Handicapping the Players in the Quest for Healthcare Affordability - Paul Keckley (2024)

As campaigns for November elections gear up for early voting and Congress considers bipartisan reforms to limit consolidation and enhance competition in U.S. healthcare, prospective voters are sending a cleat message to would-be office holders:

Healthcare Affordability must be addressed directly, transparently and now.

Polling by Gallup, Kaiser Family Foundation and Pew have consistently shown healthcare affordability among top concerns to voters alongside inflation, immigration and access to abortion. It is higher among Democratic-leaning voters but represents the majority in every socio-economic cohort–young and old, low and middle income and households with/without health insurance coverage., urban and rural and so on. It’s understandable: household economic security is declining: per the Federal Reserve’s latest household finances report:

• 72% of US adults say they are doing well financially (down from 78% in 2021)
• 54% say they have emergency savings to cover 3 months expenses ($400)—down from high of 59% in 2015.
• 69% say their finances deteriorated in 2023. They’re paying more for groceries, fuel, insurance premiums and childcare.
• Renters absorbed a 10% increase last year and mortgage interest spike has put home ownership beyond reach for 6 in 10 households

Thus, household financial security is the issue and healthcare expenses play a key role. Drug prices, hospital consolidation, price transparency and corporate greed will get frequent recognition in candidate rhetoric. “Reform” will be promised. And each sector in the industry will offer solutions that place the blame on others.

Granted, the U.S. health system lacks a uniform definition of healthcare affordability. It’s a flaw. In the Affordable Care Act, it was framed in the context of an individual’s eligibility for government-subsidized insurance coverage (8.39% adjusted gross income for households between 100% and 400% of the federal poverty level). But a broader application to the entire population was overlooked. Nonetheless, economists, regulators and consumers recognize the central role healthcare affordability plays in household financial security.

Handicapping the major players potential to win the hearts and minds of voters about healthcare affordability is tricky:

• Each major sector has seen the ranks of its membership decrease and the influence (and visibility) of its bigger players increase. They’re easy targets for industry critics.
• Each sector is seeing private equity and non-traditional players play bigger roles. The healthcare landscape is expanding beyond the traditional players.
• Each sector is struggling to make their cases for incremental reforms while employers, legislators and consumers want more. Bipartisan support for anything is a rarity: an exception is antipathy toward healthcare consolidation and lack of price transparency.
• All recognize that affordability is complicated. Unit cost and price increases for goods and services are the culprit: excess utilization is secondary.

Against this backdrop, here’s a scorecard on the current state of preparedness as each navigates affordability going into Campaign 2024:

The biggest, investor-owned health insurers own the advantage today. As in other sectors, they’re growing faster than their smaller peers and enjoy advantages of scale and private capital access to fund their growth. A handful of big players in the other sectors stand-out, but their affordability solutions are, to date, not readily active.

In each sector above, there is consensus that a fundamental change in the structure, function and oversight of the U.S. health is eminent. In all, tribalism is an issue: publicly-owned, not for profits vs. investor-owned, independent vs. affiliated, big vs. small and so on.

Getting consensus to address affordability head on is hard, so not much is done by the sectors themselves. And none is approaching the solution in its necessary context—the financial security of a households facing unprecedented pressures to make ends meet. In all likelihood, the bigger, more prominent organizations in their ranks of these sectors will deliver affordability solutions well-above the lowest common denominators that are comfortable for most Thus, health care affordability will be associated with organizational brands and differentiated services, not the sectors from which their trace their origins. And it will be based on specified utilization, costs, outcome and spending guarantees to consumers and employers that are reasonable and transparent.

Paul

PS: Many of you sent notes about accident May 22. Thank you. I’m recovering slowly but the event has reminded me of the consequence of our collective journey to create a more effective system of health. We’ve got a long way to go.

Resources

Federal Reserve Board – Survey of Household Economics and Decisionmaking May 21, 2024

New DOJ Task Force Targets Health Care (natlawreview.com)

Sections in today’s Report

• Quotables
• Capital
• Consumers
• Hospitals
• Insurers
• Physicians
• Polling

Quotables

Re: Emergency medicine evolution: “For most of human history, healthcare has followed a fine-dining model, with a highly personalized, curated experience. A century ago, physicians visited patients in their homes. Medicine subsequently became more specialized, but the essence of the patient-physician contract remained unchanged — until someone rightly became concerned that the fine-dining approach to healthcare wasexorbitantly expensive and quite inequitable.

