Consolidation among health systems and hospitals continues apace, and with it comes higher costs, more utilization, and longer disability durations.  Get the details from WCRI’s much-watch webinar on the impact of vertical provider integration on prices, medical utilization and outcomes.

It’s on Thursday May 2 at 2 pm eastern.

You can access the written report (free for members) here.

Another major factor that will greatly affect a state’s health, outcomes and costs is Medicaid expansion. A thorough yet simple discussion of implications of one state’s refusal to expand Medicaid is here.

The benefits of Medicaid expansion are broad, deep, and impactful.

Among the findings

  • A 2020 national study found that expansion was associated with a significant 3.6% decrease in all-cause mortality,
  • Two studies found significant declines in maternal mortality
  • expansion is associated with improvements in access to care and outcomes related to substance use disorder (SUD) as well as other mental health care.
  • hospitals in non-metropolitan areas and small hospitals experienced improved profit margins
  • Analyses find effects of expansion on numerous economic outcomes, including state budget savings, revenue gains, and overall economic growth
  • rural hospitals experienced particularly substantial improvements in financial performance following expansion

KFF on Texas’ uninsured population [note Texas is just one of 10 states yet to expand Medicaid]…

(a) significant proportion of adults in the coverage gap are employed unless they are elderly or disabled. The most common jobs among adults in the coverage gap are construction laborer, cashier, cook, waiter, house cleaner, retail salesperson, and janitor. These workers usually do not have access to employer-based health insurance and cannot afford plans on the federal insurance exchange. [emphasis added]


Most of the non-expansion states:

  • have major problems with rural hospital cutbacks and closures
  • have significantly worse health outcomes
  • have healthcare access challenges

What does this mean for you?

Pay attention to the real drivers of healthcare outcomes and costs – they have more impact on duration and ultimate costs than anything else.



Two big things

Aren’t getting near enough coverage from industry media.

We’re talking about the battle over prior authorizations (PA) and the Change Healthcare cyber attack.

Both have major implications for healthcare and workers’ comp; I’ll very briefly summarize both here and we’ll dive in next week.

Prior Auth.

PAs are used by healthcare payers to evaluate medical procedures, drugs, facility services and treatments before approving them. There’s been a major effort by the AMA and others to restrict the use of PAs, claiming PAs are all about increasing insurer profits, harming patients, delaying care, and leading to the end of civilization.

Well, maybe not the last, but pretty close.

PAs were instituted decades ago because some treatments/services/procedures/ hospital stays appeared to be unnecessary.

Several states appear ready to restrict the use of PAs or otherwise limit their use, add requirements and tighter time limits. 

Needless to say, there’s a lot of claims and counter-claims out there, some pretty strident with language intended to inflame.

Net – keep a close eye on this…it’s an election year and pols may well lean into the PA fight…likely on the side of physicians.

Change cyber attack.

I posted on this a few days ago…Change, which is part of UnitedHealthcare’s Optum subsidiary, suffered a major cyberattack a few weeks ago, one that has crippled a huge chunk of payer-provider electronic communications.

From WebMD

Change Healthcare, part of Optum and owned by UnitedHealth Group, processes about half of medical claims in the U.S. for about 900,000 doctors, 118,000 dentists, 33,000 pharmacies, 5,500 hospitals, and 600 laboratories…

Much of the system is (reportedly) back up and running, but the fallout  – severe cash crunches for small practices, delays in PA transmissions, confusion on what’s covered and what isn’t – continues to make life miserable for office staffs, providers, insurers and banking entities. 

Net – expect the Feds to dive deep into this, assess impacts, require much studier cyber protections and regulatory controls/monitoring of healthcare’s electronic information exchanges.

note – Change was an HSA consulting client prior to it’s acquisition by Optum.



They lied to you.

A really scary study was just published…one that shows just how deadly healthcare misinformation is.

Not “can be”, but is.

Remember those politicians promoting hydroxychloroquine as a cure for COVID – AFTER studies showed it had little to no benefit – and was dangerous?

Well, they have blood on their hands.

