THCB

Categories

Category: Health Policy

“What’s Up With The Alitos?”

By MIKE MAGEE

The 1st Presidential debate is just around the corner. What should be Jake and Dana’s 1st CNN question. Here’s a suggestion:

What’s up with the Alito’s these days?

Justice Sam weighed in with tipping the American scale (by virtue of his decisions) toward “godliness,” while a seemingly unhinged flag-flying Martha-Ann invited the world inside their marriage, declaring “He never controls me.” Good to know.

Making it clear that her visceral reaction to a neighbor’s PRIDE flag was faith-based, she revealed a short-fuse and a long memory. As she said, “I want a Sacred Heart of Jesus flag because I have to look across the lagoon at the pride flag for the next month. I said (to Sam), ‘When you are free of this nonsense, I’m putting it up.’”

Harvard sociologist, Robert Putnam, and his co-author, Notre-Dame political scientist David Campbell, made it clear in 2010 that something was up with gender, religion and politics in their publication, “American Grace: How Religion Divides and Unites Us.” In two sweeping surveys reported in the book, they revealed a change in attitudes that began to gain steam in 1970. To their surprise, “By 2006, majorities of every religious tradition except Mormons had come to favor women clergy. Nearly three-quarters of Americans said that women have too little influence in religion, a view that is widely shared across virtually all religious traditions and by both men and women.”

A recent AEI survey this year that catalogued religious affiliation of Boomers (1946-1964), Gen X (1965-1980), Millennials (1981-1996), and Gen Z (1997-2012) showed that women (in much greater numbers than men) apparently have had just about enough when it comes to religious subjugation. Only 14% of the baby boomer women were self-described religious “nones,” while 34% of Millennials and a whooping 39% of Gen Z’s were turning their backs on male-led religions.

The problem, experts say, tracks back to the concept of “complementarianism”, a belief that the Bible supports strictly different roles for men and women, and that “wives should submit to their husbands.”

Subjugation of women historically has taken many forms. The most recent has been the elimination of health care access with the Dobbs decision and reversal of Roe v. Wade. But placing a lid on women’s autonomy has a rich history in America. Take for example divorce.  It was outlawed in most states south of the Mason-Dixon line until the mid-19th century. As legal historian Lawrence Friedman explained, “Essentially husband and wife were one flesh; but the man was the owner of that flesh.”

In 1847, Wisconsin newspaperman and editor of the Racine Argus, Marshall Mason Strong, warned in an editorial that the “domestic sphere” was under attack with men being “degraded, the wife unsexed, and children uncared for.” Strong lamented the loss of women’s “finer sensibilities” with “every trait of loveliness blotted out.”

Two centuries later, the majority of women are having none of it, delivering political defeat after political defeat to religious conservatives after the Dobbs decision. That decision was the culmination of a carefully planned and executed conservative takeover of the Supreme Court with Justice Alito in the lead. His intent, according to Yale legal scholar Neil S. Siegel, was to protect “Americans who hold traditionalist conservative beliefs about speech, religion, guns, crime, race, gender, sexuality and the family. These Americans were previously majorities in the real or imagined past, but they increasingly find themselves in the minority.”

What do the Alito’s fear most? They fear that traditionalists like themselves will be “branded as bigots.” Justice Alito said as much in his dissent in Obergefell v. Hodges (same sex marriage). He wrote with some sense of drama “Those who cling to old beliefs will be able to whisper their thoughts in the recesses of their homes. If they repeat those views in public, they will risk being labeled as bigots and treated as such by governments, employers, and schools.”

His campaign to “protect majorities-turned-minorities” was also on full view five months before the 2016 Presidential election in his dissent after the Court declined to hear the case of a Washington State pharmacist who refused to fill prescribed contraceptives on religious grounds. Stormans, Inc. v. Wiesman, left standing according to Alito, was “likely to make a pharmacist unemployable if he or she objects on religious grounds to dispensing certain prescription medications…If this is a sign of how religious liberty claims will be treated in the years ahead, those who value religious freedom have cause for great concern.”

AEI has little encouragement to offer the Alito’s.

The survey’s conclusion is rather stark: “None of this is good news for America’s places of worship. Many of these young women are gone for good. Studies consistently show that people who leave religion rarely come back, even if they hold on to some of their formative beliefs and practices. The decline in religious participation and membership has provoked a good deal of concern and consternation, but these latest trends represent a four-alarm warning.”

And therein lies the problem. The recent actions of the Alito’s simply dig the hole deeper, as they await a reckoning with demographic fate. For the Alito’s, “the moment has revealed the man (and the woman).”

Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical-Industrial Complex. (Grove/2020)

Adding a Sustainability Lens to Health Innovation Pilots

By MARIE COPOULOS & MONICA NAKIELSKI

Following a year of growing conversation about the links between the climate and our health, a new proposed rule from the CMS Innovation Center (CMMI) links value-based payment innovation and sustainability for the first time, creating important precedent for an emerging connection in the health care sector and for system strategy.

In mid-May, CMMI proposed its first innovation model with a sustainability component, Transforming Episode-Based Accountability, or TEAM. The TEAM model is a successor to episode-based alternative payment models and notable in that it’s a mandatory payment model overall, though the sustainability component is voluntary. As proposed, acute care organizations selected to participate will have the option to opt into emissions reporting, opening the door to receive feedback and technical assistance. This is the first visible link between value-based payment and sustainability from CMMI, a test of a concept that–like all initiatives coming from CMMI–could give way to scale.

This follows on a year in which emissions reporting and the intersection of climate and health generally (which includes thinking about the health implications of factors like heat, air, and water, or simply put climate as a social determinant of health) has become more prominent. The Joint Commission began offering its Sustainable Health Care certification, a voluntary program. The Securities and Exchange Commission (SEC) passed a ruling requiring disclosure of carbon emissions and associated risks. This SEC ruling requires Scope 1 and Scope 2 emissions reporting from all publicly traded companies, which will include many of the largest health systems. And these rules follow on the heels of new reporting requirements for organizations operating in California, requiring emissions reporting for organizations larger than $1B on not only Scope 1 and Scope 2 but also Scope 3 emissions and climate-risk disclosure for organizations operating in excess of $500 million. Most hospitals and systems fall within these financial parameters. The reporting rules follow Task Force for Climate-related Financial Disclosures (TCFD) standards, which a number of organizations use today.

These proposals and programs are in their infancy. The SEC and California rulings will no doubt be contested and the CMMI proposal is voluntary in nature. However, there is a clear trend toward speaking about climate initiatives in terms of their health impacts and grappling with the health industry’s role in mitigating emissions overall. The CMMI proposed rule is important because it puts the sustainability discussion in the context of health care delivery and payment innovation broadly at CMS.

This matters because sustainability initiatives require similar core success factors to delivery reform and benefit from alignment. In fact, some of the breakthrough thinking happening in the sustainability space builds on the skill sets and experience gained in the value-based payment over the last decades, including:

  • Financial modeling: Sustainability investments challenge existing financial models because of the long timelines for return on investment–a lot like population health models that incent preventative care over long timeframes.
  • Workforce development: In both sustainability and climate adaptation (i.e. encouraging more resilient health systems), new skillsets are needed. In value-based payment, building competencies in care management and data analysis has been a central focus over the last decade. Both these skill sets (identifying and working closely with patients with significant health risks and using data to inform the work) and the practice of re-equipping the current workforce create important precedents.
  • Data strategy: While ESG reporting is largely focused on risk and financial in nature, we expect to see new sets of best practices around data collection, monitoring, and measurement–tapping into existing data sources as the field evolves. As sustainability reporting broadens out of the financial context into strategy, there is a lot of room to take advantage of the improved data functionalities of health systems for impact.

Finally, and perhaps most critically, a natural evolution of these pilot initiatives is to think not only about reducing emissions, but to reduce the impacts of environmental factors (like heat and poor air and water quality) on population health and specifically on patients with existing complex needs. When viewed in this longer-term context, as a social determinant of health, it underscores the importance of linking new payment and delivery models to this conversation. While this new proposal from CMMI is a small step in this direction, it’s an important one that we hope will seed greater participation and conversation in the health innovation space.

Marie Copoulos is the Managing Principal of Horta Health, LLC and a subject matter expert in health delivery and payment reform in Medicare and Medicaid models. Monica Nakielski is an ESG & Sustainability Advisor at Hameda LLC and a subject matter expert in sustainability and ESG efforts.

“Truth, Justice and The American Way” – Chris Reeve on Donald Trump.

By MIKE MAGEE

As we approach the 20th anniversary of the death of Christopher Reeve, I’m drawn back to the evening of September 25, 2002, and a private conversation in a back room off the ballroom of the Marriott Marquis Hotel. As we awaited the ceremonial beginnings of the Christopher Reeve Paralysis Foundation Benefit Gala that evening, he said, “What I didn’t expect was that in this country, home of ‘Truth, Justice and the American way,’ hope would be determined by politics.”

That sentiment was, no doubt, fresh in his mind, having just appeared in his book, “Nothing Is Impossible: Reflections On A New Life” (Random House), a week earlier. And it was top of mind last month while (with millions of other Americans) I awaited a verdict in the New York trial of Donald Trump.

A month earlier, Smithsonian Magazine had run a feature on the first issue of the Superman comic book. The original copy of the 1938 “Action Comics No. 1” had just sold for $6 million at auction. A large part of that value tracked back to Chris Reeves himself – the enduring image and voice of Superman – a genuine American hero.