What followed was an era ofcountless fixes aimed at achieving the affordability, efficiency, and consistency of a fast-food joint while maintaining the quality of a fine dining establishment: standardized guidelines, outcomes tracking, cost analyses, virtual visits, the electronic medical record, integrated care delivery, specialty centralization,fast-tracks for low-acuity patients, value-based medicine, and patient-centric care. Even the legendary Atul Gawande, MD, MPH, jumped into the fray with avision of fast-casual medicine .

Unfortunately, this decades-long, well-intended effort to fix healthcare somehow saddled our EDs with the worst of both dining options: long waits, limited or strained interaction with staff, an experience that is neither consistent nor highly personalized. It’s not the kind of experience most patients want, and it’s exceedingly frustrating for staff.”

Fast-Food Medicine: EDs Desperately Need a New Model of Care | MedPage Today

Re: value-based care performance: “Nearly 20 years ago, policymakers had an epiphany: The health care system should pay for value instead of volume. Unfortunately, it’s now less clear than ever what value-based payment means, and whatever it is, it hasn’t lived up to the hype.

Value-based payment, also known as value-based care, is getting renewed attention in Congress as doctors become increasingly distressed by a Medicare pay system that does not keep up with inflation.

Lawmakers are considering changes to the way Medicare pays doctors for the first time since Congress passed a law in 2015 that leaned heavily on value-based payment. A key House committeetook up the matterlast fall. The Senate Finance Committee also held a hearing on physician payment this year and recently published a30-page paperon potential changes to the system. Congressional Medicare advisers also have been studying physician payment. Next month, they will give Congress some informal ideas for reforms.

Whatever Congress does to change physician reimbursem*nt, there will no doubt be talk of improving quality measures, aligning incentives for better outcomes, and paying for better care at lower costs. All of those goals could describe value-based care. Which begs the question: What is value-based care?”

Value-based payment gets new attention. But what does it mean? (statnews.com)

Re: CVS strategy profile: “The company operates nearly 10,000 drugstore locations across the country and more than 1,100 Minute Clinics. CVS also is theparent company of major health insurer Aetna, which has 25 million members, and pharmacy benefit manager CVS Caremark.

CVS spent nearly $20 billion to pick up Signify Health ($8 billion) and Oak Street Health ($10.6 Billion) last year. It then rebrandedits health services business to CVS Healthspire…Healthspire (that) encompasses CVS’ pharmacy services business, its care delivery assets, including home health company Signify Health and Medicare-focused primary care player Oak Street Health, as well as its new Cordavis operation…

Through Signify, CVS provides 2 million home visits annually. Oak Street employs about600 primary care providers and has more than 170 medical centers across 21 states. The company plans to increase the number of health centers by another “50 to 60” in 2024,Forbes reportedin August. CVS said in February it planned to nearly double the business to 300 clinics by 2026 and aimed to grow the number of Oak Street patients over time, Reuters reported.

Oak Street’s model has resulted innearly a 50% reduction in hospitalizations and reductions in healthcare expenditures…

We’ve now partnered with 200 health systems, 70,000 physicians, nearly a million Medicare members now are provided support services, whether that’s care management, social determinants of health screening and connection to community-based services…Through these investments, CVS is trying to offer more affordable healthcare services. .

CVS Health boasts that it connects 55 million individuals who are digitally engaged with the brand. “We have specialty pharmacy and 95% of individuals who interact with specialty pharmacyare doing that through a digital application. CVS Health works with electronic health record company Epic andis the largest install of Epic’s EHR in the U.S. CVS has nearly 80 million patients’ records and has exchanged over half a billion records between CVS Health and other providers and health systems.

