Last week, the American Medical Association (AMA) held its 2024 Interim House of Delegates (HOD) meeting in Lake Beuna Vista, Florida. The Bi-Annual confab drew 700 delegates representing 200 medical societies and physician professional organizations who considered 712 resolutions in the four-day agenda.
Per the AMA: “The House of Delegates (HOD) is the legislative and policy-making body of the American Medical Association. State medical associations and national medical specialty societies are represented in the HOD along with AMA sections, national societies such as AMWA, AOA and the NMA, professional interest medical associations, and the federal services, including the Public Health Service.”
Many consider the HOD deliberations the Association’s most important activity.
As its meeting began last Saturday, delegates heard AMA President Bruce Scott, MD encourage “Together We Can Fix It” alluding to systemic flaws in the U.S. health system– chronic underpayment to physicians by Medicare, over-reaching prior authorization requirements by insurers, threats to clinical autonomy in employed practice settings and physician burnout and more.
And retiring AMA EVP and CEO James Madera challenged delegates to think about “Intrinsic Future Challenges” asking how AMA should adapt to fewer independent and higher employed practitioners in its governance to represent the profession more effectively.
The central theme in both presentations was protecting the profession of medicine. “The AMA “helps physicians build a better future for medicine, advocating in the courts and on the Hill to remove obstacles to patient care and confront today’s greatest health crises.
Patients deserve care led by physicians—the most highly educated, trained and skilled health care professionals. Through research, advocacy and education, the AMA vigorously defends the practice of medicine against scope of practice expansions by nonphysicians that threaten patient safety.
For over 30 years, the AMA’s state and federal advocacy efforts have safeguarded the practice of medicine by supporting physician-led care and opposing attempts by nonphysicians to inappropriately expand their scope of practice.”
AMA is big, respected and influential counting among its supporters 15 physicians (12 Republican, 3 Democrats) in the upcoming 119th Congress that commences its work January 3. It is counting on the lame duck session of the 118th to temporarily suspend CMS’ Medicare 2.83% physician pay cut for 2025 since it enjoys Bipartisan Support thus allaying the most urgent of physician fears. But the context for the profession in 2025 is foreboding: a new administration, widespread consumer anxiety about food, gas, housing and healthcare prices and mounting concern about inflation and the national debt.
Against this backdrop, there is consensus in the health system and Congress that the physician workforce is unhealthy and recognition of shortages in rural areas and certain specialties. There’s consensus among consumers (patients) that physicians are trusted and well-paid but their accessibility increasingly limited. And there’s consensus among physicians that the profession is in crisis-mode.
I read the 72-page HOD report on the resolutions it considered. (Proceedings of the 2024 Annual Meeting of the House of Delegates | American Medical Association). They’re exhaustive and specific covering climate change, artificial intelligence, insurer prior authorization, disinformation/misinformation by clinicians and others, subsidies for immigrant coverage, hospital tax exemption qualifications, Medicare and Medicaid reimbursement and many others. Several resolutions defend the pre-eminence of the profession against scope of practice encroachment by non-MDs/DOs. Several call for studies to address physician shortage remedies. And some take aim at limiting private-equity’s role in the future of the profession.
My takeaways from reviewing the HOD proceedings and the plethora of recent studies about physician well-being, compensation, practice setting changes and their views on the health system are these:
- Physician payment needs fresh solutions. Current approaches are short-sighted. RVU-based models inaccurately account for total costs or care (fixed and direct) and inflation and lend to coding gamesmanship and operating losses. Alternative payment models involving risk sharing with Medicare are inadequately designed to stimulate a significant transition from volume to value. Limits on physician ownership, disclosures between suppliers and physicians, facilitating patient engagement in gain-sharing models and others need re-consideration.
- The supply and demand formula for clinical professionals (physicians, nurses, et al) should be modernized. While physicians are rightly superintendents of clinical appropriateness and protectors of patient relationships, technologies that enable self-care, transparency that facilitates patient understanding of treatment options, prices and comparative outcomes, and the role generative AI will play in care management should be aggressively integrated in clinician training, competence assessment and compensation plans. Lag indicators built on demographics, disease prevalence and severity, clinician age and experience and training program capacity do not accurately foretell the supply-demand solution in the health system of the future.
- AMA should advance a long-term view of the future of the U.S. system that’s addresses its affordability and effectiveness. The future roles played by other professions, hospitals, insurers, drug and device manufacturers, HIT solution providers and others and financing mechanisms that enable sustainability and improvement should be re-envisioned based on what and how, not who, should do the needed work.
Physicians will always play a prominent role in U.S. healthcare. The profession’s preparedness to lead its inevitable transformation is the big unknown. And its attractiveness to future generations of physicians the big risk if not addressed.
Paul
P.S. The American Hospital Association recently published the 2025 Healthcare Workforce Scan which captures well the challenges facing organizations that employ more than 18 million across the industry’s providers, payers, supply chain and support organizations. It’s well-documented and timely reading as uncertainty about the future in the U.S. health system mounts and outside forces demand urgent attention to affordability and transparency.
2025-Health-Care-Workforce-Scan.pdf
Sections in today’s report
- Quotables
- Alternative payments
- Corporate Healthcare
- Demographics
- Economy
- Hospitals
- Insurers
- Physicians
- Polling
- Prescription Drugs
- Public Health
Quotables
Thank you
Re: RFK priorities as HHS Secretary: “I’m committed to advancing your vision to Make America Healthy Again. We have a generational opportunity to bring together the greatest minds in science, medicine, industry, and government to put an end to the chronic disease epidemic. I look forward to working with the more than 80,000 employees at HHS to free the agencies from the smothering cloud of corporate capture so they can pursue their mission to make Americans once again the healthiest people on Earth. Together we will clean up corruption, stop the revolving door between industry and government, and return our health agencies to their rich tradition of gold-standard, evidence-based science. I will provide Americans with transparency and access to all the data so they can make informed choices for themselves and their families. My commitment to the American people is to be an honest public servant.”
