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The Keckley Report

The Three In-bound Truth Bombs set to Explode in U.S. Healthcare

By January 29, 2024No Comments

In Sunday’s Axios’ AM, Mike Allen observedRepublicans know immigration alone could sink Biden. So, Trump and House Republicans will kill anything, even if it meets or exceeds their wishes. Biden knows immigration alone could sink him. So he’s willing to accept what he once considered unacceptable — to save himself.”

Mike called this a “truth Bomb” and he’s probably right: the polarizing issue of immigration is tantamount to a bomb falling on the political system forcing well-entrenched factions to re-think and alter their strategies.

In 2024, in U.S. healthcare, three truth bombs are in-bound. They’re the culmination of shifts in the U.S.’ economic, demographic, social and political environment and fueled by accelerants in social media and Big Data.

Truth bomb: The regulatory protections that have buoyed the industry’s growth are no longer secure. Despite years of effectively lobbying for protections and money, the industry’s major trade groups face increasingly hostile audiences in city hall, state houses and the U.S. Congress. The focus of these: the business practices that regulators think protect the status quo at the public’s expense. Example: while the U.S. House spent last week in their districts, Senate Committees held high profile hearings about Medicare Advantage marketing tactics (Finance Committee), consumer protections in assisted living (Special Committee on Aging), drug addiction and the opioid misuse (Banking) and drug pricing (HELP). In states, legislators are rationalizing budgets for Medicaid and public health against education, crime and cybersecurity and lifting scope of practice constraints that limit access. Drug makers face challenges to patents (“march in rights”) and state-imposed price controls. The FTC and DOJ are challenging hospital consolidation they think potentially harmful to consumer choice and so. Regulators and lawmakers are less receptive to sector-specific wish lists and more supportive of populist-popular rules that advance transparency, disable business relationships that limit consumer choices and cede more control to individuals. Given that the industry is built on a business-to-business (B2B) chassis, preparing for a business to consumer (B2C) time bomb will be uncomfortable for most.

Truth bomb: Affordability in U.S. is not its priority. The Patient Protection and Affordability Act 2010 advanced the notion that annual healthcare spending growth should not exceed more than 1% of the annual GDP.  It also advanced the premise that spending should not exceed 9.5% of household adjusted gross income (AGI) and associated affordability with access to insurance coverage offering subsidies and Medicaid expansion incentives to achieve near-universal coverage. In 2024, that percentage is 8.39%. Like many elements of the ACA, these constructs fell short: coverage became its focus; affordability secondary. The ranks of the uninsured shrank to 9% even as annual aggregate spending increased more than 4%/year. But employers and privately insured individuals saw their costs increase at a double-digit pace: in the process, 41% of the U.S. population now have unpaid medical debt: 45% of these have income above $90,000 and 61% have health insurance coverage. As it turns out, having insurance is no panacea for affordability: premiums increase just as hospital, drug and other costs increase and many lower- and middle-income consumers opt for high-deductible plans that expose them to financial insecurity. While lowering spending through value-based purchasing and alternative payments have shown promise, medical inflation in the healthcare supply chain, unrestricted pricing in many sectors, the influx of private equity investing seeking profit maximization for their GPs, and dependence on high-deductible insurance coverage have negated affordability gains for consumers and increasingly employers. Benign neglect for affordability is seemingly hardwired in the system psyche, more aligned with soundbites than substance.

Truth bomb: The effectiveness of the system is overblown. Numerous peer reviewed studies have quantified clinical and administrative flaws in the system.  For instance, a recent peer reviewed analysis in the British Medical Journal concluded “An estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about 50.7% of all serious harms, so the problem may be more tractable than previously imagined.” The inadequacy of personnel and funding in primary and preventive health services is well-documented as the administrative burden of the system—almost 20% of its spending.  Satisfaction is low. Outcomes are impressive for hard-to-diagnose and treat conditions but modest at best for routine care. It’s easier to talk about value than define and measure it in our system: that allows everyone to declare their value propositions without challenge.

Truth bombs are falling in U.S. healthcare. They’re well-documented and financed. They take no prisoners and exact mass casualties.

Most healthcare organizations default to comfortable defenses. That’s not enough. Cyberwarfare, precision-guided drones and dirty bombs require a modernized defense. Lacking that, the system will be a commoditized public utility for most in 15 years.


