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The Hidden Epidemic: Challenges in Measuring Deaths from Medical Errors

Editor’s Note: This is the first in a series of posts on ‘Patient Safety’ and specifically the NMP (“not my patient, not my problem”) problem in medicine.

I recently participated in the World Patient Safety Day in Washington, D.C., September 17th, 2024, with organizing founding members of the Patients for Patient Safety, U.S., an affiliate of WHO (World Health Organization). We marched, then gathered for a ‘remembrance ceremony‘ for those lost, harmed or disabled due to medical error(s).

The event is introduced by Martin J Hatlie, JD, President & CEO, Project Patient Care for Patients for Patient Safety Day D.C.:

The first post sets context for the series framing the nature of the problem and range of suggested solutions. Additional context for the series can be found at EndNMP.org

In 2016, a controversial study published in the British Medical Journal (BMJ) “Medical error—the third leading cause of death in the US” suggested that medical errors were the third leading cause of death in the United States, claiming over 250,000 lives annually. This statistic sent shockwaves through the medical community and sparked intense debate about both the accuracy of the number and the methodologies used to arrive at such estimates. Seven years later, we’re still grappling with the fundamental question: How many Americans actually die from medical errors each year?

The Current Landscape

Truth be told, we don’t know the exact number of deaths attributable to medical error(s) – and that’s part of the problem. Current estimates vary widely, ranging from 22,000 to over 440,000 (and above) deaths annually, reflecting the significant challenges in measurement and classification. The Centers for Disease Control and Prevention (CDC) doesn’t require reporting of medical errors on death certificates, and there’s no standardized methodology for capturing this data.

Why Such Wide Variations?

Several factors contribute to the dramatic range in estimates:

1. Definition Discrepancies: There’s no universal definition of what constitutes a medical error. Some studies include only clear mistakes, while others encompass broader categories of preventable harm.

2. Reporting Mechanisms: Death certificates, the primary source for mortality statistics, don’t have a standardized way to indicate medical error as a cause of death.

3. Detection Challenges: Many errors go unnoticed or are not documented due to fear of litigation or professional repercussions.

Current Methodologies and Their Limitations

1. Global Trigger Tool (GTT) – Is a methodology developed by the Institute for Healthcare Improvement (IHI) to identify adverse events in medical records. It uses “triggers” (or clues) to identify possible adverse events, which are then investigated further to determine if an actual adverse event occurred.

Pros:

– Systematic approach using specific criteria

– Can identify errors that might otherwise go unnoticed

Cons:

– Labor-intensive and time-consuming

– Subject to reviewer interpretation

– May not capture all types of errors

2. Voluntary Reporting Systems

Pros:

– Can provide detailed information about specific incidents

– Helps identify patterns and systemic issues

Cons:

– Severe underreporting due to voluntary nature

– Bias towards more obvious or serious errors

3. Retrospective Chart Review

Pros:

– Comprehensive examination of patient records

– Can identify patterns and contributing factors

Cons:

– Time-consuming and expensive

– Subject to hindsight bias

– Limited by quality of documentation

The Case for Accurate Measurement

Despite definitional, measurement and reporting challenges, there are compelling reasons to pursue more accurate measurement of deaths from medical errors:

1. Patient Safety Improvement: Accurate data can help identify patterns and systemic issues, leading to targeted interventions and improved safety protocols.

2. Resource Allocation: Better data can inform where to focus quality improvement efforts and resources.

3. Accountability: Accurate measurement can drive accountability and motivate healthcare organizations to prioritize safety.

The Counterargument

Some argue that focusing too heavily on exact numbers could be counterproductive:

1. Defensive Medicine: Fear of being labeled as ‘error-prone‘ might lead to overly cautious medical practices and only reinforce what some referred to as the ‘blue wall of silence’, ie,, ‘thou shall not speak ill of one’s peers’.

2. Morale Impact: Constant focus on errors could demoralize healthcare workers and impact recruitment. ‘Clinical burnout‘ is already an epidemic for our often over worked and under supported clinicians.

3. Resource Diversion: Time and resources spent on measurement might be better used for direct patient care improvements and learnings from review of suboptimal outcomes, care gaps or poor handoffs during shift changes, etc.

Potential Solutions

Short-term Improvements

1. Standardized Definitions: Develop and implement consistent definitions of medical errors across healthcare systems.

2. Enhanced Reporting Systems: Create protected, anonymous reporting systems to encourage more accurate documentation.

3. Death Certificate Reform: Add specific fields for recording medical errors as contributing factors to death.

Long-term Strategies

1. AI and Machine Learning: Develop sophisticated algorithms to detect potential errors in real-time and analyze patterns across large datasets.

2. Culture Change: Foster an environment where error reporting is seen as a learning opportunity rather than a punitive measure.

3. National Database: Create a standardized, national system for recording and analyzing medical errors.

The Role of Technology

Emerging technologies offer promising solutions for more accurate measurement:

1. Natural Language Processing: Can analyze medical records to identify potential errors that human reviewers might miss.

2. Blockchain: Could provide secure, immutable records of medical events, making it easier to track and analyze errors.

3. Big Data Analytics: Can identify patterns and risk factors across large populations, potentially predicting and preventing errors before they occur.

Conclusion

While perfect measurement of deaths from medical errors may be an unrealistic goal, significant improvements are both possible and necessary. The path forward likely involves a combination of technological solutions, policy changes, and cultural shifts in the medical community.

As we work towards better measurement, we must balance the need for accuracy with the potential negative impacts of excessive focus on errors. The ultimate goal should be to create a healthcare system where errors are promptly identified, openly discussed, and systematically addressed – not to assign blame, but to save lives.

By taking a thoughtful, balanced approach to this challenge, we can work towards a healthcare system that is both more accountable and more effective at preventing harmful errors.

—

*Note to readers: This blog post aims to provide a balanced overview of a complex issue. The statistics and methodologies discussed are based on currently available research, but given the nature of the topic, exact numbers remain subject to debate and ongoing study.*

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Wal*Mart: RFI ‘Overwritten and Incorrect’

By Gregg A. Masters, MPH

Whoa! Not 24 hours after the Request for Information (RFI) issued by WalMart Health and Wellness directed to it’s ‘strategic partner’ downline hit the street, I mean was leaked to the press, WalMart’s senior management felt compelled to promptly backdown from it’s rational, comprehensive, timely and sensible approach to make a meaningful dent into the US Healthcare, I mean, ‘Sickcare’ quagmire, by issuing the following terse statement:

Walmart Statement in Response to Health & Wellness Request for Information

“The RFI statement of intent is overwritten and incorrect. We are not building a national, integrated, low-cost primary care health care platform.”
– John Agwunobi M.D., Senior Vice President & President of Walmart U.S. Health & Wellness

Yikes! What’s behind this ‘whiplash’ effect?

It’s not news that WalMart has a mixed history with respect to the way they manage or evade (depending on your point of view) offering health benefits as an incentive to their less than full time staff. Yet, WalMart is the ‘400 pound gorilla’ as Chukwuma I. Onyeije, M.D., aka @chukwumaonyeije opined in a Google+ thread to a pool of health care social media peeps on Wednesday.

Regardless of the creative health benefits offer or ‘avoidance strategy’ for their part time staff, WalMart who’s gross sales account for approximately .5% of total US GDP, is a behemoth and perhaps second only to the Federal Government, the single largest ‘wholesale buyer’ of health benefits in the US.

So when they retained Price Waterhouse Coopers to consult on the compiling and distribution of an RFI to the tighly held ‘strategic partner’ network, they clearly intended to step into the population management fray of the payor/provider conundrum. You know, your costs are my revenues…

I’ve suspected all along, that while many on the provider side whine about CMS, the PPACA and now final rule to implement ACOs, many forward thinking peeps, mostly the Wall Street crowd who smell profits in those emerging re-engineered rules around population health management are stepping foward, perhaps aided and abetted by the so called ‘2nd in position skin in the game’ employer community.

