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Category: Health Policy

Is California Staffed For the Crisis? Not Yet.

By JAKE SEGAL and KAREN LARSEN

Call 988 in California and someone picks up. In parts of the state, a mobile crisis team might arrive at your door instead of police. Through Proposition 1, the state is putting billions into treatment beds, supportive housing, and youth services. On paper, California is in the middle of the most ambitious behavioral health expansion in the country.

And yet, about two-thirds of adults and adolescents in need of care don’t get treatment. A behavioral health system that you can’t staff is just a blueprint, not a strategy.

Even as demand for mental health and substance use treatment surges, the supply of trained professionals is not keeping pace. California needs 375,000 behavioral workers by 2030, doubling positions  statewide. State officials estimate a 38% shortfall in psychiatrists and a gap of roughly one-third among the 100,000 licensed therapists needed. Rural and underserved communities are especially hard hit; many have no child and adolescent psychiatrists at all. And shortages extend beyond doctors and therapists. Clinical social workers, addiction counselors, peer support specialists, and community health workers are also in short supply. 

Building on State Leadership

California is not starting from scratch. The Department of Health Care Access and Information (HCAI) already administers several scholarship and loan repayment programs that encourage clinicians to practice in high-need settings, including loan repayment for nurses, licensed mental health providers, substance use disorder counselors, and psychiatric nurse practitioners. Through the BH-CONNECT federal waiver, HCAI is rolling out five workforce programs over 2025–2030, including a Medi-Cal Behavioral Health Student Loan Repayment Program. 

These are important efforts, but they aren’t scaled to the size of the crisis. Loan repayment awards are often a fraction of a graduate’s full debt, and have limited availability. Even the largest programs will only target a few hundred providers; California needs thousands more.

Repayment alone doesn’t solve the immediate affordability problem: people can’t enter training if they can’t pay rent while they are doing it.

A $1 Billion Statewide Workforce Fund for California

California should create a statewide Behavioral Health Workforce “Pay It Forward” Fund: a $1 billion pool that lends money to trainees at zero interest, gets paid back as they get good jobs, and lends those same dollars out again.

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The Canaries Are All Dead

By KIM BELLARD

MIT is, most people would admit, a pretty good school.  Even those who don’t know a lot about universities probably associate MIT with science, engineering, and math, and in fact, it is one of the leading universities in the world for those (and other) areas. E.g., the QS World University Rankings have named it the top university in the world the last 14 years, USN&WR Global Universities Ranking has it #2, as does The Times Higher Education World University Rankings. There have been over 100 Nobel Laureate recipients associated with MIT. If you meet a Harvard grad you might think, oh, they may not actually be all that smart – they could be just a legacy admission, but if you meet an MIT grad you probably do expect that they must be smart, especially since MIT does not have legacy admissions. Even President Trump, who rails against “elite universities” and who has slashed science funding in his second administration (more on that later), can’t help but rave about his smart uncle who taught at MIT.

So when the President of MIT warns about reductions in research funding and in graduate school admissions, we’re not talking about the proverbial canaries in the coal mine dying. We’re talking about miners going down.  

In a video message last week, MIT President Sally Kornbluth warned of some startling losses: over 20% drops in federally funded research, in new federal research awards, and in graduate student enrollment. Overall, the school’s research enterprise has shrunk 10% in the last year.

Gulp.

“That is a striking loss for one of the most influential and productive research communities in the world,“ Dr. Kornbluth said. She added:

The fact is that we’re looking at a real drop in research being done by the people of MIT. It’s a loss of momentum for faculty and students and frankly, it’s a loss for the nation. When you shrink the pipeline of basic discovery research, you choke off the flow of future solutions, innovations, and cures, and you shrink the supply of future scientists.

Make no mistake: although MIT itself may be an outlier, what is happening to it is not. Ted Mitchell, president of the American Council on Education, told The Washington Post: “This is the first of many of these kinds of alarms that will be ringing,” Brendan Cantwell, a professor of higher education at Michigan State University, also told WaPo that if MIT is scaling back how it does research, that means universities across the country should be thinking about scaling back and adjusting. The ripple effects will go far and wide, and will have bigger impacts than we realize.

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Healthcare ‘quality’ is broken. Here’s how to fix it.

By OWEN TRIPP

For decades, quality in healthcare has been defined on industry terms — not people’s terms. New technology and innovative health plan designs are finally changing that.

People know quality when they see it, and they are definitely not seeing it in healthcare. Fifty-six percent of Americans rate the quality of care as “poor” or “fair,” and 90% believe we’re overpaying for it. Likewise, 80% of employers — collectively the largest purchasers of healthcare in the country — say that higher-quality care is a top priority for their workforce.

And yet, the U.S. healthcare system remains a global leader; a lack of know-how or quality control isn’t the problem. The problem is the wide gap between how the healthcare industry has historically defined quality and how quality is experienced by the people actually receiving and paying for care.