PS: Last week’s report, “The Holy War between Hospitals and Insurers…” (The Keckley Report – Paul Keckley) prompted understandable frustration from hospitals that believe insurers do not serve the public good at a level commensurate with the advantages they enjoy in the industry. However, justified, pushback by hospitals against insurers should be framed in the longer-term context of the role and scope of services each should play in the system long-term. There are good people in both sectors attempting to serve the public good. It’s not about bad people; it’s about a flawed system.

Mike Allen “The Immigration Election” Axios AM January 28, 2024

Senate Probes the Cost of Assisted Living and Its Burden on American Families – KFF Health News

Wyden Letter on Questioning Medicare Marketers’ Business Tactics 1.23.24 ( January 11, 2024

Today’s Sections:

  • Quotables
  • Care Management
  • Hospitals
  • Insurance
  • Physicians
  • Polling
  • Public Health
  • Regulators


Re: Health policy and populism: “At the beginning of 2024, the US and several other countries are more divided politically and culturally than at any time during recent decades. Recent surveys in the US show that political views held by Republicans and Democrats are far more divergent than they have been in decades. Countries as disparate as India and Hungary have been governed by populist leaders who have galvanized some and alienated others in their electorate. Data show that health concerns drive voting decisions and subsequent political decision-making. Particularly relevant, poor health is associated with votes for populist candidates in the US and in other countries, suggesting a cycle whereby health contributes to electoral outcomes, while the latter then affect health…. An approach to creating health policy that centers on humility, compassion, and reasoned reform may be viewed as lacking ambition, and such a modest approach may also be viewed as an unnecessary self-imposed constraint in light of changing political contexts. However, this approach fulfills the values that should animate the work of promoting health, and it is more likely to create health policies that stand the test of time and improve health in the longer term.”

Guiding Values for Health Policy in Divided Times | JAMA Health Forum | JAMA Network January 25, 2024

Re: primary care shortage: “Fewer and fewer physicians are choosing primary care due to noncompetitive pay. The evidence is overwhelming: From 2012 to 2020, only 20% of physicians trained in primary care residencies stayed in primary care.

Our nation spends only 4.5% of all healthcare spending on primary care (compared to 6% for dialysis treatment). This inadequate investment in primary care is half of what other advanced nations spend. Finally, this investment percentage has been steadily declining for 30 years. All the alleged reforms to healthcare do not focus on the real problem — economic incentives that drive this decline…

Richard Afable and Michael D. Connelly 4Sight Health “The Decimation of Primary Care”  4sight Health.Connelly.Afable_Patient_Care_Part_2_1.23.24.pdf (

Re: prescription drug market regulation by FTC: “Over the past two years, the U.S. Federal Trade Commission has attempted to crack down on the pharmaceutical industry over concerns that drug companies too often use various means to thwart competition that could otherwise lower prices for consumers…To accomplish this goal, the FTC has approached this problem from different angles — rebates used by drug companies to win favorable health insurance coverage, mergers and deals that can help corner a market, and patents that keep generic rivals at bay. One FTC official maintained the agency has been on “an incredible winning streak…

The three largest PBMs — CVS Caremark, Express Scripts, and OptumRx — have also garnered attention because they run their mail-order pharmacies…Another focus is on mergers and deals…And then there is latest FTC move to pursue patents: More specifically, the agency last November challenged more than 100 patents on brand-name medicines that it says were improperly or inaccurately listed in a U.S. Food and Drug Administration registry known as the Orange Book. These listings are used to put generic companies on notice about certain types of patents that are claimed by a brand-name company for a medicine.”

FTC says it’s on ‘an incredible winning streak’ against pharma ( January 24, 2024

Re: JPM showcase for NFP systems: “Nonprofit hospitals showed off their investment appeal at the conference. Fifteen health systems representing major players across the country touted their value and the audience was intrigued: When headliners like the Mayo Clinic and the Cleveland Clinic took the stage, chairs were filled, and late arrivals crowded in the back of the room.

These hospitals, which are supposed to provide community benefits in exchange for not paying taxes, were eager to demonstrate financial stability and showcase money-making mechanisms besides patient care — they call it “revenue diversification.” PowerPoints skimmed through recent operating losses and lingered on the hospital systems’ vast cash reserves, expansion plans, and for-profit partnerships to commercialize research discoveries.

