Humana and the Payer-Agnostic Circle of Life

By Clive Riddle, March 19, 2021

Humana on Saint Patty’s Eve announced their new brand – CenterWell – “to describe and connect a range of the company’s payer-agnostic health care services offerings.”  Their senior-focused primary care facilities, including the multi-state Centerwell Primary Care, and Florida based Family Physicians Group will be included under the brand.

Centerwell will ultimately encompass Humana’s other health care services as well. Humana notes that in recent years it has “significantly expanded its health care services capabilities – from primary care to pharmacy to home care and more – in order to better serve its medical members, and to significantly strengthen its payer-agnostic care offerings. Now, the company is taking the next step with plans to unite various payer-agnostic services under the new CenterWell brand.”

“Payer-agnostic” is not a new term. A 2013 New England Journal article Payer Agnosticism, comes to mind, for example. But Humana has certainly been advancing the term to a whole new level during the past year, deploying the term seven times in their mpst recent announcement.

In January, during another “payer-agnostic” company announcement, Humana unveiled plans to open twenty more primary care centers during 2021, five more than in 2020; bringing the total Partners in Primary Care locations to 80 with a goal of 100 center by 2023.

The payer-agnostic approach for differs from a classic clinically integrated model in that the owned health care services are promoted and provided to serve multiple payers, instead of just the payer-owner. But never-the-less, it is interesting to see the Humana’s “circle of life” evolution of strategy of a healthcare provider turned health plan, now turned health plan / healthcare provider:

• 1972 - Founders David Jones and Wendell Cherry sold their nation’s largest nursing home company to capitalize acquiring hospitals
• 1974 – The new hospital company corporate name is changed to Humana
• 1984 – Humana starts its own health plan operations, as do other national hospital chains
• 1993 – Humana spins off its 77 hospitals to create Galen Health Care, similar to spin-off moves previously taken by other national hospital chains. But unlike they other chains, they spun of the hospitals as opposed to the health plans.
• 1994 – Galen Health Care is sold to Hospital Corporation of America (HCA)
• 2015 – Aetna acquisition of Humana is announced, but then falls apart over the next 18 month.
• 2018 – Humana participates with two private equity firms in acquisition of Kindred Healthcare.  Humana merges four owned Florida clinics from separate previous integrated plan acquisitions into one operating unit that will also service non-Humana patients
• 2020 - $600 million deal with New York-based private equity firm Welsh, Carson, Anderson & Stowe is announced to capitalize growth of Partners in Primary Care

Five Questions for John League with Advisory Board on the State of Telehealth Today and What’s Next?

By Claire Thayer, March 16, 2021

Thanks to the pandemic, telehealth is here to stay! Advisory Board’s Senior Consultant, John League, joined us for a recent webinar on the state of telehealth today, offering insights for health payers in rethinking the digital experience to address downstream utilization, digital inequities, and more!  We caught up with John on five key takeaways:

1. Data is essential to advancing telehealth initiatives. What are the key data elements payers need to prioritize?

John League: All stakeholders need a better understanding of the downstream impact of upstream telehealth. Payers have tended to focus on data about utilization and per-service unit cost of telehealth—which are both important—but that doesn’t provide perspective on longer-term total cost of care or outcomes. We need data on things like how telehealth facilitates care coordination (are care coordination codes used more or less frequently via telehealth?), limits readmissions (including readmission and transfer from skilled-nursing facilities), and impacts other types of utilization (including labs, imaging, referrals, and prescriptions). 

2. What are some of the major challenges and barriers patients face in telehealth adoptions?

John League: Plans and providers can’t simply offer telehealth services; they have to recommend them as appropriate. I hear a lot of organizations worry that patients are increasingly choosing to do in-person visits over telehealth options. When I dig deeper, I often find that patients are getting no guidance on whether telehealth is a good option for their visit. Providers have the most influence here, but plans have a role, too. A recent Optum survey showed that half of patients who had actually used telehealth found out about it from their own doctor. Another 27% found out from their plan. 

Patients also need a quality virtual experience. It should have as many of the features of an in-person visit as possible. It should be at least as easy to schedule. It should provide a diagnosis, treatment plan, prescription, referral, or follow-up steps as appropriate. There should be clear steps for technical preparation and support. And they need to know how much it costs. Most cost-sharing is waived during the public health emergency, but a clear understanding of out-of-pocket costs is going to be essential in the future.

3. How can payers best understand, mitigate, and eliminate disparities and inequities in healthcare using telehealth?

John League: Addressing digital disparity begins with understanding the patients and communities in front of us: Does your organization understand how digital inequity presents in its members and patients? This also means diagnosing the nature of the inequity: Is it a challenge of connectivity, digital literacy, or trust in your organization and platform?

With that information, organizations can assess how their digital health priorities and investments mitigate digital inequities—or, unfortunately, maybe even deepen them. Only when each organization understands the nature of its members’ equity challenges and its own capacity to address them can it begin to partner with other organizations or advocate for policy change.

4. What do you see as the biggest challenge for payers in widespread telehealth adoption?

John League: The biggest challenge for payers is in helping patients and providers make the most valuable use of telehealth possible. I talk a lot about overall utilization rates—percentage of total visits done via telehealth—because that’s relatively easy to understand and quantify. It’s also a decent indicator of overall interest in telehealth. It’s also deceptive.

It's much more important to get the right visit types done virtually than it is to get any specific overall percentage of visits done virtually. There are some visit types that could almost all be virtual, and that’s where there’s big value for members. Are we getting prescription refills done virtually? What about pre- or post-op visits? What about behavioral health visits, or annual wellness checks?

Creating the right incentives and pathways so that patients trust telehealth for those purposes and providers are appropriately compensated for offering it is a significant but not insurmountable challenge.

5. What are your key takeaways in terms of where payers need to go and how to get there on their telehealth journey?

John League: First, don’t rely on pre-pandemic assumptions about telehealth. Telehealth was never deployed at scale before Covid-19. There is more data on its use than ever before. We need to dig into that hard-earned evidence and reassess how telehealth can help meet strategic objectives.

Second, focus on telehealth as a part of the overall care journey. It’s easy to focus on the unit cost of a telehealth visit, but that orientation ignores its potential to reduce total cost of care in other ways.

Finally, remember that telehealth has not reached a tipping point for the underserved. Many of the patients who could benefit most from telehealth aren’t able to access it. Work to develop an understanding of the ways that digital inequity affects your own members and how your organization’s priorities for digital investment will mitigate or deepen that inequity. 

If you missed this informative webinar presentation, Understanding Telehealth Today – and Preparing for its Next “New Normal”, we invite you to watch the full On-Demand webinar video, short webinar re-cap video, or reach John League directly at leaguej@advisory.com.

A global pandemic calls for global response: The importance of equitable global vaccine distribution

By Dr. Seleem R. Choudhury, March 11, 2021

According to the United Nations, 75% of all COVID-19 vaccinations have been administered among just 10 countries, while 130 countries have not received even a single dose of the vaccine, as of mid-February 2021 (Al Jazeera, 2021). Global health and political leaders have condemned this unbalanced distribution of vaccines and are taking action to ensure vaccine equity. Dr. Tebros Adhanom Ghebreyesus, director-general of the World Health Organization (WHO), said in a recent address, “The world is on the brink of a catastrophic moral failure—and the price of this failure will be paid with lives and livelihoods in the world’s poorest countries” (United Nations, 2021).

Vaccine equity is the global intent to ensure that all have fair access to the COVID vaccine in order to overcome the virus that is threatening every nation. Unless the roadblocks to success for international cooperation on equitable vaccine access and delivery are removed, the world risks prolonging the pandemic by creating a two-tier vaccine system—the haves and the have-nots, the eternal battle of rich versus poor. Many rich nations have set the lofty goal of vaccinating at least 80% of their populations. Even if these countries were to achieve this goal, without the equitable distribution of vaccines to poorer nations, they run the risk in a global economy of contracting a COVID-19 variant more immune to the vaccine and bringing it back to their own nation, thus perpetuating the pandemic.

The movement to increase the distribution of vaccines to poorer nations has gained momentum under WHO’S 100-day challenge (United Nations, 2021). In February 2021, G7 leaders pledged to intensify cooperation on COVID-19 and increase their contribution to vaccine-sharing initiative COVAX (Parker, Williams, Peel, & Chazan, 2021). As the WHO’s January 2021 Vaccine Equity Declaration states:

“We must act swiftly to correct this injustice. Multiple variants are showing increased transmissibility and even resistance to the health tools needed to tackle this virus. The best way to end this pandemic, stop future variants, and save lives is to limit the spread of the virus by vaccinating quickly and equitably, starting with health workers.” (World Health Organization, 2021).

The data of equity

As of this article’s publication, over two million people have died from COVID-19. As a New York Times article puts into perspective, that is more than the population of the state of Nebraska, and nearly equal to the population of the entire country of Slovenia (Santora & Wolfe, 2021).

Though it has been several months since the first COVID vaccine was administered, the virus continues to spread despite the vaccine, especially in the poorer nations. Vaccine supplies are low due to richer countries purchasing more vaccines than they could distribute in the required time frame.  As a result, some experts predict that many low-income countries may not be able to reach mass immunization until 2024. Worse, some nations may never get there (Safi, 2021).

To support the equitable distribution of the vaccine moving forward, the WHO established the Covid-19 vaccine allocation plan—known as COVAX—at the end of 2020 (World Health Organization, 2020). COVAX’s goal is to ensure that the research, purchase, and distribution of any new vaccine is shared equally between the world’s richest countries and those in the developing world.  According to the WHO, 172 economies are engaged in discussions about participation in the COVAX initiative (World Health Organization, 2020).

The variants

Catalyzing vaccine distribution in poorer countries is essential to prevent the development of new variants of COVID that could cost more lives around the world. It is the natural state of RNA viruses such as the coronavirus to evolve and change gradually. The flu, for example, is an ever-adapting virus, which is why people must receive a new vaccination each year.  Viruses are primed to change, but occasionally a mutation occurs that alters how rapidly the virus spreads, its level of infectiousness, or the severity of the disease (Gray, 2021).

This is the primary concern with new variants of COVID emerging in different countries. The most recent variations of the disease in South Africa and Brazil are concerning epidemiologists as they show signs that the virus may be “adapting to evade immunity in some people” (Gray, 2021).  To stay ahead of the evolution of the virus, scientists are evaluating each new mutation to determine which ones are likely to be most impactful (Callaway, 2020).

We have established that a partially immunized population runs the risk being impacted by variants that are transmitted more easily and are more likely to result in death for those infected with the virus (Toy, 2021).  Embracing vaccine equity is the best solution to guard against this.  If nations insist on focusing only on their own populations, new variants will perpetually threaten them, necessitating changes to the vaccine.  If countries continue to choose not to share, then this ludicrous process starts again.  If everyone has immunity through vaccination, then variants’ effects will be diminished, with virtually no virus circulating or adapting (Toy, 2021).

Next steps

The COVAX initiative is a good start to addressing vaccine equity.  It has gained strength now that the US has joined under its new presidential administration (The White House, 2021). Additionally, at a virtual G7 meeting, leaders pledged $7.5 billion to the WHO-led collaboration (Parker, Williams, Peel, & Chazan, 2021).  This crucial financial backing will allow COVAX to accomplish its aim of securing and equitably allocating 2 billion doses of COVID vaccines, starting with healthcare workers and other high-risk groups as defined by the WHO, by the end of 2021 (Kettler, 2021).

While equitable distribution is being addressed globally, individual nations must also grapple with the challenges of vaccine distribution within their own populations (Liao, 2021).  The WHO has proposed a “Roadmap For Prioritizing Uses Of COVID-19 Vaccines In The Context Of Limited Supply” to aid countries in their own vaccine equity efforts. The Roadmap considers priority populations for vaccination based on epidemiologic setting and vaccine supply scenarios (World Health Organization, 2020).

Summary

Interestingly, several countries are filling the gap created by the United States and the other G7 countries. India, Russia, China and Israel appear to be waging a strategy of soft power towards global health (Mashal & Yee, 2021). It is hard to imagine populations of countries not being grateful to those that help towards timely vaccinations, and it could leave recipients obligated to repay in other ways. This could potentially realign global alliances and change geopolitics.

It is hard to ignore WHO Director-General Ghebreyesus’s concerns about the irreconcilable cost of the moral failure of continued inequitable vaccine distribution.  The world’s poorest countries will be disproportionately affected, and richer nations will continue to have on-again-off-again economies as variants of the virus wreak havoc on the health of their own populations.