RFK Post November 14, 2024 Robert F. Kennedy Jr on X / X
Re: Vaccines and Public Hesitancy:” Vaccines are a public health tool used to prevent the spread of infectious diseases and are estimated to save more than 4 million lives each year. However, as widespread vaccine use has significantly reduced the prevalence of vaccine-preventable diseases, concerns about vaccine safety and necessity have also emerged. Those who are wary of vaccines often share their views through social media, where myths and misinformation can spread widely. The strong and persistent messaging of vaccine opponents can also contribute to a societal perception that vaccines carry risks, influencing some people to question or avoid vaccinations While the World Health Organization (WHO) named vaccines one of the top ten health innovations of the 20th century, it also listed vaccine hesitancy as one of the major threats to public health.
Vaccine hesitancy is defined as reluctance or refusal to vaccinate despite the availability of vaccines. However, not all vaccine-hesitant individuals decide against immunizing themselves or their families. Some choose to skip specific vaccines, immunize on a schedule different from that recommended, or simply have concerns and questions they want addressed before proceeding with vaccination. Hesitancy can often be a result of misinformation about vaccines and/or concerns about the potential side effects of immunization. Many who are hesitant about vaccines also question the role of government and the pharmaceutical industry and are likely to prioritize personal freedoms, medical autonomy, and limited government.”
Voting for Party, Not for Public Health | Baker Institute November 13, 2024
Re: Trump healthcare agenda: “It’s hard to know exactly what change in Washington will mean for the health care industry starting next year. But we have some pretty good clues.
Among the possibilities: Newly empowered Republicans could tweak the Medicare drug price negotiation program in ways that could be more to the liking of biopharma companies. Other changes may not be as welcomed by the industry: If President-elect Donald Trump’s surrogate Robert F. Kennedy Jr. has his way, get ready for even more anti-pharma rhetoric and potential instability at the Food and Drug Administration.
Are television drug advertisements also on the line? There are reasons to think that won’t be the case.”
From hospitals to biopharma, change is coming STAT November 11, 2024 https://www.statnews.com
Re: retail health: “Attracting seniors is no easy task for big retailers, despite billions of dollars in investments in the last few years.
Investments have ranged from strategic shifts to existing clinic operations to multibillion-dollar acquisitions of senior-focused primary care providers, with varying levels of success. Retailers including CVS, Kroger and Amazon are forging ahead with plans to provide healthcare services to seniors, while Walgreens is taking a step back from its investments and Walmart has shut down its health unit.
Analysts, consultants and healthcare leaders say the quality of patients’ relationships with their providers is the key factor in determining whether seniors seek care through retailers. They say retailers’ success comes down to understanding the demographic they are trying to serve and seniors’ distinct set of needs.
Balancing that connection with retailers’ obsession with convenience is taking longer than some companies initially thought.”
Why big retailers are hitting roadblocks in senior care November 11, 2024 https://www.modernhealthcare.com/providers/kroger-health-amazon-cvs-senior-care-primary-care
Re: traditional media and Campaign 2024: “Joe Biden is likely to leave office as the first president since Franklin Roosevelt to deny The New York Times an on-the-record interview. Kamala Harris is the first presidential candidate in modern history to snub Time magazine, to the chagrin of its billionaire publisher. Donald Trump hasn’t sat down with CNN in 18 months, instead focusing his campaign media strategy on podcasters and social media influencers like Bet-David, though he has written opinion pieces for Newsweek.
It was a bold move that paid off, at least in terms of reach. His three-hour appearance on Joe Rogan‘s far-reaching podcast garnered 40 million views on YouTube in a week—more than twice the combined audience of the Big 3 television newscasts…
The mass media’s slow but steady loss of influence predates Trump. It can be traced to economic headwinds brought on by the digital revolution and evolving consumer preferences.
In 2010, about 105 million U.S. households subscribed to a cable television package. This year, that number was down to 68 million, according to Statista, for a 35% decrease in 14 years…
This year, though, Congress was eclipsed. The mainstream media is now the least trusted institution in the country. When asked by the pollster how much trust and confidence they had in the media, nearly 70% of respondents said either “not very much” or “none at all.” In the “none at all” category, the press ranked a staggering 17 points lower than Congress.
That collapse in trust was a long time coming. The media has been underwater with the public for two decades, long before Trump started referring to it as the “fake news… The last time Gallup’s survey found a majority of Americans had either a “great deal” or “fair amount” of trust in media was 2003.
The last time Gallup’s survey found a majority of Americans had either a “great deal” or “fair amount” of trust in media was 2003 ”
2024 US Election: Donald Trump Won. But the Biggest Loser Was the Mainstream Media. – Newsweek
Re: burnout in healthcare: “To treat burnout as a preventable harm, organizations need to measure and track it with the same granularity applied to patient safety. Annual surveys of clinician engagement, however relevant, should be considered summative like Leapfrog Hospital Safety Grades. More proximate indicators — such as rates of staff turnover or use of employee assistance services or off-hours logins to electronic health records — might function as trigger tools by providing real-time objective data without the burden or bias of frequent self-reporting. Hospital safety officers use trigger tools to track adverse events more robustly than self-reporting could ever achieve; the same benefit could apply to tracking burnout risk, in which trigger tools could supplement serial survey data….
The crisis in workforce well-being should be examined through the same lens that helped health care organizations overcome shame, blame, and denial in approaches to safety. Rather than taking offense at high burnout rates in their organizations, health care leaders should take notice and take action.”
Re: international comparison to U.S. health system: “The United States has the worst-performing health system among all high-income countries. Even the best-performing U.S. states lag international comparators like France, Germany, the United Kingdom, and Australia. To move the United States from laggard to leader will require significant — but doable — changes in its healthcare system, including closing remaining gaps in insurance coverage, limiting debilitating out-of-pocket-expenditures, and reviving its failing primary care capabilities… Given its collective wealth, technologic sophistication, and spending, the United States should lead, not lag, the world in its healthcare performance. Its health system holds it back.”