Note: Hospital executives thanked existing bondholders and welcomed new investors.” Not for profit health systems were 15 of the 624 presenting organizations in San Francisco at JP Morgan

What the Health Care Sector Was Selling at the J.P. Morgan Confab – KFF Health News

Re: Medical debt being taken on by cities: “New York City pledged this week to pay down $2 billion worth of residents’ medical debt. In doing so, it has come around to an innovation, started in the Midwest, that’s ridding millions of Americans of healthcare debt…In 2022, Cook County became the first local government to partner with RIP Medical Debt, a nonprofit group that uses private donor funds to buy up and forgive patient debt…

In the Chicago area, as across the country, medical debt is an ongoing problem, causing mental and financial strain that can follow patients for years. An estimated 100 million people  in the U.S. carry some form of healthcare debt totaling $195 billion…

Since Cook County announced its program, seven other local governments have followed suit, including Ohio cities Akron, Cleveland, and Toledo; New Orleans; Wayne County, Michigan; Washington, D.C.; and now New York City, which announced its commitment Jan. 22…

Medical debt is being created at high rates, Sesso said, and stronger policies — such as protecting consumers and strengthening insurance coverage — are needed to stop it at its source.

Often that boils down to high prices charged by hospitals and providers.”

“New York Joins Local Governments in Erasing Billions in Medical Debt— But stronger policies are needed to stop debt at its source” NPR January 28, 2024

Re: Medicare Advantage marketing: “Americans with Medicare who have managed care plans called Medicare Advantage should not feel like their health care is a black box. The lack of transparency in Medicare Advantage managed care plans deprives patients of important information that helps them make informed decisions. It deprives researchers and doctors of critical data to evaluate problems and trends in patient care.”

Biden-Harris Administration Launches Effort to Increase Medicare Advantage Transparency | January 25, 2024

Re: Oliver Wyman outlook for US healthcare: “We intentionally limited discussion of who will be involved in delivering and realizing the value described in each of the 2035 markets. The identity, scope, and strategic roles of different types of players will evolve and be varied — likely by geography since healthcare will remain intensely local…There are at least two primary areas that will significantly influence the pace of change. The first is developing the workforce that’s needed to meet the new demands. That means improved training capacity and focus for new roles, consistent and transferable credentialling, and rebalancing payment rates to create sustainability and stability, among other things. Additionally, we need to foster greater community investment and alignment for critical social programs in underserved and hard to reach cohorts that can both address major social determinants of health and extend the reach of care provision.”

This Is What Healthcare Systems Will Look Like In 10 Years (

Re: consolidation court precedent: “No merger in any industry could survive judicial scrutiny under the novel legal standard that Judge William Young used to block the JetBlue-Spirit merger (“Biden’s Dispiriting Antitrust Cops,” Jan. 19). The judge found that the merger would be procompetitive in the national market, and that any anticompetitive effects in individual markets would be offset by actual and potential entry. He nevertheless concluded that the merger is illegal because “entry is unlikely to be sufficient to protect every consumer, in every relevant market from harm.” Unless the appellate court quickly reverses this misguided decision, it will encourage President Biden’s antitrust cops to challenge, and potentially kill, even the most procompetitive, economically beneficial mergers.”

Ben Hirst Former Chief Legal Officer, Delta Airlines Are Mergers Still Legal in Biden’s America? – WSJ January 23, 2024

Re: McKinsey CEO selection: “The leadership of consulting giant McKinsey was thrown into doubt this week when its global managing partner, Bob Sternfels, failed to win a majority of support from the firm’s senior partners for another three-year term…

McKinsey’s vote comes as revenue growth for U.S. consulting firms slowed to about 7% in 2023 after double-digit growth earlier in the pandemic, according to market-research firm Source Global Research. Many companies have saved costs by canceling consulting contracts, which they see as discretionary spending. Analysts expect another year of slower growth ahead…

McKinsey employs about 45,000 people globally, up from 17,000 in 2012. Last year the firm restructured and cut about 1,400 mostly back-office roles. The firm also shrank its newest partnership class to about 250 people, down from 380 in 2022 and 420 in 2021.

If Sternfels is replaced, he would be the second consecutive leader to serve only one term. His predecessor Kevin Sneader lost re-election in 2021 as the firm announced it would pay a $573 million settlement for working with Purdue Pharma LP and other drug manufacturers to market opioid painkillers. He was the first global managing partner in decades to serve only one three-year term. “

McKinsey’s Top Leader Faces Vote to Unseat Him – WSJ January 26, 2024

Re: Post-pandemic fitness facility market overview: “It’s almost February, which means that 43% of people reading this have already given up on their New Year’s resolutions.

