May 27, 2022

The Weekly Gist: The Social Determinants of Death Edition

by Chas Roades and Lisa Bielamowicz MD

There is nothing witty or clever to say this week. Like everyone, we are shaken, shattered, left speechless by the horrific events in Uvalde. Doubly so, first by the taking of so many innocent young lives by an act of evil, then by the immediate realization that nothing will change, that our leaders on all sides, and at all levels, will again offer nothing but a ritualized shrug. In healthcare we speak of “social determinants of health,” but there are social determinants of death as well. They are the monsters who perpetrate evil, the monsters who profit from evil, and the monsters who do nothing in the face of evil. We can only hold our loved ones close and explain to our children as best we can why nothing changes, why this deadly scourge is a part of their lives, and ours.


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

  1. Gun violence, the leading cause of death among US children, claims more victims. Only 10 days after a racially motivated mass shooting that killed 10 in a Buffalo, NY grocery store, 19 children and two teachers were murdered on Tuesday at an elementary school in Uvalde, TX. The Uvalde shooting was the 27th school shooting, and one of over 212 mass shootings, that have occurred this year alone. Firearms recently overtook car accidents as the leading cause of childhood deaths in the US, and more than 45,000 Americans die from gun violence each year.

The Gist: Gun violence is, and has long been, a serious public health crisis in this country. It is both important to remember, yet difficult for some to accept, that many mass shootings are preventable. Health systems, as stewards of health in their communities, can play a central role in preventing gun violence at its source, both by bolstering mental health services and advocating for the needed legislative actions—supported by a strong majority of American voters—to stem this public health crisis. As Northwell Health CEO Michael Dowling said this week, “Our job is to save lives and prevent people from illness and death. Gun violence is not an issue on the outside—it’s a central public health issue for us. Every single hospital leader in the United States should be standing up and screaming about what an abomination this is. If you were hesitant about getting involved the day before…May 24 should have changed your perspective. It’s time.”

  1. Progress on the COVID vaccine front for children. Three doses of the Pfizer-BioNTech COVID-19 vaccine were shown to be 80 percent effective at preventing symptomatic COVID in children aged six months to five years old, according to the companies’ preliminary trial results. Food and Drug Administration (FDA) experts will meet in mid-June to review the data and make an authorization recommendation for both the Pfizer and Moderna vaccines for the nation’s youngest kids. This news comes on the heels of the FDA’s approval of a Pfizer vaccine booster shot for kids ages five though 11 years, though so far only 28 percent of that age group has been fully vaccinated.

The Gist: The nearly 19 million children under the age of five are the largest remaining group still ineligible for a COVID vaccine in the US. However, an approved vaccine won’t do any good until it’s in a child’s arm, and fewer than one in five parents of children under five plan to vaccinate their child right away. Vaccine access for young children is particularly important to reduce COVID outbreaks in childcare facilities, and to enable parents to return to work, but more messaging and assurance, most critically from pediatricians and community advocates, will be necessary to convince hesitant parents.

  1. Surgeon General releases advisory on health worker burnout. US Surgeon General Dr. Vivek Murthy issued a report drawing national attention to the issue of burnout in the healthcare workforce, elevating it to one of his office’s top priorities (alongside COVID-19, health misinformation, and youth mental health). Caregiver burnout was already rising prior to COVID, but stress of the pandemic, resulting workforce shortages, and rising workplace violence have pushed it to crisis levels. The report outlines the systemic causes of the mounting burnout crisis among US healthcare workers, up to half of whom report experiencing symptoms of burnout, and lays out solutions for how each healthcare sector can support workforce sustainability.

The Gist: We appreciate the spotlight that Dr. Murthy is shining on the healthcare workforce crisis. While the report and solutions offered are unlikely be revelatory to most healthcare leaders, we hope it increases the potential for meaningful national action and funding for programs to support healthcare workers. However, real long-term sustainability requires rethinking job structure and support for doctors, nurses and others on the care team, and redesigning the work to meet the needs of a new generation of clinical workers—a much larger effort that lies beyond the scope of these recommendations.

Pluswhat we’ve been reading.

