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The Keckley Report

Payers declare War on Corporate Hospitals: Context is Key

By August 21, 2023No Comments

Last week, six notable associations representing health insurers and large employers announced Better Solutions for Healthcare (BSH): An advocacy organization dedicated to bringing together employers, consumers, and taxpayers to educate lawmakers on the rising cost of healthcare and provide ideas on how we can work together to find better solutions that lower healthcare costs for ALL Americans.”

BSH, which represents 492 large employers, 34 Blue Cross plans, 139 insurers and 42 business coalitions, blames hospitals asserting that “over the last ten years alone, the cost of providing employee coverage has increased 47% with hospitals serving as the number one driver of healthcare costs.”

Its members, AHIP, the Blue Cross Blue Shield Association, the Business Group on Health, Public Sector Health Care Roundtable, National Alliance of Healthcare Purchaser Coalitions and the American Benefits Council, pledge to…

  • Promote hospital competition
  • Enforce Federal Price Transparency Laws for Hospital Charges
  • Rein in Hospital Price Mark-ups
  • Insure Honest Billing Practices

And, of particular significance, BSH calls out “the growing practice of corporate hospitals establishing local monopolies and leveraging their market dominance to charge patients more…With hospital consolidation driving down competition, there’s no pressure for hospitals to bring costs back within reach for employees, retirees and their families…prices at monopoly hospitals are 12% higher than in markets with four or more competitors.”

The BSH leadership team is led by DC-based healthcare policy veterans with notable lobbying chops: Adam “Buck” Buckalew, a former Sen. Lamar Alexander (R-TN) staffer who worked on the Health Education, Labor and Pensions (HELP) committee and is credited with successfully spearheading the No Surprises Act legislation that took effect in January 2022, and Kathryn Spangler, another former HELP staffer under former Sen. Mike Enzi (R-WY) who most recently served as Senior Policy Advisor at the American Benefits Council.

It’s a line in the sand for hospitals, especially large not-for-profit systems that are on the defensive due to mounting criticism. Examples from last week: Atrium and Caremont were singled in NC by the state Treasurer for their debt collection practices based on a Duke study that got wide media coverage. Allina’s dispute with 550 of its primary care providers seeking union representation based on their concerns about patient safety. Jefferson Health was called out for missteps under its prior administration’s “growth at all costs” agenda and the $35 million 2021 compensation for Common Spirit’s CEO received notice in industry coverage.

My take:

BSH represents an important alignment of health insurers with large employers who have shouldered a disproportionate share of health costs for years through the prices imposed for the hospitals, prescriptions and services their employees and dependents use.

Though it’s too early to predict how BSH vs. Corporate Hospitals will play out, especially in a divided Congress and with 2024 elections in 14 months, it’s important to inject a fair and balanced context for this contest as the article of war are unsealed:

  • Health insurers and hospitals share the blame for high health costs along with prescription drug manufacturers and others. The U.S. system feasts on opaque pricing, regulated monopolies and supply-induced demand. Studies show unit costs for hospitals along with prescription drug costs bear primary responsibility for two-thirds of health cost increases in recent years—the result of increased demand and medical inflation. But insurers are complicit: benefits design strategies that pre-empt preventive health and add administrative costs are parts of the problem.
  • Corporatization of the U.S. system cuts across every sector: Healthcare’s version of Moneyball is decidedly tilted toward bigger is better: in healthcare, that’s no exception. 3 of the top 10 in the Fortune 100 are healthcare (CVS-Aetna, United, McKesson)) and HCA (#66) is the only provider on the list. The U.S. healthcare industry is the largest private employer in the U.S. economy: how BSH addresses healthcare’s biggest employers which include its hospitals will be worth watching. And Big Pharma companies pose an immediate challenge: just last week, HHS called out the U.S. Chamber of Commerce for siding with Big Pharma against implementation of drug price controls in the Inflation Reduction Act—popular with voters but not so much in Big Pharma Board rooms.
  • The focus will be on Federal health policies. BSH represents insurers and employers that operate across state lines–so do the majority of major health systems. Thus, federal rules, regulations, administrative actions, executive orders, and court decisions will be center-stage in the BSH v. corporate hospitals war. Revised national policies around Medicare and federal programs including military and Veterans’ health, pricing, equitable access, affordability, consolidation, monopolies, data ownership, ERISA and tax exemptions, patent protections and more might emerge from the conflict. As consolidation gets attention, the differing definitions of “markets” will require attention: technology has enabled insurers and providers to operate outside traditional geographic constraints, so what’s next? And, complicating matters, federalization of healthcare will immediately impact states as referenda tackle price controls, drug pricing, Medicaid coverage and abortion rights—hot buttons for voters and state officials.
  • Boards of directors in each healthcare organization will be exposed to greater scrutiny for their actions: CEO compensation, growth strategies, M&A deals, member/enrollee/patient experience oversight, culture and more are under the direct oversight of Boards but most deflect accountability for major decisions that pose harm. Balancing shareholder interests against the greater good is no small feat, especially in a private health system which depends on private capital for its innovations.

