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Hospital Systems: A Framework for Maximizing Social Benefit

Tuesday, January 17th, 2023

Mar 21, 2022• 0


Hospital consolidation has risen to the top of the health policy stack. David Dranove and Lawton Burns argued in their recent Big Med:  Megaproviders and the High Cost of Health Care in America (Univ of Chicago Press, 2021) that hospital consolidation has produced neither cost savings from “economies of scale” nor measurable quality improvements expected from better care co-ordination. As a consequence, the Biden administration has targeted the health care industry for enhanced and more vigilant anti-trust enforcement.

However, as we discussed in a 2021 posting in Health Affairs, these large, complex health enterprises played a vital role in the societal response to the once-in-a-century COVID crisis. Multi-hospital health systems were one of the only pieces of societal infrastructure that actually exceeded expectations in the COVID crisis. These systems demonstrated that they are capable of producing, rapidly and on demand, demonstrable social benefit.

Exemplary health system performance during COVID begs an important question: how do we maximize the social benefits of these complex enterprises once the stubborn foe of COVID has been vanquished? How do we think conceptually about how systems produce those benefits and how should they fully achieve their potential for the society as a whole?

Origins of Hospital Consolidation

In 1980, the US hospital industry (excluding federal, psych and rehab facilities) was a $77 billion business comprised of roughly 5,900 community hospitals. It was already significantly consolidated at that time; roughly a third of hospitals were owned or managed by health systems, perhaps a half of those by investor-owned chains. Forty years later, there were 700 fewer facilities generating about $1.2 trillion in revenues (roughly a fourfold growth in real dollar revenues since 1980), and more than 70% of hospitals were part of systems. 

It is important to acknowledge here that hundreds more hospitals, many in rural health shortage areas or in inner cities, would have closed had they not been rescued by larger systems. Given that a large fraction of the hospitals that remain independent are tiny critical access facilities that are marginal candidates for mergers with larger enterprises, the bulk of hospital consolidation is likely behind us. Future consolidation is likely not to be of individual hospitals, but of smaller systems that are not certain they can remain independent. 

Today’s multi-billion dollar health systems like Intermountain Healthcare, Geisinger, Penn Medicine and Sentara are far more than merely roll-ups of formerly independent hospitals. They also employ directly or indirectly more than 40% of the nation’s practicing physicians, according to the AMA Physician Practice Benchmark Survey. They have also deployed 179 provider-sponsored health plans enrolling more than 13 million people (Milliman Torch Insight, personal communication 23 Sept, 2021). They operate extensive ambulatory facilities ranging from emergency and urgent care to surgical facilities to rehabilitation and physical therapy, in addition to psychiatric and long-term care facilities and programs.

Health Systems Didn’t Just “Happen”; Federal Health Policy Actively Catalyzed their Formation

Though many in the health policy world attribute hospital consolidation and integration to empire-building and positioning relative to health insurers, federal health policy played a catalytic role in fostering hospital consolidation and integration of physician practices and health insurance. In the fifty years since the HMO Act of 1973, hospitals and other providers have been actively encouraged by federal health policy to assume economic responsibility for the total cost of care, something they cannot do as isolated single hospitals.

  • Managed Competition. Under the Paul Ellwood/Alain Enthoven/Jackson Hole Group vision of managed competition, a fragmented care system comprised of individual hospitals and autonomous physicians would be replaced by a limited number of Kaiser-like capitated integrated delivery systems serving regions and competing on price (e.g. premium/PMPM).  This vision of a consolidated health system assuming population risk has been the holy grail of US health policy for five full decades, embraced by Republican and Democratic policy advocates alike. For hospitals to remain independent was to risk being isolated and commoditized by larger enterprises, either insurer- or provider-sponsored. This fear of isolation resulted in waves of hospital consolidation during the late 1970s and 1980s in anticipation of a health care marketplace populated by regional integrated delivery networks.   
  • Clinton Health Reforms. Under the proposed Clinton reforms in the early 1990’s, hospitals would only have access to revenues through capitated health payment from the anticipated regional purchasing alliances and could contract to be paid directly if they were capable of bearing and managing population risk. Otherwise, hospitals would have become isolated subcontractors whose offerings would have been commoditized by those who accepted population-based payment. Even though the Clinton reforms faltered, a large wave of hospital mergers and integration activity in the mid-1990’s anticipated their passage. 
  • HITech and the ACA. In the wake of President Obama’s 2009 Hitch Act, White House technocrats actively encouraged hospitals to absorb their physicians’ practices as a vehicle for facilitating the adoption of electronic health records. Similarly, the ACA’s payment reform initiatives, particularly the centerpiece Shared Savings (ACO) Program, relied upon on the ability of health enterprises to reach and manage the care of large populations as a bridge to a fully capitated future, spurring yet another wave of hospital consolidation.

Integration of Care and Financing has Failed to Achieve Ambitious Social Goals

The fact that health systems have struggled to integrate insurance financing into their care operations has left a legacy of at best partial integration. According to business historians, the core strategic idea at the root of these policy proposals was flawed; health insurance and care delivery are very different businesses, in some ways diametrically opposed to one another.  

Hospital enterprises owning a health insurance business are thus engaged in unrelateddiversification, a strategy that has long since lost favor in the business world due to poor returns on the investment. Robert Burns and colleagues found that the greater the investment in this type of diversification, the larger a health system’s losses. As we have argued elsewhere, Kaiser’s success looks increasingly like a one-off example. More than 80% of Kaiser’s enrollment remains in its originating Pacific Coast markets where it originated more than 70 years ago. 

And despite more than a decade long federal push for “value-based” payment and tens of billions invested by health systems in consulting and infrastructure, by 2020, capitated payment accounted for a scant 1.7% of median hospital revenues and risk-based payment (e.g. two-sided ACO-style risk) only 1.1%. Neither revenue source has grown measurably since 2014 (Moody’s Investor Service, 9 Sept 21). Almost 50 years after the HMO Act of 1973, in only a few communities in the country (Pittsburgh, San Diego and Portland) do at least two integrated delivery systems compete for health plan enrollment. 

