Category: Policy and politics

Healthcare predictions for 2022

published date
November 30th, 2021 by
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Looking ahead

Pandemics, wars and other large-scale dislocations lead to fundamental changes in the ensuing years and decades. Two years into COVID-19, I’m ready to hazard a few guesses about what lies ahead for healthcare. These 7 changes should start becoming visible in 2022. Some are more COVID-related than others.

Please share your feedback:

  1. Retailers make care more consumer friendly
  2. COVID becomes less political
  3. Cybersecurity threats in healthcare get bigger and scarier
  4. Consumers stake a claim to their own health data
  5. Climate change becomes a major healthcare issue
  6. Clinical trials simultaneously decentralize and centralize
  7. Old age is pushed back

1. Retailers make care more consumer friendly

Hospital-based health systems are trying to be consumer-centric, but few are succeeding. Some with the best-trained and most capable clinicians talk a good game but are hellish to deal with as a consumer: gaining initial access, scheduling, waiting, follow-up, electronic communications, billing, etc. Here I’m writing from personal experience in Boston, including a recent consumer nightmare that was resolved only when the CEOs of my health plan and hospital agreed to intervene.

Retailers are stepping into healthcare and definitely have a more consumer friendly mindset. The real questions are whether they can address the challenges that make healthcare delivery harder than other consumer services and can overcome the conflicts inherent in third-party reimbursement. I’m most bullish on Walgreens with its recent VillageMD and CareCentrix investments, which take the company directly into primary care and care at home. Walmart — despite its healthcare executive turnover and lack of clear top-level commitment to healthcare—comes second because of its laser focus on reducing costs. It’s in their DNA and matters hugely to consumers.

Amazon has massive potential, of course but I’ve yet to be persuaded that their hard-charging approach will play out in care delivery, especially without a physical footprint. And I’ve never bought into the logic of the CVS/Aetna combination nor been impressed with CVS’s IT infrastructure.

If retailers succeed, there’s a chance they –and other enlightened and well-capitalized primary care providers– will take over the primacy now enjoyed by hospital-based Integrated Delivery Networks (IDNs). This could happen rather fast, thanks to Medicare’s Direct Contracting program, which offers primary care providers major influence on referrals and spending, plus access to patient data. If big primary care providers like Walgreens’ Village MD learn how to manage this opportunity well, Medicare Advantage and commercial risk will follow quickly.

Alternative payment model experts such as Archway Health are showing risk-bearing physician groups (not just retailers) how to gain up to 20x in Medicare revenue overnight under Direct Contracting, and how to actively manage specialist and hospital referrals without being dictated to by IDNs.

2. COVID becomes less political

The response to COVID in the US –and parts of Europe and Latin America—has been blunted by political divisions. COVID denial, vaccine ‘hesitancy,’ and anti-mask sentiment are the kinds of barriers I’m talking about.  But divisions are already receding.

What’s behind the rosy outlook? Vaccines work well enough that the vaccinated are not so badly threatened by the unvaccinated. And new COVID treatments mean even almost everyone can be kept out of the hospital, assuming real world experience matches clinical trial results.

Paradoxically, vaccine mandates will make COVID less political over time, even if they inflame tensions in the near term. As my father, retired Chief Scientist for the Insurance Institute of Highway Safety recounts, when seat belts were first available, less then 10 percent of people used them. State laws drove usage toward 90 percent, despite the contention that belt use was a matter of personal freedom and misguided beliefs that belts could harm people by trapping them in their cars or causing injuries during a crash.

Seat belts are not political now. Once people started buckling up, they reconciled their views to their actions. The same can happen with vaccines.

This prediction could be completely wrong. Right now, the Omicron variant is turning countries against one another, Merck’s pill is showing weaker results than expected, and there are political leaders actively promoting division and the politicization of everything. But I’m sticking with a more optimistic view.

3. Cybersecurity threats in healthcare get bigger and scarier

Ransomware made the news in 2021 as hospitals were hit by an unprecedented wave of attacks. It was expensive for hospitals and insurance companies, and a hassle for employees. But few patients were directly affected. That has the potential to change dramatically.

The whole information economy –but especially healthcare—is built on a flawed foundation. Microsoft Windows, which powers computers, networks and many medical devices is intrinsically insecure. Devices from MRIs to ventilators are stuffed with hackable microcontrollers that are rarely secured properly.