The immediate sharing of doses will reduce the chance of ongoing variants and begin to revive the global economy.  The only way to vaccinate the majority of the world’s population with urgency is to do it together.  A global pandemic requires a global neighbourhood philosophy and response with no strings attached.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com  

Resources

Al Jazeera (2021). ‘Wildly unfair’: UN boss says 10 nations used 75% of all vaccines. Al Jazeera.

Callaway, E. (2020). The coronavirus is mutating — does it matter? Nature.

Gray, R. (2021). This is how new Covid-19 variants are changing the pandemic. BBC.

Haseltine, W. (2021). How The Covid-19 Virus Changes. Forbes.

Hernandez, J. (2021). Two Members of W.H.O. Team on Trail of Virus Are Denied Entry to China. New York Times.

Kettler, H. (2021). What is COVAX? Path.

Liao, K. (2021). What Is Vaccine Equity? Global Citizen.

Mashal, M. & Yee, V. (2021). The Newest Diplomatic Currency: Covid-19 Vaccines. New York Times.

Parker, G., Williams, A., Peel, M., & Chazan, G. (2021). G7 leaders vow to boost vaccine supplies to developing world. Financial Times.

Safi, M. (2021). Most poor nations 'will take until 2024 to achieve mass Covid-19 immunisation.’ The Guardian.

Santora, M. & Wolfe, L. (2021). Covid-19: Over Two Million Around the World Have Died From the Virus. New York Times.

The White House (2021). National Security Memorandum on United States Global Leadership to Strengthen the International COVID-19 Response and to Advance Global Health Security and Biological Preparedness. The White House.

Toy, S. (2021). Covid-19 Vaccination Delays Could Bring More Virus Variants, Impede Efforts to End Pandemic. The Wall Street Journal. 

United Nations (2021). WHO chief warns against ‘catastrophic moral failure’ in COVID-19 vaccine access. UN News.

World Health Organization (2021). Call to Action: Vaccine Equity Declaration. World Health Organization.

World Health Organization (2021). COVID-19 Vaccine Equity Declaration. World Health Organization.

World Health Organization (2020). Fair allocation mechanism for COVID-19 vaccines through the COVAX Facility. World Health Organization.

World Health Organization (2020). WHO SAGE Roadmap For Prioritizing Uses Of COVID-19 Vaccines In The Context Of Limited Supply. World Health Organization.

World Health Organization (2020). 172 countries and multiple candidate vaccines engaged in COVID-19 vaccine Global Access Facility. World Health Organization.172 countries and multiple candidate vaccines engaged in COVID-19 vaccine Global Access Facility

Medicaid Plan Risk Adjustment: A Dime Yields $15

By Clive Riddle, March 4, 2021

Sherlock Company’s March issue of Plan Management Navigator tackles the topic of Medicaid risk adjustment expenses and premiums pmpm. Their analysis attempts “to measure the efficacy of risk adjustment expenses on premium rates” for Medicaid plans; because “as a result of the increased population of Medicaid members, there is a growing need to accurately capture risk scores so that compensation to the plan is commensurate with their health care requirements.”

So what exactly is “risk adjustment” in this Medicaid plan context? They explain “the Sherlock Benchmarks define Risk Adjustment as the expenses associated with the analysis of clinical data in order to match government compensation with the risk factors of members. This includes adjustment for the “three Rs”: permanent risk adjustment, transitional reinsurance and transitional risk corridors. For Medicaid products, this includes activities such as those supporting Chronic Illness and Disability Payment System (CDPS) system. Activities in this function include determining which members should be moved from TANF to higher capitation products.”

Their analysis is based on data from the Sherlock Benchmarks 2020 edition, which segments costs according to 70 functional or sub-functional categories. They captured risk adjustment chart review metrics including: total chart reviews, total charts subject to multiple passes, the risk score improvement percentage, and the dollar reimbursement yield.”

Their findings? “The modeled regression line implies that every $0.10 PMPM spent in Medicaid HMO Risk Adjustment results in about $15.00 PMPM in additional premiums. To put this in perspective, of the 14 plans included in this analysis, no plan spent over $1.50 PMPM in Risk Adjustment expenses.”

Not a bad ROI.

By the way, President Doug Shlock says there is always room for more plans to participate in their 2021 benchmarking study. Interested plans can contact Doug at sherlock@sherlockco.com.

Need Care, Should Travel

By Kim Bellard, February 25, 2021

I find myself thinking once more about our inability to distinguish quality in our health care. I live in Cincinnati (OH).  The metro area has five hospital systems. Most Cincinnati residents go their entire lives getting all their medical care here. That’s the problem.

If, for example, someone in Cincinnati had a serious heart issue, he/she/they should really go to The Cleveland Clinic.  It is known worldwide for its cardiac care and is ranked #1 in the country for it by U.S. News & World Report.   No Cincinnati hospital is nationally ranked in this field. 

For that matter, The Cleveland Clinic is top 10 ranked in 11 other adult specialties as well, plus top 50 in two others.  It’s the #2 hospital in the nation overall (The Mayo Clinic is #1).  Frankly, if something is wrong with you, it would seem worthwhile to drive up to Cleveland to get care there.  But most don’t. 

If that drive is too far, you could go to Columbus, which is only about half as far, where The OSU Wexner Medical Center/The James Hospital is nationally ranked in 9 adult specialties, still higher than any Cincinnati hospital.  Again, though, most don’t.

Whatever state/city you live in, there’s probably a similar dynamic.  There may be many reasons why most care remains local.  For one thing, the ratings almost certainly aren’t as accurate as one would like; there is more subjectivity/ambiguity in them than anyone would like.  For another thing, a large chunk of hospital admissions come from emergency room visits, and driving two to three hours to a “better” hospital during an emergency is usually ill-advised.  Travel is a barrier generally.. 

Most importantly, though, most people don’t really understand that there might be differences in the quality of care they might expect from different hospitals.  They might be aware of The Cleveland Clinic’s reputation, or have heard of The Mayo Clinic, but the thought of travelling to either doesn’t occur to most.  People in Cincinnati, like people most places, think the care here is just fine, thank you very much.

For most care, that’s probably fine. But if you need a heart transplant or have a rare form of cancer, you should probably be thinking seriously about travelling. The trouble is that there’s no good way to help us distinguish these situations.  For which cases should I be seriously weighing going up to Cleveland for my care? I don’t know, you don’t know, and even “experts” are likely to disagree. 

What we need is what I’ll call a “quality matrix,” indicating when which type of condition needs what “quality” of care.   It might be based on the potential variation in outcomes patients might face based on using different hospitals/physicians. 

Using the USN&WR system, “low variability” conditions could be treated at any hospital (or outpatient by their physicians), but for “medium variability” conditions patients should consider hospitals that are rated at least “high performing,” and for “high variability” conditions, care should be directed to nationally ranked hospitals. 

I know: we don’t have the data.  We don’t have good data on outcomes for most conditions; we don’t quite understand the interplay between the institutions and the specific clinicians practicing within those institutions (e.g., it’s unlikely that every Cleveland Clinic heart surgeon is better than any Cincinnati heart surgeon).  No patients are the same, outcomes can’t be predicted, and so on. 

In other words, the same excuses we’ve been using for the past fifty years.   

Of course, there would be non-trivial financial implications to such a change.  Frankly, I believe our seeming indifference to actually measuring and acting on quality of care is an overarching problem in our healthcare system.  

I challenge hospitals and health plans to focus on getting patients to the right places for their condition, not just enabling patients’ desire to stay local.  And I challenge more patients to demand better. All politics, as they say, is local, but all health care shouldn’t be. 

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Setting yourself up for success in a new healthcare leadership role

By Dr. Seleem R. Choudhury, February 18, 2021

The uncertainty brought on by leadership transitions can be hard on employees and organizations (Keller & Meaney, 2017). Staff members wonder: Will the new leader understand the mission? What changes will they implement—and will that impact my ability to do my work and find fulfillment in this job? 

But leadership transitions are tough on the incoming new leaders too.  An IMD survey of 1350 HR professionals shows that transitions into new roles are the most difficult times in leaders’ professional lives (Watkins, Orlick, & Stehli, 2014).  They face pressure to make a good impression, instill confidence in their selection across the organization, and perform the balancing act of learning about the company while attempting to shape it (Watkins, Orlick, & Stehli, 2014).   

The first 30 days in a new role matter immensely, and can set the tone for a leader’s tenure in their organization. 

Four Principles for a Leader’s First 30 Days 

1. Focus on connection.  

In your first weeks in a new senior leadership role, you will likely be given many opportunities to speak to larger groups of people as you’re introduced at meetings with your team, staff, or board of directors. It is important to remember that while these opportunities to build face recognition are important, more is required. You must ensure you are taking the time to talk with each person in your organization individually (Knight, 2020). 

The importance of one-on-one connection cannot be overstated.  This allows you to build trust with your team, which will be essential to long-term success in your new role, and for the organization as a whole.  Start by making an effort to learn every person’s name. One of the best ways to make a great “second” impression with those we manage is by confidently recalling their name the next time we see them (Hedges, 2013). 

This can be a particular challenge for leaders who are more reserved or introverted (Isakson, 2015).  After getting to know your new team, continue to reach out to unfamiliar coworkers who you may not interact with as regularly (Rollag, 2015). It requires vulnerability, but the risk will not go unrewarded.

 2. Learn first, act second. 

Manage the urge to start making your mark on the organization in your first month on the job.  It is natural to be eager to prove your worth to your new colleagues and employees, but—in the wise words from the Harvard Business Review article, “Why New Leaders Should Make Decisions Slowly”—it is critical to “learn first, and act second” (Dierickx, 2019). 

Instead of taking every opportunity to share your opinion or plan of action, do the opposite in your first 30 days (Biro, 2013).  Ask questions about your team’s observations. Learn what has or hasn’t worked in the past, and why. Find out what they believe their strengths and weaknesses are (Rapid Start Leadership, 2020). As the old management adage goes, good leaders avoid being the smartest person in the room (Executive Forum, 2020).  Becoming infatuated with yourself and your own thoughts will cause your tenure to be dead on arrival (Dowling, 2019). 

As you ask questions of your team, listen actively. This is a crucial skill. It can be tempting to formulate a response or rebuttal as someone is speaking, but this prevents you from comprehending and responding to their entire message (Hersh, 2018).  Tuning out information from your co-workers deprives you of the opportunity to know and develop trust in your team, which will in turn stunt your and your team’s ability to engage in a rewarding and fulfilling workplace (Biro, 2013).

3. Create the kind of work environment you want to be part of. 

In a 2014 survey of 19,000 employees, only 25% of those surveyed believed their workplace’s leadership modeled “sustainable work practices” (Schwartz & Porath, 2014). The survey also found that the employees of leaders who engaged in sustainable work practices were “55% more engaged, 72% higher in health well-being, 77% more satisfied at work, and also reported more than twice the level of trust in their leaders” compared to other respondents (Wingard, 2020). 

The work practices of new leadership are an indicator to others of that leader’s expectations of them—whether they intend for it to be or not. Modeling a healthy work-life balance, even in your first 30 days in your new role, gives your employees permission to seek a sustainable lifestyle as well. The data on the impact this can have on employees’ quality of life, productivity, team dynamics, and overall wellness are well-documented. 

Additionally, the character you display in the early days as a senior leader sets the tone for your entire tenure.  You may have a misunderstanding with a new co-worker or make a mistake. To be human means to miss the mark once in a while, after all.  Yet your response should be carefully considered. The difference between “good leaders and great ones lies in how they handle those mistakes” (Daskal, 2018).  It’s important to know when to apologize, and when to remain firm (Kellerman, 2006). 

4. Internalize the mission. 

Use your first month on the new job to solidify your understanding of your new organization’s “why,” or their reason for being, as Simon Sinek says in his 2009 book, “Start with Why.”   

The heart of any company is its mission, vision, and values (Groscurth, 2014).  When you’re new on the job, it is easy to get wrapped up in the “what”—products or services, industry, or competitors—and the “how”—processes, methods, unique differentiators (Ranadive, 2017).  When you feel stuck in your new position, you don’t have to reinvent anything. Look to the mission as your guide. 

Even in your first weeks leading an organization, new leaders can actively be creating a culture conducive to success (Rihal, 2017; Shaffer, 2015).  Invest your time in forming genuine connections with your new colleagues and employees.  Listen well, and learn everything you can about the company and your team’s capabilities.  Even in the busyness of getting caught up to speed in a new position, model sustainable work practices and prioritize your overall well-being.  Take time to fully understand the mission, and allow it to propel you forward.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com 

Resources:

Biro, M.M. (2013). 5 Leadership Lessons: Listen, Learn, Lead. Forbes. 