Realistically, the Ellwood/Enthoven vision of a care system reorganized into risk bearing IDNs is not going to happen in the US. Yet the hospital and physician consolidation catalyzed by that vision has left most metropolitan areas with a few dominant health systems with undeniable market power in their commercial transactions with health insurer. This market dominance and observed pricing power has led to an increasing policy hostility towards health system scale, with commercial prices being used as the singular measure of performance.

Meanwhile, other large corporate actors have appeared that seek to integrate care across regions without owning hospitals. The two largest enterprises in the US health system, each exceeding $250 billion in annual revenues, do not own a single hospital. They are UnitedHealth Group and CVS/Aetna, diversified health insurers with impressive arrays of primary and ambulatory health services as well as pharmacy benefits management and operations and in CVS/Aetna’s case, a nationwide chain of retail pharmacies. How one pays or regulates these vast non-hospital enterprises, just two of which accounted for more than 13% of US health spending in 2020, in a way that maximizes societal benefit is a conversation that has not even begun.

How to Think about Measuring Social Benefit from Large Health Systems

It is not clear to us that having a highly fragmented health system with thousands of actors each covering a piece of our health needs and competing aggressively on unit price is in the society’s best interests.  A comprehensive conceptual framework for assessing the social contribution of complex health systems—hospital-centric or not—is needed. Fortunately, Donald Berwick did exactly such a thing in 2008 by proposing what he called the Triple Aim. While Berwick meant it to represent achievable goals for health systems, we think it is also valuable as a societal benefit framework measured across a region.

Berwick later added a fourth Aim, improving the work experience of clinicians, in recognition of the challenges of professional burnout and stress, which have been dramatically heightened by the COVID crisis.

 In applying Berwick’s formulation, it is not whether a system exceeds a certain numeric threshold of market concentration, but how the merged entity affects its communities’ health and welfare after the attorneys and consultants go home that really matters.

More specifically, a health system’s societal contribution should be evaluated based upon:

  1. Its ability to reduce per capita care costs in the populations they serve
  2. Its ability to reduce errors and increase measured patient satisfaction by improving the care experience.   
  3. Its ability to improve population health in their communities, especially by attacking and ameliorating social determinants of health. 
  4. Its ability to engage clinicians and improve their practice efficiency and satisfaction. 

Let’s discuss each of these and consider the ramifications for social benefit.

1. Per Capita Cost Reduction

Traditional anti-trust enforcement has focused on commercial price behavior as the measure of social impact of a merger. Yet modern systems offer thousands of products, each of which has a unique charge structure spread across multiple payers. Systems also differ markedly in the degree to which they serve government funded patients whose insurers (e.g. Medicare and Medicaid) pay less than the fully loaded cost of care, and thus rely on commercial insurance markups to offset these losses.    

However, the communities they serve generate health costs summed across all the people who live in a given region. Berwick believed that reducing per capita medical expense for the community as a whole was the highest and best use of health systems, whether or not they were paid for all those patients on a capitated basis. Since it is not realistic to expect that we will convert all provider payments to capitation, health systems will have to manage the tension between per incident payment for services and overall population level reductions in health expense. The burden of proof will lie in evaluating the specific mechanisms systems use to reduce per capita expense.

These mechanisms could include the use of targeted comprehensive primary care aimed at older and chronically ill individuals, including the use of “extensivists”—primary care physicians and advanced practice nurses that reach out into the home and workplace to manage health risks proactively, the development of palliative care models for patients with advanced illness, employing digital/telehealth services that target not only chronic illness but also various forms of addiction, particularly to food, alcohol and opiates, telehealth tools that improve adherence to risk-reducing medications like statin drugs, vaccines and the use of predictive analytics, disease registries, and “hot spotting” of vulnerably co-morbid patients, among many other promising innovations.

North Carolina’s Novant Health has used community health workers who assess high utilizer patients for social determinants in their home, shelter, or location of choice. They connect patients to a variety of trusted community partners, addressing food, housing, workforce development and transportation barriers

The result: a 33% reduction in ED utilization, a 40% increase in medication adherence, and a 21% reduction in PHQ-9 score (measuring anxiety and depression).  According to Novant Health CEO Carl Armato, the most consistent piece of feedback from CHW patients is gratitude that someone took time to listen to and address their needs–they consistently report a remarkable patient experience.

Simply focusing on commercial prices as a metric of performance of health systems misses any recognition of the market context these systems operate in such as neighborhood poverty, racial and economic inequity, payer mix and disease burden and thus fails to address the financial viability and sustainability of these enterprises. How many large health systems, particularly Academic Health Centers, would survive in the face of an arbitrary Medicare-related price ceiling for commercial payment?   

We advocate a more nuanced assessment of economic contribution that balances an examination of per capita cost with the overall financial performance of health systems[1]. Since community wide per capita spending is difficult to capture, per capita Medicare spending would be a more easily accessible proxy measure.

2. Improving Safety and the Patient Experience

Health system consolidation should lead to systematic improvements in the patient experience. COVID clearly showed that larger health care organizations with significant IT systems and technical staffs were better able to scale up telehealth operations to compensate for the loss of in-person elective and emergency care and to sustain telehealth use when elective care resumed. The ability to stand up command centers and manage health resources (ICU beds, emergency rooms, clinical staffing and related support services) across a metropolitan area or region cannot be achieved by a large number of competing, freestanding facilities. 

The ability to create condition-specific care plans that envelop and extend complex care episodes (e.g. joint replacement, cardiac nerve ablation, etc) is enhanced by having multi-disciplinary clinical teams supported by data analytics and IT systems. Similarly, the ability to identify defects in clinical and administrative processes that expose patients to risk and to wasted time and cost is enhanced by having a larger base of participating clinicians. 

Pre-COVID, many health systems were building “digital front doors” to their care systems, using smartphone apps, call centers and digital health access to smooth entry into and passage through their care systems. Larger systems created by mergers have not only enhanced clout with regional clinicians but also with health insurers that should be used to bring down patient bills.  

These improvements should be measurable through improved HCAHPS ratings and rising net promoter scores. Similarly, reduced clinical errors and improved clinical productivity are measurable and should be discoverable by patients and community members.