8.6% of the U.S. population is uninsured, 41% of Americans have outstanding medical debt, and the majority believe health costs are excessive and the U.S. system is heading in the wrong direction. Compared to other modern systems in the world, ours is the most expensive for its health services, least invested in social determinants that directly impact 70% of its costs and worst for the % of our population that recently skipped needed medical care (39.0% (vs. next closest Australia 21.2%), skipped dental care (36.2% vs. next closest Australia 31.7%) and had serious problems/ were unable to pay medical bills (22.4% next closest France 10.1%). Thus, it’s a system in which costs, prices and affordability appear afterthoughts.

Who will win BSH vs. Corporate Hospitals? It might appear a winner-take all showdown between lobbyists for BSH and hospital hired guns but that’s shortsighted. Both will pull out the stops to win favor with elected officials but both face growing pushback in Congress and state legislatures where “corporatization” seems more about a blame game than long-term solution.

Each side will use heavy artillery to advance their positions discredit the other. And unless the special interests that bolster efforts by payers are hospitals are subordinated to the needs of the population and greater good, it’s not  the war to end all healthcare wars. That war is on the horizon.


PS Wednesday, Fox News will host the first GOP Presidential debate with 7 contenders for the White House including a new face: Vivek Ramaswamy, a 38-year-old Harvard College grad who founded (2014) and sold (2021) a drug development company Roivant Sciences before starting Strive Asset Management. He follows a list of independently wealthy investor entrepreneurs who flex their muscles in politics (Tom Steyer, Donald Trump). His mother is a psychiatrist, his dad’s a patent attorney, his wife a physician and his 2 sons are 1 and 3 years old.

On the debate stage, it will be interesting to watch exchanges between the candidates, more interesting to see how healthcare figures into candidate soundbites and fascinating to see if Ramaswamy’s wealth via corporate healthcare is called out.

Resources in addition to detailed citations below:

“North Carolina Hospitals Have Sued Thousands of Their Patients, a New Report Finds August 16, 2023” August 16, 2023 KFF Health News


Michael Thompson The Hill: Congress can lower health care costs by holding hospital systems accountable” July 28, 2023 Letter Michael Thompson is president and CEO of National Alliance of Healthcare Purchaser Coalitions and Tom Lussier is administrator of the Public Sector Health Care Roundtable.

JAMA Network Open, Mapping Health Disparities in 11 High-Income Nations, July 7, 2023


Re: medical debt: “More than 100 million people in America — a startling 41% of adults — are saddled with medical bills they cannot pay, according to a KFF Health News investigation with NPR and CBS News. The project exposed that medical debt — rather than fighting disease — is now a defining feature of the nation’s health care system.”

