January 22, 2021

The Weekly Gist: The Haul Away Joe Edition

by Chas Roades and Lisa Bielamowicz MD

Ahoy! We’re back to our regular Friday rhythm, and just in time to keep us pulling on the oars comes a new musical craze to help beat out the time: sea shanties. By now you’ve surely heard or read about the unexpected popularity of Ye Olde Timey sailor songs among the TikTok generation—already, that wee laddie from Scotland has landed a record deal. It’s just the latest surreal turn in the fever dream of quarantine, but you can’t deny the music has a certain charm. Watching this week’s inauguration festivities, it struck us that the event planners missed an obvious opportunity to include the classic shanty “Haul Away, Joe” in the program, with its appropriate chorus: “Away, haul away, we’ll haul away, Joe/Away-ho! Away, we’ll hope for better weather.”

THIS WEEK IN HEALTHCARE

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

The urgent COVID question: where are the vaccines?

One year ago this week, health officials in Washington State identified the first confirmed case of COVID-19 in the US. In the intervening twelve months, the pandemic has infected 24.3M Americans, and tragically claimed the lives of more than 404,000 of our fellow citizens. We now find ourselves at a precarious moment: the “third surge” may have plateaued and even begun to decline, and more than 17.5M doses of the highly effective Pfizer and Moderna vaccines have been administered—2.4M of those as second doses. Yet frustration is mounting with the availability of vaccines nationwide. We have talked to executives at several health systems—still the nexus for much of the vaccine administration in many parts of the country—who tell us they’re not able to meet demand for vaccination with the supply of vaccines they’ve been allocated, and that the shortage is worsening. They report that the infrastructure to administer shots is ready, but with supply at a trickle, they’re cancelling vaccination appointments and cutting short vaccine clinic hours. Many are eager to transition to a mass vaccination model, moving administration out of busy clinical settings (often still overwhelmed with COVID patients) and into the community.

As of today, the CDC website reports that 20M more doses have been distributed than have been administered. The US government has agreements in place to receive 200M doses by the end of March (not counting any additional doses that could become available if a new Johnson & Johnson vaccine is approved, as hoped). That level of supply would allow the new Biden administration to handily meet its goal of getting 100M doses administered in its first 100 days—indeed, some experts are now calling that goal too modestThe most urgent challenge now is distribution and administration, not supply—doses are not finding their way into arms. Solving that problem will require a massive logistical effort, dramatically ramping up shipments (Starbucks and Amazon both offered to lend assistance this week) and standing up hundreds of mass vaccination sites. The clock is ticking: by March the CDC expects a more contagious variant of the virus to be widespread, and although scientists say vaccines will be effective against it, new evidence is emerging that the variant may result in a higher mortality rate. We are in an urgent race to ensure that we aren’t forced to endure a deadly fourth wave in the spring.

The new administration unveils a national COVID strategy

As one of his first official actions upon taking office Wednesday, President Biden signed an executive order implementing a federal mask mandate, requiring masks to be worn by all federal employees and on all federal properties, as well as on all forms of interstate transportation. Yesterday Biden followed that action by officially naming his COVID response team, and issuing a detailed national plan for dealing with the pandemic. Describing the plan as a “full-scale wartime effort”, Biden highlighted the key components of the plan in an appearance with Dr. Anthony Fauci and COVID response coordinator Jeffrey Zients. The plan instructs federal agencies to invoke the Defense Production Act to ensure adequate supplies of critical equipment, including masks, testing equipment, and vaccine-related supplies; calls for new national guidelines to help employers make workplaces safe for workers to return to their jobs, and to make schools safe for students to return; and promises to fully fund the states’ mobilization of the National Guard to assist in the vaccine rollout. Also included in the plan is a new Pandemic Testing Board, charged with ramping up multiple forms of COVID testing; more investment in data gathering and reporting on the impact of the pandemic; and the establishment of a health equity task force, to ensure that vulnerable populations are an area of priority in pandemic response.