Why the U.S. Healthcare System Is So Much Worse Than Its Peers
Re: Trump election redefines political party following: “As Donald Trump continues to build a multiethnic working-class Republican Party, the importance of race and ethnicity to voters’ choices is declining. The key division in this emerging coalition is education. Voters without college degrees tilt far more Republican than those with them. Unfortunately for Democrats, voters without a bachelor’s degree outnumber those with one in the electorate by 57% to 43%…
These preliminary findings from the 2024 election challenge two pillars of Democratic orthodoxy. First, it’s time to discard the term “people of color,” which assumes uniformity of outlook and behavior among nonwhite groups. There’s good reason to believe that Hispanics and Asian-Americans will continue to move along the classic immigrant path of upward mobility and cultural adjustment while retaining their distinctive customs. These groups have experienced difficulties along the way, but most no longer think of themselves as oppressed minorities as blacks and Native Americans are more likely to do.
Relatedly, it’s time for Democrats to bury the hope that demographic change will work to their advantage. Young people and some minority groups are trending away from the left. The party’s remaining demographic base—largely comprised of blacks and college-educated white voters—isn’t big enough to sustain a national majority. Nor is the current geographic base, which relies on cities and suburbs to counterbalance Republicans’ huge margins in rural and small-town America.
Democrats were once the party of the factory floor; they’ve become the party of the faculty club. This shift has separated the national party from much of the country’s mainstream and makes it hard for even battle-tested Democrats such as Jon Tester and Sherrod Brown to survive.
It’s time for Democrats to undertake again the hard task of reflection and reform that led them from three devastating defeats in the 1980s to wins in four of the next six presidential elections.”
Donald Trump and the College Degree Divide – WSJ
Re: Primary care compensation: “According to a primary care scorecard authored by the American Academy of Family Physicians’ Robert Graham Center, the number of primary care physicians per person in the U.S. has decreased. Between 2012-2021, primary care physicians declined from 68.4 to 67.2 per 100,000 people. And as the health needs of an aging population have increased, the share of all clinicians practicing primary care stagnated at around 28% between 2016 and 2021.
These frustrating and concerning statistics underscore an urgent access and equity issue: primary care physicians cannot keep up with today’s demand. In order to put in motion tangible solutions and proposals that will bolster our workforce, we need the help of policymakers.
To address issues facing both physicians and patients — from clinician burnout to healthcare staffing shortages to lengthy appointment wait times to difficulty finding a physician — we need to address the root causes of the problems: historic underinvestment in primary care and flawed payment systems. Primary care accounts for 35% of healthcare visits in the U.S., yet represents just 5%-to-7% of total healthcare expenditures.”
American Academy of Family Physicians www.aafp.org.
Re: hospital prices relative to other healthcare prices: “A “Chart of the Century” has been circulating in news media and among health economists, which shows that the price of hospital services has surged over 220% between 2000 and 2022. This increase is greater than that of any other goods and services category, including all medical services, which increased over 130%, and the overall inflation rate of 74.4%. In this report, we investigate whether these price increases are justified by increasing operating costs.
Hospitals often justify their price increases by citing higher expenses due to labor shortages in the health care workforce resulting from the pandemic. However, hospital prices have been rising faster than those for other medical services long before the COVID-19 pandemic’s beginning in 2020. A recent report in Health Affairs Scholar compared hospital service prices to other professional services in the medical sector, including private practice medical doctors, dentists, eye care providers, and other types of providers. The study found that prices for hospital services have been rising faster than those for other professional services in the medical sector every year since 2006.
These prices may be rising faster if hospital costs are also increasing more rapidly compared to other sectors. This report compares the commercial operating costs, net patient revenue from commercial patients, and commercial operating profits of hospitals with different price levels to examine if higher prices are charged to cover higher costs, or instead to generate higher profits.”
Prices Versus Costs: Unpacking Rising US Hospital Profits, Baker Institute
Re: Trump economic agenda impact for investors: “Exactly what parts of his economic agenda Mr. Trump will want—and be able—to implement is not yet clear. But the giddiness in America’s stock markets gives clues as to what investors expect (the S&P 500, an index of large American firms, hit successive records on November 6th, 7th and 8th). Traders reckon the incoming administration will boost profits at American firms through tax cuts and deregulation, as government borrowing soars. A combination of higher deficits and rekindled inflation, in turn, may force the country’s central bank to keep interest rates higher than it would have without Mr. Trump in power. Those higher rates would make holding dollar securities more attractive, providing a tailwind to the greenback…
Whether a strong dollar lasts remains to be seen. Donald Trump himself has long bemoaned that a mighty greenback hurts domestic manufacturers and costs American jobs. But he cannot easily force the central bank to cut rates. And as long as rates stay high, America’s currency will remain the refuge of choice for investors—and a thorny problem for the world.”
America’s strengthening dollar will rattle the rest of the world: Donald Trump’s policies could send the greenback soaring The Economist November 10, 2024 https://www.economist.com/finance-and-economics/2024/11/10/americas-strengthening-dollar-will-rattle-the-rest-of-the-world
Re: private equity, medical debt and revenue cycle management:” If you’ve recently endured surgery or some illness that required hospitalization, here’s something else to make you feel ill: Private equity has fueled a medical debt spiral in pursuit of profit, according to an industry watchdog.
A recent report from the Private Equity Stakeholder Project reveals that medical debt now impacts 14 million people and totals at least $220 billion. Remarkably — sickeningly, even — this averages $15,714.29 per person or roughly one-quarter of the median American salary of $59,436 per the U.S. Bureau of Labor Statistics.
And more than ever, consumers are feeling the squeeze to pay up. As PE ups its investment in medical debt collection (also known by the benign term “revenue cycle management”), it has adopted some fairly aggressive tactics. It cuts both ways as well since they swell the debt in the first place.
