I thought Amazon Care would work

By John League, Managing Director, Digital Health Research

Non-health care companies are getting into care delivery not because they think it will be easy, but because getting care can be so hard. There's an opportunity to amplify existing expertise by building streamlined digital experiences and connecting that to a health care service.

Amazon had all the pieces to make that a success. They had the digital platform. They provided quick access to a provider. They could serve patients anywhere in the U.S., and in some markets, they could even connect you to in-home care. Just after Amazon announced they would buy One Medical, however, they shared they would shut down Amazon Care. The market simply didn't want the product.

Why I was wrong about Amazon Care

There were probably some product-specific reasons Amazon Care didn't last. Employers, who were the primary customers for the service, didn't seem to think the offering was comprehensive enough. It may not have generated the cost savings they were expecting. Perhaps consumers weren't ready to accept an Amazon-branded health care delivery product. It's one thing for Amazon to send me my prescription, but it's something else entirely for Amazon to be my doctor.

But I think the real reason Amazon Care didn't work is because of a fundamental misunderstanding of what led people to try telehealth. Don't get me wrong: telehealth is quality care, and it doesn't drive up unnecessary utilization. Consumers are overwhelmingly positive about the care they receive via telehealth, and they say they want to continue to use it—even though most of them may never have tried it if not for Covid-19.

And that's the challenge: there is no forcing function for consumers, patients, employees, and plan members to try virtual-first care in the same way that Covid-19 forced them to try telehealth. Amazon's pivot from Amazon Care to One Medical, a hybrid, digitally-enabled practice that allows members flexibility of both telehealth and in-person visits, indicates that they too realized the value of offering both options.

I thought hospital volumes would easily rebound

By Vidal Seegobin, Managing Director, Health system research

2022 was supposed to be a better year for health systems. We had a workable set of vaccines, life was returning to normal, and unaddressed health issues during the start of the pandemic needed treatment. Despite some early chatter of recession, I thought there was going to be a dramatic snapback in inpatient demand. It turns out, that wasn't the case.

Why I was wrong about hospital volume recovery

Not many could have predicted the omicron variant's impact on hospital demand. While we knew that the virus would continue to mutate and potentially invade our immune systems, I don't think we appreciated its impact on staff absenteeism. Hospitals that aren't staffed can't deliver care—that had a huge impact on health systems' volume recovery. 

There are two glaring omissions I should have accounted for:

1. The pathway to the inpatient bed is being disrupted—structurally.

The site-of-care is shifting to the outpatient and ambulatory settings. A myriad of virtual options are now directly available to consumers. And that is coupled with a persistent (and somewhat strange) decline in diagnostics and screening. Not all roads lead to the hospital anymore.

2. Discharge bottlenecks are limiting hospitals.

For several years, systems in continental Europe have struggled to effectively discharge patients because of staffing and bed limitations. I should have known this phenomenon could happen in the U.S. too. These bottlenecks have an upstream effect on hospital length of stay—meaning we can't treat as many patients. In addition, post-acute staffing has been under duress both because of Covid-19 infections and the war on talent.

My volume prediction error renewed my appreciation for the complex interplay of productivity, throughput, and demand. We need to think about these things collectively and interpedently. For the health system C-suite, your operations story is your staffing story, is your growth story.

I thought incumbent providers could lead primary care transformation

By Rachel Woods, Managing Director, Research and host of Radio Advisory Podcast

In January 2020, I spent lots of time talking to medical groups and health systems about why they needed to transform primary care. Driven by third-party disrupters, leaders realized they needed to move away from the traditional one-size-fits-all primary care and towards more scoped services targeted at specific populations. In fact, a physician boldly asked me and their peers if primary care as we know it was dead. I published my thoughts on that very question on March 4 2020, mere days before those same physician leaders would be overwhelmed by Covid-19.

The pandemic demanded innovation—and incumbent leaders rose to the occasion. Providers stood up telehealth platforms, implemented hybrid work and care models, and autonomously deployed APPs. While it may have been forced upon them by a very different kind of disruptor, medical groups and health systems showed enormous flexibility for when, where, and how care was delivered. It may not have felt like it at the time, but incumbents had a competitive advantage, and they started operationalizing a very different kind of primary care model. 

Why I was wrong about who would lead primary care transformation

As time went on, incumbents went from leading the charge to retreating to old ways (in their defense, the number of crises on their plate hasn't exactly slowed down). As a result, telehealth volumes diminished, and leaders narrowly focused on "the video visit" rather than on how technology could expand capacity and meet rising demands for patient access. The flexibility that incumbents had during Covid-19 is slowly receding. This, combined with the same heavy administrative burdens they experienced pre-pandemic, is resulting in provider burnout.

In many ways, incumbents squandered their lead. Primary care transformation continues, however. We have new providers with new models that have proven successful (and often, profitable). Patients, providers, and clinicians have flocked to these new models, which offer improved experiences. It's no wonder we've seen competition in primary care skyrocketing. More and more third parties are throwing their hat in the ring including private equity backed groups, payviders, Amazon,  Walgreens, and more.

I still have hope for incumbent providers. They have the physicians, the care teams, the patient relationships, and the community trust to truly transform primary care. But to do that, they must put their foot back on the gas.