Cyber dangers are built right into the business models of certain equipment vendors, whose service and warranty agreements forbid customers or third parties from auditing or updating their equipment. These agreements effectively lock in vulnerabilities, such as when vendors apply custom patches to outdated Windows XP based systems and neglect to penetration test them regularly.

The danger is not limited to hospitals and medical devices. Pharmaceutical development and manufacturing are vulnerable to threats ranging from spyware, to ransomware, to malware that ruins batches and even shuts down or destroys production equipment.

Things may get worse before they stabilize or improve. For example, new Internet of Things (IoT) sensor networks will multiply the attack surface if deployed on insecure infrastructure.

Unlike financial services and defense, healthcare as a whole lacks the sophistication, resolve and funding to stop cyberattacks. Large-scale cyberattacks in healthcare are not inevitable, but the industry is among the economy’s most vulnerable and becoming more so.

4. Consumers stake a claim to their own health data

Data tokenization by Datavant and HealthVerity enables mixing and matching of disparate sources at the patient level and the generation of valuable clinical and commercial insights. We are witnessing rapid growth of the real-world data ecosystem and tremendous value creation.

But individual patients –whose data are being leveraged to build these fortunes—are not really in the conversation and are certainly not benefiting financially. At a recent health data conference, I heard CEOs confidently assure the audience that patients were grateful to be able to contribute their data for the betterment of others.

That sounded pretty self-serving to me, and I heard a few whispers to the same effect.

In 2022 I expect patients to start waking up and asserting themselves, even if the impact is limited initially. We won’t see many companies paying patients for their data, but there will be more of an effort to let individuals control how their data are used and to receive something of value in return. A few companies such as Ciitizen (recently acquired by Invitae), Picnic Health, and Seqster give patients control of their medical and health data and some chance to benefit from it in their care journeys. RxRevu’s founder is launching a new venture (I’m on the advisory board) to take the concept even further.

If you’re skeptical that consumers will wake up, look to Europe where GDPR –the European General Data Protection Regulation– has made consumers much more aware of the information being collected about them and how it’s used. GDPR also includes provisions for individuals to request their own information and to have it deleted. Similar concepts are progressing in the US, starting with the California Consumer Privacy Act.

Healthcare data is a little different, but not completely distinct. The 21st Century Cures Act enables patients to get easy access to their medical data and share it with others. Its full implementation will put patients in the driver’s seat. Now patients just need to learn how to drive and figure out where to go.

5. Climate change becomes a major healthcare issue

I’ve worried about climate change for a long time, though until about five years ago I thought it would affect my grandkids, not me. Weird and wild weather induced by climate change is here now, though, causing disruptions to the rich as well as the poor. Hurricanes, fires, floods and the rapid emergence of new pathogens are already wreaking havoc beyond expectations. It’s going to get a lot worse -even if it’s not always apparent year to year.

Emerging health problems include heat-related illnesses, water-borne and vector-borne diseases, and injuries from extreme weather. Psychiatrists are also seeing patients with a new complaint: climate anxiety. Good luck curing that one!

Near-term imperatives are to build more resilient healthcare infrastructure (like hospitals with backup generators on the roof), restore and improve global health surveillance, and direct research and development dollars to prevent and cure new diseases. Some expect pandemic-induced public health spending to decay once the immediate crisis recedes. I don’t think so. Instead, there will be sustained public and private investment because we’re not going back to the old normal.

6. Clinical trials simultaneously decentralize and centralize

The weird thing about “decentralized” clinical trials (DCTs) is that they actually involve more centralization than traditional trials. DCTs –sometimes called “virtual” trials—have been discussed for years but radically accelerated during the pandemic. DCT enablers including Medable, Science 37 and Curavit have captured investor imagination and raised hundreds of millions.

The notion is that patients in clinical trials for new drugs and devices should not have to travel to a physical site –usually a hospital or clinic—to be examined, observed and measured. Remote monitoring, video calls, and electronic surveys should suffice. It’s not easy to run trials this way, but initial results are promising. Trials enroll patients faster and data integrity is high.

It’s the patients in these trials that are decentralized. Instead of going into one of a few or several sites, each patient becomes a site. But the trial sponsor has the opportunity to centralize functions –such as recruiting, drug supply, and payments– rather than spreading resources to multiple physical sites. That’s a positive for everyone –except the traditional sites that lose out on the work.

