The epidemic of rural hospital closures is threatening small towns such as Celina, Tenn. The town of 1,500 has been trying to position itself as a retiree destination but that task has grown more difficult since the March 1 closure of 25-bed Cumberland River Hospital.


Celina became the 11th rural hospital in Tennessee to close in recent years — more than in any state but Texas. Both states have refused to expand Medicaid in a way that covers more of the working poor.

The closest hospital is now 18 miles away. That adds another 30 minutes through mountain roads for those who need an X-ray or bloodwork. For those in the back of an ambulance, that bit of time could mean the difference between life or death.

When a rural community loses its hospital, health care becomes harder to come by in an instant. But a hospital closure also shocks a small town’s economy. It shuts down one of its largest employers. It scares off heavy industry that needs an emergency room nearby. And in one Tennessee town, a lost hospital means lost hope of attracting more retirees.

Seniors, and their retirement accounts, have been viewed as potential saviors for many rural economies trying to make up for lost jobs. But the epidemic of rural hospital closures is threatening those dreams in places like Celina, Tenn. The town of 1,500, whose 25-bed hospital closed March 1, has been trying to position itself as a retiree destination.

“I’d say, look elsewhere,” said Susan Scovel, a Seattle transplant who arrived with her husband in 2015.

Scovel’s despondence is especially noteworthy given she leads the local chamber of commerce effort to attract retirees like herself. She considers the wooded hills and secluded lake to hold scenic beauty comparable to the Washington coast — with dramatically lower costs of living; she and a small committee plan getaway weekends for prospects to visit.

When she first toured the region before moving in 2015, Scovel and her husband, who had Parkinson’s, made sure to scope out the hospital, on a hill overlooking the sleepy town square. And she has rushed to the hospital four times since he died in 2017.

“I have very high blood pressure, and they’re able to do the IVs to get it down,” Scovel said. “This is an anxiety thing since my husband died. So now — I don’t know.”

She can’t in good conscience advise a senior with health problems to come join her in Celina, she said.

When Seconds Count, Delays In Care

Celina’s Cumberland River Hospital had been on life support for years, operated by the city-owned medical center an hour away in Cookeville, which decided in late January to cut its losses after trying to find a buyer. Cookeville Regional Medical Center executives explain that the facility faced the grim reality for many rural providers.

“Unfortunately, many rural hospitals across the country are having a difficult time and facing the same challenges, like declining reimbursements and lower patient volumes, that Cumberland River Hospital has experienced,” CEO Paul Korth said in a written statement.

Celina became the 11th rural hospital in Tennessee to close in recent years — more than in any state but Texas. Both states have refused to expand Medicaid in a way that covers more of the working poor. Even some Republicans now say the decision to not expand Medicaid has added to the struggles of rural health care providers.

The closest hospital is now 18 miles away. That adds another 30 minutes through mountain roads for those who need an X-ray or bloodwork. For those in the back of an ambulance, that bit of time could mean the difference between life or death.

“We have the capability of doing a lot of advanced life support, but we’re not a hospital,” said Natalie Boone, Clay County’s emergency management director.

The area is already limited in its ambulance service, with two of its four trucks out of service.

Once a crew is dispatched, Boone said, it’s committed to that call. Adding an hour to the turnaround time means someone else could likely call with an emergency and be told — essentially — to wait in line.

“What happens when you have that patient that doesn’t have that extra time?” Boone asked. “I can think of at least a minimum of two patients [in the last month] that did not have that time.”

Residents are bracing for cascading effects. Susan Bailey hasn’t retired yet, but she’s close. She has spent nearly 40 years as a registered nurse, including her early career at Cumberland River.

“People say, ‘You probably just need to move or find another place to go,'” she said.

Bailey and others are concerned that losing the hospital will soon mean losing the only three physicians in town. The doctors say they plan to keep their practices going, but for how long? And what about when they retire?

“That’s a big problem,” Bailey said. “The doctors aren’t going to want to come in and open an office and have to drive 20 or 30 minutes to see their patients every single day.”