For the past 75 years, healthcare quality has been shaped by a grab bag of federal agencies, accrediting bodies, medical organizations, health insurers, and — more recently — consumer-focused ratings outfits ranging from U.S. News & World Report to Zocdoc. Though many pay lip service to patient experience, none has clearly defined quality — or explained it intuitively enough — to help individuals make smarter healthcare decisions based on their clinical and financial context.

Healthcare needs to move beyond narrow metrics and top doc lists to create a dynamic, value-driven view of quality that consistently connects people to the best care for them, where and when they need it — and ideally, even before they know they need it. Too often, “quality” equates to some numbers on a dashboard, when it needs to be more like a combination of GPS and driver-assist technology: guiding people to their health goals, keeping them in the highest-quality lane, and nudging them if they start to drift.

This was always the vision (for some of us). But we simply haven’t had the right mix of technology and system-wide connectivity to bring it to life. Now we do.

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Officers Eat Last

By KIM BELLARD

A New York Times interview with Rep. Jake Auchincloss (D – Mass) by Bret Stephens caught my attention. I am somewhat familiar with Mr. Stephens from his various pieces in NYT; he is definitely a conservative, but in the old, pre-MAGA sense where it meant you worried about spending but you didn’t hate people who weren’t like you. Rep. Auchincloss, on the other hand, was unfamiliar to me, but the headline of the interview – The Democrat Who Makes Me Listen – proved apt.

For me, the final line the interview summed everything up. Rep. Auchincloss is a Marine veteran, having served in Afghanistan. Mr. Stephens asked: “Final question. If there is one thing you learned in the Marine Corps which every American should know, what is it?” Rep. Auchincloss’s reply was succinct, to the point, and highly instructive: “Officers eat last.”

“Officers eat last” – wow. That’s a philosophy I can buy into. That’s a credo I hope I can live up to. That’s a slogan for a political movement I could get behind.

Of course, I’m not just talking about literally only Marine officers, and I’m not just talking about eating. I’m sure Rep. Auchincloss intended that it was a life lesson that should be applied broadly. I.e., people in authority should make sure the people they are responsible for get taken care of before they take care of themselves. I don’t think that attitude is solely responsible for the esteemed Marine esprit de corps, but it’s got to be part of it.

The trouble is, we don’t see much of that attitude in the rest of America. When Congress failed to pass a budget and millions of federal workers went without paychecks, they (and their staffs) kept getting paid. When the White House went slashing various budgets, it didn’t eliminate White House jobs.

If you want to keep your blood pressure under control, don’t even ask how generous the Congressional retirement package is. Suffice it to say that, if you are one of the few workers who still qualify for a defined benefit pension, it is almost certainly less than theirs. Don’t get me started on how members of Congress seem to get richer – a lot richer – while in office, possibly due to insider trading loopholes.

According to Gallup, only 10% of Americans approve of the job Congress is doing, with 86% disapproving, but they don’t care. They get paid anyway, and most House seats aren’t competitive, so most incumbents are in little danger of getting voted out.

This is no “officers eat last.”

It’s not just politicians.

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New Podcast on Primary Care

This is one of those “Coming Soon” announcements. I spent the weekend with the wonderful gang from what I affectionately call Camp Claudia Cult, a group of mostly Californian policy wonks led by Claudia Williams, who these days is at the UC Berkeley School of public health. As you may have noticed I’ve been spending much of my time writing and talking about the notion of Concierge Care for All. Most of the group at the Health Collab wants to blow up/burn down the current system and replace it with a primary care-driven system. And there’s lots of discussion and planning on how to do that. But there is so much happening in innovation in primary care that I thought we need a dedicated channel to discuss it.

Since the sunsetting of the THCB gang, I’ve been doing lots of tech interviews, but not many about how care works. So now I will. If you want to get involved or be interviewed, please email me — Matthew Holt

CRUSHing Lab Fraud: Three Myths that Derail Real Reform

Leeza Osipenko
Ekaterina Cleary
Julie Egginton

By JULIE EGGINGTON, EKATERINA CLEARY & LEEZA OSIPENKO

When CMS issued its Request for Information under the Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) initiative in February, it zeroed in on a long-festering problem: fraud, waste, and abuse in laboratory testing, especially in genetic and molecular diagnostics.

The laboratory industry will respond. And when it does, its arguments will sound polished, familiar, and deeply reassuring. They will also be either disingenuous or unproven.

If policymakers want this effort to succeed, they should be prepared to handle three claims that have long shielded problematic practices from meaningful oversight.

Claim 1: Fraud, waste and abuse is limited to a few bad actors

Expect labs to argue that fraud, waste, and abuse is rare, isolated, and already addressed through enforcement actions. The narrative will feature a handful of egregious cases, presented as outliers in an otherwise trustworthy ecosystem.