3. Improving Population Health through Addressing Social Determinants

In his “Poverty and the Myths of Health Reform,” the late Dr. Richard (Buz) Cooper persuaded us that the most important intervening variable in the widely observed variation in hospital and specialty use from community to community was not the supply of specialists and hospital beds, but rather the prevalence of poverty—the main social determinant of health.  Homelessness, food insecurity, broken families, unemployment, health illiteracy all stem from poverty, and generate both avoidable illness and costs.

These conditions cannot be ameliorated by health systems, or “competition” between isolated pieces of the care system, because they ultimately originate in our culture and society. The United States has grossly underinvested in the social care needed to ameliorate these conditions. These underlying social conditions that drive a lot of “unnecessary” health care use cannot be ameliorated through the core businesses of health systems, but rather through their collaboration with other entities with community wide reach, as well as neighboring public health systems—the very kind of collaboration we saw across the country during COVID.  

There are many examples of this type of collaboration:

  1. California’s public health collaborative to attack and reduce maternal mortality, in which hospitals played a decisive role. This multi-year collaboration succeeded in reducing maternal mortality by more than half to rates comparable to western Europe, with concomitant reductions in PICU stays, infection-driven lengthy hospital stays, etc.
  • Blue Zone Collaboratives. These collaboratives focus on specific neighborhoods or districts, and identify gaps in access to food, housing, public safety and social/human services that, when ameliorated, contribute to lengthening life expectancy in the geography chose. Health systems are key actors in most of the 56 projects currently underway.
  • Mental Health Collaborations. In many communities, both public and private mental hospitals have closed, and services for those in mental health crisis have been absorbed, with predictable results, by local law enforcement. In metropolitan Seattle, health systems that normally compete for patients—MultiCare and CHI Franciscan Healthcare—collaborated to build a $41 million 120 bed inpatient psychiatric facility
  • Addressing Homelessness. Numerous health systems (including Kaiser Permanente, Promedica, Truman Health, etc. ) have moved to create living spaces for homeless people in their communities, which has vastly simplified bringing community-based services and job opportunities to them.

Many health systems are engaging community partners in addressing income inequality, unemployment, educational opportunity, food insecurity, homelessness and racism. Some health systems such as Promedica in Ohio and Novant Health in the Carolinas are making upstream investments in housing and social services and to act as “anchor institutions” for community development. Other systems such as Ohio Health and Inova Health focus on their core clinical mission but embrace partnerships with community organizations. 

Novant Health has created a program for “Expanding Opportunity through Education”—investing in education programs with students of color and economically-disadvantaged communities where there are significant disparities in college readiness rates. Individuals who do not graduate high school are more likely to report suffering from at least one chronic health condition—asthma, diabetes, heart disease.  

Under new CEO Dr. Stephen Jones, Virginia’s Inova Health System has a partnership model for community engagement. Inova established twenty care clinics in zip codes of need based on data and community input with over 100,000 visits in 2021. Realizing the effects of what Jones terms “social drivers of health” the Inova Cares Clinics house Community Health Workers embedded in the neighborhoods to build trusting relationships, as well as pantries to address food insecurities. In addition, in partnership with local Title I schools and non-profits, Inova is working to create career journeys for students. Inova also supports 30 community organizations through health equity grants totaling $1M to leverage relationships for real impact in the community.

The normative expectation should be that because larger health systems serve larger populations, and therefore are exposed to larger community risk factors and needs, they can and should be expected to devote resources and talent to addressing them. The existing approach to evaluation of community benefits (as in the IRS definitions and the requirements under the Affordable Care Act) are sorely in need of re-examination to account more fully the range of initiatives being pursued.   

4. Improving Care Giver Experience

One area where large health systems have struggled is in improving the working lives and professional satisfaction of its caregiving workforce. COVID clearly demonstrated how much stress and pressure in health systems devolves onto front line care givers. While large health systems were ultimately able to procure the PPE needed to make their jobs safer, they were less effective in ameliorating the stress at the root of care during this crisis. Being highly dependent on an aging workforce, health systems face huge staffing gaps in the wake of COVID as burned-out baby-boom vintage doctors and nurses retire or transition to other, less stressful work roles.

Health system leaders are acutely aware that their clinical workforce are “spent” after more than two years of delivering front line care in a pandemic, increasingly to unvaccinated  and often hostile or violent patients. It has become a strategic imperative that health systems respond effectively in acknowledging and managing the mental health problems of their clinical workforce. Failing to acknowledge this problem has resulted in avoidable shortages in clinical staffing, and excessive reliance on mandatory overtime and temporary clinical workers or travelling nurses.

Clinician engagement is an important precondition for improving clinical quality and reducing medical errors. Large health systems have fewer excuses for not having worker sensitive (as opposed to litigation sensitive) human resource policies. Workforce satisfaction is easily measured through physician and staff engagement surveys.


We do not propose this performance framework as a regulatory guide for state or federal authorities. Rather it is presented as a voluntary alternative for managements and Boards seeking to demonstrate the community benefits created by their institutions.   

At their best, large health systems can deliver sophisticated, complex care to their communities. But they can also play a key role with community partners in addressing the social determinants of health, thus reducing per capita health cost. Large multi-billion health systems are here to stay. The conversation about how to enhance the health systems’ benefits to their communities, which have been so vital during COVID, has barely begun.   

Jeff Goldsmith is President, Health Futures Inc & Ian Morrison is the former President of Institute for the Future. One of them is America’s best known health futures, but we’re not sure which!


This essay has benefitted greatly from review, comments and examples provided by colleagues. In particular, we would like to thank health system CEOs and health policy experts Nancy Agee, Carl Armato, Carmela Coyle, Stephen Jones MD, Chip Kahn, Stephen Markovich MD, Tom Priselac and Michael Gentry.

[1] Nancy Kane, Robert Berenson and colleagues have pointed out that the financial performance of health systems differs materially based on their resource position, payer mix and other variables, and proposed a financial performance evaluation framework  based on audited financial reports to account for these differences .  The same is true of the geographical areas served by systems; those which serve communities like the Bronx or South Central Los Angeles face greater challenges than those serving suburban communities. Adding socio-economic domains based on geography to the Kane/Berenson framework would facilitate “apples to apples” comparisons of potential social benefit created by systems. 