Closure of the hospital means 147 nurses, aides and clerical staff have to find new jobs. Some employees come to tears at the prospect of having to find work outside the county and are deeply sad that their hometown is losing one of its largest employers — second only to the local school system.

Dr. John McMichen is an emergency physician who would travel to Celina to work weekends at the ER and give the local doctors a break.

“I thought of Celina as maybe the ‘Andy Griffith Show’ of healthcare,” he said.

McMichen, who also worked at the now-shuttered Copper Basin Medical Center, on the other side of the state, said people at Cumberland River knew just about anyone who would walk through the door. That’s why it was attractive to retirees.

“It reminded me of a time long ago that has seemingly passed. I can’t say that it will ever come back,” he said. “I have hopes that there’s still some hope for small hospitals in that type of community. But I think the chances are becoming less of those community hospitals surviving.”








Facilities are faring better in states that expanded Medicaid, according to a new Commonwealth Fund report.


A year after facing a federal funding cliff, CHCs in expansion states are thriving. 

CHCs provide care to 27 million patients each year, according to the Health Resources and Services Administration.

The financial stability of CHCs, which serve medically vulnerable communities, is a benefit for health systems.

Community health centers (CHC) operating in states that expanded Medicaid under the ACA are 28% more likely to report improvements to their financial stability, according to a Commonwealth Fund report released Thursday morning.

CHCs in Medicaid expansion states reported were more likely to report improvements in their ability to provide affordable care to patients, 76%, than their counterparts in non-expansion states, 52%.

More than 60% of CHCs in expansion states reported improved ability to fund service or site expansions and upgrades for facilities, while only 46% of CHCs in non-expansion states said the same.

These facilities reported higher levels of unfilled job openings for mental health professional and social workers, while also implying a greater openness to operating under a value-based payment model.

The success and viability of CHCs are essential for larger health systems, according to Melinda K. Abrams, M.S., vice president and director of the Commonwealth Fund’s Health Care Delivery System Reform program, adding that CHCs act as a strong foundation for providing primary care to medically vulnerable populations in rural communities.

Abrams said that by making sure patients are insured and receiving care up front, rather than delaying treatment and exacerbating their condition, they are less likely to end up in a hospital emergency room and contribute to a rise in uncompensated care for hospitals.

She also told HealthLeaders that populations with higher enrollment rates make it easier for CHCs to innovate, invest in technology, hire new staff, train existing the workforce, and adopt new models of care.

“[Medicaid expansion] makes it a lot easier to provide high-quality comprehensive care when [a CHC’s] patients have health insurance,” Abrams said. “In this particular instance, it’s a lot easier to innovate and have financial stability when you have more paying patients, which means that it is easier if you are [a CHC] in a state that has expanded Medicaid.”

The Commonwealth Fund report provides a welcome note of positivity for CHCs, which serve vulnerable populations primarily composed by the uninsured, but have faced funding challenges in the past.

During the budget battles that produced multiple government shutdowns throughout the early portion of 2018, advocates wondered anxiously whether Congress would provide long term funding to the nearly 1,400 CHCs operating at nearly 12,000 service delivery sites across the country.

According to the Health Resources and Services Administration, CHCs provide care to more than 27 million patients annually.

The Community Health Center Fund (CHCF), created in 2010 as a result of the ACA, is the largest source of comprehensive primary care for medically underserved communities, according to the Kaiser Family Foundation.

However, Abrams said that Medicaid expansion has also been a beneficial tool for CHCs, as they have begun to see more insured patients while also benefiting from Medicaid reimbursements, even though they are low compared to other reimbursement rates.

CHCs in states that expanded Medicaid have been able to grow the services that are offered while assisting in the ongoing fight against the opioid epidemic, according to the Commonwealth Fund report.

Abrams said that one downside to the growing success of CHCs have been the unfilled positions, mostly for mental health providers, that are falling behind rising demand levels, though she added that this finding is not surprising.

