A Cup of Joe
Joe Sunderman
Ex-JNJ | MBA | High-Impact Data Analyst | Strategic Insights | Open Source Intelligence | Project Management | Research Operations | Content Marketer & Activator | NextUp Cincinnati Member | Culture Thought Leader
Tragedy Puts Spotlight On a Broken US Healthcare System
In light of the tragic news on UnitedHealth Group , the US Medical and Health Insurance became a topic with a myriad of opinions. I particularly liked Benjamin Schwartz, MD, MBA 's perspective Systemic Denial: How Healthcare's Broken System Was Exposed Last Week. Also, Jeffrey Hogan with a review of Peter Atwater "Vulnerability and Health Insurance"
According to this article, Oscar Health lth CEO Mark Bertolini US healthcare industry 'is now broken'.
"And I think that system is largely now broken, and it has been broken for some time. I've been an advocate for change for a long time, and believe that we have ways to get it better in this country. And I think it largely starts with making sure our healthcare system meets the needs of individuals, not the needs of groups. And right now, our system in large-part is built around meeting the needs of groups."
Gallup Polls Show That American Agree that US Healthcare 'Broken" Sentiment
According to a Gallup Poll, Americans' positive rating of the quality of healthcare in the U.S. is now at its lowest point in Gallup’s trend dating back to 2001. The top 3 most urgent health problems facing the country are costs (23%), access (14%), and obesity (13%).
Speaking of Costs - Insurance and Hospital Price Transparency
In this article, discusses why Americans are so upset with insurance costs and denials (Shout out to Cincinnati-based Bahl & Gaynor 's Kevin Gade, CFA, CFP in the article).
This article is full of interesting statistics.
In 2018, a case manager would need to initiate on average 16 phone calls or emails to resolve a claim; now, it’s 27, said Caitlin Donovan, the group’s spokesperson.
In an American Medical Association 2023 survey, 94% of physicians said prior authorization delayed care, and 78% said it sometimes led to patients abandoning treatment. Nearly 1 in 4 reported it had resulted in a serious adverse event for patients and 95% reported it raised physician burnout.
Denials of health claims also increased, rising 31% in 2024 from 2022, according to a 2024 survey by credit firm Experian of 210 healthcare staff responsible for billing and reimbursement.
Speaking of healthcare claims, Eric Bricker, MD did a post yesterday that puts additional context on the Consolidated Appropriations Act of 2021 (CAA) that created data roadblocks around health claims.
Denials by Insurance
Hospital Transparency Rule
The Hospital Price Transparency Rule, which took effect in January 2021, mandates that hospitals disclose their standard charges for services and procedures, including gross charges, discounted cash prices, and payer-specific negotiated rates. According to this article by Ge Bai , et al., shows compliance was initially low after the Hospital Price Transparency Rule took effect. By June 1, 2022, 55 percent of the 3,558 Medicare-certified general acute care hospitals had not posted a machine-readable file containing commercial negotiated prices. Fines could be from $300 to $5500 per day.
If you are looking to shopping around for procedure pricing, I recommend a follow of Leon Wisniewski is showing the value in multiple posts. I also recommend a follow to fellow Cincinnati Healthcare Professionals Network 's Matthew Robben of Serif Health .
As I noted in my review of the Current State of US Health, the United States spends twice the amount per capita than its average peer and is the leading nation in Medical Science & Technology according to World Index of Healthcare Innovation. Yet our results are very poor relative to OECD peers.
Universal Healthcare - Inevitable?
Another data point came from Gallup yesterday that shows Americans are warming up to the idea of Universal Healthcare. I have noted my sentiments in previous commentaries that the path to Universal Healthcare seems to be inevitable each passing year.
According to the recent poll, 62% of Americans believe it is the Federal Government's Responsibility to Ensure All. Furthermore, the poll shows that Americans are nearly split between a system of private insurance (49%) versus government run (46%). Something to ponder for self-insured companies - Greater Cincinnati Employers Group on Health .
I don't know where to include this on #340B, so here is Jennifer Snow view and perspective on a topic that has not fully reached its peak in media and lawsuits of Health Resources and Services Administration (HRSA) and the Department of Health and Human Services (HHS) from Big Pharma.
Obesity - GLP-1 - CGM - Chronic Illness
Bariatric Surgery Declines
Bariatric Surgery Demand Declines in the Era of GLP-1 Ras (Johnson & Johnson MedTech Medtronic Intuitive)
The use of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) for obesity treatment increased more than twofold between the last half of 2022 and the last half of 2023, whereas the rate of metabolic bariatric surgery dropped by around 25% during the same period, suggesting a notable shift in obesity management strategies.
Interestingly, Jihad Kudsi, MD, MBA, MSF, DABOM, FASMBS, FACS had a post on how patient costs on sleeve gastrectomy are lower than Ozempic in treating diabetes and obesity. This study may not hold up in the intermediate term.
