The decade in healthcare: 12 milestones we won't forget

"Nobody has healthcare figured out."

It's a line spoken often in the Becker's Healthcare newsroom and encouragement for our reporters to ask the next question, talk to more people, find a new perspective and explore the bigger picture.

It's also a reminder to be ambitious yet humble, both of which we are in presenting this compilation of milestones as definitive of healthcare in the 2010s.

After a decade following the industry nationwide — especially from the perspective of hospitals, health systems and surgery centers — we know only three things for sure.

One: Progress is never made in a straight line. New policies can intensify political partisanship. Innovations can solve problems while causing new complications. Even diseases we eliminated as a nation return. Nothing we deem a milestone here is considered a win or a loss. In 10 years, we saw healthcare take steps forward, backward and sideways. These events, trends and forces were all part of that inimitable dance.

Two: Healthcare contains multitudes. It accounts for nearly 20 percent of our country's GDP, is a top policy issue for U.S. voters and is one of the fastest-growing industries for jobs. Beyond the civic and economic statistics, healthcare is wildly, vividly human and personal. We're all patients. Hospitals are home to some of our highest highs, lowest lows and the mundane moments in between. Conversations without costs easily veer theoretical: It's easy to say how healthcare dollars should be spent until it's your loved one's care or medication in question. At times, it seems the only way to define healthcare is with an armful of contradictions: lifesaving, flawed, slow, urgent, redundant, necessary, broken, hopeful, expensive, heartbreaking, inspiring. 

And three: We're grateful to write about healthcare and its complexities, to have covered so many events, people and things that left their mark on the last 10 years. It's with humility and high regard that we present a dozen milestones as those we won't soon forget in an industry nearly impossible to summarize.

 

The ACA

By Brian Zimmerman, Kelly Gooch and Laura Dyrda

The last decade in healthcare was defined by the Patient Protection and Affordable Care Act, the most monumental change in U.S. healthcare policy since the passage of Medicaid and Medicare in 1965. Signed into law on March 23, 2010, the ACA made sweeping changes to the healthcare industry, notably through the health insurance mandate and Medicaid expansion. 

As a cornerstone of President Barack Obama's administration, the ACA faced challenges almost immediately and was plagued by them for the rest of the decade. Republicans in Congress had attempted to repeal, modify or curb the ACA more than 70 times by 2017. Below is a timeline of significant events:

March 2010 — The ACA is signed into law.

June 2012 — The Supreme Court rules Medicaid expansion under the ACA is optional for states; the Supreme Court also upholds the individual mandate. 

March 2016 — HHS announces that an estimated 20 million people have gained health insurance coverage under the ACA in the six years since the law's passage.

July 2017 — The GOP's "skinny" repeal bill is rejected in a deciding vote by Sen. John McCain, R-Ariz.

July 2019 — The 5th Circuit Court of Appeals hears oral arguments to review a lower court's ruling that found the ACA unconstitutional. The case could end up in the Supreme Court. 

Dec. 16, 2019 — Congressional negotiators reach a $1.37 trillion spending agreement, which would repeal the ACA's "Cadillac" tax on lucrative benefit packages, health insurer tax and medical device tax. 

Dec. 18, 2019 — The 5th Circuit Court of Appeals rules that the ACA's individual mandate is unconstitutional, but leaves the lower court to decide whether the ruling invalidates the entire law. 

The ACA remains the law of the land but has been significantly weakened since President Donald Trump took office in January 2017. With another election cycle in 2020 and neither top Democrats nor Republicans willing to support it, the ACA may be on life support. But the most popular aspects of it, including coverage for individuals with preexisting conditions and allowing children to stay on their parents' insurance plans through the age of 26, will likely be its legacy.

 

The opioid epidemic

By Angie Stewart, Mackenzie Bean and Andrea Park

The opioid epidemic is one of the country's most significant U.S. public health issues in the last decade, largely spurred by the healthcare industry's overprescription of pain pills.