Kaiser Health News

Re: interoperability, EPIC partnerships: “In the iconic film Ferris Bueller’s Day Off, Cameron Frye is a whiny, rich kid who needs the coolest and most popular of friends to dig him out of the sad life hole he is in. We doubt that Epic Systems, the electronic health record giant, has been compared to Cameron Frye before — but it is no secret that it is the unpopular kid in the American health care system. (See hereherehereherehere, and here.) Indeed, a 2019 Newsweek article explained that the Epic electronic medical record system is “so unpopular that if you mention the name, some doctors will literally start to scream.” With ~$3 billion in annual revenue and thousands of American hospitals using its systems, you would think that Epic would find a way to have more friends. And it just did. Epic is launching a new “Partners and Pals program” that will allow select third-party vendors to work closely with its electronic medical record platform. One of the first Epic “pals” is generative AI developer Abridge, which summarizes medical conversations and structures them in real-time for providers, payers, and patients inside the medical record. We already knew about two established Epic “partners” — clinical documentation company Nuance and survey software company Press Ganey — and the recent expansion of its partnership with Microsoft’s cloud infrastructure. We get it. Ferris Bueller needed a great car to have an epic day off in the city, so he had little choice but to get Cameron to come along. At the end of the movie, Cameron says: “Ferris, you’re my hero.” We wonder if Epic will be as openly appreciative if its reputation is saved by these cooler “pals and partners.”

Julie Barnes Maverick Health Policy August 17, 2023

Re: insurer middlemen: “A powerful lobbyist convinced a federal agency that doctors can be forced to pay fees on money that health insurers owe them. Big companies rake in profits while doctors are saddled with yet another cost in a burdensome health care system.

It was a multibillion-dollar strike, so stealthy and precise that the only visible sign was a notice that suddenly vanished from a government website.

In August 2017, a federal agency with sweeping powers over the health care industry posted a notice informing insurance companies that they weren’t allowed to charge physicians a fee when the companies paid the doctors for their work. Six months later, that statement disappeared without explanation.

The vanishing notice was the result of a behind-the-scenes campaign by the insurance industry and its middlemen that has largely escaped public notice — but that has had massive financial consequences that have rippled through the health care universe. The insurers’ invisible victory has tightened the financial vise on doctors and hospitals, nurtured a thriving industry of middlemen and allowed health insurers to do something no other industry does: Take one last cut even as it pays its bills.”

Cezary Podkul’ 3800 word investigative report “The Hidden Fee Costing Doctors Millions Every Year” ProPublica August. 14, 2023. 38

Re: drug prices: “This AARP Public Policy Institute Spotlight report finds that list prices for 25 top Medicare Part D drugs have increased by an average of 226%—or more than tripled—since they first entered the market, greatly exceeding the corresponding rate of general inflation.

Further, the analysis of these 25 individual products finds that lifetime list price changes increase dramatically the longer a product has been on the market and that, on average, nearly 60% of the current list price is due to price increases after the product entered the market.”

Purvis, Leigh. Prices for Top Medicare Part D Drugs Have More Than Tripled Since Entering the Market. Washington, DC: AARP Public Policy Institute, August 10, 2023.

Re: study of conflicts of interest in device approvals: “For CMS NCDs of medical devices, nearly all physicians, teaching hospitals, and organizations that submitted public comments supported expanding coverage. More than three-quarters of these public commenters had financial COIs with device manufacturer(s) potentially affected by the NCD that would benefit from coverage, and although industry has a legitimate interest in engaging in CMS’ public comment solicitation process, these financial COIs were rarely disclosed…Given the known association between financial COIs and decisions that favor industry,4 policies to promote transparency of public commenters are needed to ensure CMS can consider all viewpoints in an informed manner. These could include requirements for standardized disclosure of financial COIs and linkage to the agency’s Open Payments database. CMS could also encourage participation of commenters without financial COIs.”

Lu et al “Financial Conflicts of Interest in Public Comments on Medicare National Coverage Determinations of Medical Devices” JAMA. August 17, 2023. doi:10.1001/jama.2023.14414

Re: urgent care, retail health: “…But urgent care and retail clinics may not be a panacea for rising health care costs. A study co-authored by Harvard Medical School health policy professor Ateev Mehrotra shows urgent care clinics reduce less serious visits to the emergency room, yet 37 urgent care visits are needed to prevent a single trip to the ER, increasing total health care spending with all those trips. And ongoing research by Vanderbilt University assistant professor Kevin Griffith suggests that newly constructed urgent care or retail clinics can decrease wait times at nearby private and public sector health centers initially. Eventually, however, the increased access provided by the new clinics increases demand as well, he is finding, and wait times creep back up.”

