November 22, 2019

The Weekly Gist: The I Want Nothing Edition

by Chas Roades and Lisa Bielamowicz MD

Another week of high drama in Washington, as we were glued to our screens watching the impeachment proceedings. We thought nothing could top last week’s real-time Twitter shade-throwing (or, possibly, witness intimidation), but this week has exceeded our wildest expectations. Within hours of a West Lawn press conference where President Trump’s talking points were accidentally captured by a reporter’s camera, the internet produced this absolute classic. (Here’s an explainer for the Smiths-deficient.) Quid pro quo? “You just haven’t earned it yet, baby.”

Note to readers: We’ll be off for the holiday next week, but back in action on Friday, December 6th. Happy Thanksgiving!


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

Elizabeth Warren outlines her 100-day healthcare plan

Democratic presidential candidate Sen. Elizabeth Warren (D-MA) used Wednesday night’s debate in Atlanta to outline a new healthcare transition plan released by her campaign this week. Earlier this month the candidate provided a detailed plan to pay for “Medicare for All” (M4A), the approach to single-payer, universal coverage she favors. The plan she unveiled this week addresses the healthcare agenda for her “first 100 days”, and how she proposes to approach the rollout of M4A. She intends to use the budget reconciliation process in the Senate (assuming Democrats take control) to bypass a Republican filibuster and institute a “public option” for those over 50 to buy into an “improved Medicare program” with expanded benefits, free coverage, auto enrollment, and negotiated drug prices. A second M4A option would be made available to everyone else, free for those making under 200 percent of the federal poverty line, and with limited premiums for others. After three years, she would then put forward more comprehensive M4A legislation that eliminates private coverage and institutes a single-payer framework. Supporters of more robust M4A immediately criticized the transition plan as “backpedaling”, worried that Warren would never actually be able to implement full single-payer healthcare. If true, that puts her more in line with her moderate Democratic competitors, who have introduced similar public option plans of their own. Perhaps for that reason, discussion of M4A absorbed relatively little airtime in the latest debate, compared to earlier rounds. We continue to view M4A as more of a political rallying cry than a plausible policy outcome, but Warren’s new transition plan is as detailed as anything we’ve seen. Should she get elected, the question will be: does she expend political capital on M4A, or pursue her broader wealth-redistribution plans first? Doing both may be an impossible political lift.

North Carolina’s Medicaid overhaul is put on hold

As anticipated, North Carolina’s contentious and long-awaited Medicaid overhaul was put on indefinite hold this week, because of a disagreement between the governor and legislature over the state’s budget. A last-minute bill passed by the Republican legislature to fund the transition separately from the broader budget was vetoed by Democratic Gov. Roy Cooper. In part, the budget dispute revolves around Cooper’s desire to expand Medicaid eligibility as part of the funding plan, which the legislature refused to do. Medicaid beneficiaries have already begun to enroll in the new Medicaid managed care plans, which were slated to go into effect in February of next year. However, the lack of funding for the program has forced the state to initiate a “wind-down” process, leaving the state’s 1.6M Medicaid recipients in the traditional fee-for-service program for now. North Carolina is one of the few remaining states that has not yet moved its Medicaid recipients into private managed care coverage, and the pending overhaul was approved in 2015 by a majority Republican state legislature.

The current budget battle is another example of how the debate over Medicaid has come to dominate states’ political dynamics, as the cost burden of the coverage program consumes an ever-larger chunk of state budgets. Just across the state line, Tennessee this week formally submitted a request to the Trump administration to allow it to turn its Medicaid program into a block grant model, giving it greater flexibility over how it pays for the program. It remains unclear whether the Centers for Medicare and Medicaid Services (CMS) has the legal authority to approve such a move—a question that will surely be decided by the courts. Meanwhile, North Carolina is emerging as a proving ground not just for Medicaid transformation but for a wide variety of new approaches aimed at controlling the rising cost of care and driving innovation in care delivery. More on that below.

In the immortal words of Jerry Seinfeld…Glamour?