The famous slogan, “Truth, Justice, and the American Way”, however did not appear in that first publication. It surfaced later, in the early 1940’s comic books, written by Jerry Siegel and Joe Shuster, “to cheer on American military efforts in World War II.” Its use waxed and waned over the next three decades until 1978. That’s when the Richard Donner film “Superman: The Movie” was released starring Christopher Reeve. As the Superman Homepage News acknowledges, it was thanks to Reeve’s performance that “the ‘Truth, Justice and The American Way’ motto was really cemented in popular culture for generations to come.”

In a controversial move, at the DC FanDome on October 21, 2021, DC Publisher Jim Lee announced that Superman’s motto “Truth, Justice and the American Way” would be “evolving.” “The American Way” would now be replaced by “a Better Tomorrow.” A press statement elaborated that the move was made “to better reflect the storylines that we are telling across DC and to honor Superman’s incredible legacy of over 80 years of building a better world.” Rolling Stone was given a slightly different spin by DC Comics which said, “Superman has long been a symbol of hope who inspires people from around the world, and it is that optimism and hope that powers him forward.”

Whether commercial, philosophical or political in motivation, now two years later, as Trump self declares his own “Superman-status” its worth contrasting two very different versions of “the American way.” As NewYork Magazine reported in 2012, “Among the many laughably unrealistic images in the Donald Trump NFT collection, one stood out: the illustration of the former president in the classic Superman pose, ripping open his dress shirt to reveal a superhero costume underneath. Trump used this image, which was animated to show lasers shooting out of his eyes, to tease a ‘major announcement’ on December 15, which turned out to be a collection of 45,000 digital trading cards. ‘America needs a superhero!’ Trump proclaimed.”

Continue reading…

Oh. Never Mind

By KIM BELLARD

You may have read the coverage of last week’s tar-and-feathering of Dr. Anthony Fauci in a hearing of the House Select Subcommittee on the Coronavirus Pandemic. You know, the one where Majorie Taylor Greene refused to call him “Dr.”, told him: “You belong in prison,” and accused him – I kid you not – of killing beagles. Yeah, that one.

Amidst all that drama, there were a few genuinely concerning findings. For example, some of Dr. Fauci’s aides appeared to sometimes use personal email accounts to avoid potential FOIA requests. It also turns out that Dr. Fauci and others did take the lab leak theory seriously, despite many public denunciations of that as a conspiracy theory. And, most breathtaking of all, Dr. Fauci admitted that the 6 feet distancing rule “sort of just appeared,” perhaps from the CDC and evidently not backed by any actual evidence.

I’m not intending to pick on Dr. Fauci, who I think has been a dedicated public servant and possibly a hero. But it does appear that we sort of fumbled our way through the pandemic, and that truth was often one of its victims.

In The New York Times,  Zeynep Tufekci minces no words:

I wish I could say these were all just examples of the science evolving in real time, but they actually demonstrate obstinacy, arrogance and cowardice. Instead of circling the wagons, these officials should have been responsibly and transparently informing the public to the best of their knowledge and abilities.

As she goes on to say: “If the government misled people about how Covid is transmitted, why would Americans believe what it says about vaccines or bird flu or H.I.V.? How should people distinguish between wild conspiracy theories and actual conspiracies?”

Indeed, we may now be facing a bird flu outbreak, and our COVID lessons, or lack thereof, could be crucial. There have already been three known cases that have crossed over from cows to humans, but, like the early days of COVID, we’re not actively testing or tracking cases (although we are doing some wastewater tracking). “No animal or public health expert thinks that we are doing enough surveillance,” Keith Poulsen, DVM, PhD, director of the Wisconsin Veterinary Diagnostic Laboratory at the University of Wisconsin-Madison, said in an email to Jennifer Abbasi of JAMA.

Echoing Professor Tufekci’s concerns about mistrust, Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told Katherine Wu of The Atlantic his concerns about a potential bird flu outbreak: “without a doubt, I think we’re less prepared.” He specifically cited vaccine reluctance as an example.

Sara Gorman, Scott C. Ratzan, and Kenneth H. Rabin wondered, in StatNews, if the government has learned anything from COVID communications failures: in regards to a potential bird flu outbreak,  “…we think that the federal government is once again failing to follow best practices when it comes to communicating transparently about an uncertain, potentially high-risk situation.” They suggest full disclosure: “This means our federal agencies must communicate what they don’t know as clearly as what they do know.”

But that runs contrary to what Professor Tufekci says was her big takeaway from our COVID response: “High-level officials were afraid to tell the truth — or just to admit that they didn’t have all the answers — lest they spook the public.”