Craig, W. (2018). The Importance Of Having A Mission-Driven Company. Forbes. 

Daskal, L. (2018). 4 Impressive Ways Great Leaders Handle Their Mistakes. Inc Magazine. 

Dierickx, C. (2019). Why New Leaders Should Make Decisions Slowly. Harvard Business Review. 

Dowling, M. (2019). What Not to Do as a Leader. Northwell Health. 

Executive Forum (2020). Never Be the Smartest Person in the Room. Executive Forum. 

Groscurth, C. (2014). Why Your Company Must Be Mission-Driven. Gallup. 

Hedges, K. (2013).  The Five Best Tricks To Remember Names. Forbes. 

Hersh, E. (2018). Using Effective Listening to Improve Leadership in Environmental Health and Safety. Harvard School of Public Health. 

Isakson, T. (2015). 5 Habits Of Effective Introverted Leaders. Fast Company. 

Keller, S., & Meaney, M. (2017). High-performing teams: A timeless leadership topic. McKinsey Quarterly. 

Kellerman, B. (2006). When Should a Leader Apologize—and When Not?. Harvard Business Review. 

Knight, R. (2020). How to Talk to Your Team When the Future Is Uncertain. Harvard Business Review. 

Marie, L. (2019). The Art of Taking People and Things at Face Value. Human Parts. 

O’Hara, C. (2014). What New Team Leaders Should Do First. Harvard Business Review. 

Patel, D. (2017). Big Brands and business Are Aligning their Missions with Millennial and Gen Z Consumers. Forbes.  

Ranadive, A. (2017). The Power of Starting with Why. Medium. 

Rapid Start Leadership (2020). New Leader Checklist: 4 Questions to Ask if You Want to Lead Effectively. Rapid Start Leadership. 

Rihal, C.S. (2017). The Importance of Leadership to Organizational Success. NEJM Catalyst. 

Rollag, K. (2015). 3 Things Every New Leader Should Do Their First Week On The Job. Fast Company. 

Schwartz, T., & Porath, C. (2014). Your Boss’s Work-Life Balance Matters as Much as Your Own. Harvard Business Review.

 Shaffer, J. (2015). A Leader’s First 30 Days Are Free. Jim Shaffer Group. 

Sinek, S. (2009). “Start with Why.” Portfolio. 

Watkins, M.D., Orlick, A.L., & Stehli, S. (2014). Hit the ground running: Transitioning to new leadership roles. IMD. 

Wingard, J. (2020). Want To Be A Good Leader? Go Home!. Forbes.

Influenza Joins The 1%ers – The One Bit of Good COVID News

By Clive Riddle, February 12, 2021

It’s been widely discussed that influenza spread this flu season is significantly lower, due in great part to COVID-19 induced mask wearing, hand washing, physical distancing and reduced travel by a good portion (but certainly not all) of our population.  

Now that we’re progressing through this influenza season, it’s interesting to do a side-by-side comparison for 2021 vs 2020 as of week five of the calendar year (40 cumulative weeks for the flu season).

Summing up the numbers from the CDC Weekly Surveillance Report totals through the 40^th week of the season for both years, here’s the jaw-dropping difference:

• 2019-2020 Positive Cases through Week 40: 129,997
• 2020-2021 Positive Cases through Week 40:    1,364
• 2019-2020 Flu Test Positivity Rate through Week 40: 17.6% (738,331 tests)
• 2020-2021 Flu Test Positivity Rate through Week 40:   0.2% (593,570 tests)

So this season’s positive cases of influenza are running at 1% of last season!

Comparing the CDC Weekly Surveillance Report charts for these two snapshots in time, stark as the difference appears, actually doesn’t do the comparison justice as the scale for the current season had to be changed for the graph to be readable (the y axis grid for number of positive specimens is in increments of 50 for the 2020-2021 season, vs increments of 2,000 for the 2019-2020 season.)

Cigna COVID Global Impact Study: Physical Health Indicators Globally More Resilient, Stable Than Mental Health and Other Factors

By Clive Riddle, February 5, 2021

Cigna's International Markets business has just released its fourth COVID-19 Global Impact Study. Cigna states the series, based on Cigna's annual 360 Well-being Study, “provides further insight into the global impact of the COVID-19 pandemic on people's well-being in 11 markets around the globe.”

The new 17-page report, involved Cigna engaging “more than 23,000 people across Mainland China, Hong Kong, South Korea, New Zealand, Singapore, Spain, Taiwan, Thailand, United Arab Emirates, United Kingdom and the United States between January and October 2020, to show the changes in attitudes during the pandemic.”

Cigna reports that “the latest survey data shows that after months of pandemic-related restrictions, periodic stay-at-home orders, changing restrictions on travel and social gatherings, and multiple waves of infection, people worldwide have become even more concerned about the future. According to the study, almost half of global respondents said concern for the future is their greatest cause of stress. Another common area of stress is the balance between work life and family life. More than 40% of respondents reported low well-being scores and high stress levels in both of these areas, with 14% saying their level of stress is currently unmanageable.”

Cigna noted that while perceived well-being declined worldwide, from around a mean 62.5 on their index at the start of 2000 to 61.2 in June, and then rising slightly since – “in the U.S. it was a more positive picture, with the well-being index improving by a remarkable 2.6 points. Respondents reported significant improvements in their feelings of health and well-being.”

Cigna provides these two takeaways summarizing the report:

“What is striking about the study is that the pandemic is primarily a threat to health. And yet, the  physical indicators are the ones that remain most resilient and stable. It’s other factors, such as family, work, social and finance, that are showing the heavy toll of the virus and the global response to it. This is telling in itself of the nature of human health and well-being and the interconnected role of the factors that influence it.”

“We’re entering a new phase in response to the pandemic, one where it will be important for organizations to support their workforce by offering tailored healthcare programs that cater for a wide variety of perceptions and experiences across the globe. They need to be sensitive to the fact that emotions of employees could range across a broad spectrum and they need to provide solutions that truly address that.”

And You Thought Health Insurance Was Bad

By Kim Bellard, January 28, 2021

I spend most of my time thinking about health care, but a recent The New York Times article — How the American Unemployment System Failed — by Eduardo Porter, caught my attention. I mean, when the U.S. healthcare system looks fair by comparison, you know things are bad.

Long story short: unemployment doesn’t help as many people as it should, for as much as it should, or for as long as it should.

It does kind of remind you of healthcare, doesn’t it?

The pandemic, and the associated recession, has unemployment in the news more than since the “Great Recession” of 2008 and perhaps since the Great Depression. Last spring the unemployment rate skyrocketed well past Great Recession levels, before slowly starting to subside. Still, last week almost a million people filed for unemployment benefits, reminding us that unemployment is still an issue.

Mr. Porter reports:

· “In 2019, only 27 percent of unemployed workers received any benefits, a share that has been declining over the last 20 years.

· The benefits have eroded as well, to less than one-third of prior wages, on average, about eight percentage points less than in the 1940s.”

The states range from 58% of unemployed workers in New Jersey who receive benefits to 9% — 9%! — in North Carolina. Robert Moffitt, a Johns Hopkins economics professor, told Mr. Porter: “The program was set up to have tremendous cross-state variation. This makes no sense. It creates tremendous inequities.”

As with our healthcare system, “broken” isn’t really a good description. Each is working the way they’ve been designed. Unfortunately, if you’re poor or sick, and especially if you are both, they’re not designed to help you. Not until the poor and sick start making significant campaign contributions anyway, or at least vote in larger numbers.

Many unemployed workers, of course, also lose their health insurance when they lose their jobs, since ours is a predominantly employer-based health insurance system. As many as 15 million people may have lost their employment-based coverage due to the pandemic. If they work for the right kind/size of employer, they may be eligible for COBRA coverage, but paying for it may be difficult, between loss of employer contribution, low UI benefits, and delays in receiving UI.

At least under ACA they may have coverage options, including subsidies, through the Marketplace or Medicaid, — unless they live in one of the states without Medicaid expansion.

Even in the states that have expanded Medicaid, the economic crisis has hit their tax revenue severely, while increasing the number of Medicaid enrollees, creating a double whammy. The same, of course, is happening with the money to pay unemployment benefits, causing almost half the states to ask for federal loans.

In other words, when we have the worst crises — like a pandemic — both our unemployment insurance and our health insurance systems do worst. Those are the times we rely most on the government, but our federalism system of shared federal/state responsibilities is failing the latest crisis.

Mr. Porter sees hope:

Perhaps there is an upside to the current crisis: The glaring insufficiencies of the regular unemployment system may encourage states and the federal government to undertake comprehensive changes.

Perhaps. If the pandemic continues long enough — as it might — it might force deep structural changes. So far, the various relief bills have just added more patches to our patchwork quilt approach towards UI. But if in the coming months vaccines mitigate the impact, and the economy picks up, then our typical reaction will be to commission some studies and just kick the can further down the road.

ACA made our health insurance system less patchwork, with more uniform requirements, more subsidies, less discrimination against preexisting conditions, and broader Medicaid options. The Biden Administration may, and should, further improve these. Let’s hope that it takes a hard look at how it can do something similar with unemployment insurance.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Four Important Takes on the Key Healthcare Trends and Issues for 2021

By Clive Riddle, January 22, 2021

With the promise and peril of each new year, healthcare prognosticators weigh in on what are the significant trends and issues that lay in wait. With the stakes in 2021 seemingly like no year in recent memory, here is a capsule of items put forward from four important perspectives as we move forward in the calendar:

PwC’s Health Research Institute (HRI) annually publishes their report on top issues for the new year, which will be featured next week in the 2021 Future Care Web Summit. This year’s report: Top health industry issues of 2021: Will a shocked system emerge stronger? “examines how the healthcare industry is expected to face the uncertainty of 2021, building resilience for long-term survival by developing its own forecasting systems, reshaping business portfolios post-pandemic for financial stability and growth, and creating a more nimble, modern supply chain.” 

They find the key issues will include:

• Virtual health reshapes healthcare delivery
• Clinical trials are changing—for good
• Digital relationships can help improve the clinician experience
• Enhanced Healthcare forecasting for an uncertain 2021
• Health portfolios reshaped for growth: increased investment in and by healthcare companies
• A resilient and responsive supply chain built for long-term health
• Interoperability 2021: potential foundation to power forward a more consumer-centric healthcare system after the pandemic

The employer perspective, from the Business Group on Health, is offered in their new report: Key Insights: Health Care Trends in 2021, which cities these five trends:

• The Proliferation of Virtual Care—  More attention will be given to the evaluation of the quality, outcomes, effectiveness, patient experience and cost of virtual care options and innovations, as well as the appropriateness of virtual vs. in-person care for specific services.
• A Reimagining of Health Care Delivery— Even though employers and plans may have momentarily slowed the expansion of alternative payment and delivery models because of the pandemic, a redoubling of efforts in 2021 will drive improvements in quality and value.
• A Spotlight on Mental Health and Emotional Well-being—In 2021, novel approaches such virtual counseling and the integration of Employee Assistance Programs and mental health benefits, will place mental health on par with other medical conditions.
• Adapting to the Well-being Needs of a Changing Workforce— In 2021, employers will continue to demonstrate flexibility and support employee needs through leave, remote work and other benefits.
• Addressing Gaps in Health Equity—In 2021, the health care ecosystem, including providers, suppliers and payers, will boost efforts to examine and address health equity, while mitigating the harmful effects of social determinants of health.

A hospital perspective is offered by the American Hospital Association in their AHA Trustee piece: Top 10 Emerging Trends in Health Care for 2021: The New Normal

1. More Strategic and Agile Supply Chains
2. Coopetition as a Viable Strategy
3. Patient Consumerization
4. Personalization of Care
5. Workforce Diversity and Safety
6. Virtual Care
7. Artificial Intelligence and Automation
8. Revenue Diversification
9. Mergers and integration
10. Payer Shifts

And finally, with the pandemic further bringing behavioral health issues to the forefront, the American Psychological Association offers their report on Emerging trends for 2021:

• Healing the political divide
• Social media is increasing impact
• The fight against racism must continue
• Psychology research is front and center
• Mental health apps are gaining traction
• Psychologists’ skills are in great demand
• The national mental health crisis
• The great distance learning experiment continues
• There’s a new push to reach underserved communities
• Psychology’s involvement in policing
• Psychologists are moving up in academia
• Online therapy is here to stay
• Advocacy will help secure expanded telehealth coverage
• Employers are increasing support for mental health

Monitoring the safety and effectiveness of COVID-19 vaccines

By Dr. Seleem R. Choudhury, January 14, 2021  

Next to clean water, no single intervention has had such a dramatic effect on decreasing mortality as has the widespread introduction of vaccines (Howson, Howe, & Fineberg, 1991). The World Health Organization (WHO) describes immunization as a “key component of primary health care and an indisputable human right,” as well as “one of the best health investments money can buy” (World Health Organization, 2020). Vaccines play a critical role in the prevention and management of the outbreak of infectious diseases.  The rapid spread of COVID-19 during the months-long wait for a vaccine have highlighted their importance to public health. 