The FDA took clear, yet ineffective, action in 2010, approving an "abuse-deterrent" formulation of OxyContin in the wake of manufacturer Purdue Pharma's admission that the opioid wasn't as safe as advertised. But abuse remained a major problem, and the Drug Enforcement Administration sought to address it by targeting the biggest suppliers of illegally diverted pharmaceuticals. During the DEA's Operation Pilluted in 2015 — the largest prescription drug bust in the agency's history — 280 people, including 22 physicians and pharmacists, were arrested for unlawfully dispensing large amounts of opioids. As the number of lawsuits against illegal prescribers and drug manufacturers kept rising from there, so did the death toll. 

In 2016, more Americans died from drug overdoses than in the Vietnam War. About three-fourths of the 64,000 deaths were linked to opioids, according to the CDC. The epidemic peaked in 2017, with the CDC reporting an estimated 72,000 deaths. That same year, HHS officially declared the crisis a national public health emergency, and with good reason — about 99.2 percent of total global hydrocodone consumption was in the U.S., according to a 2017 report by the International Narcotics Control Board. As the number of overdose deaths skyrocketed between 2011 and 2016, physicians continued to prescribe opioids, often in excess, according to a 2019 analysis from Kaiser Health News.

Other repercussions of the epidemic include rapidly escalating unemployment, homelessness and opioid-related crime rates across the nation. A lawsuit filed by Washington state’s King County against Purdue Pharma in 2018, for example, cites opioids’ involvement in approximately 40 percent of all drug-related criminal cases, up from 15 percent a decade prior, and theorizes that the county’s fast-expanding homeless population "is due in part to the opioid epidemic." A study of individuals living on the street and in shelters in Boston found that homeless individuals were nine times more likely than those in stable housing to die from an opioid overdose, according to a report from the National Health Care for the Homeless Council. The report concluded that, beyond introducing systemic changes such as prescription regulation and parity laws, increasing access to social services and other resources will be key to addressing the social consequences of opioid abuse and addiction.

The skyrocketing overdose rate spurred healthcare organizations, federal agencies and other companies in the industry to declare war on the epidemic. Some retail pharmacy operators, such as Walmart, have introduced limits on opioid prescription supplies, while major health systems such as Danville, Pa.-based Geisinger have implemented systemwide opioid reduction initiatives to cut prescriptions in half. At least a dozen pharmaceutical companies have also settled cases regarding their role in the opioid epidemic this year. This includes OxyContin maker Purdue Pharma, which reached a tentative deal in September after being sued by 23 states and more than 2,000 local governments.

The tail end of this decade marked a turning point in the epidemic. In 2018, overdose deaths fell for the first time since 1990, which the CDC attributes to fewer deaths from prescription opioids. Despite these efforts, the country still faces an extremely high overdose death rate fueled by an increasing amount of fentanyl, cocaine and methamphetamine overdoses, as evidenced by the epidemic's $696 billion cost for the nation in 2018. Continuing to reverse this trend, along with reducing opioid prescriptions and providing adequate addiction treatment, will remain a problem for the U.S. going into 2020.

 

Global and public health concerns that defined the decade 

By Emily Rappleye and Eric Oliver

The past decade was characterized by several global and public health threats, some a redux of diseases previously eradicated or overlooked, like measles and Zika, others born purely of the modern age, like vaping. 

The 2010s saw two major outbreaks of high-threat pathogens previously considered rare. First was the Ebola epidemic of 2014-15, the largest outbreak of the virus in history. Ebola ravaged West Africa — 11,310 people died and nearly 29,000 cases were reported as of April 2016 — and it crossed borders. Two people died and 11 cases were reported on U.S. soil. The outbreak's broad reach stemmed from a poorly coordinated international response, according to an analysis by Médecins Sans Frontières.

Then from 2015-17, the Zika virus spread from Brazil throughout South and North America. Cases peaked in 2016 when Brazil counted 205,578 cases and the U.S. and its territories counted more than 40,000 cases combined. Zika was previously considered a rare, relatively mild disease. However, the scope of the 2015-17 outbreak established a link between Zika, microcephaly and other congenital birth defects, of which the long-term effects for thousands of babies remains unknown. 

Capping off the decade in communicable diseases was a resurgence of measles that almost cost the U.S. its elimination status of nearly 20 years. The CDC recorded 1,249 cases of measles between Jan. 1 and Oct. 4, 2019, the most since 1992. The cases spanned 31 states, but most were concentrated in New York among unvaccinated children and linked to unvaccinated international travelers. The outbreak occurred at the nexus of two trends — an increasingly interconnected world, and an uptick in groups going unvaccinated due to hesitancy and misinformation about vaccine safety.  

