May 14, 2021

The Weekly Gist: The Unmasked! Edition

by Chas Roades and Lisa Bielamowicz MD

Well, that was sudden. After weeks of confusing public guidance on masking, during which fully vaccinated Americans were told to keep wearing masks in most public settings (but maybe not outdoors, if you were standing in the middle of an empty field, and the sun was shining), the Centers for Disease Control and Prevention unexpectedly reversed course yesterday, letting us know we could all take off our masks as long as we’re vaccinated. Public health experts were left struggling to explain how the “science” changed over the course of two weeks, vulnerable people who want the vaccine but may have challenges getting it were left to figure out how to navigate a new world governed by the “honor system”, and the rest of us were instantly confronted by a series of difficult grooming decisions (do I keep the pandemic beard, or not?). As any good comic book fan knows, you don’t just spring an “unmasking” on people. You’ve got to build up to it, get the reader ready for it. See also: Spider-Man (“Civil War” issue #2); The Flash (issue #345); Iron Man (issue #55); Daredevil (issue #32).

Hmm…bearded, in the basement, bingeing on comic books. Maybe it is time for a change.


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

Missouri backtracks on Medicaid expansion

Missouri Gov. Mike Parson announced Thursday that his state would not expand Medicaid coverage to 275,000 residents who will become eligible on July 1st, despite a 2020 ballot initiative in which a majority of the state’s voters approved the expansion. Because the Missouri legislature has blocked funding for the expansion, Parson declared that the state’s Medicaid program, MO HealthNet, would run out of money if it moved forward. The legislature’s decision to block funding was bolstered by an appeals court opinion last year, which challenged the expansion because the ballot initiative did not include a funding mechanism for widening coverage. Under the Affordable Care Act (ACA), the federal government would have picked up 90 percent of the cost of expanding Medicaid in the state, in addition to boosting funding for existing Medicaid enrollees by 5 percent, thanks to a measure in the recent American Rescue Plan Act. The governor’s decision leaves in place one of the strictest Medicaid eligibility standards in the nation: a family of three in Missouri must earn less than 21 percent of the federal poverty level—$5,400 per year—in order to qualify for coverage. The expansion measure would have opened the program to childless adults, and raised the eligibility limit to 138 percent of the federal poverty level. The Missouri Hospital Association called the decision an “affront” to voters, pointing out that the state is currently running a budget surplus, and could easily allocate funds for the expansion. The status of Medicaid expansion in Missouri, which would become the 38th state to undertake expansion since the ACA’s passage, will ultimately be decided by court ruling, according to observers. Meanwhile, like other states (mostly in the Southeast) that have resisted Medicaid expansion, Missouri will continue to see tax dollars flow out of the state to fund benefits in states that have expanded eligibility—despite the express will of voters. Given ample evidence that Medicaid expansion boosts access to care, health status, and health system sustainability, it’s nearly unfathomable that the politics of “Obamacare” continue to complicate the extension of this critical safety-net program.

Walmart, Amazon continue to build healthcare presence

Late last week, retail giant Walmart announced its plan to acquire national telemedicine provider MeMD, for an undisclosed sum. According to Dr. Cheryl Pegus, Walmart’s executive vice president for health, the acquisition “complements our brick-and-mortar Walmart Health locations”, allowing the company to “expand access and reach consumers where they are”. MeMD, founded in 2010, provides primary care and mental health services to five million patients nationally. The acquisition extends Walmart’s health delivery capabilities beyond the handful of in-store and store-adjacent clinics it runs, and follows the launch of its own Medicare Advantage-focused broker business, and partnership with Medicare Advantage start-up Clover Health to offer a co-branded insurance product. Walmart has been climbing the healthcare learning curve for several years, building on its sizeable retail pharmacy business, and seems to have hit on a successful formula in its latest in-person clinic model, which includes primary care, behavioral health, vision, and dental services. The retailer plans to add 22 new clinic locations by the end of this year, and its new telemedicine offering will allow it to expand its virtual reach even further. The MeMD acquisition also represents a new front in Walmart’s head-to-head competition with Amazon, which launched its own national telemedicine service earlier this year. That service, Amazon Care, is targeted at the employer market, and right on cue, Amazon announced its first customer sale last week—to Precor, a fitness equipment company. Both retail giants are slowly circling the $3.6T healthcare industry, targeting inefficiencies by deploying their expertise in convenience and consumer engagementIncumbents beware.

