September 24, 2021

The Weekly Gist: The Autumn All Year Edition

by Chas Roades and Lisa Bielamowicz MD

Stepping outside this morning to a cool, crisp autumn day in the DC area—easily the best time of year in the nation’s capital—only made the news we read in this week’s Washington Post all that much more disturbing: thanks to climate change, every season except summer is getting shorter, and summers are getting longer and hotter. Living inside the Beltway, in what is literally and figuratively a swamp, we’re all too aware of how miserable summer can be—especially when getaway plans are unexpectedly curtailed by a resurgent pandemic. (If we’d known the Roaring ’20s was going to be two weeks in June, we would’ve packed in more fun.) Climate change scientists are pushing for measures to counteract the worsening summer heat, and we hope progress comes soon. Is there a way to make autumn in DC last the whole year?


What happened in healthcare this week—and what we think about it.

The Biden administration’s booster strategy gets clumsily underway

After a confusing week of mixed messaging and conflicting opinions from the public health officials advising the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC), late Thursday night CDC Director Dr. Rochelle Walensky announced her decision to recommend COVID booster vaccines for adults over 65, residents of long-term care facilities, and those younger than 65 with underlying medical conditions. Controversially, Dr. Walensky contradicted the CDC’s own Advisory Committee on Immunization Practices (ACIP) by also recommending that people who are at greater risk of COVID exposure due to occupation or institutional setting—including healthcare workers and teachers—receive a booster shot. Earlier Thursday, ACIP members voted down a recommendation to provide boosters to healthcare workers, despite the FDA’s endorsement of that approach earlier in the week.

By Friday morning, President Biden announced he would soon get a booster shot himself, urging those eligible to do so, and re-emphasizing the administration’s primary focus on delivering first doses to those still unvaccinated. There will be more to come on boosters: the FDA and CDC guidance only applies to those who received the Pfizer-BioNTech vaccine at least six months ago; boosters for the Moderna and Johnson & Johnson vaccines are still under review. This week’s saga caps a month of back-and-forth between public health officials, the White House, and the medical community, following Biden’s August promise—considered by many to be premature—that boosters would be broadly available starting September 20th. The inclusion of healthcare workers in the booster campaign is welcome news; we were flummoxed by ACIPs decision to bypass that critical segment, given mounting hospital staffing shortages amid the surging Delta variant. More broadly, we’re increasingly distressed by the relatively uncoordinated and poorly-managed communication approach of the Biden administration on vaccines—particularly following a campaign in which competence was touted as a key advantage over the previous administration.

Intermountain, SCL Health to create $11B system 

Salt Lake City-based Intermountain Healthcare announced plans to merge with Broomfield, CO-based SCL Health to form a 33-hospital, $11B dollar system working in six states. The combined system will keep the Intermountain name, be based in Salt Lake City, and be led by Intermountain CEO Dr. Marc Harrison. Harrison said that the merger will accelerate the evolution toward population health and value, and “swiftly advance that cause across a broader geography”—a similar value proposition to the system’s previously proposed combination with South Dakota-based Sanford Health, which fell apart last December after Sanford’s CEO stepped down following his controversial comments about mask-wearing. Intermountain has long been regarded as a national leader in clinical quality, and its integrated payer-provider approach is often cited as a model for US healthcare. The merger with SCL Health will enable expansion of its SelectHealth insurance plan and integrated care model into Colorado, Montana and Kansas, including the fast-growing Denver metropolitan area, making the combined system a formidable player across the Mountain West. But as we’ve written before, achieving that vision will require a level of integration not often realized in similar mergers, and the burden of proof is on health systems to demonstrate that the merger will create meaningful value for patients and consumers. We’ll be watching closely to better understand their plans for lowering costs and improving access and quality for patients across the region.


A key insight or teaching point from our work with clients, illustrated in infographic form.

Preparing for generations of Medicare growth

The healthcare industry is now at the peak of the long-awaited transition of the Baby Boom generation into Medicare. The “greying” of the Boomers will continue to bring a rapid influx of new Medicare beneficiaries, but this is just the beginning of a protracted period of growth for the program, with the number of Medicare-eligible Americans increasing by more than 50 percent over the next three decades. Using data from the US Census Bureau, the graphic below shows how the generational makeup of the Medicare population will change across time. The next decade will bring the fastest growth, as the latter half of the Baby Boom generation turns 65. Over that time, the Medicare-eligible population will increase by almost a third. Gen X will begin to age into Medicare in 2029. (Go ahead, take a minute. It hurts.) While fewer in number, Gen X beneficiaries, combined with the longer lifespan of Baby Boomers, will bring no respite from Medicare growth, with enrollment still increasing 11 percent between 2030 and 2040. As the country looks at a prolonged period of Medicare cost growth, we’ll be counting on a ballooning workforce of Millennials and Gen Z youngsters—each part of generations even larger than the Baby Boom—to continue to fund the Medicare trust across the next 25 years, when the first Millennials will receive their Medicare cards. (See how it feels?)


What we learned this week from our work in the real world.

What strategies will help to deliver telemedicine “at scale”?