A very well done meta-analysis (rigorous review of all available research studies)  estimated there were 16,990 hydroxychloroquine related deaths in hospitalized patients in six countries.

One of the studies, known as the RECOVERY trial, showed a significant increase in cardiac mortality among patients receiving hydroxychloroquine (HCQ). 

The study published in PubMed this February is here.

Two things.

First, anyone willfully lying – or passing along someone else’s lies – to people terrified of a deadly disease has much to apologize for. Would these people tell friends and family to eat rat poison?

Drive drunk?

Inject fentanyl?

Of course not – yet by pushing HCQ misinformation out to friends and family, they did much the same thing.

Second, in a case before the Supreme Court, some politicians are trying to argue that spreading misinformation – like “hydroxychloroquine cures COVID” is “protected free speech.”

What utter BS. Again, is it okay to tell kids – “hey, vaping is good for you!”… or “Sure, unprotected sex is fine!” or “No car seat needed – just carry your baby sister in your lap!”

Tobacco companies and the opioid business are just two examples of industries forced to pay billions for publishing lies.


As noted in yesterday’s post, thousands of us are dying from preventable causes…that’s really, really bad…what’s much worse is politicians legitimizing deadly disinformation. 

What does this mean for you?

Spreading deadly misinformation is NOT “free speech”. It is a cynical and disgusting abuse of power.





Hackers disable nation’s largest healthcare data interchange

A major cyber attack has crippled the nation’s largest healthcare authorization and payment system, leading to weeks of missed payments.

From WaPo:

The hackers stole data about patients, encrypted company files and demanded money to unlock them. Change Healthcare subsequently shut down most of its network as it tried to recover.

The system owned by Change Healthcare, a subsidiary of United Healthcare, has been down since February 21; reports indicate BlackCat, a shadowy hacking group is responsible. BlackCat and/or a closely related entity reportedly received what appears to be a ransom payment of $22 million

UHC reported Change’s pharmacy processing functionality had been restored last week, and its

electronic payment platform would be reestablished beginning March 15, and that it expected to start testing and establishing claims network connectivity on March 18, with service restored through the week.

Don’t expect a full recovery then; that’s the date UHC will start testing a rebuilt system.

Change’s electronic communications, billing and payment system handles everything from utilization review to bill submission to validation to payment and reconciliation for hospitals, health systems, provider groups, clinics, specialty providers, pharmacies and Pharmacy Benefit Managers.

According to Change, the system handles about 15 billion transactions a year, or about half of all medical claims.

What does this mean for you?

P&C insurance execs and Boards should re-think  their chronic under-investment in all things IT.

note: HSA consulted for Change prior to its acquisition by UHG in 2022.


To know why some think the US healthcare system is going to get better and cheaper – and why I strongly disagree, read on.

David Cutler PhD led off the WCRI’s confab with a discussion of the future of healthcare. It was GREAT that a conference has finally tried to educate work comp people about healthcare – after all that is the biggest driver of workers’ comp.  Sorely needed.

But…(more on that in a minute)

Dr Cutler noted that US healthcare is about as unstable as it has been for some time. And there is much more uncertainty to come.

He then asked the audience to vote on whether healthcare will get better and cheaper, stay the same, or collapse.

I voted collapse.

He also differentiated between “Trend” and “Wiggle”, noting it is important to consider what is actually a trend vs what is more likely slight ups and downs – need to differentiate between one-time factors and overall structural issues with long-lasting implications.

Cutler attributes consolidation among small providers to the drop off in patient service demand; that is, demand for providers’ services declined and therefore the smaller providers needed to merge or be acquired. I’d note that Cutler did not mention other factors driving consolidation, namely:

  • Interoperability (CMS IT requirements that can be a big lift)
  • small office staffing woes,
  • office operational expense increases, and
  • PE buyouts that make owners wealthy overnight.