Coming on the heels of a flurry of announcements of policy measures to increase transparency in healthcare, new revelations regarding contracting practices at CMS may have some in Washington wishing for a little less openness. As reported this week by Politico, officials at the agency engaged public relations consultants for a $2.25M contract to provide suggestions for how to boost the profile of CMS Administrator Seema Verma, including by having her profiled by Glamour magazine and other media outlets. The story was first uncovered in March by intrepid healthcare reporter Dan Diamond (our former colleague—miss you, Dan!), best known for breaking an earlier story that led to the firing of former Health and Human Services (HHS) Secretary Tom Price. According to Diamond’s reporting, CMS paid consultants hundreds of thousands of dollars for “strategic communications” support over the course of two years, much of it aimed at crafting a publicity plan for Verma, who has played a much more visible, and political, role in advancing the administration’s healthcare agenda than her predecessors. Verma faced tough questioning about the PR contracts from Rep. Joe Kennedy (D-MA) in House oversight hearings last month, although the use of consultants was halted after Politico began reporting on them earlier this year. While Kennedy made the valid point that money spent on PR could be better spent on providing health coverage to kids, we’re willing to believe that a more thorough campaign to educate the public on policy initiatives is a worthy idea. Less clear, though, is why Verma’s personal profile seems to have been a focus of the effort. We’d rather see George Costanza and other readers of Glamour get more information on how to shop for healthcare services, or how to make smarter decisions about how to get the most out of their coverage. Or perhaps the best use of public relations dollars would be to restore funding to the Navigator program, aimed at helping individuals sign up for coverage on—especially given the lagging results of this year’s open enrollment season thus far.


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

Surveying the landscape of healthcare’s most dynamic state

North Carolina has developed a national reputation as a hotbed of healthcare transformation. We’ve spent a lot of time in the Tar Heel State across the past year and can report that the reputation is well-deserved. The graphic below breaks down some of the forces driving change in the state. Two major state-led policy initiatives look to reshape the healthcare marketplace. While North Carolina has resisted Medicaid expansion, the state is poised to move its Medicaid program to a managed care model, while maintaining its historic focus on care management and social care. And no policy has been more controversial than State Treasurer Dale Folwell’s plans to implement reference pricing for the state’s health benefits plan.

While both of these initiatives have hit delays and roadblocks, private sector-led transformation continues apace. With the state’s two largest health systems joining its shared-risk Blue Premier program earlier this month, Blue Cross Blue Shield of North Carolina (BCBS-NC), the state’s dominant commercial payer, continues to pursue its ambitious goal of moving nearly all health system contracts to risk. The state’s doctors see opportunity in disruption. Two large physician groups recently left hospital employment arrangements and “returned independent”, raising the question of whether these moves are a harbinger of further physician “secession” to come. And with a strong economy coupled with fast growth in Medicare Advantage, it seems nearly every venture-backed disruptor is targeting the state, from physician network builder Aledade, to health plan start-ups like Bright Health and Devoted Health, and care managers Iora Health and Cityblock—presence confirmed by the myriad billboards seen on a recent drive through the middle of the state. We’ll keep watching the state closely for lessons on how the interplay of these changes affects healthcare consumers and providers.


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

A new vision for rural healthcare

Last week we had the chance to spend time with Community Care of North Carolina (CCNC), an organization with decades of experience providing care management, analytics, and other support to North Carolina providers, largely focused on enabling better care for the state’s Medicaid population. CCNC is tightly affiliated with Community Care Physician Network, a clinically integrated network of over 2,700 primary care doctors across the state, roughly half of whom practice in a rural setting.  CCNC has been a leader in rural healthcare delivery, and Dr. Allen Dobson, the organization’s President and CEO, posed a compelling idea for resourcing and reorganizing rural healthcare. “Every rural community needs three things: primary care, a pharmacy, and an ambulance,” Dobson shared. He drew on his experiences from observing healthcare in the remotest regions of Alaska, where state and local providers have long utilized a care platform built around these three services to deliver high-quality care, often hundreds of miles from the nearest hospital. For a variety of reasons ranging from care access to local economic concerns, rural health policy has largely focused on propping up the current hospital-centric delivery system. But providing high-quality rural healthcare requires a re-envisioning of the full healthcare continuum with less reliance on acute care. Coupled with telemedicine support, Dobson’s vision of a local triad of a primary care doctor for routine care, a pharmacy to access medication, and ready transportation when emergencies happen, could provide a sustainable foundation for local, quality care.

