





https://mailchi.mp/699634d842fa/the-weekly-gist-november-1-2019?e=d1e747d2d8

Succession planning is a frequent topic of conversation among the boards and executive teams we work with at health systems, and for good reason. There’s a large cohort of CEOs and other C-suite members in their late 50s to mid-60s who are probably two or three years away from retirement. Smart organizations are way ahead of these transitions, creating a deliberate bench of next-generation leaders, and explicitly evaluating their performance at a board level to determine who will fill key leadership spots in the future.
One aspect of succession planning that’s gotten less attention but can prove equally disruptive to the organization if ignored, is what role the CEO will play after retirement. We’ve worked with a number of systems over the years whose CEOs have been in seat for a decade or more, and who are reluctant to take a full step away from the post once their time is over. Of course, it’s ideal to have a transition period that lasts for a defined time, to give the new executive time to get up to speed and build confidence.
But what we sometimes see is former CEOs whose shadows loom large over the system, as they continue to provide (often unsolicited or unwanted) advice, stay in close touch with former subordinates, or keep a running dialogue with board members. This creates an awkward situation for the new CEO, who finds her own plans and ideas constantly tested, sometimes explicitly, against the “What does [former CEO] think of that?” standard.
The key to avoiding this problem is to address it well in advance. We’ve been part of explicit conversations between incoming and outgoing CEOs about expectations and role definition post-exit, and even seen a few outgoing CEOs engage career counselors to help them manage the personal challenge of letting go of the organizations they’ve poured their hearts and souls into. A delicate situation to be sure—but a critical one to get right.
https://mailchi.mp/699634d842fa/the-weekly-gist-november-1-2019?e=d1e747d2d8

Our graphic this week captures a phenomenon that we’ve observed in our strategy work with regional, “super-regional” and national health systems. We call it the “up and out” phenomenon—healthcare delivery is increasingly being pulled up and out from local, siloed hospitals. The traditional hospital enterprise, operating in what we refer to below as the “fee-for-service zone”, has typically pursued a service approach that delivers all things to all people. Commonly, the combination of reimbursement incentives and health system governance structures has encouraged hospital executives to prioritize facility profitability over system performance.
One important source of value creation for regional systems is service line rationalization—essentially, consolidating key services in one facility rather than performing duplicative services in every hospital. Centralizing open heart surgery, for example, in one “center of excellence” in a region often results in both lower cost and higher quality, thanks to clinical and operational scale economies. But the economies of scale don’t necessarily run out at the regional level—for some high-end specialty services (transplants, for example) it makes sense to consolidate at a super-regional or national level. For a better outcome and lower price, consumers will be increasingly willing to travel to receive the best value care.
Meanwhile, many services currently performed in the hospital can be more efficiently performed in non-hospital settings and should be distributed across the market in ways that are more convenient and accessible for patients. Traditional hospital economics make the “inpatient-to-outpatient shift” problematic, but as price and access become important consumer engagement levers, there’s little use fighting that shift. Indeed, the logical setting for much care delivery is in the patient’s home itself. This puts systems in the position of pushing care delivery to the hyper-local level, a strategy that can be powered by digital medicine delivered at a national level. All of this raises an important question for the regional health system: as hands-on care is increasingly pulled “up” to the national level (centers of excellence) and pushed “out” to the community setting (home-based care), and as national providers of digital health services can deliver services to anywhere, from anywhere, what is the value of the regional system? We’re working with a number of members to better understand and prepare for this new operating model.
https://www.thefiscaltimes.com/2019/10/30/Number-Uninsured-Children-Increases-400000