PEs have expanded the use of medical credit cards, interest-bearing payment plans and strategic partnerships with banks “to indebt patients who cannot afford to pay a full medical bill at one time,” the report states…”
Re: SNL on Kennedy HHS nomination: “Congratulations to Robert F. Kennedy Jr., who became the first brain worm survivor nominated into a cabinet level position. Kennedy, whose skin is always cooked to a perfect medium rare, will lead the Department of Health and Human Services.”
Colin Jost Saturday Night Live November 16, 2024
Alternative payments
Alternative payments: Per the Healthcare Payment Learning and Action Network’s annual report based on its analysis of data from 73 health plans accounting for around 93%% of those insured:
- In 2023, 38.4% of healthcare dollars were spent in fee-for-service arrangements with no link to quality or value, down from 40.6% in 2022. According to the survey, 28.5% of healthcare dollars were spent in arrangements with downside risk, up from 24.5% in 2022.
- Medicare Advantage and Medicare had the highest share of payments with downside risk in 2023. In Medicare Advantage, 43% of payments were in models with downside risk in 2023, up from 39.9% in 2022.
- In traditional Medicare, 33.7% of payments were made in two-sided risk arrangements, up from 30.2% in 2022.
- The commercial market saw the largest growth in two-sided risk payments from 2022 to 2023. In the commercial market, 21.6% of payments were in two-sided risk models in 2023, up from 16.5% in 2022.
- In Medicaid, 21.1% of payments were in two-sided risk models in 2023, up from 18.7% in 2022.
APM Measurement: Progress of Alternative Payment Models Healthcare Payment Learning and Action Network https://hcp-lan.org/wp-content/uploads/2024/11/2024-HCPLAN-Methodology-Report-11-13.pdf
CMS: ACO Reach model results:” In PY 2023, REACH ACOs generated approximately $1.643 billion in gross savings, representing approximately a 5.8% gross savings rate relative to the retrospective adjusted PY benchmarks. Net savings to CMS were $694.6 million (2.6%) and the net savings to ACOs were $948.4 million (3.4%) compared to model benchmarks. This is an increase from the $371.5 million in net savings to CMS and the $484.1 million in net savings to ACOs in PY 2022.” Highlights:
- Among the 132 ACOs participating in the ACO REACH Model for PY 2023, 96 ACOs (73%) earned net savings from financial settlement, while 36 ACOs (27%) accrued net losses.
- 79% of ACOs in the Global risk option and 67% of ACOs in the Professional risk option earned shared savings.
- Savings increases from PY 2022 are due to performance improvements by model participants as they gained experience and growth in model participation.
- Between PY 2022 and PY 2023, per beneficiary per month gross savings increased by 72% to $71.15.
- 132 ACOs (from 99 ACOs in 2022) with 23 million beneficiary months (from 21 million in PY 2022)
ACO Realizing Equity, Access and Community Health (ACO REACH) Model: Performance Year 2023 Financial and Quality Performance Results’ Highlights November 8, 2024
Corporate Healthcare
UnitedHealthcare-Amedisys deal challenged by DOJ: The U.S. Department of Justice sued to block UnitedHealthcare’s $3.3 billion purchase of Amedisys, a home healthcare and hospice provider. The antitrust lawsuit, filed in Maryland federal court, alleges the combination could lead to higher prices in home health care in 23 states and Washington, DC, where Amedisys is a main competitor to UnitedHealth’s LHC Group. Last year, the insurer bought LHC, which was folded into its Optum Health business. The attorneys general of Maryland, Illinois, New Jersey and New York also joined the complaint.
DOJ files lawsuit to block UnitedHealth-Amedisys deal Bloomberg
Microsoft Azure: “The Federal Trade Commission is expected to launch an investigation into Microsoft’s cloud computing platform, Azure, based on allegations that the company is using anti-competitive tactics to maintain its dominance in the cloud market.
The FTC is examining claims that Microsoft has imposed punitive licensing agreements to block customers from moving their data off its platforms to competitors, the Financial Times reported, citing people with direct knowledge of the probe.”
US Regulators plan to investigate Microsoft cloud business November 14, 2024 https://www.ft.com/content/62f361eb-ce52-47c1-9857-878cfe298d54
Demographics
Study: Government income support: “Government transfers are an increasingly important part of American incomes. They are the third largest source of Americans’ personal income, after income from work and investments. The average American received $11,500 in income from government transfers in 2022, compared to $40,500 in income derived from work and $12,900 from investments. Transfer income is also the fastest-growing component of total personal income. The average American received nearly six times more in government transfer income in 2022 than they did in 1970, adjusting for inflation. Income earned from other sources increased less than half as much. The result: transfers’ share of Americans’ total personal income has more than doubled over the past 50 years, from 8.2% in 1970 to 17.6% in 2022…
The rise in transfers—both in absolute terms and as a share of personal income—is a long- running trend. Total transfer income has increased in real terms for 47 out of the past 52 years and increased as a share of total personal income in 32 of them…
The steadily aging American population is the overriding contributor, in large part because the two biggest components of transfer spending are the old-age benefits of Social Security and Medicare. The share of the population ages 65 and over has risen from 9.8% in 1970 to 17.3% in 2022—neatly tracking transfers’ rise as a share of total personal income…
…rapidly rising healthcare costs also push the transfer share higher. Healthcare cost inflation directly feeds into key transfer programs, and medical costs have risen nearly twice as quickly as overall inflation over the past several decades. “
The Great Transfer-mation: How Communities become Reliant on Income from Government Economic Innovation Group September 2024 https://eig.org/great-transfermation/
Census report: household composition: Per the U.S. Census Bureau’s America’s Families and Living Arrangements report:
“64% of households were classified as family households in 2024. This marks a significant change from 50 years ago, when 79% of households were family households. Family households are defined as those that include at least one person related to the householder by birth, marriage or adoption.