Continue reading…

Cost Containment Through Health Improvement

By BEN WHEATLEY

The U.S. is in the midst of an ongoing—and still expanding—health care cost crisis. Even among people with health insurance, medical debt has become a persistent problem. Top executives at nearly 90% of large employers believe the cost of providing health benefits to employees will become unsustainable in the next 5-10 years. And the nonpartisan Congressional Budget Office (CBO) is warning that expanding federal debt—driven largely by health expenditures and compounding interest payments—indicates that a major fiscal crisis is looming.

On this last point, it is true that reputable people have been predicting fiscal collapse for many years. In 1988, Benjamin Friedman wrote that we’re facing a Day of Reckoning. Pointing to the rising federal debt, he said: “we are living well by running up our debt and selling off our assets. America has thrown itself a party and billed the tab to the future.”

Peter G. Peterson wrote a book in 1993 called Facing Up: How to Rescue the Economy from Crushing Debt and Restore the American Dream. In it, he said that “runaway medical costs are the single most important reason that federal spending and federal deficits have now become ‘uncontrollable.’”

Not everyone agreed that deficits and debt were problematic. In 2003, as Republicans were pursuing further income tax cuts, Vice President Dick Cheney declared: “Reagan proved that deficits don’t matter.”

David Stockman was Ronald Reagan’s first budget director and one of the chief architects of the Reagan Revolution—a plan to cut taxes and reduce the size and scope of government. He wrote in The Triumph of Politics that the Reagan Revolution failed because the administration had not been able to control spending, leading to massive increases in the federal debt.

In 2013, Stockman wrote a book called The Great Deformation: The Corruption of Capitalism in America. He said that during the Great Recession, the Federal Reserve Bank had carried out “the greatest money-printing spree in world history.” Between 2004 and 2012, 70 percent of rising U.S. debt was absorbed by central banks. He said that “the world’s central banks have morphed into a global chain of monetary roach motels. The bonds went in, but they never came out.” He concluded that it was easy money, which the Federal Reserve System had supplied for decades, that was responsible for “deficits without tears.” “American politicians…had essentially died and gone to fiscal heaven.” They were able to spend money “without the inconvenience of taxing.” Both Democrats and Republicans have taken advantage of this changed reality.

In 2020, Stephanie Kelton wrote a book called The Deficit Myth: Modern Monetary Theory and the Birth of the People’s Economy. In it, she called for a paradigm shift: since the U.S. has the ability to print its own money, we should recognize that federal spending is not financed by tax revenue or borrowed funds. Whenever the need is pressing enough (e.g., warfare), we can and do supply whatever money is needed. The real deficit, she said, is not the fiscal deficit, but societal needs that are going unmet. Regarding health care, “our failure to provide proper insurance and care for every American is not because the government cannot ‘afford’ to cover the cost.” It’s just that we are operating under the wrong budget paradigm.

Importantly, though, Kelton wasn’t saying that there is a free lunch. She wrote, “It is possible for the government to spend too much. Deficits can be too big. But evidence of overspending is inflation, and most of the time deficits are too small, not too big.” This dovetails with David Stockman’s concerns about unsound money. And it mirrors the concerns of the CBO, which has said that a fiscal crisis would involve higher rates of inflation and an erosion of confidence in the U.S. dollar.

Containing Health Care Costs

If the CBO is to be believed, deficits and debt do matter. And although there have been “Cassandras” saying the sky is about to fall for many decades now, there may come a point in time when the need for cost containment becomes immediate and vital. (Some would argue that we’re already there.) Health care is a primary driver of fiscal deficits and, in an emergency, it would become a primary target for budget savings.

In this context, cuts to Medicare and Medicaid become a central focus.

Continue reading…

A Call for Responsible Antibiotic Use in the Era of Telehealth

By PHIYEN NGUYEN

Telehealth has revolutionized health care as we know it, but it may also be contributing to the overuse of antibiotics and antimicrobial resistance.

Antibiotics and the Risks

Antibiotics treat infections caused by bacteria, like strep throat and whooping cough. They do this by either killing or slowing the growth of bacteria. Antibiotics save millions of lives around the world each year, but they can also be overprescribed and overused.

Excessive antibiotic use can lead to antimicrobial resistance (AMR). AMR happens when germs from the initial infection continue to survive, even after a patient completes a course of antibiotics. In other words, the germs are now resilient against that treatment. Resistance to even one type of antibiotic can lead to serious complications and prolonged recovery, requiring additional courses of stronger medicines.

The Centers for Disease Control and Prevention reported that AMR leads to over 2.8 million infections and 35,000 deaths each year in the United States. By 2050, AMR is predicted to cause about 10 million deaths annually, resulting in a global public health crisis.

Increase in Telehealth and Antibiotic Prescriptions

Surprisingly, the growth of telehealth care may be contributing to antibiotic overprescribing and overuse.

