October 1, 2021

The Weekly Gist: The Finstas of Fellow Kids Edition

by Chas Roades and Lisa Bielamowicz MD

The older we get, the more we appreciate the wisdom of elders, and the less we understand “kids these days”. But still, you’ve got to make the effort. In this week’s episode of Tales from the Gerontocracy, we bring you the cringeworthy moment during a Senate hearing yesterday when 75-year-old Sen. Richard Blumenthal (D-CT), grilling a Facebook executive, demanded, “Will you commit to ending Finsta?” Welcome to life as a meme, Senator. The video clip of his question has been viewed more than 6M times in the last 24 hours, presumably mostly by smirking Gen Z-sters, who (eyeroll) know that “finsta” is just slang for an Instagram account made under a fake name to avoid parental scrutiny, not, as Blumenthal suggested, “one of [Facebook’s] products or services”. Don’t worry, Senator. We’ve all had our share of “How do you do, fellow kids?” moments…it’s hard out there for an old dog trying to learn new tricks. Next time, though, maybe ask your (surely 20-something) staffers first?


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

A new antiviral pill shows promise, as do vaccine mandates

Two pieces of hopeful news on the COVID front this week. First, pharmaceutical manufacturer Merck announced this morning that molnupiravir, the oral antiviral drug it developed along with Ridgeback Biotherapeutics, reduced hospitalizations among newly diagnosed COVID patients by 50 percent. A five-day course of the drug was so successful in Merck’s clinical study that an independent monitoring group recommended halting the study and submitting the pill to the Food and Drug Administration (FDA) for emergency use authorization. Molnupiravir is activated by metabolism, and upon entering human cells, is converted into RNA-like building blocks, causing mutations in the COVID virus’s RNA genome and interfering with its replication. For that reason, the drug is unlikely to be prescribed during pregnancy, but otherwise the therapy seems to hold great promise in adding to the limited armamentarium available to fight the pandemic. One possible concern: the drug’s price tag. The federal government has agreed to purchase 1.7M courses of the drug at $700 per course, and with most insurance companies having returned to normal cost-sharing for COVID treatments, the drug may be out of reach for some patients. Still, a major clinical development to be celebrated, and more to come as Merck’s drug is vetted by the FDA.

At $20 to $40 per dose, with costs fully absorbed by the federal government, and remarkable effectiveness at preventing severe disease, hospitalizations, and deaths, vaccines remain far and away our best frontline weapon for fighting the COVID pandemic. Promising, then, that the much-debated vaccine mandates have begun to demonstrate success in increasing vaccination rates, even among those who have thus far resisted getting the shot. Despite concerns about massive staffing shortages among hospitals resulting from the implementation of its mandate, the state of New York found that 92 percent of healthcare workers had been vaccinated by Monday, when the mandate went into effect. That was a 10-percentage-point increase from a week earlier, holding promise that the Biden administration’s planned federal mandate for healthcare workers could have the desired effect. California’s mandate for healthcare workers went into effect yesterday, and was credited with boosting vaccination rates to 90 percent at many of the state’s health systems. Among private employers considering mandates, the experience of United Airlines may also be instructive: its employee mandate led to the vaccination of more than 99 percent of its workers, resulting in the termination of only 700 of its 67,000 employees. Of course, everyone prefers carrots to sticks, but sweepstakes and bonuses have only gotten so far in encouraging people to get vaccinated—now it appears mandates have a useful role to play as well. With 56 percent of the population fully vaccinated, the US now ranks 43rd among nations, just ahead of Saudi Arabia and far behind most of Europe. In the next few days we’ll reach the grim milestone of 700,000 COVID deaths in this country—anything that helps stop that number from growing further should be welcome news.