Communicable diseases were not the only public health threats to define the decade. Health systems were forced to prepare and respond to mass shootings, and numerous healthcare professionals took to social media to champion gun violence prevention efforts. They were met with resistance from national gun advocacy organizations like the National Rifle Association. In one instance, after the NRA tweeted that medical professionals should "stay in their lane," a national campaign responded with physicians sharing their experiences dealing with gun violence from the emergency response perspective. 

Later in the decade, the U.S. faced another health emergency brought on by vape products causing unexplained illness. The first cases were reported in Wisconsin in July 2019, when Milwaukee-based Children's Hospital of Wisconsin treated eight teenagers for lung damage, all who reported vaping beforehand. In August, the first patient died from what was believed to be vape-related injuries in Illinois. By November 2019, the CDC-reported the U.S. had 2,290 cases of vaping-associated respiratory illness, along with 47 deaths. The culprit behind the disease was undetermined until late November, when the CDC identified vitamin E acetate as the chemical behind the illness, in turn designating those afflicted by the disease by the acronym EVALI, e-cigarette, or vaping, product use-associated lung injury. As the decade draws to a close, vape products continue to remain heavily-debated with the possibility of an all-out ban looming. 

 

Healthcare spending hits $3 trillion — and counting

By Maia Anderson, Alan Condon and Morgan Haefner 

After five straight years of historically low growth, U.S. healthcare spending ballooned to $3 trillion in 2014, spurred by coverage expansion and prescription drug costs.

Today, annual spending is closer to $3.65 trillion, or $11,172 per person. That's larger than the gross domestic product of Mexico, Canada and Spain, and by far the highest annual healthcare spending in the developed world. Nearly 60 percent of that total cost goes toward hospitals, physicians and clinical services. By 2027, CMS projects annual healthcare spending will reach $6 trillion.

The increased growth is hitting the pockets of patients hard. In 2018, CMS said out-of-pocket healthcare spending grew to $375.6 billion, or 10 percent of total annual healthcare spending. Citing a study from the Urban Institute, Sen. Elizabeth Warren, D-Mass., has said while promoting her "Medicare for All" policies, that out-of-pocket spending will climb to $11 trillion in the next 10 years under the nation's current healthcare system. Economists have called the estimate reasonable.

But rising cost hasn't translated to higher levels of healthcare quality in the U.S. A 2018 study from the Institute for Health Metrics and Evaluation at the University of Washington in Seattle found the U.S. ranks 27th in the world for its investments in healthcare as a measurement of its economic growth. U.K. residents, who have most of their healthcare covered by the National Health Service, have a longer life expectancy, lower infant mortality and higher health statistics than their U.S. counterparts, at a far lower cost (about $258 billion in 2017). The flip side of that longer life expectancy, however, is the U.K.'s growing demand for services from chronically ill and older patients.

America's "$3 trillion healthcare system" is a statistic that informs most healthcare discussions in the country. It’s also become a convenient slogan to cite as reason to abandon one thing or invest in another, even if those investments produce lackluster results in curbing costs and spending. Meanwhile, the growing price of admission in healthcare is cutting out the industry's have-nots, such as rural providers who can't keep their doors open and nurses who are forced to buy supplies from Dollar General. Mounting healthcare spending is one of the top threats the industry will carry over into the next decade.  

 

Rural hospital closures 

By Ayla Ellison, Mackenzie Garrity, Rachel Popa and Gabrielle Mason

About 60 million people — nearly one in five Americans — live in rural areas and depend on their local hospitals for care. Over the past decade, 120 of those hospitals closed. 

Heavy reliance on government payers, high levels of uncompensated care and low patient volume are among the challenges rural hospitals have faced for years. A variety of new challenges, such as the shift from inpatient to outpatient care and increased regulatory burden, have also put rural hospitals in a fragile position, according to a report by the American Hospital Association.