You might feel bad about that, but the leading beneficiaries of those broken promises, fitness clubs, usually don’t. Budget gyms, which get crowded in early January and sign up most of their new members early each year, operate on the principle of selling people a service most won’t use too often. Keep the cost low, make the process of canceling your membership annoying enough, and the supply of new customers should exceed that of frustrated people literally throwing in the towel each year.

That model has felt the burn recently: Weight-loss drugs can help people meet their resolutions with far less willpower and perspiration, the pandemic saw a boom in sales of fitness equipment like Peloton bikes that offered spinning classes in your basement and the Covid-19 emergency itself devastated gyms more than any other business.

Like a bodybuilder suddenly cutting back on calories, though, the industry lost bulk during shutdowns, but emerged looking chiseled. In 2019 there were more than 41,000 health clubs in America with 64.2 million members—anything from mom-and-pop gyms to yoga studios to office gyms to YMCAs to outlets of national chains. Three years later that had shrunk to barely 31,000 with plenty of new customers. While chains suffered too—24 Hour Fitness went bankrupt and closed locations—those that survived captured new customers.”

These Gyms Survived the Pandemic. They’re Still Sweating. – WSJ January 26, 2024

Care Management

Re: diagnostic error: “An estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined. This study provides the first national estimate of permanent morbidity and mortality resulting from diagnostic errors across all clinical settings, including both hospital-based and clinic-based care (0.6–1.0 million each year in the USA alone).”

Burden of serious harms from diagnostic error in the USA | BMJ Quality & Safety

Study: trends in use of complementary health: Using data from the 2002, 2012, and 2022 National Health Interview Survey (NHIS), researchers analyzed adults use of 7 widely used complementary health approaches (CHAs): acupuncture, guided imagery and/or progressive muscle relaxation, massage, naturopathy, and yoga. Findings:

  • Adults reporting use of any of the 7 approaches increased significantly between 2002 and 2022 from 19.2% to 36.7%.
  • The CHA with the highest prevalence was meditation, used by 17.3%of individuals in 2022.
  • Use of acupuncture, which was increasingly covered by insurance, increased from 1.0% in 2002 to 1.5%in 2012 and 2.2%in 2022.
  • Among participants reporting use of any of the 7 approaches, the percentage reporting use for pain management increased significantly from 42.3% in 2002 to 49.2% in 2022. Of the 7 approaches, adults practicing yoga reported the largest increase in use for pain management, from 11.4% in 2002 to 22.8% in 2012 and 28.8% in 2022. The CHA with the highest use for pain management was chiropractic care (85.7%) in 2022)

Use of Complementary Health Approaches Overall and for Pain Management by US Adults | Complementary and Alternative Medicine | JAMA | JAMA Network

Study: telehealth uses 2022: Researchers analyzed the relationship between demographic and health characteristics and (1) use of telehealth services in the previous 12 months and (2) each of 5 motivations for using telehealth among telehealth users. Findings:

The most common reason for using telehealth was recommendation or requirement by a clinician (73.6%). Respondents with depression were more likely to use telehealth than those without depression and were more likely to be motivated by convenience and Hispanic respondents were more likely to use telehealth to avoid exposure to infection.

Characterizing Telehealth Use in the US: Analysis of the 2022 Health Information National Trends Survey (

Senate Aging Subcommittee opens hearings on assisted living: Last Thursday, the Senate Special Committee on Aging launched an examination of assisted living, holding its first hearing in two decades on the industry as Chairs Bob Casey (D-PA) and Mike Braun (R-IN) expressed concern about the high cost and mixed quality of the long-term care facilities.

The federal government has minimal oversight of assisted living, which is regulated by states, unlike skilled nursing homes. Both the Democratic and Republican leaders of the Senate Special Committee on Aging said their inquiry aimed to detail the financial practices and quality levels in the industry so that consumers would be better able to choose facilities.

More than 800,000 older Americans reside in assisted living facilities, which cater to people who have dementia or trouble walking, eating, or doing other daily activities. Most residents have to pay out-of-pocket because Medicare doesn’t cover long-term care and only a fifth of facilities accept Medicaid, the federal-state insurance for people with low incomes or disabilities. The industry is quite profitable, running median operating margins around 20% and often charging residents with extensive needs $10,000 or more a month. The national median cost of assisted living is $54,000 a year, according to a survey by the insurer Genworth.