We’ll watch and report with interest how this drama and retraction plays out.

See recent article released today by NPR, ‘Wal-Mart’s Clarification on Health Care Leaves Room For Big Moves‘.

Trump’s Cannabis Executive Order: Schedule III, 280E, and the Long Road to De-scheduling

by Gregg Anthony Masters, MPH **

The news is monumental for the cannabis space and public health writ large. Here’s what actually happened today (Dec 18, 2025) and what the Trump cannabis Executive Order (EO) actually does – plus the 280E implications and the road ahead.

An interesting ‘sidebar‘ came via CMS Administrator Oz who indicated beginning Q2 2026 (April), CBD will be available for ‘free’ via physician order from ACOs, noting as well Medicare Advantage plans are ‘evaluating’ whether to include CBD in their supplemental benefits offerings to seniors as well.

We do live in interesting times!

Considering the relative underreporting of this signature event in the cannabis space, I’ve compiled a news summary and ‘explainer’ for your consideration with an AI assist in research and claim validation.

The news in plain English

President Trump signed an EO titled “Increasing Medical Marijuana and Cannabidiol Research” directing the Attorney General to complete the already-started federal rulemaking to move marijuana from Schedule I → Schedule III “in the most expeditious manner” (while staying within the Controlled Substances Act process). Source: The Washington Post+3The White House+3The White House+3

This is significant because it’s a White House-level push to break a procedural logjam: the Schedule III proposal has been pending since DOJ’s 2024 proposed rule and was sitting in the administrative hearing phase that got postponed. Source: Federal Register+2DEA+2

The actual EO (what it says)

From the EO text: Source: The White House

Directs the Attorney General to “take all necessary steps” to complete the Schedule III rescheduling rulemaking as fast as possible, consistent with 21 U.S.C. § 811 (the CSA scheduling process).
Directs White House legislative staff to work with Congress on updating the statutory definition around hemp-derived cannabinoid products (esp. “full-spectrum CBD”) and building a regulatory framework (e.g., THC-per-serving concepts).
Directs HHS/FDA/CMS/NIH to develop research methods/models using real-world evidence to improve evidence and standards of care around medical marijuana/CBD.
Includes standard language that it doesn’t create enforceable rights and must be implemented consistent with law/appropriations.

Important nuance: The EO is best read as an acceleration directive, not a magic wand that unilaterally “changes the schedule tomorrow.” The CSA still routes the change through the administrative rulemaking record. Source: The White House+2Federal Register+2

Does this eliminate 280E – and who benefits?

What 280E actually says

IRC § 280E disallows deductions/credits for businesses “trafficking in controlled substances”, “within the meaning of schedule I and II” of the CSA. This otherwise normal deduction of routine operating expenses has put cannabis dispensary operators (multi and single state) as a distinct competitive disadvantage. Source: Legal Information Institute

The key implication

So, if marijuana is finalized as Schedule III, 280E no longer applies to marijuana trafficking (because 280E is keyed to Schedule I or II, not III). Source: Legal Information Institute

Medical only, or recreational too?

Not medical-only. If marijuana is Schedule III federally, the 280E relief would generally benefit state-legal operators regardless of “medical vs adult-use” label, because 280E’s trigger is the schedule, not whether a state calls a sale medical or recreational. Source: Legal Information Institute

But: rescheduling does not federally legalize adult-use commerce; it just removes this specific tax penalty once the rule is final/effective. Source: The Washington Post+1

Timing: when would 280E relief actually start?

Not on EO day. It starts only after a final rule is issued and becomes effective (typically after Federal Register publication with an effective date). Until then, operators are still under the current Schedule I framework for federal tax purposes.

Why the EO matters (even though it’s “only” rescheduling)

If Schedule III is finalized, the high-impact wins are:

280E relief → ordinary business deductions return (rent, payroll, marketing, etc.), which can materially change cash flow and valuation math for operators. Source: Legal Information Institute+1
Research friction decreases vs Schedule I, potentially expanding clinical research and product development pathways. Source: The White House+1
It’s a federal acknowledgement of medical use, aligning more with current state realities—without ending federal control. Source: The White House+1

What it does not do

Even with Schedule III (and certainly with just the EO):

No federal legalization of recreational cannabis.
No interstate commerce greenlight for state markets.
No automatic SAFE/SAFER banking fix (banks still weigh federal illegality/risk; legislation is the clean solution).
No de-scheduling (removal from the CSA schedules entirely).
No broad criminal justice reform baked in (Editor’s note: some say the absence of AG Bondi at signing ceremony is a curious absence?).

(Those limits are why some coverage frames this as big-but-not-the-finish-line.) Source: AP News+1

What’s next (near-term roadmap)

DEA/DOJ completes the administrative process: resolving the stalled posture and moving to a final agency action. The rule has been pending since DOJ’s May 2024 proposed rule, and the hearing phase was postponed. Source: Federal Register+2DEA+2
Final rule published (Federal Register) + effective date.
Litigation risk / judicial review: major federal changes like this often draw court challenges, which can affect timing and certainty.
Parallel track: Congress (banking, taxation, states’ framework, descheduling bills) if political will exists.

Road to full de-scheduling (the real “endgame”)

De-scheduling generally requires Congressional action (amending the CSA) or a far more sweeping administrative move than the current Schedule III track – and it also runs into broader regulatory architecture questions (FDA framework, commerce, taxation, public safety, treaties). Practically, most paths to true normalization run through Congress.

Bottom-line?

The December 18, 2025 signing ceremony delivered a headline that – depending on where you sit – reads like long-overdue common sense, political triangulation, or a regulatory Rorschach test: President Donald J. Trump signed an executive order titled “Increasing Medical Marijuana and Cannabidiol Research.” Source: The White House

Here’s the crucial nuance right up front: the Executive Order (EO) does not itself reschedule marijuana. Under federal law, rescheduling happens through a formal rulemaking process anchored in the Controlled Substances Act (CSA) – not by presidential decree. What the EO does is direct the Attorney General to “take all necessary steps” to complete the ongoing rulemaking to move marijuana from Schedule I to Schedule III “in the most expeditious manner in accordance with Federal law,” explicitly referencing 21 U.S.C. § 811. Source: The White House+1

If you’re running a state-legal cannabis business – or tracking one from the investor side – the part that lands like a thunderclap is the tax angle: Schedule III would typically remove cannabis from the scope of IRS Code Section 280E, the federal provision that disallows ordinary business deductions for “trafficking” in Schedule I or II controlled substances. Source: Legal Information Institute+1

Let’s unpack what’s actually in the EO, why it matters, what it likely means for 280E (medical and adult-use), and what “next” looks like on the road to full de-scheduling.

What the Executive Order actually says (and does)

The EO frames federal cannabis policy as lagging behind widespread medical use and clinical reality—particularly around chronic pain, seniors, and veterans. It argues that Schedule I status has “impeded research” and left patients and clinicians without adequate guidance. Source: The White House

The operational heart of the order is Section 2, which sets out three main directives:

Expedite Schedule III rescheduling (Attorney General).
The EO instructs the Attorney General to move the rescheduling rulemaking forward “in the most expeditious manner” under the CSA, citing 21 U.S.C. § 811 – the statute that governs adding, removing, or transferring substances between schedules through rulemaking and hearings. Source: The White House+1
Push a legislative/regulatory pathway for hemp-derived cannabinoids and full-spectrum CBD (White House Deputy Chief of Staff + Congress).
The EO calls for working with Congress to update the statutory definition and establish a regulatory framework, including THC-per-serving limits and ratio considerations. Source: The White House+1
Accelerate research methods and “real-world evidence” (HHS, FDA, CMS, NIH).
It directs federal health agencies to develop research methods—explicitly including real-world evidence—to inform standards of care and improve lawful access to hemp-derived cannabinoid products. Source: The White House+1

The EO also explicitly references the existing federal rescheduling process already in motion: DOJ issued a proposed rule in May 2024; the proposal drew nearly 43,000 public comments; and it is “awaiting an administrative law hearing.” Source: The White House+1

That matters because it signals the administration isn’t “starting a new process.” It’s trying to finish an already-started one – faster.

