Welcome to The Compass, a weekly exploration of data stories and The Washington Compass, 
a bi-weekly analysis of health policy developments impacting the $4T health economy from Trilliant's SVP, Market Strategy and Chief Research Officer, Sanjula Jain, PhD. 


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Narrowing Primary Care Gap Requires Predicting Demand and Consumer Behavior
Sanjula Jain, Ph.D., November 21, 2021

According to the Association of American Medical Colleges’ (AAMC) most recent Physician Workforce Projections, the primary care physician (PCP) shortage is projected to reach between 17,800 – 48,000 physicians by 2034. The reasons that the current supply of physicians is unable to meet demand for primary care services could be attributed to several factors, such as inefficiency, physician preference (e.g., location, practice hours), and geographic mismatch of supply and demand. Other contributing factors include primary care entrants (e.g., One Medical, Tia) and retail players (e.g., CVS, Walgreens, Walmart), which are leveraging allied health professionals to deliver primary care services.

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Vast Majority of Benefit-Eligible Veterans Obtain Care Outside of the Veterans Health Administration

Sanjula Jain, Ph.D., November 17, 2021

Last week, America celebrated Veterans Day, and we join in honoring the selfless service of all of those who have ever served in the United States military.

Much has been written about the challenges of the Veterans Health Administration (VHA), from patient safety, provider staffing, health record management, and administrative efficiency. Moreover, there has not been a Senate-confirmed Under Secretary of Veterans Affairs for Health since 2018. However, given renewed priorities, the Department of Veterans Affairs (VA) has recently assembled a commission to recommend candidates to lead the VHA.

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Health Systems in Competitive Markets Associated with High Percentage of Splitters
Sanjula Jain, Ph.D., November 14, 2021

In our most recent analysis examining consumer loyalty to provider networks, we found that most health systems do not achieve strong consumer loyalty. Of the health systems included in our analysis, no system delivered inpatient care to more than 21% of the consumers in their primary market. In addition, overall consumer loyalty ranged from 42% to 70.8% among the systems in our analysis.

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Most Health Systems Lack Strong Consumer Loyalty
Sanjula Jain, Ph.D., November 7, 2021

It is a commonly held misconception that patients, who are consumers, are loyal to their provider. The reality, however, is that healthcare consumers "split" where they receive care across an average of 4.2 provider networks. Contextualized differently, U.S. healthcare consumers are 60% loyal to consuming services within a single provider brand or network.

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The Data Behind Z Codes for Social Determinants of Health

Sanjula Jain, Ph.D., November 3, 2021

It is well established that social determinants of health (SDOH) drive 80% of health outcomes, particularly for identifying barriers to care, determining necessary social care, and both financing and facilitating delivery of appropriate resources. Even so, SDOH-specific Z codes, which are poised to address this gap in care have been underutilized, primarily because of administrative burden and lack of provider awareness. Reducing disparity in health equity is hindered by the disparate and inconsistent use of SDOH-related Z codes across markets.

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High Proportion of Behavioral Health Services Rendered by Primary Care Providers Underscores Lack of Sufficient Specialized Supply
Sanjula Jain, Ph.D., October 31, 2021

In our most recent analysis, we examined the most common diagnoses driving behavioral health demand and projected national inpatient demand to grow annually by 0.7% through 2029. We found that demand for behavioral services varies both geographically and by age. Specifically, inpatient behavioral health demand is projected to change across age groups in terms of compound annual growth: 0-24 (1.0%), 25-44 (1.0%), 45-64 (-0.5%) 65-84 (2.0%), and 85+ (-0.75%).

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Appropriately Matching Supply to Projected Behavioral Health Demand Requires Localized Analysis
Sanjula Jain, Ph.D., October 24, 2021

It is well documented that the current supply of behavioral health providers does not meet current or projected demand for services. The provider shortage is further compounded by COVID-19’s exacerbation of many conditions, with anxiety and depression in U.S. adults alone having increased four times that of pre-pandemic levels. Additionally, mental health status has worsened for over 20% of school-aged children in the U.S since the onset of the pandemic.