But Biden can only do so much by executive order. Funding for much of his ambitious COVID plan will require quick legislative action by Congress, meaning that the administration will either need to garner bipartisan support for its proposed “American Rescue Plan” legislation, or use the Senate’s budget reconciliation process to pass the bill with a simple majority (with Vice President Harris casting the tie-breaking vote). Even that may prove challenging, given skepticism among Republican (and some moderate Democratic) senators about the $1.9T price tag for the legislation. We’d anticipate intense bargaining over the relief package—with broad agreement over the approximately $415B in spending on direct COVID response, but more haggling over the size of the economic stimulus component, including the promised $1,400 per person in direct financial assistance, expanded unemployment insurance, and raising the federal minimum wage to $15 per hour. Some of the broader economic measures, along with the rest of Biden’s healthcare agenda (see graphic below) and his larger proposals to invest in rebuilding critical infrastructure, may have to wait for future legislation, as the administration prioritizes COVID relief as its first—and most important—order of business.

Optum expects to acquire 10,000 more doctors in 2021

UnitedHealth Group, both the nation’s largest health insurer and largest employer of physicians, just announced plans to continue to rapidly grow the number of physicians in its Optum division. This week CEO Dave Wichmann told investors in the company’s fourth quarter earnings call that Optum entered 2021 with over 50,000 employed or affiliated physicians, and expects to add at least 10,000 more across the year. (For context, HCA Healthcare, the largest for-profit US health system, employs or affiliates with roughly 46,000 physicians, and Kaiser Permanente employs about 23,300.) Optum is already making progress toward its ambitious goal with the announcement last week that the company is in talks to acquire Atrius Health, a 715-physician practice in the Boston area.

As was the case with other health plans, United’s health insurance business took an expected hit last quarter due to increased costs from COVID testing and treatment, combined with rebounding healthcare utilization. Optum, however, saw revenue up over 20 percent, which drove much of the company’s overall fourth quarter growth. Expect United, and other large insurers, flush with record profits from last year, to continue to expand their portfolio of care, digital and analytics assets (see also Optum’s recently announced plan to acquire Change Healthcare for $13B) as they looks to grow integrated insurance and care delivery offerings. It’s part of what we expect to be a 2021 “land grab” for strategic advantage in healthcare, as providers, health plans, and disruptors look to create comprehensive platforms to secure long-term consumer loyalty.


GRAPHIC OF THE WEEK

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

A look at the broader Biden healthcare agenda

Beyond the initiatives directly tied to COVID relief (as discussed above), President Biden’s healthcare agenda includes a broader bolstering of the protections and coverage mechanisms in the Affordable Care Act (ACA), as well as the rollback of several of the previous administration’s regulatory changes. We’ve outlined that agenda in the graphic below, as well as highlighting key members of the Biden healthcare team. While much will depend on how the COVID pandemic continues to unfold, and how successful Biden is at striking bipartisan compromises with a closely divided Congress, we’re watching closely for the answers to several key questions: (1) how aggressive can and will the new administration be in unwinding Trump-era reforms, particularly regarding Medicaid work requirements; (2) what will be the thrust of Biden’s antitrust policy in the healthcare space; (3) how hard will Biden be willing to push for expanded subsidies for individuals purchasing insurance on the ACA exchanges; (4) how will the Biden team build on the transparency measures implemented by the Trump administration; and (5) how will the new administration use payment reforms and other regulations to address racial and other disparities in healthcare? All of that preceded by one burning question that has us holding our breath: who will Biden pick to run the all-important Centers for Medicare and Medicaid Services?