Across the U.S., rural hospital closures have steadily increased over the past three years, hitting a record high of 19 closures this year, according to the Cecil G. Sheps Center for Health Services Research. Thirty-one states have seen at least one rural hospital shut down since 2010, and the closures are heavily clustered in states that have not expanded Medicaid under the ACA. The 14 states that have not adopted Medicaid expansion have seen 101 hospitals close in the past 10 years. 

Patient access to care suffers when a rural hospital shuts down, and consequently, patient outcomes can worsen. A working paper published by the National Bureau of Economic Research found rural hospital closures increased inpatient mortality by 5.9 percent. Communities have reported rural hospital closures resulted in increased cost of transportation to healthcare services and created barriers to care for vulnerable groups. 

Rural hospital closures can also have devastating effects on the local economy. In many rural communities, the hospital is one of the largest employers. When the hospital shuts down, healthcare professionals and their families often leave the area. Hospital closures can also lead to higher unemployment rates and stunt local economic growth

To avoid shutting down, many rural hospitals are forced to cut unprofitable service lines to stave off losses. Obstetric units are often the first to close. More than half of rural counties don't have a hospital-based unit for obstetric services, with the percentage of rural counties lacking hospital obstetric units jumping from 45 percent in 2004 to 54 percent in 2014, according to a study from the University of Minnesota Rural Health Center in Minneapolis. Fewer than half of rural women live within a 30-minute drive of a hospital offering perinatal services. 

Private hospital ownership, a limited local supply of physicians and low birth volume are among the factors associated with rural obstetric unit closures, and a growing shortage of physicians in rural areas may force more hospitals to end obstetric services. CMS estimates the U.S. will experience a shortage of 6,000 to 8,000 obstetricians and gynecologists by 2020.

 

The rise and fall of Theranos

By Molly Gamble

On Oct. 15, 2015, The Wall Street Journal hit publish on a front-page, 2,720-word story by investigative journalist John Carreyrou. It was the beginning of the end for Theranos, and the introduction of a winding cautionary tale for healthcare. 

Theranos was a Silicon Valley biotech startup founded by Elizabeth Holmes, a Stanford University dropout, that claimed to offer hundreds of lab tests with only a few drops versus vials of blood thanks to its proprietary technology, called Edison. When Mr. Carreyrou looked closer, he actually found Theranos used traditional blood testing devices to run the vast majority of blood tests — machinery from Siemens, not its own Edison. When Edison was deployed, the results were inaccurate.

Theranos formally dissolved 1,055 days after the publication of Mr. Carreyrou's first story about the once-valued $9 billion company. By then, the company was subject to investigations by the Securities and Exchange Commission, Department of Justice and FBI. Walgreens ended its partnership and shuttered testing locations, investors and blood test patients sued, Forbes reduced disgraced CEO Elizabeth Holmes' estimated wealth from $4.5 billion to $0. Ms. Holmes and former COO Ramesh Balwani each face up to 20 years in prison for multiple counts of wire fraud and conspiracy to commit wire fraud; their trials are set to begin July 28, 2020.

What made the downfall of Palo Alto, Calif.-based Theranos so disturbing is the number of regulators, investors, dignitaries, journalists, biotech experts and healthcare institution leaders who were, for lack of a better word, had. This is what makes Theranos more than a case study of corruption and deception: Although its collapse occurred in a steady cadence over about three years, Ms. Holmes founded the company in 2003. A dozen years came and went before Theranos received the scrutiny worthy for any company claiming to process more than 240 laboratory tests with only a finger prick's worth of blood. 

The Theranos board was stacked with U.S. military leaders and former secretaries of state, including Henry Kissinger, George Schultz and James Mattis. It raised more than $700 million from venture capitalists and private investors, including Oracle cofounder Larry Ellison. The Food and Drug Administration cleared Theranos to run tests for herpes on its "proprietary" technology. Walgreens partnered with Theranos in 2013 to install kiosks in thousands of stores without ever validating its technology. In its 2014 cover story titled "This CEO's out for blood," Fortune quoted sources who compared Ms. Holmes to Bill Gates and Steve Jobs alongside the photo of a vial of blood the size of an Advil gel capsule with the caption, "Theranos can run as many as 70 tests on a sample this size, obtained by pricking a finger." Days after WSJ published its first expose on Theranos, Ms. Holmes flew to Boston for a previously scheduled appearance at the Harvard Medical School Board of Fellows, where she was honored as an inductee, as reported by Vanity Fair.

