💌 🏥 Denied.
 PARTNERED WITH  Good morning! Welcome to the first Hospitalogy x Healthcare Huddle crossover Sunday edition. These newsletters will hit your inbox every Sunday AM, so be on the lookout for them in the future. These stories have been written by Jared Dashevsky, my friend and colleague at Workweek who heads up the Healthcare Huddle newsletter. I'll add my thoughts where I think it's appropriate (look for the "Blake" sections), but otherwise I hope you enjoy the perspective that Jared provides! You can subscribe to Healthcare Huddle by itself to get the industry news, insights, and analysis you need every Sunday by clicking here (one click and you're signed up)! In today's edition:
Was this email forwarded to you?  SPONSORED BY MARKETERHIRE You excel at providing the best care for your private practice patients. But how do you find the right person to help with what you're not good at? Like brand marketing, social, search? These are important areas that will grow your business. MarketerHire is an on-demand marketing talent platform that can match you with expert freelance marketers to help you do just that. MarketerHire’s proprietary, data-driven matching engine uses millions of data points to find you the ideal marketer in as few as 48 hours. They can work as much or as little as you need to help you grow your business. If you need a marketer, take 2 mins to fill out this form. You won’t be disappointed.  BUSINESS Strike.Around 5K Stanford nurses went on strike last week. The ask? Better pay and better staffing. The strike highlights a trend of unionized nurses fighting for better working conditions. The Deets Unionized Stanford nurses have three asks:
Stanford nurses and administrators will inevitably reach a compromise, but whether they’ll be satisfied with it remains unclear. Hospital administrators have since said they’ll withdraw health care benefits from striking nurses on May 1. This strike is far from extraordinary in today’s healthcare climate. Thousands of nurses at Catholic Health’s Mercy Hospital in Buffalo, Tenet Health in Massachusetts and Kaiser Permanente in SoCal have all gone on strike, or threatened to go on strike. But their labor unions and hospital executives have all reached a contractural agreement for better pay and working conditions. Jared's Thoughts on the Strike and Labor Union The pandemic has hit nurses hard. They’re mentally and physically exhausted, underpaid and about to leave the industry entirely. I’m not only talking about nurses working in hospitals, but in nursing homes as well. While nurse employment in outpatient centers, physician offices, hospitals and home healthcare are trending towards pre-pandemic levels, that of nursing homes is trending away.  Nursing unions have proven to be effective at representing nurses’ needs, which have allowed for better patient care. Professor Adam Dean at GWU and his colleagues published new pandemic data showing that unionized nursing homes had an 11% lower resident mortality and a 7% lower worker infection rates compared to non-unionized nursing homes. Main point: nursing unions work to benefit not only nurses, but patients as well. Which brings me to my next point: The problems plaguing the nursing workforce must be addressed to prevent increased patient morbidity and mortality. Nurses are the primary touch points in patient care, and any problems they face, trickles upstream to doctors and hospital administrators and downstream to patients. Given revenue and labor costs constraints, hospitals and other institutions have tried to address nurses’ needs. It’s not easy for hospitals, but it hasn’t been easy for the nurses working within those hospitals either. Contracting with travel nurse agencies, or even creating in-house travel nursing agencies, have been hospitals’ solution so far. But, I’d think that the travel-nurse solution will only get hospitals so far with current inflation rates and hospitals’ thin operating margins. It’s unsustainable. Jared's Prediction More and more nurses across the country will strike for improved working conditions, including increased benefits, wages and staffing. A unionized workforce will help. Hospitals need to stay ahead. Blake's Thoughts Hospitals are in consistent conflict with nurses and labor unions, representing a timeless battle between employee and employer. Right now, more than ever, nurses have the upper hand as health systems battle with shortages and sustained margin pressures from travel agency rates and contract labor. My only concern is how hospitals and unions find a happy medium. According to Kaufman Hall's latest report, about a third of hospitals are operating on negative margins. The future only holds more consolidation if current difficulties continue.  INSURANCE Medicare Disadvantage?Some Medicare Advantage health plans have wrongfully denied or delayed prior authorizations and payment requests, according to a new report from the Office of the Inspector General. Are these MA plans truly “great” if they only burden patients and providers? Some Background The $412 billion MA market is booming. MA plans saw an 8.8% increase in enrollment this year, totaling 28.5 million MA beneficiaries. These plans are growing around 10% per year and the Congressional Budget Office projects the share of MA enrollees will surpass that of Original Medicare beneficiaries by 2030. MA is attractive to both payers and patients: insurers make a lot of money per patient (over $1,000/patient/month), and beneficiaries get extra health benefits not covered by Original Medicare like vision, hearing and dental health. The Deets Here’s what the new investigation of the 15 of the largest MA organizations found:
Health plans rejected prior authorizations for either not being “medically necessary” or not having sufficient evidence to support a test or treatment. Health plans denied payment requests because of human or system errors (the story of U.S. healthcare) Profits have likely risen from denying prior authorizations while problems have risen for providers and patients. Jared's Thoughts Prior authorizations suck. No one likes them except for insurance companies. These above findings show that prior authorizations delay timely access to care, force patients to pay out-of-pocket for denied coverage and add an unnecessary burden to providers’ already busy workflow. The doctor is meant to practice medicine—not deal with the bureaucracy of insurance companies.  I can’t emphasize this enough—providers should not have to deal with the prior authorization system, especially when it’s not necessarily another providers doing the denying. In one of his satirical videos, Dr. Glaucomfleken describes the prior authorization process to someone not in healthcare:
Essentially. While one of the “pros” of prior authorizations is that they “support” value-based care efforts, I’m sure a majority of providers will say the cons outweigh the pros. Get rid of this system or rebuild it from the ground up. Overall, the above findings makes me skeptical of MA companies’ tactics. Are they truly here to provide advantages to their beneficiaries or make as much profit as possible, given the lucrative reimbursement model? Blake's Thoughts Jared highlighted just how popular Medicare Advantage is and how fast the program continues to grow. At its current trajectory, MA will reach 79 million beneficiaries by 2030 and holds widespread, bipartisan support. MA gets the most criticism from opponents who argue that the increased privatization and narrow networks restrict access to beneficiaries. Since MA is the path we're headed down, we need to see reform to restrictive practices like prior auth and other purposeful delays insurance co's pull to retain premium dollars.  PHARMA The Next Frontier of Weight LossEli Lilly’s diabetes drug, tirzepatide, led to a max 22.5% weight loss—or 52 pounds—in adults with obesity or overweight. Some have described tirzepatide’s effects as the “equivalent of inventing nuclear fusion.” Bold statement. But I agree nonetheless that these clinical trial results are a BFD for public health. The Deets Tirzepatide is a GLP-1 receptor agonist mixed with a GIP receptor agonist. Together, these drugs work to reduce appetite, slow down food release from the stomach, increase insulin response and inhibit glucagon.  In Lilly’s phase 3 study, 2,539 participants were randomly assigned to a placebo group and tirzepatide group (low-dose, medium-dose, high-dose). After 72 weeks, participants’ bodyweight decrease on average by 16% in the low-dose group, 21% in the medium-dose group and 23% in the high-dose group. Those in the placebo group only lost 2% of their bodyweight.  One analyst predicts the drug will bring Lilly $4B in revenue at peak sales. The only comparable drug is Nova’s semaglutide—a GLP-1 analogue—which showed significant weight loss compared to placebo in a recent clinical trial. It seems that Lilly’s drug is more efficacious, but it doesn’t matter—both drugs are better than anything else on the market. Jared's Thoughts “Diet and exercise.” That’s the classic response to someone saying they need to lose weight. Newsflash, it ain’t that easy. And if it were easy to lose weight, then around the world 1.5B adults wouldn’t be overweight and 400M adults wouldn’t be obese. While diet and exercise are effective to lose weight in the short-term, it’s significantly harder to maintain the weight loss in the long-term. Your body essentially works against you by increasing hormones that promote weight gain in response to a caloric deficit (e.g., dieting). These hormones remain elevated past 12 months post-weight loss. Imagine fighting your body for over a year just to prevent weight gain. Simply put, there is a strong physiologic component resisting sustained weight-loss in patients who are overweight or obese. Therefore, any subsequent weight gain, which was preceded by weight loss, isn’t simply because someone returned to prior habits. The above being said is why medications such as tirzepatide and semaglutide will be such game changers for promoting and sustaining weight loss. I imagine a future when tirzepatide and semaglutide will be as common as anti-hypertensive medications currently are. The issue, of course, will be whether insurance companies decide to cover it and for which populations. The drug will likely be priced at around $5,500 per year. If the drug can prevent the expensive, and omnipresent obesity-related commorbidities such as hypertension, dyslipidemia and type 2 diabetes, then it seems like a cost-effective medication. Blake's Thoughts Jared owned me on this one. I definitely was in the 'diet and exercise' camp but had no idea about the physiological and metabolic aspects of weight loss and retaining that weight loss. Looks like Eli Lilly and future weight loss drugmakers are about to make some bank!  OUTSIDE THE HUDDLE
 HUDDLE HITS
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 THE WEEK AHEAD
 Thanks for the read! Let Jared and me know what you thought about the first Hospitalogy x Healthcare Huddle send by replying back to this email. Keeping it simple, — Jared & Blake    Loving this newsletter? Get in front of 14,000 doctors, nurses, PAs and healthcare decision-makers by clicking below: |
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