The rescheduling process is rulemaking on the record – no shortcuts

Under the CSA, the Attorney General (delegated to DEA) can transfer a drug between schedules via rulemaking, and the process includes notice, comment, and an opportunity for a hearing. Source: U.S. Code+1

The DOJ/DEA proposed rule published in May 2024 is the backbone: it proposes moving marijuana from Schedule I to Schedule III, relying on HHS’s medical/scientific assessment (which the proposal describes as deserving significant deference). Source: Federal Register+1

Also important: the proposed rule is unusually candid about what rescheduling does not do.

It does not federally legalize marijuana.
Criminal prohibitions under the CSA still apply.
Products containing “marijuana” under the CSA remain subject to the Federal Food, Drug, and Cosmetic Act (FDCA), including FDA approval requirements for lawful interstate commerce absent an IND framework. Source: Federal Register

So: Schedule III is a big change – but it’s not “legalization,” and it’s not “de-scheduling.”

The 280E question: medical only, or does adult-use benefit too?

You asked the question that matters to operators’ cash flow:

Does this eliminate 280E for medical dispensaries only, or do recreational dispensaries benefit too?

If marijuana is finalized into Schedule III, the benefit is not limited to “medical-only” dispensaries. The reason is simple: 280E is keyed to Schedule I and II substances – not to whether a state labels cannabis “medical” vs “adult-use.” Source: Legal Information Institute+1

The statutory text of 26 U.S.C. § 280E denies deductions/credits for a trade or business that traffics in controlled substances “within the meaning of schedule I and II” that are prohibited by federal law or the law of the state in which the business operates. Source: Legal Information Institute

That means:

Schedule I/II status is the trigger.
If marijuana moves to Schedule III, it is no longer a Schedule I/II substance.
Therefore, 280E generally should no longer apply to businesses “trafficking” in marijuana—even though marijuana would still be federally controlled and the CSA would still criminalize unauthorized distribution. (280E doesn’t care about “illegality” in the abstract; it cares about illegality involving Schedule I/II.) Source: Legal Information Institute+1

The Congressional Research Service (CRS) describes 280E as denying deductions and credits for trafficking in Schedule I/II substances and explains why it has applied to state-legal marijuana businesses while marijuana remains Schedule I. Source: Congress.gov

Bottom line: Both medical and adult-use cannabis operators would generally benefit from the end of 280E disallowance once – and only once – marijuana is officially moved out of Schedule I/II. (I’m emphasizing “once” because the EO alone does not change the tax treatment today.) Source: The White House+1

Still true even after Schedule III: cannabis businesses would still face complex federal-state contradictions (and likely continued banking and interstate-commerce constraints), but the tax math changes materially when ordinary and necessary business expenses become deductible again. The Federal Register notice itself flags that 280E is a major economic consideration in the rule’s impact analysis. Source: Federal Register

Quick note (not tax advice): even under 280E, businesses have typically been able to reduce gross receipts by cost of goods sold (COGS) – the real pain is losing ordinary deductions (rent, payroll, marketing, admin, security, etc.). That’s why Schedule III is viewed as an immediate profitability lever.

Why this EO is significant (even though it doesn’t “legalize”)

1) It tightens the federal narrative around “medical use” and “research”

The EO is explicitly framed around medical marijuana and CBD research, and it leans into the health system’s reality: chronic pain is widespread (CDC reports 24.3% of U.S. adults had chronic pain in 2023). Source: CDC

That framing matters because re-scheduling requires findings about medical use and abuse potential under the CSA’s criteria. Source: U.S. Code+1

2) It puts “real-world evidence” on the table

Traditional cannabis research has been constrained for decades by Schedule I barriers and supply bottlenecks. The EO’s push toward real-world evidence isn’t just a research preference—it’s an implicit acknowledgment that millions of Americans are already using these products, and clinicians need better data to counsel patients.

The National Academies’ landmark 2017 report found substantial evidence supporting cannabinoids’ effectiveness for chronic pain in adults, while also documenting risks and research gaps. Source: National Academies+1

3) It spotlights CBD product integrity and safet

CBD is widely used, but product labeling accuracy and contamination remain uneven across an under-regulated marketplace. Peer-reviewed analyses have found widespread mislabeling in commercially available CBD products. Source: PMC+1

The EO’s CBD provisions—especially talk of THC-per-serving limits and a clearer regulatory framework—signal a federal attempt to reduce harm from today’s “Wild West” consumer cannabinoid market. Source: The White House+1

4) It is (also) an economic policy move – via 280E

Let’s be honest: the fastest, most measurable impact of Schedule III isn’t a new randomized trial. It’s a cleaner P&L.

News coverage today highlights that rescheduling could deliver meaningful tax relief by ending 280E’s punitive treatment for cannabis businesses. Source: AP News

What happens next: the near-term roadmap

Here’s the “what’s next” sequence in plain English:

Administrative law hearing + record building
The EO itself says the proposed rule is awaiting an administrative law hearing. Source: The White House+1
DEA decision + final rule
After the hearing process and review of the administrative record, DEA can publish a final rule (or withdraw/modify the proposal). The Federal Register proposal underscores that rescheduling must happen through formal rulemaking on the record. Source: Federal Register
Effective date + downstream compliance
If finalized, marijuana would become Schedule III under federal schedules. At that point, the 280E issue changes in a very practical way. Source: Legal Information Institute+1
Legal challenges are likely
Given the stakes and polarization, expect litigation – either challenging the procedure, the scientific basis, or treaty compliance logic. The proposed rule itself spends notable space discussing how Schedule III could be made consistent with U.S. international treaty obligations through additional controls. Source: Federal Register

And after Schedule III: the longer road to “full de-scheduling”

If Schedule III is the on-ramp, de-scheduling is the freeway interchange that still requires legislative engineering.

De-scheduling can happen in two broad ways:

Path A: Administrative (harder)

In theory, DEA could initiate a rulemaking to remove marijuana from control. In practice, de-scheduling raises deeper questions – especially around international treaty obligations and how the U.S. would structure controls absent CSA scheduling. The DOJ proposal already signals treaty constraints are non-trivial even for Schedule III. Source: Federal Register

Path B: Congressional (more direct, still politically difficult)

Congress can amend the CSA, create a federal regulatory framework for cannabis, address interstate commerce, taxation, public health guardrails, advertising, product standards, and banking. In other words: Congress can do what patchwork state markets can’t create coherence.

Even if you’re “team de-schedule,” Schedule III may be the pragmatic bridge: it normalizes medical research pathways and reduces the tax distortion that has functionally subsidized the illicit market by kneecapping compliant operators.

The public health lens (because this is ACOwatch)

As a public health guy, I can’t help noticing what this EO is – and isn’t.

It is not an endorsement of “everyone should use cannabis.” It’s an administrative acknowledgment that millions already do, many for pain and symptom management, and our federal research posture has been out of step with reality. Source: The White House+1

The evidence base is evolving and nuanced. For chronic pain, data suggest cannabinoids may provide small to modest improvements for some patients and some conditions, with meaningful variability and real adverse effect considerations. Source: BMJ Open+1

For ACOs and value-based care organizations, the more interesting question is less “culture war” and more:

Can better evidence, tighter product standards, and rational tax policy reduce harm, improve outcomes, and shrink the gap between what patients do and what clinicians can responsibly guide?

