Watch:

The Supreme Court will consider the fate of President Joe Biden’s student loan debt forgiveness program, which is currently on hold. Biden’s program would offer up to $20,000 of debt relief to millions of qualified borrowers, but it has been met with legal challenges. Relevance to healthcare: young and middle age adults have student-loans—the second biggest debt held by Americans. Loan forgiveness increases the likelihood that these adults will pay their medical bills and seek care appropriately.

The first round of the election takes place on tomorrow. Nine candidates are standing, all Democrats. Unless one wins over 50% of the vote, which nobody thinks is likely, the top two will compete in a run-off on April 4th. Relevance: Chicago is a much-watched market for trend analyses of urban health, et al.

The Conservative Political Action Conference — known as CPAC — will begin just outside Washington, DC. Billed as “the largest and most influential gathering of conservatives in the world.” Relevance: abortion rights, coverage decisions are high-profile issues in conservative voter circles.

Quotable from Last Week’s Reading

Re: maternal child rural health: “From 2015 to 2019, there were at least 89 obstetric unit closures in rural hospitals across the country. By 2020, about half of rural community hospitals did not provide obstetrics care, according to the American Hospital Association.

In the past year, the closures appear to have accelerated, as hospitals from Maine to California have jettisoned maternity units, mostly in rural areas where the population has dwindled and the number of births has declined….

The United States is already the most dangerous developed country in the world for women to give birth, with a maternal mortality rate of 23.8 per 100,000 live births — or more than one death for every 5,000 live deliveries.

Recent figures show that the problems are particularly acute in minority communities and especially among Native American women, whose risk of dying of pregnancy-related complications is three times as high as that of white women. Their babies are almost twice as likely to die during the first year of life as white babies.”

Rural Hospitals Are Shuttering Their Maternity Units NYTimes February 26,

Re: physician compensation: “The Recovery Plan for America’s Physicians is where a lot of our work is focused on legislative activity around reviving and supporting physician practices as we come out of this first 3 years of the pandemic.

For instance, Medicare payment — things have gotten worse. We have a 2% cut across the board on January 1, which is just incredibly demoralizing for the physician community who is dealing with rampant inflation, trying to keep their practices open, dealing with misinformation, and held their practices together through this difficult pandemic.

We need inflation-based, automatic, yearly, positive updates — just like hospitals get, just like nursing facilities get, just like hospices get. Why physicians are different is a weird accident of history that has got to be fixed. So that is the focus.”

Jack Resnick, MD, President, American Hospital Association Advocacy Is Hard, and Washington Is a Difficult Place Medpage February 20, 2023

Re: health sharing ministry industry: “Despite a history of fraud, one family has thrived in the regulatory no man’s land of health care sharing ministries, where insurance commissioners can’t investigate, federal agencies turn a blind eye and prosecutors reach paltry settlements.”

Ryan Gabrielson, J. David MoSwane A Christian Health Nonprofit Saddled Thousands With Debt as It Built a Family Empire Including a Pot Farm, a Bank and an Airline ProPublica February 25,

Re: Millennials’ spending, debt buildup: American millennials in their 30s have racked up debt at a historic clip since the pandemic. Their total balances hit more than $3.8 trillion in the fourth quarter, according to the Federal Reserve Bank of New York, a 27% jump from late 2019. That is the steepest increase of any age group. It is also their fastest pace of debt accumulation over a three-year period since the 2008 financial crisis.

The debt buildup could worsen a generational wealth gap that was already on the rise for millennials. …Now, rapid inflation is forcing many to spend more on gas, groceries and rent, eating into pandemic savings. The last round of stimulus checks went out in 2021. Families are back to commuting, traveling and eating out again. The Federal Reserve’s campaign to curb inflation has pushed up interest rates on credit cards and other types of loans.

But there are signs that millennials are overstretched. The average credit-card balance for millennial borrowers was about $6,750 in January, up 26% from three years earlier, according to credit-score provider Vantage Score Solutions. Balances were little changed for Gen X, and fell between 11% and 15% for older generations. Average personal-loan balances for millennials rose more than they did for overall borrowers.”