Every health system and physician group is now focused on strategies to make telemedicine more scalable across their networks. When we spoke recently with a chief medical information officer (CMIO) leading his system’s telemedicine strategy, he shared, “If there is one thing I wish executives would understand about telemedicine, it’s that it will never make doctors more efficient.” His data show the average video visit takes just as long as an in-person encounter. True, there is no physical exam, but the virtual conversations can be lengthy. And adding in time lost to helping patients troubleshoot technology, some of his colleagues report that virtual visits may actually take a little longer. He went on to explain that other kinds of virtual encounters, specifically asynchronous communication with a provider, sometimes supported by automated symptom triage engines like Zipnosis, are far more time-efficient ways to communicate with patients. Certain clinical situations may better lend themselves to these types of “e-visits”. Take dermatology, where sending a high-resolution picture of a rash to the clinician is more valuable than trying to view the problem live on a Zoom call. Of course, video visits can be far more convenient for patients—and there is huge value in in providing access to patients wherever they are. But delivering telemedicine “at scale” to meet rising consumer expectations will require finding the right balance of asynchronous communication, telemedicine, and in-person visits to best fit specific clinical circumstances. And we’ll need to rethink clinical workflow—centralizing some telemedicine delivery at the system level across individual practices.


All the headlines in healthcare policy, business, and more, in ten minutes or less every weekday morning.

On last Monday’s episode, we heard how San Francisco-based Carrum Health is making the “center of excellence” model more accessible to midsized companies through its digital marketplace by connecting self-insured employers with a network of providers.

Capacity and staffing challenges from ongoing COVID surges are creating a domino effect, delaying access to other medical care and backing up emergency departments. Coming up next Monday, Dr. Gregg Miller, Chief Medical Officer of hospital staffing company Vituity, tells us that these compounding factors are bringing sicker patients into overwhelmed and understaffed emergency departments.

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We would’ve worked harder, but we watched this instead.

Before you settle down for the coming season of high-budget, prestige TV dramas, it’s a good time to catch up on some of the fare that’s been on offer recently—and few summer shows have been better than The Other Two. Just wrapping up its second season after a move from Comedy Central to HBO, the show follows the travails of two Millennial siblings (played Drew Tarver and Heléne Yorke) struggling to break into the entertainment industry but finding themselves overshadowed by their Gen Z brother rocketing to fame as a Bieber-esque TikTok celebrity, and their Boomer mother finding sudden success as a daytime talk show host. What makes this concept more than just another insider-y send up of Hollywood is the show’s sophisticated look at the gender and generational dynamics at play, the whip-smart writing, and the over-the-top performances of Tarver and Yorke, whose angsty portrayal of 30-somethings “failing to launch” is achingly accurate. Great supporting work from Wanda Sykes as the talent agent pulling everyone’s puppet strings, and Molly Shannon as the stage-mother-turned-Oprah, add delicious spice to the mix. (Three cheers for Shannon, who also makes a devastating cameo as a mother in another summertime sensation, The White Lotus). Fair warning: the show is plenty raunchy; combined with its satirical outlook you might think of The Other Two as this summer’s anti-Ted Lasso. The perfect tart treat to wrap up the season.


Stuff we read this week that made us think.

What health systems might learn from Kodak—it’s not what you think

In addition to catching up on summer shows, the beginning of fall is a good time to attack the pile of unread magazines that have accumulated across a busy summer. As we’ve been working our way through the stack, we came across a great piece in the Atlantic, from a writer who grew up in Rochester, NY, and returned to report on recent attempts to revive the fortunes of Kodak, historically the main economic engine of the city. Followers of the business press will surely know the oft-told tale of Kodak’s demise—literally a textbook example of disruptive innovation. Deeply rooted in the production of film for cameras, Kodak’s engineers actually invented digital photography, but the company could never overcome its addiction to legacy profits from film to capitalize on the invention, ultimately leading to the company’s decline and bankruptcy. Of late, Kodak has been attempting a “pivot” to produce materials for pharmaceuticals, with dubious success.

The Atlantic piece covers that whole saga well, but piqued our interest for a different reason: it’s the parable of a city’s largest employer and benefactor that couldn’t figure out how to maintain relevance in a changing world, eventually pulling the entire town’s economic fortunes down with it. As the writer explains, Rochester was Kodak—not just the biggest employer, but the source of stability and meaning for the city, the thing residents were most proud of. Even if you didn’t work at Kodak, you were a “Kodak citizen”, justifiably proud of being associated even tangentially with the company, and you likely benefitted from the community programs they sponsored. Well, we work with a lot of health systems who occupy the same position in their communities: largest employer, community benefactor, economic engine. Beyond learning from Kodak’s obvious mistakes on the innovation front, we wonder whether there’s something for health systems to learn about their role as guardians of a community’s pride and identity. (For instance, do Cleveland residents feel like “citizens” of the Cleveland Clinic? Could they?) One hopeful sign: the intentional steps many systems are now discussing (and some are actually pursuing) to address “social determinants of health” and racial inequities in care. As the piece points out, Kodak’s hiring and investment policies helped make Rochester one of the most segregated cities in America. Health systems have a role to play in avoiding that trap. Food for thought.

So ends another busy week, and another Weekly Gist. Thanks so much for taking time to read our work, and for sharing your comments and suggestions with us. Keep it coming—we love to hear from you! And remember to share this with your friends and colleagues, encourage them to subscribe, and to listen to our awesome daily podcast!

As always, please let us know if we can be of assistance in your work. You’re making healthcare better—we want to help!

Best regards,

Chas Roades
Co-Founder and CEO

Lisa Bielamowicz, MD
Co-Founder and President