Senate Probes the Cost of Assisted Living and Its Burden on American Families – KFF Health News


Study: insurance benefits and worker earnings: Researchers sought to quantify how growth in employer-sponsored health insurance (ESI) premiums is associated with reduced annual wages, disparities in earnings by race and ethnicity and wage level, and wage stagnation among US families with ESI for the period 1988 to 2019 Findings:

“If ESI costs had remained at the same proportion of the 1988 average compensation package, then in 2019, the median US family with ESI could have earned $8774 ($8354-$9195) more in annual wages… From 1988 to 2019, the mean cumulative lost earnings associated with growth in health care premiums for the median US family with ESI was $125,340 ($120 155-$130 525) in 2019 dollars, 4.7% of earnings over the 32-year period. This study suggests that increasing health insurance premium costs are likely associated with decreased earnings and increased income inequality, including by race and ethnicity, among US families receiving employer-sponsored health insurance and are meaningfully associated with wage stagnation.”

Employer-Sponsored Health Insurance Premium Cost Growth and Its Association with Earnings Inequality Among US Families | Health Policy | JAMA Network Open | JAMA Network January 16, 2024


Kaufman Hall: Non-profit hospital margins up: Nonprofit hospital operating margins increased 20% and operating EBITDA increased 9% January to November of 2023.

Operating margins for hospitals with 500-plus beds margin were up 59.3% year over year for November, and operating EBITDA margin was up 20.5%.

National Hospital Flash Report: December 2023 | Kaufman Hall

Re: dentistry and health systems: “Hospitals and health systems have begun investing more in dentistry as organization leaders look to provide holistic patient care.

“Every patient that has a valve replacement from cardiac surgery needs a clean mouth, otherwise they risk the valve being infected. Every patient that has an organ transplant needs clearance from dental medicine so you don’t reject that. Anybody who’s going to have a radiation treatment to the head and neck needs clearance from dental medicine. Almost every service in the hospital needs a dental medicine team…Without that, what happens is a patient goes for a transplant or is going to have a valve placed and they’re scrambling to try and get the patient to some private dental clinic that can be difficult to get them to and can be very costly…. the health system has known about the link between oral health and overall well-being, but the challenge was figuring out how to get started with offering these services.

“The challenge has been how do we get it up and standing? How do we fund it? And then how do we connect it to the rest of the health system? The data is clear, specifically now about cardiovascular disease [and] diabetes, that great oral care taught young [and] persistent through the rest of your life [can] prevent some of these other challenges that you have as you age.”

| Dental News ( January 25, 2024

Study: Hospital value-based purchasing disparity:” Using Medicare claims for beneficiaries ages sixty-five and older who were hospitalized for three target conditions at 2,908 US hospitals participating in the VBP Program, we found that thirty-day mortality rates were consistently higher for two of three conditions at hospitals with high proportions of Black adults compared with other hospitals. There was no evidence of a differential change in thirty-day mortality among all Medicare beneficiaries with targeted conditions at high-proportion Black hospitals versus other hospitals seven years after the implementation of the VBP Program. However, gaps in mortality between these sites did widen in the subgroup of Black adults with pneumonia. These findings highlight that important concerns remain about the regressive nature and equity implications of national pay-for-performance programs.”

Medicare’s Value-Based Purchasing And 30-Day Mortality at Hospitals Caring For High Proportions Of Black Adults | Health Affairs

Senate proposes bonuses for hospitals to handle drug shortages: A key Senate committee is proposing that Medicare pay bonuses to hospitals that take measures to prevent drug shortages. It also wants to change the way doctors are paid to administer drugs in outpatient settings.

The Senate Finance Committee released a paper Thursday that includes multiple bipartisan ideas for fixing the drug shortage crisis. The paper includes as many questions as proposals, but a theme has emerged. Many proposals call for paying hospitals more when they maintain buffer supplies and buy from drugmakers that invest in shortage mitigation measures.

Medicare could pay bonuses to hospitals that have procedures for fending off shortages and pay an additional bonus when hospitals demonstrate that those procedures work. Similarly, hospitals could be paid for how well they perform on drug shortage measures, which could include either bonuses or pay cuts.