My 22 Oldest Jokes and Why they Still Matter in 2022

Wednesday, January 19th, 2022

I have been studying American healthcare for more than 40 years and I have assembled a large number of one-liners over the years. As we enter 2022, I thought I’d share my 22 oldest jokes and why they still matter.

Coming to America

  1. I grew up in Glasgow, Scotland.  In Glasgow, healthcare is a right, carrying a machine gun is a privilege. America got it the wrong way round.

Gun violence continues to ravage the United States. We have more guns than people. Kids get gunned down in school playgrounds and classrooms routinely. It happened once in Dunblane, Scotland in 1996 when a local shopkeeper walked into Dunblane Primary School and opened fire, killing 16 5- and 6-year-olds and their 45-year-old teacher.  It so galvanized public opinion, according to Smithsonian Magazine:  “By the end of 1997, Parliament had banned private ownership of most handguns, including a semi-automatic weapons ban and required mandatory registration for shotgun owners”.

Last time I looked, gun violence was the second leading cause of death in children in the US.  In America when we have mass shootings all we get are thoughts and prayers.

And when it comes to healthcare as a right, even if we Build Back Better, it won’t be a right for millions of American residents, especially those who are undocumented.

2. I am a Scottish Canadian Californian which gives me a unique perspective on healthcare (and all things to do with healthcare, including death and dying) because the Scots see death as imminent, Canadians see death as inevitable, and Californians see death as optional.

This is one of my oldest jokes and it remains true.  In Silicon Valley, where I live, my affluent VC friends want to live forever and are working out and taking supplements to achieve that. In contrast, my British friend Dr. Richard Smith (former Editor of the BMJ) is sitting on the Lancet Commission on the Value of Death.  Enough said. (

3. Canada could have been the best country in the world: it could have combined American know how, British ethics, and French culture. Unfortunately, it got American culture, British know how and French ethics, a particularly nasty combination.

Canada is still a great place, especially in contrast to a Trumpian America, but they have had their own issues with competence and corruption in recent years.

4. As to why Americans can’t do Canadian-style healthcare: “I lived in Canada, I trained in health economics and health policy in Canada, my wife is Canadian, and most of my extended family live in Canada.  So the short answer is “You are not Canadian:  Canadians are different from Americans they describe themselves as Unarmed Americans with Health Insurance.” (The latter part is borrowed). 

Despite all their troubles, including waiting times for MRIs and elective surgery, Canadians remain fiercely loyal to their healthcare system and view it more positively than their American counterparts do their own system.

For Canadians their health care system is a proud point of cultural differentiation from Americans.

5. Why do the French have the highest rated health system in the world? It has very little to do with their health system. The real reason is that the French walk, they drink red wine, and they get naked in the summer. Nothing will keep your BMI down better than getting naked in the summer.

The French still smoke at higher rates than the US and consume more alcohol, and in recent years their diet has increasingly been Americanized by fast food, hypermarkets, and industrialization of cafes and restaurants.  Even though they had their own challenges with Covid, they have life expectancy above comparable countries, whereas America is far below that metric and going in the wrong direction.

On Being a Health Consumer or a Patient

6. (Healthcare) Quality is being in a waiting room with people who earn more money than you do.

Despite enormous investments in what I call the quality police (the health industry agencies and actors who measure, manage, accredit, approve and regulate healthcare quality), the public still has a great deal of difficulty in judging health quality.   Consumers confuse choice with quality.  Patients are frightened and usually defer to their doctors when the chips are down.   Having gone through a serious healthcare surgery recently at Stanford, I would say a pretty good surrogate for quality is being in a waiting room with the affluent crowd. 

By the way, I used this line in a talk to venture capitalists a few years ago.  They looked at me with incredulity and nobody laughed, because nobody makes more money than they do.

7. Good Health is a state of incomplete diagnosis (Borrowed). 

I credit my friend Bill Rosenburg, formerly of KPMG and Met Life with this line.  It was also widely circulated by my old mentor Bob Evans at UBC.  No matter the ultimate provenance of the joke, it is one of the best descriptors of modern medicine.  

If you look hard enough, everyone has something wrong.  Most cultures don’t bother finding out and it either resolves itself or it doesn’t.

8. The Quantified Self movement is going to lead to a Frenzy of Cyberchondria, overwhelmed with false positives and the hyper worried well 

Do you really want to know your blood pressure in real time, all day long from your smart watch?  Does your doctor want 15 terabytes of data from your Peloton? Let me tell you: she does not. 

This technology can be incredibly helpful if we develop the right use cases, particularly in managing vulnerable folk.  Continuous monitoring of the buff seems like a waste of resources.

9. It’s tough to be cost conscious when you’re unconscious.

I used to tease the great Alain Enthoven with this line.  I’m all for more cost consciousness by consumers, but as Mike Tyson famously said: “Everyone has a plan until they are punched in the mouth.” 

10. How to pick a health plan 

Step 1.  Decide on the diseases you and your family are going to have in the coming year

Step 2.  Find the best doctors and hospitals for those diseases

Step 3. Identify which plans offer those doctors and hospitals

Step 4.  Select the cheapest plan

Step 5.  If there are no affordable plans with all the doctors and hospitals you want, go back to Step 1 and pick some new diseases

This accurately describes how many Americans are asked to select health plan options whether in Exchanges, Medicare, employer sponsored coverage or even Medicaid. The joke tries to point to the absurdity of selecting a plan that meets your needs when by definition no one has perfect vision of their future health and disease.  (See Mike Tyson).  Maybe we should figure out a system to pay for care for people who need it, rather than paying for coverage that doesn’t cover what patients may need when they get sick.

On the Role of Employers

11. When it comes to healthcare employers are Cranky, Confused, Aimless and Spineless.

The genesis of this line was a meeting in the early 1990s with the CEO of Baxter Vern Loucks and his leadership team.  My colleague Bob Leitman of the Harris Poll and I were presenting the results form our annual Healthcare Outlook surveys of consumers, physicians and employers.  We had too many slides and generated great discussion and so of course, we ran out of time.  As the meeting closed Loucks turned to me and asked what does the employer survey show in a nutshell: “When it comes to healthcare Employers are cranky, confused, aimless (I said)…..and spineless (Bob added)”.  