In 2024, almost three-quarters (74%) of family households were married-couple households. Family households that did not include a married couple were more likely to have a female householder (68%) than male householder (32%). Among nonfamily households, about 52% included a female householder, while 48% had a male householder. A substantial portion of nonfamily households were homes with someone living alone — 81% in 2024 compared with 89% 50 years ago.” Additional highlights:
- Households: In 2024, there were 38.5 million one-person households, which was 29% of all U.S. households. In 1974, one-person households represented only 19% of all households. As the population ages, the portion of householders age 65 and older has increased from about 1 in 5 50 years ago to over 1 in 4 in 2024.
- Families: The percentage of families with their own children under age 18 in the household declined from 1974 to 2024. In 1974, 54% of all U.S. families lived with their own children under age 18, compared to 39% in 2024.
- Marriage: In 2024, 34% of adults age 15 and over had never been married. The estimated median age to marry for the first time was 30.2 years for men and 28.6 years for women in 2024, up from ages 23.1 and 21.1, respectively, in 1974.
- Living Arrangements: In 2024, more than half (57%) of adults ages 18 to 24 lived in their parental home compared to 16% of adults ages 25 to 34.
Nearly Two-Thirds of U.S. Households are Family Households https://www.census.gov/newsroom/press-releases/2024/families-and-living-arrangements
Census: Childless households increase: Per the 2023 American Community survey:
- “The share of both same-sex and opposite-sex households with children under 18 — married and unmarried — declined from 2019 to 2023, a reflection of drops in U.S. fertility rates.”:
- Married same-sex couples were more likely than their unmarried counterparts to have children living in the household.
- 17% of marriedsame-sex households had a child present compared to 19% in 2019.
- The share of married opposite-sex couple households with children declined statistically, though the percentage in both years rounded to 38%.
- The share of unmarriedcouple households with children present also dropped from 2019 to 2023: 12% to 10% in same-sex households and 36% to 34% in opposite-sex households.
- Married same-sex couples were more likely than their unmarried counterparts to have children living in the household.
- Among female couple households, 25% of marriedand 16% of unmarried couples had children in the household in 2023. Among male couples, 9% of married and 3% of unmarried couples had children in the household.
- About 21% of female couple households included a child in 2023, compared to just 6% of male couple households.”
Share of U.S. Coupled Households with Children Declined in 2023
Economy
October CPI: Up 2.6% for LTM: From BLS’ release last Wednesday:
“The index for all items less food and energy rose 0.3% in October, as it did in August and September. Indexes that increased in October include shelter, used cars and trucks, airline fares, medical care, and recreation. The indexes for apparel, communication, and household furnishings and operations were among those that decreased over the month.
The all-items index rose 2.6% for the 12 months ending October, after rising 2.4% over the 12 months ending September. The all items less food and energy index rose 3.3% over the last 12 months. The energy index decreased 4.9% for the 12 months ending October. The food index increased 2.1%over the last year. “
The medical care index increased 0.3% over the month after increasing 0.4% in September. The index for physicians’ services increased 0.5% in October and the prescription drugs index rose 0.2% over the month and up 3.8% in last 12 months.
The relative importance of key categories to overall CPI: shelter (36.54%), food (13.46%), energy (6.63%), medical care services 6.51% (which includes physician services 1.81%, hospital 1.99%)
Note: Changes to physicians’ services and outpatient hospital services source data and methodology: Effective with this release, the CPI program will use secondary source medical claims data for the private insurance portion of the physicians’ services and outpatient hospital services indexes.
Consumer Price Index Summary November 13, 2024 https://www.bls.gov/news.release/cpi.nr0.htm
Re: Trump administration health agenda: “A focus on health care access and affordability will remain front and center in the new political landscape following the recent elections…
At the end of the day, the Trump Administration and Congressional Republicans will need to set priorities among these complex health policy decisions, then determine what requires legislation and what can be accomplished through regulation or other agency action…
It is safe to say that litigation by Democratic state attorneys general, patient and consumer groups, and other advocacy organizations should be expected on any high-profile regulatory initiative that the Trump Administration pursues that will affect health care access and affordability. In light of potentially novel issues related to agency authority, spending and grant restrictions, and the balance between state and federal power, some of these disputes may ultimately be decided by the Supreme Court.”
The Impact of The Election on Health Policy and The Courts https://www.healthaffairs.org/content/forefront/impact-election-health-policy-and-courts
Hospitals
AHA Year-end requests to Congress: In the AHA’s November 12 letter to Congressional leaders, it requests Congressional Action on 7 issues:
- Address the Medicaid Disproportionate Share Hospital (DSH) Payment Reductions.
- Protect Rural Communities’ Access to Care.
- Reject Site-neutral Payment Proposals
- Hold Commercial Health Plans Accountable.
- Extend Telehealth and Hospital-at-home Waivers.
- Prevent Reimbursement Cuts for Physicians.
- Protect America’s Health Care Workers.
AHA Urges Congress to Act on Key Priorities in Lame-duck Session | AHA
Moody’s: Hospital financial results: Per the November 13 Moody’s Investor Services report:
- Labor costs and inflation are likely to be problematic for hospitals in 2025.
- The supply of healthcare employees next year will meet 94% of the demand.
- Supply costs are likely to stay high as drug costs are expected to see mid-to-high single digit percentage ranges.
- Median operating cash flow margin will improve to 7% in 2025 vs. 6% in 2024. 60% of nonprofit hospitals next year will have 6%-plus margins, up from 40% in 2023. However, pre-pandemic 78% of hospitals hit that threshold.
- Hospital revenue growth to het 7% in 2025 as a result of. higher reimbursements from commercial insurers next year and adoption of state-directed pay programs.
- If hospital operating cash flow exceeds 9%, Moody’s will update its outlook to “positive.” Or, negative if average margins drop under 6%.
Moody’s Investor Service www.moodys.com; United States | Hospitals & Health Service Providers | Reports | Moody’s
Kaufman Hall Hospital Flash Report for September 2024: Key Takeaways:
- “September data show relative stability. Though most indicators are down this month, performance remained relatively stable overall.