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Telehealth As a Substitute Good for Expanding Access is Contingent on Beneficiary Attributes

Sanjula Jain, Ph.D., October 20, 2021

In the last issue of The Washington Compass, we explored the question of whether telehealth might substitute for or supplement Medicaid non-emergency medical transportation (NEMT) benefits. While the number of Medicaid patients utilizing NEMT services declined and telehealth utilization temporarily increased following the onset of the COVID-19 pandemic, a small proportion of beneficiaries that used NEMT prior to the pandemic substituted or supplemented these services with telehealth, suggesting that telehealth and NEMT are fundamentally different access-enabling benefits.

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Maximizing Record Investments in Women's Health Requires an Understanding of Regional Demand
Sanjula Jain, Ph.D., October 17, 2021

Women typically utilize more healthcare services than men according to the U.S. Department of Labor and make approximately 80% of the healthcare decisions for their families. Yet, women are slightly less loyal to provider networks than men, a trend that will continue as women have even more options.

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Variation in Downstream Share of Care Suggests Need for Greater Care Coordination Across Access Points
Sanjula Jain, Ph.D., October 10, 2021

The most important question for a health system to consider is whether its goal is to be in the hospital business, or rather to be in the healthcare delivery business. Offering integrated and accessible healthcare entry points can foster consumer loyalty, coordinated care, and improved health outcomes.

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Telehealth as a Substitute Good for Medicaid Beneficiaries

Sanjula Jain, Ph.D., October 6, 2021

As a health economist, I am interested in the ways in which certain medical services constitute a “substitute good” for other medical services, particularly in the context of access, cost and quality. Non-emergency medical transportation (NEMT) benefits have been recognized as a critical component to expand care access for patients with complex health and social needs. The growing number of ride-sharing company partnerships continues to expand NEMT options for eligible beneficiaries. The Medicaid-funded benefit was further codified by Congress into federal statute under the Consolidated Appropriations Act of 2021, nullifying former proposals that sought to change NEMT from a mandatory to an optional Medicaid benefit. However, because Medicaid is managed at the state level, there is significant variability in the eligibility for, financing of, and delivery of NEMT benefits. 

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Retailers’ Relatively Lower Prices and Brand Loyalty Will Disrupt the Urgent Care Market
Sanjula Jain, Ph.D., October 3, 2021

In the post-pandemic health economy, population growth in the Sunbelt will outpace other markets, with five of the fifteen fastest growing CBSAs in Florida and Texas. For example, the Austin-Round Rock-San Marcos, TX and Orlando-Kissimmee-Sanford, FL CBSAs are projected to see compound annual population growth of more than triple (2.2%) and double (1.7%) that of the average U.S. growth rate (0.7%) between 2021 and 2029. States with growing populations will experience significant changes in the behavioral profiles and preferences of its residents, subsequently influencing consumer demand for healthcare services.  

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Psychographic Mix of the Healthcare Workforce May Guide Strategies for Nursing Shortage Mitigation
Sanjula Jain, Ph.D., September 26, 2021

Earlier this month, the American Nurses Association wrote a letter to HHS requesting immediate action to address the current U.S. nurse staffing shortage. Burnout stemming from patient care during the COVID-19 pandemic has been attributed as the primary factor for this shortage, as nurses and other hospital staff quit, retire, or seek employment elsewhere. To compound this shortage, many health systems and at least 23 states have announced COVID-19 vaccination requirements for healthcare workers. In addition, CMS has expanded an emergency regulation to require all staff of Medicare- and Medicaid-certified facilities to be vaccinated against COVID-19. Vaccine-hesitant staff may be more inclined to leave their post in response to these health system, state, and national vaccine mandates.

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Characteristics of Medicare Beneficiaries Utilizing Audio-Only vs. Other Telehealth May Influence Future Coverage and Reimbursement Permanence

Sanjula Jain, Ph.D., September 22, 2021

Utilization of telehealth before the COVID-19 pandemic was low for traditional fee-for-service (FFS) Medicare beneficiaries given stringent requirements (e.g., geography, originating site, service type, and modality). In response to the pandemic, HHS waived many of these restrictions for traditional Medicare beneficiaries for the duration of the declared public health emergency (PHE). 

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Amazon’s Expanding Healthcare Footprint Uniquely Positioned to Meet Consumer Preferences in New Markets
Sanjula Jain, Ph.D., September 19, 2021

Traditional healthcare providers (e.g., hospitals and health systems) are facing growing competition from new entrants, namely retail brands such as Walmart and Amazon. Although healthcare was not the founding pillar of these companies, their low unit prices and strong consumer loyalty uniquely position them to succeed in the post-pandemic health economy. 