That’s the promise the EO gestures toward – if the bureaucracy follows through and if Congress eventually does its job.

Key takeaways for operators, investors, and clinicians

The EO is real and specific. It directs the AG to expedite Schedule III rulemaking and pushes federal agencies toward research and cannabinoid regulatory clarity. Source: The White House+1
It does not reschedule marijuana by itself. Rescheduling still requires DEA rulemaking, hearing processes, and final publication. U.S. Code+1
If Schedule III is finalized, 280E relief is not “medical-only.” 280E is tied to Schedule I/II, not to state program labels. Adult-use businesses would generally benefit too. Source: Legal Information Institute+1
Schedule III is not legalization. CSA prohibitions still apply; FDCA constraints still matter; and federal-state contradictions don’t vanish overnight. Source: Federal Register
De-scheduling is a bigger lift. Expect Schedule III (if finalized) to be a waypoint—not the destination.

**Disclosure and guardrails

This post is compiled by Gregg Anthony Masters, MPH, with an AI assist in policy research, analysis and public health commentary with authoritative third-party support for or challenges to unsubstantiated claims. It is not legal, tax, or investment advice. If you operate in the space, talk to counsel and a tax professional who lives and breathes cannabis compliance.

Open Mic Predictions

By Gregg Anthony Masters, MPH**

As producer or executive producer of six shows, both live and on demand, for Healthcare NOW Radio, including our most recent launch ‘Inside the Revival‘

we (the hosts and producers) were asked for our ‘Open Mic’ predictions for 2026 as follows:

What major event, transformation, or innovation in 2025 had a lasting impact on healthcare, whether positive or negative, and is likely to shape its future trajectory?

Pasted below is my one paragraph version, followed by a ‘long form‘:

The singular “impact event” of 2025 has been the politicization and destabilization of U.S. public health leadership at the very moment competence and continuity are most needed, against a backdrop of a structurally mispriced “sickcare” economy: in 2023 the U.S. spent about $4.9T on health care (≈ $14,570 per person; 17.6% of GDP) while federal public health spending fell sharply as pandemic-era funds expired (down 58.3% from $90.2B in 2022 to $37.6B in 2023), and CDC’s FY2025 budget request was $9.683B – a rounding error compared with the trillions spent treating disease after it matures. That underfunded prevention and surveillance backbone has now been hit by operational and governance shocks: USAID was dismantled following the 2025 foreign-aid review (with courts finding DOGE-linked actions likely unlawful), impairing a core global health delivery and surveillance apparatus whose disruption is associated with catastrophic projected mortality (including Lancet-linked estimates warning of >14 million additional deaths by 2030 under severe cut scenarios – think the ‘BBB’ Medicaid and Medicare cuts and ACA premium credit defunding), while immunization governance was destabilized when HHS removed all 17 ACIP members on June 9, 2025 – an action with real-world implications because ACIP recommendations are tightly linked to vaccine coverage and access across payers. Bottom line: the nation’s public health infrastructure = already treated as a political punching bag and fiscal afterthought relative to the acute care “non-system”- is perilously compromised and may take a generation to rebuild; for the full long-form, sourced analysis and timeline, see my post on ACOwatch.com. – Gregg Anthony Masters, MPH, Managing Director, Health Innovation Media

Long Form

The singular “impact event” of 2025 has been the politicization of U.S. public health leadership at precisely the moment when competence and continuity matter most – because public health is not a branding exercise; it is operational infrastructure.

Start with the structural imbalance. In 2023, the U.S. spent $4.9 trillion on health care- about $14,570 per person – and health spending consumed 17.6% of GDP.

That is the financial footprint of an acute, downstream “sick-care” model. Meanwhile, federal public health spending fell sharply as COVID-era funds expired dropping 58.3% from $90.2B (2022) to $37.6B (2023).

Even the CDC’s FY2025 budget request was $9.683B – a ’rounding error’ relative to the trillions spent treating late-stage disease.

Against that backdrop, public health has been dealt a potentially lethal blow – not only through chronic underinvestment, but through destabilizing governance and dismantling core capabilities.

First: USAID

On January 20, 2025, the White House issued Executive Order 14169, initiating a foreign aid review and pause. In the wake of that process, USAID was dismantled, according to the Congressional Research Service’s overview of the 2025 restructuring.

Separately, a federal judge ruled that DOGE’s reckless dismantling of USAID likely violated the Constitution and blocked further cuts.

Whatever one’s politics, this is not “efficiency” – it is the impairment of a core global health delivery and surveillance apparatus, executed at speed by clueless DOGE actors with limited operational insight into what USAID does, how programs are implemented, and how health security risk is managed.

The downstream human cost is not hypothetical – in my book it’s borderline criminal. A Lancet-reported analysis warned that severe USAID funding cuts could contribute to more than 14 million additional deaths globally by 2030, including millions of children under five.

When you break global disease surveillance, reporting control practices (HIV, TB, malaria, maternal-child health, outbreak readiness), you don’t just harm “over there.” You increase the odds of delayed detection, disrupted containment, and cross-border spread – problems that always return. Think the iconic Fram oil filter commercial: where a mechanic holds up a new oil filter opining ‘you can pay me now (preventively) or pay me later‘ (in the shop).

Second: immunization governance and trust

On June 9, 2025, HHS announced it removed all 17 sitting members of ACIP. CDC later stated the 17 were replaced with eight new, shall we say more aligned with the Secretary of Health and Human Services anti-vax ideology, members.

This matters because ACIP is not symbolic: ACIP recommendations are tightly linked to vaccine access and coverage. Federal law generally requires most private plans to cover ACIP-recommended adult immunizations without cost-sharing, and KFF documents how ACIP recommendations function as a key trigger for coverage requirements.

Destabilizing that system invites confusion, coverage churn, and reduced uptake – fuel for outbreaks in an era when vaccination rates and trust are already strained. As a lead monitoring and declaring outbreaks in K-12 school districts for San Diego County, the trust of the public was a key driver of both trust and in the efficacy of the pandemic response (both NPI, non-pharmaceutical interventions and mass immunization efforts).

Bottom line: the management of our aggregate public health infrastructure is perilously compromised by ‘leaders’ at HHS, CMS, CDC, FDA and NIH who value the ideology over science mantra of the ‘charlatan in chief” RFK. Jr. We have a nation that can mobilize trillions to treat disease after it ‘matures’, yet repeatedly treats prevention, surveillance, and preparedness as foolishly expendable line items – until the next emergency arrives.

The consequences of dismantling USAID capabilities and destabilizing evidence-based advisory systems will not be measured in headlines; they will be measured in avoidable morbidity and mortality, domestically and globally.

It will likely years – possibly a decade or more – to rebuild durable surveillance, preparedness capacity, and the credibility required for effective public communication for potentially “unpopular” but necessary interventions.

==##==

Medicare Open Enrollment: To Dis-enroll or Not? Searching For Answers with an AI Assist

by Gregg Anthony Masters, MPH

Some of you may have heard about the whining by UnitedHealthcare’s leadership on a recent earnings call which included the required ‘management’s discussion or operating results and market conditions’ analysis. A BIG WHAAAA!

Overfunded since inception and having perfected the art of ‘upcoding‘ (i.e,, severity of illness and intensity of medically necessary services) Medicare Advantage (MA) operators with often market-specific and generous redistribution of the Center for Medicare and Medicaid Services (CMS) funds thus enabling Zero premium plans with expanded benefits, I’m totally fed up with the relentless ‘ad copy’ of my current health plan (KP San Diego) where I’ve been a loyal member and advocate of their ‘best in class’ IDN status and outcomes performance. They are NOT, and my journey into ‘e-patient‘ hood affords me this opportunity to opine in public.