- Inpatient revenue and average length of stay increased. This indicates that hospitals are treating more high-acuity patients, which results in a decline in volume and an increase in expenses.
- Expenses, with the exception of labor, are still high compared to 2021-2023. Contract labor rates and utilization have decreased, but the overall labor market is still tight.”
Key data:
- Profitability: +16% (9/24 vs. 9/23); +17% (YTD24) vs. YTD23; -13% (YTD24 vs. YTD21)
- Bad debt & charity per calendar day: +6% (9/24 vs. 9/23); +19% (YTD24 vs. YTD23); +20% (YTD24 vs. YTD21)
- Bad debt & charity as % of gross: -4% (9/24 vs. 9/23); +10% (YTD24 vs. YTD23); -4% (YTD24 vs. YTD21)
National Hospital Flash Report: September 2024 Data https://www.kaufmanhall.com/insights/research-report/national-hospital-flash-report-september-2024
Leapfrog: Hospitals improve infection control, medication safety: Leapfrog incorporated changes to its methodology in its fall report released last Friday including fall grading, removal of an elective deliveries measure, the collection of nurse staffing data from mixed patient units, the addition of questions on diagnostic error prevention and an expanded bar code medication administration standard. Results:
“For fall 2024, Utah ranks number one with the highest percentage of “A” hospitals for the third cycle in a row, followed by Virginia and Connecticut in second and third. The latest Grades also show hospitals are making progress in patient safety across several performance measures including notable improvements in healthcare-associated infections, hand hygiene and medication safety. “:
Hospital Ratings and Reports | Leapfrog
Lown study: unnecessary spine surgeries in hospitals: “The Lown Institute Hospitals Index is the first to evaluate how well individual hospitals avoid overuse of common low-value tests and procedures. The Institute measured overuse of spinal fusion/laminectomy and vertebroplasty at hospitals with the capacity to perform the procedure using Medicare fee-for-service (2020-2022) and Medicare Advantage (2019-2021) claims data. Excerpts:
- “Over three years, U.S. hospitals performed more than 200,000 unnecessary back surgeries on Medicare beneficiaries…
- These low-value back procedures cost Medicare about $2 billion in total over three years.
- On average, 14% of spinal fusions/laminectomies met criteria for overuse, with individual hospital overuse rates ranging from less than 1% to more than 50%.
- On average, 11% of patient visits for osteoporotic fracture resulted in an unnecessary vertebroplasty, with individual hospital rates of overuse ranging from zero to 50%.
- New Hampshire, Iowa, Massachusetts, and Pennsylvania had the highest overuse rates of spinal fusion/laminectomy with rates over 18%. Arkansas, Kansas, Oklahoma, and Nevada had the highest overuse rates of vertebroplasty, with rates over 16%.
- A total of 3,454 physicians performed a measurable number of low-value back surgeries. Over three years, these physicians received a total of $64 million from device and drug companies for consulting, speaking fees, meals, and travel, according to Open Payments data analyzed by Conflixis.”
Unnecessary Back Surgery – Lown Institute Hospital Index
Insurers
NCHS Report: Insurance coverage status: Per the Centers for Disease Control and Prevention report released Friday:
- 6% of Americans, or 25.3 million people, lacked health insurance during the time of data collection from April to June– a 0.4%increase from the year-ago period consistent with 2023’s full-year uninsured rate.
- 1% of Americans, or 205.8 million people, from April to June. Had private insurance last year—vs. 60.2% last year.
- Affordable Care Act marketplace plans enrolled a record3 million people for 2024 coverage.
- 40% of Americans, or 129.5 million people, received coverage through public health plans, including Medicare, Medicaid, Children’s Health Insurance Program and military plans, down from 41.8% during April to June last year.
National Center for Health, Statistics www.nchs.gov
Study: provider-sponsored MA plans: “In this study, we used the Agency for Healthcare Research and Quality (AHRQ) Compendium of US Health Systems to identify health systems operating MA plans through direct ownership or partial management with another organization.” Findings:
- In 2022, the compendium identified 640 health systems; 121 (18.9%) self-reported operating an affiliated MA plan. The number of beneficiaries enrolled in system-operated MA plans increased from 3,313,709 to 4,173,688 between 2018 and 2022. In 2022, this represented 13.1% of all MA beneficiaries. The number of identified system-operated MA plans also steadily increased from 135 to 196 from 2018 to 2022.
- Health systems operating MA plans were on average larger (2177 vs 780 beds) with more clinicians (2515 vs 744 physicians) and affiliated nursing homes (5.14 vs 0.89 nursing homes) than systems not operating MA plans. Systems treating lower proportions of White Medicare beneficiaries (73.7% vs 78.8%) were associated with operating MA plans.
- Compared with other ownership types, a disproportionate number of church-affiliated health systems operated MA plans. Further, health systems operating in 3 or more states were more likely to offer MA plans than more concentrated systems. System-operated MA plans had higher overall quality star ratings (4.38 vs 4.03) and patient satisfaction (4.41 vs 3.78) compared to plans not operated by health systems.
Characteristics of Health Systems Operating Medicare Advantage Plan November 8, 2024 https://jamanetwork.com
Health Insurance Coverage in 2023: Highlights from U.S. Census Bureau’s September report: “Health Insurance Coverage in the United States: 2023”:
- In 2023, 92% percent of the population had health insurance, either for some or all of the year: private health insurance coverage 65.4% vs. public coverage 36.3%.
- Of the subtypes of health insurance coverage, employment-based insurance was the most common, covering 53.7% of the population for some or all of the calendar year, followed by Medicaid (18.9%), Medicare (18.9%), direct-purchase coverage (10.2%), TRICARE (2.6%), and VA and CHAMPVA coverage (1.0%).
- While the private coverage rate was statistically unchanged between 2022 and 2023, the employment-based coverage rate declined by 0.7 percentage points in 2023. At the same time, the rate of direct-purchase coverage increased by 0.3 percentage points.
