October 14, 2022

The Weekly Gist: The Unbearable Voter Fraud Edition

by Chas Roades and Lisa Bielamowicz MD

Voting is underway nationwide, and already we’ve been rocked by a scandal over ballot box stuffing—albeit one that pales in comparison to the wild salmon stuffing that led up to it. That’s right, we’re talking about Fat Bear Week, the annual tourney hosted by nature-cam nonprofit Explore. The candidates were brown bears in Katmai National Park in Alaska, each with its own group of ardent supporters eager to vote their favorite bear to victory. This year’s winner was 747, a bear worthy of his jumbo-jet moniker, whose triumph was nearly tarnished by a wave of phony ballots cast for a competitor, the blond-eared Holly. Nonetheless, the big fella walked (trundled?) away with it in the end, weighing in at more than 1,400 lbs. Happy hibernation 747; sleep soundly with the knowledge that Fat Bear election integrity remains secure.

THIS WEEK IN HEALTHCARE

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

  1. CommonSpirit confirms large-scale ransomware attack. The fourth-largest US hospital system, Chicago-based CommonSpirit Health, is struggling with the impact of a major cyberattack, more than a week after it began disrupting electronic health record access and delaying care in multiple regions across the country. Beyond confirming the attack, the system has not provided many details, other than that it took immediate steps to protect its systems and has begun an investigation.

The Gist: Healthcare hacking is on the rise—our industry experienced the largest increase in cyberattacks of any in 2021. Sitting on troves of valuable patient data, health systems must ready themselves for the reality that hacking attempts are no longer a question of “if,” but “when.” Now is the time not only to ensure proper safeguards are in place to prevent such attacks, but also to prepare response plans for once a hack is confirmed, to be able to continue patient care amid disruption when time is of the essence and patient lives are at stake.

  1. Colonoscopies fail to reduce colon cancer deaths in landmark study. In a randomized controlled trial (RCT) study of 85K Europeans, published this week in the New England Journal of Medicine, colonoscopies were found to reduce incidence of colorectal cancer by only 18 percent—much less than earlier large studies—and have no impact on ten-year colorectal cancer mortality rates. This is the first study to directly compare individuals invited to receive colonoscopies with a control group receiving no cancer screening. While the study’s findings surprised many researchers, an important caveat to the headline takeaways is that a secondary analysis of study participants who actually completed their colonoscopies found a 50 percent reduction in death, though the decision to accept the invitation likely correlates with other factors that improve mortality outcomes.

The Gist: We were surprised to learn this was the first RCT to assess the effectiveness of colonoscopies—15M of which are performed in the US each year—and which comprise a $36B market. While the study’s results need careful interpretation, it reminds us that much of established medical consensus has yet to be “proven” by rigorous scientific research. While we don’t expect this study’s results to significantly change colonoscopy recommendations, it does place greater emphasis on the question of value generated by widespread preventative screenings. Colonoscopy will almost certainly remain the gold standard for colon cancer screening in the US, but if these results bear out, other less invasive types of screening, like home-based fecal immunochemical testing, could be viewed as equivalent options and receive more traction.  

  1. Bright Health exits nine more states. Coming off a $1.2B net loss in 2021, Minneapolis-based insurtech Bright Health announced this week it will stop offering commercial and Medicare Advantage (MA) plans in all states except Florida and California, where it will solely offer MA plans. In its remaining markets, the company plans to focus on its care delivery and provider support business, NeuHealth. Bright has reportedly struggled to contain its medical spend, due to rapid growth and COVID-related costs; its claims processing backlog also earned a $1M fine from the Colorado Department of Insurance last April. Once valued at over $11B, Bright’s stock has lost 95 percent of its value since going public in June 2021.

The Gist: The largest digital health IPO to date is now rapidly shrinking, not even two years later—and Bright is not alone amongst its peers. After years of hype, most insurtechs still have minimal market share, and most have yet to turn a profit. With a market cap now under $1B—and dropping by the day—Bright could be an easy pickup for an established health plan interested in its consumer-centric technology, though given reports of dissatisfied beneficiaries, the value of that technology is still unclear.  

Pluswhat we’ve been reading.

  1. Insurers under fire for Medicare Advantage billing practices. In a blistering article published in the New York Times, reporters Reed Abelson and Margot Sanger-Katz detail widespread fraud allegations involving the nation’s largest MA insurers. Nine of the ten largest plans have been accused by the government of fraud or overbilling, generally for upcoding practices that exaggerate the disease burden among their beneficiaries, without providing them more care. Insurers have disputed most allegations, and regulators have been slow to punish known infractions. As a growing steam of seniors continue the enter the program, aggressive risk adjustment has significantly increased the government’s costs. The Centers for Medicare and Medicaid Services has yet to reduce payments in response to overbilling, despite having the power to do so.

