June 24, 2022

The Weekly Gist: The Hearing Voices from the Past Edition

by Chas Roades and Lisa Bielamowicz MD

Continuing to bolster its reputation as the Faustian Bargain company, offering incredible new services at a cost we’ll only come to understand later, Amazon announced this week that it’s developing a technology that will allow Alexa voice-enabled speakers to respond in the voice of specific person. In their demo for the new capability, the company showcased a child asking Alexa to read a bedtime story in the voice of their late grandmother. Based on a short audio sample, Alexa was able to reproduce speech mimicking Granny’s voice. Creepy, right? A technology for our times: evidently there are at least six people who think they can hear the ghostly voice of James Madison telling them his views on reproductive rights and concealed handguns.

THIS WEEK IN HEALTHCARE            

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

  1. Supreme Court overturns Roe v. Wade, eliminating the constitutional right to an abortion. The 6-3 decision in Dobbs v. Jackson Women’s Health Organization, challenging a Mississippi law banning most abortions after 15 weeks, overturns the nearly 50-year precedent providing a constitutional right to abortion. The opinion was little changed from a draft that was leaked last month, returning most decision making on abortion to states. At least 13 states have so called ‘trigger laws’ in place that will almost immediately make abortion illegal, and another 13 states are likely to pass similar laws.

The Gist: In over half of states, existing or new laws will likely prevent pregnant people from accessing critical and evidence-based reproductive healthcare services, including medically safe abortion, miscarriage care, pregnancy termination for severe fetal anomalies, and endangerment of the childbearing parent’s life. Patients in Texas, which passed one of the strictest abortion laws last year, have already been facing challenges obtaining prescriptions for medications for miscarriage and abortion care. Many state laws which criminalize providing the procedure put physicians and other medical providers in legal jeopardy. And as legal experts point out, most malpractice insurance doesn’t protect physicians from damages incurred from criminal charges. Moreover, most laws have been written by legislators with little or no medical expertise, leading to lack of clarity about which potentially life-threatening situations, in what circumstances, merit pregnancy termination—forcing physicians to delay lifesaving obstetric care. (Read this NEJM piece to understand what this looks like for doctors and patients in Texas today.) Regardless, today’s decision will lead to increased mortality for pregnant people and those unable to seek safe abortion care.

  1. Walgreens launches its clinical trial business. The company plans to leverage its expansive retail footprint of 9,000 stores, as well as its pharmacy business and other care delivery assets, to connect patients with late-stage pharmaceutical trials either at retail clinics, at home, or virtually. To match patients with trials, Walgreens is partnering with health data company Pluto Health, which aggregates information across medical records, insurance claims, and other sources.

The Gist: The decentralized clinical trial business has been growing since the pandemic spurred a rapid switch to remote trial participation. This announcement comes roughly a year after competitor CVS announced its entry into the clinical trial space. Most clinical research is centered in academic medical centers, which are disproportionally located in large urban areas, forcing many patients to travel long distances to participate. With large amounts of patient data and footprint spanning all fifty states, retail pharmacies are well-positioned to partner with investigators to reach patients who lack access to clinical trials today, given lack of financial resources or ability to travel.

  1. Two more hospital mergers scrapped after federal antitrust scrutiny. Steward Health Care is abandoning its proposal to sell five Utah hospitals to HCA Healthcare, and New Jersey-based RWJBarnabas Health dropped its plan to purchase New Brunswick, NJ-based Saint Peter’s Healthcare System. These pivots come just weeks after the Federal Trade Commission (FTC) filed suits to block the transactions, saying they would reduce market competition. The FTC said in a statement that these deals “should never have been proposed in the first place,” and “…the FTC will not hesitate to take action in enforcing the antitrust laws to protect healthcare consumers who are faced with unlawful hospital consolidation.”

The Gist: These latest mergers follow the fate of the proposed Lifespan and Care New England merger in Rhode Island, and the New Jersey-based Hackensack Meridian Health and Englewood Health merger, which were both abandoned after FTC challenges earlier this year. Antitrust observers find these recent challenges unsurprising, as all were horizontal, intra-market deals of the kind that commonly raise antitrust concerns. What will be more telling is whether antitrust regulators can successfully mount challenges of cross-market mergers, or vertical mergers between hospitals, physicians, and insurers.

  1. Study finds Medicare could save billions buying generic drugs from Mark Cuban’s pharmacy. An analysis published in the Annals of Internal Medicine finds that if Medicare had purchased 77 common generic drugs from Mark Cuban’s Cost-Plus Pharmacy in 2020, it would have saved $3.6B dollars. That translates to more than a third of the $9.6B Medicare spent on generic drugs that year. In January, Dallas Mavericks owner and billionaire Cuban launched the generic drug company as a transparency play, cutting out pharmacy benefit managers (PBMs), negotiating directly with manufacturers, and selling drugs at a flat 15 percent markup.