THIS WEEK AT GIST—ON THE ROAD PHONE

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

Early evidence on disparities in vaccine acceptance

Although only 17 states are currently reporting data on the racial and ethnic breakdown of vaccine recipients, the early data indicate that there are significant disparities in who is getting vaccinated, with the share of Black and Latino people among vaccinees lower than their share of the total population in those states. Alarmingly, in our recent conversations with health system executives, those same disparities seem to be present among healthcare workers employed by hospitals and health systems. Anecdotally, across a half-dozen health systems we’ve spoken with in the past week, most report that they’ve had about 70 percent of their workers agree to get the first dose of the COVID-19 vaccine. However, that number looks significantly different when broken down by race and ethnicity: on average, the uptake rate among White, Asian, and Pacific Islander workers has been closer to 90-95 percent, while among Black and Latino workers, it’s been closer to 30-40 percent. Bear in mind these are employees of health systems—in many cases they’re frontline caregivers—and given their work environments you might expect them to be less hesitant to get the vaccine. That 30-40 percent uptake rate is very worrisome, in two ways: caregivers outside of hospital settings, especially home care and nursing home workers, likely include a larger number of workers hesitant to get vaccinated. And in the general population, among whom health literacy is presumably much lower than among healthcare workers, it’s precisely those populations who are at highest risk of COVID infection, hospitalization, and death. (A further complication: health systems made it easy for their employees to get the shot. With vaccines for the general population still scarce, at-risk populations will inevitably have the most difficult time getting signed up, even if they want the vaccine.) If health systems are the canary in the coal mine for vaccine hesitancy rates, we’re in for a tough challenge in getting the most vulnerable populations vaccinated in the months to come.

Is vaccine distribution a health system loyalty opportunity?

As vaccine eligibility guidelines have expanded to include adults over 65, we’ve heard from several friends and acquaintances looking for the inside scoop on getting a place in line. They’ve heard that their local health system is taking appointments, but only for established patients—do we know someone at the local system who could help them (or their mother, or their aunt with Stage IV cancer) get the shot? One acquaintance was livid that his local hospital was prioritizing established patients: “They’re just rewarding people who have already paid them money. Is that fair?” It’s likely that system was making decisions based not on prior business relationships, but rather logistics. If patients are already “in the system”, they can be contacted and scheduled through the patient portal, fill out information online, and have their doses tracked in the EMR. As health systems have been thrust into leading frontline vaccine distribution some have recognized an unprecedented opportunity to earn loyalty by connecting current and potential patients with the vaccine. Outreach must provide clear information around vaccine access and how eligibility decisions are made (consider the difference in message between “we’re offering vaccines to current patients only”, and “because established patients can be quickly scheduled and monitored, we are beginning with this group, and plan to expand quickly”). Systems’ ultimate goal should be getting vaccines to as many people as possible, as fast as possible, given supply and resource constraints.


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 Jack Hooper, CEO of Dallas-based Take Command Health, about a new type of defined contribution health benefit offering that he says has the potential to shake up employer-sponsored coverage and double the size of the individual market.

Coming up next Monday, we’ll talk with Kristen Valdes, CEO of the consumer digital health platform b.well Connected Health. With price transparency and interoperability rules going into effect this year, she believes the industry is shifting toward consumerism, and early adopters of transparency will gain patient loyalty. Make sure to listen!

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


BINGE WATCH ALERT

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

Fans of heist movies (think Ocean’s Eleven), roguish action heroes (think James Bond), and mystery thrillers (think Sherlock) will not want to miss Netflix’s latest streaming sensation, the French mini-series Lupin. Stealthily sneaking past The Queen’s Gambit and Bridgerton to become the first French-language series to top the Netflix streaming charts, Lupin’s compact, five-episode run features Omar Sy as the dashing Senegalese master thief Assane Diop, who draws his criminal inspiration from the early 20th century mystery novels of Maurice LeBlanc. Arsène Lupin, the hero of LeBlanc’s novels, is something like the French counterpart of Sherlock Holmes, but he commits, rather than solves, ingeniously constructed crimes. The subtitled Netflix series centers around the outlandish theft of Marie Antoinette’s diamond necklace from the Louvre, using that as the starting point to deliver a satisfying origin story for the Parisian immigrant Diop. Sy is magnetic as the thief, and the series both stands alone as a satisfying adventure story, and sets up a promising run of Lupin stories to come. (The show is available with subtitles or dubbed, but as always you should opt for the titles, to get the true flavor of the sharp dialogue.) A perfect streaming treat for a chilly January weekend—get in on the action!