CVS bets big on health services despite retail health struggles (fiercehealthcare.com)

Re: international comparisons: “Comparing health system performance internationally is complicated, though, as each country has unique political, economic, and social conditions. Because health spending and health outcomes are often correlated with a country’s wealth…

Despite spending far more money than any peer nation, Americans live shorter lives and often face more barriers to care. Some of this disparity can be attributed to aspects of the U.S. health system, but socioeconomic and other factors also play a role…

The largest category of health spending in both the U.S. and comparable countries is spending on inpatient and outpatient care, including payments to hospitals, clinics, and physicians for services and fees such as primary care or specialist visits, surgical care, provider-administered medications, and facility fees. Americans spent $7,500 per person on inpatient and outpatient care, compared to $3,851 in peer countries, on average. The U.S.’s higher spending on providers is driven more by higher prices than higher utilization of care. Patients in the U.S. haveshorter averagehospital stays andfewer physician visitsper capita, while manyhospital procedureshave been shown to have higher prices in the U.S.­ Higher spending on inpatient and outpatient care drives most of the difference in health spending between the U.S. and its peers

Cost is not the only reason why a person may miss or delay needed medical care. Physician availability can also impact access to care. The U.S. has just 2.7 practicing physicians per 1,000 residents, compared to an average of 3.9among peer nations.

Also of concern in the U.S. is the ratio of primary to specialty care providers… only 12% of doctors are primary care physicians (PCPs). Specialist care is more expensive than primary care, driving costs up for patients and health systems.

The U.S. faces thisphysician shortageand high rates of specialization partly due to how medical education is structured…Additionally, the U.S. has only 0.14 psychiatrists per 1,000 residents, the second lowest of all peer nations. Although the U.S. has a high number of specialist providers, only 6% are psychiatrists, compared to an average of 10% of specialists in other countries examined. Despite clear and increasing demand for mental health treatment, psychiatry remains one of thelowest-paid physician specialties in the United States.”

International Comparison of Health Systems | KFF

Re: DOJ Antitrust enforcement: “Everyone deserves access to a competitive healthcare marketplace.

If you need medical care, fair competition helps lower the price you pay and improve the quality of your care. If your job is in healthcare, competition helps you get a fair wage and opportunities to grow.

The Department of Justice’s Antitrust Division, the Federal Trade Commission, and the Department of Health and Human Services work to promote competitive and fair healthcare markets.

Information from the public is vital to our work. If you would like to submit a healthcare competition complaint, please use the button below.

Antitrust Division | Help us ensure access to fair and competitive healthcare markets for you and your family. | United States Department of Justice

Re: hospital performance vs. regulator reports: “A Tennessee agency that is supposed to hold accountable and grade the nation’s largest state-sanctioned hospital monopoly awards full credit on dozens of quality-of-care measurements as long as it reports any value — regardless of how its hospitals actually perform.

Ballad Health, a 20-hospital system in northeast Tennessee and southwest Virginia, has received A grades and an annual stamp of approval from the Tennessee Department of Health. This has occurred as Ballad hospitals consistentlyfall short of performance targets established by the state, according to health department documents.

Because the state’s scoring rubric largely ignores the hospitals’ performance, only 5% of Ballad’s final score is based on actual quality of care, and Ballad has suffered no penalty for failing to meet the state’s goals in about 50 areas — including surgery complications, emergency department (ED) speed, and patient satisfaction.”

State Gives Hospital Monopoly an ‘A’ Grade — Even When It Reports Failure | MedPage Today

Re: Cancer care costs: “Nearly 60% ofworking-age cancer survivorsreport facing some financial difficulty. Many patients struggle to afford care and end up taking on debt, with some getting payday loans or running up credit cards. Cancer alone accounts for some 40% of medical campaigns seeking financial help on GoFundMe, research shows.

The problem starts withcosts for medical careandcancer drugsthat have either risen above the rate of inflation or have high starting prices. Common cancer drugs have list prices that go well into the six figures…

Many insurers have shifted rising healthcare costs to patients. Some employer-backed plans require patients to pay a percentage of a drug’s cost, which can add up to thousands of dollars. One report found a15% increase in out-of-pocket costsfor privately insured, working-age cancer patients from 2009 to 2016. Patients also foot the bill for transportation, lodging, child care and parking…

People with cancer are at higher risk of ending uplate on credit-card payments, mortgage payments, and experiencing other financial challenges than noncancer patients…”

Cancer diagnosis and treatment in working‐age adults: Implications for employment, health insurance coverage, andfinancial hardship in the United States – Yabroff – CA: A Cancer Journal for Clinicians – Wiley Online Library

Capital Markets: Private Equity, Venture Capital, Investment Banks

Re: PE deals in healthcare IT in 1Q2024: VC and PE activity In Q1 2024, healthcare IT companies cumulatively raised $1.0 billion in VC funding across 74 deals, representing a 3.3% increase in deal value and a 10.4% increase in deal count QoQ. Cumulative VC deal value for healthcare IT over the past 12 months decreased by 11.9% compared with the previous 12 months… PE investors announced or closed 23 healthcare IT deals in Q1 2024, down 14.8% from Q4 2023. Over the past 12 months, PE investors have announced or closed 25.7% fewer healthcare IT deals than in the previous 12 months.