A new report from the Georgetown University Health Policy Institute says the number of uninsured children in the U.S. increased by more than 400,000 between 2016 and 2018.
Some key findings from the report:
The report’s authors said it’s no coincidence that the increases in the number of uninsured children have occurred since President Trump took office in 2017.
“This serious erosion of child health coverage is likely due in large part to the Trump Administration’s actions that have made health coverage harder to access and have deterred families from enrolling their eligible children in Medicaid and CHIP,” they wrote in their conclusion. “These actions include attempting to repeal the ACA and deeply cut Medicaid, cutting outreach and advertising funds, encouraging states to put up more red tape barriers that make it harder for families to enroll or renew their eligible children in Medicaid or CHIP (or ignoring it when they do), eliminating the ACA’s individual mandate penalty, and creating a pervasive climate of fear and confusion for immigrant families.”
https://www.thefiscaltimes.com/2019/11/01/Elizabeth-Warren-s-205-Trillion-Plan-Fund-Medicare-All

Elizabeth Warren on Friday detailed how she intends to pay for Medicare for All without raising costs for middle-class households. The senator from Massachusetts said her plan will cover everyone in the country without raising overall spending, “while putting $11 trillion back in the pockets of the American people by eliminating premiums and virtually eliminating out-of-pocket costs.”
Warren’s plan relies in large part on redirecting existing spending toward a universal, federal health care system, while adding new revenues from taxes on the wealthy, the financial sector and large corporations. “We can generate almost half of what we need to cover Medicare for All just by asking employers to pay slightly less than what they are projected to pay today, and through existing taxes,” Warren said.
Some key details from the Warren plan:
Much lower cost estimate: Warren starts with the Urban Institute’s estimate that the federal government would need $34 trillion more over 10 years to pay for Medicare for All, but she slices that number dramatically — down to $20.5 trillion — by using existing federal and state spending on programs including Medicaid to fund a portion of her proposal, along with larger assumed savings produced by a streamlined system paying lower rates to hospitals, doctors and other health care providers.

