October 25, 2019

The Weekly Gist: The Spicy Beef Edition

by Chas Roades and Lisa Bielamowicz MD

It’s a big weekend in our nation’s capital, featuring the first World Series games to be played in Washington since 1933. With our hometown underdogs up 2-0 in the series so far, denizens of DC have unexpectedly found something to bring together partisans from across the spectrum, even in the midst of one of the ugliest political seasons we’ve seen. Still, this historic occasion won’t be without a measure of inside-the-Beltway drama. The first pitch for Sunday’s game 5 (if needed…and one of us is pinning her hopes on that possibility) will be thrown out by Washington’s luminary restaurateur José Andrés, in full view of President Trump, who plans on attending the game. Let’s just say that those two have a bit of a beef with each other. Spicy!


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

Healthcare? She’ll have a plan for that.

Facing a growing chorus of attacks from rival Democratic presidential candidates, Sen. Elizabeth Warren (D-MA) pledged this week that her campaign would soon deliver details on how she plans to pay for “Medicare for All” (M4A). Warren has not proposed a healthcare plan of her own but has expressed support for Sen. Bernie Sanders’s (I-VT) single-payer plan, which would replace the nation’s existing insurance system with a new, government-run program. Sanders has been clear that his proposal would entail higher taxes for many Americans, in exchange for eliminating the burden of premiums, deductibles and copays. Warren, however, has been reluctant to say whether she would also raise taxes on middle-income Americans to pay for M4A. Having earmarked all of the revenue from her proposed 2 percent wealth tax on those with more than $50M in assets to pay for her education plans, Warren must find other ways to pay for the estimated $30T in increased spending over ten years that M4A would entail. “This is something I’ve been working on for months and months,” Warren said at a town hall on Sunday, “and it’s got just a little more work until it’s finished.” Several ideas are being considered inside the Warren camp, according to the Washington Post, including a tiered sales tax, lowering the threshold for those subject to a wealth tax, and increasing taxes on businesses. As moderate candidates continue to criticize Warren for her vagueness on the topic, it’s clear she will need to be more explicit about her healthcare plans, or risk losing the momentum that has propelled her to front-runner status in the primary race. As is usually the case with healthcare reform, the devil is in the details.

Healthcare? They have a plan for that.

This week the Republican Study Committee (RSC), a group of 145 GOP lawmakers in the House of Representatives, released a healthcare plan intended to serve as a counterweight to the ongoing discussion of M4A among Democratic presidential candidates. The plan provides a framework for how the largest caucus of conservatives in Congress would approach healthcare legislation should their party win back the House and retain the Senate and White House. It largely mirrors legislative proposals considered by Congress in 2017, including transforming Medicaid into a block-grant system, increasing the use of health savings accounts, dismantling the essential health benefits provisions of the Affordable Care Act (ACA), and relying on high-risk pools to stabilize the individual insurance market. In a nod to the Trump administration’s efforts to encourage states to implement work requirements for Medicaid enrollees, the RSC proposal includes a new “flex grant” option for Medicaid block grants that would provide greater funding to states that implement such rules. The plan also allows greater flexibility for short-term insurance plans, health sharing ministries, association health plans, and other less-expensive alternatives to plans currently offered in the insurance marketplace. In a press release accompanying the framework, the RSC said, “With the introduction of our plan today, we are beginning a desperately needed conversation on how to save our country’s broken health care system.” With nearly a decade’s worth of contentious political battles over “repeal and replace” behind us, and in the midst of yet another election cycle in which healthcare reform is the central issue, House Republicans are scarcely “beginning a conversation”, but rather adding to the seemingly endless cacophony of partisan shouting about healthcare.

Amazon adds to its new healthcare platform

This week Amazon confirmed a CNBC report that it had agreed to acquire Health Navigator, an online symptom checker and virtual triage service. The acquisition is the second healthcare-related pickup for the e-commerce giant, which bought online pharmacy PillPack last year. Health Navigator is a much smaller acquisition and will become part of the newly launched Amazon Care, the company’s virtual care platform for its own employees. Health Navigator was founded in 2014 by David Thompson, an emergency medicine physician who is best known for helping to develop the triage protocols now widely used by nurse navigators at many insurer and provider call centers. The company works with a range of telemedicine, electronic health record, and call center companies, providing clinical content and a diagnosis engine that enables virtual triage of patients based on symptoms, using a natural language processing tool to capture patient complaints and match them to clinical conditions. Amazon is likely to incorporate the Health Navigator platform into Amazon Care’s virtual care services, helping connect employees to the appropriate care provider through virtual visits or home-based care. While initially offered only as a benefit for its Seattle-based workers, Amazon Care generated widespread buzz upon launch, with many speculating that it will become the basis for a broader consumer health offering in the future. Whether that’s true remains to be seen—for now, Amazon appears to be in the R&D phase of its healthcare play, using its own employees as a proving ground for new delivery approaches.