Medicare bonuses could stop drug shortages under Senate plan ( January 25, 2024

USNWR Hospital Rankings: A dispute between U.S. News & World Report and the San Francisco city attorney’s office over the media company’s well-known but increasingly scrutinized system for ranking hospitals and other healthcare institutions has in recent weeks turned into an all-out legal battle.

San Francisco City Atty. David Chiu issued two subpoenas to the media company earlier this month. The first demanded answers about the company’s process for ranking hospitals. The outlet also makes money from the healthcare facilities, including through its sale of “badges” that high-scoring institutions can and often do place on their websites and other branding materials.

The second subpoena demanded internal business records that might reveal more about U.S. News’ rankings process, and whether the financial relationships with hospitals are a factor.

PK Note: Mission Hospital in Asheville appears in the USNWR Top 50 (it’s Top 1% of hospitals) while also being accused of putting patients in “immediate jeopardy” by the NC Department of Health and Human Services.

U.S. News sues S.F. city attorney over hospital ranking subpoenas – Los Angeles Times ( January 24, 2024

Asheville Watchdog January 23, 2024

Study: Hospital Adverse Events and Private Equity Acquisition: Hospital-acquired adverse events (or conditions) were observed within 10,091 hospitalizations. Findings:

  • After private equity acquisition, Medicare beneficiaries admitted to private equity hospitals experienced a 25.4% increase in hospital-acquired conditions compared with those treated at control hospitals.
  • This increase in hospital-acquired conditions was driven by a 27.3% increase in falls and a 37.7% increase in central line–associated bloodstream infections at private equity hospitals, despite placing 16.2% fewer central lines.
  • Surgical site infections doubled from 10.8 to 21.6 per 10,000 hospitalizations at private equity hospitals despite an 8.1% reduction in surgical volume.

JAMA Network, Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition, December 2023

Study: safety net hospital mark-ups: Researchers analyzed 2020–2021 national Blue Cross Blue Shield claims data for patients who had drug-infusion visits for oncologic conditions, inflammatory conditions, or blood-cell deficiency disorders. Findings:

“The study included 404,443 patients in the United States who had 4,727,189 drug-infusion visits. The median price markup (defined as the ratio of the reimbursement price to the acquisition price) for hospitals eligible for 340B discounts was 3.08 (interquartile range, 1.87 to 6.38). After adjustment for drug, patient, and geographic factors, price markups at hospitals eligible for 340B discounts were 6.59 times as high as those in independent physician practices, and price markups at noneligible hospitals were 4.34 times (interquartile range 3.77 to 4.90) as high as those in physician practices. Hospitals eligible for 340B discounts retained 64.3% of insurer drug expenditures, whereas hospitals not eligible for 340B discounts retained 44.8% and independent physician practices retained 19.1%.

This study showed that hospitals imposed large price markups and retained a substantial share of total insurer spending on physician-administered drugs for patients with private insurance. The effects were especially large for hospitals eligible for discounts under the federal 340B Drug Pricing Program on acquisition costs paid to manufacturers. (Funded by Arnold Ventures and the National Institute for Health Care Management.)”

Hospital Prices for Physician-Administered Drugs for Patients with Private Insurance | NEJM January 25, 2025

EPIC: looking beyond hospitals: “Electronic health record company Epic is amping up efforts to expand its customer base beyond health systems with a focus on payers, telehealth and life science companies.

The company’s strategy to move beyond hospital EHRs came into focus on Jan. 17 when it launched Showroom, a website for customers to learn about products and services that work within its EHR. Within Showroom, Epic is promoting a feature called Health Grid to help non-health system customers collaborate with its legacy health system customers.”

How Epic is growing beyond the hospital EHR market | Modern Healthcare January 25, 2024


Moody’s Medicare Advantage assessment: Earnings in Medicare Advantage shrunk by 2.1% among the insurers Moody’s rated from 2019 to 2022, despite premiums and members growing by 40% in the same time period.