There is a long and impressive list of highly educated experts in their field who missed a chance to dig deeper, ask the right question and press for results. Many smart people believed lies and exaggerations. The scars they bear? Lost investments, retractions, blemishes on resumes, public humiliation, legal expenses — these and more, none of them good. 

But in the 2020s, after Ms. Holmes' trial and the movie premiere, healthcare needs to remember the people too often overlooked in the rise and fall of Theranos: the patients. They were not biotech, healthcare or investment experts. They trusted Theranos for answers about their health, and they believed its promises for convenience, reliability and affordability. What they got were perplexing and flawed results, some signaling serious or even life-threatening problems. 

Theranos was a dark chapter of healthcare in the 2010s, but it reminded the industry that the trust put forth by patients in hopes of a less painful healthcare experience deserves fierce protection. That faith moves healthcare forward, and it does not run in endless supply. 

 

Employers challenge healthcare's status quo 

By Maia Anderson, Alan Condon and Morgan Haefner

In 2019, average annual premiums for employer-based family health insurance plans grew to $20,567, surpassing $20,000 for the first time. Through the decade, major companies, including Walmart, Amazon and Berkshire Hathaway, responded to this rising cost with programs to lower their employee healthcare spending. 

In 2013, Pacific Business Group on Health, a San Francisco-based group of private employers and public agencies focused on improving the quality and affordability of healthcare, created the Employers Centers of Excellence Network. Companies can join the network, which designates physicians, hospitals and health systems as "Centers of Excellence" based on their quality statistics. 

Employer use of some type of Centers of Excellence program rose to 88 percent in 2019, up from 79 percent in 2016, according to the National Business Group on Health. In order to boost quality and cut costs of these programs, employers have become increasingly selective about the physicians, hospitals and health systems they include.

In 2013, Walmart launched its Centers of Excellence program, available to the 1.1 million people on the corporate giant's medical plan. Through the program, Walmart has partnered with some of the nation's largest health systems, including Cleveland Clinic, Baltimore-based Johns Hopkins and Danville, Pa.-based Geisinger. Walmart's program flies employees, all expenses paid, when necessary, to top hospitals around the world.

Lowe's quickly followed in Walmart's footsteps, joining the Centers of Excellence network in October 2013. General Electric began offering a Centers of Excellence program in 2014 to provide hip and knee replacement surgeries for its employees. Boeing, along with Blue Cross Blue Shield of Illinois, launched a Centers of Excellence program in 2015, which benefits more than 15,000 Boeing employees. McKesson joined the Centers of Excellence network in 2014 to provide hip and knee replacement surgeries for its employees. 

Perhaps one of the largest examples of employers entering the health insurance market came in 2018, when Amazon, Berkshire Hathaway and JPMorgan Chase launched Haven Healthcare, a company aimed at cutting healthcare costs for the companies' combined 1.2 million employees. Haven began testing its insurance offerings in November, presenting 30,000 workers in Ohio and Arizona with two separate plans.

Why has employers' role in healthcare changed so much in the last 10 years? In 2010, employers began prepping for the ACA's employer mandate, which requires larger employers to share responsibility for their employees' health coverage. The mandate went into effect in 2015. To avoid fines, large employers began rolling out their own healthcare programs, while those who already had programs had to keep theirs competitive. 

Harder to prepare for was an unstoppable rise in premiums and deductibles that in the last half of the decade made the coverage employers are mandated to offer unaffordable for employees. Going into the 2020s, expect large employers who are sick of the healthcare cost status quo — and this includes health systems that are often the largest employer in a state — to find new ways to squeeze out cost. Employers are arguably more motivated than any other player to keep their healthcare costs down, which are rising two times the rate of wage increases. How else will they ensure competitive salaries and attract top talent in the labor market of the 2020s?

 

Progress made against cancer 

By Molly Gamble

The 2010s saw steady improvement in the survival rate for men and women with all types of cancer as well as several prominent discoveries and significant advances in cancer care.

