May 6, 2022

The Weekly Gist: The Citrus Collector’s Item Edition

by Chas Roades and Lisa Bielamowicz MD

You may have celebrated it as Star Wars Day, but May the 4th also happened to be National Orange Juice Day. And right on cue, the good people at Tropicana unveiled a new product designed to highlight the versatility of the citrus beverage. Say hello to Tropicana Crunch Honey Almond Cereal, a breakfast treat designed to have orange juice, instead of milk, poured on top. But before Big Dairy could even mount a milky response to this act of acidic aggression, the full-scale launch was scrubbed. Turns out it was just a publicity stunt—much to the relief of People Who Have Tongues all across America. So if you managed to get your hands on the novelty breakfast box, resist the urge to gulp it down with your morning OJ. That’s a collector’s item you’ve got there! (Ew.)


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

1. Federal health officials to investigate increase in “Paxlovid rebound” cases. The Food and Drug Administration (FDA) says there’s “no evidence” that a second course of Paxlovid, Pfizer’s COVID antiviral drug, will help patients who are experiencing a relapse of symptoms after taking the medication. In the wake of a growing number of reports that patients’ COVID symptoms are returning after a five-day dose of Paxlovid, Pfizer’s CEO Albert Bourla told Bloomberg that patients should take another course. As it’s unclear why some patients are experiencing a so-called “Paxlovid rebound,” federal health officials said they plan to study the phenomenon.

The Gist: The Biden Administration has made Paxlovid a key tool in the fight against COVID, encouraging physicians to prescribe it, and launching the “Test to Treat” initiative to allow patients to get both tested and be prescribed the medication in the same pharmacy visit. Yet the drug’s rollout has, to date, been riddled with confusion, inconsistency, and subpar access for both physicians and patients. It’s important that the FDA step up its monitoring of Paxlovid, in order to better determine who benefits from it and who doesn’t, so that it can more clearly message and promote its use.

2. Providers ponder a post-Roe future. If the leaked Supreme Court draft opinion overturning Roe v. Wade—which in 1973 established an individual’s constitutional right to an abortion—is finalized, as many as 26 states are either certain or likely to ban abortion. The resulting patchwork of abortion laws across the country could create confusion for providers and hospitals on multiple fronts, including cases related to the federal Emergency Medical Treatment and Labor Act (EMTALA), as well as for health systems that operate in multiple states. Medical training on the procedure could become much more limited, as about half of the nation’s obstetrics and gynecology residencies are in states likely to ban abortion. Recognizing the precarious position that abortion bans will put some providers in, the American Medical Association released a statement on Thursday saying that it is “deeply concerned” with the draft opinion, and that it “would lead to government interference in the patient-physician relationship, dangerous intrusion into the practice of medicine, and potentially criminalizing care.”

The Gist: Abortion is just one of a raft of issues where the provision of health services increasingly intersects with charged politics in this country. If Roe is overturned, medication abortionthe use of abortion pills—which already accounts for more than half of all abortions, will increase, although multiple states are already seeking to limit access. Restricting access to safe abortions will also further exacerbate health disparities, driving up the already distressingly high US maternal mortality rate, especially among Black women. And overturning Roe would have implications far beyond access to abortion, especially for patients experiencing miscarriages, ectopic pregnancies, or other life-threatening medical conditions related to pregnancy.

3. Questions resurface about nonprofit hospitals’ tax-exempt status. A report from The Lown Institute, a Boston-based think tank, finds that many health systems—227 of the 275 evaluated—spend less on providing “community benefit” than the value of their tax exemptions. The American Hospital Association (AHA) criticized the report’s methodology, claiming it “cherry-picks categories of community investment.” This report builds on previous analyses that have found that, taken together, nonprofit hospitals spend less on charity care than government or for-profit hospitals.

The Gist: Policymakers and academics, prompted by massive capital projects, high executive salaries, and—especially—aggressive pricing and billing strategies, are increasingly questioning whether nonprofit health systems provide sufficient community benefit to retain their tax-exempt status. A recent piece in Health Affairs suggests updating the community benefit standard, which the Internal Revenue Service (IRS) uses to evaluate nonprofit status, to focus on social determinants of health and measurable health outcomes. We’d expect tougher scrutiny on this topic in the future, especially if state budgets come under pressure from a deterioration in the broader economy.

Pluswhat we’ve been reading.

4. Scrutiny of Adderall telehealth scripts intensifies. Digital mental health company Cerebral will stop prescribing medications like Adderall and Ritalin for new patients who suffer from attention deficit hyperactivity disorder (ADHD), as the company faces increasing scrutiny of its marketing and prescribing practices. The San Francisco-based startup, founded in 2020, has grown quickly; it now prescribes to patients in all 50 states and has been endorsed by Olympic gymnast Simone Biles. Former Cerebral employees allege they were pressured to prescribe more Schedule II controlled stimulants to retain patients. The Wall Street Journal reported that Truepill, Cerebral’s preferred online pharmacy, is halting prescriptions of Schedule II drugs from the company.