“I think it’s in part because the supply of the workforce is lagging a little bit behind the demand,” Abrams said. “There’s no reason to think that over time that this gap wouldn’t be closed. But we did find that as a challenge, that [CHCs] have a lot of positions open [yet] they’re hiring. A number of these CHCs are in economically depressed areas, so the good news is that there are some jobs available.”

CHCs are much more likely to participate in value-based payment models as a result of Medicaid expansion, with Abrams explaining that changes in payments and delivery models are common during insurance expansions.

She sees the continued progress made on the value-based front by CHCs as a way to “promote better healthcare and save money” over time.



Ex-hospital exec sues DMC for wrongful discharge, retaliation

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The former top Detroit Medical Center cardiologist is suing the health system, arguing he was forced out of his job for complaining about alleged fraud at the health system, including unnecessary surgeries billed to Medicare and Medicaid. 

The wrongful discharge and retaliation lawsuit was filed in Detroit U.S. District Court by Dr. Ted Schreiber, who was recruited by the DMC in 2004 and developed a trademarked process to speed life-saving treatment for heart attack patients.  He also was the founding president of the new DMC Heart Hospital that opened with fanfare in 2014.

Schreiber’s accusations are “unsubstantiated,” a DMC spokeswoman said Monday night, and the health system continues to have a “culture of integrity.”

Heart Hospital shares facilities with Harper University Hospital that is poised to be terminated from the federal Medicare program in less than two weeks after failing inspections in October and December. Since Harper and Heart Hospital are considered a single facility by the Centers for Medicare Medicaid Services, both would be barred from the federal health insurance program for the elderly and disabled if Harper fails to pass an unannounced inspection by the April 15 deadline.

Michigan prohibits hospitals barred from receiving Medicare funding from participating in Medicaid, the health insurance program for mostly low-income people that is jointly funded by the state and federal governments. The two programs combined pay for 85 percent of Harper’s inpatient hospital stays, according to Allan Baumgarten, a Minneapolis-based hospital analyst.

The inspections in October and December were prompted by complaints from Schreiber and three other health system cardiologists who said they were forced from their leadership roles in retaliation for complaining about quality of care issues at the DMC. 

Cardiologists Dr. Mahir Elder and Dr. Amir Kaki filed a similar lawsuit last week in Detroit federal court, saying they were forced from leadership posts for complaining to leaders of the DMC about unnecessary surgeries, dirty surgical instruments and other problems. 

In his lawsuit, Schreiber said he brought concerns about physician competency and unnecessary and/or dangerous procedures to DMC peer review meetings in a bid to ensure that they were investigated. But his concerns were ignored by DMC and its for-profit owner, Tenet Healthcare of Dallas, according to Schreiber’s lawsuit.

“(T)he profitability of physicians was being weighed more heavily by DMC and Tenet executives than the physicians’ ability to provide services to patients within the standard of care,” Schreiber alledged in his lawsuit. “This policy resulted in an increase in unnecessary and/or risky procedures conducted by some physicians leading to bad patient outcomes and even patient deaths.”

The DMC continues to argue that Schreiber and the other cardiologists violated the company’s conduct code. The health system’s top priority is delivering “safe, high quality care to the people of Detroit,” said spokeswoman Tonita Cheatham.

“We have a culture of integrity, which means we don’t look the other way, we don’t condone inappropriate behavior of any kind, and we don’t compromise on our priorities,” Cheatham said in a statement.

“That also means we expect physicians to uphold our Standards of Conduct, including treating fellow physicians, nurses and staff members with respect and dignity.  We welcome the opportunity to present the facts underlying the claims made in the complaint.”

In the lawsuit, Schreiber indicated he also complained to Tenet and DMC leaders that some cardiologists were away from the hospital during times they were required to be on-site as members of Cardio Team One’s 24-hour on-call team. He also said he raised concerns about staffing cuts that resulted in poor nursing care for cardiac patients. 