If COVID-19 were a Shakespearean play, the administration of the vaccine would ideally be the final act, and widespread adoption and effectiveness, the epilogue. However, just like Shakespeare’s Timon of Athens, this play may be also be left unfinished. According to the WHO, at least 198 COVID-19 vaccines are currently in the development pipeline, with 44 currently undergoing clinical evaluation (2020). National Institute of Allergy and Infectious Diseases Director Anthony Fauci, M.D., recently stated a date to a possible “normal” is tricky at best (McCarthy, 2020). He explains: 

“If the vaccine is reasonably if not quite effective, but not a very large proportion of the population take it, then that would really be unfortunate because it wouldn’t provide that umbrella of protection over the community so that you could feel reasonably certain that when you go to a family function, a wedding, or the like, that there’s not going to be a couple of people in there that are actually infected.”

Continued monitoring: Reasons and methods

The effectiveness of the COVID-19 vaccine to usher in a “new normal” hinges on its widespread administration. Continuous and transparent monitoring is essential to encourage the maximum number of people to choose to be vaccinated.  This article was written fully acknowledging that the SARS-CoV-2 variant exists, yet the implications of the variant remains unclear and the impact upon the vaccines remains unknown (Public Health England, 2020). 

Reasons for monitoring the vaccine

The primary reason for conducting additional vaccine effectiveness assessments is to ensure a vaccine “protects people from getting a disease under real-world conditions, outside of the strict setting of clinical trials” (National Center for Immunization and Respiratory Diseases, 2020). Numerous factors, such as how a vaccine is transported, the method of storage, or even the way patients are vaccinated, can affect a vaccine’s effectiveness in real-world situations.  

Even after administration trials of the COVID-19 vaccine, organizations will continue to monitor longer-term safety and efficacy (Cyranoski, 2020).  Teams of experts will evaluate the effectiveness of the vaccine in real-world conditions, outside of more controlled clinical environments (WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation, 2020).  Furthermore, underlying medical conditions not present in patients who participated in the clinical trials can also change the effectiveness of the vaccine in real-world use, or in groups not included or represented in clinical trials, such as children under 12, or pregnant or lactating women (National Center for Immunization and Respiratory Diseases, 2020).   

Additionally, transparent monitoring will prove essential to improve the public’s trust in the vaccine so that people will choose to vaccinate. Public trust in the storied public health institutions cited above is now deeply compromised. According to recent polls, 62% of Americans worry the U.S. Food & Drug Administration (FDA) will rush to approve vaccines without adequately assuring safety and effectiveness because of political pressure (Hamel, Kearney, Kirzinger, Lopes, Muñana, & Brodie, 2020; Miller, Ross, & Mello, 2020).  Only 25% of Americans have “a great deal” of trust in the Centers for Disease Control and Prevention (CDC), and only 21% definitely plan to get vaccinated, while 49% probably or definitely will not (Tyson, Johnson, & Funk, 2020). 

Vaccine safety is a significant concern for many, given the uncommonly rapid development and testing process, underlying suspicion about vaccines in general among segments of the population, and mistrust of the government’s pandemic response thus far (DeRoo, Pudalov, & Fu, 2020).  Efforts to provide the population with ample information addressing these reasons for apprehension should be made before and during vaccine program rollout. 

In addition to widespread misinformation about vaccines, health organizations must also contend with mistrust of vaccines borne out of the U.S.’s historical mistreatment of people of color in the spread and prevention of infectious diseases. This includes actions such as using ethnic minorities as test subjects for medical advances in the 20th century, or giving blankets laced with smallpox to indigenous peoples in Jamestown in the 1700s, to name a few examples.  In fact, some studies link mistrust of the health care system and fears of experimentation among some African American people to historical and contemporary mistreatment and disparities in care (Yancy, 2020). 

Methods for monitoring the vaccine

Clinical trial results show whether vaccines are effective.  The FDA evaluates the data from the clinical trials, as well as manufacturing information, to assess the safety and effectiveness of vaccines, then decides whether to approve a vaccine or authorize it for emergency use in the United States (National Center for Immunization and Respiratory Diseases, 2020; U.S. Food & Drug Administration, 2018). 

However, even after a vaccine is approved by the FDA and released for public use, more assessments are necessary. According to the CDC, the goal of these assessments is “to understand more about the protection a vaccine provides under real-world conditions, outside of clinical trials” (2020).  This is accomplished by comparing groups of people who do and don’t get vaccinated, and people who do and don’t contract the COVID-19 virus to assess how well COVID-19 vaccines are working to protect people compared to other protection measures (National Center for Immunization and Respiratory Diseases, 2020). 

Future implications and vaccine resistance

These vaccine monitoring activities are the norm, but they will take place on a larger scale during this pandemic. The post-licensure vaccine evaluation will be a crucial component of an evidence-based vaccine program. This should include four aspects.

1. Collecting exposure data for COVID-19 vaccines.

The data when reviewing the efficacy of the trial is thus far encouraging and builds confidence in the continued effectiveness of the vaccine. Dedicated trials will be needed to deepen our understanding of the impact of COVID-19 vaccines among different groups, specifically children, pregnant women, and black, indigenous and people of color (Hodgson, Mansatta, Mallett, Harris, Emary, & Pollard, 2020). 

Additionally, data must be collected to assess the effectiveness of a promising administration method: heterologous prime-boost vaccination. A heterologous prime-boost vaccination is a “repeated immunization regimen designed to increase and sustain vaccine-induced immune responses” involving “sequential delivery of different vaccine platforms” (Jeyanathan, Afkhami, Smaill, Miller, Lichty, & Xing, 2020). This method has proven effective with vaccines for other diseases such as hepatitis B24 and Ebola virus (Logunov, Dolzhikova, Zubkova, Tukhvatullin, Shcheblyakov, & Dzharullaeva, et al., 2020). In past studies of other coronaviruses, “prime-boost regimens using different viral vectors expressing the same recombinant antigen proved very efficient in enhancing the target antigen-specific immune responses” (Schulze, Staib, Schätzl, Ebensen, Erfle, & Guzmana, 2008).

2. Adopting specific safety signal detection and management measures.

A vaccine safety signal is “information that indicates a potential link between a vaccine and an event previously unknown or incompletely documented, that could affect health” (World Health Organization, 2020). Experts monitor this data to decide whether changes are needed in U.S. vaccine recommendations in order to ensure that the benefits continue to outweigh the risks for people who receive vaccines (National Center for Immunization and Respiratory Diseases, 2020; European Medicines Agency, 2020). 

3. Using real-world evidence (RWE) from clinical practice.

At the beginning of the pandemic, there were well documented errors made by many countries, including notable errors in the U.S. from the CDC, the Trump administration, and hospitals (New York Times, 2020; Nather, 2020; Evans & Berzon, 2020). As a nation, the U.S. was slow to respond and react to an ever-evolving situation. Real-world evidence gathered from longitudinal studies of COVID-19 patients and vaccine recipients will play a crucial role in responding to new information quickly and effectively in clinical practice. 

4. Applying exceptional transparency measures.

The combination of data and technology makes it possible to conduct near real-time analyses of healthcare trends and, for the first time, create a more robust and accurate understanding of disease and treatments (Christian & Reynolds, 2020). This data will have to be shared in its entirety, with no detail withheld or deemed unimportant. The data must be open to criticism and analysis so that trust can be allowed to grow, and fear subsides (Nature, 2020).

Summary

Dr. Seleem R. Choudhury receiving his 1st dose of Pfizer COVID vaccine.

The COVID-19 vaccine will not be able to single-handedly eliminate the virus from our lives. It will not necessarily allow us to return to the life we led before the pandemic reared its ugly head, but it has great potential to save countless lives and make a way forward into a new normal.  The key to making this a reality is continuous monitoring of the vaccine’s effectiveness and high levels of transparency to build public trust. 

Research indicates that a majority of Americans may trust scientific research findings more if data and information were publicly shared (Funk, Hefferon, Kennedy, & Johnson, 2019; Miller, Ross, & Mello, 2020). It is essential to widen public access to information about vaccine clinical trial design, conduct, and data. This exchange of information will provide the necessary transparency and ease of interpretation of data.  

Big pharma will need to be comfortable understanding the public hesitancy and be prepared to counter this reluctance with openness and a level of transparency never seen before as the stakes could not be higher: “History has shown that once public trust in vaccines has been compromised it is difficult to win back” (Nature, 2020).

Read more from Dr. Seleem Choudhury at seleemchoudhury.com  

Resources:

Christian, J.B., & Reynolds, M.W. (2020). Combatting COVID-19 With Real-World Evidence. American Journal of Managed Care.  

Cyranoski, D. (2020). Why emergency COVID-vaccine approvals pose a dilemma for scientists. Nature, 588, 18-19. 

DeRoo, S.S., Pudalov, N.J., & Fu, L.Y. (2020). Planning for a COVID-19 Vaccination Program. JAMA Network. 

European Medicines Agency (2020). COVID-19 vaccines: development, evaluation, approval and monitoring. European Medicines Agency. 

European Medicines Agency (2020). Pharmacovigilance Plan of the EU Regulatory Network for

COVID-19 Vaccines. European Medicines Agency. 

Evans, M., & Berzon, A. (2020). Why Hospitals Can’t Handle Covid Surges: They’re Flying Blind. The Wall Street Journal. 

Funk, C., Hefferon, M., Kennedy, B., & Johnson, C. (2019). 3. Americans say open access to data and independent review inspire more trust in research findings. Pew Research Center. 

Hamel, L., Kearney, A., Kirzinger, A., Lopes, L., Muñana, C., & Brodie, M. (2020). KFF Health Tracking Poll - September 2020: Top Issues in 2020 Election, The Role of Misinformation, and Views on A Potential Coronavirus Vaccine. KFF. 

Hodgson, S. H., Mansatta, K., Mallett, G., Harris, V., Emary, K. R., & Pollard, A. J. (2020). What defines an efficacious COVID-19 vaccine? A review of the challenges assessing the clinical efficacy of vaccines against SARS-CoV-2. The Lancet Infectious Diseases. 

Howson, C.P., Howe, C.J., & Fineberg, H.V., editors. Adverse Effects of Pertussis and Rubella Vaccines: A Report of the Committee to Review the Adverse Consequences of Pertussis and Rubella Vaccines. (1991). Institute of Medicine (US) Committee to Review the Adverse Consequences of Pertussis and Rubella Vaccines. National Academies Press.

McCarthy, M. (2020). Fauci and Other Experts Debate When Our COVID-19 Lives Will Return to Normal. Healthline. 

Jeyanathan, M., Afkhami, S., Smaill, F., Miller, M.S., Lichty, B.D., & Xing, Z. (2020). Immunological considerations for COVID-19 vaccine strategies. Nature Reviews Immunology, 20. 

Logunov, D.Y., Dolzhikova, I.V., Zubkova, O.V., Tukhvatullin, A.I., Shcheblyakov, D.V., & Dzharullaeva, A.S., et al. (2020). Safety and immunogenicity of an rAd26 and rAd5 vector-based heterologous prime-boost COVID-19 vaccine in two formulations: two open, non-randomised phase 1/2 studies from Russia. The Lancet, 396(10255). 

Miller, J.E., Ross, J.S., Mello, M.M. (2020). Far more transparency is needed for Covid-19 vaccine trials. Stat News. 

Nather, D. (2020). Trump's war on the public health experts. Axios. 

National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases (2020). Ensuring COVID-19 Vaccines Work. U.S. Centers for Disease Control and Prevention. 

National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases (2020). Ensuring the Safety of COVID-19 Vaccines in the United States. U.S. Centers for Disease Control and Prevention. 

Nature (2020). COVID vaccine confidence requires radical transparency. Nature, 586(8). 