  • Humana, the second-largest Medicare Advantage insurer by membership, posteda $541 million loss in the fourth quarter of 2023, a result of what executives called an unprecedented increase in medical utilization.
  • UnitedHealth and Humana controlled nearly half of the Medicare Advantage market in 2023 Aetna had another 11%, and all Blue Cross Blue Shield plans combined had 14%.
  • From 2019 to 2022, the market leaders were able to grow earnings and maintain margins, according to Moody’s, while smaller payers struggled to achieve profitability.
  • As costs are rising, CMS is also phasing inchanges to the risk adjustment program between 2024 and 2026. Insurers maintain the changes, which removed some diagnostic codes used to pay plans on a per-member basis, are a cut in funding. The agency has said the notice amounts to a slight increase in payments.
  • MA accounts for more than half of the program’s enrollment. Over the past 10 years, MA membership has grown at a rate of 8% per year, while traditional enrollment has shrunk by 1%. The program is expected to account for 62% of Medicare enrollment in 2033, according to Congressional Budget Office estimates.



Survey: Physician awareness of FDA drug approval processes: Researchers surveyed 509 internists, cardiologists, and oncologists. Findings:

  • “41% reported moderate or better understanding of the FDA’s drug approval process, and 17% reported moderate or better understanding of the FDA’s medical device approval process.
  • Nearly all physicians thought that randomized, blinded trials that met primary endpoints should be very important factors required to secure regulatory approval.
  • nearly all physicians thought that the FDA should revoke approval for accelerated-approval drugs or breakthrough devices that did not show benefit in post-approval studies.

Our findings suggest that physicians commonly lack familiarity with drug and medical device regulatory practices and are under the impression that the data supporting FDA drug and high-risk device approvals are more rigorous than they often are. “

Physicians’ Perspectives On FDA Regulation Of Drugs And Medical Devices: A National Survey | Health Affairs January 2024


Commonwealth survey: clinician opinion about climate change: “Within the United States, the health care sector is responsible for 8.5% of greenhouse gas emissions, largely from hospital care and from physician and clinical services…  In this brief, we present findings from a national survey of 1,001 U.S. clinicians (conducted by Qualtrics between October 3 and October 19, 2023) about their views of what health systems can do to address climate change.” Highlights:

  • 79% believe that it’s important for their hospital to address climate change and that doing so is aligned with their organization’s mission.
  • Most hospitals are engaged in climate change activity: reducing waste via recycling (76%), reducing energy consumption (67%) but only 35% measure the hospital’s carbon footprint or set emissions targets.

U.S. Health Workers Want Employers to Address Climate Change | Commonwealth Fund January 24, 2024

Report: Healthcare bankruptcy filings:  Per a report which looked at Chapter 11 bankruptcy case filings from 2019 to 2023 with more than $10 million in liabilities released last Thursday by Gibbins Advisors:

  • 79 healthcare companies filed for bankruptcy protection in 2023. Pharmaceutical and senior care companies made up nearly half of the list. The next-highest year was 2019, when 51 companies filed for protection.
  • 28 healthcare companies with liabilities exceeding $100 million filed for bankruptcy protection in 2023, compared with 15 in 2021 and 2022 combined, the report found.
  • 12 hospital companies filed for bankruptcy protection in 2023, compared with two in 2022 and three in 2021, according to the report. Some of that can be attributed to the end of government funding and waivers to support cash flow during COVID-19.
  • “The end of 2023 offered some possible encouragement. After six consecutive quarters of increases, bankruptcies decreased in the fourth quarter to 11, compared with 28 in the third quarter.”

Public Health

Study: sugar-sweetened beverage taxes Taxing sugar-sweetened beverages was linked with higher prices and fewer drink sales, according to data from more than 26 000 stores from 5 large cities across the US.

“After the cities—Boulder, Oakland, Philadelphia, San Francisco, and Seattle—started taxing these beverages in 2017 and 2018, prices increased by about 33% while purchases declined by the same percentage. About 92% of the higher cost for the taxed beverages was passed along to consumers. The changes occurred soon after the tax was introduced and remained throughout the study period ending in February 2020.

People who drink sugar-sweetened beverages tend to have more adverse health conditions, including cardiovascular disease. Previous evidence showed that cutting sales of these drinks by even 15% to 20% resulted in fewer heart attacks, strokes, and heart disease…. This study’s findings suggest that a nationwide tax “would likely generate significant improvements in population health and substantial cost savings.”

Tax on Sugar-Sweetened Drinks Tied to Higher Prices, Fewer Purchases | Lifestyle Behaviors | JAMA | JAMA Network January 24, 2024

Study: Rape-related pregnancy: Researchers estimated rape-related pregnancies in the 14 states that outlawed abortion post Roe v. Wade. Findings: “In the 14 states that implemented total abortion bans following the Dobbs decision, we estimated that 519, 981 completed rapes were associated with 64 565 pregnancies during the 4 to 18 months that bans were in effect. Of these, an estimated 5586 rape-related pregnancies (9%) occurred in states with rape exceptions, and 58, 979 (91%) in states with no exception, with 26 313 (45%) in Texas.