Science magazine deemed cancer immunotherapy the “breakthrough of the year” in 2013, highlighting its potential to radically change cancer treatment based on the results of several patients. The editors cited an emerging belief among oncologists that "a corner has been turned and we won't be going back." 

That belief was strengthened in 2018, when two cancer immunotherapy researchers — James P. Allison, PhD, of the University of Texas MD Anderson Cancer Center and Dr. Tasuku Honjo of Kyoto University in Japan — earned a Nobel Prize for their pioneering work in checkpoint therapy, which unleashes the body's own immune system to attack cancer cells. Their work represented advancements in research that many had given up on well before the 2010s. Leading oncologists said the pair's work lifted decades of skepticism about immunotherapy; the Nobel committee described it as “an entirely new principle for cancer therapy.”

The FDA approved the first CAR-T cell therapy in 2017, expanding its use in standard therapy for the treatment of pediatric and young adult patients with B-cell acute lymphoblastic leukemia. The milestone was one of several FDA approvals for leukemia drugs in the 2010s, including more than 10 for acute leukemia in three years. Progress in leukemia treatment was relatively rare in the 25 years before this decade. For instance, the majority of advances for acute myeloid leukemia — the most common form of leukemia in the U.S. — had not come from the introduction of new therapeutics, but rather from optimizing use of older drugs.

Genetic testing and the demystification of cancer genomes also marked the 2010s.

"We now have a blueprint of cancer genes in every type of cancer and information about the frequency and type of mutations that occur," said William Hahn, MD, PhD, chief research strategy officer for Dana-Farber Cancer Institute. 

Progress was especially apparent in the medical community's understanding of the genomics of gynecologic cancers and the ability to identify several premalignant states that raise people’s risk for certain hematologic cancers. 

Culturally, actress Angelina Jolie Pitt brought wider public awareness of genetic testing in 2013 when she wrote a New York Times op-ed detailing her choice to undergo a double mastectomy after testing positive for a high-risk gene mutation, BRCA1. Her test results estimated an 87 percent risk of breast cancer. In the two weeks after her op-ed ran, researchers identified a 64 percent uptick in the rates of genetic testing for breast cancer but no uptick in mastectomy rates, suggesting the tests did not result in more breast cancer diagnoses. The researchers dubbed it "The Angelina Effect" — while her testimonial raised awareness of genetic testing for breast cancer mutations, it possibly inadvertently influenced overtesting in low-risk groups.

Progress made with cancer drugs or therapies inspired much-needed hope and presented new options, but it also served as a reminder of the steep costs of cancer care that are unsustainable for individual patients and the health system as a whole. The average cost of cancer drugs increased from $50,000 per patient in the mid-1990s to $250,000 in 2018 — four times the median U.S. household annual income, according to Vox. Immunotherapies in particular often cost more than $100,000 per patient. 

These are but two findings from a decade in which the financial costs of cancer increasingly came to light. Medical expenditures for cancer are expected to reach at least $158 billion by 2020, according to estimates from the National Institutes of Health. Another study published in Health Affairs found cancer patients were 2.65 times more likely to go bankrupt than their peers without the disease.

The medical community made progress toward cures for cancer in the 2010s, and the next decade begins with a growing need for structural changes throughout the health system to ensure cancer patients can actually access and benefit from the research and breakthroughs.

 

Healthcare's blame games persist

By Brian Zimmerman, Kelly Gooch and Laura Dyrda

Investigative reporting shed brighter light on several deep-rooted industry problems in the last decade. Stories on surprise billing and skyrocketing drug prices captured the nation's attention and became the subject of public ire, spurring legislators to demand and promise reform. To date, little substantive action has been taken. Instead, industry stakeholders and partisan lawmakers have taken to finger-pointing, and gridlock has largely prevailed.

Federal lawmakers ramped up efforts this year to end surprise medical bills after President Donald Trump vowed to address the issue and media continued to highlight the breadth of the problem. Insurance companies, hospitals and physicians agree: Patients should not be on the hook for surprise out-of-network charges. However, they disagree over the best way to resolve payment disputes between insurance companies and physicians once the patient is protected. Progress was made on legislation in December after key lawmakers announced a bipartisan agreement. But surprise-billing legislation has since stalled, reports The New York Times, as it was not included in a $1.37 trillion spending agreement reached by congressional negotiators Dec. 16. 