Americans in Their 30s Are Piling On Debt Wall Street Journal February 25, 2023

Re: court dispute about abortion pill access: “THE FIGHT over abortion access in America was never going to end with the overturning of Roe v Wade. Last summer the Supreme Court returned the matter to individual states… The fight at first focused mostly on physical clinics, but has expanded to abortion medication. Both sides believe these pills are the key to getting what they want, and are using the courts to try to get there….

Anti-abortion activists want to see them banned. In perhaps the highest-stakes abortion case since the overturning of Roe, a federal district judge in Amarillo, Texas, on February 24th received final briefs for a claim that mifepristone—half of the two-drug regime used in medicated abortions—should be taken off the shelves across America. The lawsuit, against the FDA, was filed in a district with an ultra-conservative, Trump-appointed judge. The Alliance Defending Freedom (ADF), representing pro-life groups, claims that the agency’s approval of the drug, 22 years ago, was flawed and “jeopardized the health and safety of women and girls”. The FDA points to decades of experience and studies that demonstrate mifepristone’s safety…

Americans’ views on abortion, meanwhile, are shifting. Some 64% say it should be legal in most or all cases, up from 55% in 2010, according to a poll last week by Public Religion Research Institute. And more than half believe Congress should pass a law preserving the right to abortion.  “

The big American post-Roe battle over abortion pills The Economist February 26, 2023

Re: hospice care, death literacy: “Improving death literacy within our medical professions will improve care for those approaching the end of life. So much of our focus in medicine is on the latest, greatest treatment approach, but we need to recognize and honor those we cannot cure. They deserve expert care too. When people ask why I chose to specialize in this field, my response is simple: a good death is the last gift we can offer someone.”

Aldebra Schroll, MD,opens in a new tab or window is a hospice and palliative care physician, and a consulting physician at Butte Home Health & Hospice. Medpage February 20, 2023

Hospitals, Health Systems

Sullivan Cotter study: wage increases costly to health systems: Using data from 62 health systems, SC found that wage increases meant an additional $115 million, on average, in costs last year for health systems paying around $1.6 billion for worker salaries. The growth of full-time equivalent healthcare employees last year was between 1.9% and 2.6%, according to the survey published Tuesday.

Overall, nursing and human resources departments at the country’s largest health systems saw the most significant declines in employees, with decreases of 8.8% and 8.3%, respectively, in 2022. Regulatory and compliance areas have seen between 20% to 25% employment growth at small and midsize organizations, per the survey.

As a share of hospitals’ total labor expenses, contract labor costs grew by about 179% from 2019 to 2022, according to the American Hospital Association.

Sullivan Cotter

Study: SNF integration in health system networks: Researchers analyzed the association of vertical integration of SNFs within hospital networks with SNF utilization, readmissions, and spending for Medicare beneficiaries undergoing elective hip replacement using Medicare claims data from 2016-2017. Findings:

A total of 150 788 patients (61.4% women; mean [SD] age, 74.3 [6.4] years) underwent hip replacement. After risk adjustment, vertical SNF integration was associated with a higher rate of SNF utilization (21.7% vs 19.7%) and lower 30-day readmission rate (5.6%vs 5.9%. Despite higher SNF utilization, the total adjusted 30-day episode payments were slightly lower ($20 230 vs $20 487driven  by lower post-acute payments and shorter SNF length of stays. Adjusted readmission rates were particularly low for patients not sent to an SNF (3.6%) but were significantly higher for patients with an SNF length of stay less than 5 days (41.3%)

“These findings support the purported value of integrating SNFs into hospital networks but also suggest that there is room for improving the postoperative care of patients in SNFs early in their stay.”

Kalata et al Association of Skilled Nursing Facility Ownership by Health Care Networks With Utilization and Spending JAMA Network Open February 20, 2023. 2023;6(2):e230140. doi:10.1001/jamanetworkopen.2023.0140

Capital Markets

Pitchbook: 2022 Year End investment Category Results: Capital raised (Mil) vs. YoY returns:

Private capital $1,167.1  (-21.4%)
Private equity $460.8  (-17.2%)
Venture capital $252.6  (-11.4%)
Real estate $85.3  (-44.7%)
Real assets $108.2  (-22.9%)
Debt $200.2  (-19.7%)
Fund of funds $23.5  ( -51.2%)
Secondaries $36.5 (-29.0%)

Pitchbook: private funding slowdown expected: “…we forecast that AUM held in closed-end fund vehicles across PE, VC, private debt, real estate, and real assets will reach $13.0 trillion by 2027. While we show AUM reached a plateau of $12.4 trillion in 2022 after five consecutive years of double-digit growth, this figure is inclusive of funds of funds (FoF) and secondaries, which were excluded from our AUM forecasting study to avoid double- counting the assets seeking to invest in private markets.”