Why Cutler is positive about the future of the US healthcare system

  • Delivery of medical care (number of services rendered) fell off during covid and really hasn’t fully recovered, which implies there are fewer unnecessary procedures/visits/treatments these days. (assumes the decline was mostly in unneeded services)
  • Elective stuff didn’t come back – such as hip replacements, shoulder surgery, etc.
  • Staff shortages are less of an issue of late

Dr Cutler also noted that in his view, medical staff burnout and labor force withdrawal from healthcare delivery roles will be temporary…Employment is coming back.

Very briefly, Dr Cutler’s thinking is that hospitals have too many beds; a lot of care has moved to outpatient facilities and ambulatory surgical centers (ASCs)…as a result hospitals will close floors, other hospitals will close, and the need for nurses in hospitals will thus decline.

Notably, Dr Cutler provided data from CMS to build a case that healthcare itself is better controlled – Medicare growth has been relatively flat over the last few years, and some analysts believe this has reduced total spend by several trillion dollars.

Finally, Dr Cutler also discussed value-based care and the move to bundled care, I suppose as evidence that healthcare is getting more efficient.

So here’s the “But…” in which I respectfully disagreed – and and still do disagree – with Cutler’s optimistic outlook.

Cutler – Shift of care away from and hospital closures will reduce costs and staffing needs

MCM – I don’t have the data, and I’m sure Dr Cutler does, but there’s both anecdotal “evidence” (family members have left patient care for other jobs in healthcare) and actual research that clinical staff shortages are NOT moderating.

Here’s rather compelling evidence that the shortage is NOT going away.

According to the United States Registered Nurse Workforce Report Card and Shortage Forecast published in the September/October 2019 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country through 2030. In this state-by-state analysis, the authors forecast a significant RN shortage in 30 states with the most intense shortage in the Western region of the U.S.

Perhaps Dr Cutler is talking over the very long term – and perhaps the Journal’s authors are not accounting for the shift in care to outpatient facilities.

Perhaps. On the other hand, change is very, very slow in healthcare.

Also, hospitals are major assets, assets which are providing a ton of revenue to the health system or hospital’s owners. Sure, many owners might like to walk away…but they can’t – not without huge pressure from unions, workers, communities and politicians. So, they’ll do anything they can to keep the patients coming, to keep the hospital open – if they don’t they will go belly up – oh and some of the hospital’s execs will not have jobs.

Cutler – Value-based care is saving money…

MCM – There is very little evidence that VBC actually saves money, and a lot of evidence that it doesn’t. In fact, a CBO study indicates that overall, well-funded, well-designed and well-run VBC initiatives actually resulted in higher costs. I’d note that some disagree with CBO’s results. – however those disagreements generally focus around better outcomes, health indicators and the like – NOT on cost reductions.

Cutler – Medicare spending is below predictions thus healthcare is less costly

MCM – But other payer spend has not.

Yes, Medicare’s costs have been below predictions…but that’s NOT the case for individual insurance, group health and Medicaid spend – which has has increased.

To be fair, Cutler agreed with my comment (which I made after his talk), but noted Medicaid spend per enrollee has declined.

He is correct…however in my view but likely because the expansion of Medicaid involved more healthier people being signed up before and during the COVID emergency.  And, their costs prior to enrollment were likely uncompensated care…so my take is overall medical costs weren’t reduced, just shifted to a different payer.

At least for the next few years – and likely longer – the “shiftee”, dear reader, is often workers’ comp.

Finally, good friend and colleague Gary Anderberg PhD of Gallagher Bassett commented that all of us are getting older and sicker and how does that factor into predictions re cost. Cutler indicated he sees it as a mixed picture as cognitive and CV health are improving while others – obesity-related such as diabetes in particular – are declining.

What does this mean for you?

I still vote collapse.



Rural hospitals – and healthcare – are in deep trouble.

With the unwinding of Medicaid post-COVID emergency, rural healthcare is falling deeper into financial trouble.

Consulting form Chartis just published their review of rural healthcare…among the findings

The unwinding issue is exacerbating problems in states that failed to expand Medicaid…the vast majority of which are those with the most hospitals in financial distress.  Simply put – they have to deliver way more healthcare to people without health insurance.