New York Times (2020). The Unique U.S. Failure to Control the Virus. New York Times. 

Public Health England (2020). PHE investigating a novel strain of COVID-19. Public Health England. 

Schulze, K., Staib, C., Schätzl, H.M., Ebensen, T., Erfle, V., & Guzmana, C.A. (2008). A prime-boost vaccination protocol optimizes immune responses against the nucleocapsid protein of the SARS coronavirus. Vaccine, 26(51). 

Tyson, A., Johnson, C., & Funk, C. (2020). U.S. Public Now Divided Over Whether To Get COVID-19 Vaccine. Pew Research Center. 

U.S. Food & Drug Administration (2018). Step 3: Clinical Research. U.S. Health and Human Services.

WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation (2020). Placebo-Controlled Trials of Covid-19 Vaccines — Why We Still Need Them. New England Journal of Medicine. 

World Health Organization (2020). Draft landscape of COVID-19 candidate vaccines.  

World Health Organization (2020). Investigation of safety signals. World Health Organization. 

World Health Organization (2020). Vaccines and immunization: Overview. 

Yancy, C.W. (2020). COVID-19 and African Americans. JAMA Network.

Health Plan Companies Start New Year M&A Activity With a Bang

By Clive Riddle, January 8, 2021

The first week of the new year witnessed a flurry of merger & activity from health plan companies, highlighted by the continuing diversification trend in which many such organizations can’t really be labeled just a health plan company anymore.

UnitedHealth Group’s Optum has acquired Change Healthcare. We are told “Change Healthcare will join with OptumInsight to provide software and data analytics, technology-enabled services and research, advisory and revenue cycle management offerings.” The agreement calls for the acquisition of Change Healthcare’s common stock for $25.75 per share in cash and is expected to close in the second half of 2021.

In a statement, Andrew Witty, President of UnitedHealth Group and CEO of Optum commented “together we will help streamline and inform the vital clinical, administrative and payment processes on which health care providers and payers depend to serve patients. We’re thrilled to welcome Change Healthcare’s highly skilled team to create a better future for health care.” Neil de Crescenzo, President and CEO of Change Healthcare, who will serve as OptumInsight’s chief executive officer, added "this opportunity is about advancing connectivity and accelerating innovations and efficiencies essential to a simpler, more intelligent and adaptive health system."

Centene Corporation announced they will acquire Magellan Health for $95 per share in cash for a total enterprise value of $2.2 billion. We are told the transaction "will broaden and deepen Centene's whole health capabilities and establish a leading behavioral health platform," with the Magellan Health CEO and management to remain in leadership roles. Centene summarizes the additional benefits of the merger as including: a combined platform to deliver better health outcomes for complex populations through the integration of physical and mental health care; an important addition to Centene's Health Care Enterprises, under which Magellan Health will continue to operate independently; creation of a next generation behavioral health platform, aligned with Centene's technology strategy with additional growth opportunities in specialty care and pharmacy.

In a statement, Michael F. Neidorff, Chairman, President and Chief Executive Officer of Centene commented "This acquisition accelerates our diversification strategy and enhances our ability to build next generation capabilities in our specialty care business by leveraging our scale and investments in technology. Furthermore, we are very familiar with the range of Magellan Health's healthcare solutions as we have been one of their customers over many years.”

Molina Healthcare, Inc. announced that its acquisition of the Magellan Complete Care line of business of Magellan Health, Inc. closed on December 31, 2020. Magellan Complete Care serves approximately 200,000 members. The transaction helped clear the way for Centene's acquisition of Magellan Health.

Harvard Pilgrim Health Care and Tufts Health Plan announced their organizations have formally combined, effective January 1, 2021, having received all regulatory approvals. Tom Croswell , head of Tufts will serve as CEO for the combined organization, and Michael Carson, head of Harvard Pilgrim, will serve as President. We are told that "while Tufts Health Plan and Harvard Pilgrim Health Care are officially one organization, both heritage brands and products will remain in the market for a period of time, and the benefits, programs and services its members rely on will not change in 2021 as a result of the combination.  The new organization’s headquarters will be located in Canton, MA; move in is slated to begin in Q4 of this year.  The new organization also anticipates announcing its new name in the second quarter of 2021."

Smaller regional plans are at it as well. Physicians Health Plan of Northern Indiana  announced they acquired Core Benefits, Inc., effective December 31, 2020, to provide additional reach into the third party administration (TPA) and employee benefits market. And Bright Health announced it has signed an agreement to acquire Central Health Plan of California. Upon closing, Bright Health will serve approximately 110,000 individuals within its Medicare Advantage business.

What will the rest of January bring in the health plan M&A world, let alone the rest of 2021?

Streaming, Baby Yoda, and Healthcare

by Kim Bellard, December 15, 2020

I’ve never seen The Mandalorian. I don’t have Disney+. But I know who Baby Yoda is, and I’m pretty sure Disney is counting on that. Hollywood, in case you haven’t been paying attention, is going through some radical changes. There may be some lessons for healthcare in them.

Hollywood has made some startling announcements in the past few weeks that illustrate how swiftly changes are coming to the entertainment industry:

Disney: Disney expects to have 100 new titles — TV shows or movies — each year for the next few years. Disney chairman Bob Iger noted modestly: “The pipeline of original content we’re making is much more robust than originally anticipated.” Of particular note, though, CEO Bob Chapek said, “Of the 100 new titles announced today, 80 percent of them will go to Disney Plus.”

Warner Bros: Although Disney expects some of its movies to still have theatrical runs prior to streaming, Warner Bros announced in early December that all of its 2021 releases will be available for streaming on its HBO Max service upon release, rather than after the “traditional” 90+ day wait.

If you’re worried about the original streaming service — Netflix — don’t be. Although its growth has slowed, that’s partly because it already has close to 200m subscribers worldwide. Its stock is up over 50% YTD, and even the announcements from Disney and Warner didn’t seem to shake that. Similarly, Amazon Prime has over 150m video users, more than half of them in the U.S., and continues to invest heavily in new streaming content.

It’s a new world for Hollywood. Brooks Barnes, NYT entertainment reporter, wrote: “one Warner Bros. executive told me that “the town” felt like a dismantled movie set: The gleaming false fronts had been hauled away to reveal mere mortals wandering around in a mess.” Another Hollywood insider told him: “I see this as a time of opportunity. Sometimes you have to take it down to the studs and build something new.”

Healthcare’s “false fronts” have been torn down too. If ever there was a time to take healthcare “down to the studs and build something new,” this is it.

We brag about the increases in telemedicine, but we should note the CMS rules that have expanded its use are only temporary. We haven’t addressed the inter-state licensing issues. We’re not even doing telehealth visits all that well; the Press Ganey survey concluded: “The bad news is that patients clearly feel that the process of telemedicine (logistical things like ease of scheduling and making audio/video connections) falls short.”

We’ve seen dramatic declines not just in office visits but also in use of preventive services and screenings, elective surgeries, emergency room visits, even heart attacks. We just don’t know if these declines are good or bad. Researchers Allison H. Stokes, PhD, and Jodi B. Segal, MD, suggest in Health Affairs: “We see a unique methodological opportunity to evaluate the harms of low-value care.”

But will we take advantage of that opportunity, or will we just go back to our old ways once the vaccines work their magic?

E.g., will healthcare just expect patients to go back to the theater? Or will major healthcare companies bet big on the future: “streaming” (aka telehealth) as the main consumer point-of-contact, with patient convenience as a main driver? Where digital is the norm?

Disney’s physical locations — its theme parks — are hemorrhaging money, and Warner Bros has suffered dramatic declines from theater revenues, but both are betting big on their virtual strategies — and the markets are rewarding them. Warner says its announcement is only a strategy for 2021, but, as NYT put it:

It will be almost impossible to go back, and it may force other studios to abandon the old model.

We shouldn’t expect patients to go back to the “old” healthcare system either.

I’m not expecting healthcare to have a Baby Yoda caliber idea, but it can certainly do better than its current Jar Jar Binks strategies.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Overcoming barriers to provide patient-centered care

By Dr. Seleem R. Choudhury, December 10, 2020

The term "patient-centered care" is in vogue and utilized by health system administrators, marketing gurus, hospital staff, and clinicians alike. It's a catchy phrase that resonates with stakeholders, and it sounds like something every healthcare organization would heartily embrace. However, the heart of patient-centered care and its implications for how care is actually provided to patients is not well understood.

The Institute of Medicine defines patient-centered care as "providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions" (HealthLeads, 2018; Wolfe, 2001). The goal of patient-centered care is focused primarily on the health outcomes of the individual rather than the entire population (NEJM Catalyst, 2017). However, by prioritizing the individual's health, populations' health outcomes are improved as well (Cramm & Neiboer, 2016).  Additionally, patient-centered care presents possible economic advantages for both hospitals and patients (David, Saynisch, & Smith-McLallen, 2018).

However, there are many barriers that must be overcome to live up to the aspirational definition of patient-centered care and experience the benefits this approach offers. 

Barriers to patient-centered care

An article released last year by Academy Health outlines many of the barriers to patient-centered care (Sinaiko, Szumigalski, Eastman, & Chien, 2019). It highlights that these barriers are "pervasive" within the healthcare system.  The current lack of agility within healthcare as an industry has limited the customizability of care delivery, and there are many broad sections of the population that are paying the price.

Reimbursements

Erasmus spoke of "the talking power of money," and it is true that "money talks" centuries later in today's healthcare system. Many healthcare systems continue to utilize fee-for-service. While this approach is hotly debated amongst healthcare professionals and economists, many believe fee-for-service models create incentives for providers to encourage face-to-face or volume building visits, and are widely indicted for promoting care that is inefficient, uncoordinated, and too often fails to meet the needs of patients (Agency for Healthcare Research and Quality, 2002). 

The fee-for-service system serves to drive up volume and encourages hospital and community health organizations to make money and support their healthcare system rather than the needs of the patient.  This may lead providers to perform unnecessary surgeries, x-rays, or lab work, to name a few common examples, in order to increase revenue, rather than focus on the patient's desire to receive only the care they need at a cost they can afford.

It is recognized, however, that the fault does not just rest with the organization. Often, the regulatory burden on providers and hospitals is unrealistic and cumbersome, stifling innovation (Secretary of Health and Human Services, 2018). This can lead to the tail wagging the dog with organizations feeling pressure to meet regulatory needs before addressing patient needs in order to gain reimbursements.

Organizational culture

Unsurprisingly, the culture of the organization impacts patient outcomes and the practice of patient-centered care (Hahtela, McCormack, Doran, Paavilainen, Slater, Helminen, & Suominen, 2017). It is not enough to simply tout a patient-centered approach in annual reports, periodic training, glossy posters, mission statements, email signatures, or quick notes in a staff meeting. Everyone associated within the organization—from executives to clinicians to non-clinical support staff to volunteers—must hold attitudes and beliefs consistent with patient-centeredness (Gorli, Liberati, Galuppo, & Scaratti, 2016; Agha, Werner, Reddem, Huseman, Long, & Shea, 2018).

The organization must become transformational to make patient-centered care a reality, not just a nice sentiment.  This will require training for all employees and a mindset shift from the top down.

Inadequate trust

Patients often do not trust their clinician's management of their health. This is due in part to a lack of transparency combined with the steadily rising cost of care over decades. Healthcare is the only industry in the world where consumers have no idea how much money they will be required to spend on a service prior to receiving it.  Clinicians are unable to tell their patients how much their care is going to cost—how could there not be a lack of trust?

We see evidence of this lack of trust consistently in issues with medication compliance among patients with chronic medical conditions.  According to a recent article in Practical Pain Management, "approximately 125,000 people with treatable diseases die each year in the U.S. because they do not take their medication as prescribed, while 10% to 25% of hospital and nursing home admissions result from uninitiated or incomplete prescribed treatment plans" (Cosio & Demyan, 2020).  Data suggests that if a stronger, more respectful, and trusting relationship exists with the patient, then the patient is likely to be more compliant with their treatment (Sladdin, Ball, Bull, & Chaboyer, 2017).

Social determinants of health

Social determinants of health include the social factors that impact a patient's ability to achieve health and wellness.  We live in an electronic age, and it seems bizarre that this crucial information is missing from patients' medical history. But the fact is that data on social determinants of health is not consistently collected, thus stunting patient-centered care efforts.

A lack of understanding or reliable methods for collecting this information translates to a lack of understanding of the needs of the patient.  When providers do not have information on what patients have and what they need—whether poverty, educational issues, or homelessness, for example—it impacts their ability to achieve positive health outcomes for their patients (Heath, 2017). 