PitchBook 2022_Annual_Global_Private_Market_Fundraising_Report

Healthcare services deal flow: “The worker shortage across the US healthcare system is restricting private equity dealmaking in the sector as some businesses struggle to grow and higher payrolls cut into margins…The year wrapped with an estimated 26.4% decrease in deals from Q3 to Q4, according to the report, which also attributes general macroeconomic worries and the higher cost of capital for the slowdown

Since the coronavirus pandemic began, healthcare workers have quit or avoided signing up for longer hours with higher risks. Throughout 2022, job openings in the industry outpaced new hires by roughly 250%, according to Bureau of Labor Statistics data. According to the report, the healthcare labor shortage is especially acute in lower-skilled roles that require fewer credentials, as those workers have had greater flexibility to switch industries in search of higher pay.”

Emily Burleson Worker shortage plagues PE healthcare deals Pitchbook February 23, 2023

Care Management

Study: Relationship between middle-age low wage earners and mortality: Columbia University researchers followed 4002 workers (aged 50-57 years at the beginning of exposure period and 61-69 years at the end), 1854 (46.3%) were female; 718 (17.9%) experienced employment instability; 366 (9.1%) had a history of sustained low-wage earning; 1288 (32.2%) had intermittent low-wage earning periods; and 2348 (58.7%) had never earned a low wage. Those who had never earned low wages experienced 199 deaths per 10 000 person-years, those with intermittent low wages, 208 deaths per 10 000 person-years, and those with sustained low wages, 275 deaths per 10 000 person-years.

Kezios et al History of Low Hourly Wage and All-Cause Mortality Among Middle-aged Workers JAMA February 21, 2023 . 2023;329(7):561-573. doi:10.1001/jama.2023.0367 “

Obesity market: “The effectiveness of GLP-1 agonists—e.g., semaglutide (Wegovy)—in reducing weight has caught nationwide attention, causing a frenzy among celebrities and the wealthy to get their hands on the drug. It has also prompted startups to launch new weight management programs.

2022 was an inflection point for obesity treatment. Novo Nordisk, Eli Lilly, and Amgen’s novel obesity medications demonstrated impressive results in clinical trials (which I’ve summarized here). These anti-obesity medications target three types of receptors throughout the body: GLP1R, GIPR, and glucagon-R. The total addressable market for obesity care is vast:

  • 42% of adults have obesity, ((Hispanic: 46%; non-Hispanic white: 41.4%, Asian: 16%).–up from 30.5% two decades ago.
  • 9.2% of adults have severe obesity (up from 4.7% two decades ago).
  • 20% of children (2 to 19 years old) have obesity. (25% of Hispanic and non-Hispanic Black children have obesity, non-Hispanic white: 17% and Asian 9%). 20% of children in low- and middle-income families have obesity compared to 11% in high-income families.

Do Weight-management Startups Have a Future? Work Week February 18, 2023


Study: Provider Directory listing accuracy for mental health professionals in CA: In 2018, surveyors were able to reach 68.1% of listings for psychiatrists and 59.1% of listings for NPMHPs to verify the accuracy of provider directory information. The results are essentially similar for psychiatrists in 2019. However, there seem to be improvements for NPMHPs. Surveyors in 2019 were able to verify directory information for 76.5% of providers and, conditional on successful contact, 81.1% of providers were appropriately listed.”