Bram Sable-SmithFunyuns and Flu Shots? Gas Station Company Ventures Into Urgent Care” August 16, 2023

Re: high deductible health plans: “Lawmakers on both sides of the aisle want Americans to embrace more risk when it comes to their health care. They’re proposing to do it by making high-deductible health insurance plans a little less risky. The plans, which already enroll more than 60 million people, offer low premiums and tax breaks but require patients to pay more toward their care before benefits kick in.

A push led by House Republicans to allow insurers offering the plans to cover more expenses than they do now is gaining momentum in Congress and dividing Democrats…

The proposed changes reflect the new state of play on health care for Republicans, who have turned away from efforts to repeal Obamacare but see high-deductible plans as a way to boost market forces in the system. They also appeal to Democrats such as Blumenauer as a way to make access to care more affordable.

But other Democrats, including Ways and Means Health Subcommittee ranking member Lloyd Doggett (D-Texas), worry the plans would still pose financial and medical risks for low-income employees who can’t afford to pay their deductibles and would skip care as a result.”

Ben Leonard GOP push to get more Americans into high-deductible health is dividing Democrats Politico August 18, 2023

Re: defining, connecting public health: “Health is not the same as health care or population health management; as defined by the World Health Organization, health includes physical health, mental health, and social well-being. The public health focus is thus on improving health for populations and not just for the individual. The medicalization of health has created barriers for funding public health priorities and presents challenges for improving the public health system. Establishing a shared purpose and using a shared language is required to ensure public health and primary care can work effectively together.

COVID-19 highlighted the systemic challenges the US faces in its ability to respond to a public health crisis. However, these challenges are not one-time issues seen only during a pandemic. These issues are ongoing, faced day-in and day-out by all those trying to improve the public’s health: medical care practitioners, public health providers, and community leaders. The siloed nature of public health and primary care, the fragmentation of leadership for public health, and the inconsistent and constrained funding of public health all contribute to poor health outcomes.”

Udow-Phillips “Strengthening Public Health Through Collaboration with Primary Care: Lessons From The States” Health Affairs August 14, 2023

Study: nursing home costs: Per the Genworth Cost of Care Survey: In 2021, the median cost to stay in a private room in a nursing home in the U.S. was $9,034, a semi-private room in a nursing home was $7,908/mo., to stay in an assisted living facility was $4,500/mo.; home health aide services were $5,148/mo. and adult day care $1690/mo.

Genworth Cost of Care Survey


Study: hospital price transparency: Key findings from Patient Rights Advocate’s Hospital Price Transparency Compliance Report:

  • 36% of the 2,000 hospitals reviewed were fully complying with the rule (64% were not in full compliance).
  • 69 hospitals did not post any usable standard charges file and were in total noncompliance.
  • Although 61.4% of hospitals posted negotiated prices clearly associated with payers and plans, 41.3% of these were deemed non-compliant due to missing or incomplete pricing data.
  • None of the hospitals owned by HCA Healthcare, Tenet Healthcare, Providence, Avera Health, UPMC, Baylor Scott & White Health, or Mercy were found to be compliant.
  • 88% of hospitals owned by CommonSpirit Health, 97% of hospitals owned by Community Health Systems, and 98% of hospitals owned by Kaiser Permanente were found to be in compliance.

Only 36% of reviewed hospitals fully compliant with federally-mandated price transparency rule, July 20, 2023

Study: Emergency department spending: This study quantified the contributions of price increases and upcoding to the rise in ED spending in five US states representing 19.4% of the US population (CO, NC, OH, TX, MA) between 2012 and 2019 while accounting for changes in patient characteristics and severity. Findings:

“In an analysis of more than three million ED visits in five states, we found that price increases were the largest source of overall per visit spending increases between 2012 and 2019 for Colorado, North Carolina, Ohio, and Texas. Upcoding was the largest source of spending increases per patient in Massachusetts (49%). However, spending per ED visit only rose $228 in Massachusetts between 2012 and 2019, whereas mean spending increases for the other states ranged from $703 to $976. Health care spending growth in Massachusetts has been below the national average every year since 2010. The state’s Health Policy Commission, which conducts detailed cost benchmarking, may have been particularly successful at restraining price growth.

