December 6, 2019

The Weekly Gist: The Spotify Anxiety Edition

by Chas Roades and Lisa Bielamowicz MD

It was bad enough when the start of December brought a mounting sense of panic over everything that needed to get done—write the cards, do the gift shopping, hang the decorations, here come the holidays. We could just about cope with that level of anxiety. But this year ushered in a new source of stress—the Spotify year-end wrap up. It’s not the first time the streaming service has delivered a December summary of our personal listening habits, but as this week’s release date approached, we found ourselves rushing to get one more hip song in, lest we be faced with a “Top Artists” list that wasn’t quite…cool enough. Even worse, this year they added a “Best of the Decade” feature, triggering an urgent mental review of the highs and lows of ten years of music. And sure enough, despite all the cutting-edge indie and obscure “undiscovered” music we listened to, there he was, smugly sitting atop our lists…Drake. What a letdown!


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

Hospital groups file suit to block new transparency rule

As expected, industry lobbying groups filed a lawsuit this week to halt the Trump administration’s attempt to force hospitals to reveal the rates they negotiate with insurance companies for services. The suit, brought by groups including the American Hospital Association, the Federation of American Hospitals, the National Association of Children’s Hospitals, and the Association of American Medical Colleges, asserts that the new regulations represent significant overreach of legal authority by the government, as well as a violation of hospitals’ First Amendment rights to keep their negotiations with insurance companies private. Meanwhile, insurance industry groups wrote to the administration this week seeking to extend the comment period for a parallel rule that would require insurers to give patients information about expected out-of-pocket costs in advance of seeking care. Some legal analysts believe the industry lawsuit may prove successful in turning back the transparency regulations, based on other recent court cases in which executive overreach and First Amendment violations have been ruled to invalidate attempts to reform healthcare pricing.

Seeking to push back against industry opposition, Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma wrote an op-ed in Tuesday’s Chicago Tribune, stating that “the decades long norm of price obscurity is just fine for those who get to set the prices with little accountability and reap the profits, but that stale and broken status quo is bleeding patients dry. The price transparency delivered by these rules will put downward pressure on prices and restore patients to their rightful place at the center of American health care.” We’ll soon know whether the courts agree, but meanwhile we’d observe (again) that engaging in a public battle to keep pricing secret from consumers—particularly in this political season—leaves hospitals open to being further demonized as bad actors driving healthcare costs ever higher. Dangerous ground.

Virginia joins backlash against Medicaid work requirements

Newly emboldened by his party winning control of the legislature for the first time in a generation, Virginia Democratic Gov. Ralph Northam’s administration is dropping its federal approval request for Medicaid work requirements. Following years of partisan opposition, Democrats conceded to Medicaid work requirements in mid-2018 as a compromise to gain Republican support for expansion beginning last January. Since then, more than 300,000 Virginians have signed up for coverage—about a 30 percent increase in the state’s total Medicaid population. Northam’s decision comes amidst a flurry of legal challenges and delays to work requirements nationwide. Earlier this year a federal judge blocked such requirements in New Hampshire, Arkansas, and Kentucky—actions which the Trump administration is appealing. Indiana, often seen as “ground zero” for strict Medicaid eligibility rules, announced in late October that it would delay work requirements scheduled to go into effect in January through its “Gateway to Work Program.” Arizona recently announced it would also delay its program until the ongoing court cases are resolved. And just this week Michigan Democratic Gov. Gretchen Whitmer called for a pause on work requirements to avoid coverage losses, although the Republican-led state legislature immediately rebuffed Whitmer’s proposal.

As we’ve written previouslyMedicaid work requirements cost states a lot of money to implement, especially in comparison to the size of the population they’re intended to targetResearch 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. Further, the burden of having to report working status will probably 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.

