October 21, 2022

The Weekly Gist: The Lettuce Move Forward Edition

by Chas Roades and Lisa Bielamowicz MD

By resigning yesterday, Prime Minister Liz Truss secured her legacy as one of the shortest-tenured heads of government in British history, having nearly crashed the UK economy and completely upended the traditional decorum of her parliamentary party. Also, she got beat by a head of lettuce. The British tabloid Daily Star was running a widely followed online stunt, openly speculating whether Truss would outlast a head of lettuce sitting on a desk, or whether she’d resign before the vegetable began to rot. Lettuce 1, Truss 0. The British press being what they are, the headlines were coming thick and fast: “Lettuce Liz on Life Support”; “Lettuce Rejoice”; and “Salad Daze” were among the best. Now that Truss is out, there’s no word on whether the famously meat-free King Charles III will ask the leafy victor to form a new government, or simply instruct it to get in his belly. England awaits.


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

  1. Over-the-counter hearing aids begin hitting store shelves. As of this week, US consumers can purchase hearing aids for mild to moderate hearing loss without a prescription, thanks to a Food and Drug Administration (FDA) rule issued in August. For the 15 percent of adults reporting at least some difficulty hearing, this change could lower their cost of obtaining a pair of hearing aids by up to $3,000, after factoring in clinician visits, hearing tests, and fittings. The change does not apply to more specialized devices needed by those experiencing severe hearing loss, which remain available only by prescription.

The Gist: As retailers rush to offer the best hearing aid deals to capture this new market, millions of individuals availing themselves of this new opportunity will be navigating the purchase on their own, despite calls from hearing specialists to seek professional testing and assistance. That’s because this new rule is a regulatory reform workaround, as Congress continues to refuse to expand Medicare coverage to include hearing benefits. But, importantly, it’s also part of a broader movement to make healthcare more accessible and affordable by reducing unnecessary prescription barriers—and with a new approval request filed with the FDA, over-the-counter birth control pills may be next.

  1. Babylon Health announces planned sale of California physician group. In a press release, London-based telemedicine provider Babylon Health said it intends to divest Meritage Medical Network, its 1,800-physician independent practice association located in Northern and Central California. Babylon claims the sale will allow it to better focus on its core business model of digital-first, value-based care contracts. After going public last year at $4.2B, Babylon’s valuation has fallen over 95 percent.

The Gist: Yet another highly touted healthcare startup with digital-first “solutions” has announced a massive pullback in its care footprint. As we wrote about Bright Health last week, these companies have failed to meet investor demands, and must now shutter services or sell assets to buy time to prove their core business model can actually turn a profit. In Babylon’s case, integrating established physician practices into a digital-first, value-based care model was always going to be costly, challenging and time-consuming—too slow to deliver the returns demanded by an increasingly difficult investor market.

  1. Report finds majority of health systems now following price transparency rules. After a Centers for Medicare and Medicaid Services (CMS) rule requiring hospitals to publish clear, accessible pricing information went into effect in January 2021, most hospitals were slow to comply, in part due to weak CMS enforcement. However, a recent scorecard developed by Turquoise Health, a startup that works with providers and payers to provide clear pricing information for healthcare consumers, estimates 65 percent of US hospitals have now published their prices in compliance with the regulation. The report also found that 80 payers have published negotiated rates, following a tandem rule that went into effect earlier this year requiring price transparency from insurers.

The Gist: It’s encouraging to see this progress from health systems, after many initially dragged their feet. So far, only two hospitals have received fines for noncompliance. In January, CMS raised the maximum penalty to $2M per hospital per year, which could add up to a sizeable penalty for a large system, but it remains questionable whether the elevated penalties are yet stiff enough to drive compliance and investment in needed resources and technology. Despite this, most payers and providers are now following the letter of the regulation. The challenge now is to embrace the spirit of the rule, which is to make hospital services more “shoppable” for consumers. Just because some pricing information is available, doesn’t mean consumers will know where to find it, how to interpret it, how to act on it. This is only the first step in a long journey.

Pluswhat we’ve been reading.

  1. The alarming way doctors approach caring for the disabled. In a concerning New York Times article, reporter Gina Kolata relates the findings of a recent Health Affairs study that convened focus groups of physicians to anonymously discuss the ways they provide—or too often, don’t provide—care to disabled patients. Many admitted to avoiding seeing patients in wheelchairs and complained about having to provide accommodations to speech-impaired patients, citing the high costs of adapting their clinic operations while dealing with disruptions to workflow. People with disabilities interviewed for the article, including Harvard professor of medicine Dr. Lisa Iezzoni, who ran the study, found its results confirmed impressions of widespread bias against the disabled, which is pervasive across healthcare.