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

Sizing the impact of Medicaid work requirements

One of the centerpiece healthcare policies of the Trump administration has been the use of waivers to allow states to implement work requirements for Medicaid enrollees. Yet the policy has met with considerable opposition. During a hearing earlier this month, Federal appeals court judges seemed skeptical of the use of work requirements in Arkansas and Kentucky, while just this week Arizona shelved its plans to implement work requirements. And in her appearance before a Congressional committee on Wednesday, Centers for Medicare and Medicaid Services Administrator Seema Verma was pressed on the issue. Beyond the politics, as we’ve written elsewhere, there’s another problem with Medicaid work requirements—they don’t seem to address a real issue, but they could have a significant negative impact. The eligible population that would likely be subject to work requirements is small. Research from the Kaiser Family Foundation estimates only one in five non-working Medicaid enrollees—1.7M nationwide—will fall under work requirements once exemptions are taken into account, as shown in the graphic below. Balanced against that, the cost of implementing processes to confirm work status for those subject to the requirement will likely be high and may even offset any savings in reduced Medicaid spending. Further, the burden of having to report working status may be onerous for potential Medicaid enrollees, discouraging them from seeking coverage in the first place. That will likely mean larger numbers of low-income patients with no coverage—a persistent challenge for providers, who will be put in the position of delivering even more uncompensated care.


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

Not your usual healthcare conference

This week I was honored to deliver a keynote presentation for the Group Performance Improvement Network (GPIN) semi-annual meeting which brings together over 300 leaders from large, integrated medical groups, both independent and health system-affiliated—a “who’s who” of the most progressive physician organizations from around the country. For years, medical group and physician leaders have lauded GPIN as their go-to source for networking and sourcing new ideas for medical group operations and practice change, praising the collaborative ethos of the membership. But this was the first chance I’ve had to observe GPIN in action. The first thing I noticed is that despite its size, the group feels like family. Everyone knows each other, with connections that extend outside the meetings. Much of the time was spent in a combination of rapid-fire, well-honed presentations and focused small-group discussion. “Action” is not a word that defines the typical conference-going experience of sitting in a chilly ballroom listening to speaker after speaker. But based on my day with the group, GPIN has managed to create something truly unique, a conference experience that engenders real-time idea sharing and problem-solving for issues as diverse as behavioral health treatment models to AI-driven scheduling algorithms. If I were leading a medical group, it would be my go-to resource for practice improvement.

Growing concern about violence in the hospital setting

During a visit to one of our member health systems recently, I polled the executive team for a list of their most pressing, “up-at-night” concerns, and again heard about an issue that’s been coming up with alarming frequency in the past few months—patient violence against healthcare workers. It’s an endemic problem in our industry, one that’s been well-documented but for which there are few real solutions. Data from the Occupational Safety and Health Administration (OSHA) indicate that of the more than 25,000 workplace assaults reported each year, more than 75 percent occur in healthcare and social services settings. And that’s probably a significant undercounting of violent incidents—in many places, clinical workers simply assume that dealing with patient assaults “comes with the territory”, and don’t report incidents. The executives I spoke with expressed frustration with their ability to mitigate the problem—measures such as adding security personnel and screening for weapons have only put a small dent in the trend. The hospital is seeing a growing number of patients under the influence of drugs—particularly methamphetamines—assaulting nurses and emergency department personnel. Some states have stiffer penalties in place for those who commit violent acts against healthcare workers, but only a handful require tracking and reporting of violent patient incidents. In an environment where caregivers are already under intense pressure to increase efficiency, reduce cost, and deliver better outcomes for patients, having to deal with the pervasive issue of workplace violence is incredibly demoralizing—clearly, more needs to be done to address this problem.