Amazon launches new medical transcription service 

In addition to capturing your personal conversations at home through its ubiquitous Echos, Amazon is now in the business of recording physician-patient conversations. This week the company announced Amazon Transcribe Medical, a machine learning service for quickly creating accurate speech-to-text transcriptions for providers in clinical settings. Cerner, a co-developer, has already signed on as a customer “to develop a digital voice scribe that can ‘listen’ in the background during a patient’s visit”, transcribe the conversation into text, and automatically document the note in its electronic health record (EHR) system. Amazon’s move into this space is a natural extension of both its “Transcribe Service”, which automatically converts speech to text with natural formatting and punctuation, and its “Comprehend Medical” technology, which can read and mine unstructured medical text for specific information. While cloud rivals Microsoft and Google are also making a play for speech-to-text tools that work with EHRs, Amazon is looking to differentiate on the basis of providing highly accurate automatic speech recognition specifically designed to go directly into medical records. The company claims the service can understand the nuances of medical language, including the myriad abbreviations used by clinicians.

Amazon is focusing on an area ripe for improvement in cost, time, and patient experience. At a cost of less than a quarter of a cent per minute (!), Transcribe Medical looks like a very cost competitive alternative to what most providers are paying for medical transcription today—especially those who rely heavily on scribes. It remains to be seen if providers and patients will be comfortable having their often very personal conversations added to Amazon’s cloud, word for word. Providers who adopt this new service should be as transparent as possible with their patients about their partnership with Amazon, as well as how personal data is being stored and used.


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

Rethinking the model for managing chronic disease

As we’ve discussed before, the greatest challenge facing health system economics is demographics. Simply put, with 80M Boomers entering their Medicare years, hospitals beds will fill with elderly patients receiving treatment for exacerbations of congestive heart failure (CHF), diabetes, or other chronic conditions, of which the average Medicare beneficiary has four. It’s easy to envision the hospital becoming a giant nursing facility, with the vast majority of beds occupied by Medicare patients receiving nursing care and drugs, only to be sent home until their chronic disease flares again and the cycle repeats, four or five times a year. Health systems must create a new model for managing Medicare patients with multiple chronic conditions, one that does not rely on care delivered in an inpatient setting. In the graphic below, we outline two approaches for managing a Medicare patient with advanced CHF. The top path illustrates today’s legacy model, where limited support for ongoing care management leaves the patient vulnerable to exacerbations, leading to numerous ED visits and admissions for diuresis, after which the patient returns home to a sub-optimal diet and lifestyle and is likely to return.

A better alternative is illustrated in the second path. Here our CHF patient has access to the ongoing support of a care team, which regularly monitors her status from home with the help of remote monitoring and can communicate with the patient to adjust therapy if early symptoms are detected. At Gist, we’re working with clinicians to understand just how to build this system of care and maximize its impact. One example: a leading heart failure specialist told us that admissions for CHF could be reduced by one-third if patients with severe heart failure were monitored with a CardioMEMS implantable device, which can detect changes in pressure before the patient has symptoms, allowing for very early intervention. Developing these kind of care approaches to manage chronic disease outside the hospital will be the key to sustainable health system economics—and may have the greatest impact on lowering the total cost of care for the growing Medicare population.


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

Saying goodbye to Granny

I’ve written here about the healthcare challenges faced by my grandmother before. “Granny” passed away last weekend, and I’m writing this on the plane to her funeral in Houston. Granny was fortunate to be healthy and active for most of her 97 years. She was a healthcare skeptic, rarely seeing a doctor until her health started to decline two years ago, when (mostly) managed mild diabetes and congestive heart failure (CHF) started to catch up with her. Those two years provided a stark contrast in how to manage the care of a very elderly person with mounting clinical issues. Granny was admitted to the hospital several times during that first year for CHF exacerbations. It was a constant struggle to prevent “over-medicalization”. Doctors proposed a heart cath to look for arterial blockages, and a colonoscopy to investigate anemia—despite our assurances we wouldn’t pursue treatment if underlying disease was found. A long stay in a skilled nursing facility set her back physically and mentally.