Telehealth exploded during the COVID-19 pandemic and, today, 87 percent of physicians use it regularly. Telehealth allows patients to receive health care virtually, through telephone, video, or other forms of technology. It offers increased flexibility, decreased travel time, and less risk of spreading disease for both patients and providers.

Popular platforms like GoodRx and Doctor on Demand market convenient and easy access to health care. Others offer specialized services, like WISP that focuses on women’s health. Despite its benefits, telehealth is not perfect.

It limits physical examinations (by definition) and rapport building, which changes the patient-provider relationship. It’s also unclear whether providers can truly make accurate diagnoses in a virtual setting in some cases.

Studies also show higher antibiotic prescribing rates in virtual consultations compared to in-person visits.

For instance, physicians were more likely to prescribe antibiotics for urinary tract infections during telehealth appointments (99%) compared to an office visit (49%). In another study, 55 percent of telehealth visits for respiratory tract infections resulted in antibiotic prescriptions, many of these cases were later found to not require them.

Continue reading…

It’s the Bureaucrats, Stupid

By KIM BELLARD

Universities are having a hard time lately. They’re beset with protests the like of which we’ve not seen since the Vietnam War days, with animated crowds, sit-ins, violent clashes with police or counter protesters, even storming of administration buildings. Classes and commencements have been cancelled. Presidents of some leading universities seemed unable to clearly denounce antisemitism or calls for genocide when asked to do so in Congressional hearings. Protesters walked out on Jerry Seinfeld’s commencement speech; for heaven’s sake – who walks out on Jerry Seinfeld?

Derek Thompson wrote a great piece for The Atlantic that tries to pinpoint the source problem: No One Knows What Universities Are For. The sub-title sums up his thesis: “Bureaucratic bloat has siphoned power away from instructors and researchers.”  As I was nodding along with most of his points, I found myself also thinking: he might as well be talking about healthcare.

Mr. Thompson starts by citing a satirical piece in The Washington Post, in which Gary Smith, an economics professor at Pomona College, argues that, based on historical trends in the growth of administration staff, the college would be best served by gradually eliminating faculty and even students. The college’s endowment could then be used just to pay the administrators.

“And just like that,” Professor Smith says, “the college would be rid of two nuisances at once. Administrators could do what administrators do — hold meetings, codify rules, debate policy, give and attend workshops, and organize social events — without having to deal with whiny students and grumpy professors.”

It’s humorous, and yet it’s not.

The growth in universities’ administrative staff is widespread. Mr. Thompson acknowledges: “As the modern college has become more complex and multifarious, there are simply more jobs to do.” But that’s not always helping universities’ missions. Political scientist Benjamin Ginsberg, who published The Fall of the Faculty: The Rise of the All-Administrative University and Why It Matters in 2014, told Mr. Thompson: “I often ask myself, What do these people actually do? I think they spend much of their day living in an alternate universe called Meeting World.”

Similarly, Professor Smith told Mr., Thompson it’s all about empire building; as Mr. Thompson describes it: “Administrators are emotionally and financially rewarded if they can hire more people beneath them, and those administrators, in time, will want to increase their own status by hiring more people underneath them. Before long, a human pyramid of bureaucrats has formed to take on jobs of dubious utility.”

All of these administrators add to the well-known problem of runaway college tuition inflation, but a more pernicious problem Mr. Thompson points to is that “it siphons power away from instructors and researchers at institutions that are—theoretically—dedicated to instruction and research.”

The result, Mr. Thompson concludes is “goal ambiguity.” Gabriel Rossman, a sociologist at UCLA, told him: “The modern university now has so many different jobs to do that it can be hard to tell what its priorities are.”  Mr. Thompson worries: “Any institution that finds itself promoting a thousand priorities at once may find it difficult to promote any one of them effectively. In a crisis, goal ambiguity may look like fecklessness or hypocrisy.”

So it is with healthcare.

Anyone who follows healthcare has seen some version of the chart that shows the growth in the number of administrators versus the number of physicians over the last 50 years; the former has skyrocketed, the latter has plodded along. One can – and I have in other forums – quibble over who is being counted as “administrators” in these charts, but the undeniable fact is that there are a huge number of people working in healthcare whose job isn’t, you know, to help patients.

It’s well documented that the U.S. healthcare system is by far the world’s most expensive healthcare system, and that we have, again by far, the highest percent spent on administrative expenses. Just as all the college administrators helps keep driving up college tuition, so do all those healthcare administrators keep healthcare spending high.

But, as Mr. Thompson worries about with universities, the bigger problem in healthcare is goal ambiguity.

