TSR's Small Incisions - 10/20/2024
Hot healthcare takes from the Surgeon's Perspective
A rundown of stories from across the healthcare ecosystem — health tech, health policy, digital health, value-based care, and more — with commentary.
Presented by Commons Clinic
This week:
Yet another reason to side eye Medicare Advantage
Karen Lynch, Big Swings, and the Dis-Integration of CVS Healthspire
The Clinical Enterprise
8 years ago, AI would replace radiologists in 5 years
Debunking Blue Zones
Is Private Equity a Convenient Consolidation Scapegoat?
How to Properly Incentivize Physicians
Giving the Digital Medicine Society (DiMe) the credit it deserves
ICYMI: Data quality > Data quantity (TSR Guest Post by Dr. John Lee)
Plus — A surprise bonus!
Use of Prior Authorization Up in Medicare Advantage Plans, Senate Report Finds (MedPage Today)
Medicare Advantage — everything you hate about commercial insurance, reimbursed at sub-Traditional Medicare prices! MA plans are ramping up their use of prior authorization to deny expensive post-acute care (at a rate 3x higher than denials for other types of care). Rehab centers and skilled nursing facilities are the biggest cost driver in joint replacement episodes of care. Studies show that discharge to a location other than home is associated with an increased risk of readmission and complications. But do the ends justify the means? Denying such care causes patient angst and anxiety at the worst possible time. Instead, we should educate patients on the downsides of post-acute facilities. Care pathways should support safe return home. Using AI for these care denials is especially insidious (but likely to continue). I support using AI to make care more cost-effective, but for the right reasons — identifying and improving risk factors before the fact. The continued twisting of Medicare Advantage and AI for the sake of profits is extremely disappointing and counterproductive. The worst part is that doing so is probably unnecessary for success.
CVS Health CEO Karen Lynch steps down as the drugstore chain struggles to right its path (NPR)
Big swings, big misses. CVS tried to create its version of an integrated system (Healthspire), but the whole never added up to the sum of its parts. Now, there’s talk of a breakup (dis-integration?). CVS is not alone here. We’ve entered the winter of Big Retail healthcare in more ways than one. Where does this leave Oak Street Health (and VillageMD)? A once bright future for Advanced Primary Care has darkened. Or has it? CVS and Walgreens’ failures shouldn’t be seen as a failure of the integrated, accessible care concept. Neither should Walmart Health’s demise. These companies pushed too many of their chips onto Medicare Advantage and bought high. Their strategies seemed reactionary, not cohesive. Whether you like it or not, United Health’s approach has been much more calculated, thoughtful, and skillfully executed. Love or hate UHG, they’ve run circles around their competition. United (Optum) hasn’t been afraid to buy traditional provider groups. Nor has it shied away from specialty care or ownership of healthcare facilities (smartly, UHG has leaned hard into ASCs and outpatient centers). United Health Group is healthcare’s version of the Evil Empire. By taking large swings and whiffing, Big Retailers showed themselves to be pretenders to the crown. (Meanwhile, Amazon lurks, feeling its oats and honing its blade).
The Clinical Enterprise is the Beating Heart of Health Systems (The Health Care Blog)
In an article that builds upon results from a recent Bain & Company survey (covered in last week’s Small Incisions), Jeff Goldsmith outlines the components of a successful clinical enterprise. A common value set. Rigorous quality and safety standards. High levels of collegiality and mutual trust. Effortless communication and consultation. Inspirational leadership. I couldn’t agree more. “Physicians should feel a sense of ownership, autonomy, and empowerment. Clinical enterprises that connect with and animate their workforces will have a prohibitive competitive advantage…” In short, a successful clinical enterprise is created by clinicians, for clinicians.
Computer scientist, AI researcher, and Xoogler Geoffrey Hinton was recognized by the Nobel Prize Committee for his work on artificial neural networks. Hinton predicts that AI will replace radiologists in 5 years. Or, more accurately, he predicted — back in 2016. Almost nine years later, that prediction proved to be a bit too bold. As the AI hype machine gathers steam (and health tech investment dollars), another round of “AI will replace (or outperform) doctors” predictions has followed. After some backlash, most have softened their stance. The general thinking now is that AI will enhance healthcare, not replace doctors. Hinton remains bullish on AI’s future in healthcare suggesting that AI systems will provide second opinions and “surpass doctors in specific aspects of clinical decision-making.” Maybe Hinton is tempering his expectations, or maybe he’s just learned to be more vague and bank on a longer time horizon. FWIW, I’m bullish on AI in healthcare too and actually think Hinton maybe underselling it. (More to come in this week’s TSR blog post!)