So, here’s the first installment:

Prompt

I am 72-year-old man in good health. Open enrollment for Medicare ends tomorrow (12/7/2023). I need to make a decision whether to dis-enroll from a Medicare advantage program and return to statutory Medicare, not a term based, private contract with a Medicare advantage operator. I was recently diagnosed with prostate cancer with a Gleason score of 7 (3+4) and am in active monitoring & surveillance (including periodic PSA, mpMRI & targeted biopsies) and am not under treatment, yet. What are the pro’s and con’s of staying with my current health plan (Kaiser Permanente, San Diego) vs. opting for Medicare plus a supplement? What are my best choices? Do you need additional context or prompting? Do you understand?

ChatGPT

I understand your situation and the importance of making an informed decision about your Medicare options, especially in light of your recent prostate cancer diagnosis. Here’s a general overview of the pros and cons of Medicare Advantage plans versus Original Medicare with a Supplement (Medigap) plan, particularly in the context of your condition and current health plan with Kaiser Permanente in San Diego.

Medicare Advantage (like Kaiser Permanente):

Pros:

All-in-One Plan: Medicare Advantage plans often include Part D (prescription drug coverage) and may offer additional benefits like dental, vision, and wellness programs not covered by Original Medicare.
Cost-Capping: These plans usually have an out-of-pocket maximum, which can help manage costs.
Provider Networks: Plans like Kaiser Permanente often have a network of doctors and facilities, ensuring coordinated care and sometimes easier appointment scheduling.

Cons:

Limited Provider Networks: You may be restricted to doctors and facilities within the Kaiser network, limiting your choices for specialists, especially if you need specialized cancer treatment.
Referrals Required: Some plans require referrals for specialist visits, which might delay access to care.
Plan Restrictions: Some treatments or medications might not be covered, or may require prior authorization.

Original Medicare with a Supplement Plan:

Pros:

Wider Network: You have the flexibility to see any doctor or specialist that accepts Medicare, which can be beneficial for specialized cancer care.
No Referrals: Generally, no referrals are needed to see specialists.
Predictable Costs: Supplemental (Medigap) plans can help cover Medicare Part A and B deductibles, co-insurance, and other out-of-pocket costs, making expenses more predictable.

Cons:

Additional Premiums: You’ll likely pay a premium for both Medicare Part B and the Medigap policy.
Separate Drug Plan: You’ll need to enroll in a separate Medicare Part D plan for prescription drugs.
Potential Gaps: Some Medigap plans don’t cover extras like dental, vision, or wellness programs.

Considering Prostate Cancer Treatment:

Access to Specialists: With Original Medicare and a Supplement, you might have more flexibility in choosing specialists for your prostate cancer treatment.
Coverage for Treatments: Check the specific coverage details for cancer treatments under both options to understand potential costs and restrictions.

Making Your Decision:

Compare Costs: Consider premiums, deductibles, co-pays, and out-of-pocket maximums.
Evaluate Provider Network: Ensure your preferred doctors and hospitals are covered and consider the ease of access to specialists.
Review Drug Coverage: If you’re on medications, check how they’re covered under each option.
Consider Future Health Needs: Think about potential changes in your health and how each plan would accommodate those needs.

Given your specific health situation, it’s crucial to consider how each option would cover your ongoing monitoring and any potential future treatments for prostate cancer. Additionally, it might be beneficial to consult with a healthcare advisor or a Medicare specialist who can provide more personalized advice based on your health status and needs.

Please remember that this is a general overview and not personalized medical or insurance advice. It’s important to review the specific details of your current plan and compare them with the benefits offered under Original Medicare plus a supplement.

You

continue. if i dis-enroll from current health plan and given the current prostate cancer diagnosis, will I qualify for a Medicare supplement via community rating? Or will I be medically underwritten and potentially denied coverage? And will the rate be adjusted to reflect pre-existing conditions? Do you understand or need further prompting?

ChatGPT

Yes, I understand your question regarding eligibility and rates for a Medicare Supplement (Medigap) plan after disenrolling from a Medicare Advantage plan, particularly in the context of your current prostate cancer diagnosis. Here are the key points to consider:

Medigap Eligibility and Underwriting:

Guaranteed Issue Rights: Normally, when you first enroll in Medicare Part B at age 65 or older, you have a 6-month Medigap open enrollment period where you can buy any Medigap policy sold in your state without medical underwriting. During this period, you cannot be denied coverage or charged more due to pre-existing conditions.
Switching from Medicare Advantage to Medigap: If you are in a Medicare Advantage Plan, you can switch to Original Medicare with a Medigap policy under certain conditions. These conditions generally include moving out of your plan’s service area or if the plan stops providing care in your area. However, these situations would grant you a Special Enrollment Period with guaranteed issue rights for a Medigap policy.
Medical Underwriting Outside of Protected Periods: If you’re switching from Medicare Advantage to Medigap outside of these specific periods, insurance companies may use medical underwriting. This means they could charge higher premiums based on your health status, or potentially deny coverage due to pre-existing conditions.
Community Rating in Some States: Some states, like New York and Massachusetts, use “community rating” for Medigap policies, where premiums are not based on age or health status. In these states, your prostate cancer diagnosis would not affect your premium rates.
California Rules: Since you are in San Diego, California’s rules for Medigap plans apply. California uses a “birthday rule,” allowing Medicare beneficiaries to switch to a Medigap policy with the same or lesser benefits during the 30 days following their birthday each year, without medical underwriting. However, this is only applicable if you already have a Medigap policy.

Considering Your Situation:

Current Health Status: Given your prostate cancer diagnosis, if you are outside of a guaranteed issue period or special enrollment period, there is a risk of higher rates or denial of coverage due to medical underwriting.
Advice: It’s highly recommended to consult with a Medicare specialist or insurance advisor who can provide detailed information based on your specific situation, including your current health status and the rules in your state.

Remember, these are general guidelines and may not cover every nuance of your situation. It’s important to get personalized advice before making a decision, especially given the complexities surrounding health conditions like cancer and their impact on insurance eligibility and rates.

You

continue: create a blog post titled: “Medicare Open Enrollment: To Dis-enroll or Not? Searching For Answers with an AI Assist”. Use the above query and explanation. Create in witty yet professional tone. Do you understand or need further prompting?

ChatGPT

Absolutely, I understand your request. Here’s a blog post based on our previous discussion:

Medicare Open Enrollment: To Dis-enroll or Not? Searching For Answers with an AI Assist

Welcome to the rollercoaster ride of Medicare open enrollment! It’s that time of the year when we, the silver-haired brigade, scratch our heads, pore over pamphlets that might as well be written in Klingon, and try to make sense of our health insurance options. Fear not, dear reader, for today we have a secret weapon in our arsenal – an AI assistant (that’s me, by the way)!

The Great Debate: Medicare Advantage vs. Original Medicare with a Supplement

Imagine you’re at a health insurance buffet. On one table, we have Medicare Advantage plans, like the one from Kaiser Permanente in sunny San Diego. It’s like a combo meal – a bit of everything in one package. On the other table, there’s Original Medicare with a side dish of Medigap (Supplement) plans. More à la carte, you pick and choose what suits your palate.

The Medicare Advantage Plate: A Mixed Bag

Pros:

Convenience: These plans roll your Medicare Parts A, B, and often D into one. It’s like getting a burger, fries, and a soda in one go.
Cost Caps: There’s a limit on out-of-pocket expenses. It’s like knowing you won’t spend more than $20 on your meal, no matter how many extra fries you grab.
Extra Goodies: They often throw in benefits like dental and vision – the cherry on top.

Cons:

The Network Maze: You might be restricted to their network of doctors. It’s like only being able to eat at restaurants in one neighborhood.
Referral Hoops: Need a specialist? Get ready to jump through some referral hoops.
Coverage Caveats: Some treatments or drugs might not be on the menu.