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

On this past Monday’s episode, host Alex Olgin talked to healthcare attorney Jim Daniel about proposed changes to enforcement of the Stark law and anti-kickback regulations, and what those changes might mean for hospitals looking to work more closely with physicians on value-based care initiatives. Hear what Daniel has been hearing from his clients, and what changes to the proposed rule he expects to see.

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Give this a spin—you might like it.

With her 2017 debut album Infinite Worlds, Camaroon native and New York City transplant Laetitia Tamko, better known as Vagabon, burst onto the music scene with a collection of indie tracks featuring her soulful, confessional lyrics and self-taught electric guitar that gained her a place on Album of the Year charts, and an opening slot on Courtney Barnett’s tour. She’s back this month with a very different, but equally powerful, sophomore album, self-titled and nearly guitar-free. In the interim, she’s schooled herself in electronica, synths, and computer audio production, and Vagabon showcases a completely different artist—but with the same searching, stripped-down lyrical talent that made her a darling of the indie scene. Tamko has created a lush, almost orchestral collection of sounds, layered with Afrobeat rhythms and soaring keyboards, that feel more like performance art than straight-ahead album tracks. The lyrics are often opaque and inward-looking, reflecting on personal tales of love and loss that we understand only obliquely. Fittingly, on an album where almost every sound was created, recorded and engineered by Tamko herself, what she delivers is a generous but highly idiosyncratic portrait of herself. With Vagabon, she’ll surely discover herself at the top of best-of lists again this year. Best tracks: “Every Woman”; “Water Me Down”; “Flood”.


Stuff we read this week that made us think.

Widely used care management algorithm shows racial bias

An algorithm behind patient risk stratification software sold by Optum, a division of UnitedHealth Group, was found to be biased against black patients, according to research published this week in Science. Over 50 health systems and other organizations use this software tool to identify patients with a high chronic disease burden who could benefit from additional care management resources. Researchers found that relying on a patient’s prior cost of care as a major evaluative factor reduced the number of black patients referred for additional management by more than half, even though race was excluded from the algorithm. Black patients received less care and accrued lower costs over time compared to white patients with the same disease burden, leading to the bias. One of the study’s authors, a researcher at Boston-based Partners HealthCare, said her team first questioned the software when they found patients identified with the highest risk scores concentrated in Boston’s most affluent suburbs. The spread of machine learning technology will create exponential growth in algorithm-driven care. Amid hopes for more efficient and accurate diagnosis, there is a real risk that flaws in methodology can negatively impact whole populations of patients—signaling the need for more rigorous, scientific vetting.

Moving toward fewer, better ACOs

A new analysis in Health Affairs shows that for the first time since the Medicare Shared Savings Program (MSSP) was launched seven years ago, there were fewer accountable care organization (ACO) contracts compared to the prior year. The analysis, conducted by Leavitt Partners and researchers from Duke University found the number of ACO contracts dropped 8 percent between the fall of 2018 and 2019, and hypothesized that the decrease was due to the implementation of the CMS’s Pathways to Success programwhich requires participating ACOs to move more quickly to downside risk, paying a penalty if spending on care exceeds targets. (About a third of ACOs take downside risk today.) However, despite the decrease in contracts, the overall number of patient lives in ACOs increased by 3M across the past year, largely due to increases in the number of commercial ACO contracts. Travis Broome, Vice President for Policy and ACO Administration for Bethesda, MD-based Aledade, which helps create physician-led ACOs, posits that most future growth in ACOs will come from the commercial market, estimating half of eligible Medicare beneficiaries are now assigned to an ACO, leading to a natural slowing of growth. The shift toward fewer, larger ACOs, each managing greater numbers of patients under downside risk arrangements, signals an important maturation point for program participants, who appear to be reaching new levels of scale and sustainability. Regardless, we still believe that models built around shared-savings economics are time-limited, and that successful ACOs will look to partner with or launch Medicare Advantage or other capitation-based programs that allow them to manage the full premium dollar and keep more of the savings they generate.

Thanks for taking time to read this week’s edition of the Weekly Gist. We’re so appreciative of your support and feedback—thanks for sharing your thoughts! Thanks, too, for passing this along to a friend or colleague and encouraging them to subscribe. We love our readers! (And podcast listeners!)

Most of all, we’d love to hear how we can be of assistance in your work, so don’t hesitate to get in touch. You’re making healthcare better—we want to help!

Best regards,

Chas Roades
Co-Founder and CEO

Lisa Bielamowicz, MD
Co-Founder and President