- The 2023 public coverage rate was not statistically different from the rate in 2022; whereas, Medicare coverage increased by 0.2 percentage points.
- The uninsured rate for children under the age of 19 increased by 0.5 percentage points to 5.8% between 2022 and 2023.
U.S. Census Bureau, Health Insurance Coverage in the United States: 2023, September 2024
Surprise Medical Bills by Type of Insurance: Percentage of insured adults ages 19-64 who reported receiving a bill or being charged a copayment for a health care service that they thought was free or covered, by type of insurance coverage.
- Total: 45%
- Employer: 48%
- Individual + Marketplace: 50%
- Medicaid: 30%
- Medicare: 45%
- Other: 43%
Commonwealth Fund, Unforeseen Health Care Bills and Coverage Denials by Health Insurers in the U.S., August 2024
WSJ Investigation: MA enrollee churn: “A Wall Street Journal analysis of Medicare data found a pattern of Medicare Advantage’s sickest patients dropping their privately run coverage just as their health needs soared…
People in the final year of their lives left Medicare Advantage for traditional Medicare at double the rate of other enrollees from 2016 to 2022, the Journal’s analysis found. Those private-plan dropouts—300,075 during that time span—often had long hospital and nursing-home stays after they left, running up large bills that taxpayers, not their former insurers, had to pay.
They cost the federal government an average of $218 a day during that period. That is more than seven times the cost of a typical Medicare recipient, and about twice the cost of other recipients in the last year of their lives. The Journal’s analysis excluded hospice expenses, which traditional Medicare typically covers for all patients.
Medicare Advantage insurers collectively avoided $10 billion in medical costs incurred by the dropouts during that period, the analysis found. If those beneficiaries had stayed in their plans, the government would have paid the insurers about $3.5 billion in premiums, meaning the companies netted more than $6 billion in savings during that period…”
The Sickest Patients Are Fleeing Private Medicare Plans—Costing Taxpayers Billions – WSJ
Physicians
Kaufman Hall Physician Flash Report, September 2024 released November 12: The KF physician data is based on hospital employed physician financial metrics reported by hospitals: Highlights:
- Investment/subsidy per physician topped $300,000 in Q3 for the first time. “The increase underscores the unsustainable nature of traditional employment models.”
- Labor expenses remain elevated. The total direct expense per provider FTE rose 5% from Q3 2023 to reach $640,062.
- Physician and provider productivity continues to increase. Physician productivity, as measured by unit of work (wRVUs) per FTE rose 6% from Q3 2023.
“The employment model where hospitals and health systems subsidize physician employment is broken and needs to change. As the trend continues of increased expenses, higher subsidies, and physicians and providers working more but revenue per work unit decreasing, organizations need to reconsider physician employment models. Compensation models should reward efficiency and more effectively use APPs. As more clinical work shifts to outpatient settings and revenue streams diversify, the employment mix needs to be rebalanced. New models that establish physician incentives and that help reclaim physician interest could result in both an increase in workforce engagement and decreased expenses.”
Kaufman Hall’s Physician Flash Report
Study: Medical board oversight of clinician misinformation: “This cross-sectional study analyzed and coded publicly reported medical board disciplinary actions in the 5 most populous US states… from January 1, 2020, through May 30, 2023, for California, Florida, New York, and Pennsylvania and from January 1, 2020, through March 30, 2022, for Texas. Findings:
“The frequency of discipline for physician-spread misinformation observed in this cross-sectional study was quite low despite increased salience and medical board warnings since the start of the COVID-19 pandemic about the dangers of physicians spreading falsehoods. These findings suggest that there is a serious disconnect between regulatory guidance and enforcement and that medical boards relied on spreading misinformation to patients as a reason for discipline 3 times more frequently than disseminating falsehoods to the public. These results shed light on important policy concerns about professional licensure, including why, under current patient-centered frameworks, this form of regulation may be particularly ill-suited to address medical misinformation.”
Medical Board Discipline of Physicians for Spreading Medical Misinformation JAMA November 12, 2024 https://jamanetwork.com/journals/jamanetworkopen
Study: telehealth in primary care: Researchers analyzed the association between telehealth use in primary care practices and changes in the rates of low-value care from 2019-2022.Findings:
“Of the other 6 outcomes examined, there was no association between practice-level telehealth use and rates of low-value care services. In this cohort study of Medicare fee-for-service beneficiaries who received care from primary care practices in Michigan, some low-value care services (i.e., cervical cancer screening among women older than 65 years and low-value thyroid testing) were lower among practices with high telehealth use, and there was no association between practice-level telehealth use in rates of most other low-value care services not delivered in the office. As telehealth continues to be an important part of care delivery, evaluating how it may encourage or discourage low-value care services is critical to understanding its impact on quality of care.”
Primary Care Practice Telehealth Use and Low-Value Care Services November 7, 2024 https://jamanetwork.com/journals/jamanetworkopen
Study: Vaccine voting by health professionals in Red States: “The Baker Institute studied voting patterns about vaccines by physicians and health professionals in 4 red states (OK, TX, AR, LA). Findings: “Given their health-related backgrounds, one might expect these legislators would recognize the importance of vaccines to public health. However, veterinarians and medical doctors almost all had negative vaccine scores, often supporting bills that would weaken immunization programs and increase the risk for vaccine-preventable diseases.
In addition, Republican health legislators often voted for anti-vaccine bills, a position due to party politics and not based on their background in biology, medicine, or health. In fact, several health legislators in Texas promoted anti-vaccine legislation by authoring and/or sponsoring these bills…
Although the sample was small, it revealed that elected medical doctors are less often primary care or infectious disease experts who understand the role of vaccines and see the effects of vaccine-preventable disease. Instead, they are more often specialists, such as surgeons and anesthesiologists. As such, they may have limited patient interactions. In contrast, nurses typically have more frequent contact with patients and their families and are often responsible for administering vaccines. This may help explain why nurses were more likely to support vaccine-related legislation.”