Pandemic

A barrier not mentioned in the Academy Health article is the current global pandemic.  COVID-19 has impacted patient-centered care, especially as care delivery is focused on the most acute cases (Carlos, Lowry, & Sadigh, 2020). Staff are stretched too thin to take into account patient preferences.

Non-COVID treatment often comes with a list of precautions to prevent spreading the virus and less flexibility in care and support options.  Many hospitals have suspended visitors, so the patient is left alone without their loved ones, who often act as a support system and a channel of communication with care providers.

Strategies and solutions

Despite the many substantial barriers to implementing patient-centered care in the healthcare industry, hospitals and healthcare professionals are finding ways to overcome these obstacles and put the needs of the patient first.  A 2018 report supported by the Robert Wood Johnson Foundation, titled Moving Patient-Centered Care Forward: How Do We Get There?, identifies several actionable strategies.

Improve diversity.

Improved diversity among the healthcare workforce will result in increased opportunities for patients to receive care from someone who shares the same racial or ethnic background.  This is essential for improved individual health outcomes, as data has repeatedly shown that compliance with physician recommendations is heightened when patients identify with the ethnicity of their provider and clinical team (Khullar, 2018).

In addition, a study found that patients were more likely to give the maximum patient rating score and were more compliant with the treatment regime when they identified with their provider's ethnicity (Takeshita, Wang, & Loren, 2020). In addition to hiring a more diverse workforce, hospitals must also collect information regarding patient ethnicity, and take steps to take ethnicity into account in a patient's care.

Embrace innovation.

The healthcare industry needs to think outside the box not only when it comes to improving care, but also reimbursement for care. Patient-centered care is increasingly delivered in teams, both within healthcare systems and through referral relationships with other organizations. A lot of work goes on behind the scenes that is often not reimbursable. Developing an innovative system that rewards collaboration will help undo a payment system that does not adequately compensate for this work. 

Collaborate with community organizations.

The African proverb, "It takes a village to raise a child," rings true for organizations that have embraced patient-centered care. Too often hospitals think they are the be-all-end-all of their patients' care, but in reality, there are many people and organizations, such as schools, food banks, and local agencies, to name a few, that contribute to a person's health.  Hospitals must change their focus from protecting their volume and growing their service line to embracing their role as a contributor to the health of their community for the sake of their patients.

Serve the "whole patient."

Transforming the culture of an organization to deliver care in a way that better serves the "whole" patient is a complex endeavor. To put a patient's needs first requires that the organization be willing to put its own needs second. A commitment within the organization to permit staff to address patient needs as they arise, even if the service is not in their job description, sounds good on a mission statement or strategic plan. However, it will require hospitals to invest in training their staff and creating a culture that focuses on customer service, respect, and patient empowerment.

Promote transparency.

A lack of transparency inevitably leads to a lack to trust, and we must listen to patients' and the government's demands for increased transparency in the healthcare industry. The 21st Century Cures Act, set to take effect in April 2021, will help all patients to have immediate electronic access to their detailed notes and records. The intent is to lower costs, create improved trust with transparent conversation between provider and the patient, and empower the patient to make more informed healthcare decisions. 

Transparency doesn't end there. There needs to be greater openness and ease in hospital billing practices, billing and cost understanding, and the ins and outs of the insurance reimbursement system. Hospitals' pay codes are indecipherable to patients trying to interpret their billing statements. Patients need to see actual costs if they are to be empowered to make wise decisions for their physical and financial health. 

Rethink compliance.

Regulations meant to ensure that all patients receive quality care have unwittingly turned the healthcare industry into a tick-box culture where hospitals are incentivized to provide care to the lowest common denominator to keep agencies off their back.

There is something for healthcare leaders to ponder in Amazon CEO Jeff Bezos's statement to shareholders in 2016: 

"Good process serves you so you can serve customers. But if you're not watchful, the process can become the 'thing.' This can happen very easily in large organizations. The process becomes the proxy for the result you want. You stop looking at outcomes and just make sure you're doing the process right."

In healthcare as well as in the tech sector, the process of ensuring regulatory compliance can too easily become the "thing," much to the chagrin of clinicians. As a result, care can become encumbered, slow, and legalistic, rather than dynamic, patient-focused, and friendly (Sims, Leamy, Levenson, Brearley, Ross, & Harris, 2020).

It is clear that to deliver patient-centered care organizations must not be held hostage to meeting regulatory requirements. Instead, they should look beyond the minimum and understand their patients when designing a patient-centric model that not only surpasses the minimum requirement for compliance, but also delivers clinical excellence.

Placing the patient in their rightful place at the center of all healthcare organizations do is an ongoing journey and not an endpoint.  Embracing patient-centered care is a paradigm shift that will require healthcare partnership, adoption and acceptance by every person in the healthcare organization, and openness to innovative approaches in an ever-evolving and complex healthcare system.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com 

References:

Agency for Healthcare Research and Quality (2002). Improving Health Care Quality.

Agha, A., Werner, R., Keddem, S., Huseman, T., Long, J., & Shea, J. (2018). Improving Patient-centered Care. Medical Care, 56(12).

Bezos, J. (2017). 2016 Letter to Stakeholders. Amazon News.

Brickley, B., Sladdin, I., Williams, L., Morgan, M., Ross, A., Trigger, K., & Ball, L. (2019). A new model of patient-centred care for general practitioners: results of an integrative review. Family Practice, 37(2).

Carlos, R., Lowry, K., & Sadigh, G. (2020). The Coronavirus Disease 2019 (COVID-19) Pandemic: A Patient-Centered Model of Systemic Shock and Cancer Care Adherence. Journal of the American College of Radiology, 17(7).

Cosio, D., & Demyan, A. (2020). Adherence and Relapse – How to Maintain Long-Term Gains in Patients with Chronic Conditions. Practical Pain Management, 20(6). 

Cramm, J. & Nieboer, A. (2016). Is "disease management” the answer to our problems? No! Population health management and (disease) prevention require “management of overall well-being.” BMC Health Services Research.

David, G., Saynisch, P., & Smith-McLallen, A. (2018). The economics of patient-centered care. Journal of Health Economics, 59.

Delaney, L. (2018). Patient-centred care as an approach to improving health care in Australia. Collegian, 25(1). 

Gorli, M., Liberati, E., Galuppo, L., & Scaratti, G. (2016). Promoting Patient Engagement and Participation for Effective Healthcare Reform. IGI Global.

Hahtela, N., McCormack, B., Doran, D., Paavilainen, E., Slater, P., Helminen, M., Suominen, T. (2017). Workplace culture and patient outcomes: What's the connection? Nursing Management, 48(12). 

Health Leads (2018). Patient-Centered Care: Elements, Benefits And Examples

Heath, S. (2017). Using Social Determinants of Health in Patient-Centered Care. Patient Engagement Hit.

Hughes, T., Varma, V., Pettigrew, C., & Albert, M. (2015). African Americans and Clinical Research: Evidence Concerning Barriers and Facilitators to Participation and Recruitment Recommendations. The Gerontologist, 57(2).

Khullar, D. (2018). Even as the U.S. grows more diverse, the medical profession is slow to follow. The Washington Post.

Moretta Tartaglione, A., Cavacece, Y., Cassia, F. and Russo, G. (2018). The excellence of patient-centered healthcare: Investigating the links between empowerment, co-creation and satisfaction. The TQM Journal. 30(2), pp. 153-167.

National Institutes of Health (2020). The 21st Century Cures Act.

NEJM Catalyst (2017). What Is Patient-Centered Care?

Ogden, K., Barr, J., & Greenfield, D. (2017). Determining requirements for patient-centred care: a participatory concept mapping study. BMC Health Services Research.

Robert Wood Johnson Foundation (2018). Moving Patient-Centered Care Forward: How Do We Get There?

Ruppar, T., Ho, P., Garber, L., & Weidle, P. (2017). Overcoming Barriers to Medication Adherence for Chronic Diseases. Centers for Disease Control and Prevention. 

Secretary of Health and Human Services (2018). Secretarial Response.

Sims, S., Leamy, M., Levenson, R., Brearley, S., Ross, F., & Harris, R. (2020). The delivery of compassionate nursing care in a tick-box culture: Qualitative perspectives from a realist evaluation of intentional rounding. International Journal of Nursing Studies, 107.

Sinaiko, A., Szumigalski, K., Eastman, D., Chien, A. (2019). Delivery of Patient Centered Care in the U.S. Health Care System: What is standing in its way?. Academy Health.

Sladdin, I., Ball, L., Bull, C., & Chaboyer, W. (2017). Patient‐centred care to improve dietetic practice: an integrative review. Journal of Human Nutrition and Dietetics, 30(4), 453-470.

Takeshita, J., Wang, S., Loren, A., et al. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open. 

Wall Street Journal (2015). Should the U.S. Move Away From Fee-for-Service Medicine?

Wolfe, A. (2001). Institute of Medicine report: Crossing the quality chasm: a new health care system for the 21st century. Policy, Politics, & Nursing Practice, 2(3), 233-235.

Yuan, S., Freeman, R., Hill, K., Newton T., & Humphris, G. (2020). Communication, Trust and Dental Anxiety: A Person-Centred Approach for Dental Attendance Behaviours. Dentistry Journal.Communication, Trust and Dental Anxiety: A Person-Centred Approach for Dental Attendance Behaviours.

ThoughtLeader Excerpts: What key healthcare business trend(s) for 2021 are you most concerned about?

By Clive Riddle, December 3, 2020    

We are all so done with 2020. The current issue of MCOL ThoughtLeaders asks our panel: “What key healthcare business trend(s) for 2021 are you most concerned about stakeholder preparedness for, beyond continued efforts to contain the pandemic and deployment of vaccines?”

 Here’s some excerpts of what they had to say, peering into the new year:

Mark Lutes, Chair of the Board of Directors and Member of the Firm at Epstein Becker & Green tells us in part that “I am concerned that delivery system participants are not sufficiently planning for the impact of health delivery in the retail setting. The conceptualization is that the big box retailers will predominantly play a role in urgent care. However, these retailers can use their convenience and price predictability to win consumers for other clinical journeys. As they scale, they will have the opportunity for referrals to imaging, labs, and ambulatory surgery among others. Particularly where the retailer adds the power of digital tracking and follow-up, traditional health systems may find they lose key revenue segments to the pervasive consumer experience generated by these brands.”

Mark continues - “the tech giants’ health care initiatives have not yet moved much of the health care market. It would, however, be foolish to underestimate the degree to which the digital giants will eventually participate. Digital pharmacy has been only an early foray. Other service lines can be anticipated, and scale, brand and connectivity will, in time, transform other segments. Prudence in planning suggests anticipating where those inroads will occur and assessing, and adopting to, the downstream impacts. “

Chris Sukenik, Principal, at BDC Advisors weighs in with “looking beyond continued efforts to contain the pandemic and prepare for the deployment of vaccines, healthcare is on the verge of a new era of price transparency which will cause a value revolution for providers, health plans and patients. CMS’ Hospital Price Transparency and Transparency in Coverage rules require unprecedented levels of transparency of negotiated rates, which will have far reaching impacts on the healthcare system. The key questions for providers are “what impact will these changes have on my organization” and “how should we prepare to take advantage of this looming disruption.” It is important to note that there are ongoing legal challenges to both rules. However, whether these challenges are successful or not, the market is moving steadily toward greater transparency of price, quality and service and providers and health plans will need to proactively prepare.”

Chris goes on to say “with negotiated rates publicly available, providers and health plans will need to focus on sharpening and delivering on their value propositions for consumers, including individuals and employers. Transparency of negotiated rates will reveal substantial price variations across providers and health plans. Providers will find themselves in a position of needing to explain the price variability and high-priced providers will need to justify their price premiums to patients. Healthcare providers will need to follow in the footsteps of other industries by finding and delivering a differentiated value proposition to consumers across dimensions likely to include clinical quality (e.g. hospital performance, episode performance), patient service / experience and price position. In parallel, providers will need to deploy strategic pricing to maintain and strengthen market position. Providers will be faced with important strategic decisions on which services to price competitive to market and which services warrant a premium. How effectively health systems recalibrate price by services—based on size, growth potential, price relative to market and price elasticity—will help decide who wins and loses market share in the coming years.”

