March 31, 2023

The Weekly Gist: The Mochachino Pitch Clock Edition

by Chas Roades and Lisa Bielamowicz MD

Baseball is back! The new season, which opened yesterday, brings a number of widely anticipated rules changes intended to speed up the game in this era of shortened attention spans. A pitcher now has 15 seconds to start the throwing motion if the bases are empty, and 20 seconds if there are runners on base. Batters must also be ready to bat with no fewer than 8 seconds left on the clock. Already the pitch clock is having a measurable impact: games using the clock are nearly a half-hour shorter than before. That makes us wonder about other useful applications of the pitch clock. How about for those bloated Marvel movies? You’ve got 8 second to toss that shield, Captain America, so step on it. Or for the Q&A section of conference presentations? Step up to the mike and ask the question, you’ve got 3 seconds—no filibustering! Our best idea so far: a pitch clock for placing your order at Starbucks. No time for your half-caf peppermint mochachino with frothed soy milk, Ashley…step away from the counter!


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

  1. Texas federal judge rules against no-cost ACA preventative care services. US District Judge Reed O’Connor ruled on Thursday that the Affordable Care Act’s (ACA’s) requirement for most insurers to cover certain preventative care services without cost-sharing is unlawful. Judge O’Connor—who invalidated the entire ACA in 2018, before the Supreme Court reversed that ruling—had already sided with the plaintiffs in Braidwood vs. Becerra last September, on the grounds that mandatory coverage of HIV prevention treatment, also known as PrEP therapy, violated their religious beliefs. His latest ruling applies to the ACA-mandated preventive services that are compelled by the US Preventative Services Task Force (USPSTF), on the grounds of the task force’s makeup and the fact that some of its recommendations predate the ACA. Services covered for no cost today include screening tests for a variety of cancers, sexually transmitted infections, and diabetes. The ruling does not impact other ACA preventative care services, like contraceptive services and children’s immunizations, as they are based on the recommendations of other government advisory groups. The immediate impact of this week’s ruling is unclear, as the Biden administration has already filed an appeal and may seek to stay the ruling, while most insurance contracts are set on an annual basis.

The Gist: Given the reasoning laid out in Judge O’Connor’s Braidwood v. Becerra ruling last fall, this decision was expected. As with previous attempts to repeal the ACA that have come through his district, the ultimate fate of the ACA’s cost-free preventative care services will likely be decided by the US Supreme Court. It’s possible that the Court may find the narrow targeting of this case more reasonable, making no-cost preventive care coverage optional for employers. If that happens, millions of Americans could again have to pay for some of the most common and highest-value healthcare services. That additional financial burden, along with tightening of health plan benefit designs, could create barriers to access and exacerbate health disparities.

  1. Payers revise prior authorization policies ahead of new regulations. On Wednesday, UnitedHealth Group (UHG) announced that it will reduce its prior authorization claims volume by 20 percent for its commercial, Medicare Advantage, and Medicaid businesses later this year. Next year, it will launch a “gold card” program for qualifying providers that will further streamline care approvals. Cigna also shared that it has removed nearly 500 services from prior authorization review since 2020, relying on an electronic process for faster response times. These changes come in the wake of a Centers for Medicare and Medicaid Services (CMS) proposed rule, set to be finalized in April, that aims to streamline prior authorization by requiring certain payers to establish a method for electronic transmission, shorten response time for physician requests, and provide a reason for denials.

The Gist: These changes address two of providers’ primary complaints around prior authorizations: there are too many of them, and payers take too long to process them. However, technology options aiming to solve this problem through automation are by no means a foolproof solution. As ProPublica recently reported, algorithm-based electronic claims processing solutions that improve response times can create other challenges, including improper automatic denials, and can expand prior authorization to lower-cost services, for which it was previously determined to be inefficient to rely on human review. Quicker responses must still be accurate and fair, necessitating that insurance companies closely monitor, audit, and hone technology solutions.  

  1. Oscar Health appoints insurance veteran Mark Bertolini as CEO. On Tuesday, New York City-based “insurtech” Oscar Health announced that Mark Bertolini, the former Chairman and CEO of Aetna, will be taking over as CEO. While Oscar’s latest financial results slightly outperformed expectations, the company has been plagued by significant net losses, absorbing high medical loss and administrative expense ratios to cover just over 1M members. Bertolini said that his primary mission will be achieving full-company profitability by 2024.

The Gist: Bertolini’s appointment comes at a difficult time for many “insurtechs.” Rising interest rates have created a tough environment for digital health and insurance startups: with their cheap funding sources cut off, investors are expecting profitable returns sooner rather than later. Oscar is betting that bringing in a “traditional” insurance executive to run its “nontraditional” insurance platform will allow it to finally turn a profit.

Pluswhat we’ve been reading.