I thought post-acute partnerships would be on the back burner

Monica Westhead, Managing Director, Post-acute Care Research

In the decade-plus I've studied post-acute care, I've seen health systems' motivation to develop and maintain close partnerships with post-acute providers wax and wane. Historically, it has taken something major—the introduction of the HRRP or bundled payments—to drive hospital interest in aligning more closely with post-acute care. This is because traditional incentives don't make collaboration with post-acute providers a priority. It takes dedicated investment and time to maintain a post-acute network, which is often spent on other hospital priorities that drive growth.

Frankly, I thought post-acute partnerships would be the last thing on health systems' minds in the aftermath of Covid-19's impact on the delivery system. They're focused on the most urgent problems—and as long as the skilled nursing facility (SNF) is there to take patients, there's no problem.

Except now, in many markets, the SNF isn't there to take patients. 

Why I was wrong about post-acute partnerships

The staffing shortage impacting all of health care has hit post-acute care hardest.  Even as other care settings have recovered, most post-acute settings—SNFs in particular—remain below pre-pandemic staffing levels. This limits post-acute providers' ability to intake patients and to maintain full capacity. And that's just the SNFs that continue to operate. Between staffing costs, supply costs, and changing payer mix that results in lower overall reimbursement, SNF closures are concerningly common.

When SNFs are at capacity or otherwise unavailable, it hits health systems where it hurts—in throughput. If a hospital can't discharge a patient to a post-acute setting, that patient remains in the hospital bed, meaning that someone from the emergency department can't be admitted to that bed. It causes backups throughout the delivery system, negatively impacting health systems' operations, causing staff and patient frustration, and harming the hospital's bottom line.

This backlog drives increased interest in partnering with post-acute providers and developing solid post-discharge care strategies. I didn't think hospitals would focus here, because I thought there was urgency regaining other aspects of hospital financial health. But in a time of shortage, supporting and collaborating with post-acute providers is critical to hospitals' financial health.

I thought I knew what the workforce crisis meant for non-health systems

By Solomon Banjo, Managing Director, Life Sciences Research

It was clear to me in January 2022 that the workforce crisis had implications beyond the four walls of the hospital. The conversations I was having with life sciences and health system clients centered around the budgetary impact of the crisis. What more was there to say on the topic other than 1) health systems will have less money to invest in other areas and 2) there might be an incumbency bias for products and vendors as health system leaders wonder if it's worth using their limited social capital to advocate for change? Turns out, a lot.

Why I was wrong about the workforce crisis's impact

There were three factors that led me to miss the broader implications until recently. First, I was viewing this problem as primarily a supply and demand issue tied to broader economic factors. Second, I thought that this was one area where a return to pre-pandemic status quo was not only possible but desirable. Third, I was looking at the wrong data. I was focused on data around costs and vacancy rates and less focused on data around demographic shifts and attitudes towards desirable employment.

While speaking with Carol Boston-Fleischhauer, Advisory Board's Chief Nursing Officer, she brought up the Experience-Complexity gap—a lightbulb moment for me. This is pre-Covid research that Advisory Board had done outlining many of the structural fissures Covid-19 would exacerbate. In a nutshell, it's the concept that patient care is becoming more complex to deliver while nursing is undergoing a demographic transformation as experienced nurses retire. I have personally presented this research to at least a thousand nurses and nursing leaders globally, yet I had not thought to ask myself what role health system partners should play in addressing what Carol now describes as a chasm, not merely a gap. There needs to be a re-orientation to the structural nature of this challenge and an appreciation of the time it will take for us to shift from crisis staffing to a sustainable model.

I thought physician turnover told the entire story

Eliza Dailey, Consultant, Physician & Ambulatory Research

I've tracked physician turnover closely this year. And for most of the year, I anxiously awaited data from 2021 (there's often a lag in benchmarking). I thought 2021 turnover numbers would answer the question on all our minds: What was the pandemic's impact on our doctors? Historical trends reveal that median physician turnover has hovered at 6-7% since 2016—even during the height of the pandemic in 2020. So, back in March, we went out on a limb and predicted that we wouldn't see a Great Resignation of physicians, that historical trend would continue as is. And, we were right: We just reported that 2021 median physician turnover was 7%, yet again.

But by overly focusing on turnover, we failed to consider a holistic picture of the physician workforce. 7% turnover indicated that things were stable—but that couldn't be further from the truth. 

Why I was wrong about physician turnover

There are some concerning trends, other than steady turnover, that should set off alarm bells for the entire industry:

• Burnout: Depending on the source, between 47% to 63% of physicians report feeling burned out. While the pandemic exacerbated these numbers, many physicians were burned out well before Covid-19.

• Intent to leave: For the past ten years, about half of doctors, ranging anywhere from 44% to 54%, have considered a major career change, such as retiring early, switching employers, or leaving medicine altogether.

• Looming retirement: In 2019, 44.9% of active physicians were 55 or older, meaning that almost half of doctors will age of the workforce across the next ten years. This number is the one that alarms me the most because we aren't training and graduating enough doctors to fill this critical gap.

Our physician workforce is on shaky ground that isn't fully captured by the absence of elevated turnover. With this in mind, I'd urge all provider executives to do two things:

1. Measure some, if not all, of the above metrics to get an accurate diagnosis of your physician workforce. Don't just look at median turnover alone. Stable turnover paints an incomplete and misleading picture.

2. Address the root causes of burnout, intent to leave, and looming retirement.

While it's easy to blame the pandemic (and it sure didn't help), these problems were set in motion long ago and won't go away as Covid-19 recedes. We must address an aging physician workforce and unsustainable practice of medicine if we’re going to make real progress on these challenges.