“Exactly” Loucks responded “you two are going to come with me next month to tell some other CEOs exactly that”.  Loucks was an ex-marine and a central casting CEO you would follow him anywhere. 

Loucks office called the next day and we were asked to appear in St. Louis at Emerson Electric in a couple of weeks time.  We waited in the board room and in walked Loucks with fellow CEOs Chuck Knight of Emerson Electric and Auggie Busch of Anheuser Busch.

“Tell them what you told me” Loucks said.  “Employers are cranky, confused, aimless and spineless,” we said.

Not missing a beat Auggie Busch said: “Yeah but we are not stupid.  Labor costs are a small part of our business, (we spend more on advertising) and healthcare costs are just 10% of labor costs”. We had a great discussion about healthcare.  Oh, and they did fire the benefit manager some months later, sorry.

I am a long-time advisor to PBGH (Purchaser Business Group Health) which represents industry giants like Wal-Mart, Disney, Boeing and Apple and more than 40 others household names.  They are becoming much more activated in both purchasing and policy making as they deal with the consquences of Covid, and the reality that the healthcare provider “game” is completely dependent on self insured employers for their financial sustainability.

Stay tuned for more employer activation in 2022.

On Obamacare and Replacing It

12. On Republican Plans to Repeal and Replace Obamacare: “It’s like breaking up the Beatles where you just keep George and Ringo and expect it to sound good.”

Mercifully, John McCain gave Repeal and Replace a thumbs down, but Republicans were close to repealing Obamacare and ripping out the essence of the program (the John and Paul) of raising taxes and subsidizing exchanges and Medicaid expansion.

13. Republican policies are ideologically coherent, they’re just not actuarially coherent

All of the Republican proposals to replace Obamacare were consistent with smaller government principles but they all fell short on affordability for consumers, reduction in the uninsured, and the resulting positive effects on health and financial security of the newly covered.

On Medicaid

14. Medicaid is bigger than France, It’s bigger than Wal-Mart

Medicaid expansion has occurred over the last ten years in 38 states and more recent government action to fight Covid has further expanded Medicaid rolls in every state.  Build Back Better provisions, if enacted, would further expand eligibility for the program.  Even if BBB doesn’t pass, Medicaid will still be bigger than France in terms of number of enrollees and bigger than Wal-Mart in total revenue.  Massive Medicaid is the default program for an increasing number of poor, elderly and vulnerable populations, yet payment rates to providers are inadequate, this will be a central challenge for the future.

15. It’s easier to get into Princeton than to get a Medicaid card in Texas.

This is a true statement for childless adults, because like many other Southern states childless adults are not eligible for Medicaid.  And even worse, if you are in a category eligible for Medicaid but you earn more than $3,733 per year for a family of 3 (17% of the Federal Poverty Level), you are too rich to qualify for Medicaid in Texas.  Princeton has got to be easier to get into.

On Business Models

16. The prevailing metaphor for American healthcare is “Pimp my Ride”

As I wrote back in 2005:

“If you have teenage kids, you end up watching a lot of MTV or you have nothing to talk to your children about.  My kids are both in college now, but I have watched a lot of MTV in my time.  My favorite show of the moment is “Pimp My Ride”.  The show is in the genre of all makeover reality shows.  In this case a rapper host introduces a poor kid and their beaten up old car (the ride).   The car is taken from the young adult and transformed by a team from West Coast Custom (a body shop and customization company in LA).  

Each episode shows a different kid and a different car:  clapped out Pintos, beaten up Suburbans, and a plethora of ugly, weird, old and dilapidated camper/truck hybrids.  The process is always the same: they strip the car’s interior and install an unbelievable array of stereo equipment (woofers and sub-woofers included), video displays (even laptops) and the whole thing is topped off with an amazing paint job in vibrant blue or dazzling yellow, topped up with custom painted flames on the side.  They never seem to do anything to the engine, drive train, or chassis of any of these vehicles.    At the close of each episode the youngster is shown the transformed vehicle that has been “pimped” and they can never contain their excitement.  They are deeply grateful.

The prevailing vision of quality in American healthcare is “Pimp My Ride”.

We take a really bad chassis and engine and bolt on unbelievable amounts of high technology on a frame that is tired, old and ineffective.  We spend extravagantly on buildings, machines, drugs, devices, and people at West Coast Custom Healthcare.  The people who own the rides are very grateful because they don’t have to pay for it in a high deductible catastrophic coverage world, once you are over your deductible and ensconced in an American hospital the sky’s the limit.  It all looks great, has a fantastic sound system, and nice seats but it will break down if you try and drive it anywhere”.

I rest my case.

17. Really rich people don’t pay taxes, unless they have bad accountants

I actually got this joke from my accountant.  He was correctly pointing out to me the fact that the ultra-rich have a wide variety of offshore and other tax avoidance schemes that are unavailable to even the ordinary affluent.

18. One man’s waste is another man’s income.  Modern variant:  One man’s surprise bill is another man’s lucrative business model

The whole surprise billing policy shenanigans has underscored the fact that many providers such as ER doctors and anesthesiologist (especially if they are private equity backed), air ambulance services and many others are completely dependent on surprises as their business model. Hospitals and health systems are often complicit in these models and it is why they are resisting the rules of adjudication of surprise bills which will inevitably reduce the economic yield from out of network activity.

19. Managed Care Definition: An organized system of healthcare financing and delivery that takes the excess profits of hospitals, specialists, and drug companies and gives them to consultants

Managed care been “berry, berry” good to me.  Managed care unleashed a gravy train for consultants that has continued for 30 plus years (with only minor perturbation by Covid).  The current managed care variants of value-based purchasing and population health still haven’t dealt with the fundamental question if managed care is so great why have American healthcare costs continued to rise faster and higher than anywhere in the world over the last 30 years and life expectancy and other indicators have gotten worse relative to our advanced country peers. 

20. At some point in the next five years the revenue from the Revenue Cycle Industry will exceed the revenue of the hospitals they serve in the financial management equivalent of the Rapture.

We have armies of people faxing things to each other and in the modern version we have dueling robots where automatic upcoding by hospitals meets automated denials by health plans.  At some point the robots will explode and the health system will meltdown.