The Gist: Reducing disparities in access and quality of care for disabled people often receives less attention than reducing economic, racial, and gender disparities. What’s revealing about this piece is how these disparities among disabled patients manifest, ranging from personal biases (physicians not wanting or knowing how to care for certain groups of disabled people) to structural challenges (constraints of time, money, and facilities needed for proper care). However, for disabled patients, these factors result in an often substandard and unacceptable healthcare experience, which must be addressed head-on by physician and health system leaders.


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

Still a long way away from real “value” 

The belief that healthcare should, and would, transition from “volume to value” was a key pillar of the Affordable Care Act (ACA). However, with more than a decade of experience and data to consider, there is little indication that either Medicare or the healthcare industry at large has meaningfully shifted away from fee-for-service payment. Using data from the National Association of Accountable Care Organizations, the graphic below shows that the Medicare Shared Savings Program (MSSP)—the largest of the ACA’s payment innovations, with over 500 accountable care organizations (ACOs) reaching 11M assigned beneficiaries—has led to minimal savings for Medicare. In its first eight years, MSSP saved Medicare only $3.4B, or a paltry 0.06 percent, of the $5.6T that it spent over that time.  

Policymakers had hoped that a Medicare-led move to value would prompt commercial payers to follow suit, but that also hasn’t happened. The proportion of payment to health systems in capitated or other risk-based arrangements barely budged from 2013 to 2020—remaining negligible for most organizations, and rarely amounting to enough to influence strategy. The proportion of risk-based payment for doctors is slightly higher, but still far below what is needed to enable wholesale change in care across a practice. While Medicare has other options if it wants to increase value-based payment, like making ACOs mandatory, it’s harder to see how the trend in commercial payment will improve, as large payers, who are buying up scores of care delivery assets themselves, seem to have little motivation to deal providers in on risk. While financial upside of moving to risk hasn’t been significant enough to move the market to date, we aren’t suggesting health systems throw out their population management playbook—to meet mounting cost labor pressures, systems must deliver lower cost care, in lower cost settings, with lower cost staff, just to maintain economic viability moving forward.


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

Are professional guilds exacerbating the workforce crisis? 

This week we met the CEO of a large, independent orthopedics group, and our conversation quickly turned to how the shortage of healthcare workers was impacting her practice. The practice is experiencing the challenges recruiting nurses that are ubiquitous across the industry, but this CEO was more concerned about recent changes in the certification of athletic trainers, who comprise a significant part of the practice’s workforce. “We’ve built our PT and rehab around athletic trainers (ATs),” she shared. “Not only are they really good at it, but they’ve allowed us to really lower the cost of care.” But recently the main professional organization for ATs announced they will now require a master’s degree for certification, which this CEO predicts will have a huge impact on her practice. “The average trainer makes about $50K a year. It will be next to impossible to get an ROI on a master’s degree, unless salaries go way up—I’d tell my own kid it’s not worth it.” And if AT salaries increase significantly, the practice would have difficulty performing under their bundled payment contracts. Ultimately, consumers will bear the cost: either care costs will go up and be passed on, or the practices will have to pull back on services. Could more education for trainers bolster skills and improve care, we asked? There wasn’t a clear argument, as ATs would be competing with physical therapists and others for that work.

It’s a similar story in many areas of healthcare training. Moves toward more bachelor’s prepared nurses, or BSNs, make it more expensive to staff hospital units, with questionable benefits to patients. Or pressure comes from above, with physician professional organizations pushing back around titles and scope of practice for advanced practice providers. Addressing demonstrated quality gaps is critical, but it’s often just assumed, without evidence, that quality will erode if a lower-level provider assumes key care tasks. To ensure a sustainable clinical workforce in the long term, healthcare leaders must focus on developing career ladders that are not dictated by the professional guilds, but rather are designed around patient and care team needs.

Thanks for joining us for the Weekly Gist! We’re grateful for your readership, and for your continued engagement—keep the emails and messages coming! We want to hear your thoughts and perspectives. Don’t forget to tell your friends and colleagues to subscribe, and remember to check out our re-launched daily podcast, too. We appreciate it!

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