Hospital giants bet big on hospital at home

This week Mayo Clinic and Kaiser Permanente announced a $100M joint investment in Boston-based Medically Home, a provider of virtual hospital solutions. Founded in 2016, Medically Home is one of a handful of companies that coordinate with hospitals and doctors to provide in-home clinician visits, round-the-clock communications and monitoring, and access to support services to enable hospital-level care in the home. While interest has surged during the pandemic, the first hospital at home programs launched in the 1990s, and the model has a proven track record of delivering care that is lower cost and clinically equivalent (or better), when compared to a traditional hospital admission. A confluence of market forces has driven rapid expansion in the model across the past year. Health systems are increasingly looking to hospital at home to address emerging consumer demand for care outside the hospital, and achieve the longer-term goals of providing flexible, lower-cost acute care capacity. And payers are looking to add hospital at home capabilities to their growing virtual and home-based care platforms to manage acutely ill Medicare Advantage beneficiaries in a lower-cost care setting.

Early adopters estimate that as many as 30 percent of patients admitted to hospitals today could be candidates for treatment at home. The large infusion of funding from Kaiser and Mayo will enable Medically Home to scale across the US, and also provides an endorsement of, and commitment to, the care model from these respected systems, which may help convince physicians who remain skeptical. Coupled with the Centers for Medicare & Medicaid Services’ waiver program, allowing payment for home-hospital care, this investment should drive a new wave of growth in the model—and will likely make hospital at home a routine part of the care options available to patients.


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

Hospital volume continues an uneven recovery

Though consumers say they’re increasingly confident in returning to healthcare settings, hospital volume is not returning with the same momentum across the board. Using the most recent data from analytics firm Strata Decision Technology, covering the first quarter of this year, the graphic below shows that observation, inpatient, and emergency department volumes all remain below pre-COVID levels. Consumers are still most wary about returning to the emergency department, with volume down nearly 20 percent across the past year. Meanwhile, hospital outpatient visits rebounded quickly, and have been growing steadily month over month, finishing March 2021 at 36 percent above the 2019 level. Meanwhile, a recent report from the Commonwealth Fund shows that no ambulatory specialty fully made up for the COVID volume hit by the end of last year. But some areas, including rheumatology, urology, and adult primary care, have bounced back faster than others. With continued success in rolling out vaccines and reducing COVID cases, we’d expect a continued recovery of most hospital visit volume. It may be, however, that some areas, such as the emergency department, will never fully recover to pre-COVID levels. To the extent those visits are now being replaced by more appropriate telemedicine and urgent care utilization, that’s welcome news. But the continued lag of inpatient admissions indicates that some of the loss of emergency volume is more worrisome—warranting continued efforts on the part of providers to reassure patients it’s safe to use healthcare services. Stay tuned as our team continues to dig into this data.