Notably, General Catalyst involved in 3 of the 10 HCIT deals in 1Q: HIPPOCRatic AI (Process Automation), Chamber Cadio (VBC Enablement), & Fabric (Resource Management)

Q1_2024_Healthcare_IT_Report_Preview.pdf (pitchbook.com)

Private equity market in 2024: “The largest publicly traded PE firms generated strong fund inflows year-over-year, driven primarily by private credit. However, the weak exit environment carried into 2024, impacting realizations in buyouts and other core PE strategies, ourQ1 2024 US Public PE and GP Deal Roundupfinds.

Firms continue to flock to private credit, which drew 69.8% of fund inflows.Private wealth and insurance remain major fundraising channels, after accounting for an estimated 47.8% of credit fundraising in 2023.“

Q1 2024 US Public PE and GP Deal Roundup | PitchBook

Private equity in nursing homes: “Berkley East is one of the more than 70% of the roughly 15,000 U.S. nursing homes now run by companies seeking to make a profit in a field beset by challenges. A CBS News investigation found….The vast majority of quality problems in the U.S. are centered in for-profit nursing homes,” said Harvard professor David Grabowski, who told CBS News the ownership structures of for-profits have become more complicated, as investment from private equity firms and real estate companies have poured in.

There is mounting evidence patients are paying the price.A studyreleased by the federal government in November shows these for-profit facilities tend to have lower quality ratings, fewer registered nurses, and more safety violations.

In a statement to CBS News, the American Healthcare Association, a nursing home industry lobbying group, called the federal staffing mandate “unrealistic.” It said while it supports financial transparency and accountability, those matters are “a distraction” from larger issues it says most nursing homes are facing, including chronic government underfunding and worker shortages.

Inan August 2023 report,the group said 24% of nursing facilities were forced to close a wing, unit, or floor due to labor shortages.”

As investors pour in, for-profit nursing homes leave some seniors in need – CBS News

Consumers:

Study: Financial burden of healthcare on commercially insured populations: The Brigham Women’s researchers examined the finances of 96,075 families, as well as a weighted cohort of 83.5 million families for total spending– premiums, copays and out-of-pocket expenses for care and prescription drugs. Financial medical burden was calculated on average at 8.4% of post-subsistence income in 2007. That number climbed to 9.8% by 2019. Highlights:

• For low-income families who did not qualify for Medicaid and had private insurance, the burden of medical expenses reached 23.5% in 2007 and hit 26.4% in 2019. Families were classified “low income” if they brought in less than 200% of thefederal poverty line, which in 2019 was $25,750 in annual income for a family of four.
• The cost of medical expenses increased from 5.4% in 2007 to 6.5% in 2019 for higher income families.

“[Our findings] suggest that, without stronger emphasis on regulating premiums, controlling out-of-pocket costs is necessary but not sufficient to alleviate the burden of healthcare. The factors contributing to risings costs included the aging of the population over time, but drug costs, healthcare service mergers, and increased profits for insurers have also significantly increased the cost of care.”

Shashikumar, S.A., Zheng, Z.N., Maddox, K.E.J., et al. (May 28, 2024). “Financial Burden of Health Care in the Privately Insured US Population.”JAMA Internal Medicine.