Calling BS on an all-too-common refrain

At a recent conference, I heard a health system executive say something that nearly triggered me to go into full Grumpy Old Man mode, which is not my usual demeanor (despite what my kids might tell you). Echoing the increasingly popular rhetoric that hospitals are the bad guys of American healthcare, here’s what he said: “We need to move from a sick care system to a ‘well care’ system. We should view every hospital admission as a failure of the system.” Look, I’m no stranger to applause-line pablum, but come on. Of course, it’s true that the payment system leads hospitals to over-rely on costly settings for care that could be delivered more effectively elsewhere. And it goes without saying that if we did a better job of helping people stay healthy, many people who end up in hospital beds, wouldn’t. But “a failure of the system”? Hardly. I’d argue that modern hospital care is a crowning achievement of healthcare—think of the lives saved and medical miracles performed every day—at least if used appropriately. It does us no good to demonize hospitals, especially as we confront the realities of an aging population and 80M or more Baby Boomers who are just now hitting their “peak healthcare years”. Don’t get me wrong, I’m a big proponent of “population health” approaches that let us move care into ambulatory clinics, community settings, and even patients’ homes. But the line of argument that treats hospitalization as a failure will lead us to overly simplistic policy solutions, all the while demoralizing the world-class doctors, nurses and other clinicians that work in our nation’s hospitals. Our healthcare challenges call for a much more sophisticated, nuanced view of the role hospitals play in our society.


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

You may have noticed the vinegary tang of Tar Heel BBQ in today’s edition. Well, it’s also been North Carolina Week on Gist Healthcare Daily, where each morning we’ve shared interviews with key stakeholders across that state’s fascinating healthcare scene:

On Monday North Carolina Secretary of Health Dr. Mandy Cohen talked about how the state’s budget stalemate is causing big problems in the move to Medicaid managed care. The state is also trying innovative approaches to address social determinants of health centered around primary care.

Then, on Tuesday, Chief Medical Officer of Blue Cross Blue Shield of North Carolina Dr. Rahul Rajkumar predicted the company would hold healthcare cost growth to less than wage growth by 2022, which he says is necessary to make a dent in affordability. The company is aggressively moving providers, both big and small, to value-based care and shared risk agreements.

Cone Health CEO Terry Akin said Wednesday he believes the market will ultimately catch up with and reward his system’s value-based approach to healthcare. Akin said health systems have to decide whether they will be paralyzed by current payment realities or be a part of evolving the system.

Thursday, Charlotte-based primary care Dr. Tagbo Ekwonu explained how coming together with other doctors has renewed confidence in his decision to remain independent. He’s excited about starting value-based care arrangements with payers for his commercial, Medicare and Medicaid patients.

Friday, North Carolina State Treasurer Dale Folwell discussed his months-long public battle for price transparency. He believes the way to lower the cost of healthcare is to give consumers the power to choose based on quality and price.

And coming up on Monday, we’ll hear from Dr. Allen Dobson, President of Community Care of North Carolina. As Lisa described above, that organization brings together close to 3,000 primary care doctors across the state to help serve Medicaid patients.