Provider Directory Inaccuracy and Timely Access for Mental Health Care AJMC Feb 9, 2023

Study: ACA exchange markets lowered annual spending in individual, small group markets: Researchers analyzed trends in utilization, unit price, and service mix increases in overall health care spending from 2015-2019 for 14.5 million individual and 12.8 million small businesses who purchased coverage through the ACA health exchanges. Findings:

“Overall annual growth trends in health care spending per member per month during that period were 4.0% in the small-group market (increases for professional services 5.1% annually and outpatient facility services 4.7& annually) and 1.1% in the individual market. In the small-group market, professional and outpatient facility services contributed the most to spending growth, driven by unit price increases. In the individual market, pharmacy and outpatient facility services accounted for the greatest growth in spending, driven by a combination of unit price increases and changes in the mix of services. “Previous to the study period, spending increases on both markets had been significantly higher and volatile year-to-year.

Jacobson et al Trends In Medical And Pharmacy Spending In The Affordable Care Act Markets, 2015–2019 Health Affairs: February 2023

Study: Medicare enrollment associated with increased access to dental care: “When US adults reached age 65 years and became eligible for Medicare, their visits for restorative dental procedures such as fillings or crowns fell by 8.7%, according to survey responses from 97 108 participants aged 50 to 85 years. Moreover, the loss of all teeth, or complete edentulism, increased by 4.8% at age 65 years. In addition, enrollment in Medicare Advantage, which often offers dental coverage, was not tied to increased use of dental services compared with enrollment in traditional Medicare. “

Oral Health Worsened, Visits Decreased in Medicare Beneficiaries JAMA. February 22, 2023. doi:10.1001/jama.2023.2096

Study: MA enrollees discharged faster from EDs than FFS enrollees: “This cross-sectional study of more than 10 million beneficiaries found that patients who experienced an ambulatory care−sensitive condition and were covered by Medicare Advantage were less likely to be hospitalized and more likely to be discharged directly from the ED or have an observation stay than were patients with traditional Medicare.”

Beckman et al Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare JAMA Health Forum February 24, 2023;4(2):e225530. doi:10.1001/jamahealthforum.2022.5530


Pew: Majority uncomfortable with AI: The findings of a survey of 11,004 US adults conducted December 12-18, 2022:

  • 60% of Americans say they would be uncomfortable with a health care provider who relied on artificial intelligence to do something like diagnose their disease or recommend a treatment.
  • 57% said that the use of artificial intelligence would make their relationship with their provider worse.
  • 38% felt that using AI to diagnose disease or recommend treatment would lead to better health outcomes; 33% said it would lead to worse outcomes; and 27% said it wouldn’t make much of a difference.
  • 79% said they wouldn’t want AI involved in their mental health care.

60% of Americans Would Be Uncomfortable with Provider Relying on AI in Their Own Health Care Pew Research Center February 22, 2023

Axios Ipsos Poll American Health Index: Opinions about public health issues vary greatly across political, demographic groups: The survey of a nationally representative probability sample of 1,213 adults 18+ was conducted February 17 to February 21, 2023. Findings:

“Americans view opioids, obesity, and guns as the main threats to public health at the moment. Yet, some leading causes of death like cancer or auto fatalities are further down the list. Education also has a strong connection to concerns about opioids and obesity. People with a high school education or less are, by a three-to-one margin, more concerned with opioids over obesity compared to those with a college degree, who see obesity as the bigger issue.

 When it comes to public health priorities, Americans look to their pocketbooks. When asked what the government should prioritize for public health, half of Americans say reducing the cost of healthcare and prescription drugs. The next closest priorities are research into breakthrough cures to major diseases and reducing gun deaths, both distantly behind reducing healthcare costs, at 14%.

 The large majority of Americans report their health as “good” right now. But, reading between the lines, only a few are totally happy with their diet, physical health, or personal finances. Three-quarters or more Americans report they are in good health, ranging from emotional to financial. However, only about three in ten or less say that their diet (21%), physical health (27%), or personal finances (29%) are “very good,” suggesting these areas still have much room for improvement for most people.

 Americans do not believe the country is ready for another pandemic Axios-Ipsos February 23, 2023 /

Morning Consult: Trust in Generative AI low: Per Morning Consult’s Survey conducted Feb. 11-13, 2023, among a representative sample of 10,044 U.S. adults:

  • 52% are convinced that generative AI is not a fad, and is here to stay.
  • About equal shares of consumers find generative AI’s output “very trustworthy” (10%) and “not at all trustworthy” (11%), while the rest of the public sits somewhere in the middle.
  • 51% of those employed in healthcare think Generative AI will be helpful to the industry vs. 26% who think it will hurt—the most negative reaction compared to workers in other industries.