Continue reading…

Want to get rich in health care? Ditch the startup and run a hospital

By MATTHEW HOLT

Given that I ran a health technology conference for many years, I tend to run in a circle of people who have some ambition to get rich in health care. After all, billions of dollars of VC money have been dropped in lots of startups over the last decade, and a few prime examples have done very well. For example Jeff Tangey of Doximity, Glen Tullman of Livongo,  Chaim Indig of Phressia and many others did fine when their companies IPOed in the late 2010s. But the truth is that many, many more have either started a health tech business that didn’t make it, or were foot soldiers in others that died along the way (Olive, Babylon, Pear, etc, etc). Which has been leading me lately to thinking about whether that’s the right approach to take if you want to make money in health care. Hint: it’s not.

There’s still tremendously little transparency about which health care organizations have what amount of money and what people earn. There is though one sector that by law has to publish information about revenue, profits, investments and executive compensation. That is the non-profit hospital/health system sector. Nonprofits are required to file Form 990 with the IRS that has that information and more on it. Having said that, most hospitals are frequently late in filing them, and file them in a very confusing way. The wonderful journalism organization ProPublica maintains a database of all 990 filings and it’s instructive to look around in it.

Some health systems make it relatively easy. UPMC, the huge western PA conglomerate files one 990 for the whole group. Others, not so much. I know that Providence, the huge west coast system, has overall revenue of $28bn but only because Fierce Healthcare told me. Had I tried to piece that together from its 990s, I’d have started with its Washington filing ($6bn), moved on to its Oregon filing (~$5bn) and then started getting confused..

Let’s say you wanted to easily figure out Advocate, the system that was the merger of the huge midwestern system with Atrium, the North Carolina-based one. Good luck. You can find Advocate but Atrium’s seems to be missing. Ditto for Carolinas Health, its previous name. There is a page calling itself Financial Information on the Atrium website, but it doesn’t have any, and tells you to go to a website set up for municipal bondholders. In fact I couldn’t find any evidence of the IRS auditing any large system, or fining them for non-compliance in filing.

The good news is that last year the North Carolina State Employees plan, i.e. a pissed off purchaser, dug into all the N. Carolina hospital systems and found out that Atrium’s CEO pay went up nearly five-fold over six years. But even the state had real trouble finding out the truth:

“It is important to understand that these figures are significant underestimates for three reasons. First, a legal loophole denies the public the right to see how much publicly owned hospitals reported paying their top executives on their tax filings. This failure of oversight hides the tax filings of more than three in 10 nonprofit hospitals in North Carolina, including Atrium and UNC Health. UNC Health did not answer a public records request for executive compensation data until February 13, 2023, two days before this report’s publication and almost three months after its receipt of the request. UNC Health’s system wide data is therefore not included in this report.” 

So the very top dogs are doing well. At UPMC it turns out that seven made more than $3m including the CEO Jeff Romoff –the same one who forgot on 60 Minutes whether he made $6m or $7m. Turns out he didn’t have to remember that number for long as by 2021 he was making $12m.

But the munificence is spreading down the executive ladder. To demonstrate, let me introduce you to Tracey Beiriger Esq. There’s almost no information about Tracey on Linkedin or anywhere else on Google other than it appears he or she is an IP lawyer at UPMC. So why do I bring them up?

Because in 2021–the last year for which UPMC filed a 990 –Tracey was the 118th highest paid executive at UPMC and had the misfortune to only make $499,446.

Which means that 117 executives working at UPMC made more than $500,000. It’s a little tricky figuring out the similar numbers at Providence because of the multiple 990s in 2021 but there are 38 in Washington (not including CEO Rod Hochman who made $9m in 2020 and then vanished from the 2021 990!), 18 in Oregon and another 21 in Southern California. So call it 80+.

I bring this up because $500,000 is a pretty decent individual income. When I asked ChatGPT it estimated about 1.2 million Americans earned that much or more. Given the workforce is 167m, that puts those several hundred hospital execs way into the top 1%.

Now I have no objection to people earning good money. I’m sure they have all worked very hard for it. But if you look at these organizations, they do not seem to be spreading the wealth very far. 

Last year UPMC was accused by unions of suppressing staff wages. There is yet to be an outcome from that complaint to the DOJ, but last week there was one from a formal class action complaint about Providence shortchanging employees by rounding down their pay to the nearest half-hour, even though they were clocking on and off by the minute. Providence was fined $200m which probably isn’t much split between 33,000 employees but at least indicates that their senior management acts just like any other aggressive business in terms of cutting costs on the backs of their employees. And it’s not just their employees. They also just got fined $137m for aggressively suing patients.

Which leads me to two final points.

The first is, is it more likely you’ll make that $500K+ in a hospital system or in a tech startup? Blake Madden at Hospitology has been tracking systems that have more than $1bn in revenue. He’s found 113 so far. Second bottom of the list is Atlanticare in NJ, which has 16 execs making more than $500K.  Which by my wild guess means that the average system has about 50 employees making $500k+  which rounds up to something like 5,000 hospital execs making at least $500K and many of them are making a whole lot more. 