On Disruption

21. When smart Alec start up CEOs call me with a plan to disrupt American healthcare I give the same speech.  The American healthcare system is larger than the entire Italian economy and about as well organized.  So if you think you are going to disrupt healthcare it’s a bit like saying you are going to disrupt Italy. Good luck with that.

US healthcare just edged out the German economy as the fourth largest economy in the world (it is actually twice the size of the Italian economy).  Such massive incumbency is not easily moved. The new disruptors with the massive resources thrown at them in 2021, also have massive burn rates which will be challenged in the next 24 months to deliver on the lofty promises.  I wish them well, we need the innovation. Ciao.

On Being a Futurist

22.  My definition of a futurist is an economist who couldn’t handle the calculus.

I have been in the sweeping generalization business for more than forty years.  I like data and arithmetic, calculus not so much.  But I believe that if something is going to be a big deal in the future it has to start some time and be detectable to human beings without fancy mathematics.  Jokes can help tell those fundamental truths.  

Ian Morrison, PhD is an author, consultant and futurist in Menlo Park, California

Key Lessons Learned for the Healthcare Industry with Governor Mike Leavitt, Andrew Croshaw, and Ian Morrison

Friday, December 18th, 2020

In this Leavitt Partners Future Frame Series you will hear Governor Mike Leavitt, Andrew Croshaw, and healthcare futurist, Ian Morrison, discuss lessons learned in 2020 and the on-going implications for the healthcare industry in 2021.

The future of employer sponsored insurance, a conversation with Health Evolution

Wednesday, December 9th, 2020

In this webinar, Ian Morrison hosted Health Evolution’s virtual gathering, The Future of Employer Sponsored Health Insurance: Implications for Healthcare Stakeholders with Elizabeth Mitchell, CEO, Pacific Business Group on Health and Barry Arbuckle, President & CEO, MemorialCare Health System.  

American Physicians Group Podcast with Don Crane

Thursday, September 24th, 2020

What does our healthcare system look like post-COVID? How is healthcare innovating to meet the many challenges? How will this pandemic impact the value-based care movement? APG President and CEO, Don Crane, talks frankly with Ian Morrison, author, futurist, internationally known consultant and speaker specializing in the future of healthcare and the changing business environment. Morrison gives his insight about the changes and challenges ahead for employer-sponsored commercial insurance, Medicare, and Medicaid.

Tuesday, May 19th, 2020

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Emergency Care

Sunday, November 13th, 2016

The Affordable Care Act has expanded coverage and increased demands on the health care system. In many states, patients without a regular source of care are defaulting to emergency rooms as their touch point in health care, even though coverage expansion holds promise to create more stable and appropriate primary care options. At the same time, in many states such as Texas, Ohio and Colorado, freestanding emergency rooms and urgent care centers are growing like wildfire, worrying critics that cherry picking will undermine the economics of emergency medicine for many community providers. Where are we headed with emergency care?

Emergency and Urgent Care

Across America there is a wide and growing array of ambulatory care options for urgent or emergency care. According to industry sources, there are more than 5,000 hospital emergency rooms, 10,000 urgent care centers, 5,000 ambulatory surgery centers, 2,800 retail clinics and more than 500 freestanding emergency rooms (a phenomenon we will focus on in detail below). This growth in options reflects a broader shift to the ambulatory environment enabled by technology (such as rapid recovery anesthesia) and by consumer preference for rapid treatment in convenient locations.

With the passage of the Affordable Care Act, emergency room activity seems to have increased across the country. Overall in the United States, the number of emergency room visits per 1,000 has increased from 350 to approximately 434 in the last 20 years. Nationally, the promise of the ACA was that providing health insurance would dampen the use of ERs because newly insured patients would have access to a regular source of primary care, but this promise has not been completely fulfilled.

Medicaid recipients are largely immunized from the higher out of pocket cost of ER visits experienced by exchange or commercially insured patients, and this may lead them to seek routine care in the ER more often.  While there is evidence that (over time) primary care options are put in place for the newly covered under Medicaid and through exchanges (see an excellent review by Deloitte by visiting the experience of most provider groups I talk to is that ER use is up, driven largely by Medicaid expansion. We are not going to litigate that particular argument here; suffice it to say there is scholarly research being developed to analyze both the short-term and long-term effects of coverage expansion on sources of care, and stay tuned for a definitive history five years from now.

I became interested in the changing landscape of emergency room use following a Martin Luther King Community Hospital board discussion. I have the honor to sit on the hospital board in Los Angeles and I am very proud of the work our CEO Dr. Elaine Batchlor and her colleagues have done in successfully opening a new community hospital in a unique public-private partnership with the county, the regents of the University of California, UCLA and an independent nonprofit community hospital board (a topic for a future column).

The hospital is doing really well and, in particular, its emergency room is providing this underserved community a vital element in a high-quality health care system.

Wally Ghurabi, a distinguished UCLA emergency room physician, is the chief of staff. Dr. Ghurabi’s group services not only the ER at Martin Luther King but also UCLA’s Nethercutt Medical Center in Santa Monica (thereby nobly treating the whole range of socioeconomic populations in Southern California). The hospital opened just over a year ago, but is now seeing a rate of 70,000 emergency room visits per year.

Dr. Ghurabi told me in an interview that this growth is bimodal. At one extreme is a significant group of patients who could be treated by primary care. At the other extreme, a significant proportion of patients are extremely sick – many with psychiatric and behavioral health issues, or with severe untreated diseases such as diabetes and hypertension, who have been attracted to the new hospital because of its emerging reputation for quality and service and because of its location in the heart of an underserved community with historically limited access to primary and specialty care.

I asked Dr. Ghurabi during our board conversation about freestanding emergency rooms. (California is the only state that outright prohibits the freestanding emergency rooms through the stringent regulatory environment for emergency room status.) Dr. Ghurabi is a veteran ER physician who has trained many residents and fellows in emergency medicine in the United States and has a keen understanding of all ER trends within California and the nation. In an interview, Dr. Ghurabi provided his perspective on what is happening across the country with urgent care and freestanding ERs.

Urgent Care

Dr. Ghurabi explained that urgent care centers are open usually from 8 a.m. until 10 p.m. (California urgent care clinics cannot keep patients over 23 and a half hours in the facility.) Typically, urgent care centers charge at rates that are a third of the emergency department rates. A facility fee is included in the single bill for services rendered in these facilities. They can be located almost anywhere, but typically the desired location is high-traffic areas. (Because this is episodic care, the service may be needed by patients only once every few months.) The socioeconomic status of the location is less important because the goal is volume.