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

Thanksgiving Week looms, and with that comes open vistas of time to sprawl on the couch and get your binge-watching game on. If you’re on the hunt for something a little grittier and more exciting than college football or the back catalog of Disney princess and Star Wars movies on your new streaming service, may we recommend Fauda, the hit Israeli counterterrorism drama on Netflix? Launched on Israeli TV in 2015, the show (whose title means “chaos” in Arabic) is the creation of two former members of the Israeli Defense Forces, one of whom also plays its main character. It tells the story of a special infiltration unit working in the occupied West Bank and is notable not only for its gripping plot and Homeland-style pacing, but also for its nuanced portrayal of the Hamas and (in the second season) ISIS terrorists that are the show’s main villains. There’s plenty of heart-pounding, special-ops set pieces along the way, but Fauda provides a fuller picture of life on the Palestinian side of the Green Line, and a better sense of the complicated situation at the heart of the Israeli-Palestinian divide, than we often get to see on TV. Some of the plot devices are a bit wooden and predictable, but the characters are no cardboard-cutout clichés. The show is in Hebrew and Arabic, with English subtitles, though a dubbed English version is available (but not recommended). Now’s a good time to get into it—a third season will premiere in Israel next month, and on Netflix next spring.


We said it, they quoted it.

To Lower Costs, Trump to Force Hospitals to Reveal Price of Care
New York Times; November 15, 2019

“The administration’s decision to aggressively tackle the secrecy surrounding hospital prices came amid widespread concern about rising costs for medical care. Democrats have also been campaigning on soaring health care costs, and both parties fear entering the 2020 campaign season with unfulfilled promises to gain control of out-of-pocket health spending.

People ‘are increasingly exposed to the crazy pricing of health care,’ said Chas Roades, one of the founders of Gist Healthcare, a consulting firm in Washington. ‘We are overdue for a public airing of how all of this works.’

While the hospitals’ legal challenge may succeed, they are vulnerable to the increasing public outcry over high prices, Mr. Roades said. ‘It’s not a good look for the industry to push back on transparency on prices.’”


Stuff we read this week that made us think.

Major study questions advantage of heart surgery and stents  

Results from a major multi-institution study showed that invasive therapy was no more effective than medical treatment for patients with symptomatic but stable coronary artery disease. The ISCHEMIA trial enrolled over 5,000 patients with moderate to severe stable ischemic disease (defined as having chest pain with exertion, but no recent changes in level of symptoms) who were randomly assigned to an “interventional” track, treated with bypass surgery or angioplasty and stents, or a “medical therapy” track. Interventional treatment provided a modest decrease in chest pain while exercising but gave no advantage over optimal drug therapy in reducing cardiac death, heart attacks, or heart-related hospitalizations. These findings suggest that invasive procedures should be used more sparingly, as early intervention for stable blockages provides little advantage. While some elements of the study’s design are controversial, the study is good news for many patients, who can feel more confident choosing medical management. Further, the outcomes raise the longer-term question of whether payers might alter coverage for invasive procedures for this category of heart disease sufferers, who comprise over half of symptomatic patients. And should the results bear out, physicians and hospitals could see a significant decline in profitable cardiac procedures—potentially lowering the total cost of care but dealing a major blow to providers’ bottom lines.

A look inside rural America’s busiest emergency room

The country’s busiest rural emergency department treats over 15,000 patients a year—and is located in a South Dakota industrial park, according to a fascinating Washington Post profile of the country’s largest emergency care telemedicine program. Avera eCare, part of Sioux Falls-based Avera Health, provides coverage to 179 hospitals in 30 states. Connected to rural EDs via a sophisticated technology setup that can even provide a camera-eye view down an unconscious patient’s throat during intubation, 15 doctors and 30 emergency nurses rotate through the program. The acuity of the patients treated is high. The program manages over 300 cardiac episodes, 200 traumatic injuries, and 80 overdoses in the average month; doctors report seeing more critical cases in one shift than they would see in a month in a regular ED. The eCare program supports many emergency rooms staffed solely with nurses and advanced practice providers—but has paradoxically helped retain rural doctors as well, providing them much-needed thought partnership and vacation coverage. The piece is well worth a read to see high-impact telemedicine in action, and provides a glimpse into a rural care delivery model that could be expanded across settings and specialties to bring the best clinical expertise to the most underserved areas of the country.

Thanks for joining us for the Weekly Gist! Among the many things we have to be thankful for, we truly appreciate you taking the time to read our work, and we hope you’ll share your comments and feedback! If you’ve enjoyed this, please pass it along to a friend or colleague and encourage them to subscribe. And don’t forget to check out our daily podcast!

Most importantly, please let us know 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