The Original Medicare with Supplement Platter: Customize Your Meal

Pros:

Freedom of Choice: See any doctor who accepts Medicare. It’s like having a pass to dine at any restaurant in the city.
No Referrals Needed: Straight to the specialist you go, no pit stops.
Predictable Costs: Supplement plans can cover those pesky out-of-pocket costs, making your expenses more like a fixed-price menu.

Cons:

Extra Bills: You’re paying for two plans – think of it as buying a main dish and a side separately.
Drug Plan Detour: You’ll need a separate plan for medications – yes, another dish to order.
Extras Not Included: Want dental or vision? That’s another order you’ll need to place.

The Plot Twist: A Prostate Cancer Diagnosis

Here’s where the plot thickens. With a recent prostate cancer diagnosis and a Gleason score of 7, the decision gets more nuanced. You want a plan that covers your needs, like a chef who can cater to your specific dietary requirements.

Dis-enrolling and Medigap: Navigating the Maze

If you’re thinking of waving goodbye to your Medicare Advantage plan and waltzing over to Original Medicare with a Medigap policy, hold your horses. There are things to consider:

Guaranteed Issue Rights: This is your golden ticket to get a Medigap plan without being penalized for health issues. But it’s time-sensitive.
Medical Underwriting: Miss the golden period, and insurers might look at your health as closely as a chef inspects produce. This could mean higher rates or a polite “no thank you” to offering you a plan.
California’s Birthday Rule: In the Golden State, you get a chance to switch Medigap plans around your birthday without medical underwriting. It’s like getting a free dessert on your special day – but only if you already have a Medigap plan.

The Verdict?

It boils down to personal preference, health needs, and a bit of timing. Think of it like choosing between a set menu and a build-your-own meal. Each has its perks and drawbacks.

So, dear readers, as you navigate these choppy waters of Medicare decisions, remember: it’s about finding the right fit for your health and lifestyle. And while I, your AI assistant, can provide a map, it’s always wise to consult a human expert – think of them as your personal health insurance sommelier.

Happy enrolling! May your health insurance choices be as satisfying as your favorite meal.

ACO Digital Assets Available

by Gregg A. Masters, MPH

It’s been quite some time that I’ve updated this site though not for a lack of news. Yet some 434 posts later following the rollout of the Affordable Care Act, the signature, and against all odds accomplishment of then President Barack Obama, I thought I’d update both subscribers and followers of the blog including a number of generous guest contributors.

Since SARS-CoV-2 entered our collective consciousness in March 2020 as a global pandemic and has reconfigured any sense of ‘normal’ , like many of you, I have been reflecting on the nature and meaning of this uniquely challenging journey.

NOTE: See ‘We’re All Carriers‘.

Today, I celebrate 71 years of existence on this ‘pale blue dot‘. Yet, it doesn’t feel like a celebratory moment. With seemingly everything upside down from ‘truthiness’ and ‘alternative facts’ driving wedges of relentless tribalism between people and moments that matter, I am revaluing where are how I spend my time.

As Nick van Terheyden MD aka ‘Dr Nick’ once offered:

Gregg you may want to try the 5/25 approach. Where you concentrate on the 5 of the twenty five priorities on your to-do list.

As a public health graduate from the UCLA School of Public Health in the 70s (post HMO Act) and following serial up and down c-suite cycles (peppered by severe bouts of clinical depression) leading health system participation in managed care spanning, community and tertiary hospitals in the ‘non-profit’ and ‘proprietary’ sectors for nameplate health system parents and academic medical centers, I feel quite discouraged that the more things ‘change’ in healthcare delivery and finance, the more things remain the same. Or as otherwise put legacy momentum is likely to prevail as the status quo – or as our industry once characterized by Esther Dyson as a ‘calcified hairball’ – is likely to resist or assimilate all meaningful innovation (think population health or value based care).

In anticipation of the enshrinement of accountable care organizations or ‘ACOs’ in healthcare innovation lexicon for the foreseeable future, in addition to ACOwatch.com, I acquired a range of digital assets to potentially develop, co-develop, lease or sell.

So years ago, when twitter burst into the landscape of an emerging digital health economy (circa 2008/09), sitting in a Health 2.0 annual gathering and listening to the presentations two ideas came to mind as cute twitter handles that might host and gain conversational traction in health policy circles and the soon to be emerging tweetchats.

They included @HealthcareBorg (a somewhat witty ‘resistance is futile’ play on the then very popular Healthcare Blog, courtesy of Matt Holt, et al). The other session generated name ID was @ReplaceMyMD (inexplicably suspended by content managers at twitter – including @ACOwatch, @DocTweets, @HospitalTweets, @TweetHealth, @PreferredPharma, @ACOalliance, @CancerCenterTV, @JustOncology, @BioMarkersToday and many others) which I thought was more than cute given the bifurcation of consumer friendly (from a retail POV, ie, app savvy and tech enabled) tools likely to flood the market to enable the essential literacy to navigate a progressively complex health policy environment that assumed the consumer with high deductible health plans would be interested in ways to shelter their out-of-pocket (cost shifting) spending from increasing co-pays, co-insurance and deductibles unfortunately enshrined in the ACA as an offset to the total cost of the Act.

Available ACO Assets Include:

ACOalliance.com

ACOroundtable.com

ACOregistry.com

ACOcor.com (anyone remember PhyCor??)

AccountableCare.Center

ACOchat.org

AccountableCare.Solutions

So with perhaps with more than a tinge of ‘battle fatigue’ and the increased participation of smart, motivated, and confident digital natives convinced value based healthcare is within sight, I am pivoting away from active work in this domain.

Instead I am concentrating on developing services for popupstudio.productions offering onsite ‘pop-up studios’ to simultaneously livestream conference, exhibition, tradeshow or event specific ‘user group’ streams across most major social channels including: YouTube, FaceBook Live, LinkedIn or enterprise/organization website(s).

My 2nd pivot is to concentrate on both B2B and B2C educational messaging in the emerging medical cannabis marketplace and the closely aligned and re-invigorated research activity into the therapeutic benefits of psychedelics.

If you have an interest in working with any of the ACO themed domains above, please follow then ping @GreggMastersMPH via DM on twitter.

As I note on the Health Innovation Media website,

“It is not necessary to change”

“Survival is not mandatory” W. Edwards Deming

Peace!

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CMS Announces 2019 Shared Savings Results

by Gregg A. Masters, MPH

Some eight plus years in, ACOs are still earning their ‘shared savings‘ industry ‘sea-legs’.

While they remain a central actor of transformation from volume to value birthed by the ACA for both the public (Medicare and Medicaid) and private (commercial health plans) sectors, the results are continuing to build.

The skeptics think they’re at best transitional vehicles toward more fully expressed and mature risk bearing entities with culture and risk infrastructure suitable to participate in an MA plan.

Below are are two recent articles that dive into the results:

2019 Medicare Shared Savings Program ACO Performance: Lower Costs And Promising Results Under ‘Pathways To Success’

Medicare Shared Savings ACOs Saved $2.6B in 2019

CMS posted the dataset on September 14, 2020 for program year 2019 for both financial and quality performance:

CMS released financial and quality performance results for Performance Year (PY) 2019 and PY 2019A. PY 2019 includes the performance periods beginning January 1, 2019 and ending June 30, 2019 as well as the performance period beginning January 1, 2019 and ending December 31, 2019. PY 2019A refers to the performance period beginning July 1, 2019 and ending December 31, 2019.

To view the complete performance results, refer to PY 2019 Performance Results and PY 2019A Performance Results.

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Need Another Acronym? Think ‘CHART’ Courtesy of ‘CMMI’

by Gregg A. Masters, MPH

In a sea of relentless ‘acronym soup’ that peppers the landscape and too often separates us from the constituency we ostensibly serve (patients) via added layers of dubious complexity to the dysfunctional U.S. healthcare delivery and financing ecosystem, the Centers for Medicare and Medicaid Innovation (CMMI) has added the ‘Community Health Access and Rural Transformation (CHART) Model‘ to our expanding nomenclature.