Tenet Healthcare signed a three-year “corporate integrity agreement” as part of a $513 million settlement with the U.S. Department of Justice over allegations of a kick-back scheme involving involving four Tenet hospital subsidiaries in the South, according to Schreiber’s suit. The agreement required Tenet and all of its hospitals to self-report all complaints to the federal Justice Department.

“Senior management, including these Defendants, failed to do so and blatantly allowed legal violations to occur in order to generate more income by cutting medically necessary support and allowing unnecessary medical procedures, among other things,” the former cardiologist executive said in his lawsuit.

Schreiber referred a request for comment on the lawsuit to his attorney, David Ottenwess of Detroit.

“Tenet Healthcare, the current for-profit owner of the DMC, has been continually cited by the federal government for placing profits over people,” Ottenwess said. “Tenet has continued that course with its retaliation against Dr. Schreiber and others at the Heart Hospital who had the courage to question Tenet’s practices of profits over safety.”


Americans’ healthcare paradox: ‘angst’ on costs, overconfidence on quality

Dive Brief:

  • More than three in four Americans expect healthcare costs to increase over the next few years and result in “significant and lasting damage” to the U.S. economy, according to a survey by nonprofit West Health and Gallup. And 69% were “not at all” confident policymakers will fix the situation.
  • Given the choice between a 10% increase in income or a complete five year freeze of healthcare costs, 61% of people said they’d choose the latter, in line with the almost half of Americans concerned that a major health event would lead to bankruptcy for their family. In the past year alone, 12% have borrowed money to pay for care and 10% had foregone treatment due to cost.
  • However, although just 39% of those surveyed were pleased with the U.S. healthcare system as a whole, 64% were satisfied in how it worked for their households. Roughly half believe the quality of U.S. healthcare is either the “best in the world” or “among the best.”

Dive Insight:

Frustrations faced by Americans in paying for healthcare are understandable given that the U.S. ranks first among the 36 OECD developed nations in healthcare cost per person.

But their belief in the supremacy of the U.S. healthcare system is misplaced at best.

The U.S. ranks 31st among the OECD group in terms of infant mortality, a key indicator of overall quality, and a depressing 28th in overall life expectancy.

While healthcare is more regulated in nearly every other developed country, mammoth bills pack a bigger punch because they can come out of nowhere in the U.S. Some 47% of Americans reported never knowing what a visit to the emergency room will cost before receiving care. Just 19% of respondents said they “always” knew their out-of-pocket costs before visiting the ER.

Outpatient surgery, visits to a physical therapist or chiropractor, and check-ups and physicals didn’t fare much better, with only 17%, 23% and 39% of respondents respectively saying they always knew their out-of-pocket costs at those sites of care.

Obfuscation of prices may lead to “risky and unhealthy behavior,” according to the West Health report. It found 41% of Americans surveyed reported forgoing a visit to the ER over the past year due to cost concerns.

And this fear over costs is affecting people at every rung of the socioeconomic ladder. West Health and Gallup found the concern wasn’t just unique to people struggling financially — it was consistent up to the top 10% of earners.

“Angst is a very appropriate word to use when you see the data,” Mike Ellrich, healthcare portfolio leader at Gallup said at the West Health Healthcare Costs Innovation Summit on Tuesday.

Political debate over fixing this problem has centered of late on drug prices, surprise medical billspre-existing conditions and lowering insurance premiums, which are rising faster than income. And CMS has prodded providers and payers to make out-of-pocket costs more transparent for patients.

But Americans largely don’t think politicians will be able to fix the problem, with more than two-thirds of Republicans and Democrats alike not at all confident that elected officials will be able to achieve bipartisan legislation to lower costs.

However, perceptions of quality diverged among party lines. West Health and Gallup found 67% of Republicans view the U.S. healthcare system as delivering the best or among the best care in the world. Just 38% of Democrats agreed.

“I’m all for patriotism, but this is a disconnect from reality,” Ellrich said. “This issue is not red or blue.”