Across the 10 remaining non-expansion states (Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming), the percentage of facilities with a negative operating margin increased year-over-year from 51% to 55%. These states are home to more than 600 rural hospitals…Several of these states are among the most severely affected by hospital closures and a loss of access to care.

The percentage of America’s rural hospitals operating in the red jumped from 43% to 50% in the last 12 months.

418 rural hospitals are “vulnerable to closure” according to a new, expanded
statistical analysis.

Healthcare deserts are a huge problem for rural America, especially in areas with lots of extractive industries (mining, energy, agriculture. Workers in those industries are much more likely to suffer severe occupational injuries, injuries that benefit greatly from care delivered in the “golden hour”.

What does this mean for you?

Not expanding Medicaid is killing rural healthcare.


Signs of the coming apocalypse

Medicare is slashing what it pays physicians, an annual event that – till now – was almost always rejected by Congress.

That will reduce old folks’ access to care, cut workers’ comp fee schedules, and likely lead to more provider consolidation. 

This from Becker’s:

In its 2024 Physician Fee Schedule Final Rule released Nov. 2, CMS reduced overall physician pay by 1.25% and updated the Medicare conversion factor to $32.74, a 3.4% decrease from last year.

Nope, a fix wasn’t in any of the “continuing resolutions” Congress passed last year and earlier in January (“CRs” are a stop-gap, emergency funding step more often seen in desperately poor banana republics than in the “greatest nation in the world.)

As a result, docs’ pay will be cut about 3 1/2%…and they are none too happy about it. (Read this for details on potential implications)

Okay that’s bad, right?

Not as bad as what’s coming.

Reminder – if Congress doesn’t pass a budget – in exactly one month – all Federal agenciesincluding Medicare, the VA, Defense, the FAA… face budget cuts. Weapons procurement, care for veterans, agriculture inspections, airplane safety inspections (this isn’t a problem, right??) are just a few.

Remember way back (as in two years ago) when Congress’ wait-till-the-last-minute-to-get-stuff-done made us all nuts…if we knew then how dysfunctional the House would be now we’d have been quite happy for what we did have.

Yep, Republicans in the House of Representatives’ refused to even vote on an immigration reform bill – THE hot issue in Washington and around the country – a bill that gave them everything they wanted.

House GOP – Yay, we finally got the soccer ball!  Let’s play! Wait…how do you play? I dunno…you know?  Nope – you? Nuh-uh…you? No clue…you? Uh…I thought it had pointy ends…Someone pick it up…NO way dude! Not me…

What does this mean for you?
To quote HL Mencken, you get the government you deserve, and you deserve to get it good and hard.

PS – Over the lastly 20 years I’ve written a lot about the incredibly screwed-up Medicare reimbursement  process…


Predictions for healthcare in 2024

Some of you know Jay Stith – he’s been working with HSA for half a decade now, heading up data analytics and research. Jay’s brilliant, has a great dry wit, and most of all very insightful.

He sees stuff – others – including me – don’t.

So, I asked Jay to make his predictions for healthcare in 2024…lest the work comp folks stop reading here, remember workers’ comp is the flea on the tail of the healthcare elephant.

Outside of employment, the biggest single factor affecting workers’ comp is healthcare – hands down.