Hospitals

AHA Report: ‘Costs of Caring’ asserts gap between hospital costs, insurer premiums and inflation: Per the new American Hospital Association report:

• Hospital expenses in 2023 were comprised of labor (60%), supplies (13%), drugs (8%), other expenses (19%)
• Economy-wide inflation grew by 12.4% between 2021 and 2023 vs. 5.2% increase in Medicare reimbursem*nt for hospital inpatient care
• Cumulative Medicare & Medicaid underpayments to hospitals were: $375 billion for 2013-2017 vs. $522 billion from 2018-2022.
• In 2023, insurer premiums increased 6.7% vs. hospital price increases of 2.6%

Costs of Caring | AHA

Hospital margins, volume: According to theLabor Department, prices for medical care increased by 2.7% year-over-year in April. Meanwhile, prices for hospital services grew by 7.7%, the largest increase in any month since October 2010.

According to aSTAT+analysis of 20 large nonprofit health systems, 16 reported higher operating and net margins in the first quarter of 2024 compared to the same period in 2023. These higher margins are largely due to increased patient volumes and reduced reliance on expensive contract labor.

Hospital margins are increasing — and so are prices (advisory.com)

Hospitals push back on CMS’ TEAM program: Last month, the Center for Medicare and Medicaid Innovation requested comments on its Transforming Episode Accountability Model, or TEAM, which employs a mandatory episode-based reimbursem*nt for lower-extremity joint replacements, femur fracture surgeries, spinal fusions, coronary artery bypass grafts and major bowel procedures for care coordination through 30 days post procedure starting in 2026.

CMS set a June 10 deadline for comments: theAmerican Hospital Association and Federation of American Hospitals‘ request for a one-month extension as hospitals face “alternative payment model” overload. Per AHA, the five types of surgical procedures proposed for inclusion in TEAM comprised over 11% of inpatient [prospective payment system] payments in FY 2023.

Medicare pay bundling program may overwhelm providers: AHA, FAH | Modern Healthcare

Report: Hospital imaging volume down: From 2020 to 2023, general X-ray procedure volumes in main hospital radiology departments declined by 16%, from 88.7 million in 2020 to 74.5 million in 2023, an annualized rate of decline of 4.3%…Hospitals with fewer than 200 beds saw an annual decrease of 4.6%, while those with 200 to 399 beds experienced a 7% decrease. Hospitals with 400 or more beds had a marginal decrease of 0.1%.

In 2023, chest, spine, abdomen/pelvis, and extremity scans combined for a total of 79% of X-ray procedures in main radiology departments. Between 2020 and 2023, chest exams sustained an average annual decrease per site of 8.5%; spine a 1% increase; abdomen/pelvis a 7.2% decrease; and extremities a 4.8% decrease.”

95% of hospitals with fewer than 200 beds, 81% of hospitals with 200 to 399 beds, and 66% of hospitals with 400 beds or more reported wait times under 24 hours.

Hospital-based X-ray volumes dropped 16% from 2020 to 2023 (dotmed.com);”IMV 2024 Diagnostic X-Ray Market Outlook Report.”

Insurers

Study: The J.D. Power 2024 U.S. Commercial Member Health Plan Study, released last week measured member satisfaction on 8 dimensions for 147 health plans in 22 regions of the U.S. Highlights:

• Large gap emerges between top- and bottom-ranked health plans:Overall satisfaction with commercial health plans is 565, up 3 points from 2023. Beneath that improvement, however, a 79-point gap in customer satisfaction has emerged between top- and bottom-ranked health plans. While the highest-performing plans in the study see their overall satisfaction scores rise 20 points this year, those for the lowest-scoring performers have declined 8 points.
• Cost, access to care and trust drive biggest gaps in customer experience:The overall gaps in customer satisfaction between top- and bottom-performing health plans are largest in the dimensions of helping to save time and money (87 points); ability to get health services how/when I want (84); and trust (84).
• Many insurers have portal problems:One universal challenge observed across nearly all health plans evaluated in the study is digital customer experience. “The overall satisfaction score with the commercial health plan digital experience is just 565, which is significantly lower than for other service industry digital experiences, such as mortgage origination (730); direct banking (718); telehealth (698); and Medicare Advantage (652).”
• Increasing wait times to see providers:The average wait time to see a specialist is now 22 days, and the average wait time to schedule an annual physical exam is 15 days. These wait times climb to 25 days and 18 days, respectively, among the lowest-performing health plans.