  1. Understanding the impact of the growing dominance of Medicare Advantage (MA). A recent piece in JAMA argues that policymakers need to be proactive in addressing how the rise of MA enrollment will affect the Medicare program as a whole, including its role in national quality and utilization measurement, rural healthcare access, and graduate medical education. The ability to monitor care delivered to the traditional, fee-for-service Medicare beneficiary population has been critical for assessing cost growth and shifting care patterns, distributing subsidies, and basing MA payments—all things that will become increasingly difficult as traditional Medicare becomes both smaller and less representative of the entire Medicare population.

The Gist: Traditional Medicare has been a springboard for national healthcare policy goals and industry-wide innovations. However, consumers’ preference for, and policy shifts supporting, the growth of Medicare Advantage are proving to be unstoppable. Providers must prepare for a future in which a shrinking minority of beneficiaries are enrolled in traditional Medicare. If current trends continue, Medicare policymakers must bolster ongoing support for medical education, and build a higher standard of transparency and quality reporting for MA carriers and providers to maintain the sustainability of one of the country’s greatest healthcare data resources.


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

Becoming a healthcare platform

As we’ve been discussing over the past few years, several environmental forces—shifting consumer behavior, evolving demographics, new technology, and a flood of new market entrants—are pushing health systems to adopt a more consumer-centric business model. Systems must develop the capabilities needed to create an omnichannel consumer loyalty and population management platform. This platform will be the foundation for connecting consumers, curating providers, and coordinating care.

To achieve this vision, health systems must deliver value across two dimensions: increasing their proximity to the consumer (our y-axis) and their proximity to the premium dollar (our x-axis), as shown in the graphic below. Traditionally, health systems have operated primarily in the lower-left quadrant, as “care suppliers.” Some have spent considerable time and resources across the last decade, pushing closer to the premium dollar, to become “population managers.” But, importantly, managing population health is neither patient-facing, nor something consumers demand and seek. To build deeper consumer loyalty, health systems must also move up the y-axis, creating a “care ecosystem” that provides “anywhere, anytime” care through multiple channels, including virtual and home-based solutions. And for certain populations, like Medicare Advantage, it will make sense for many systems to also explore becoming the “premium owner”, owning the full care budget and ensuring the incentives to design a consumer-centric offering. The ideal health system platform should combine all four of these identities, tailored to the local market situation.


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

Kids in the Hall (Amazon Prime)—The legendary quintet of absurdist Canadians reprises their classic sketch comedy show after a 27-year absence, with eight episodes that find them just as bizarre and edgy as they were in the early 90s. Binge the original series, then enjoy the boys in their greying, paunchy years. As a bonus, catch the “Comedy Punks” documentary streaming alongside the new show. They’re still crushing our tiny heads.


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

One of us recently participated in a panel discussion at a conference hosted by Roundstone Insurance, a company that helps small and medium-sized businesses convert to self-funding via pooling of risk. There was a lot of discussion about strategies to move beyond traditional group insurance approaches to benefit design and cost management. As you’d expect, there was a fair amount of provider bashing, largely about excessive pricing, access challenges, and aggressive billing strategies. But there was also real interest among the business owners in attendance about how to identify and partner with high-quality, value-driven doctors and hospitals, and how to tailor benefit design to encourage better utilization of those providers by employees. New care models like direct primary care and virtual care were top of mind for participants. In general, there seemed to be agreement that breaking out of traditional, arms-length relationships with providers, especially by disintermediating the full-risk insurers, was an important step to making healthcare costs more sustainable for employers and employees. Key to that task: finding savvy and progressive benefits advisors who can play a more proactive role than what’s typical among insurance brokersparticularly those who serve smaller companies. Overall, a fascinating conversation—one that providers would do well to tune into more often.


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

This week we’ve been revisiting our recent four-part series, “Toward a Platform Future.” We shared our thinking with Alex on the ways health systems can create care ecosystems to deliver seamless access and experiences, build consumer loyalty, and fend off competition. Alex explored these ideas with several leading healthcare strategists, and with Derek Streat, CEO of health tech company DexCare.

Make sure to tune in next week, when Alex will return with all new episodes beginning Wednesday, June 1st.

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

Thanks for reading the Weekly Gist this week. We hope you can spend time with friends and family this long weekend, holding in your hearts the families in Texas and elsewhere who will not be able to do the same.

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

Lisa Bielamowicz, MD
Co-Founder and President