  1. Hospital/ Health System M&A will ramp up in a big way leading to even more consolidation around the country.
    1. M&A dropped dramatically during COVID so there is an element of catch-up on top of a rapidly changing healthcare industry, financially distressed hospitals/health systems offering themselves as prime takeover candidates, and potentially dropping interest rates all point toward high levels of M&A activity.
  2. And…Facility fees will continue to be the elephant stomping around the room. Remaining high and potentially going higher all while limited efforts are made to curtail them.
    1. A next step to prediction #1 – as consolidation often means high prices. Little activity has occurred to combat facility fees so far and with sexier issues like AI monopolizing meetings I don’t see meaningful action broadly coming.
  3. Staffing shortages will keep already high labor costs high – looking at nurses in particular.
      1. The thousands of physicians and nurses entering the workforce lags the number of physicians who are retiring or simply exiting the industry. This decline coupled with the aging US population is exacerbating the already critical problem. We are, and have been, under-supplied with nurses across the healthcare landscape and between structural issues like not enough nurse education faculty and the median age of nurses >50 this issue is unlikely to change.
  4. Human-caused climate change will disrupt even more businesses with policy progress being slow and insufficient.
    1. We don’t know what we don’t know – climate-related problems are impacting a wide range of business and employee needs. In addition to the obvious employee-injury issues associated with climate change, disruptions to care access, employee-personal-life problems (e.g. damage to home), and climate migration make climate-associated changes more difficult to model and properly account for.
    2. As if we needed more proof, here’s what’s happening in California..
  5. The AI arms race will continue with companies everywhere announcing new AI tools for various business segments BUT true internal buy-in will still be far away as the tools will underwhelm managers dreams for headache-reduction.
    1. Managers are dreaming about the volume of tasks that AI will be able to effectively handle in a fraction of the time while producing higher quality work than their current teams. As companies learn how difficult properly training an AI tool is and how much time/resources are required to make even marginal gains, people will get frustrated about having over-promised and/or having to deal with poorly functioning AI tools – e.g. a bad chatbot or an internal system lacking proper training on a costly outlier situation.
    2. AI and technology improvements will dominate the headlines and capex allocations BUT customer service will remain more correlated to client satisfaction.
    3. Healthcare and insurance have changed a lot over the decades but as technology has gotten fancier and the industry more complex, high quality customer service has remained the top-rated factor when assessing a successful vendor-client relationship… and it will not change this year.

What does this mean for you?

Consolidation = higher facility costs.

Staffing shortages = higher facility costs.

Human-caused climate change = BIG problem.

AI ≠ panacea.


Hospitals are…

a) in desperate financial shape, on the verge of bankruptcy…

b) doing quite well thank you, enjoying very healthy profits…

c) both.

The answer is…C.

For-profits – HCA, Tenet et al are doing great, while (most/many) not-for-profits are really struggling, with some on the verge of/going into bankruptcy.


Very briefly, for-profits (there’s lots of nuance here, but generally);

  • don’t take Medicaid patients,
  • have very strong orthopedic and cardiac surgery practices which are very profitable;
  • do their best to avoid/transfer/not care for the uninsured.


  • include inner-city and rural facilities that must take Medicaid and
  • serve as primary care providers for the indigent and uninsured and
  • deliver lots of babies and provide general med/surgical services which are marginally profitable

What does this mean for you?

Hospitals of all types are looking to maximize revenue, especially from very profitable payer types.

Is that you?




Optum employs(?) more doctors than any other organization

The giant subsidiary of United Healthcare employs [>]90,000 MDs and 40,000 more advanced practice clinicians – far more than any other entity.

That’s more than one out of every ten physicians, and a far higher percentage of practicing MDs.

While that’s pretty amazing, its just one of the many investors, healthplans, private equity firms, large healthcare systems, and insurers snapping up all manner of healthcare providers.

In fact, almost three-quarters of all physicians are employees of companies or healthcare systems/hospitals – not members of physician-owned practices.

As with everything in healthcare, location makes a big difference.

One of the biggest drivers has been Optum’s acquisitions, which included Kelsey Seybold, a very large practice in Texas…Optum reportedly paid $2.2 billion for the business.  And, that happened AFTER the time period in the graph.

What does this mean for you?

Your healthcare will be driven by investors’ goals.

note – Optum’s communications folks asked me to publish a correction, because not all of the 90k docs are “employees”…I asked how many of those 90k docs are “employees”; Optum’s reply was “We don’t break out the numbers because we focus on the total number who serve our risk-based patients.”

I’m quite sure Optum knows the number. why they won’t release it is a mystery.

I also asked – twice – whether the “physicians who contract directly with Optum” (which make up some/part of the 90k docs):

  • exclusively contract with Optum,
  • are allowed to contract directly with other payers, and/or
  • is Optum the contracting intermediary?.

I didn’t get an answer.

So, all I can tell you, dear reader, is Optum directly employs ≤ 89,999 physicians, and may or may not allow those “non-employed” physicians to contract with other payers.