February 12, 2021

The Weekly Gist: The Getting Your Goat Edition

by Chas Roades and Lisa Bielamowicz MD

By now you’ve seen the infamous “lawyer cat video”— sublime moments of confusion during an online court proceeding in Texas, in which one of the participants was unable to turn off a Zoom filter, leading him to utter the timeless remark, “I’m here live. I’m not a cat.” Priceless, but you may be left wondering, Why are my Zoom meetings never that fun? Well, Cronkshaw Fold Farm in Lancashire, England has you covered. For just £5—about $7—the family farm will dial into your team’s next online meeting…with a live goat. You can book a drop-in visit from a variety of barnyard guests: Lulu (“the floppiest ears”), Elizabeth (“frequent bouts of the hiccups”), Sebastian (“a genuine interest in what you have to say”), and several other adorable goats. Over the last year, the farm’s goats have participated in more than 10,000 virtual meetings. So, go ahead—get your goat on!

(Could life ever be sane again?)


THIS WEEK IN HEALTHCARE

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

Reversing course on Trump-era healthcare policy

Ahead of a Supreme Court hearing in March to consider the legality of imposing work requirements as a condition of gaining Medicaid coverage, the Centers for Medicare and Medicaid Services (CMS) were expected to inform states on Friday of plans to rescind the controversial Trump administration policy. Under the previous administration, ten states had applied for and were approved to use waiver authority to impose work requirements on Medicaid enrollees, and several other states were in the process of submitting applications. Critics (including us) have long held that such requirements, while nominally intended to introduce an element of “personal responsibility” to the safety-net coverage program for low-income Americans, actually serve to hinder access to care, and jeopardize the health status of already vulnerable populations; in addition, the added expense of program infrastructure often exceeds anticipated cost savings. The policy was a favored project of former CMS administrator Seema Verma, who helped craft a similar program for the state of Indiana before joining the Trump administration. Among states granted waiver authority to impose work requirements, only Arkansas ever fully implemented the policy, before the legality of the waivers was challenged successfully in lower courts.

The Biden administration’s recission of work requirements is part of a broader reversal of Trump-era healthcare policies. This week the Justice Department notified the Supreme Court that it was switching sides in the closely watched case questioning the constitutionality of the Affordable Care Act (ACA), although the court has already heard the case and is expected to rule this spring. Starting Monday, the Biden team will also reopen the federal insurance marketplace for a special enrollment period, bolstering funding for outreach to ensure those eligible are aware of coverage options. And as part of its proposed COVID relief legislation, the administration plans to increase subsidies to help individuals buy coverage on the exchanges, and to increase funding to support state Medicaid programs—policies that got a boost this week from a broad coalition of healthcare industry groups, including health plans, doctors, and hospitals. As the administration rounds out its health policy team, we’d expect a continued focus on strengthening the core pillars of the ACA, along with a greater focus on ensuring health equity and addressing disparities. Meanwhile, two key positions remain unfilled: CMS administrator and commissioner of the Food and Drug Administration (FDA). These slots will likely remain open until the looming confirmation battle over Biden’s nominee for Secretary of Health and Human Services (HHS), California Attorney General Xavier Becerra, has been settled.

Oscar is going public

Health insurance startup Oscar Health filed for its IPO at the end of last week. One of the earliest of a crop of new entrants in the insurance market, Oscar has raised a total of $1.6B since its debut in 2012. The insurer currently serves 529,000 members—almost double the number it served in 2019—primarily in the individual and small group markets across 18 states, with its largest presence in Florida, Texas, and California. (Membership in New York, where the company got its start, declined from 51K to 39K members in 2020.) Oscar started selling Medicare Advantage (MA) plans last year, but has captured fewer than 2,000 lives, demonstrating how difficult it is for newcomers to break into the competitive MA market, and raising questions about how well the Oscar value proposition, built on a technology-driven member experience, translates to the senior population. According to the filing, Oscar plans to expand into additional markets and segments, and to establish partnerships to monetize its consumer-friendly technology and administrative services and care management platform. In addition to supporting the insurance business, Oscar seems to be betting that its tech platform will be leveraged by a variety of partners—which currently include Cleveland Clinic, Montefiore Health System, Cigna, and Health First. It’s unclear whether future profitability will come from Oscar’s data and technology platform, or its core insurance business: despite consistent growth and impressive technology, Oscar has yet to turn a profit, losing $407M in 2020, a year when many insurers saw record profits.