Voting for Party, Not for Public Health | Baker Institute
RPM, CCM codes added: “Remote physiological monitoring (RPM) and chronic care management (CCM) are well-established programs with years of operational and billing experience in many practices. These billable activities have allowed health care providers to offer more comprehensive care to Medicare beneficiaries outside of their traditional in-person doctor’s visits. Because the U.S. Centers for Medicare & Medicaid Services (CMS) views these as complementary activities, providers are also able to leverage the right program for each patient, which often means enrolling some patients in both RPM and CCM services and billing for these services concurrently.
CMS’ recently issued rule finalized changes to the 2025 Physician Fee Schedule (PFS), which includes the introduction of new Advanced Primary Care Management (APCM) Healthcare Common Procedure Coding System codes, shedding light on the potential future of CCM coding. The new PFS goes into effect on Jan. 1, 2025, furthering an evolution that underscores a significant shift toward longitudinal, outcomes-focused care. Medical practices must stay abreast of these changes to leverage platforms supporting RPM, CCM and APCM programs effectively, ultimately optimizing revenue and patient care.
Finalized 2025 Medicare Physician Fee Schedule advances CCM and value-based care with new advanced primary care management codes Medical Economics, November 15, 2024
Polling
Pew: Trust in scientists: Per Pew Research Center Oct. 21 to 27, 2024 survey of. 9,593 of adults released last Thursday:
- 76% Americans express “a great deal” of confidence in scientists to act in the best interests of the public–up from 73% last year but below pre-pandemic levels (87% peak in April 2020).
- Majorities view research scientists as intelligent (89%) and focused on solving real-world problems (65%).
- 45% of U.S. adults describe research scientists as good communicators. A slightly larger share (52%) say this phrase does not describe research scientists well.
- 51% saying scientists should take an active role in public policy debate vs. 48% who think that scientists should focus on establishing facts instead of participating in public policy.
- 80% of Democrats view research scientists as honest, compared with 52% of Republicans.
Public Trust in Scientists and Views on Their Role in Policymaking Pew Research November 14, 2024https://www.pewresearch.org/science/2024/11/14/public-trust-in-scientists-and-views-on-their-role-in-policymaking
Prescription drugs
Peterson-KFF analysis: Projected Change in Per Capita Health and Retail Prescription Drug Spending, 2023-2028: In 4 of the 6 years, prescription drug spending is projected to increase faster than total health spending:
1. 2023: Total health spending: 6.9%; Prescription drug spending: 6.3%
2. 2024: Total health spending: 4.5%; Prescription drug spending: 6.1%
3. 2025: Total health spending: 4.2%; Prescription drug spending: 3.9%
4. 2026: Total health spending: 4.3%; Prescription drug spending: 5.9%
5. 2027: Total health spending: 5.3%; Prescription drug spending: 6.0%
6. 2028: Total health spending: 4.9%; Prescription drug spending: 5.7%
Peterson-KFF Health System Tracker, October 2024
Public Health
CDC: Drug deaths down: Reported drug deaths fell nearly 17% during the 12-month period ending in June, to 93,087 per the Centers for Disease Control and Prevention. The opioid epidemic’s toll remains immense, but is substantially lower than the 111,615 lives lost to overdose during the 12 months ending in June 2023. Fentanyl, the potent illicit opioid that now dominates the U.S. illicit drug supply, contributed to a large majority
www.cdc.gov
Nutrition and processed foods: “As the saying goes, you are what you eat. And, unfortunately, the food we eat is only solidifying America’s tragic title: We have the lowest life expectancy among large high-income countries.
The U.S. Food and Drug Administration is taking a number of steps to help people in the U.S. build healthy diets — including with respect to ultra-processed foods — and the food industry and research community should, too.
Ultra-processed foods are usually characterized by industrial processing, the presence of food additives such as flavors or colors, and nutrients intended to make them appetizing (sodium, added sugars, and saturated fat). Research points to ultra-processed foods being associated with diet-related diseases such as heart disease, diabetes, obesity, and even dementia. These and other diet-related conditions account for at least half of all U.S. deaths, disproportionately impacting Black, indigenous, low income, and rural Americans, and contribute to $4.5 trillion in annual health care costs.
The clear association between ultra-processed food and negative health outcomes is cause for major concern. A groundbreaking clinical trial performed at the National Institutes of Health, published in 2019, raised the troubling possibility that ultra-processed foods may actually stimulate the appetite, creating a cycle of overeating and obesity. What we don’t yet fully understand is why and how.
If ultra-processed foods cause poor health, what factors are responsible? While ongoing research at NIH aims to help find out, most studies dominating medical journals and newspaper headlines are observational studies that can’t fully demonstrate causality. One study showed that while consuming more ultra-processed food was associated with higher rates of cancer, intake was also associated with higher rates of accidental death, raising questions about what’s truly causing the negative outcomes.”
FDA commissioner: We need action and higher-quality research on ultra-processed foods November 15, 2024 https://www.statnews.com/2024/11/15/ultra-processed-foods-fda-califf-research-diet-related-disease
Study: GLP-1 use in alcohol use: This cohort study was an observational study conducted nationwide in Sweden using data from January 2006 to December 2023. The population-based cohort was identified from registers of inpatient care, specialized outpatient care, sickness absence, and disability pension. Participants were all residents aged 16 to 64 years who had a diagnosis of AUD. Result:
Among patients with AUD and comorbid obesity/type 2 diabetes, the use of semaglutide and liraglutide were associated with a substantially decreased risk of hospitalization due to AUD. This risk was lower than that of officially approved AUD medications. Semaglutide and liraglutide may be effective in the treatment of AUD, and clinical trials are urgently needed to confirm these findings.
Repurposing Semaglutide and Liraglutide for Alcohol Use Disorder JAMA Network November 13, 2024 https://jamanetwork.com/journals/jamapsychiatry