Total health care spending stays about the same: Warren projects about $52 trillion in national health care spending over 10 years, close to estimates for the existing system, despite covering more people and offering more generous benefits, including long-term care, audio, vision and dental benefits. Applying Medicare payment levels across the health care system is projected to produce substantial savings that would be used to finance the expanded size and scope of the plan.
Heavy reliance on employer funding: The employer contribution to Medicare for All is pegged at $8.8 trillion, with employers required to contribute to the federal government 98% of what they would pay in employee premiums. Businesses with fewer than 50 employees would be exempt.
Public spending continues: State and local governments would be still on the hook for the $6 trillion they currently spend on Medicaid, the Children’s Health Insurance Program and public employee premiums.
New taxes on the wealthy: Warren proposes a new 3% tax on household wealth over $1 billion — and that’s on top of her proposed wealth tax, which calls for a separate 3% tax on wealth over $1 billion (and a 2% tax on wealth between $50 million and $1 billion). Combined with an annual capital gains tax on the top 1% of households, her proposal projects that the new health-care-focused wealth taxes would produce $3 trillion.
Taxes on business and finance: Warren says she can raise $3.8 trillion through “targeted” taxes on big business and financial transactions, including a financial transaction tax of .01% on the sale of stocks, bonds and derivatives.
Reduced tax evasion: Cracking down on tax evasion is projected to bring in $2.3 trillion. “The federal government has a nearly 15% ‘tax gap’ between what it collects in taxes what is actually owed because of systematic under-enforcement of our tax laws, tax evasion, and fraud,” Warren said. “By investing in stronger enforcement and adopting best practices on tax reporting, withholding, and filing, experts predict that we can close the tax gap by a third.”
Revenue increase from higher take-home pay: Employees would no longer pay premiums for health insurance, providing a pay hike and higher tax revenues, estimated to total $1.4 trillion.
Abolishing the Overseas Contingency Operations fund: Warren is calling for reduced military spending, with a focus on what some call the “slush fund” that covers the cost of overseas military operations. Eliminating this off-budget spending is projected to save $800 billion.
Immigration reform: Expanded legal immigration would bring in $400 billion in revenue as more incomes are subject to taxes, Warren says.
A record tax cut? Once the new revenues and cost savings are added up, Warren says her plan will deliver what amounts to an historic tax cut. “No middle class tax increases. $11 trillion in household expenses back in the pockets of American families. That’s substantially larger than the largest tax cut in American history.”
Warren won plaudits from some analysts and policy wonks for releasing a plan, but the details she laid out are also being picked apart by critics and rivals, with some experts already expressing doubts about her assumptions and numbers. Here’s some of the reaction:
Congratulations from a conservative: “Kudos to Senator Warren for actually releasing a plan,” said Scott Greenberg, formerly an analyst with the right-leaning Tax Foundation. “There are a lot of things in here that will draw attacks from the left and from the right, and it might have been politically easier not to release it at all. But Warren has stuck by her commitment to explain her proposals.”
Criticism from a key rival: “The mathematical gymnastics in this plan are all geared towards hiding a simple truth from voters: it’s impossible to pay for Medicare for All without middle class tax increases,” said Kate Bedingfield, deputy campaign manager for Joe Biden. Bedingfield argued that employees would end up paying the tax on employers.
Dire warnings from the White House: “It is the middle class who would have to pay the extra $100 billion or more to finance this kind of socialist government takeover of health care,” said Larry Kudlow, President Trump’s top economic adviser. “It would have a catastrophic effect on the economy and all these numbers that we’re seeing, all these numbers, on incomes per household, on wage increases, on jobs, all these numbers would literally evaporate and by the by, so would the stock market.”
Tax vs. premium: Warren’s plan will likely kick off a debate about the difference between taxes and health care premiums, and whether that difference matters, says William Gale of the Brookings Institution. “Does [the Warren plan] raise ‘taxes’ on the middle class?,” Gale asked Friday. “Short answer — it does not raise ‘burdens’ on the middle class.”
Cost reduction is crucial: “The key to Warren’s plan for financing Medicare for all is aggressively constraining prices paid to hospitals, physicians, and drug companies. We’d still have the most expensive health system in the world, but it would be less expensive than it is now,” said Larry Levitt of the Kaiser Family Foundation. “Warren’s plan to aggressively constrain health care prices under Medicare for all would be quite disruptive. On the other hand, every other developed country has managed to figure it out, so we know it’s possible.”
And the battle is ultimately political: “In laying out the specifics of her Medicare for all plan, Warren’s challenge is more about politics than arithmetic,” Levitt continued. “She is taking on the wealthy, corporations, and pretty much every part of the health care and insurance industries. Those are some powerful enemies.”
So don’t expect major legislation soon: “Experts will argue for months whether [Warren is] being too optimistic — whether her cost estimates are too low and her revenue estimates too high, whether we can really do this without middle-class tax hikes,” said economist Paul Krugman. “You might say that time will tell, but it probably won’t: Even if Warren becomes president, and Dems take the Senate too, it’s very unlikely that Medicare for all will happen any time soon.”

The California Department of Justice denied a proposed merger between nonprofits Adventist Health System/West and St. Joseph Health System Oct. 31, stating it’s not in the public’s interest.
The transaction would increase healthcare costs and possibly limit healthcare access in Northern California, the department determined.
In June 2018, Roseville, Calif.-based Adventist and Irvine, Calif.-based St. Joseph requested to form a joint operating company to integrate 10 select facilities in Northern California. At the time, the systems said their integration would improve healthcare access, especially for vulnerable and underserved patients.
Sean McCluskie, chief deputy to California’s attorney general, disagreed with those predictions.
“The California Department of Justice is responsible for ensuring that any proposed sale or transfer of a nonprofit health facility protects the health and safety interests of the surrounding community. After careful review, we found this proposal falls short of protecting consumers,” he said.
In a joint statement to Becker’s, Adventist and St. Joseph expressed disappointment about the department’s decision.
“Our intent has always been to better serve our communities, increase access to services, and create a stronger safety net for families in Northern California,” they said. “At this time, our organizations will need to take a step back and determine implications of this decision. The well-being of our communities remains our top priority.”