Day: 19 December 2024

THCB Gang Dec 19, 2024 Joining Matthew Holt on #THCBGang on Thursday December 19 at 1pm PST 4pm EST are three leaders in the patient movement Hugo Campos (@HugoCampos); Gilles Frydman (@GillesFrydman); and ePatient Dave deBronkart (@DavedeBronkart). They will be bring us up to speed on the very latest in patients using AI. You can see the video below live (and later archived) & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels. 2024-12-19 19:17:05

“After a while, every couple will get bored. That’s why trying new things together is key.” ~Unknown When life gets busy with work, kids, and the steady hum of daily responsibilities, it’s easy for relationships to fall into a familiar rhythm. Routines are comforting, but they can also lead to a kind of autopilot in love—a state where everything feels predictable and, eventually, a bit uninspired. My partner and I have a strong bond, but we’d both noticed that something felt… different. It wasn’t bad, but we missed that spark of excitement that had defined our early days together. So we decided to shake things up with some new, shared experiences. We didn’t make grand plans or book an extravagant vacation. Instead, we chose to weave newness into our relationship in small ways. We started trying little things that felt unfamiliar, even a bit challenging, to see if we could rekindle the thrill of discovery we’d had in the beginning. And what I discovered was that novelty—no matter how small—has a way of bringing you closer, helping you see each other in a new light and reminding you of why you fell in love in the first place. Here’s what I learned as we explored together and how these simple shifts helped us reconnect. 1. Reigniting Passion Through Novelty One of the first things we did was something simple but unexpectedly refreshing: We talked about what made us attracted to each other. I don’t mean the usual compliments but a real conversation about the things we loved, admired, and found endearing about one another. It felt strange at first—like a conversation we might have had in the early days of dating rather than years into marriage. But as we each shared what made us feel drawn to one another, it brought a sense of excitement back into our connection. Hearing my partner describe the little quirks and qualities they loved about me was like seeing myself through fresh eyes. It reminded me that attraction isn’t just about the initial spark but about the ways we keep noticing each other. Psychologists say that novelty can trigger the release of dopamine, the same brain chemical that floods our brains during those early, intense stages of love. For me, this little exercise felt like a reminder of why we fell for each other in the first place. Since that conversation, we’ve made it a habit to try new things together—whether it’s a different recipe, a walk in a new part of town, or even a conversation about something we’ve never discussed before. These little moments of novelty keep things exciting, reminding me that sometimes, all it takes is a fresh perspective to bring back the thrill. 2. Seeing Each Other in a New Light One evening, we decided to make a simple dessert together, but we turned it into something a bit more intentional. We dimmed the lights, put on some music, and treated the experience like a date night. At first, it seemed like an ordinary thing to do, but the way we slowed down, paid attention, and enjoyed the process made it feel special. Without our usual distractions, I found myself noticing things about my partner I hadn’t appreciated in a while—their laugh, their patience, the way they enjoyed small details. It’s funny how easily routine can make us forget the qualities that first made us fall in love. That evening, I felt like I was seeing my partner with fresh eyes. It reminded me that relationships are not only about supporting each other through life’s responsibilities but about genuinely enjoying each other’s company. After that night, I found myself feeling more connected, holding onto those little things I had seen in them that night, like a renewed spark in our relationship. 3. Building Connection Through Silent Presence One of the most surprising experiences was the time we spent just sitting in silence, holding hands, and focusing on our breathing. We’d decided to try it as a way to calm down after a busy week, but it turned out to be a much deeper experience than I expected. In that quiet moment, without any words or expectations, I felt a connection with my partner that I hadn’t felt in a long time. At first, it felt strange—like I was supposed to be doing something, saying something. But as I settled into the silence, I realized that sometimes, just being present together is enough. This kind of non-verbal connection has become a powerful part of our relationship. It showed me that we don’t always need to communicate through words or actions; sometimes, just being fully present can say more than anything. This experience taught us to find peace together, even when the world outside feels busy and overwhelming. 4. Rediscovering Vulnerability Through Playfulness One of the most fun moments came when we decided to share some of our most embarrassing stories with each other—things we hadn’t talked about in years. We laughed so hard that night, feeling a kind of lightheartedness that was rare amidst our usual routine. It was like peeling back layers and remembering the silly, imperfect parts of ourselves we don’t usually show. Sharing these vulnerable, sometimes awkward moments brought us closer. Studies show that vulnerability can strengthen trust in relationships, and that night, I realized that it’s not only deep conversations that build intimacy but shared laughter, too. That lightheartedness brought a fresh sense of joy into our relationship, reminding me of how much fun we have together when we let go of the serious sides of ourselves. 5. Finding Calm Together in Nature One of the most grounding experiences we’ve tried together has been spending time outdoors without any real agenda. We decided to take a walk in nature one day, moving slowly, letting ourselves relax, and just talking (or not talking) as we went along. It was peaceful, freeing, and a perfect escape from our busy lives. Being outside, away from everything, reminded me of