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Seemingly Similar Markets are Dissimilar in Projected Demand
Sanjula Jain, Ph.D., September 12, 2021

The notion of benchmarking organizations against others has become a mainstay in healthcare, especially among hospitals and health systems. As an industry, we have become accustomed to leveraging quality scores and external rankings relative to any number of methodologies from U.S. News & World Report and The Leapfrog Group to CMS’ Star Ratings and Hospital Compare, to name a few.

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he Government’s Role as the Largest Payer of Healthcare Services is Growing

Sanjula Jain, Ph.D., September 8, 2021

With nearly half of all Americans covered by Medicare or Medicaid, the U.S. government is and will continue to be the single largest payer (and regulator) of healthcare services. As of March 2021, more than 82M Americans were covered by Medicaid or the Children’s Health Insurance Plan (CHIP), representing a 20M increase from average 2019 enrollment levels. Coverage shifts due to unemployment during the COVID-19 pandemic were a contributing factor to this spike in enrollment. Additionally, enrollment in either traditional Medicare or Medicare Advantage totaled almost 63M as of July 2020, a figure that is only projected to increase as the Baby Boomers continue to age into Medicare.

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Variation in Intra-Market Demand Demonstrates How Local Healthcare Really Is
Sanjula Jain, Ph.D., August 29, 2021

As discussed in prior research, burden of disease is not directly correlated to demand for healthcare services. No two health systems, markets, or facilities will experience the same demand curve, irrespective of a general increase in burden of disease at the national level. Accurately predicting demand requires analyzing the nuances of both consumer characteristics, such as demographics and psychographics, and care trends, such as incidence rates, within a given market.

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Downstream Share of Care from Telehealth Does Not Suggest Strong Consumer Loyalty
Sanjula Jain, Ph.D., August 22, 2021

The recent growth in telehealth utilization is largely attributable to the law of small numbers, with utilization already beginning to taper. These trends are reinforced by quarterly reports from publicly traded telehealth companies, which is further reason to evaluate the notion that telehealth is a “digital front door.” 

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Analyzing the Psychographic Distribution of a Locality Allows for More Targeted Vaccine Messaging Strategies
Sanjula Jain, Ph.D., August 15, 2021

Following the authorization of COVID-19 vaccines, experts have examined the characteristics of regions with low rates of vaccination. Much has been published on the reasons why individuals are delaying or foregoing vaccination, with concerns ranging from the timing of vaccine development and pending FDA approval to perceived safety.

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Women are Less Loyal to Provider Networks than Men
Sanjula Jain, Ph.D., August 8, 2021

Women typically utilize more healthcare services than men according to the U.S. Department of Labor and make approximately 80% of the healthcare decisions for their families. As a result, it is commonly believed that if providers win the heart of Mom, they win the family.

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The Unintended Consequences of the Stark Law on Health System Strategy
Hal Andrews, August 1, 2021

Most health system executives, and all health system attorneys, understand the importance of compliance with the Stark Law.

What most C-suite executives fail to realize is the pernicious effect of a law about physician compensation on strategic planning. The late Michael Sachs skillfully leveraged the Stark Law definition of a “market" into a franchise, creating a model of demand whose key variable was a list of ZIP Codes applied to a constant of national demand. I know, because I bought that report from HCIA-Sachs/Solucient/Truven dozens of times in the 1990s and early 2000s. Only later did I realize that I was buying the same answer every time.

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Specialists are More Loyal Than Primary Care Physicians 
Sanjula Jain, Ph.D., July 25, 2021

As posed most recently, health system executives must ask themselves “is our goal to be in the hospital business, or rather to be in the healthcare delivery business?”

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AAMC’s Projections Confirm Declining Growth in Demand 
Sanjula Jain, Ph.D., July 18, 2021

Last week, we shared our forecasts for the average rate of growth for surgical services year over year through 2029. With demand for healthcare services projected to be flat to declining, inevitably the next question becomes whether physician supply matches that demand.