2024 U.S. Commercial Member Health Plan Study | J.D. Power (jdpower.com)

Physicians

Growth in Hospital or Corporate Employment by Physicians: Percent increase in hospital or corporate-employed physicians and owned practices, 2019-2023 (by region)

Physicians Advocacy Institute (PAI) Report: Hospital and Corporate Acquisition of Physician Practices and Physician Employment 2019-2023, April 2024

Medicare, Medicaid Behavioral Health Providers per 1,000 Enrollees: Urban vs Rural Counties

HHS, A Lack of Behavioral Health Providers in Medicare and Medicaid Impedes Enrollees’ Access to Care, March 2024

Report: Physician compensation: Highlights of the 2024 Doximity Physician Compensation Report:

• The average pay for doctors rose by 5.9% in 2023, rebounding from a 2.4%decline the previous year.
• The gender pay gap is 23%, down from 26% in 2022 with male physicians earning nearly $102,000 more on average than their female counterparts, even after controlling for specialty, location, and years of experience.
• 81% of physicians reported feeling overworked, 59% considered changing their employment situation, and 30% contemplated early retirement. Burnout remains a pressing issue, primarily on the administrative side.
• 75% say they are willing to accept lower pay for more autonomy or better work-life balance.

2024 Doximity Physician Compensation Report

Report: MGMA Provider Compensation and Production 2024: Highlights reflecting 2023 data from more than 211,000 physicians and advanced practice providers (APPs):

• The pace of growth in median total compensation for primary care physicians held at 4.44% from 2022 to 2023.
• Surgical specialist physicians saw a 4.42% jump in median total compensation in 2023, nearly 2 percentage points higher than the 2.54% growth from 2021 to 2022.
• Nonsurgical specialists reported only a 1.81% uptick in median total compensation in 2023.
• APP median total compensation increased 6.47% in 2023
• Providers’ gains kept pace with inflation, exceeding the 3.4% change in 2023 in the Consumer Price Index (CPI). However, these providers’ compensation shifts lag the 5-year CPI surge of 22%.
• Setting differences:
  • Primary care physicians operating in physician-owned settings reported $154,940 more in total collections, 289 more total encounters and $11,163 more in total compensation than those in hospital-owned settings.
  • On average, nearly 25% of primary care physicians’ total compensation is based on productivity, while around 3% is tied to their performance related to improving care quality and the patient experience.
  • Surgical specialists in physician-owned settings saw $88,250 more in total collections, 372 less total encounters and $88,250 less in total compensation.
  • Advanced practice providers in physician-owned settings saw $129,001 more in total collections, 483 less total encounters and $11,631 more in total compensation.
  • In physician-owned settings, primary care physicians had 549 more work RVUs, surgical specialists had 1,607 and APPs had 1,027.
  • Across the board, physician compensation increased in every region, with the exception of nonsurgical specialists, who saw a 3.4% decrease in pay in Midwestern states.

2024 Provider Compensation Data Report (mgma.com)

Study: Physician inducements: A JAMA study found that93% of physicians who endorsed a prescription drug or medical device on X — formerly known as Twitter — received at least one payment from the manufacturers of these products.

The average was more than $27,400 for things such as food and beverages, speaking, consulting, or travel. 61% of the endorsem*nts were sponsored testimonials and nearly half of the doctors failed to disclose any compensation from the manufacturers.

Industry Payments to Physicians Endorsing Drugs and Devices on a Social Media Platform | Ethics | JAMA | JAMA Network

Polling

Pew: May 2024 polling: Poll conducted May 13-19 among 8,638 members of the Center’s nationally representative American Trends Panel:

• 23% of U.S. adults say the economy is in excellent or good shape, down from 28% in January but higher than the 19% who rated the economy positively last April.
• The public again sees inflation as one of the top problems facing the nation, with 62% saying inflation is a very big problem for the country – only slightly down from the 65% who said this last year. But another economic concern – unemployment – isnotwidely viewed as a very big problem for the country. Just 25% of Americans currently say it’s a very big problem.
• Overall, 57% said the affordability of healthcare is a “very big problem” in the U.S. today including 48% of Republicans and 65% of Democratic voters. It is 3^nd of 16 issues behind inflation (62% overall, 46% Dem, 80% GOP) and the ability of Rep and Dem in Congress to work together (60%/57% Dem, 63% GOP). Drug addiction is #4 (55%),

Americans’ Views of Economy Slip, Inflation Still Seen as Major Problem | Pew Research Center