Setting the rules for settling “surprise bills”

On Thursday the Department of Health and Human Services (HHS), along with other federal agencies, released the long-awaited second half of its proposed regulations implementing the No Surprises Act, passed by Congress at the end of last year, which bans “surprise billing” of patients who unsuspectingly receive care from out-of-network providers. The interim final rule, which will take effect on January 1st after a comment and review period, lays out a process for addressing disputed patient bills, first through a 30-day “open negotiation” between the patient’s insurer and the out-of-network provider, and then through a federally-managed arbitration process. Of most interest to insurers and providers who have lobbied fiercely for months to ensure a favorable interpretation of the law, the new regulation specifies that the outsider arbitrator, to be agreed upon by both parties, must begin with the presumption that the median in-network rate for services in the local market is the correct one. The arbitrator can then modify that price based on the specific circumstances of the case. That method was broadly favored by insurers, and AHIP strongly endorsed the proposed approach, saying in a press release that “this is the right approach to encourage hospitals, healthcare providers, and health insurance providers to work together and negotiate in good faith.” Predictably, the hospital lobby felt otherwise; the American Hospital Association reacted by calling the rule “a windfall for insurers”, saying that it “unfairly favors insurers to the detriment of hospitals and physicians who actually care for patients.” The ultimate winners here are patients, who will gain important new protections against the potentially crippling financial implications of surprise billing. We’d agree with HHS Secretary Xavier Becerra, who told the New York Times that the new rule would “[take] patients out of the middle of the food fight,” and provide “a clear road map on how you can resolve that food fight between the provider and the insurer.” It’s about time. Still unresolved: the high cost of out-of-network ambulance services, left out of the No Surprises Act altogether. Let’s hope Congress circles back to address that issue soon.

Walmart partners with Epic for its health technology platform

This week, retail giant Walmart announced a partnership with Epic, the country’s most widely-used electronic health record (EHR) system, as the technology platform to support its health and wellness businesses. Epic will first be installed in four Walmart Health Center clinics slated to open in Florida early next year. The company currently operates 20 health centers in Georgia, Arkansas and the Chicago area, offering an expanded range of services including comprehensive primary care, behavioral health, dental, hearing and vision care, as well as labs and other diagnostics. Skeptics have noted that Walmart has fallen behind in its ambitious plans to broadly roll out the expanded clinics, the first of which opened in an Atlanta exurb in 2019. The partnership with Epic, which is used by more than 2,000 hospitals nationwide, signals that Walmart is serious about expanding its role as a healthcare provider—and sees opportunity in being able to share information and connect with health systems and doctors’ offices. However, the vision of a “unified health record across care settings, geographies and multiple sources of health data” outlined by Walmart’s EVP of health and wellness may be more difficult to achieve than expected, if the experience of health systems, who have been stymied by upgrades and version mismatches in their quest for a unified EHR, is any indication. Welcome, Walmart, to the wonderful world of EHRs—if you thought healthcare was complicated, just wait until you begin your first Epic install!


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

An unsettling start to the school year

As a long hoped-for sign of the “return to normal”, most children went back to in-person learning this fall. And with the patchwork of COVID safety protocols and masking policies across school districts, classrooms became a learning lab for scientists studying the efficacy of masking and other precautions. Unsurprisingly, getting a bunch of unvaccinated kids back together caused a surge in pediatric COVID cases. But recent Centers for Disease Control and Prevention (CDC) data from 500 counties demonstrate just how effective mask mandates have been at mitigating outbreaks. The graphic below shows that cases in counties without school mask mandates increased at nearly three times the rate of those with mask mandates. In the five-week period spanning the start of the school year, cases in counties without a mask mandate rose by 62.6 cases per 100K children, while cases in counties with a mask mandate rose by only 23.8 per 100K. COVID outbreaks are incredibly disruptive to learning; according to a recent KFF survey, nearly a quarter of parents report their child has already had to quarantine at home this school year following a possible COVID exposure. Even once vaccines are approved for children under 12, recent data suggest that a majority of parents will be hesitant to vaccinate their child. Just over half of 12- to 17-year-olds have received at least one dose of the vaccine so far, and only a third of parents of 5- to 11-year-olds plan to vaccinate their child right away, once the shot is approved. Many want more information, or are worried about side effects—concerns that will best be assuaged by their pediatricians and other trusted sources of unbiased information.