While we work through and perhaps finally remedy chronic and historically prevailing health in-equities across both urban and sub-urban settings vs. that typically found in rural markets driven by a ‘book of business’ (or financial class) series of incentives, the CHART model:

…aims to continue addressing disparities by providing a way for rural communities to transform their health care delivery systems by leveraging innovative financial arrangements as well as operational and regulatory flexibilities.

No doubt a noble cause and the ‘innovators’ at CMMI are to be recognized and commended for their efforts to make a meaningful difference in the lives of American’s who do not benefit from the typical healthcare asset concentrations in major markets – primarily urban and sub-urban.

While the range of ACO models – both commercial and public sector, i.e., Medicare and Medicaid – are seen by many as tepid responses to an uncharacteristically change or reform resistant healthcare economy fueled principally by still prevailing fee-for-service production incentives, we’re still early on in the evolution of this managed competition model of healthcare innovation, i.e., the ‘efficacy’ jury of ACOs to deliver on the ‘triple aim’ in aggregate is still out.

So read on and see what you think about the prospects of the CHART model to materially impact healthcare delivery while adding value to restraining the cost basis for accessing essential health services for largely under-served communities.

As always, your thoughts and comments are welcome.

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National Association of ACOs et al Weigh in on the ‘Value in Health Care Act of 2020’

by Gregg A. Masters, MPH

Article discovered via the National Association of ACOs (NAACOs) a ‘501 (c) 6 non-profit organization that allows Accountable Care Organizations (ACOs) to work together to increase quality of care, lower costs and improve the health of their communities’ . NAACOs et al weigh in on the Value in Health Care Act of 2020:

In association with the following health care industry advocacy groups including: the American Academy of Family Physicians, American College of Physicians, American Hospital Association, American Medical Association, America’s Essential Hospitals, America’s Physician Groups, the AMGA, Association of American Medical Colleges, the Federation of American Hospitals Health Care Transformation Task Force, Medical Group Management Association, National Association of ACOs and Premier have all endorsed the ‘Value In Health Care Act of 2020’.

The Act intends to:

‘further strengthen ACOs and APMs and ensure their continued success. We are pleased that the bill provides appropriate shared savings rates, modifies risk adjustment methodologies, removes barriers to participation, ensures fair and accurate benchmarks, and provides educational and technical support for ACOs. The bill also makes important steps to reinforce the transition to value through extending and modifying Advanced APM bonuses and addressing aspects of APM overlap. These reforms will ensure that value-based care models continue to be viable for physician and hospital participants’

Read a section by section summary here.

Also, the American Hospital Association (AHA) further reports via a ‘Coalition Voices Support for the Value in Health Care Act of 2020‘.

In a letter to Representatives. Peter Welch, Suzan DelBene, and Darin LaHood, thirteen organizations representing health care providers, including the AHA, voiced support for the Value in Health Care Act, legislation to strengthen Medicare’s value-based payment models and accountable care organizations.

You can read the full text of the letter here.

Clearly the systemic stressors associated with Covid-19’s impact on the usual and customary operations of U.S. healthcare financing and delivery may qualify as an unparalleled (perhaps ‘Black Swan’ scale) ‘may you live in interesting times’ challenge to healthcare leadership – perhaps of a lifetime?

So from a holistic perspective, it seems our leadership cohort across the continuum of an over-engineered, hierarchical, perhaps needlessly too complex but clearly stressed healthcare delivery and financing construct, we’re simultaneously presented with both clear and present ‘danger’ but also considerable ‘opportunity’ to re-engineer our change resistant healthcare borg?

If not now, when?

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Will Health Systems Recover from the COVID-19 Pandemic?

by Gregg A. Masters, MPH and Fred Goldstein, MS*

In the still unfolding operating ‘new normal‘ wrought by the COVID-19 pandemic the path forward presents perhaps the career challenge of a lifetime to both seasoned and emerging U.S. healthcare leadership. No doubt, in health system c-suites across the nation the strategic question is and will likely remain for some time, how to best position admittedly complex enterprises to re-tool, optimize and align their mission in service of the communities in which they operate.

There are many economic challenges we face as a nation, let alone the unique headwinds and potential ‘opportunities‘ health system leaders must assess. Yet, much is on the line. Vetting strategic signals from noise around the pandemic in order to identify the key actionable steps with the greatest potential to deliver the outcomes essential to maintain successful operational portfolios is the strategic imperative laid before our healthcare leadership.

Likely included in top of mind issues to be vetted is the need to examine the role of legacy momentum driven, fee-for-service-fueled health system (and related JV or affiliated entity) business models. Who can fault health system leadership for maximizing revenues to generate the bottom-lines typically required to support a broad range and mix of both ‘profitable’ and ‘un-profitable’ service lines? Yet, habituating (vs. innovating) to the inertia of an aging tapestry of payment incentives may have inadvertently played a role in incentivizing the ‘myopia‘ of short term performance vs. the re-tooling required by an aspiring value based enterprise focused on long term viability.

For instance, we’ve known for quite some time that an estimated 30% of the aggregate national healthcare spend is of the ‘waste, fraud and abuse (over-treatment)‘ variety. Yet whatever the percentage of an average health system’s base revenue can be so attributed, the historical contribution may have meant the difference between insolvency and viability for many health systems. In a production incentivized $3.7+ trillion annual spend healthcare economy, critical healthcare infrastructure (both professional and institutional) may have unwittingly put themselves ‘at risk’ by focusing solely on the short-term revenue optimization.

COVID-19: A Healthcare ‘Black Swan’ Event?

Wikipedia summarizes Nassim Taleb‘s theory of black swan events as follows:

The black swan theory or theory of black swan events is a metaphor that describes an event that comes as a surprise, has a major effect, and is often inappropriately rationalized after the fact with the benefit of hindsight. The term is based on an ancient saying that presumed black swans did not exist – a saying that became reinterpreted to teach a different lesson after black swans were discovered in the wild.

Does the disruption to U.S. healthcare operators presented by the COVID-19 pandemic qualify as a black swan event, or, was this ‘surprise‘ a wholly predictable event in the cross hairs of U.S. healthcare leadership for at least the last 20 years? For instance, might some of those ‘risk averse’ health system executives be re-assessing their choice to pass on percent of premium or global or partial PMPM capitated offers? Clearly those health systems that chose to work with their physicians and scalably enter into risk based contracts are in a better position than those who chose to stay with the familiarity of fee-for-servies incentives even of the ‘value based’ variety

Bottom-Line?

Without considerable transitional support if not operating subsidies to weather the storm and engineer the operating efficiencies of a ‘population centric’ health system with a holistic (vs. current payor class segmented book of business driven) mission to serve the communities in which they operate, our production driven health system chassis is at risk and on balance largely ill equipped to survive the demands of a post COVID-19 environment.

To address these critical issues and explore possible remedies, many national leaders will convene at the ‘Virtual Summit on Health System Recovery from the COVID-19 Pandemic‘ this June 22nd – 24th 2020. Loaded with top talent from major health systems, leading health plans and analysts this conference will explore the tremendous impact the COVID-19 Pandemic has had on the health care system and what the aftermath will look like.

Just thinking of the short and long term implications of the shutdown of elective procedures, the public health systems response, the management of the disease itself, the variable impact on communities around the country, the political response, lack of PPE, rapid move to telehealth, reopening facilites, employer responses and more, the effects have and will be profound.

Gaining an understanding of what the impact has been across the spectrum of healthcare delivery and finance and the likely road forward from key leaders who have and are managing through these issues will be critical to create a sustainable system able to deal with this new world.