Morning Consult | Decision Intelligence & Custom Research

Rock Health 2022 Digital Health Consumer Adoption Survey: The 2022 survey involved 8,014 respondents July 12 to August 22, 2022. Findings:

  1. Telemedicine reached the 80% adoption mark overall, becoming the preferred channel for prescription care and minor illness

  2. Audio-only and asynchronous telemedicine beat out point-to-point video chats as the most-used telemedicine modalities, with live phone, apps, and messaging resurging

  3. While adoption of wearable devices rose, clinical use of wearables hasn’t caught up to D2C

  4. Health data sharing only moves at the speed of trust, and right now it’s slow going

Consumer adoption of digital health in 2022: Moving at the speed of trust Rock Health February 21, 2023

Revive Polling December 2022: Revive surveyed 1,200 working-age adults found that in December 2022. Highlights:

  • 65% say trust in healthcare has declined since 2020
  • 32% of consumers said hospitals care most about profits vs. 19% patient health and 12% hospitals prioritize the health of their communities
  • 36% think pharma is most responsible for the cost of care, 36% health insurers, 22%, physicians, and 22% hospitals.

The Value Attack Revive Health

Study: awareness of Medicaid re-determination low: Background: The nation has been under continuous Medicaid enrollment since early 2020, which allowed 17.7 million people to gain coverage — a 25% increase in the program. On April 1, states will begin determining who is and is not eligible for Medicaid once again, with an estimated 15 million to 18 million people facing a loss of health coverage. The Inflation Reduction Act extended ACA premium tax credits through the end of 2025, which will allow some Medicaid members to regain coverage through the federal or state marketplaces.

According to a survey conducted in December by the Robert Wood Johnson Foundation, 64% of Medicaid members or those with family enrolled said they have heard nothing about upcoming redeterminations. In June, the same survey found 62% of adults had no knowledge of Medicaid renewals.

Update: Awareness of the Resumption of Medicaid Renewal Processes Remained Low in December 2022 Brief Feb-15-2023 | Karpman M , Gonzalez D , Haley JH , Kenney GM , and Zuckerman S

Prescription Drugs

Commentary: patent parity for biologics and small molecule drugs: “If small-molecule and biologic drugs should have equal periods of exclusivity, then the right solution is to align both at no more than the nine years given to small molecules. There is no evidence to support exempting biologics from negotiation for 13 years. Brand name biologic drugs typically face less competition than small-molecule drugs, and research shows that research and development costs for the two categories are similar. A prolonged exemption from negotiation leaves people covered by Medicare footing the bill for biologic drugs with launch prices that can exceed $200,000. These prices are harming the health of Medicare enrollees: an estimated  3.5 million seniors had difficulty affording medications in 2019.

To put this into perspective, other high-income countries provide small-molecule and biologic drugs with identical periods of market exclusivity. The only reason the U.S. is not on that list is because the pharma industry spent millions lobbying Congress for a longer monopoly period for biologics.”

Another pharma industry flip-flop: Claims about the IRA’s effect on small-molecule versus biologic drugs Statnews February 17, 2023

Health system economy utilization, spending

Altarum Health Sector Economic Indicators (HSEI) February 2023 Brief: Highlights:

  • National health spending grew by 3.8% in 2022–up 0.6%, year over year.
  • Nominal GDP in December 2022 was 6.3% higher than in December 2021 as GDP growth continues to outpace health spending growth.
  • Health care price and utilization growth slows in early 2023: The overall Health Care Price Index increased by 2.7% year over year in January, down from the updated 2.9% reported growth rate a month prior in December. Revised data for 2022 show that overall health care price growth averaged 2.6% over the entire year, up from the 2.3% average growth in 2021.
  • Economywide inflation slowed slightly in January, as overall CPI growth fell from 6.5% to 6.4% and PPI price growth fell from 6.5% to 6.0%. Economywide services (less healthcare) inflation continues to increase, up to 8.2% year-over-year growth last month.
  • Among the major health care categories, prices for dental care (6.6%), nursing home care (4.8%), and hospital services (2.7%) were the fastest growing, while physician services (0.5%) and home health care (1.8%) price growth were the slowest.