Further Storms for Bariatric Surgery
While bariatric surgery is declining, further pressure will mount at as GLP-1s are declining in price.
In 2024, the U.S. list price for a one-month supply is $1,349 for Wegovy and $968 for both Ozempic and Rybelsus, according to HHS. However, after payer negotiations and rebates, the net prices for Ozempic and Rybelsus have decreased in recent years. In 2024, the net price is $649 for Wegovy, $296 for Rybelsus, and $290 for Ozempic. In the U.S, net prices for GLP-1s are between 24% and 73% lower than list prices, indicating that most payers are paying less than the manufacturer's list price.
Since 2018, Ozempic's net price has fallen from $531 to $290, or 45%. Since 2020, Rybelsus' net price has dropped from $376 to $296, or 21%. In contrast, Wegovy's net price has increased 21% since 2021, rising from $534 to $649.
Similarly, more GLP-1R are in Phase III trials and likely heading to the market to further drive prices lower in this oligopolistic space, which will cost/benefit equation for bariatric surgery even more challenging in years to come.
Recommended by LinkedIn
There are currently 63 oral GLP-1R drugs in active development, according to GlobalData’s drugs database. Of these, four products are currently in Phase III.
Let's Get Personal - Personal Health
Some sugar myths to reconsider on your heart health.
Science Says We Age Faster Twice During Our Lifetime. Here's When It Happens
Are wearables making us into hypochondriacs? Interesting post from Steven Dodsworth
It's shocking to learn patients with chronic wounds have a five-year survival rate around 70%, worse than that of breast cancer, prostate cancer and other serious diseases. Treating wounds is also expensive, costing an estimated $28 billion each year in the U.S. alone. More responsive wound care can not only save lives, it can also improve the quality of life for many patients.
Speaking of Personal Health, We are in Need of Primary Care Doctors
According to a report from Kaiser Permanente , the percentage of U.S. doctors in adult primary care has been declining for years and is now about 25% — a tipping point beyond which many Americans won’t be able to find a family doctor at all.
Dana Corriel, MD provides her perspective on concerns of primary care doctors in this post.
A Solution for Adult Primary Care Provider Shortage?
A joint program between the Cleveland Clinic and Ohio University Heritage College of Osteopathic Medicine may alleviate some of this shortage - at least for northeast Ohio. In June 2024, inaugural class from their 6-year program that launched in 2018. For students they "have to know early on that they want to go into family medicine and the quick pace of the program can be difficult." Maybe more hospital and universities will adopt such joint programs to streamline medical education.
Tangent Thought #1
If you are medical history nerd (my hand is raised), there were numerous medical schools and curriculum with no regulation and that varied widely until the Flexner report from 1910
Tangent Thought #2
We are starting to see similar standards and regulations being formed in the wellness/longevity space of human health. This academic paper No More Wild West: The Need for Wellness Professional Standards covers this growing health space.
Food, Health & Agriculture
Nina Teicholz, PhD with a couple interesting articles and contributions to USDA guidelines. She posts an opinion piece on The Hill on We have a chronic disease epidemic because government has fattened us up.
Furthermore, Nina is quoted in this article from Newsweek Media Group on how the new administration could change nutrition policy.
Speaking of nutrition policy, here is how the UK is stepping up their ultra-strict new guidelines.
Erin W. Martin with her Wizard of Oz story around food, health and policy makes for a great read.
Kroger and Albertsons Companies merger decision is forthcoming today.
In the News ... Weekly News Roundup
Holly Scott with her Sunday curation
Joseph W. Sunderman is an Intelligence Analyst/Strategist that is a student of understanding the Current State of the US Health and its impact for the next decade. I developed the thesis over several months for Directions Research Group. Upon completion of boiling the ocean on the topic and created an impeccable deliverable, which can be found in my project section of my LinkedIn page.
In the past, Joe spent seven years at medical device giant Ethicon (division of Johnson & Johnson) with the most recent role as US Regional Manager of Strategic Insights and Pricing. In his seven years at JNJ, he received recognition for his servant leadership, where he was a stand out in performance by being a top 10% recipient of Encore and Inspire Awards over multiple years. Dozens and dozens of accolades from contributors to senior leaders for his collaborative work. Prior to Ethicon, Joe has had a wide variety of experiences in medical claims, banking, publishing, and retail. He began his career at Schaeffer's Investment Research as a financial analyst, where he was ranked by Bridge Information Systems as one of the top 10 market analysts for three straight years for his commentary and stock picks found in Schaeffer's Daily Bulletin. Joe has been published in the Market Pulse Journal and Chartpoint and his market comments have been printed in the USA Today, Wall Street Journal, Barron's, Investor's Business Daily, Dow Jones News Wire, and Reuters. Also, Joe has made appearances on Bloomberg television.