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

Will choosing a “white coat CEO” advance physician alignment?

We recently got a call from a health system board chair seeking our perspective on the system’s ongoing search for a new CEO. At the top of his list: trying to understand how important it will be for the next CEO to be a physician. “We’ve never had a doctor in the role,” he mused. “But now we employ hundreds of doctors. And you’d have to imagine that having a physician as CEO would help with physician alignment.” While choosing a physician CEO brings great signal value to the medical staff, we cautioned that it’s far from a panacea. Of course, there are advantages in having walked in a frontline clinician’s shoes, being able to personally identify with their challenges and speak their language. But over the years, working with hundreds of health system CEOs, we’ve found that the most important characteristic of a CEO who will advance physician strategy is the desire to form strong personal relationships with doctors and draw on their counsel. Does the CEO build a “kitchen cabinet” of physician leaders whom he can consult? Are physicians viewed as something to be managed, a problem to solve, or seen as true partners in strategy? Even more simply, does she like spending time with physicians, or groan every time a meeting with doctors pops up on the calendar? We’ve seen many non-physician CEOs excel at building strong, strategic ties with doctors, and some physician executives, who become jaded by never-ending physician alignment struggles, fail to advance partnerships with their colleagues. One retiring physician CEO, reflecting on his replacement by a nonclinical executive, summed it up well: “I have a feeling he’ll do well with our doctors. He counts several physicians among his closest friends, which is a great sign.”


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

On last Monday’s episode, Dr. Gregg Miller, Chief Medical Officer of hospital staffing company Vituity, says he expects sicker patients to be the “new normal” for emergency departments. As lower-acuity patients have adjusted to seeking telehealth as a first stop for care, he says hospitals must rethink how to staff EDs to care for a more chronically ill patient population.

Coming up next Monday, we’ll hear from Dr. Jeremy Cauwels, Sanford Health’s Chief Physician. The Sioux Falls, SD-based health system is building a virtual care center to consolidate its telemedicine offerings and deliver virtual care at scale.

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Give this a spin, you might like it.

Happy Rocktober to those who celebrate! We’re kicking it off with a new release from a band that combines two guilty pleasures: metal and goth. If you secretly love galloping bass, two-guitar attacks, and machine-gun drum fills, but also long to paint your nails and lips black and wallow in the morose maunderings of The Cure, have we got the band for you. Unto Others, a Portland, OR-based outfit formerly known as Idle Hands, is out with their sophomore album Strength, which sounds for all the world like a metal album made by Robert Smith. Lead singer Gabriel Franco is a vocal dead-ringer for Dave Gahan from Depeche Mode, and several of the tracks here would fit right in with some of the heavier work of DM or similarly darkwave bands of the 80s. But instead of noodling synths between verses, Unto Others substitutes in the kind of riffage that will have you throwing up the horns and banging your head. The subject matter is suitably introspective and downcast—alienation, disaffection, nihilism—without wandering into Morrissey-esque despair; instead of hanging their heads, this band shakes their fists. One strange choice: the inclusion of a Pat Benetar cover (“Hell is for Children”), repositioned as a Sisters of Mercy-style anthem—but somehow even that works. As you start planning your Halloween get-up, consider hauling out the Doc Martens, black jeans, and black eyeliner, and check out this record while you do—a perfect start to October. Best tracks: “Downtown”; “When Will God’s Work Be Done”; “Strength”.


Stuff we read this week that made us think.

Did a ransomware attack result in the death of an Alabama baby?