Large health systems band together on data research

Fourteen of the nation’s largest health systems announced this week that they have joined together to form a new, for-profit data company aimed at aggregating and mining their clinical data. Called Truveta, the company will draw on the de-identified health records of millions of patients from thousands of care sites across 40 states, allowing researchers, physicians, biopharma companies, and others to draw insights aimed at “improving the lives of those they serve.” Health system participants include the multi-state Catholic systems CommonSpirit Health, Trinity Health, Providence, and Bon Secours Mercy, the for-profit system Tenet Healthcare, and a number of regional systems. The new company will be led by former Microsoft executive Terry Myerson, who has been working on the project since March of last year. As large technology companies like Amazon and Google continue to build out healthcare offerings, and national insurers like UnitedHealth Group and Aetna continue to grow their analytical capabilities based on physician, hospital, and pharmacy encounters, it’s surprising that hospital systems are only now mobilizing in a concerted way to monetize the clinical data they generate. Like Civica, an earlier health system collaboration around pharmaceutical manufacturing, Truveta’s launch signals that large national and regional systems are waking up to the value of scale they’ve amassed over time, moving beyond pricing leverage to capture other benefits from the size of their clinical operations—and exploring non-merger partnerships to create value from collaboration. There will inevitably be questions about how patient data is used by Truveta and its eventual customers, but we believe the venture holds real promise for harnessing the power of massive clinical datasets to drive improvement in how care is delivered.


GRAPHIC OF THE WEEK

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

Bolstering coverage availability with consumer education

Starting next week, millions of uninsured Americans will have the opportunity to sign up for coverage on the federal insurance marketplace, the result of President Biden’s executive order to create a 90-day special enrollment period. The graphic below highlights the potential impact of this enrollment period on the uninsured population. According to a Kaiser Family Foundation analysisof the nearly 15M uninsured who are marketplace-eligible, nearly 9M qualify for free or subsidized coverage. Enrollment of these individuals will come with added challenges, as they tend to be less educated, younger, more rural, and less likely to speak English, as compared to the general population. An Urban Institute survey found almost half of uninsured individuals are unfamiliar with marketplace coverage options, and nearly two-thirds lack an understanding of available financial assistanceThe federal government is dedicating $50M to advertise the special enrollment period, to assist with outreach and education. Given the population most likely to have lost insurance due to the COVID pandemic, this funding will be critical to making sure eligible people take advantage or free or low-cost coverage.


THIS WEEK AT GIST—ON THE ROAD PHONE

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

Stop thinking of telemedicine as a “substitute” for the office visit

“I don’t think we have good enough information to show how we should be deploying telemedicine,” a physician leader recently told us. “If we can’t show that a virtual visit can adequately substitute for an in-person visit, then we should be focusing on making sure patients know it’s safe to come in.” It struck us that viewing telemedicine as a direct substitute for an office visit was a narrow and antiquated way to think about virtual care. Moreover, the argument that telemedicine visits are potentially cost-increasing if they are “additive” to other care interactions, rather than “substitutive”, is rooted in fee-for-service payment: more patient-provider interactions equals more billable visits, and with more visits, we run the risk of increasing costs. Telemedicine (both video and phone visits) likely taps into pent-up demand for access by patients who would otherwise not seek care. Some patients could be aided by more frequent, brief encounters; this is considered a failure only when viewed through the lens of fee-for-service payment. (Honestly, with primary care accounting for less than 6 percent of total healthcare spending, it’s hard to argue that additional telemedicine visits will be responsible for supercharging the cost of care.) Of course, there are many clinical situations in which in-person interaction—to perform a physical exam, measure vitals, observe a patient—is fundamental. Patients know this, and understand that sometimes they’ll need to be seen in person. But hopefully that next encounter will be more efficient, having already covered the basics. The ideal care model will look different for different patients, and different kinds of clinical problems—but will likely be a blend of both virtual and in-person interactions, maximizing communication, information-gathering, and patient convenience.

Paying due attention to the “why” of strategy

We spend a lot of our time helping health system executives craft and communicate enterprise-level strategy: entering new markets or businesses, developing new services, responding to competitive threats, exploring partnership opportunities. Strategy is about the “what” and “when”—what moves are we going to make, and when is the right time to make them? Answering those questions requires an understanding of industry and market forces, organizational capabilities, and consumer needs. But there’s another important component that often goes missing in the rush to get to the “how” of strategy execution: the “why”. Yet understanding why we’re pursuing one path and not another is critical for aligning stakeholders: physicians, operators, and (importantly) the board. Joan Didion famously wrote that “we tell ourselves stories in order to live”, and we’d agree; the “why” is about storytelling. What’s the strategic narrative, or story, that frames our intended actions? Making sure that everyone involved—including our patients and consumers—has a clear understanding of why we’re opening a new facility, or launching a new service, or entering into a new partnership, is a key to success. It’s about sharing the vision of our desired role as a system, and the part we see ourselves playing in improving healthcare. We’re sometimes criticized for spending so much time on “framing” and drawing “pretty graphics”, but we’ve come to believe that the ability to succinctly and compellingly describe the “why” of strategy is as important as coming up with the vision in the first place. And then, of course, delivering on the “why”—a job made easier if all involved are clear on just what it is.


THIS WEEK AT GIST—ON THE PODCAST

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

On last Monday’s episode, we heard from Dr. Mark Prather, CEO and co-founder of Denver-based DispatchHealth, which is expanding its hospital at home program through a new partnership with Humana.