The fact that price increases were the largest reason for rising ED spending in four of the five states we examined supports concerns that hospitals have gained significant pricing power in emergency care and other hospital services, particularly in concentrated provider markets…”

Ho et al “Price Increases Versus Upcoding as Drivers of Emergency Department Spending Increases, 2012–19” August 2023

NC Study: Hospital debt collection: Report by the state treasurer and Duke University School of Law researchers: “From January 2017 through June 2022, North Carolina hospitals brought 5,922 lawsuits to collect medical debt against 7,517 patients and family members. These actions were brought in small claims court, state district, and state superior courts, and generated 3,449 judgments for hospitals totaling $57.3 million, or an average of $16,623 per judgment.

Hospitals took advantage of North Carolina’s allowance of 8% annual interest on judgments, including by refiling actions to sustain judgments issued ten years earlier. These interest charges and other additional fees totaled an estimated $20.3 million, or 35.4% of the judgments awarded. Some patients faced more than a decade’s worth of interest charges, and 463 families owed more than $10,000 in interest alone. There is also evidence that patients had little say in these judicial proceedings, as 59.8% of all judgments in state district courts were default judgments.

A small subset of North Carolina’s hospitals was responsible for a vast majority of lawsuits. Five hospital systems filed 96.5% of the collection actions over the studied time period…”

In ProPublica’s reporting about this study…

“Researchers found that the most aggressive debt collector was Atrium, a medical system with roots as a public hospital in Charlotte that, following a merger last year with Midwest-based Advocate Aurora, is now a multistate colossus with $27 billion in annual revenue. Atrium filed almost 2,500 lawsuits against patients from Jan. 1, 2017, to June 30, 2022.

Similar analyses of court records in Wisconsin, New York, Maryland, and other states in recent years have uncovered extensive use of the court system by hospitals…The attention on these debt collection activities has helped catalyze state efforts to expand protections for patients. Several states, including Arizona, Colorado, Maryland, and New York, have enacted medical debt laws in recent years.”

Hospitals Suing Patients: How Hospitals Use N.C. Courts to Collect Medical Debt

Allina faces physician union vote: More than 550 doctors and healthcare providers working for Minneapolis-based Allina Health have filed to unionize which could ultimately create the largest private-sector union of clinicians in the U.S. The group, to be represented by Doctors Council SEIU Local 10MD, filed an election petition  with the National Labor Relations Board last week. Its goal is to take a vote within the next 2 months…

While most unionization efforts thus far have focused on residents and fellows, this filing is different in that it involves doctors, nurse practitioners, and physician assistants employed by Allina’s primary and urgent care clinics in Minnesota and western Wisconsin.

Allina clinicians said a number of concerns prompted their move to unionize, including patient safety concerns due to understaffing and inadequate resources; limited input and decision-making power in matters affecting patient care, provider safety, and professional autonomy; the threat of corporate influence on medical decision making; and moral injury caused by pressure to prioritize productivity and profit over patients, according to KSTP-TV.    

Kristina Fiore “Allina Doctors File to Unionize”MedPage Today August 17, 2023

Hospital investment activities: “While many hospital systems pull back, the country’s biggest ones are throwing even more of their weight into investments. But even they are trending away from using their own teams in favor of striking partnerships with established firms.

Health care providers made up a slightly larger share of corporate venture capital spending on digital health in the first half of 2023 compared with years past, according to data from Rock Health. In that time period, providers contributed roughly 38%, compared with 36% in 2022.

Tara Bannow “Hospitals are dialing back on venture capital investing” Stat News August 14, 2023

Health insurers

Study: insurers fall short on ACA preventive health compliance: Georgians for a Healthy Future commissioned this study to assess insurer compliance with no-cost preventive services coverage offered through the Affordable Care Act (ACA). “Despite its potential benefits, implementation of the ACA’s preventive services has been inconsistent. Consumers and providers are not fully utilizing the services, even though the coverage requirements and cost sharing protections are incredibly popular among consumers who know about them. When consumers take advantage of the covered services, they regularly report being erroneously charged cost-sharing… Key findings from the research include the following:

  • Plan information describing preventive services varied, with gaps and inconsistencies in how services and coverage were described in consumer-facing brochures and fact sheets;
  • Formularies did not consistently list preventive medications as covered without cost sharing and even formularies that did include a notation for preventive medications were often difficult to navigate; and
  • Plan payer guidance that informs how providers code services as preventive was inconsistently available and rarely provided complete information that providers would need to appropriately code and bill preventive services to ensure they are adjudicated as preventive (without cost sharing) instead of diagnostic.