A wrenching piece in the Wall Street Journal this week makes it tragically clear that cyberattacks on healthcare facilities can have fatal consequences for patients, in addition to costing hospitals millions of dollars in ransom paid, and operations disrupted. The article covers an ongoing court case in Alabama, stemming from the death of an infant delivered at Springhill Medical Center in Mobile in the midst of a ransomware attack in the hospital in 2019. Refusing to pay the ransom demanded from the hackers, likely the Russian “Ryuk” group, the standalone, family-owned hospital stayed open during the attack, attempting to maintain full patient care services despite losing access to most networked systems—including centralized fetal monitors on the labor and delivery unit. According to court documents, overwhelmed, often inexperienced nurses scrambled to keep up with data from paper strips from bedside monitors, hand-recording vital signs, and deal with an unfamiliar “analog” care environment. When Teiranni Kidd was admitted for delivery of her daughter, neither patients nor the public were aware of the ransomware attack. Her baby was born with the umbilical cord wrapped tightly around her neck, suffering severe brain damage and ultimately dying nine months later. Records indicate that the bedside monitor registered abnormal vitals an hour before delivery, and subsequent text messages between the independent obstetrician and hospital nurses indicate that doctor would have opted to perform a C-section had she known about the problem at the time. While the court case is still ongoing, the situation resulted in a catastrophic outcome—one that might be the nation’s first cybercrime-related patient fatality. Hundreds of hospitals and other healthcare facilities have been targeted by hackers, and even if the Kidd case is determined not to have been impacted by the system outage, ongoing ransomware attacks will inevitably result in patient harm—exactly the outcome hackers are banking on when they make their threats. It’s worth taking the time to read the piece, and considering whether we should be responding more aggressively to healthcare cybercrime on a national level to protect citizens’ access to safe care.

Here’s how your crazy uncle got his ivermectin prescription

Ever wonder how hundreds of thousands of Americans obtained prescriptions for hydroxychloroquine, ivermectin, and other medications deemed “highly not recommended” by the CDC, FDA, and World Health Organization for the treatment of COVID-19? This fascinating piece from online investigative journalism outfit The Intercept untangles a complex web of right-wing doctors, telemedicine startups and pharmacy companies to reveal how providers made an estimated $15M delivering consultations and prescriptions to nearly 300,000 patients for medications hawked as COVID cures. An anonymous hacker provided The Intercept data from telemedicine start-up Cadence Health and online pharmacy Ravkoo (both of which the hacker noted were “hilariously easy” to hack) revealing a huge volume of prescriptions from physicians who are members of America’s Frontline Doctors (AFLDS), an organization founded in May 2020 to organize “extremely pro-Trump” doctors to express their support for the administration’s pandemic policies. (AFLDS’s founder, physician Simone Gold, was arrested and charged after participating in the January 6th attacks on the US Capitol.)

AFLDS enthusiastically supports dubious COVID treatments and offers training to member doctors. Grabbing patients with tag lines like, “Find out how to obtain prescription medication for COVID-19 with our AFLDS-trained physicians in three easy steps”, the group’s website referred over a quarter million patients to telemedicine platform SpeakWithAnMD.com, powered by Cadence Health. 72,000 patients paid $90 for consultations with AFLDS-trained physicians, who made $6.7M off the visits alone. 340,000 resulting prescriptions were filled by Ravkoo, the vast majority for debunked COVID treatments, accounting for in $8.5M in drug costs. Pressure has grown for state medical boards to suspend or revoke licenses of “superspreader” doctors responsible for disseminating misinformation about the COVID virus, vaccines and treatments via social media. The investigation by The Intercept reveals another layer of danger to patients, where hundreds of doctors, motivated by ideology and profit, can utilize virtual care start-ups to skirt the boundaries of practice regulation, and deliver dubious advice and treatment to desperate patients.

That’s all for this week! Thanks for taking time to read the Weekly Gist, and for sharing your comments and suggestions. We’ll be off next week, busy with one of our members at an offsite retreat, but will look forward to seeing you here again soon. In the meantime, please remember to share this week’s edition with a friend or colleague, and encourage them to subscribe, and to listen to our daily podcast.

And as always, please let us know if there’s anything we can do to assist 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