Wendy Gerhardt Dorfman, Senior Manager with The Deloitte Center for Health Solutions leads in by stating “among other key topics in health care, price transparency and interoperability are critical regulations taking effect in 2021 and their strategic implications may be unfortunately overlooked by some.....”  Wendy reports that “The Deloitte Center for Health Solutions recently conducted a survey of 30 finance executives to determine whether hospitals and health systems were prepared to abide by the new rules. Only about half of respondents (53%) said they were “prepared” or “very prepared” to comply. A majority of respondents said the COVID-19 pandemic put them behind in their efforts to comply with the new regulations.”

Wendy reminds us that “being compliant with regulations is of course important. The rules require significant resources (people, technology, dollars) to comply. With many indicating they are unprepared, some may need to immediately figure out their compliance plan. Organizations also should put in place a replicable process since hospitals will be required to comply annually starting in 2021 and health plans will need to do so monthly starting in 2022. Strategically, there are broader considerations for executives. Organizations may need to consider how they will better engage with consumers. Both regulations aim to enable consumers to make their own health care decisions. The data being shared should be done so with the end-user in mind: the consumer. Consumer-friendly apps, tools, and trained staff also should be put in place. 43% of surveyed executives said that they would undertake consumer engagement initiatives as a result of the regulations.”

Wendy also notes that “the regulations also may drive the competitive landscape to change, and organizations may need to consider how they will position their data (rates, quality, and outcomes) and better collaborate with other stakeholders. In our survey, 57% of executives said that they would likely conduct a market and competitor analysis, which can be important for helping drive strategic decision-making. “

Hank Osowski, Managing Partner at  Strategic Health Group feels that “if there is one characteristic that has best defined healthcare in 2020 it is disruption.......Though there are many areas where rapid disruption is transforming healthcare sectors and marketplaces, two standout as particularly transformative. First is a new work dynamic that is fundamentally changing how and where we conduct business and provide services in an uncertain and quickly changing ecosystem. For leadership and staff this includes finding new means of collaborating in a disconnected and remote environment. Physicians and nurses have needed to develop new care protocols for treating the conditions of this virus on the fly, and to do so under pressure of an increasingly fragile patient population. In several healthcare sectors, the challenges of workforce shortages effected many clinical disciplines (nurses, pharmacists, therapists, etc.) as well as countless support areas. Long after the current pandemic has subsided, these shortages are bound to continue given the aging demographics of our population and the increased penetration of retailers in the healthcare space. If they have not already done so, hospitals and traditional healthcare providers will need to realize that they are competing for labor not just with other hospitals and clinics but with the corner supermarket and big box retailers which also need pharmacists, physicians, nurse practitioners and clinical technicians too.”

Hank then states “a second area of disruption impacting our industry is the cloud of uncertainty hanging on the possible opinion options for the Supreme Court’s consideration of the constitutionality of the Affordable Care Act “ACA”)…..Speculation by “legal experts” based on oral arguments held on November 10th, suggests that the Court will find a way to sever the potentially unconstitutional provision from the remainder of the ACA thereby keeping the other major provisions of the Act alive. This would be a positive outcome, but it is far from certain. “

Finally, Lindsay Resnick, EVP at  Wunderman Thompson Health lists “six areas of focus to be prepared for as we move into next year:

1. UNINSURED AMERICA At the end of 2019 there were approximately 29 million uninsured Americans, and it was trending upward. With massive COVID-driven layoffs and furloughs the loss of employer-based health care coverage is estimated to result in upwards of 10 million people being added to the ranks of the uninsured. The impact on payer product strategy, provider uncompensated care, and Medicaid expansion will be widespread.

2. HEALTHCARE CONSUMERISM The nation is dealing with unprecedented financial burdens—COVID business closures, unemployment, and health care costs outpacing wages. People are delaying care, skipping prescriptions, and scaling back on preventive health. Now more than ever the onus is on health care stakeholders to help customers make personalized, value-based financial and clinical decisions.

3. TRUST BARRIERS The pandemic has shaken consumer confidence. Debates over evidence-based science, public health failings, and the politics of COVID has wary consumers asking: will you do the right thing when it comes to my health? There’s a trust gap, and to overcome it health care brands must exude empathy and sincerity, deliver health information that moves consumers to action, and adapt quickly to the pace and scale of market change that’s ahead.

4. HEALTH DISPARITIES Black and Latinx communities see significantly higher rates of diabetes, hypertension, dementia, and COVID deaths at younger ages. Addressing health inequities, Social Determinants of Health, and factors such as health literacy among different population groups has to be part of every stakeholder’s approach to solving for the imbalance in access to health services in underserved, vulnerable communities.

5. MENTAL HEALTH 2020 is the year everything changed—work, school, travel, entertainment and healthcare—and it’s taken a far-reaching psychological toll on Americans. Over half of GenZ and Millennials report struggles with mental health during the pandemic. Support of mental and behavioral health is essential: identification of warning signs, elimination of barriers to care interventions, and removal of social stigmas around mental health disorders.

6. CYBER HEALTH In reality, it’s not cyber health...it’s health for the cyber consumer! It’s estimated that 20% of all medical visits in 2020 will be virtual. Digital technology helps consumers take ownership of their health—self-diagnose, change health behaviors, enable compliance, monitor treatments, and interact with providers. The revolution is over. Cyber health has won. Digital transformation is now table stakes.”

A New Era in Psychiatric Hospital Accreditation: Four Questions for DNV GL Healthcare

By Claire Thayer, November 19, 2020

Recently, we hosted a Healthcare Web Summit webinar discussion with DNV GL Healthcare to learn about why CMS awarded it 4 years of deeming authority to provide accreditation services to Psychiatric Hospitals. We caught up with DNV GL Healthcare’s Thomas Quinn and Barry Smith on four key takeaways from the webinar:

1. Why did CMS award DNV GL Healthcare 4 years of deeming authority to provide accreditation services to Psychiatric hospitals?

DNV GL Healthcare: CMS will deem an organization between 2 and 6 years for the accreditation service that they are providing. Four years seems to be our initial experience with any newly deemed service we have offered.

2. What are some of the types and different roles for Surveyors?

DNV GL Healthcare: There are 3 different surveyors on each annual survey. We have our clinical surveyor, our generalist surveyor and our physical environment surveyor. The clinical surveyor is going to be focused on patient care units, the clinical setting, chart review, seeing what is going on in a unit, and observing patient and staff interactions. The generalist surveyor is focused on quality management issues, how your quality management system functions, medication management, and they are also involved in reviewing competency and utilization review. The Physical Environment surveyor’s role is to look at the entire physical plant of the organization – they will look at HVAC, fire drills, emergency management, biomed, safety and more.

3. Briefly tell us more about the accreditation process and what can Psychiatric hospitals expect in terms of onsite involvement?

DNV GL Healthcare: The accreditation process begins with the hospital completing a confidential application at no charge.  Once the hospital accepts the pricing and terms, DNV GL Healthcare will add the hospital to our schedule for an unannounced survey.  Initial surveys will consist of an onsite survey by a DNV GL Healthcare survey team.

The NIAHO® and ISO surveys are done together through Tracer Methodology as well as staff and patient interviews. While surveying the hospital to the NIAHO® Requirements, DNV GL Healthcare surveyors also ensure the application of the ISO 9001 standard. Tracer Methodology has been a staple of ISO 9001 audits since ISO 9001’s inception in 1987. All areas of the hospital are surveyed, both clinical and non-clinical. The number of surveyors and the mix of qualifications are determined specifically for each hospital and type of survey being performed. 

The hospital will receive a final report from DNV GL Healthcare within ten business days. The hospital will then have ten calendar days to submit its Corrective Action Plan with timelines for implementation. Once the Corrective Action Plan has been approved, the documentation is submitted to the Accreditation Committee for the final accreditation decision. 

Upon approval by the Accreditation Committee, DNV GL’s accreditation is typically effective on the date of receipt of an approved corrective action plan.  Individual survey results vary and certain circumstances may impact the initial accreditation effective date.  For hospitals new to the Medicare program, or applying for new provider status, the effective date for Medicare participation is always determined by CMS.

4. Where can we learn more about your standards and what's included in the application process?

DNV GL Healthcare: You can view and download all of our standards free of charge at this link: https://www.dnvgl.us/assurance/healthcare/standards.html  

You can also contact us at contacthc@dnvgl.com to request a short conversation to go over the application process and what all you will need to have in order to apply for DNV GL Psychiatric Hospital Accreditation.  Again, all of our standards are available at no charge as is the application.

If you missed this informative webinar presentation, Psychiatric Hospitals Now Have a Choice on Who They Partner With for Their Accreditation, we invite you to watch the full On-Demand webinar video or short webinar re-cap video.

Healthcare’s Bridge Fire

By Kim Bellard, November 17, 2020

We had a bridge fire here in Cincinnati last week. Two semis collided in the overnight hours. The collision ignited a blaze that burned at up to 1500 degrees Fahrenheit and took hours to quell. Fortunately, no one was killed or injured, but the bridge remains closed while investigators determine how much damage was done. It is expected to remain closed for at least another month.

Unfortunately, the bridge in question is the Brent Spence Bridge, which is the focal point for I-71 and I-75 between Ohio and Kentucky. It normally carries over 160,000 vehicles daily, and is one of the busiest trucking routes in the U.S. Over $1 billion of freight crosses each day. There are other bridges nearby, but each requires significant detouring, and none were designed for that traffic load.

What makes this all so galling is that it has been recognized for over 25 years that the bridge has been, to quote the Federal Highway Administration, “functionally obsolete” — yet no action was taken to replace it. This most recent disaster was a disaster hiding in plain sight.

Just like, as the coronavirus pandemic has illustrated, we have in health care.

Epidemiologists had long warned of a global pandemic. The Obama Administration prepared a detailed “playbook” for such a pandemic, but, nonetheless, the Trump Administration was caught flat-footed when COVID-19 hit.

Our global, just-in-time systems for supplies was found severely wanting in the case of an exponentially spreading global pandemic, leaving healthcare workers short of essential protective gear and equipment like ventilators. Similarly, our testing efforts were botched from the beginning.

As we’ve learned, COVID-19 hits people with comorbidities hardest; as we’ve long known, the U.S. leads in world in people with chronic conditions. It has also disproportionately impacted people of color — reflected, in part, their increased likelihood of being essential workers who cannot work from home, and underlying health disparities.

Just within the past week, we’ve received promising news on vaccines from Pfizer and Moderna. Unfortunately, vaccine development has become politicized.

We’ve thrown trillions of dollars at COVID-19 relief, including large amounts to the healthcare system, yet hospitals claim they are losing hundreds of billions of dollars, and our already weakened system of primary care is on the verge of collapse. Burnout among healthcare workers was already a problem, but the pandemic has caused it to reach new levels, especially when many people shun basic precautionary measures like masks or social distancing.

It’s embarrassing that in the richest country in the world, 11% of the non-elderly lack health coverage. It is disturbing that 25% of Americans report that they or a family member have put off treatment for a serious medical condition in the past year due to cost — and that was before the pandemic.

All of which is to say, the pandemic is a bridge fire, all right, but it is taking place on a healthcare bridge that we’ve long known is “functionally obsolete.”

We can’t entirely avoid bridge fires, but we can design the bridges to minimize their likelihood and can ensure they are structurally sound enough to withstand them. Similarly, we can’t preclude the possibility of a pandemic, but we can have the public heath infrastructure in place for one, and a healthcare system that is robust enough to cope with one.

What we can’t do — or, rather, what we shouldn’t do — is to wait for disasters to happen and only then try to figure out what to do.

The pandemic may be healthcare’s bridge fire, but it didn’t cause our healthcare system’s shortcomings; it only helped expose them. The question is, will it spur us to do something about them?

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Medicaid Traditional Rx Cost Savings Can’t Offset Specialty Rx Costs As Much Going Forward

By Clive Riddle, November 13, 2020

Magellan Rx Management just released its fifth annual Medicaid Pharmacy Trend Report, examining Medicaid FFS gross and net drug spend trends, with data derived from Magellan Rx’s pharmacy programs in 25 states and the District of Columbia.

Magellan Rx found the overall FFS Rx claim trend during the past four years changed from 1.9% in 2016, to -4.4% in 2017, 0.8% in 2018 and 4,3% in 2019; certainly a trend in the wrong direction as Medicaid enrollment expands with the pandemic.

During that time, the traditional drug trend has decreased every year (-5.1% in 2016 and -0.4% in 2019), while the specialty drug trend has increased (20.5% in 2016 and 8.6% in 2019.) One could surmise that while specialty trend increases aren’t as eye-popping as half a decade ago, the savings from ratcheting down traditional drug costs have diminished to the point where they can’t offset specialty drug cost increases to the same degree.