In this cross-sectional study, thousands of girls and women in states that banned abortion experienced rape-related pregnancy, but few (if any) obtained in-state abortions legally suggesting that rape exceptions fail to provide reasonable access to abortion for survivors. Survivors of rape who become pregnant in states with abortion bans may seek a self-managed abortion or try to travel (often hundreds of miles) to a state where abortion is legal, leaving many without a practical alternative to carrying the pregnancy to term.”

Rape-Related Pregnancies in the 14 US States With Total Abortion Bans | Emergency Medicine | JAMA Internal Medicine | JAMA Network January 24, 2024

Study: Dobbs decision impact on depression: Using the nationally representative repeated cross-sectional Household Pulse Survey (December 2021-January 2023), difference-in-differences models were estimated to examine the change in symptoms of depression and anxiety after Dobbs (either the June 24, 2022, Dobbs decision, or its leaked draft May 2, 2022, Findings:

“In this retrospective analysis of survey data from 718,753 participants, residents of states that had passed trigger abortion bans experienced a significantly greater worsening of anxiety and depression symptoms than residents of states without such bans after the Dobbs decision compared with a baseline period before its draft was leaked. Notably, Differences in estimates for males and females aged 18 through 45 were statistically significant especially among women in trigger states where depression rates increased.”

Anxiety and Depression Symptoms After the Dobbs Abortion Decision | Law and Medicine | JAMA | JAMA Network


Commerce Department January 25, 2024: 4Q 2023

  • The U.S. economy saw 3.3% GDP growth in 4Q2023, down from +4.9% in 3Q2023.
  • Consumer prices increased at a 2.8% annual rate—down from the 3.1% in the previous quarter.
  • “Meanwhile, fixed investment — spending on factories, equipment and more — rose 1.9%, up slightly from the 1.4% in the third quarter.
  • Housing activity, meanwhile, slowed from the prior quarter’s rapid pace: 1.1% in the fourth quarter, compared to 6.7% in the third quarter”.


  • Marketplace enrollment: The Centers for Medicare & Medicaid Services (CMS) reports that 3 million consumers have signed up for 2024 individual market health insurance coverage through the Marketplaces since the start of the 2024 Marketplace Open Enrollment Period (OEP) on November 1. Total nationwide plan selections include 5 million consumers (24% of total) who are new to the Marketplaces for 2024, and 16.3 million consumers (76% of total) who have active 2023 coverage and returned to their respective Marketplaces to renew or select a new plan for 2024 Marketplace 2024 Open Enrollment Period Report: Final National Snapshot | CMS January 24, 2024
  • Medicare Advantage data accessibility: “This RFI is an extension of our ongoing work on MA data as we solicit feedback from the public on how best to meet the shared goals of enhancing data capabilities to have better insight into our programs, consider areas to increase MA data transparency, and propose future rulemaking. Our eventual goal is to have, and make publicly available, MA data commensurate with data available for Traditional Medicare to advance transparency across the Medicare program, and to allow for analysis in the context of other health programs like accountable care organizations, the Marketplace, Medicaid managed care, integrated delivery systems, among others. ” Medicare Program; Request for Information on Medicare Advantage Data” CMS January 25, 2024 Federal Register https://publicinspection.federalregister.


  • SPAC oversight: The goal of the agency’s proposed Wednesday’s rule change first announcedin early 2022 is to give SPAC investors the same protections that investors in traditional IPOs receive, mainly by requiring more disclosures from companies and making executives liable for them. SPAC deals typically include favorable terms for their creators, known as sponsors. They initially put up a small amount to cover expenses before the SPAC goes public and then get a 20% stake at a deep discount if the SPAC combines with another company. This makes it possible to earn returns several times the original investment—even if the acquisition is a bad deal for other investors…Of 401 SPACs that have closed acquisitions since the beginning of 2021, only 27 have seen their share prices rise… At their peak, SPACs accounted for 70% of all IPOs, with $95 billion raised. But now, the market has dried up and shares of companies that did SPAC deals have crashed SPAC Mania Is Dead. The SEC Wants to Keep It That Way. – WSJ January 24, 2024