But the problem is not a few rotten apples. It is the orchard’s design.

Take “code stacking” for example, in which laboratories bill multiple individual genetic test codes rather than a single panel code, often inflating reimbursement. In one analysis, laboratories used between 1 and 12 billing codes for hereditary cancer panels with the same indications for testing, with estimated average charges ranging from $679 to $8,589 for ostensibly comparable tests. The repetition of these behaviors across companies suggests systemic incentives, not isolated misconduct.

Ample Medicare billing data, whistleblower cases, and Department of Justice settlements point to patterns, not anomalies: high-volume genetic panels ordered with little clinical justification, molecular pathology tests billed under grab bag and overly permissive billing codes, and aggressive marketing and patient harvesting practices targeting vulnerable populations.

A key driver is opacity. Many laboratory-developed tests (LDTs) are marketed under similar or identical names despite meaningful differences in design, accuracy, and intended use. To a clinician or payer, they appear interchangeable. In reality, they are not.

This naming ambiguity allows lower-quality tests to ride the coattails of better-validated ones, while still commanding reimbursement. Fraud, in this context, is not always a dramatic act. It is often embedded in routine billing.

Claim 2: Precision medicine advanced by genetics is worth the cost due to improved patient outcomes

The second argument will appeal to aspiration. Labs will emphasize that genetic testing is the backbone of precision medicine and therefore a worthwhile investment for CMS, despite the ballooning costs.

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Bribery, Corruption and the American Health Care Way

By MATTHEW HOLT

These days you just have to wonder about the greed and corruption that is going on all around. Senator Dick Blumenthal is one of many who’ve been pointing out the naked corruption in the Trump family–Qatari jets, memecoins, Trump’s son being on the board of so many defense and prediction market companies you can’t keep it straight. Issac Saul has tried to detail it all, but reading just the cryptocurrency part of his piece has me spinning. And we’re nowhere near assessing the naked corruption of so many others in the administration. Kristi Noem, despite being fired, is still living in her government house, and has not had to answer for routing some of a totally unnecessary $220m ad campaign to a company that her friends own. The company was incidentally established a whole 8 days before it got the contract.

So it’s a little absurd to be worrying about fraud and corruption in health care. But apparently HHS is. At least Oz and RFK Jr are going on about Somalis defrauding Medicaid and Armenians running fake hospices in California. (Let’s not even consider the optics of a Turkish citizen with close ties to the Erdogan regime criticizing Armenians–I mean the genocide was over a century ago!)

But of course, fraud and corruption in health care has been going on forever. Back in 2011 a Florida man was convicted of Medicare fraud to the tune of tens of millions and got a 50 year sentence. Don’t be surprised that Trump commuted his sentence. And that’s just one of thousands and thousands of cases, mostly by providers inventing fake patients to defraud Medicare or Medicaid.

But the ones who get convicted and go to jail are the amateurs.

If you’re a big company in health care, you fight with lawyers and you settle. For example, every big pharma company has settled for things like off-label promotion of their drugs. GSK paid $3bn, Pfizer over $2bn, J&J over $2bn. In fact back in the 2000s THCB had a regular correspondent called The Industry Veteran who basically suggested that whistleblowing in qui tam suits inside big pharma was the way to wealth and fame.  And of course HCA in its days when it was run by Rick Scott – now (somehow not a) convicted felon as well as Florida senator – settled for $1.7bn. This was all back in the 1990s and early 2000s, but it’s all still going on.

The venue though may have moved. Risk adjustment in Medicare Advantage has become one of the biggest venues for fraud. The key here is that the DOJ and HHS found that while Medicare Advantage plans were upcoding their patients, and therefore getting paid more for them, they weren’t actually delivering more services.

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Come help save democracy!

Tuesday, May 5 | 8-9 pm ET, 5-6 pm PT 

Protecting Healthcare and Our Democracy: A conversation with Mandy Cohen, Former Director, Centers for Disease Control and Prevention PLUS former NC Governor Roy Cooper & Dr. Donald Berwick, IHI founder/former president

REGISTER & DONATE

A matching fund of $70,000 is in effect for this event!

This supports the Movement Voter Project which makes grassroot investments to organize to support democracy at the local level.

I’m a co-host–Matthew Holt

A Unified Sense of Self

By MIKE MAGEE

Stanford neuroscientist, David Eagleman, reminded us this week that “A coherent explanation of consciousness eludes modern science.” That was his opening line in the New York Times book review of Michael Pollan’s latest effort, “A World Appears.” In it, Pollan asks innocently, “How does the brain generate a unified sense of self?”

According to Eagleman, “Pollan is not able to furnish the answers (no one can, yet), but he presents a captivating exploration, one that is highly personal and sensitive.” In this, he is not alone. Other fields are engaged in the same pursuit.