This is part 3 of Jeff Goldsmith’s history of managed care. If you missed it read Part 1 & Part 2 By JEFF GOLDSMITH Two major changes in health insurance ensued as the US health system entered the 21st century- a strategic shift of health cost risk from providers to patients and the emergence of machine driven managed care. Insurers Shift Strategy from Sharing Risk with Hospitals and Doctors to Markedly Implicating their “Patients’. After the 2008 recession, employers and their health plans shifted strategy from putting physicians and hospitals at risk through delegated risk capitation to putting patients at risk through higher patient cost sharing. In the wake of the recession, the number of patients with high deductible health plans nearly quintupled–to over sixty million lives. By 2024, 32% of the lives in employer-based plans (50% among small employers’) were in high deductible plans regardless of patient economic circumstances.    The stated intention of the High Deductible Health Plan movement was to encourage patients to “shop” for care. In real care situations, however, patients found it difficult or impossible to determine exactly what their share of the cost would be or which providers did the best job of taking care of them. For an extensive review of the literature on how healthcare “consumers” struggle to manage their financial risk, read Peter Ubel’s 2019 Sick to Debt: How Smarter Markets Lead to Better Care. Employers and insurers,  working together to “empower consumers”,  rapidly shifted “self-pay”  bad debts onto their provider networks. Some 60% of hospital bad debts are now from patients with insurance. Instead of “shopping for care”, consumers found themselves saddled with almost $200 billion in medical bills they could not pay, and hospitals and physicians ended up eating most of it.     This escalating “insured bad debt” problem forced providers to hire revenue cycle management (RCM) consultants to revise and strengthen their policies regarding patient financial responsibility, “revenue integrity” (meaning crossing all the “t’s” and dotting all the “I’s” in each medical claim and making sure care is coded properly) and rigorously monitoring the flow of claims to and from their major insurance carriers. As a result many providers found themselves spending 10-15% of their total operating expenses on RCM!  Medicare Advantage Enables Insurer Market Dominance The movement from Ellwood’s vision of regionally-based provider sponsored health plans to market dominance by huge national carriers was cemented by the emergence of Medicare Advantage as the most significant and profitable health insurance market segment. In 2013, Medicare Advantage accounted for 29% of total Medicare spending. A decade later, in 2024, it was 54% (of roughly a trillion dollar program). And until a federal crackdown on MA coding and payment policies by the carriers, it was a 5% margin business, significantly more profitable than commercial insurance, ObamaCare Exchange or managed Medicaid businesses. As Medicare Advantage emerged as the largest health insurance market, it was dominated by a cartel of large publicly traded carriers.  Six publicly traded carriers (United, Humana, CVS/Aetna, Elevance/Anthem, CIGNA and Centene) accounted for 69% of MA’s 34.6 million enrollment as of November 2024.  Kaiser, the “founder” of the movement, added another 5.5%. The top two MA plans, United and Humana, account for almost 46% of MA’s enrollment! Sixty percent of United and CVS/Aetna’s health insurance premium flow and 90% of Humana’s now come from this single program, according to a recent Bank of America analysis. However, owing to the aggressive promotional activism of consultants and private equity financed “management services organizations”, the median MA plan enrollment is less than 2000 lives (!). During the 2010’s, Medicare Advantage became an industry in and of itself. An amazing number of small hospital and physician sponsored plans are fighting over less than a quarter of MA enrollment, and, predictably, losing money on every subscriber (negative 5% margins are typical).  Some communities have as many as forty MA plans competing for their share of this lucrative market.  The Rise of Machine Driven Managed Care The huge national carriers rely, in turn, on a complex network of contractors to manage their Medicare Advantage care management and payment. A shadowy industry populated with billion dollar high tech firms no one in the care system had ever heard of–with names like Emdeon (now Change Healthcare,), Equian,  MultiPlan (taken private by Carlyle in 2024), naviHealth, Signify and Cotiviti–emerged to service health plans with automated systems to review hospital and physician claims prior to payment.  These firms used AI driven machine learning to analyze and process the flow of hundreds of billions of dollars in medical claims. A significant fraction of those claims are denied, either because of data errors in the claims themselves, or because AI rules engines kicked them out for not conforming to constantly evolving medical necessity criteria. Prior authorization, a forty-year-old HMO expense control tool for managing “elective care”, has been augmented by “prospective pre-payment review” applied after hospitals have admitted and cared for patients and submitted insurance claims. According to the American Medical Association, each practicing physician in the US is required to submit 45 prior authorization requests for their patients each week.   Hospitals saw, in some cases, a doubling of claims denials or repricing in just a twelve to eighteen-month period after 2016 based on these automated “prospective” reviews. This surge of machine-driven denials played a major role in the mysterious 39% plummet in hospital operating earnings seen in 2016 and 2017.  A key factor in the wave of denials was the increased centrality of hospital emergency admissions as the main gateway to complex and expensive inpatient care. Upwards of 70% of patients in many health systems are admitted through the emergency room and care is rendered to those patients on an urgent basis.    With primary care physicians withdrawing from hospital practice, decisions to admit patients to hospitals were increasingly made by employed physicians or physician contractors to the hospital, many of whom are “out of network” with the insurance carriers, and under limited control by the hospitals themselves.      After-the-fact denials by insurers often result in unexpected higher bills to patients with high deductible plans as well as significant new administrative expenses for hospitals to track and contest the surge of denials.  UnitedHealth Group Makes its Move Following the more than