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

Sharing experiences from the “COVID war zone”

At a recent health system board meeting, we moderated a panel of physicians who shared their experiences taking care of patients during the pandemic. They didn’t hold back on the details or the raw emotion. One doctor shared the deep trauma nurses are experiencing after so many of their COVID patients died during the winter surge. ICU nurses are used to losing a patient every week or two, but during the worst of COVID, multiple patients were dying every day. However, it wasn’t just the number of deaths, he said, but the intense bonds nurses developed with patients. A patient who ultimately dies from COVID is often in the hospital for three or four weeks. With no visitors, nurses took the place of a patient’s family, so the deaths hit even harder. And funeral homes were overwhelmed during the worst of the surge, leaving nurses with the awful task of placing deceased patients in body bags —often for the first time in their careers. “Our nurses experienced trauma similar to being a soldier in a war zone,” he concluded, “and we’ll surely see many of them showing signs of PTSD.” Soon, strategic discussions will shift away from COVID. Directly hearing the unforgettable experiences of caregivers, shared in a very honest and private forum, can provide critical context for the inevitable questions boards and executives will face around labor cost control and workforce shortages.

Should hospitals mandate the COVID vaccine for employees?

As we’ve talked to health system executives about the challenges of rolling out COVID vaccines in their communities, one topic keeps coming up: how difficult it’s been to get hospitals’ own workers fully vaccinated. One system told us recently that only 55 percent of their frontline caregivers have opted to get vaccinated, despite early and easy availability, and ongoing encouragement from the hospital’s leaders. Healthcare workers, it turns out, are just like the general population, bringing the same diversity of perspectives and concerns about vaccination to work with them from their own communities. Vaccine hesitancy is not a new issue for hospital staffers; getting the workforce to take the flu vaccine is an annual struggle for many hospitals. But given the risks of COVID-19, why not just mandate that hospital employees get the vaccine, as other employers have started to do? We commonly hear two concerns. One is a labor relations worry: will mandating vaccination cause workers to quit, or make it harder to hire staff in an already difficult market for talent? And given growing concerns about unionization of healthcare workers, will mandatory vaccination become a flashpoint issue? The second concern is medical liability: can we force workers to get a vaccine that hasn’t been fully approved by the FDA? Would that expose the hospital to legal challenges down the road, if there turn out to be long-term complications from the vaccine? Our own view is that the first concern is overblown—we suspect vaccine mandates are going to become more and more common as the economy reopens. As to the second, we’re more sympathetic. But once the FDA does grant full approval for the vaccines, we’d hope hospitals will get tougher about vaccine mandates (with the necessary exemptions for health, religious, and other concerns). At the end of the day, hospitals are in the patient care business, and they should view vaccine mandates—whether for COVID or for influenza—as a patient safety issue, not a workforce engagement issue.


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

On last Monday’s episode, we heard from Spencer Hutchins, CEO of the San Diego-based virtual behavioral health group Concert Health. The company works with primary care practices to collaboratively address patients’ physical and mental health needs.

Next Monday, we’ll be joining Alex in the studio to talk about recent investment activity in primary care startups, which are trying to revamp the traditional practice model by putting consumers at the center.

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Give this a spin—you might like it.

It’s turning out to be a banner year for the UK post-punk/post-rock scene, with the constellation of young bands in the Speedy Wunderground production stable delivering album after album of great material. The most recent: the long-anticipated debut album from Squid, a foursome from Bristol, entitled Bright Green Field. It’s a daring album for the band’s first outing—while they generally adhere to the “classic” post-punk sound, there are heavy elements of krautrock, drone, punk-funk, and even antique instrumentation (the father of one of the bandmembers makes a guest appearance playing the rackett, or “sausage bassoon”—a Renaissance-era wind instrument). It’s a sprawling album, built around dystopian themes drawn from the sci-fi writing of J.G. Ballard and others, but it manages to cohere, rather than feeling like a box of broken toys. That’s partly thanks to the vocals of Ollie Judge, who also serves as the band’s drummer; sounding like a manic Mark E. Smith or one of the Sleaford Mods, his shouty singing propels the album forward, giving the band a center of gravity around which they can spin their improvisational ideas. In true post-rock, collectivist fashion, Squid’s songs are never really finalized—even the studio recording captures just one version of a dozen different directions each track could take, with each band member bringing their own creative inventions to each recording. With a debut this good and this unpredictable, there’s no telling where they’ll go next as a band. But it’s sure to be fascinating. Best tracks:Narrator”; “Pamphlets”; “Boy Racers”.