Last winter after a particularly stressful admission, a hospitalist referred Granny to hospice. It was a bit of a stretch, given that she didn’t have a condition that was likely to be terminal in the next six months. But hospice care turned out to be a godsend for Granny and all of us who took care of her, providing both the medical “cover” to forgo excessive treatment, plus the invaluable clinical and social support of a visiting hospice nurse. After several medications were stopped, Granny was happier and healthier. Stress on her caregivers went down dramatically. She spent 2019 enjoying family, with no hospital or ED visits, until a few weeks ago, when she declined quickly and died peacefully at home. In her last year Granny had a higher quality of life, and surely incurred a lower cost of care due to hospice support. Families like ours shouldn’t have to “luck” into supportive care. It should be an option available, explained, and funded for any patient like her. As tens of millions of Baby Boomers age into their “high utilization” final years, the financial sustainability of the health system may depend on it.

Remembering Michael Sachs

I was so saddened this week to hear of the untimely passing of Michael Sachs. A brilliant thinker and serial entrepreneur, Michael dedicated his life to improving healthcare delivery. He was perhaps best known as a trusted strategic advisor to healthcare organizations through Sg2, the research and analytics firm he founded. Michael was an early and important innovator in using data and insights to drive better decision-making and higher quality of care at health systems across the country. I only had the chance to meet him in person a handful of times, but he played an outsized role in my professional world for almost two decades. His sharp insights and thoughtful approach to advising healthcare leaders were a major inspiration for how we are building Gist. But the most important thing I learned from Michael was the value of having a competitor to push you to do better. Shortly after he launched Sg2, we at Advisory Board (where I worked at the time) recognized we had a problem—after years of enjoying a near monopoly on health system “research and insights” memberships, we were suddenly confronted with someone coming right after our core business. Sg2 was running faster, and producing better, more innovative work—and at the heart of that was Michael’s clear and unique vision. I can’t tell you how many hours we spent over the years trying to figure out how to respond to what Michael and his team were producing, and how to keep up—all the while secretly admiring how damn good his stuff was. That lesson has stayed with me, and it’s one that could serve us all well in an industry rife with sleepy, slow-moving incumbents. If you want to run faster, find someone faster to race against. Michael Sachs is gone too soon, and he’ll be missed. He leaves an incredible legacy of insight and impact on our industry. Safe home, Michael.


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

Last Monday’s episode was our special North Carolina Omnibus edition. Gist Healthcare Daily spent six days covering public policy changes and private sector disruption across the state. This episode combined interviews with changemakers like Secretary of Health Dr. Mandy Cohen, Chief Medical Officer of Blue Cross Blue Shield of North Carolina Dr. Rahul Rajkumar, State Treasurer Dale Folwell and others. It’s a broad view of how healthcare is changing across the state.

Coming up next week, Gist talks to Dan Weissmann, host of the podcast An Arm And a Leg, which covers stories about the cost of healthcare and how consumers are dealing with it. This season Dan highlights the troubles even informed consumers have figuring out their out-of-pocket expenses, including a recent episode in which he profiles a woman facing an enormous hospital bill for an emergency department visit with her son for non-emergency care that she will probably regret for a long time. We’ll talk to Dan about what he learned. Listen in!

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


We would’ve worked harder, but we watched this instead.

“I hear you paint houses.” Fans of gangster movies will recognize that phrase as code for “I’d like you to kill someone for me,” and for a true fan, the experience of hearing Al Pacino (as Jimmy Hoffa!) say it to Robert De Niro, in a film directed by Martin Scorsese, is a cinematic dream come true. By now you’ve surely heard about The Irishman, Scorsese’s latest epic released on Netflix and in theaters last month. It’s a landmark movie, the first time De Niro and Scorsese have worked together since 1995 (Casino), the first time Pacino has worked with Scorsese (unbelievable), and the first film Joe Pesci has made in a decade, since going into retirement. Weighing in at three-and-a-half hours long, the movie recounts a version of the “what happened to Jimmy Hoffa” story, told through the eyes of aging Irish gangster Frank Sheeran. It’s full of great performances, with an all-star cast including Ray Romano, Harvey Keitel, Anna Paquin, Bobby Cannavale, and more. On one level it’s a Mafia movie on par with the best of Scorsese’s wiseguy canon—Mean StreetsGoodfellasCasino—but it’s also a slow, moving meditation on memory and aging, and how even the most shocking events and colorful characters fade away with the passage of time. Pesci in particular is a revelation, with his own age transforming his usual manic energy to a transcendent quiet and grace. Even the widely discussed “de-aging” technology, used in the film to allow Pacino, Pesci and De Niro to play much younger versions of their characters, works to underscore the theme of time’s inexorable decay that runs through The Irishman. If you haven’t yet set aside time to savor this Scorsese swan song, don’t be deterred by the movie’s long run time. As the credits rolled at the end, all I could think was that I wished it could go on forever.