In short, the ways that insurers organize and expose information to providers and consumers is a meaningful barrier to effective understanding and use of preventive service benefits. While regulators have not historically taken a direct oversight role in how insurers organize information for the public, we believe oversight is necessary to ensure that consumers and providers can practically access and use information they need to understand coverage and billing rules.”

Preventive Services Coverage and Cost-Sharing Protections Are Inconsistently and Inequitably Implemented Georgians for a Healthy Future August 13, 2023.

KFF: Medicaid Disenrollment: “At least 4,816,000 Medicaid enrollees have been disenrolled as of August 17, 2023, based on the most current data from 44 states and the District of Columbia. Overall, 37% of people with a completed renewal were disenrolled in reporting states while 63%, or 7.8 million enrollees, had their coverage renewed (three of the reporting states do not provide data on renewed enrollees) …There is wide variation in disenrollment rates across reporting states, ranging from 72% in Texas to 8% in Wyoming. Differences in who states are targeting with early renewals as well as differences in renewal policies and systems capacity likely explain some of the variation in disenrollment rates.”

Note: On August 9, The CMS has warned 36 states they were falling short of regulatory requirements in at least one area (Medicaid call center wait times and call abandonment rates, rates of procedural terminations, and the average wait time for applications to be approved). Alaska, Florida, New Mexico, Montana and Rhode Island were falling short in all three categories.

KFF Medicaid Enrollment and Unwinding Tracker August 17, 2023

Differences Between MA vs. Traditional Medicare Enrollees:

Commercial (Employer Sponsored Insurance) Plan Type Prior to Medicare Eligibility Medicare Fee-For Service Medicare Advantage
Health Maintenance Org (HMO) 27.8% 45.8%
Preferred Provider Org (PPO) 56.6% 43.4%
Point of Service (POS) 4.7% 2.7%
Exclusive Provider Org (EPO) 9.1% 5.2%
Other 1.7% 2.9%

Source: Harvard-Inovalon Medicare Study: Who Enrolls in Medicare Advantage vs. Medicare Fee-for-Service, July 6, 2023


eHealth: Opinions about Medicare sustainability: Highlights of eHealth online survey of 3582 U.S. adults conducted in June 2023: “On balancing what’s due to current beneficiaries with what future generations should expect”:

  • 74% of current beneficiaries worry about the long-term sustainability of the Medicare program.
  • 73% of current beneficiaries feel that Medicare “works” today,
  • 84% of current beneficiaries say that significant changes to Medicare will be needed
  • To secure the program for future generations. 47% of current Medicare beneficiaries think that the payroll contributions of future beneficiaries should be increased, 21% say the Medicare eligibility age should be raised for future beneficiaries, 10% would make specific changes that impact current beneficiaries and 40% say that none of these solutions are acceptable.
  • 62% of Republican voters give the government a D or F grade for working to secure the future of Medicare vs. 73% of Democrat who give it an A, B, or C grade.

The Future of Medicare: A Survey of Beneficiaries eHealth August 2023

Survey: addiction: KFF surveyed 846 adults who said they had personal/familial experiences with addiction between July 11-19, 2023. Findings:

  • 66% of American adults have a personal or familial experience with alcohol or drug addiction. That includes homelessness due to addiction or a drug overdose that resulted in an emergency room visit, hospitalization or death.
  • 29% say they or someone in their family have ever been addicted to opioids, including prescription painkillers and illegal opioids like heroin.
  • Among those who say they or a family member experienced addiction to prescription painkillers, alcohol, or any illegal drug, 46% report they or their family member got treatment for the addiction
  • 51% of adults are worried that someone in their family will experience substance use disorder or an addiction to drugs or alcohol and one-third (32%) are worried that someone in their family will overdose on opioids, such as prescription painkillers or illegal drugs like heroin

KFF Tracking Poll July 2023: Substance Use Crisis And Accessing Treatment KFF August 15, 2023

Physicians, Nurses

AMN Report: specialists income up: Per AMN Healthcare’s 2023 Review of Physician and Advanced Practitioner Recruiting Incentives based on a representative sample of its 2,676 permanent physician and AP search engagements from April 1, 2022 to March 31, 2023.