Compare that to a successful health tech startup that actually makes it. Take Phreesia, a VC-backed start-up that went public in 2019 having started way back in 2007. (I know the year because CEO Chaim Indig launched at Health 2.0 in 2008. He was nice enough to let me buy some stock at the IPO and I made a few bucks). Chaim made $300K the year it went public and as CEO of a public company that’s bounced around at being worth between $1Bn and $4Bn, he made $750K last year. No one else made more than $500K. Now yes, he owned 4% of the company at the IPO and got awarded more stock. He is doing very well, but the point is that there were dozens of companies launching at Health 2.0 in 2008 and the vast majority don’t get close to an IPO or making any money for the founders, let alone the staff. 

My conclusion is, it’s not a rational bet to go the health tech route if instead you can find a regional hospital chain and brown-nose your way up into the exec ranks!

The second point is more fundamental. Remember UPMC and its 117 execs making $500K+? What would a comparable government agency be paying out? I looked at the state of California salaries.There look to be about 50 state employees making more than $500k a year, almost all working for the state investment fund CALPERS. But the top paying one only makes $1.6m a year. I’m not saying that CALPERS should be paying out that much even if it is competing with Wall Street, after all members of the Senate only make $205,000 a year and the state could just put the whole pension into an S&P index fund. But what I am saying is that we should be thinking about paying our big non-profit systems similarly to government employees because they essentially are government employees.

Beckers posted UPMC’s payor mix last year. I highly suspect you’ll find something similar at almost every big system. 

  • Medicare 48%
  • Medicaid 17%
  • UPMC as Insurer 11%–(60% of whom are Medicaid/Medicare patients)
  • Commercial, Self Pay, Other 24%

More than 70% of the money comes from the government, and the rest from the suckers who have to buy their insurance on the “open market”–which includes those buying via the ACA exchange, receiving government subsidies, and government employees.

So while these huge systems act like Fortune 100 companies and reward their executives accordingly, almost all the money comes from the taxpayer.

I wish I could say we are getting good value for it.

And yes, I didn’t even mention the for-profits and the big insurers, but that will have to wait for another day….

Matthew Holt is the founder & publisher of THCB

You Bet Your Life

By KIM BELLARD

America is crazy about gambling. Once you had to gamble illegally with a bookie, or go to Atlantic City or Las Vegas; now 45 states – plus the District of Columbia, Puerto Rico, and the U.S. Virgin Islands – have state lotteries. Since the Supreme Court struck down PASPA, the federal ban on sports betting, 38 states – plus the D.C. and Puerto Rico – offer legal sports betting. I didn’t think we could get any crazier, until I saw last week that arcade chain Dave & Busters was going to allow betting on some of its games.

Honestly, healthcare may be the only industry upon which you can’t bet, and I’m beginning to think that’s too bad.

Dave & Busters are working with Lucra Sports, a “white-label gamification” technology company. “We’re thrilled to work with Lucra to bring this exciting new gaming platform to our customers,” said Simon Murray, SVP of Entertainment and Attractions at Dave and Buster’s. “This new partnership gives our loyalty members real-time, unrivaled gaming experiences, and reinforces our commitment to continuing to elevate our customer experience through innovative, cutting-edge technology.”

“Friendly competition really is a big fuel for our economy, whether you’re playing golf on Sunday with your buddies, or you’re going to play pickleball or video games or even cornhole at a tailgate. There’s so many ways that you can compete with friends and family, and I think gamifying that and digitizing all this offline stuff that’s happening is a massive opportunity,” Lucra CEO Dylan Robbins told CNN.

The companies are careful not to describe what they’re doing as gambling; they avoid terms like “bet” or “wager.” Michael Madding, Lucra’s chief operating officer, told The New York Times that the focus was on “skills-based” games, such as Skee-Ball or shooting baskets: i.e., “recreational activities for which the outcome is largely or entirely dependent on the knowledge, ability, strength, speed, endurance, intelligence of the participants and is subject to the control of those participants.”

This falls into a category I had never heard of: “social betting.” With social betting, there is no third party setting the odds, and more head-to-head competition with people you know. You’re not betting against the house; you’re challenging your friends. It is estimated by gaming research firm Eilers & Krejcik to be a $6b market, and its proponents argue that it is not subject to licenses & regulations that other gambling does.

Not everyone agrees. Marc Edelman, a law professor and the director of sports ethics at Baruch College in New York, told NYT:

If two people are competing against one another in Skee-Ball, presuming that there is nothing unusual done in the Skee-Ball game and physical skill is actually going to determine the winner, there is no problem. If I am taking a bet on whether someone else will win a Skee-Ball game, or whether someone else will achieve a particular score in Skee-Ball, if I myself am not engaged in a physical competition, that very likely would be seen as gambling.