Stuff we read this week that made us think.

Does the UK’s NHS have the answers? Does anyone?

Given all of the recent attention paid to the Medicare for All (M4A) proposals of leading US presidential candidates, we were interested to read a new study in The BMJ from a team of researchers at Harvard University and the London School of Economics, which analyzed the performance of the National Health Service (NHS), the government-run health system in the United Kingdom. Supporters of M4A often point to the NHS as a paragon of how healthcare ought to work, while critics use the same comparison to raise serious concerns about the negative consequences of moving to a single-payer system. The new study compares the NHS’ performance to healthcare systems in nine other countries, across a spectrum of 79 different performance metrics. The result? A mixed bag. The NHS has lower spending and slower spending growth than comparable systems, with lower rates of healthcare utilization. But it suffers from inadequate doctor and nurse staffing, has lower than average quality, and delivers worse health outcomes to its patients. As the authors point out, the NHS has suffered from significant funding pressures, and may face even worse staffing challenges in a post-Brexit world. As another recent article pointed out, these performance challenges have prompted NHS reformers to turn to the US for answers, and there have been a number of attempts to implement US-style initiatives—like accountable care organizations—to address the issues. The results have been disappointing thus far. Nonetheless, we think there’s real value in looking across borders for innovative solutions to healthcare challenges, and we’re excited to learn that Ashish Jha, one of the Harvard researchers who published the recent study of the NHS, is launching a broader project to study the health systems of several advanced economies, looking for the best solutions. We’ll be tracking the effort closely—and keeping our fingers crossed for some new answers.

Here come the prediabetics

Alarming statistics appeared this week in the journal JAMA Pediatrics, based on an analysis conducted by researchers at the Centers for Disease Control and Prevention (CDC) that showed that 20 percent of adolescents (ages 12-18) and 25 percent of young adults (ages 19-34) in the US are now prediabetic. These young people are at substantially increased risk for developing type 2 diabetes, as well as related cardiovascular diseases, as they grow older. The numbers are a staggering picture of what confronts the American healthcare system as the millennial generation (whose median age is now 30) and the younger “Gen-Z” generation (born after 1997) move closer to their prime care consumption years. These age cohorts are likely to be much more medically complex, and will drive even higher healthcare costs, than previous generations—especially since both of the younger generations are larger than those that preceded them. But the statistics also raise important health policy questions. To what extent should we “medicalize” prediabetes? In other words, should we begin to flag and treat prediabetes, which is more of a predisposition than an actual medical condition, with medications and interventions? Surely the reimbursement system will create a powerful temptation to do exactly that—at exorbitant cost. Or will we instead focus efforts on “reversing” prediabetes, with more robust attempts to encourage lifestyle changes (diet, exercise) and drive environmental changes (neighborhood walkability, availability and affordability of healthy foods)? And there’s an information privacy issue looming as well—how will “prediabetics” be flagged, and could prediabetes be viewed as a “pre-existing condition” that might be used in coverage (and even employment) decisions should the regulatory environment change? As much as we focus today on the healthcare impact of the aging Baby Boom generation, we need to get out ahead of some of the issues we’re certain to face as our younger citizens grow older (and sicker).

And so ends another edition of the Weekly Gist. Thanks for reading! We’re so grateful for your time and attention, and for your willingness to share your thoughts and feedback with us. Don’t forget to forward this to a friend or colleague and encourage them to subscribe (and tell them to check out our podcast while they’re at it).

Most of all, we’d love to hear from you 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