WHAT WE’RE READING

Stuff we read this week that made us think.

Geriatrics—not just more geriatricians—will improve care for the elderly

Anyone who has navigated an elderly relative through health issues and been lucky enough to work with a geriatrician can vouch for the difference they make in the quality of life of an older person with complex medical challenges. CEO of the SCAN Health Plan and noted healthcare thinker Dr. Sachin Jain was spot on in a recent Forbes piece, in which he identified geriatrics as the “solution right under our noses” that could improve healthcare for the elderly. Geriatricians, doctors who are fellowship-trained in care for elderly adults, deploy a holistic approach that balances the treatment of illness with a deep understanding of the physical and social challenges of aging, to maximize quality of life. About 6.9K geriatricians practice in the US today, far short of the number we’d need to care for the 30 percent of elderly who could benefit from access to their care.

We clearly need more geriatricians, which will require encouraging more students to enter the field, and frankly, paying them more. Geriatricians are among the lowest-paid physicians, making an average of $190-200K per year, less than half the average salary of a cardiologist. And in 2020, geriatric medicine had the largest number of unfilled program slots of any specialty. But even if we could encourage more young doctors to enter the field, significant increases would be a decade away. What we must do now is infuse the philosophy of geriatrics—a focus on a patient’s holistic goals, and an understanding of how the treatment of illness needs to evolve across the aging process—into a broader range of primary care solutions. We should be asking more of our country’s limited supply of geriatricians to work in a consultative role with primary care teams that include a physician, nurse, social worker, and pharmacist. Combined with a payment model that rewards comprehensive outpatient management over volume-based fee-for-service incentives, geriatric-supported primary care could scale limited geriatric resources and provide better care to millions of the aging Baby Boomers who would likely benefit.

Are manly men showing a little too much…nose?

If you, like us, wanted to reach into your television this week, tap former President Bill Clinton on the shoulder and remind him to pull up his mask while attending the inauguration, a piece by New York Times science writer James Gorman says you weren’t alone, posing the question: “Is mask-slipping the new manspreading?” Just as every man on a plane or bus does not “manspread” into the middle seat, not every man’s mask slips off his nose. But whether you’re watching the inauguration or milling around the grocery store, it does seem that men are far more likely than women to be found with their mask dangling at their chins. Gorman notes it’s unlikely that the shape of men’s noses or their need for more air flow account for the mask-slipping. And, examples seem to abound across the political spectrum (see also Chief Justice John Roberts at the inauguration), so it’s not a Republican or Democratic thing. It’s a man thing. Also in this category: the dude on every airline flight we’ve taken in the past year, often outfitted in a Titleist cap and Greg Norman polo, who sports a neck gaiter plucked from his ski bag instead of a real mask (despite the large body of highly publicized evidence noting the gaiters’ inferior performance). His demeanor says, “I am paying lip service to this mask rule, but I don’t like it. Now I will pull down my gaiter and slowly nurse this whiskey and soda until we land.” Perhaps men are less afraid of catching COVID, or, as some surveys suggest, ignoring mask rules is seen as a sign of machismo. But regardless of the motivation, fellas, we need you to wear your masks. And pull them up over your nose. There’s nothing manly about a chin diaper.


And so a new year begins for the Weekly Gist! We’re looking forward to continuing to share our thoughts and observations with you, on as close to a weekly basis as our crazy calendars allow. We’re so appreciative of the many emails and messages you send our way, letting us know your feedback. Keep it coming—we love hearing from you! And if you would, please share this with a friend or colleague and encourage them to subscribe, and to listen to our daily podcast.

Most important, 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
chas@gisthealthcare.com

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