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Burden of Disease ≠ Demand for Healthcare Services
Sanjula Jain, Ph.D., July 11, 2021

For decades, our industry has operated under the assumption that burden of disease is directly correlated to demand for healthcare services. Yet, analysis of both national and market-level data reveals fallacies in this widely held belief.   

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Figure2.Medicaid Birth Rates

Competition for Commercially Insured Share of Care is Intensifying
Sanjula Jain, Ph.D., June 27, 2021

Last week, CMS released its latest Medicaid enrollment numbers reporting a record number of enrollees during the pandemic. An additional 9.7M individuals enrolled in Medicaid from February 2020 to January 2021 totaling approximately 73.8M Medicaid beneficiaries at the beginning of 2021. The projected growth in the nation’s safety net program compounded by more Baby Boomers aging into Medicare will significantly reduce the share of patients covered by commercial insurance.

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Leading Consumer Brands are Best Positioned to Meet Consumer Preferences for Omni-Channel Care Delivery 
Sanjula Jain, Ph.D., June 20, 2021

In the aftermath of telehealth volumes spiking during the pandemic, a number of established companies have entered the market, joining early market entrants such as Teladoc and Amwell. The net effect, as previously written, is telehealth supply is already exceeding consumer demand.

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REPORT // 2021 Trends Defining the Post-Pandemic Health Economy 
Sanjula Jain, Ph.D., June 16, 2021

The health economy creates more data than any other part of the economy. As an industry we are prone to gather and analyze data in silos, make decisions using data that is more “directionally correct” than statistically valid, and extrapolate trends that may be true of only 10% of the population to 100% of the population.

Anchored in trends that are grounded in facts about the past and sophisticated machine learning models about the future, the inaugural 2021 Trends Shaping the Health Economy Report intends to offer all of us in the industry a foundational framework for decision making.

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Sneak Peek: 2021 Trends Defining the Post-Pandemic Health Economy 
Sanjula Jain, Ph.D., June 13, 2021

Data without context is just noise, but data as a story is insight that enables action. It seems every few weeks there is a new headline trend - whether it be MedPAC’s latest payment rate update, the AAMC’s physician shortage estimates, Rock Health’s report on digital health investments, or McKinsey’s survey of consumer preferences for virtual care, to name a few. While I always enjoy digging into the richness of those data, the challenge is discerning what each discrete finding means in the context of where trends are headed at the health economy level.

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FIGURE 1 - Number of Brands Affiliated with Consumers by Industry_v2

Patients are Consumers, and Consumers are not Loyal: An Overview of Loyalty in Healthcare vs. Other Industries
Sanjula Jain, Ph.D., June 6, 2021

Underlying many executive leadership and board discussions over the last few years has been the core question of “how can we be more consumer focused as an organization?” Every stakeholder from health systems to pharma companies is enacting strategies to shift our historically physician-centric healthcare system to one that is built around the individual.

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FIGURE 2_Telehealth Users by Gender and Age_FINAL

Post-Pandemic Telehealth Supply Exceeds Consumer Demand  
Sanjula Jain, Ph.D., May 23, 2021

It is no secret that telehealth utilization increased exponentially in the past year. Several researchers have attempted to quantify and characterize the magnitude of the telehealth spike, each leveraging a different calculation methodology. In our analysis of all-payer claims, we observe a 1015% increase in telehealth visits at the peak of the pandemic. As a result of the unprecedented increase in demand, we’ve seen health systems, payers, employers, and Wall Street financiers aggressively pursue telehealth expansion strategies based on (1) a belief that crisis accelerates existing trends, and (2) surveys indicating that both physicians and individuals who used telehealth during the pandemic are more likely to continue to use it.

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Percent Deviation from the Average-2

Demographics ≠ Consumer Loyalty  
Sanjula Jain, Ph.D., May 16, 2021

As consumer choice increases with the increase in provider supply, consumers will increasingly "split" their healthcare consumption across a number of brands. Healthcare providers that understand the psychology underlying the consumer’s decision-making process will be better positioned to earn the loyalty of healthcare consumers with abundant choices.

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As Supply Increases, Consumer Loyalty is at Risk
Sanjula Jain, Ph.D., May 9, 2021

In this week's debut issue, we introduce the health economy framework and examine the impact of growing provider supply on consumer loyalty. The finding: Even though loyalty varies by CBSA, by in large, earning the consumer's share of care is going to become a lot more challenging.

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