Insights

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THMA-Tegria research surveyed senior health system executives and interviewed Chief Financial Officers to understand how systems are defining, governing, and investing in access strategy. The headline finding: 82% now call access a strategic pillar, but most still can't solve basic appointment availability.

In this episode, Wes Adams, Managing Director of Industry Custom Services at THMA, walks us through where the alignment breaks down — from "priority fog" across the C-suite, to the fact that only 6% of systems involve finance in operationalizing access, to how tightening ROI timelines are reshaping where capital flows and where it doesn't.

Resources mentioned in this episode:

• The Access-Driven Enterprise report from THMA and Tegria

• THMA-Tegria webinar featuring executives from Emory, Sutter, and IU Health

• Access as a Strategic Product case studies and webinar

• Secret Shopping research webinars on urgent care and primary and specialty care access benchmarking

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• In its annual update to the OPPS payment rule, CMS is proposing a significant reimbursement cut for 340B-acquired drugs. Because the changes are budget neutral, for-profit health systems and hospitals with low 340B uptake could see a boost to their payments.

  • Unlike a similar effort in 2018, this proposed cut might survive legal challenges because the Trump administration recently undertook a survey of hospital drug acquisition costs.

  • The proposed rule also includes site-neutral reform for imaging services.

• Sen. Bill Cassidy unveiled draft legislation that would reform the 340B drug discount program by letting drug manufacturers choose whether they want to offer providers upfront discounts or rebates. Providers can opt for a different payment mechanism if they voluntarily pass all 340B savings on to patients.

  • The draft is intended to solicit industry feedback and is not immediately headed through the committee markup process. The proposal’s chances to pass this year are somewhat limited with slim congressional majorities in a midterm election year.

  • Restrictions on eligible prescriptions, contract pharmacies, and out-of-pocket costs would reduce the savings that health systems realize under 340B, and new data reporting requirements could increase scrutiny by the media and policymakers.

• Optum is negotiating with several New York health systems to sell orthopedic, general surgery, and urology practices attached to Optum Medical Care and Crystal Run Healthcare.

  • Optum is effectively unbundling Crystal Run, not retreating from the market entirely.

  • Optum is keeping control of the primary care panels, and UnitedHealthcare controls benefit design above them. Once these specialty practices leave that ecosystem, United might steer these volumes to lower-priced providers.

• This week’s featured graphic comes from a new JAMA study showing that patient messages to providers have steadily continued to increase since the pandemic.

  • Female patients, patients between the ages of 40 to 64, and patients in affluent neighborhoods were the most likely to send messages to providers.

  • The trend is worth watching because inbox fatigue is a major driver of burnout and turnover among physicians.

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• The House Appropriations Committee voted unanimously to bar CMS from funding WISeR, its AI-enabled prior authorization pilot for traditional Medicare. But the model is still running in all six pilot states, and an identical defunding effort died last year. 

  • While the defunding vote is meaningful, it’s unclear if the funding bill that the provision is attached to will become law. Other legislative efforts to stop the program via the Congressional Review Act are more likely to succeed. 

• Eli Lilly has followed through on threats to cut off 340B discount pricing for certain hospitals that won’t submit their underlying claims data, but the list of impacted providers is not public. 

  • The drugmaker is targeting large health systems first, possibly to maximize publicity while limiting the impact on smaller and rural providers that garner more sympathy from policymakers. 

  • AHA proposed a compromise that would create a federally-run clearinghouse for 340B data, but the idea hasn’t gained traction with Eli Lilly or HRSA. The federal agency’s efforts are likely focused instead on standing back up its proposed rebate pilot program that was halted by a federal court ruling in late December. 

• This week’s edition takes a special look at Nebraska Medicine’s National Quarantine Unit, which was recently used to monitor Americans exposed to hantavirus in a widely publicized cruise ship outbreak. 

  • While the unit has also been used to handle patients exposed to Ebola and COVID, it went for nearly a decade without patients when it was first established in 2005. The program maintained executive support by reframing itself as a business continuity and workforce protection effort, not pandemic preparedness. 

  • Nebraska Medicine’s experts work with other systems to assess their capabilities and right-size their preparedness rather than replicate the unit.  

• A new HHS OIG report found that the three largest Medicare Advantage insurers—UnitedHealth, Humana, and CVS Health—deny post-acute prior authorization requests far more often than peers. 

  • CMS declined to commit to the report’s recommendations and has shown little appetite for heavy-handed regulation. On the other hand, the report could provide valuable evidence for an ongoing class-action lawsuit against UnitedHealth and bolster the case to lawmakers for reform.  

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• CMS is proposing broader caps on Medicaid state-directed payments—significantly broader than those outlined in last year’s budget reconciliation legislation—which would reduce federal healthcare spending by $510B over ten years.

  • The proposal would increase the financial impact of H.R. 1 (also known as OBBBA) by roughly one-third, forcing health systems to accelerate strategic plans to fill the financial hole with outpatient growth, AI savings, and other internal transformations.

  • Democratic lawmakers could try to reverse the cuts if they take control of Congress after the midterms, but advocacy efforts might be better targeted at the state level.

• Discussions at a recent THMA forum showcased how chief physician executives are among strategy leaders' strongest allies for growth, but the issues they surface are architectural, not behavioral—requiring redesigning organizational structures rather than changing individual behavior.

  • Access stalls because compensation models reward keeping low-acuity patients on specialist schedules. Transforming the care model with greater APP reliance requires changing the comp model alongside it.

  • AI governance lags the pace of deployment because it was built to manage risk, not capture value. The fastest systems separate clinical AI (which needs rigorous review) from administrative AI (a faster lane).

  • Physician well-being is an organizational design problem deserving a dedicated C-suite owner. Efficiency gains can backfire unless there’s a clear answer for how recaptured physician time will be used.

• This week’s featured graphic shows that the U.S. graduates 8.6 medical students for every 100,000 people—far below the OECD average of nearly 15.

  • A Commonwealth Fund report ties the gap to two upstream constraints: the highest medical tuition fees of any country in the analysis, and limited residency training positions.

• Eli Lilly is threatening to cut off 340B discounts for hospitals that won't share claims data. Health systems that comply could face significant administrative burden while regulators stay on the sidelines.

  • Lilly says roughly 1,000 hospitals have refused while more than 2,300 have complied, and it is starting enforcement with the largest non-responders.

  • The data could let manufacturers eliminate duplicate discounts, quantify hospitals' contract-pharmacy spread, build the empirical case for narrowing 340B, and gain demand intelligence on high-value drugs.

  • HRSA has so far declined to block the policy despite AHA pressure to declare the policy unlawful.

• A federal judge's ruling for Clover Health—ordering CMS to recalculate its MA star rating after finding 20 measures were improperly included—reframes a routine scoring dispute as a challenge to CMS's authority over how Medicare Advantage quality is measured.

  • If the reasoning survives appeal, it could force the program to drop measures CMS still relies on, creating exposure for health systems running provider-sponsored health plans.

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