“Blue Zones” are regions of the world where people (allegedly) live exceptionally long lives. They’ve been studied and ballyhooed as evidence that combining physical activity, rich social interactions, local whole-foods diets, and low disease incidence is the secret to longevity. If we all lived the way people in blue zones live, the world would be a much healthier (and happier) place. As it turns out, blue zones are also probably complete bunk. UCL researcher Dr. Saul Justin Newman claimed his first Ig Nobel prize (awarded for research that “makes people laugh, and then think”) by poking many olive-sized holes in the Mediterranean diet and other blue zone concepts. As it turns out, the data upon which blue zone mysticism is built are deeply flawed and inaccurate. The world’s oldest man has three different birthdays. The best predictors of living past 100 are poverty and pressure to commit pension fraud. Many centenarians are alive on paper — but otherwise quite dead. People in Japan adhering to the Okinawan diet eat the least amount of vegetables and sweet potatoes and have the highest BMIs. The original research on Blue Zones blew it. The lesson here is that conclusions are only as good as the data upon which they’re based. We assume apples-to-apples comparisons when what we really have is apples-to…sweet potatoes. Garbage in, garbage out. And that makes me blue.
‘Hospital consolidation’ means higher prices (STAT)
Doesn’t it feel like private equity was just a little too convenient a scapegoat in the Steward Healthcare debacle? Don’t get me wrong, Cerberus Capital is no saint. Neither is Medical Properties Trust, the real estate company that’s every bit as complicit (if not more so). Both are bad actors and deserve no quarter. But while politicians and policy makers wag their collective fingers at PE, hospital consolidation (and the increased costs it brings) continues. Health systems are more than happy to let PE be the target of ire — and legislation. Are private equity roll ups or VC-backed health ventures any worse than sprawling health systems? At least PE firms don’t try to pretend they’re “not for profit.” It’s great that Massachusetts was able to save many of the Steward Hospitals and preserve access to care. But those hospitals will consolidate into existing systems. The harmful effects of consolidation shouldn’t be pinned solely on entities with lower Q ratings. Regulators remain unwilling to address the underlying problems that contribute to consolidation — a fact that makes all the grandstanding about VC and PE in healthcare ring hollow.
Physicians Can Help Cut Costs. They Just Need the Right Incentives (Harvard Business Review)
The failures of value-based care can be traced back to an inability to devise effective, sustainable incentive structures (also to be covered in this week’s TSR blog post!). By nature, physicians are competitive, especially with one another. Incentives that tap into this competitiveness can be highly effective. Collecting and sharing accurate, transparent data on costs and outcomes inspires high quality, cost-effective care. Too often, bundled payment models, gainsharing arrangements, and co-management agreements become a race-to-the-bottom. Metrics flip to favor downside risk over upside risk leaving little juice left to squeeze. Presented here is a rational and practical approach to developing the right incentives that keep physicians engaged. Having experienced various incentive models including BPCI and co-management agreements, I can attest that there’s nothing more frustrating than feeling like a victim or your own success. It doesn’t have to be that way. This article together, Jeff Goldsmith’s article above, and the Bain & Company survey discussed last week present a compelling framework for sustainable care innovation. Give clinicians ownership, autonomy, and sensible incentive structures and watch what happens.
DiMe partners with Google, Mayo Clinic to maximize AI investment (Fierce Healthcare)
Congrats to Jennifer Goldsack and the team at The Digital Medicine Society (DiMe) for this collaboration. DiMe has been at the forefront of taking a practical, measured, and scientific approach to technology implementation in healthcare. The organization is as objective and thoughtful when it comes to envisioning a future where tech has meaningful impact on care delivery. “There’s danger that AI could become like the digital therapeutics industry, which experienced the new technology hype cycle and a huge wave of investment in 2021. Afterward, payer uptake lagged, big names like Pear Therapeutics went under and investments fell off.” We are absolutely at risk for repeating the mistakes made with digital therapeutics and digital health when it comes to AI. This partnership, with DiMe’s work serving as the backbone, will ensure that we don’t miss another opportunity to prove technology’s worth.
ICYMI: The New Data Equation: Quality > Quantity (The Surgeon’s Record)
Thanks to Dr. John Lee for sharing his thoughts on the healthcare data quality v. quantity issue. “The bottom line is this: if we want to improve healthcare, we need to rethink what we’re measuring. We need to go beyond the legacy data points and start measuring to improve outcomes that represent true quality.” This point is critical. Legacy data points arose from legacy care delivery models. If we want to innovate, we have to rethink the way we collect data and how to determine what data is important. Current systems do a poor job of sorting signal from noise, in part because EMRs, claims data, and other sources of information provide the wrong lens. I look forward to Dr. Lee’s companion piece, coming soon!
Bonus
Business of MSK “Podcast” brought to you by NotebookLM, sourced from my own materials. What a time to be alive!
Ben Schwartz, MD, MBA
Editor-in Chief, The Surgeon’s Record
Commons Clinic Senior Clinical Fellow
We’re looking for collaborators! If you’re interested in writing an article for The Surgeon’s Record or appearing on a webinar, please reach out. For all of you looking to build a network or an audience, this is your chance.
Ben, another great column. Enjoyed it. Thank you!