Urgent care centers generally offer very basic on-site diagnostic services, such as plain film X-rays and minimal laboratory services, such as point-of-care testing, with no advanced imaging such as CT or MRI. Industry estimates indicate that 20 to 24 patients per day are required to break even. The regulatory barriers are relatively low as they need only the same licenses as any medical office or clinic. In terms of hospital referrals, they’re not engaged in high-referral patterns to hospitals unless they’re tied by ownership or geography to a specific health system or hospital partner. Urgent care centers are typically staffed by primary care physicians and nurse practitioners; formal emergency medical training is not required.

Urgent care centers are well received by consumers in almost every survey I have seen: Patients greatly value the convenience, short waiting time and speedy resolution of episodic care issues. In many parts of the country, urgent care is being systematized into franchise-like offerings. The market leader Med Express (which was purchased by Optum in 2015) operates, according to its website, in 15 states and has approximately 200 urgent care centers in those states. The clinics are open 12 hours a day, seven days a week to serve consumers. A relatively low percentage (perhaps as low as 2 percent to 3 percent) of visits actually result in a hospital admission compared with the 10 percent to 30 percent of a typical hospital ER seeing patients. The key driving force behind urgent care is convenience.

Freestanding Emergency Rooms

A thoroughly researched Health Affairs article by Harvard researchers estimated that there were 400 freestanding ERs operating in 32 states by December 2015. However, more recent industry assessments put the number at over 500. The Harvard researchers identified 21 states with regulations that allowed freestanding emergency rooms while 29 states did not have regulations that applied specifically to such EDs. Only one of those states, California, specifically precludes such

Texas, Colorado, Ohio, Minnesota and Arizona are the states with the most freestanding emergency rooms per capita. Harvard researchers estimated that if the rate of penetration of these early adopter states is emulated in areas where regulations provide for them, there could be as many as 2,000 of these facilities in the near future.

There are two basic types of freestanding emergency rooms: those affiliated with hospitals that are recognized by CMS as being part of a hospital billing number and therefore can be reimbursed for a facility fee under Medicare, and those that are independent and not recognized by CMS. The latter also tend not to accept Medicaid patients because they cannot bill for the facility fee.

Nationally, according to researchers, 54 percent of all freestanding emergency rooms are hospital affiliated while 37 percent are independent. However, in Texas only 22 percent are hospital affiliated, and a full 71 percent are for profit. In Ohio virtually all the freestanding emergency rooms are hospital based. In Colorado the split is 60 percent hospital and 40 percent independent.

Dr. Ghurabi told me that, from his perspective, freestanding emergency department are fundamentally different from urgent care in that they are open 24/7, 365 days a year. And while some have no beds (as in Texas), other states require a small number (typically two to four beds) to qualify for hospital-based charges.

Most freestanding emergency departments charge standard ER rates, and payers presently pay those emergency department rates. Physicians bill a professional fee, and a facility fee is collected (usually three times the professional fee). The facility fee can be collected by the owner, which can be a professional group, a sponsoring hospital or an investor group depending who is providing the technical services. In some states, new locations require certificate of need clearance where nearby hospitals can veto freestanding emergency departments by challenging the need.

Again, as with urgent care centers, the desired location is a high-traffic area because it is episodic care. But research has shown that these freestanding emergency departments are disproportionately located in affluent communities where a high percent of privately insured patients either live or work. Because the charges are so high, they don’t need high volume and depend more on high acuity. The break-even point is a remarkably low eight to 10 patients per day. Typically they offer more advanced diagnostic equipment, including X-ray, lab and CT scanner, which can be either inside or outside the building.

Freestanding emergency departments are much more complex to license compared with urgent care, requiring medical practice committees like a hospital. Referrals from freestanding emergency departments, though again relatively infrequent compared with typical hospital ERs, are extremely attractive to the hospital since almost every admission will be a commercially insured patient. Freestanding emergency departments require staff with formal training in emergency medicine.

Texas is the hotbed of freestanding emergency rooms. Adeptus, a for-profit publicly traded corporation, is the oldest and largest provider in the freestanding emergency department business. Under its First Choice Emergency Room brand, the company has nearly 100 locations (according to its website) in Texas alone, with 52 in metro Dallas (20 of which are in partnership with Dallas health system powerhouse Texas Health Resources) and 30 in Houston, seven in San Antonio, and five in Austin. Parent company Adeptus indicates in its latest 10 Q filing with the SEC that it also has active partnerships with HCA, Concentra, Dignity Health, University of Colorado Health System and Trinity Health in addition to their joint venture with Texas Health Resources. The 10 Q filing also reveals that over 90 percent of its revenue comes from commercial patients, with Medicare and Medicaid being a tiny sliver of revenues.

These data seem to support the critique that Dr. Ghurabi and many other ER professionals make of this freestanding emergency room phenomenon: While it is obviously a business that satisfies consumers (particularly commercially insured consumers) and seems to be incredibly profitable for investors and physicians participating in such practices, it is clearly an example of cherry picking through location.

A Question of Mission

This raises some fundamental questions about the future of American health care delivery. On one hand, we want to encourage innovation in health care payment and delivery that serves consumers and patients more conveniently and makes the health care system better, faster and cheaper overall. And we should encourage and celebrate that.

But if we are developing only consumer-friendly solutions targeted at affluent consumers with good health insurance, what are the consequences for those institutions serving less affluent areas, or for those institutions with complex, quaternary care, or for research and teaching missions, or for those essential community providers who deliver trauma care, burn units, transplantation, and complex chronic disease and behavioral health services?

I think we should be careful that freestanding emergency rooms do not become a metaphor for the health system more broadly. Namely, if the best way to survive and flourish economically and to serve most consumers with convenience and high quality is to avoid the poor, the sick, the vulnerable and the infirm, such practices challenge the mission of many health systems across the country and will heighten in stark relief the tension between market forces and mission-oriented health care.