Stuff we read this week that made us think.

Digital health explosion leaves benefits managers overwhelmed

Digital health has boomed during the pandemic, and the flow of investor capital has spawned hundreds of apps that purport to help employees with anything from wellness and weight loss to managing diabetes or post-op physical therapy. There are well over 100 mental health start-ups alone. And now, several companies are offering apps to help employees…manage all of their health apps. According to a recent Wall Street Journal articlethe pressure to evaluate “literally thousands” of digital health services is leaving corporate benefits managers feeling inundated and overwhelmed. Most large employers are self-insured, ultimately responsible for the cost of care for their employees. Digital health services claim they will help employers lower costs and improve health, but many are selling on vision rather than demonstrated results. And while consumers have grown accustomed to virtual care during the pandemic, creating an opening for digital solutions, employers are growing wary of an ever-expanding menu of disconnected apps. Case in point: PepsiCo’s former head of benefits chose a telemedicine service offered by the company’s existing health plan, over Teladoc, which they viewed as a standalone service. The push for coordinated solutions from fewer vendors will inevitably spur even more consolidation—and those companies that can move toward a single-source platform for health management needs will most likely find success.

How COVID has changed evidence-based practice

It’s understandable that doctors were willing to try almost any plausible treatment during the chaos of the first wave of the pandemic, when hundreds of people were dying every day from a novel pathogen. But a new paper in Nature argues that the rush to try any treatment for COVID-19 that could plausibly work, rather than working to understand what was actually effective, inflicted lasting damage on the field of evidence-based medicine. One specialist compares doctors’ views on evidence-based treatment before and after COVID to dining. Before COVID, doctors viewed scientific evidence similarly to how diners viewed restaurants with high Michelin star ratings: impeccably produced food, with highly curated and sourced ingredients. But during the pandemic, it was “as if doctors were staggering home from a club after ten pints of lager and would swallow any old evidence from the dodgy burger van on the street…they didn’t know where it came from, or what the ingredients were…they would just eat anything.” A troubling metaphor, to be sure.

Clinicians’ willingness to accept unproven treatments wasn’t the only blow to evidence-based practice. The pandemic spurred a flurry of “junk research”, with thousands of poorly designed, subscale studies, generating clinically insignificant results—and often examining the same topics, but with little or no coordination (such as the 250 independent trials examining the effectiveness of hydroxycholoroquine). This led to a waste of time and resources. These myriad trials were then summarized in review papers, frequently written by authors who had not participated in any of the research (for example, the 30 review papers evaluating the same 11 trials of convalescent plasma, none of which included all 11 source studies). And scientists point to masking as an example of the overuse of evidence-based process, with the cry for randomized, controlled, evidence-based study data delaying the implementation of a public health measure which, in contrast to untested medications, was likely to inflict little or no harm. But the pandemic experience also provided a roadmap for better investigation during an uncertain event. The UK-based RECOVERY trial, which quickly demonstrated the efficacy of steroid treatment across a large base of COVID patients, showed the importance of simple study design, short consent, and a single, consistent outcome metric to measure. COVID has also sparked the launch of “living systematic reviews”, in which researchers source and review ongoing trials, and provide a single, curated source of updated guidance. If researchers and clinicians can use the COVID experience to create a nimbler, more coordinated process to develop new clinical guidelines, the field of evidence-based medicine might just emerge from the pandemic stronger than before.

That brings us to the end of another edition of the Weekly Gist. Thanks to everyone who got in touch last week to check on us—we missed a week because things got busy with our day jobs, but we’re glad to be back. Keep the messages coming; we love hearing your feedback and suggestions. And please remember to pass this along to friends and colleagues, and encourage them to subscribe, and to listen to our excellent daily podcast!

Most of all, please let us know if there’s anything we can do to 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