Doddering Doctors: Hospitals Take a Stab at Weeding Them Out

Image result for PAPA, the University of California, San Diego's PACE Aging Physician Assessment program

Screening programs take shape in San Diego as nationwide trend gains steam.

Interventional cardiologist Jerrold Glassman, MD, spent the first week of March schussing down Park City’s powdery slopes. He even braved black diamond runs, belying the fact that this July, he’ll be 69 years old.

“A 60-year-old today is not the 60-year-old of three decades ago,” he said proudly. “Skiing is my passion and I’m going back up tomorrow.”

He and his ski buddies, older physicians like himself, dodge moguls some 30 days a year. A new app tracks his stats, like altitude, speed and distance, and said he did 25 downhill miles that day.

Glassman has no plans to retire from the cath lab — or from skiing — anytime soon. But in coming weeks, medical executive committees for his 3,000-physician Scripps Health system in San Diego are expected to require screening for all physicians age 70 and older for cognitive impairment, among other things. It’s to be a condition for recredentialing every two years.

Doctors up for review will sit in a room alone, with no pencil or mobile aid, while they answer dozens of questions in the MicroCog, a computer-based test also used by the Air Force. The test scores thinking skills, such as the ability to solve simple math problems, count backwards from 100, or find similarities among shapes or pictures.

Following the computer test comes history, physical, and mental health screens that review issues like substance use and tests for hearing and vision. They fill out a form that asks about sleep patterns, continuing medical education, patient load, and typical hours at work. The entire process takes about three or four hours.

The policy is a major change for the system, acknowledged James LaBelle, MD, chief medical officer for Scripps Health. “About 150 physicians 70 or older are due to be recredentialed in 2019 and all would be subject to the policy,” he said. LaBelle did not respond when asked whether the two-year recredentialing cycle would subject a similar number to mandatory screening in 2020 — which would bring the total to about 10% of Scripps’ medical staff.

An undisclosed number of allied health professionals such as dentists and optometrists who seek status as a Scripps staff member are also covered by the policy, LaBelle said.

For most hospitals around the country, “this is pretty new. I do think Scripps is leading in trying to understand how to manage the aging physician,” he said, adding, “I hope it’s going to be easier than I think it’s going to be.”

Failing the MicroCog won’t automatically end a physician’s credentialing at Scripps. But it will flag him or her for further evaluation, perhaps prompting recommendations for more rigorous fitness-for-duty review lasting several days. Physicians who perform poorly there would see their ability to practice limited or revoked.

Come to PAPA

For Scripps and many other organizations, the plan is for screening to be done by PAPA, the University of California, San Diego’s PACE Aging Physician Assessment program — said to be the largest to provide this service in the nation. (PACE is an acronym for Physician Assessment and Clinical Education.) Many other organizations perform various screenings in house, with or without cognitive computer tests, or are working on plans to contract with four other service providers.

Surgeons and interventionalists like Glassman will likely also undergo PAPA’s 15-minute dexterity screen — in which they must correctly place shaped pegs into grooves in a board.

Although leadership’s commitment to a uniform policy is set at Scripps, some details are still being worked out, like how the system’s peer review committees will repurpose those long-time senior physicians who fail the tests but can still provide value to the workforce. LaBelle suggested the exact process Scripps will adopt “is a moving target” that may change, but added, “I have no doubt we’re going to learn a lot over the next few years around how to do this right.”

PACE is a multiple-day testing program which began 22 years ago to assess doctors referred by the Medical Board of California after negligence or behavioral issues threatened their license. Of the 1,000 physicians referred to PACE, an undisclosed number had age-related cognitive impairment that resulted in colleagues’ concerns, but the physicians continued to practice because the complicated peer review process takes a long time, and doctors don’t want to report on each other.

“In all honesty, when we started PAPA, it was because we saw so many wonderful careers that ended in disgrace and tragedy,” said PACE/PAPA director David Bazzo, MD. “Time and time again, the message we heard was ‘Gosh, I wish I had known, or I wish I had stopped or retired one case sooner,’ maybe because of a cognitive issue or dexterity issue. The regret is there.”