  1. Mississippi hospitals are dying without Medicaid expansion. Published this week in the New York Times, this article describes the decaying state of Greenwood Leflore Hospital, a 117 year-old facility in the Mississippi Delta that may be within months of closure. While rural hospitals across the country are struggling, Mississippi’s firm opposition to Medicaid expansion has exacerbated the problem in that state, by depriving providers of an additional $1.4B per year in federal funds. Instead, only a few of the state’s 100-plus hospitals actually turn an annual profit, and uncompensated care costs are almost 10 percent of the average hospital’s operating costs. Despite a dozen or more hospitals at imminent risk of closure, Mississippi officials would rather use the state’s $3.9B budget surplus to lower or eliminate the state income tax.

The Gist: Expanding Medicaid doesn’t just reduce rates of uncompensated care provided by hospitals, it changes the volume and type of care they provide. Further, Medicaid expansion has been found to result in significant reductions in all-cause mortality. Ensuring that low-income residents in Mississippi and other non-expansion states have access to Medicaid would allow providers to administer more preventive care and manage chronic diseases more effectively, before costly exacerbations require hospitalization.


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

The concerning rise in colorectal cancer

A new study from the American Cancer Society revealed a startling phenomenon in colorectal cancer: cases are trending younger while the severity of diagnoses is increasing. As shown in the graphic below, despite an overall reduction in the incidence of colorectal cancer—thanks to an emphasis on earlier detection and treatment—more severe diagnoses of colorectal cancer (termed “regional” and “distant”) each grew by over 30 percent in adults under age 50 from 2010 to 2019. While researchers are still exploring the causes for the increase in younger people, it underscores the importance of new guidance from May 2021 which lowered the recommended colorectal cancer screening age from 50 to 45. One bright spot: unlike most other cancer screenings, screenings for colorectal cancer actually increased during the pandemic, thanks to the rise of at-home stool testing. Stool testing was especially common among lower income and minority populations who often struggle to access colonoscopies. However, there is evidence that flagged patients are not scheduling critical follow-up colonoscopies. Better connection between at-home assessments and more thorough diagnostic services is a critical next step in the broader home-based care movement.


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

The Record by boygenius—Three solo artists at the top of their songwriting powers coming together to release a “supergroup” album? Yes, please! Phoebe Bridgers, Julien Baker, and Lucy Dacus go full CSN mode on this outstanding collection of harmonies and alt-rockers. A landmark LP.


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

How can boards keep up with health system growth?

It feels like governance questions are coming to the fore in a lot of places these days, at least judging by several recent conversations we’ve had with health system CEOs. Probably not surprising, given the number of potential mergers and other partnerships under consideration. As one CEO told us, growth by M&A raises particularly thorny issues for a not-for-profit system board. “Our governance structure grew out of a single hospital board, which was made up of community members and local physician leaders,” he told us. As the system acquired hospitals in adjacent markets, the combined board took on a representational character—each hospital had local stakeholders involved in governance. “Now we’re talking about merging with an out-of-state system, and our board suddenly seems way too parochial and unsophisticated. Everyone’s still asking what’s in it for their community.” That’s a frustration we hear frequently. There are legitimate reasons why a tax-exempt community institution should have local representation on the board, advocating for local priorities and resources. But a larger, multi-state board must also oversee the entire portfolio of assets, and make trade-offs across markets, sometimes making decisions that favor one hospital over another. The larger system board also has a greater need for sophistication, both on business and healthcare issues, as its members are often responsible for billions of dollars of assets. What frequently results from this tension is a nesting series of system and community boards, with varying degrees of accountability—a recipe for tangled, lengthy decision processes, and an enormous time-sink for senior system executives. We’re keeping our eye out for next-generation solutions to the governance question in healthcare—let us know what you’re seeing.


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

Last Monday, JC spoke with healthcare industry veteran Craig Samitt, MD,  whose 30-year career has included leading Blue Cross and Blue Shield of Minnesota and WI-based Dean Health System. He shared more about his new role as CEO of Surround Care’s National Physician Enterprise and EVP at Navvis, as well as his thoughts on the current state of the healthcare industry.

This coming Monday, we’ll revisit JC’s conversation with David Jarrard, Executive Chairman of strategic healthcare communications consulting firm Jarrard Inc., about the results of his company’s recent national consumer survey on the public’s perception of hospitals and healthcare in the United States. (You can also check out our summary graphic of the survey’s findings.)

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Another week in the books—hope it was a good one for you! Thanks for taking time to read the Weekly Gist, and for sharing it with friends and colleagues. Tell them to subscribe, and to check out our daily podcast, too! And while you’re at it, let us hear from you. We love reading your comments and suggestions—keep ‘em coming!

Most importantly, 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-President and Managing Director

Lisa Bielamowicz, MD
Co-President and Managing Director