Future of Medicaid – National Association of Medicaid Directors

Tuesday, November 8th, 2016

Health care futurist and author Ian Morrison and state Medicaid professionals from Florida and Hawaii discussed the future of Medicaid.

“Looking Forward: The Future of Medicaid and the Health Care System” was a plenary session of the 2016 Fall Conference of the National Association of Medicaid Directors (NAMD). 


  • Matt Salo Executive Director National Association of Medicaid Directors
  • Justin M. Senior Deputy Secretary Florida Agency for Health Care Administration->Medicaid

The Trump Healthcare Interview

Monday, February 15th, 2016

Donald Trump is leading in the polls and could become the Republican nominee and maybe even President.  He has not been specific on healthcare.  The Healthcare Blog (THCB) asked Scottish-Canadian-Californian healthcare futurist Ian Morrison to conduct an interview with Trump, figuring that Morrison would have an in with Trump given Trump’s praise for Scottish and Canadian healthcare.  Note, this interview is a fake, but Donald Trump is real.  Think about it.

MORRISON:  Thanks for making time Mr. Trump, I was asked to interview you on healthcare because I am Scottish and your mother was a Scot.

TRUMP:  Yes she was, a beautiful person.  I love Scotland.  I own Turnberry, the best golf resort in Europe.  I built a magnificent new course near Aberdeen.  The Scots love me, I get along with the Scots.

MORRISON:  Actually, Mr. Trump, with all due respect, they think you are a bit of an asshole and were offended when you told them not to build a wind farm off shore from your new golf course because you thought it would spoil the view for your American visitors.

TRUMP: (Angrily).  Look, the problem with the Scots is they don’t win any more.  When was the last time you won…Braveheart, right?  When was that 1800 or something?


TRUMP: See. Losers for 800 years.  So don’t talk to me about the Scots winning.

MORRISON: So why did you point to Scotland and Canada as good example of healthcare.

TRUMP:  I saw it on a show. A….nd I thought that if Scotland and Canada do well…and they are both losers…then we are really bad at healthcare.  By the way, Canada are such losers we don’t even need to build a wall because they are not smart enough to come here illegally.  So I want to make America great again, and especially healthcare.

MORRISON:  So let’s turn to healthcare, you don’t like Obamacare?

TRUMP:  Let me tell you something.  Obamacare is a disaster.  The costs are going about 20, 30, 40 percent, the doctors are quitting it is a disaster, because of Obama.

MORRISON:  Mr. Trump those rate increases are what insurers asked for in some states, but reputable studies show that if consumers shop around on the exchanges they can secure a better deal. For example, in Nebraska some insurers asked for 15, 20, 30 percent rate increases but two new insurers entered the market at zero premium increases over 2015.  So isn’t it working?

TRUMP: Nebraska, do they even have a primary?   Look, everyone knows Obamacare is a disaster and we have to repeal and replace.  Everyone.  But I will do it.  I will get it done.  I will make American Healthcare great again.

MORRISON:  So you don’t think that covering 20 million uninsured people was a good idea?

TRUMP:  Look we are not going to let people die in the streets the way they are now.  So we  will repeal and replace Obamacare. Period.  And everyone will be taken care of.

MORRISON:  So you would be in favor of universal health insurance provided by the government like Bernie Sanders has proposed?

TRUMP:  I want to to debate Bernie so badly, because we would win.  Hillary is a bigger name so part of me wants her because it would be two great brands going head to head.  But Bernie, he is a socialist.  I make a lot of money.  I don’t like socialists.

MORRISON:  With all due respect Mr. Trump, you did not answer the question.  How are you going to take care of everyone after you repeal Obamacare?

TRUMP:  Look.  The way I do things I get the best people together in a room, I have a beautiful conference room at Trump Tower on 5th Avenue.  It’s a beautiful, classy room, Ivanka did it.  So I would get a few of the best people.  Not a lot,  just a few.  We’d take a day.  Figure it out.  And I’d sleep on it overnight and come up with a plan.  And then the next day we ‘d go ahead and get it done.

MORRISON:  Have you thought about who you would invite to the meeting to redesign healthcare.

TRUMP:  No I haven’t, not yet.  (Smiling)  I am kind of busy right now, running for President.  And by the way we are winning everywhere.  The polls ahead…… far ahead.

MORRISON: You lost to Senator Cruz in Iowa.

TRUMP:  No technically…We actually won because Cruz defrauded Ben’s vote.  But I am not worried about Cruz…people say he’s a pussy.  I didn’t say that.  People call him that.  I like him.  But the people they come to my rallies.  They love me.  They say these things.  “Cruz is a pussy”, and I reprimand them for saying it, but what can you do?

MORRISON:  Back to the meeting to design the replacement of Obamacare, what kinds of best people are we talking about?

TRUMP:  Look we will get to healthcare, when we are finished winning all these elections.  But let me give you some examples.  And this isn’t final.  But, I would probably invite Ben Carson, nice man.  He’s a pretty good doctor and he’s black, so he’s a twofer, so Ben for sure.  Dr. Oz he’s in New York, great brand guy, and he’s making a fortune from the vitamins.  So he would be good.  And look New York has some great hospitals like Mount Sinai and, by the way I do fundraisers for all of them. They love me.  I do these fund raisers I get my friends to donate millions.  So I would get someone from the hospitals, probably New York Presbyterian, because I’m a Presbyterian.  Which by the way goes over big in the Bible belt.  They are very religious.

MORRISON:  So Ben Carson, Dr. Oz and someone form New York Presbyterian.  Anyone else?

TRUMP:  Ivanka….she is very fit, she has a beautiful body.  By the way, I have tremendous children.  They are very healthy because like me , they don’t smoke (never have), don’t drink and they work out.  So I would get Ivanka involved.  Maybe she would run the whole thing, we’ll see.

MORRISON:  Your children are a real credit to you and your wives, Mr Trump.  But back to healthcare what will Trump healthcare look like?

TRUMP:  Look we will get the specifics out later.  But let me tell you this.  We will get rid of Obamacare, we will make America great again, and…..we will make American Healthcare great again.  It will be huge, classy, unbelievable, it will have the best people…and by the way the utilization will be very low because there will be a gigantic wall around it paid for by the Mexican government.

MORRISON: Mr. Trump, thank you.  This has been incredible.