Sponsors are committed to increasing diversity in trials so participants more closely match the racial, ethnic, language, age, gender and geographic profiles of those affected by the condition being addressed. DCTs are a promising way to achieve diversity. Science 37 is emphasizing this advantage; Diversity & Inclusion is one of its five main offerings.

Expect to see more DCTs, especially as sponsors compete for the attention of the limited number of patients who are candidates for trials. Patients with certain (i.e., lucrative-to-pharma) diseases often have a choice of trials and enroll based on convenience. Not surprisingly, consumer-oriented providers are turning their attention to trials. CVS Health is introducing clinical trials services and 2020 On-site shifted its mobile vision clinics from exams for employers to exams for clinical trial sponsors.

To really increase recruitment, we could allow sponsors to pay subjects to participate in trials and stop worrying so much about offering “unfair inducements.” I’m not predicting that change for 2022, however.

7. Old age is pushed back

We still label people as “seniors” when they turn 65, just like we did 50 years ago when life expectancy was almost 10 years lower. Today’s typical 75-year-old is more like the 65-year-old of yore in terms of health and productive years ahead. But COVID strikes older people hard, and those as young as 50(!) were put in the “old” column for pandemic safety purposes. Therefore, if I’d made this prediction in early 2020 I would have been dead wrong. But with higher vaccination rates and better treatments, older people will breathe easier, get back to work and stay there.

Why? They are needed in the workforce to address shortages caused by the Great Resignation and reduced immigration –especially in healthcare– and with the shift from defined benefits to 401(k) accounts they don’t have enough saved for retirement.

Another thing I’ve noticed is that young adults don’t shun seniors the way my generation did, so the workplace should become less hostile for the aging.

That’s a happy note to end on.

Interview with 2Life Communities CEO Amy Schectman

published date
April 29th, 2021 by

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Amy Schectman, 2Life CEO

Amy Schectman cut her teeth in state government, where her excellence in writing and thinking got her appointed to key task forces on issues like higher education and prison overcrowding. Over the last decade as CEO of 2Life Communities (formerly Jewish Community Housing for the Elderly), Amy has improved the lives of thousands of older adults with first-rate living quarters and activities.

Amy professionalized the real estate team at 2Life, enabling the organization to open a new affordable housing complex nearly every year. During my time as president of Congregation Kehillath Israel in Brookline, MA I worked closely with Amy to construct a beautiful new affordable, independent living building on the synagogue campus.

In the last year, she’s led an unbelievably successful effort to keep COVID away from 2Life.

Amy’s mother and the Gray Panthers were early influences, and she looks back fondly on her summer camp experiences, Johns Hopkins and MIT. She’s charging ahead into the future, with plans to address the middle income market and leverage technology along with the human touch.

She makes time for reading every night, with recent favorites The Secret Diary of Hendrik Groen, 83 ¼ Years Old, the Neapolitan Novels by Elena Ferrante, Caste by Isabel Wilkerson, and The Splendid and the Vile: A Saga of Churchill, Family and Defiance During the Blitz by Erik Larson.

Check out the rough (AI generated) transcript.

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By healthcare business consultant David E. Williams, president of Health Business Group.

Vaccine reimbursement is equal across providers and insurers. What if we did the same for all care?

published date
April 5th, 2021 by
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What adjustments are needed?

A seemingly straightforward story caught my eye last week: all Massachusetts providers are being paid the same, generous fee for COVID-19 vaccine administration (Boston Globe). The fee is essentially identical whether the patient has Medicaid, Medicare, commercial insurance –or no insurance. And it doesn’t matter whether the shot is given in a pharmacy, clinic, community hospital, or academic medical center.

It seems logical and makes intuitive sense to the average consumer. But for those in the healthcare field, it’s pretty radical! After all, reimbursement rates for commercially insured patients are usually a multiple of what Medicaid pays and substantially higher than Medicare. And providers and insurers exert extreme efforts negotiating rates (and then trying to keep them secret). Some providers use their market power to drive harder bargains, and insurers do the same.

Bottom line: Reimbursement rates are all over the map, varying wildly depending on who’s the provider and who’s paying. A 2020 Health Care Cost Institute study provides some detail.