The Gist: While these practices were well known to many in the healthcare industry, MA’s growth—set to overtake traditional Medicare enrollment next year—has added a spotlight worthy of national attention. While many beneficiaries report being satisfied with their MA benefits, the program was also intended to improve the cost efficiency of senior care. With payers gaming the system to garner record profits, the government has seen higher per-enrollee spending in MA compared to traditional Medicare. There are some signs that the strings are starting to tighten for insurers, as many of the largest are losing Medicare star bonuses in 2023, impacting both plan revenue and ability to market throughout the year. However, reduced quality bonuses change nothing about the underlying MA payment structure, and could even drive insurers to more profit-seeking behavior.


GRAPHIC OF THE WEEK

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

Virtual care solidifying its post-COVID role 

After COVID restrictions introduced millions of Americans to telehealth, it became an open question whether virtual care would revolutionize healthcare delivery, or turn out to be a flash in the pan. Using commercial claims data from Fair Health, the graphic below reveals that roughly one in twenty commercial medical claims are now for virtual care, a rate that has held fairly steady since dropping from its early pandemic peak. (These use rates likely extend to Medicare, as a Kaiser Family Foundation analysis showed that the virtual share of outpatient visits barely differed between those younger and older than 65.) What could be considered a true revolution is virtual care’s impact on behavioral healthcare, which makes up nearly two-thirds of overall virtual care volume. According to Zocdoc, an online marketplace booking both in-person and virtual care services, 85 percent of psychiatric appointments booked in the first half of 2022 were for virtual care, dwarfing the virtual visit levels of the other top specialties.

Meanwhile, consumers have incorporated virtual care into their lives as a useful option, though not as the sole way they access care. A recent survey found that a near-majority of consumers have accessed care both virtually and in-person, far more than the number who rely exclusively on one channel or the other. The pandemic changed consumers’ baseline expectation of what care could be delivered at home. The ability to deliver accessible, efficient virtual visits and connect that care to in-person care delivery will be a competitive advantage in the “hybrid” care environment sought by many consumers.


INTERMISSION

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

Artbound: Love & Rockets (KCET)This new, hourlong documentary from Southern California public broadcaster KCET focuses on the work of LA’s Hernandez brothers, who for 40 years have been producing one of the longest running, best regarded American comic books. A perfect introduction for those new to the Love & Rockets universe, which revolves around the vibrant Latino punk scene in SoCal and Central America. Watch it, then dip into the back catalog of L&R work, available in gorgeous editions from Fantagraphics Books.


THIS WEEK AT GIST—ON THE ROAD

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

Managing against a decline in “physician hours worked”

Last week a health system chief medical officer asked if we were hearing other systems complain of difficulties in securing call coverage for key specialties, particularly orthopedics, GI and urology. We agreed: with proceduralists building larger outpatient businesses, often funded by investors, there is less incentive for groups to support hospital call. To fill the gaps, hospitals are having to negotiate lucrative deals for coverage, and the market feels like the “deal for every doc” years in the early 2000s, when specialists had leverage to negotiate bespoke partnership contracts. In this leader’s case, he ended up brokering a deal with gastroenterologists to serve in a hospital-based role, providing in-house coverage for consults. “These docs are able to make $600K a year, working about 30 hours per week. It’s insane,” he lamented.

But beyond the cost of talent, he was concerned about the larger ramifications of these kind of roles on physician supply. “I’ve been thinking about a metric along the lines of ‘lifetime physician hours worked’, and how that has changed over time,” he shared. He explained that physicians of his generation expected to work 60- to 80- hour weeks for most of their careers. Most younger doctors want to work much less, say 40 or 50 hours. Over a forty-year career, he calculated, the healthcare system could get 36,800, or roughly a third fewer, “lifetime work-hours” from a doctor starting today. And most early-career doctors also plan to retire younger. “Now don’t get me wrong,” he continued, “We probably worked too hard, and these younger guys are onto something.” But he was concerned about the ramifications for physician supply, and posited we are poised for a deep shortage of clinical talent. Creating the future physician workforce will require not only training more doctors, but also finding ways to make their work hours more efficient, with greater use of technology and other caregivers, who must also be trained in greater numbers. It takes at least four years to train a nurse, and nearly a decade before a student entering medical school today becomes a practicing physician—we can’t afford such a long lag time before more physician capacity comes online.


THIS WEEK AT GIST—ON THE PODCAST

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

We’re thrilled to announce that Gist Healthcare Daily will be back on the airwaves starting this Monday, October 17. We’ve welcomed Senior Producer J. Carlisle Larsen to our team, who comes to Gist after a more than a decade as a public radio journalist. Remember to refresh your podcast feed and tune in for all-new episodes!

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Thanks for joining us for another edition of the Weekly Gist! We truly appreciate your readership, and we’d love to hear from you—get in touch with your feedback, suggestions, and what you’re hearing out there. And don’t forget to share this with a friend or colleague, and encourage them to subscribe, and listen to our all-new podcast!

As always, please let us know if we can be of assistance with something you’re working on. You’re making healthcare better—we want to help!

Best regards,

Chas Roades
Co-Founder and CEO
chas@gisthealthcare.com

Lisa Bielamowicz, MD
Co-Founder and President
lisa@gisthealthcare.com