This Virtual Conference will Bring together key leaders like:

Michael Dowling, CEO of Northwell Health, whose facilites have been dealing with the largest outbreak of COVID-19 in the World in New York City,
Humana’s CEO Bruce Broussard whose business has focused on the elderly on Medicare and innovative primary care models to
Donald Rebhun, MD Regional Medical Director, HealthCare Partners Medical Group and Affiliated Physicians,
Grace Emerson Terrell, MD, MMM, FACP, FACPE, General Internist, Wake Forest Health Network, chair of AMGA
Susan Dentzer, Senior Policy Fellow, Duke-Margolis Center for Health Policy.

And many others, this conference will provide a look into all sectors, players and issues. Here are just a few key highlights that caught our eye:

Primary Care has been uniquely impacted, from the financial threats associated with closing/scaling back practices to the rapid uptake of virtual visits. Presentations in this area will include:

The “New Normal”: How Primary Care can Reboot and Reopen
Advanced Primary Care/Medical Home COVID Impact Update
Health Care Without Walls: Telehealth and Virtual Care in the Public Health Emergency and Beyond

What about the move to value based care and alternative payment models? Are there opportunities in there, are some of these models a hindrance? Again some key presentations:

ACO COVID Impact Update
Bundled Payment COVID Impact Update
MACRA COVID Impact Update
Advanced Primary Care/Medical Home COVID Impact Update

And what of those areas that seem to receive less focus like The Post-Acute and Long-Term Care Systems in Covid-19 or Pandemic Palliative and Hospice Care. This conference will cover it all from an Update on Molecular and Serology Testing to Social Determinants of Health, Safety Net Hospitals and FQHCs to Big Data and AI. So join this two day conference to learn from others in your field and the broader healthcare system and help us all work to recover from this pandemic.

For a complete faculty listing and agenda, click here.

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*Post sponsored by GHC Health Care LLC.

Surprise Medical Bills In Context: Is Tech the Solution?

By Fred Goldstein, MS and Gregg Masters, MPH

It’s Q1 2020 and everyone is now rightfully preoccupied with the recent World Health Organization (WHO) declaration of the COVID-19 as a global pandemic.

Congress, the White House, National Institutes of Health (NIH), the Center for Disease Control (CDC) and local state and county health departments (collectively the public sector) and private or commercial healthcare ecosystem stakeholders are scrambling to ‘flatten the curve‘ on the spread of this novel coronavirus.

One of the many issues being debated includes who bears the cost burden, whether there should be co-pays or deductibles and whether the public health sector and private healthcare delivery and financing system can get on the same page to aggressively test the population at scale, and incidentally avoid the downstream drama of surprise medical billing. This will get interesting folks!

Meanwhile, some forty years have passed since ‘selective contracting’ or the managed care era launched in California and spread across the nation, driving the need for more accurate and complete databases to effectively drive ‘in-network’ utilization for health plan and managed care organization members, beneficiaries and patients. However, inaccurate provider directory information, both online and in print, is still common and often leads to (directly or indirectly) ‘surprise medical bills.’

Over the past few years the issue of in and out of network providers and ensuring patients can identify which providers are in network has received considerable attention. Almost everyone has a personal story ranging from annoyance to distress about the difficulty of finding the right in-network doctor or choosing a health plan — which is hard to reconcile in our otherwise digitally enabled information age.

Not only are accurate provider directories critical for health plan selection and referrals to appropriate care, it helps ensure that patients do not suffer the financial burden of having unintentionally gone to an out of network provider. In 2019, surprise medical bills associated with out of network providers has become a major political issue, with Congress this past year attempting to develop and pass legislation aimed at reducing the negative impact on patients.

In an article entitled ‘Surprise bills vary by diagnosis and type of admission’[1] the authors estimated that 18% of all emergency room visits and 16% of inpatient admissions resulted in at least one out of network bill.

While according to a 2018 survey^[2] by the American Medical Association (AMA) and LexisNexis® Risk Solutions, more than half of U.S. physicians (52 percent) say they encounter patients every month with health insurance coverage issues due to inaccurate directories of in-network physicians.

This issue not only impacts patients and their ability to access the care they need without experiencing a financial burden, but also the overall patient satisfaction for providers and facilities, who often times will hear from upset patients about unexpected out-of-network bills.

This is also a costly business issue for health plans and providers — It is estimated that health plans spend upwards of $2.1 billion per year maintaining their directories^[3] including on provider outreach efforts. On the receiving end, providers may work with a dozen health plans, each with quarterly campaigns to keep their directories updated. In a climate of provider fatigue and strained plan-provider relations, this is both figuratively and literally adding more paper on our overflowing desks.

In 2015, California took a lead in seeking to solve this issue by passing SB-137 Health care coverage: provider directories. This bill recognized the importance of an accurate provider directory as the key piece to solving these issues.

This legislation requires:

a health care service plan, and a health insurer that contracts with providers for alternative rates of payment, to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plan’s enrollees or the health insurer’s insureds, and would require the plan or health insurer to make an online provider directory or directories available on the plan or health insurer’s Internet Web site, as specified.

It also:

requires a plan to review and update their directory at least annually and to update its online provider directory or directories, at least weekly.

That’s a tall order given the systems that health plans already had in place at the time. In an effort to meet compliance requirements, plans initiated even more outreach but the accuracy of provider directory data See CMS report: “Online Provider Directory Review Report”. Furthermore, many updates requested by providers did not end up reflected accurately in a plan’s member directories.

Shortly after SB 137 was passed, Blue Shield of California was tasked by the California Department of Managed Health Care (DMHC) to tackle the industry-wide provider directory inaccuracies in California as part of a large set of industry undertakings associated with their merger with Care1st (now Promise Health Plan).

Non-profit organization, Integrated Healthcare Association (IHA) was selected by Blue Shield, the California Department of Managed Care (DMHC) and a multi-stakeholder committee to lead the roll-out of a statewide solution for all plans and providers in California. This centralized platform, launched in 2019 as a the single place for healthcare providers and commercial, Medicare, and Medi-Cal health plans to update and reconcile the demographic and contractual information including primary phone number, address, specialty and accepting new patient status — information that patients ultimately depend on to make decisions about access and care.

[NOTE: On PopHealth Week we chat with IHA’s President and CEO Jeff Rideout. To listen, click on PopHealth Week logo.]

In a white paper summarizing results from the first year of Symphony’s roll-out in California, a baseline and early analysis shows that:

Nearly 30,000 records^[4] contained at least 1 major provider identification issue that could cause significant consumer confusion
317 records⁴ service locations listed are actually PO boxes
Nearly 4,000^[5] unique providers were listed with a specialty inconsistent with their medical degree/training
276⁵ unique providers still listed were actually deceased

While initial results are promising, a lot of work remains as more plans and providers onboard with Symphony. This data is a snapshot of how inaccurate current provider data can be. Understanding this baseline enables plans and providers to actionably correct these errors, leading to more accurate and up to date member directories and a more positive impact for patients, providers and payers.

The new white paper from the Symphony Provider Directory can be downloaded You can also learn more by watching this video or by going here.

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References:

^[1] Pollitz, K., Rae, M., Cox, C., & Kurani, N. I. (2019, December 9). Surprise bills vary by diagnosis and type of admission. Retrieved from https://www.healthsystemtracker.org/brief/surprise-bills-vary-by-diagnosis-and-type-of-admission/

^[2] Physicians, health plans must collaborate for network directory accuracy. (2018, February 27). Retrieved from https://www.ama-assn.org/press-center/press-releases/physicians-health-plans-must-collab-network-directory-accuracy.

^[3] Issue Brief: Administrative Provider Data. CAQH [Analysis completed by Booz & Co., now Strategy&, Inc.]

^[4] Based on 475,000 provider data records

^[5] Based on 160,000 unique providers