This reality has shaped and distorted the US healthcare system:

  • Providers avoid Medicaid patients to cherry pick those with commercial coverage
  • The true cost of Medicaid (and to a lesser extent, Medicare) is obscured by cross-patient subsidies
  • Providers use their market power to extract higher rates, and generate reimbursement ‘synergies’ by acquiring providers with weaker negotiating positions or reclassifying  physician offices as hospital ‘facilities’ that generate their own upcharges
  • Patients get treated in settings that maximize providers’ margins rather than where it’s best for the patients
  • Health plans merge to bulk up against provider systems
  • Health disparities are exacerbated as poorer patients are worth less to providers and get lower priority
  • Tremendous administrative costs are expended to manage the complexity, exploit the rules and search for those who are bending or breaking them

It’s tempting to think we could reform healthcare payment by using this COVID-19 vaccine approach for all reimbursement. But the vaccine is a special case, because there is a specific, national objective to get as many people vaccinated as quickly as possible to end the pandemic and because vaccine administration is pretty simple. Lots of providers are capable of it, and there are unlikely to be differences in outcomes based on provider experience or setting. Across the political spectrum, there is genuine agreement that we want everyone –including poor people and immigrants regardless of status– to get a shot or even two. And we’re happy for providers to prioritize vaccination by allowing them to make good money doing it.

Those conditions don’t hold generally in healthcare. Still, I am in favor of policies that encourage or mandate reducing the gaps in what providers are paid for the same service. There should be a convergence between Medicaid, Medicare and commercial rates, and reimbursement should not vary so dramatically by provider or setting of care.

New approaches, like alternative payment models, often bake in the fee-for-service biases. They shouldn’t.

By healthcare business consultant David E. Williams, president of Health Business Group.

How the new surge and vaccine success are connected

published date
March 31st, 2021 by
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Catch a wave and you’re sitting on top of the surge

It’s counterintuitive: a fourth covid-19 wave is evident even as vaccine rollout accelerates. Conventional wisdom blames it on more contagious variants, pandemic fatigue, and states reopening too fast. There’s truth to all of that, but it overlooks the role that vaccination itself plays.

I shared my thinking with the Boston Globe (CDC Director Walesnsky stresses ‘hope,’ not ‘doom,’ after touring Hynes Convention Center. Vaccinations are accelerating even as COVID-19 cases also rise.)

“As spring comes, people in their 20s are relaxing their behavior and going out to restaurants with their friends,” said David Williams, president of Health Business Group, a Boston management consulting firm. “They don’t have to feel as guilty about infecting them if Ma and Grandma have already been vaccinated.”

It’s actually pretty straightforward. We’ve asked younger people to make severe sacrifices over the past year. A central argument has been that they are protecting their older relatives and others in society, who are at mortal risk if infected. Now that the old are largely protected through vaccination, the argument loses its logic.

Vaccine rollout priority has focused on reducing death and hospitalization. That’s why we started with the elderly. If we wanted to reduce the number of infections, we would have started with the young.

Now that the old are vaccinated, we need to make sure young adult vaccination is quickly ramped up. There should be plenty of vaccine available shortly to do so.

“This is the time when we’re going from scarcity to surplus,” said Williams of the Health Business Group. “People who are eligible are now getting appointments, even if they have to work a bit, and a lot more people are now eligible. It still feels tight. But in the next two to three weeks, instead of waking up at 1 in the morning to book an appointment, you should be able to do at 2 in the afternoon.”

Today’s news that the Pfizer vaccine seems to work well in kids and not pose safety concerns is also great news. We should vaccinate the whole population by summer if at all possible.

Image by Manie Van der Hoven from Pixabay

By healthcare business consultant David E. Williams, president of Health Business Group.

COVID-19 vaccinations are going poorly in MA. I’m quoted in the Boston Globe

published date
January 29th, 2021 by

For months we’ve been focused on the shortage of COVID-19 vaccine doses. That’s still a problem, but for now the bottlenecks are further downstream. Massachusetts is struggling to get the doses distributed and administered. More than half sit unused. Even if we have 10 million (or a billion) doses we’d still be stuck.

In today’s Boston Globe (State’s hope of vaccinating almost everyone by the end of summer depends on a lot going right) I encourage the state to assume there will be enough vaccines and just get them out to people.

“We’re only using half of what we’ve been given,” said David Williams, president of Health Business Group, a Boston management consulting firm. “It’s not an excuse to say because supplies are slow, we can just sit back. We should assume there’ll be more supply, and we owe it to the citizens of Massachusetts to be ready when it comes.”

By healthcare business consultant David E. Williams, president of Health Business Group.