The Gist: The moves by Truepill and others, including CVS, Walmart, and Walgreens, to delay or halt filling Adderall and other controlled substance prescriptions by telehealth companies, are fueling the debate about the limits of telehealth. While pandemic-era flexibilities have increased consumers’ access to behavioral healthcare, several startups have focused on quick access to medication. As the country is still dealing with the effects of the opioid crisis, concerns about the overprescribing of controlled substances will surely weigh on lawmakers’ minds as they decide how to regulate telehealth companies.


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


Hospital volume return remains uneven, while virtual care holds

More than two years after the pandemic’s onset, some types of hospital volume still haven’t returned to pre-pandemic levels. The graphic below uses recent data from analytics firm Strata Decision Technology to track monthly hospital volume across various care settings. While outpatient volume continues to exceed pre-COVID levels, inpatient, emergency department (ED), and observation volume is still below the 2019 baseline. The unpredictability of volume trends is likely to continue, as COVID continues to ebb and flow regionally, and care continues to shift outpatient. By contrast, the volume of virtual care visits has remained consistent, even as consumers return to in-person outpatient visits, driving up the overall level above the pre-pandemic baseline. Some of this increase in outpatient visit volume has been driven by consumers turning to urgent care clinics or doctors’ offices—either in-person or virtually—for their lower-acuity care needs. While temporary reimbursement and licensing policies for telehealth have been the main stumbling blocks for many organizations’ longer-term planning for virtual visits, about half of states have now implemented permanent payment parity for telemedicine. As such, provider organizations that are still taking a “wait and see approach” must develop an economically sustainable virtual care model to reduce costs and meet evolving consumer demands.


A recommendation from our weekly diet of music, movies, TV, and other good stuff.

Timbuktu by Oumou Sangaré—Always worth celebrating a new release from the “Songbird of Wassoulou”, a Grammy award-winner and UN goodwill ambassador from Mali. Her ninth, recorded while in lockdown, continues her exploration of feminist themes, but it’s Sangaré’s gorgeous voice, atop soulful rhythms and bluesy West African instruments, that vaults this LP to the top of her canon. Elementally groovy.


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

A personal brush with COVID reveals cracks in our current response

When it comes to seeking care for an incipient case of COVID, there’s frustrating, and then there’s moan-to-the-national-media frustrating. A recent personal experience drove home the challenges that patients face in getting access to Paxlovid, Pfizer’s highly effective antiviral treatment that has become central to the Biden administration’s “Test to Treat” approach to COVID. After a positive test, an initial telemedicine visit with a primary care provider (PCP) demonstrated that there’s been insufficient education on prescribing the drug—who’s eligible, how to navigate drug interactions, even where to find and fill the prescription. It took more than a little cajoling on the part of this (unusually motivated and healthcare-literate) patient to finally secure the drug.

After a successful five-day course, with symptoms resolving and a negative antigen test, it appeared that COVID was in the rearview window. But that wasn’t the end of it. Four days later, it was back—with a vengeance. Worse symptoms, a blaringly-positive test: the fabled “Paxlovid rebound”. If the PCP required coaching the first time around, they were entirely flummoxed by the second call. There’s no protocol for the Paxlovid rebound yet—with the FDA and Pfizer collectively shrugging about the growing number of reports of the phenomenon (see item #1, above). What’s been clear throughout is that the tacit policy shift away from public health support to “individual responsibility” is not working out smoothly as a way to manage a pandemic that’s still very much ongoing. With cases on the rise and hospitalizations beginning to mount again, there’s reason to be concerned about the situation we may find ourselves in come summer. Contrary to the current White House rhetoric, it’s not at all clear that “we have the tools” to manage the next phase of the pandemic.


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

Houston-based Memorial Hermann Health System embarked on a plan to reorganize the system around service lines a little over two years ago. On last Monday’s episode, service line SVPs Kyle Price and Heath Rushing discussed how the system shifted to a product line focus, and how the new model sets up the system for future success.

Coming up this Monday, we’ll explore the drivers of private equity’s growing interest in cardiology practices in a conversation with consultant Anthony D’Eredita, Founder and CEO of TrustWorks Collective, and Dan Blumenthal, MD, CEO of PE-backed cardiovascular care delivery platform Nocovardia.

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That’s all for this week! It’s good to be back after a terrific team retreat last week. We returned to work even more excited about the opportunity to share our insights with you—now let us know what you think! We’d love to hear your feedback and guidance. And we’re most appreciative of your willingness to share the Weekly Gist with friends and colleagues, and encourage them to subscribe and check out our daily podcast. Thanks!

Most of all, we’d love for you to let us know how 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