Other key findings in this Magellan Rx’s 28-page report include: 

• In 2019, specialty drugs accounted for 48.5 percent of net cost in Medicaid while making up just 1.3 percent of utilization.
• Traditional net spending on drugs decreased 0.4 percent from 2018 to 2019.
• Unit cost, not utilization, drove specialty trend in 2019. The net cost per claim increased by $141.12, while utilization decreased by 0.9 percent.
• While claim volume remains virtually unchanged, the total net spend on specialty drugs increased by 2.4 percent which indicates that specialty drugs will account for 50 percent of total net spend for 2020.
• In 2019, specialty drugs accounted for 48.5 percent of net cost in Medicaid while making up just 1.3 percent of utilization.Traditional net spending on drugs decreased 0.4 percent from 2018 to 2019.Unit cost, not utilization, drove specialty trend in 2019. The net cost per claim increased by $141.12, while utilization decreased by 0.9 percent.While claim volume remains virtually unchanged, the total net spend on specialty drugs increased by 2.4 percent which indicates that specialty drugs will account for 50 percent of total net spend for 2020.

Managing the effects of pandemic-induced burnout among healthcare professionals

By Dr. Seleem R. Choudhury

As the COVID-19 pandemic continues, healthcare workers face unprecedented levels of stress, fear, and anxiety. Situations that trigger chronic stress have always been present within the important and weighty work of caring for patients, but routine stressors are now intensified by the serious risks of working on the frontlines of a pandemic. Together, this creates a perfect storm of heightened risk of burnout.

Accounts of non-healthcare workers experiencing burnout from the challenges of working during a pandemic, such as learning to work remotely, constant technological mediation, and navigating new family schedules, are well documented. Though the phenomenon of burnout among healthcare professionals stretches back decades, the literature and recent data for U.S. healthcare workers during the pandemic is scarce (Jha, Shah, Calderon, Soin, & Manchikani, 2020).

Burnout: definitions and warning signs

The term “burnout” emerged in the early 1980s, and is defined by psychologists as “exhaustion that workers can experience when they have low job satisfaction and feel powerless and overwhelmed at work” (Mathieu, 2012).  A definition from a recent study by Dr. Sachin Jha, et al., emphasizes the root cause of burnout as long-term job stress, resulting in a “mixture of fatigue, cynicism, and exposure to inefficacy” (2020). Though often thought of as a form of primarily emotional exhaustion, the impact of burnout can go beyond mental health, manifesting in physical ailments (Figley, 1995). 

Burnout among healthcare professionals specifically has long been a concern.  The Bureau of Labor Statistics projects 200,000 RNs will be needed per year over the next six years. But, according to Nursing Solutions Inc., since 2015, the average hospital has turned over nearly 90 percent of its workforce—these are all pre-COVID-19 numbers (2020).

Although burnout has been around for many decades, it has been exacerbated by the unique challenges of the pandemic, and exposes the insufficient methods that have historically been used to mitigate the symptoms of burnout among healthcare workers.

COVID-related burnout

Numerous personal accounts and experiences regarding providing care during COVID include feelings of being overwhelmed and powerless. According to a survey of nearly 60,000 nurses by the National Order of Nurses, a French nursing union, 57 percent of France’s nurses have described their condition as a “state of professional exhaustion” since the beginning of the pandemic (2020). 

In the U.S., median self-reported stress, measured on a scale from 0 to 10, among intensive care unit clinicians increased from 3 to 8 during the pandemic (Society of Critical Care Medicine, 2020).

There are many root causes of the skyrocketing levels of burnout during the pandemic. Feelings of powerlessness are practically inevitable when, despite you and your colleagues’ constant efforts to fight the virus, you continue to see the same symptoms and give the same diagnosis repeatedly.

An article from researchers at Texas A&M University explains other sources of stress:

“Health care workers are experiencing added stress from multiple areas. Many of them are working longer shifts and experiencing more loss of life. The lack of personal protective equipment (PPE) and training on how to use new equipment causes many professionals to question if they have been exposed. This leads to fear that they could infect their family and loved ones. In addition to those fears, there is anxiety surrounding job security. To reduce the spread of infection, many states have stopped elective procedures and consequently, many health care professionals have been laid off or had their hours reduced” (Salazar, 2020). 

Additionally, Amnesty International has released new data showing that an estimated 7,000 health workers have died due to COVID-19 around the world so far (2020).  As of September 2020, the United States has suffered the second-highest death toll worldwide with 1,077 health workers dying from COVID, while the United Kingdom has the next-highest number of deaths at 649 (McCarthy, 2020).  Working in such a high-risk job—especially when you entered into the profession assuming that it would not cost you your life—must have an impact on an individual's psychological well-being. 

Responding to burnout

These are stressful times to be a healthcare professional. At all times, but especially under current circumstances, it is essential to be proactive to remain healthy mentally and physically and prevent burnout.

Individuals may benefit from the following strategies:

• Focus on meaning. Remember why you chose the healthcare profession.
• Try to set boundaries. In a global pandemic this is especially challenging, but where possible set time to disconnect from work.
• Strengthen your resilience. Take a 5-minute breather. Focus inward through journaling, yoga, etc.
• Practice mindfulness. Many studies show that mindfulness programs mitigate burnout symptoms.
• Stay positive, but also be realistic. Burnout is worsened when you expect too much of yourself.
• Practice gratitude. Gratitude has the power to improve our psychological health. Studies have shown it increases personal and professional well-being, boosts happiness, and helps to prevent depression (Chowdhury, 2020).
• Reach out to trusted peers or friends and talk it out (Rogers, Polonijo, & Carpiano, 2016).

Though individuals must recognize the importance of guarding themselves against burnout, healthcare organizations bear a great weight of responsibility in caring for their employees, creating an empathetic and supportive work environment, and providing resources to help their employees cope with the stresses of the pandemic.

Organizations should consider adopting the following strategies:

• Where possible, make sure that staff and providers have the necessary resources and skills to meet expectations. This is a crucial consideration, especially in regard to PPE.
• Organizations must understand that if staff and providers are working many hours, burnout is inevitable, and so provisions and appropriate support must be provided (Centers for Disease Control and Prevention, 2020).
• Organizational leaders need to express authentic empathy (Moss, 2020).
• There should be a robust support mechanism that is known, supported, and promoted consistently by leaders.  This process needs to be ready to employ when a staff member expresses a need (Moss, 2020).
• Ask the question: “Are you doing ok?” Pause and listen for the response. Don’t be afraid to hear what is said, and don’t take the response personally. Associate no stigma with struggling with burnout.
• Prioritize and organize workloads. Be sensitive to what is happening and ensure that priorities match the situation. Be judicious with the number of priorities.

There are many factors that have contributed to the sudden increase in burnout among healthcare professionals, including issues with the initial management of the virus outbreak such as rapidly increased workload hours, inadequate PPE, and a lack of consistently updated guidelines (Wang, Zhou, & Liu, 2020). Even with some of these early issues resolved, many others remain, and I join many other healthcare leaders in our concern that “the constant exposure may result in a permanent fracture in the mental health of many healthcare professionals” (Wang, Zhou, & Liu, 2020).

As leaders of healthcare organizations, we must reprioritize what is important to us at the organizational level.  Trying to do and focus on too many things will overload our teams at such a fragile time for their mental health. We must listen to ensure we fully understand the essential needs of our frontline staff during COVID-19, as stressors may also exist outside work that may contribute to the feelings of powerlessness.

Navigating this pandemic brings prolific uncertainty. It is essentially impossible to get away from the constant stressors in and out of work, and even the most resilient among us are not immune to the effects of burnout. It is imperative for the long-term health of our teams and organizations that we go above and beyond to offer support and resources to our employees on a continual basis.

Resources

2020 NSI National Health Care Retention & RN Staffing Report. Published by: NSI Nursing Solutions, Inc. March, 2020.

Chowdhury, Madhuleena Roy, BA. The Neuroscience of Gratitude and How It Affects Anxiety & Grief. January 9, 2020.

Clinicians Report High Stress in COVID-19 Response. Society of Critical Care Medicine. May 2020. 

COVID19: The National Order of Nurses warns of the situation of 700,000 nurses in France as the epidemic accelerates again. Ordres National des Infirmier. October 11, 2020.

Employees: How to Cope with Job Stress and Build Resilience During the COVID-19 Pandemic. Centers for Disease Control and Prevention. May 5, 2020.

Figley, C.R. (Ed). (1995) Compassion Fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel.

Global: Amnesty analysis reveals over 7,000 health workers have died from COVID-19. Amnesty International. September 3, 2020. 

Jha, Sachin “Sunny”, MD; Shah, Shalini, MD; Calderon, Michael David, MS; Soin, Amol, MD; and Manchikanti, Laxmaiah, MD (2020). The effect of COVID-19 on interventional pain management practices: A physician burnout survey. Pain physician, 23, S271-S282.

Mathieu, F., (2012) The Compassion Fatigue Workbook. New York: Routledge.

McCarthy, Niall. Where Most Health Workers Have Died From Covid-19. Statista. September 3, 2020.

Moss, Jennifer. Preventing Burnout Is About Empathetic Leadership. Harvard Business Review. September 28, 2020.

Rogers, E., Polonijo, A. N., & Carpiano, R. M. (2016). Getting by with a little help from friends and colleagues: testing how residents’ social support networks affect loneliness and burnout. Canadian Family Physician, 62(11), e677-e683.

Salazar, Alexandra. Infecting the mind: Burnout in health care workers during COVID-19. ScienceDaily. May 13, 2020.

Simmons, Micha’le. Three things executives can do to get ahead of leader burnout amidst Covid-19. Advisory Board. April 7, 2020.

Wang J., Zhou M., Liu F. Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China [published online ahead of print, 2020 Mar 6]. J Hosp Infect. 2020; pmid:32147406

Read more from Dr. Seleem Choudhury at seleemchoudhury.com 

How the Pandemic Impacts Physician Revenue, Visits, Well-Being and View of the Future

By Clive Riddle, October 29, 2020

A new AMA physician survey indicates COVID-19 impact has caused a 32% average drop in physician practice revenue. Their just released results of their mid-summer survey of 3,500 physicians also found that:

• 81% said revenue was lower and they were providing fewer in-person patient visits compared to February
• Revenue reductions were 50% or greater for nearly 1 out of 5 physicians.
• In-person patient visits decreased 50% or greater for more than one-third of physicians.
• Even including telehealth visits, almost 7 out of 10 physicians were providing fewer total visits (in-person + telehealth).
• Total patient visits decreased 50% or greater for more than 1 out of 5 physicians.
• Spending on personal protective equipment (PPE) since February increased 50% or greater for nearly 2 out of 5 medical practice owners.
• 36% said that acquiring PPE was very or extremely difficult

The Physicians Foundation last month released the results of part two of their national survey conducted by Merritt Hawkins of 1,270 physicians, which address physician how Covid-19 has affected physician well-being, and found:

• 30% of physicians have been made to feel hopeless or that they have no purpose as a result of Covid-19’s effects on their practice or employment situation
•  18% have increased use of medications, alcohol or illicit drugs as a result of Covid-19
• 24% have sought medical attention for a physical problem
• 18% have sought mental healthcare
• 8% have considered self-harm
• 22% report they know a physician who has committed suicide

The Foundation last week released the results of part three of their national physician survey conducted by Merritt Hawkins, with this component addressing future of the health care system, which also found that:

• 44% of physicians indicate that 26% of their patients delay or decline care due to costs
• 42% strongly agree that conditions worsened by the pandemic induced delays will place a high demand on our health care system in 2021

Regarding the central focus of part three of their survey - on the future - the Foundation found this:

"While physicians' overall preference is for a hybrid approach, their opinions on other options for organizing our system yielded significant insights. Most surprisingly, maintaining or improving the current Affordable Care Act (ACA) influenced program did not initially rank high, with only 19% selecting this as number one on the one to four scale. Instead, 30% of physicians (the second highest percentage) chose moving to a market-driven system with Health Savings Accounts (HSAs) and catastrophic policies as number one. It wasn't until the next levels (two to four) were added that improving the current ACA system became more highly ranked (49%) than transitioning to a market-driven/HSA model (45%). The survey found significant polarity in support for HSAs: thirty percent of physicians rated it a number one, but 42% also rated it a four.  Support for a "single payer/Medicare for All" type of system consistently scored last with physicians, who rated the option either one through three. The only time it was not the least preferred option was among level four ratings, in which it was surpassed by HSAs 42% to 38%."