The Gist: This isn’t the first study to find that Medicare overpays for generic drugs, as it’s unable to negotiate drug prices under current law. Another recent analysis found that Costco can offer consumers lower prices than Medicare drug plans for half of the most common generic drugs. The fact that both Costco’s and Cuban’s pharmacies, neither of which accepts health insurance, can offer consumers cheaper generics is another indication of how PBMs’ perverse incentives and opaque pricing and rebate models lead to consumers being steered to higher priced drugs. We’re hopeful that the FTC’s new investigation into PBMs will shed light on their pricing practices, and create a path for lawmakers to finally address unsustainably high prescription drug prices. 

Plus–what we’ve been reading.

  1. Dozens of hospitals are inadvertently sending identifiable patient information to Facebook via website trackers. A new investigation from The Markup, a non-profit technology watchdog news organization, revealed that the websites of dozens of hospitals have an embedded tracking tool that sends identifying patient information, like patient and provider names, prescriptions, and appointment times, to Facebook. These hospitals installed the “Meta Pixel” tracker on their websites to receive analytics about advertisements on Meta-owned social media platforms, including Facebook and Instagram. Since the investigation was published late last week, several hospitals have removed the trackers and a class action lawsuit was filed against Meta Platforms, alleging that the company is invading patients’ privacy, and violating the Electronic Communications Privacy Act.

The Gist: This story reminds us of the controversy which ensued when Ascension was called out for not de-identifying patient data before sharing it with Google, when the two first partnered to consolidate and analyze personal health information. The story comes amid concerns about the ethical behavior of technology firms and increasing scrutiny of how sensitive personal data is shared and monetized. As hospitals and other providers continue to partner with “Big Tech” to reach consumers and improve data capabilities, it is incumbent on them to conduct due diligence about what information is being shared, and for what purposes, in order to safeguard patient privacy and maintain trust.


GRAPHIC OF THE WEEK

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

Younger hospital nurses leaving the profession altogether

The prevailing opinion earlier this year was that the hospital registered nurse (RN) shortage was being driven by older nurses retiring early or leaving hospital employment for less-demanding care settings during the pandemic. However, recent data shown in the graphic below paint a different picture. Hospital RNs with over ten years of tenure actually turned over at lower rates in 2021, compared to 2019. Meanwhile, the turnover rate for nurses with less tenure (who are typically younger) increased in 2021. While less-tenured nurses have always turned over at higher rates, we are seeing a new uptick in younger RNs leaving the profession.The size of the total RN workforce decreased by 1.8 percent between 2019 and 2021and the decline was twice as steep for hospital-employed RNs. Younger RNs disproportionately drove this decline: nurses under age 35 left the nursing workforce at four times the rate of those over age 50. A recent survey suggests younger RNs are less likely to feel their well-being is supported by their organization, and more likely to define themselves as “emotionally unhealthy.” To keep younger nurses in the profession, hospitals must increase the support available to them. Investments might include expanding preceptorship and mentorship programs, many of which were cut during the pandemic, and increasing behavioral health support and job flexibility.


INTERMISSION

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

RRR (Netflix)—This sprawling, over-the-top action thriller is the craziest movie you’ll see this summer. A three-and-a-half hour, Telugu-language epic, it’s got everything: muscle-bound heroes, balletic fight scenes, exotic animals, elaborate dance numbers, and a stirring anti-colonial message. One of India’s biggest-budget and highest-grossing movies of all time, it will blow you away. The perfect summer blockbuster.


THIS WEEK AT GIST—ON THE ROAD

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

Is healthcare still recession-proof?

A recent conversation with a health system CFO made us realize that a long-standing nugget of received healthcare wisdom might no longer be true. For as long as we can remember, economic observers have said that healthcare is “recession-proof”—one of those sectors of the economy that suffers least during a downturn. The idea was that people still get sick, and still need care, no matter how bad the economy gets. But this CFO shared that her system was beginning to see a slowdown in demand for non-emergent surgeries, and more sluggish outpatient volume generally. Her hypothesis: rising inflation is putting increased pressure on household budgets, and is beginning to force consumers into tougher tradeoffs between paying for daily necessities and seeking care for health concerns. This is having a more pronounced effect than during past recessions, because we’ve shifted so much financial risk onto individuals via high deductibles and cost-sharing over the past decade. There’s a double whammy for providers: because the current inflation problems are happening in the first half of year, most consumers are nowhere near hitting their deductibles, leading this CFO to forecast softer volumes for at least the next several months, until the usual “post-deductible spending spree” kicks in. Combined with the tight labor market, which has increased operating costs between 15 and 20 percent, this inflation-driven drop in demand may have hospitals and health systems experiencing their own dose of recession—contrary to the old chestnut.


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 Nigel Ohrenstein, president of digital musculoskeletal care startup Kaia Health. He estimates that in the future, 80 percent of physical therapy may be done virtually.

This month, two groups of hospital-employed physicians in Oregon filed to join a union. On next Monday’s episode we’ll hear from some of those doctors, as well as Mollie Skov-Ortega, MD, president of the hospitalist union at PeaceHealth Sacred Heart Medical Center in Eugene, OR.

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


That’s all for now. We’ll be taking next week off, but will return with a new Weekly Gist on Friday, July 8th. Thanks for taking the time to read our work, and for sharing your suggestions with us. We love hearing from you! Don’t forget to forward this to a friend or colleague, and encourage them to subscribe, and to check out our daily podcast.

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