Coming up on Tuesday’s episode we’ll hear from Michael Topchik, national leader for rural health at healthcare consulting firm The Chartis Group. Although the pandemic has hit struggling rural hospitals hard, he’s optimistic the Biden Administration’s focus on health equity could lead to new payment models that allow rural hospitals to focus more on emergency and outpatient care. Make sure to tune in, you won’t want to miss it!

Note to listeners: The Gist Healthcare Daily podcast will be taking a break Monday, February 15th, and will return Tuesday, February 16th. Alex wishes everyone a safe and happy holiday weekend!

[Subscribe on Apple, Spotify, Google, or wherever fine podcasts are available.]


ON THE GIST TURNTABLE

Give this a spin—you might like it.

Imagine if Joni Mitchell produced a cover album of Fleetwood Mac breakup songs that were really about climate change—that’s what indie folkster Tamara Lindeman, who fronts the Canadian band The Weather Station, has delivered on her latest release. Lindeman is a former child actress turned singer-songwriter whose musical career over the past decade has seen her transform from a willowy-voiced folkster to a fully formed bandleader, as well as an outsized voice in the fight against climate change. The new record, Ignorance, is the Lindeman’s strongest work to date, with a complete, mid-80s style pop group (two drums, strings, guitars, flute, bass) surrounding her soaring vocals with something approaching a soft-rock, Laurel Canyon sound. Lindeman’s lyrics are at once personal and universal, with the loss of the planet mirrored in, and constantly measured against, her anguish over the loss of love. In one song, Lindeman likens a songbird’s struggle (“Its small chest rising and falling/As it sang the same song…over the traffic and the noise”) to her own weariness in a relationship (“Is it alright if I don’t wanna sing tonight?/I know you are tired of seeing tears in my eyes/But are there not good reasons to cry?”). In other hands, this kind of thing could sound mawkish, but Lindeman finds just the right balance on track after track. Her soft voice and subtle lyrics let her wrap a message of anguish about the natural world in hauntingly personal detail—a heartbreak album for the planet. Best tracks: “Robber”; “Parking Lot”; “Atlantic”.


GIST IN THE NEWS

We said it, they quoted it.

Major Hospitals Form Company to Capitalize on Their Troves of Health Data
The Wall Street Journal; February 11, 2021

“Pulling together in-depth data from so many hospital owners makes it even more powerful for research, and as a business opportunity, said Chas Roades, chief executive of Gist Healthcare, a consulting firm not involved in Truveta. ‘It’s a really valuable data asset,’ he said. ‘These systems are moving to monetize that asset in a way that is going to be very beneficial for them.’”


WHAT WE’RE READING

Stuff we read this week that made us think.

Time to stop the hygiene theater

The billboards along the interstate near our houses still flash, “Wash your hands and wear a mask to stop the spread of COVID”. As we learn more about the virus, it’s increasingly clear that those two actions are not equivalent. A new piece in the Atlantic makes a strong argument that our obsessive surface cleaning and handwashing is largely “hygiene theater”, doing very little to stop the spread of the disease. COVID-19 is spread almost exclusively by aerosol transmission, breathing in virus particles emitted from an infected person that remain suspended in the air. Spread by fomites, or virus particles lingering on surfaces, is responsible for little-to-no documented transmission, despite numerous studies (of varying quality) showing the virus can “live” on surfaces for up to a month. The author concedes it’s not impossible, but the attention to surfaces is misdirected: “If somebody with COVID-19 sneezes three times onto a little spot on a cold steel table, and you rub your hand around in the snot for a bit and immediately lick your fingers, that disgusting act may well result in you infecting yourself. But the threat of such unbelievably stupid behavior at a mass level shouldn’t warrant a multibillion-dollar war on fomites.”

Our obsession with surface cleaning has harmful consequences. The billions of dollars spent on regimented cleaning could be redirected toward better uses. Schools are still waiting for funding to safely reopen. The money devoted to surface cleaning should instead be spent improving ventilation and making sure all teachers and students have high-quality masks. All of the harsh cleaning chemicals we are inhaling may be harming our health. And most importantly, surface cleaning creates a false sense of security, sending a message that it’s OK to dine maskless, indoors, at a restaurant because they’re lowering risk by thoroughly cleaning the menus and tables. As we navigate our way to the end of the pandemic, we need to reinforce the point that masks, ventilation and vaccines, not Lysol and Clorox, are our best weapons against the virus.


We made it through another week—and a long weekend awaits! (We’ll be enjoying a delayed Presidents’ Day break next Friday, but will be back the following week.) Thanks for taking the time to read the Weekly Gist, and for sending your feedback and suggestions—we love hearing from you! We hope you’ll share this with a friend or colleague, and encourage them to subscribe, and to listen to our daily podcast.

As always, please 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
chas@gisthealthcare.com

Lisa Bielamowicz, MD
Co-Founder and President
lisa@gisthealthcare.com