To begin with, there are the epigeneticists. They study “how our environment influences our genes by changing the chemicals attached to them.” In the hands of these scientists, genes are not “set in stone and (fully) predetermined.” Of late, these investigators have been unraveling how various chemicals, working on the surface and inside cells are constantly altering and adjusting how our genes work. Thus the title, since “epi” is Greek for “over, outside of, around.”

Other investigators like Professor Eddy Keming Chen in the department of Philosophy at University of California San Diego come at the problem from a different direction. She bolstered her PhD in Philosophy with a Masters in Mathematical Physics, and a graduate certificate in Cognitive Science. She teaches the PHIL 130 course on Metaphysics.

In the UCSD college syllabus, she tees up the question, “Why study metaphysics?” She promises enrollees that if they sign up, they’ll find a bit of magic in exploring tough questions, like: “Do we have free will? Is it compatible with causal determinism? What is the place of the mind and of the consciousness in a physical world?”

In the Jesuit world that I came from, such courses were mandatory as part of the core curriculum. In my own alma mater, they no longer carry the same mandate, but still remain alive and well.

Consider, for example PHL 365 – a 3 credit course at LeMoyne College titled Philosophy of Mind. Once again, there is magic in the air for inquiring minds.

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Concierge Care for All: Yes, It Really Is That Simple

By MATTHEW HOLT & CLAUDE

You’ll recall that a few weeks back I gave Claude some prompts and my entire corpus of work on THCB and asked it to write a piece. It was about 70% my ideas and 50% my writing tone. I’m back trying it again. This time I gave it a lot of prompts from some Linkedin pieces and comments I wrote and then I spent about 20 minutes editing it. This one is about 85% my idea and maybe 70% my tone? I have rewritten something in every paragraph. But it’s a hell of a lot faster than me writing from scratch. So I am going to keep experimenting like this for a while.

This started as a LinkedIn post about Merril Goozner’s plan to cut health care costs. He pointed out that the Center for American Progress’s new 10-point health reform plan is just more incrementalism and–worse–too boring for anyone to pay attention. Goozner’s own proposal, capping out-of-pocket expenses, isn’t much better. We’ve spent nearly a century proving that incremental reform in American health care doesn’t work — we still have tens of millions uninsured, patients going bankrupt, and outcomes that trail most of the developed world. And of course it enables profiteers to massively extract wealth from the system. In other words, from us.

My alternative: go to the barricades and blow the whole thing up. We need revolution because modest evolution cannot work.

My proposal, which you should go and read is to give everyone a voucher for primary care, but make it Concierge care for all.

The post got some pushback, and some of the objections reveal something important. My idea isn’t too complicated, but so many of us are so imbued in our broken system that  we can’t see beyond it. And to be fair, it’s only after 35 years looking at it, that I’ve got the “burn it all down” religion.

My Basic Idea

My proposal is Concierge Care for All. Every American gets a voucher worth somewhere between $2,000 and $3,000 a year, which they have to spend with a primary care physician (or primary care organization) of their choice. Each PCP or equivalent takes on a panel of around 600 patients — roughly 1/3 to 1/4 what a typical fee-for-service PCP practice manages today, and the same as most current direct primary care practices. 

That’s $1.2 to $1.8 million in annual revenue per physician; enough to pay the doctor $500,000 to $600,000 a year and still leave $600,000 to $1.3 million for clinical staff, technology, and overhead. This is basically the MDVIP model. It works. People who use it love it. And the latest studies show that it saves a lot (31%) on hospital emergency room use and inpatient costs.  That alone saves a significant fraction of what this transition would cost.

The bulk of what a PCP does in this model is managing chronic illness — diabetes, hypertension, heart disease, COPD. These are the conditions that drive the majority of health care spending but which our current system sucks at managing. A well-resourced primary care practice, freed from the hamster wheel of volume-based billing, can do this proactively and can deploy the technology to do it at scale. Remote patient monitoring, AI-assisted care management, continuous data from wearables and home devices — the tools that many digital health companies have shown working well — all of that gets directly integrated into primary care where it belongs. The PCP organization is the purchaser of those technology services. This is basically the logic behind CMS’s new ACCESS program, except that ACCESS tries to bolt these capabilities onto the system from the outside. In this model they’re baked into primary care practice because the PCP wants to manage their patients and has the professional ethics and responsibility to do so.

I’d include a lot of mental health and dental care in the definition of primary care, as well as minor urgent care. Plenty of primary care groups in the US and elsewhere do that now, even though we’ve historically pretended that the head isn’t connected to the body and the teeth are outside it.

What isn’t there is equally important.  No co-pays, no coinsurance, no deductibles, no claims. No staff managing all that bureaucratic crap. Your PCP manages your care, knows you, and when you need a specialist or a scan or a surgery, they refer you.

What About Specialty Care?

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