Brett Abarbanel, executive director of the University of Nevada, Las Vegas, International Gaming Institute, went further, telling CNBC: “regardless of the legal classification of the activity as ‘not gambling’ vs. ‘gambling,’ this is an activity in which participants are risking something of value on an outcome that is uncertain. Therefore, there should be consumer protection measures in place for players, particularly when the target audience is skewed toward younger participants.”

Both Illinois and Ohio gambling authorities have already expressed concerns; Illinois State Rep. Daniel Didech, chairman of the Illinois House Gaming Committee,, told CNBC: “It is inappropriate for family-friendly arcades to facilitate unregulated gambling on their premises. These businesses simply do not have the ability to oversee gambling activity in a safe and responsible manner.”

There are also numerous “social sportsbooks,” including Flitt, PrizePicks, and Underdog Fantasy, that are blurring the line between online sports gambling and social betting, between fantasy leagues and plain old gambling. And they do it with users as young as 13 and with little or no state oversight. Keith Whyte, executive director of the National Council on Problem Gambling, told The Washington Post: “What a lot of these social gaming — social casinos, social sportsbooks — have found is that the regulators … either don’t feel like they have the jurisdiction or the time or energy to go after every single app that springs up.” 

Whether we like it or not, people are going to bet. “People will place a bet on ‘Will we have rainfall?’, or ‘How much snow will a certain place get?’, or ‘What will be the first day of snowfall?’” sports policy expert John Holden, JD/PhD, associate professor at Oklahoma State University, told Fox 5 NY last year.

So why shouldn’t they bet on health care?

Let’s face it: we all already bet on health care.

Continue reading…

Is getting people off weight loss medications the right move?

By RICHARD FRANK

Demand for GLP-1 medications soared last year and shows no signs of stopping in 2024. Employers and health plans are understandably anxious about how long they should expect to pay for these pricey drugs. They’re itching for an easy off-ramp.

Some solutions are cropping up to pave the way. Many of them claim they can help patients reap the benefits of GLP-1s within a short time frame, and get them off the drugs within 12 months to save costs. But the data doesn’t support that promise. In fact, studies suggest some patients may need to stay on the drugs indefinitely to sustain outcomes while other patients may be able to discontinue the drugs and at least maintain their cardiometabolic risk reduction even if they cannot maintain all of their weight loss. 

A better strategy to control costs is to more accurately pinpoint those who really need the drugs—and keep those who don’t off of them from the start. Of course, there will be times when deprescribing is appropriate, and we need to clinically support patients through that process. But one-size-fits-all solutions centered on medication as a silver bullet to obesity are only setting up patients and payers for failure. Similarly, those whose sole promise is to deprescribe, don’t follow the evidence.

Prescribing GLP-1s with the goal to deprescribe is foolhardy

GLP-1s treat obesity, but they don’t cure it. GLP-1 agonists increase the body’s own insulin production and slow the movement of food from the stomach to the small intestine. The drugs help people eat less by curbing cravings and boosting satiety. Studies show that once people go off semaglutide, the cravings come back in full force—and so does much of the weight.

While GLP-1 medications produce nearly miraculous outcomes in some people, they’re no quick fix. Obesity is a complex chronic disease. Drugs alone can’t solve for genetic predisposition, behaviors, mental and emotional components, social determinants of health, and other compounding elements that contribute to obesity. In the right circumstances, drugs can give people a solid leg up in better managing those contributing factors—but they’re not for everyone.

Keto is not a sustainable replacement for GLP-1s

Highly restrictive diets like the keto diet aren’t for everyone either. Keto requires a drastic reduction in carbohydrate intake, which can be difficult to maintain long-term. Not to mention, the high-fat content of keto diets can also lead to other health issues and isn’t conducive to tapering off of GLP-1 medications. Side effects from the drugs can make a high-fat diet difficult to tolerate.

It’s good to be wary of solutions that promise an off-ramp by way of highly restrictive diets. While a keto diet may help people lose weight in the short term, studies show that weight loss is rarely sustained over the long run and may be detrimental to overhaul health. The diet is associated with many complications that often lead to hospital admissions for dehydration, electrolyte disturbances, and hypoglycemia.

Triage the right care to the right people at the right time

Obesity’s complex nature requires a personalized approach to treatment that delivers the right care to the right people at the right time. That takes a whole care team of specialized providers—like registered dietitians, health coaches, and prescribing physicians to help people at various stages of the disease. And since obesity often occurs alongside other cardiometabolic conditions like hypertension, diabetes, COPD, and more, patients need the help of specialists who understand how those different conditions interact.

Continue reading…