December 2, 2022

The Weekly Gist: The Crown Jewels of Soccer Edition

by Chas Roades and Lisa Bielamowicz MD

We’re through! After a tense, must-win match played amid a charged political atmosphere, the young US men’s national team notched a critical 1-0 victory this week against Iran, ensuring they will advance to the knock-out rounds of soccer’s World Cup. The victory came thanks to what can only be described as a “brave” goal from forward Christian Pulisic, who collided dangerously with Iran’s goalkeeper in the process of scoring. To say that Pulisic took one for the team is an understatement. If Maradona’s famous 1986 goal for Argentina against England became known as the “Hand of God” for his infamous use of his hand in scoring, perhaps we’ll come to know Pulisic’s goal as the “Crown Jewel(s) of US Soccer”. Pulisic had to be rushed to the hospital with an abdominal injury that doctors described as a “pelvic contusion”. It looked bad. Surely hoping to avoid his career-defining goal being known more for the injury than the result, Pulisic hastened to tell the media, “I didn’t get, like, hit in the balls.” Timeless words from Captain Courageous, a quote for the ages. Onward!


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

  1. Twitter no longer policing COVID misinformation. Amid a flurry of policy changes initiated by Elon Musk since his takeover of the social media company last month, Twitter has ceased its formal efforts to combat COVID misinformation. To date, Twitter had removed over 100K posts for violating its COVID policy. The company will now rely on its users to combat disinformation through its “Birdwatch” program, which lets users rate the accuracy of tweets and submit corrections. Many of the 11K accounts suspended for spreading COVID misinformation, including those of politicians like Rep. Marjorie Taylor Greene (R-GA), have also been reinstated.

The Gist: We’ve seen the damage caused by inaccurate or deliberately misleading COVID information, which has likely played a role in the US’s lower vaccination rates compared to other high-income countries. Around one in five Americans use Twitter, far fewer than Facebook or YouTube, but the platform is seen as highly influential, both for the reach of its content and also its moderation decisions. This policy change is worrisome, not only because COVID is still taking the lives of hundreds of Americans daily, but also because COVID misinformation catalyzes broader healthcare misinformation, including antivax sentiments and an overall mistrust of medical experts.

  1. More health systems are charging patients to message their physicians. A growing number of health systems have begun to bill for certain electronic communications with patients via portals like MyChart. The systems instituting these practices, including Cleveland Clinic and Chicago-based Northwestern Medicine, have justified the billing based on the time demands placed on their providers to answer messages involving additional efforts, including extensive patient chart review. Northwestern shared that fewer than one percent of MyChart messages incurred fees, which are typically covered by insurance, and require patient consent before billing.

The Gist: In a time of significant margin pressure, we understand the instinct to seek additional revenue by collecting whatever reimbursement is available. However, in the ongoing transition to technology-enabled hybrid care, this practice has the potential to confuse, or even drive away, patients, who finally began to embrace virtual provider communication during the pandemic. Viewing portal messaging as a “digital front door” for patients, rather than a revenue-generating service in and of itself, may prove more fruitful in the long run. 

  1. Latest Alzheimer’s drug trials generating mixed results. Pharmaceutical companies Eisai and Biogen published findings from a Phase Three trial, showing that lecanemab, their experimental Alzheimer’s drug targeting amyloid deposits in the brain, reduced cognitive and functional decline by 27 percent in patients with early Alzheimer’s. Though the drug caused severe side effects in some patients, the drugmakers—who are also the makers of the controversial Alzheimer’s drug Aduhelm—submitted an accelerated Food and Drug Administration (FDA) approval request. Also this week, Genentech, a division of drugmaker Roche, released results showing that gantenerumab, its drug that similarly targets amyloid buildup, failed to slow the growth of plaques significantly.

The Gist: As we’ve seen with Aduhelm, accelerated FDA approval for lecanemab won’t necessarily mean it will end up reaching many patients. Given the pervasiveness and severity of Alzheimer’s, the FDA faces a difficult decision each time an experimental drug shows promise, as the lack of viable treatment options creates public pressure for approval. But the study result we’re anxiously waiting for is the one aiming to either prove or disprove whether amyloid plaque actually causes Alzheimer’s—a largely accepted hypothesis that has been increasingly scrutinized in recent years.