  • Biggest increases: Psychiatry: $299,000 to $355,000, up 19%;  Dermatology: $350,000 to $427,000, up 16%; Anesthesiology: $400,000 to $450,000, up 12.5%; Orthopedic surgery: $565,000 to $633,000, up 12%; and Ob/gyn: $321,000 to $367,000, up 10.5%.
  • Biggest decreases: cardiology (non-invasive) and neurology reported decreases of 10% (from $484,000 to $433,000) and 1% (from $356,000 to $354,000), respectively.
  • Average salary offers made to nurse practitioners (NPs) also were up 9% year-over-year, from $138,000 to $151,000, according to the review.
  • The average annual billing by physicians for 18 medical specialties to commercial payers was $3.8 million, according to the review. General surgery topped the list, with average annual billing approaching $11.7 million, followed by orthopedic surgery, at $9.8 million.


AMN Nurses survey: Highlights of AMN s 2023 Survey of 18,000 Registered Nurses:

  • Nurse career satisfaction has been at 80-85% for a decade; in 2023, it dropped to 71%. Likelihood of encouraging others to become a nurse is down 14 points from 2021.
  • Only 15% of nurses employed in hospitals say they will “continue working as I am” in one year. 36% of hospital nurses say they will continue working as nurses but seek a new place of employment.
  • 30% of nurses say they are likely to leave their career due to the pandemic, up 7 points since 2021.
  • Four of five nurses say they experience a great deal or a lot of stress, up 16 points from 2021. Worry that their job is affecting their health is up 19 points. Often feeling emotionally drained rose 15 points.
  • 94% of respondents agree there is a severe or moderate shortage of nurses in their area, with half of nurses saying the shortage is severe.
  • 80% of nurses expect the shortage to get much worse or somewhat worse in the next five years, with half of nurses saying the shortage will get much worse

2023 AMN Healthcare Survey of Registered Nurses

Public Health

Re: new fentanyl substitute drug discovered: “IN THE EARLY 2010s reports emerged of a nightmarish drug appearing in Russia and eastern Europe. Krokodil, a cheap substitute for heroin that was concocted in kitchen laboratories, left users with scaly skin and rotting wounds. Now a similarly damaging drug, a fentanyl mix known as tranq dope, has arrived in America. Deaths associated with it have almost quadrupled since 2019, rising as a share of fentanyl-related deaths from 3% in January that year to 11% in June 2022. Last month the White House announced a plan to stop its spread. How worrying is tranq dope?

Tranq dope combines fentanyl, a synthetic opioid drug, with xylazine or “tranq”, a strong non-opioid tranquiliser used to sedate horses, deer and other large animals. It was first detected by drug authorities in the early 2000s in Puerto Rico and, in the years since, circulated there and in limited areas within the American north-east, such as Philadelphia. But the drug has now been detected in nearly every state in the country and, according to the Drug Enforcement Administration (DEA), is probably being mixed by local dealers. “

How dangerous is tranq, the new drug sweeping America? The Economist August 17, 2023

Regulatory Update

CMS:  Final Payment Rule for Hospitals Care in Underserved Communities: Released last Tuesday, the rule targets underserved and under-resourced communities encompassing Medicare payments, policies, and hospital quality measures for inpatient and long-term care hospitals. One of the measures is a health equity adjustment in the scoring methodology for the Hospital Value-Based Purchasing (VBP) Program. Hospitals catering to a higher proportion of dual-eligible patients will be rewarded for providing excellent care. This rule also permits rural emergency hospitals (REHs) to be designated as graduate medical education training sites.

New CMS rule promotes high-quality care and rewards hospitals that deliver high-quality care to underserved populations. News release. Centers for Medicare & Medicaid Services (CMS). August 1, 2023. Accessed August 15, 2023.