Absent screening, procedures for dealing with accusations of physician impairment, can take years. For example, a California medical board filing indicated that concerns about one gastroenterologist with a tremor were expressed internally in 2015, including that he “had forgotten that he was on call … exhibited occasional forgetfulness and confusion and had shown up on at least two occasions at the wrong surgery center.” The medical board didn’t receive a complaint until January 2017, however, and another 15 months elapsed before his license was revoked.

So it’s understandable that proactive screening is gaining traction. “I know it provokes a lot of anxiety, but in the end, it’s really around assessing how much deeper a doctor needs to be looked into, or doesn’t need to be looked into,” LaBelle said. It’s not a slam dunk that they would be sent packing — unless they refuse the tests, LaBelle said. “That’s a hard stop.”

Growth mode

With five PAPA contracts with healthcare organizations or medical groups now active and three more pending, Bazzo sees the demand for late career physician screening as a service line in growth mode. He gives talks about the process to hospitals and medical groups around the country, and estimates 10% of health systems now have some form of screening triggered only by a birthday, even if limited to certain departments. “It’s on the national radar,” he said.

Outside San Diego, other hospitals and health systems have also begun screening their senior clinicians, with or without the MicroCog. Among them are Stanford Hospital, Clinics in Palo Alto, and Eisenhower Medical Center in Rancho Mirage, California; Driscoll Children’s Hospital in Corpus Christi, Texas; and the University of Virginia Health System in Charlottesville. Many others have policies they declined to discuss with MedPage Today.

An American Medical Association report discussed at the November interim meeting noted that 300,752 physicians were 65 years or older in 2017, up from 241,641 in 2013, and 120,000 were “actively engaged in patient care,” up from 97,000. The literature is clear, an AMA report said, that cognitive and physical skills generally decline with age, and physicians are not excepted.

That report urged delegates to adopt principles to guide screening senior physicians for competency. “It is critical that physicians take the lead in developing standards … to head off a call for nationally implemented mandatory retirement ages or imposition of guidelines by others that are not evidenced based,” it said. The suggested guidelines failed to win approval but are being rewritten.

Clearly the issue is a touchy one at many organizations around the country, especially those with many clinicians who’ve long served as their hospitals’ elder statespeople and may serve on influential committees.

Asked if UCSD’s hospitals and clinics screened their senior physicians, a communications director replied, “UC San Diego Health is in discussion on a potential policy, however, it hasn’t established one because the science on the topic is unsettled.”

That prompted a strongly worded retort from William Perry, PhD, vice chair of the UCSD department of psychiatry and a PACE program psychologist.

Robust data

The data is fairly robust in two domains,” regarding the impact of age on physician care, Perry told MedPage Today, emphasizing that the communications director’s message was patently incorrect. “Abilities decline after a certain age and, as one gets older, adverse outcomes increase,” he said, citing unpublished data from PACE and other studies. “There’s no denying it; as we get older a lot of our functions decline.”

Perry said that these days, he’s receiving calls every week from around the country wanting him to give talks. “Organizations in North Carolina and New Jersey are putting together policies. It’s not a question of if, it’s a question of when this will become standard,” he said.

“I’m struck by how much science has demonstrated a connection between aging and impaired physician practice,” said Richard Barton, an attorney who represents physicians, medical groups, and hospitals and helped author a paper on the topic in 2015 for a Sacramento-based physician wellness group. In San Diego alone, Barton knows of three organizations, including Rady Children’s Hospital and UCSD Medical Center, who are also working on late career screening policies due to concern that some older physicians are at higher risk for causing patients harm.

Glassman, who has practiced at 655-bed Scripps Mercy Hospital since 1979 and was chief of staff for four years, said most older Scripps physicians favor the idea. “It’s kind of mom and apple pie. How can you say a physician who is not competent should be allowed to practice?” The big question is, after a clinician fails, which follow-up tests correctly determine whether an experienced physician can still practice?