Pluswhat we’ve been reading.

  1. Hospice industry awash with for-profit bad actors. An unsparing piece published this week in the New Yorker examines the unscrupulous and exploitative practices of AseraCare and several other for-profit hospice providers, who have gone from controlling 30 percent of the hospice market to more than 70 percent across the last decade. The article outlines the companies’ playbook of delivering the least amount of care to the greatest number of patients, many of whom are not actually in need of hospice services at all. In order to game Medicare’s policy to extract repayments from hospice providers whose average patient stay exceeds six months, many of these companies have employed strategies ranging from recruiting “last breath” patients from oncologists to lower their average length of stay, to “graduating” an absurd 70 percent of enrolled patients once they reach their six-month limit.

The Gist: While it only takes a few bad apples spoil the bunch, the US hospice industry appears to be in a thoroughly rotten state. Caring for the elderly and dying is already a difficult (and expensive) proposition, and the questionable practices detailed in this piece further undermine the good work being done by those providers committed to helping patients and their families during extraordinarily difficult times. Currently subject to only minimal federal oversight, the hospice industry is in dire need of stronger regulation, which might take its cue from California, which recently issued a licensing moratorium for hospice providers while redesigning its auditing process.


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

Many insured Americans still struggle to afford care 

Driven by the steady progress of Medicaid expansion and pandemic-era policies to ensure access to health insurance coverage, the US uninsured rate hit an all-time low of 8 percent in early 2022. Since the Affordable Care Act passed in 2010, the US uninsured rate has been cut in half, with the largest gains coming from Medicaid expansion. However, using data from Commonwealth Fund, the graphic below illustrates how this noteworthy achievement is undermined by widespread underinsurance, defined as coverage that fails to protect enrollees from significant healthcare cost burdens. A recent survey of working-age adults found that eleven percent of Americans experienced a coverage gap during the year, and nearly a quarter had continuous insurance, but with inadequate coverage. High deductibles are a key driver of underinsurance, with average deductibles for employer-sponsored plans around $2,000 for individuals and $4,000 for families. Roughly half of Americans are unable to afford a $1,000 unexpected medical bill. Americans’ healthcare affordability challenges will surely worsen once the federal COVID public health emergency ends, because between 5M and 14M Medicaid recipients could lose coverage once the federal government ends the program that has guaranteed continuous Medicaid eligibility. The process of eligibility redeterminations is sure to be messy—while some Medicaid recipients will be able to turn to other coverage options, the ranks of uninsured and underinsured are likely to swell.


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

Will health systems see the usual end-of-year spike in elective care? 

2022 has disproven the old trope that “healthcare is recession-proof”. With the average family deductible nearing $4,000, a significant portion of healthcare services are exposed to consumer concerns about affordability. Reflecting the impact of the recession, health systems nationwide have reported sluggish volumes, particularly for elective cases, in the second half of the year. One COO recently shared, “We’re 15 percent off where we expected to be on elective cases…We didn’t see the usual pick-up in early fall, after summer vacation. I’m not sure if it’s related to the economy, or whether demand changed during COVID, but this decline has eroded any possibility of a positive margin for the quarter.” The recession hit just as providers mostly finished working through the backlog of cases delayed by COVID in 2020 and 2021. To determine whether demand declines are related to the current economic environment, or signal real shifts in care patterns, health systems are looking closely to see if the usual end-of-year swell of demand for elective care materializes, as patients max out their deductibles. But even if the demand is there, some systems are worried about being able to accommodate it: “We’ve been so short-staffed for nurses and surgical techs, we’ve had to intermittently take some ORs and units offline…If we get a big December spike in elective care, I’m not sure we’ll have the staff to accommodate it.” Facing the triple threat of sky-high costs, sluggish demand, and a worsening payer environment, the ability to accommodate this demand will be critical to securing margins as providers move into 2023.

That’s all for this week! As the leftover turkey runs low, we’re gearing up with lights and decorations for the winter holidays—the most wonderful time of the year! Thanks for taking time to read the Weekly Gist. Please let us know what you’re seeing out there, and don’t forget to share this with friends and colleagues, and encourage them to subscribe, and to listen to our daily podcast.

Most importantly, 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