One of Glassman’s fellow skiers, Jeff Sandler, MD, a Scripps endocrinologist, will be 72 this June and supports the idea of screening doctors his age. “If you think you shouldn’t be screened, maybe you shouldn’t be practicing,” he said. “It sounds discriminatory, but we have to protect the public from bad actors.”

But the issue remains controversial because screening based solely on age smacks of illegal discrimination and the age cutoffs are inherently arbitrary.


Healthcare Triage: Hospital Competition Can Impact Your Health

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It turns out, hospital and health system consolidations can result in worse outcomes for patients. These mergers reduce competition, and it turns out that hospitals compete more often on quality than they do on prices. The result is that quality suffers in markets with less competition.



A review of health care costs: deck chairs and the Titanic, part 1

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This article is Part I of a two-part series on the cost of health care and its component parts. Part I explores the recent growth of health care costs in the United States as well as the utilization inputs in the cost equation.

Part II will break down the pricing component of cost, determined by market leverage and the cost of delivering services. 


If you ask policymakers, industry leaders, and health care consumers, many will tell you that their number one concern with health care today is the cost.

For the most part, as a society we’ve moved past the days when access or quality were of primary concern to stakeholders. I would wager it’s not because those issues aren’t important.  Everyone knows we have wild challenges still with access and quality.

Rather, the acuity of the cost problem has risen so much, so quickly, that cost as an issue overshadows everything else.

This is a big topic, but it’s not really that hard to understand. Health care costs are actually a simple story.

There are only two categories of health care costs in America today. There are the deck chairs, and there is the Titanic.

Context matters, so let’s start there

Here’s one data point, but it’s largely the same point everywhere you look in health care.

These are average annual premiums for single and family coverage in the employer-based market. Those costs have doubled in the last 14 years, reflecting an average annual growth rate of roughly 5 percent since 2004.



Here’s another data point. According to CMS in an article in Health Affairs, “health care spending growth averaged 4.3 percent per year during 2008–17, compared to an average annual rate of 7.3 percent over the 1998–2007 period.” That might seem like costs are slowing, but it’s not the whole story.

Remember the “Great Recession?” It was the period of time when the economy almost fell apart. So, measuring health care spending growth should be done within some context of the overall economy.

For this, we can use a standard inflation calculator of the overall economy to compare its growth to the growth of health care costs. When viewed this way, health care inflation grew at a multiple of 2.7x the broader economy’s inflation rate between 1998-2007 and a multiple of 3.0x during 2008-2017.

So, not only are costs high in health care today, but they are growing faster than ever compared to overall inflation in the US economy.


Moving around the Titanic’s deck chairs

Let’s explore this metaphor a bit.

The Titanic is a big ship with a big deck. And so there are lots and lots of deck chairs to move around. And moving them around can cause authentic improvement to the quality of the experience.

A view out over the bow at a setting sun is a much better view than the one provided by a chair facing the steam funnel. Sometimes, chairs facing other chairs can foster comity and community through conversation. Sometimes, having alone time to ponder the stars in the night sky from the ship deck is nice.

How the chairs are deployed has a meaningful impact on the user’s experience of sailing on the Titanic.

I run with this analogy because there are a lot of things we do in health care today that meaningfully improve the experience, outcome and cost of health care.

You can probably name 10 such efforts without blinking an eye: improved care coordination, tele-health, community health workers, shared risk payment methods, integration of behavioral health, access to oral health, strong vaccination standards, online forums for shared patient experiences, good bedside manners, etc., etc.

All of these initiatives, as well as others, improve care and the user experience. They all can address cost in various ways, too. They can reduce hospital utilization, allow patients to access care remotely, reduce re-admissions or complications from drug interactions. There is a lot to like here that is meaningful and worth our time as a society to implement.

Put differently, in the cost equation where total health care cost equals utilization times prices (THC = U x P), I would categorize these initiatives as part of the utilization input of the cost equation. All of these initiatives address how we access and use health care in our system today.

But, at the end of the day, these are deck chairs.