In a unilateral effort to curb the burden of patients' rising healthcare costs, the Trump administration finalized a rule requiring hospitals to disclose the prices they negotiate with insurers for a range of services, beginning in 2021. The rule also mandates that hospitals make the fees they charge patients public. At the same time, the administration issued a health plan transparency proposal that would require insurers to share price information with members before treatment. The dual moves spurred controversy, drawing both derision and support from industry groups.

In December, hospital organizations moved to block the rule by filing suit against HHS, arguing the federal agency lacks the proper statutory authority necessary to enforce such regulation. Even if the price transparency rule takes effect as planned, it's unclear how effective it will be at helping patients avoid cumbersome healthcare bills.  

Rising drug prices were, and are, also at the center of legislative and industry blame games. The origins of America's drug price crisis stretch back into the late 1990s, when prescription drug spending increased at an average rate of 9.9 percent annually between 1997 and 2007, according to a Health Affairs analysis. In the subsequent decade, the trend worsened. In one memorable drug price-hike story of the 2010s, the drug manufacturer Mylan increased the price of its EpiPen by 400 percent between 2007 and 2016.

Even those outside of healthcare came to associate "pharma bro" Martin Shkreli with the industry. As CEO of Turing Pharmaceuticals, Mr. Shkreli hiked the price of a lifesaving HIV drug by more than 5,000 percent in 2015. The 36-year-old was lambasted on Saturday Night Live and considered costume inspiration for Halloween 2016.  

Who's to blame for sky-high drug prices? Everyone and no one. Pharmaceutical companies and pharmacy benefit managers have blamed one another, and politicians have attributed fault to both stakeholders but largely failed to take action in a climate of severe partisanship. In December, the House of Representatives passed House Speaker Nancy Pelosi's signature drug-pricing bill. However, the bill is not likely to become law, as U.S. Senate Majority Leader Mitch McConnell, R-Ky., and President Donald Trump have spoken out against it.

The decade closes with other major issues unresolved. Interoperability remains a challenge for healthcare organizations, and the large EHR companies have not stepped up to fill the gap. Opioid prescriptions, while largely curtailed in the last two to three years, have left thousands of individuals in need of treatment for substance use disorders. Finally, access to affordable healthcare remains elusive, as insurance plans on the exchange market are often expensive, have high deductibles and leave significant gaps in coverage.

 

The move from paper to digital records via EHRs

By Ayla Ellison, Mackenzie Garrity, Rachel Popa and Gabrielle Mason

This was the decade in which hospitals moved from paper to digital medical records, a monumental transition that came with its fair share of costs and obstacles. 

Hospitals began shredding their paper records for EHRs in 2009 when Congress passed the Health Information Technology for Economic and Clinical Health Act, which was signed by President Barack Obama as part of the American Reinvestment & Recovery Act. The law included provisions about EHRs and the meaningful use of the technology. For showing meaningful use of the technology, hospitals could be eligible for incentives. 

As of 2017, 95 percent of hospitals had adopted an EHR, according to data collected from the American Hospital Association and cited by the ONC. Of those hospitals, 94 percent were using EHR data to improve quality, patient safety and organizational performance. Although hospitals were installing EHRs prior to HITECH, the dramatic increase in adoption can be attributed to the legislation.  

Throughout the decade, four major competitors emerged: Allscripts, Cerner, Epic and Meditech. For years, Epic and Cerner have continued to dominate the market. A study conducted by KLAS Research of 5,447 acute care hospitals in 2018 found that Epic controlled 28 percent of the market followed by Cerner with 26 percent. 

Cerner and Epic have also battled for government contracts, including contracts with the Department of Veterans Affairs and the Department of Defense. In 2015, the VA signed a $624 million agreement with Epic to adopt its Medical Appointment Scheduling System. But in December 2018, after spending $23 million on the project, the VA switched to Cerner in a 10-year agreement worth around $16 billion. The DoD also signed a deal with Cerner to develop and rollout a new EHR by 2022. 

EHRs led to the proliferation of patient portals, which give patients more access and flexibility, particularly in terms of contacting their providers and scheduling and canceling appointments. Patient portal use has also been shown to improve patient engagement and reduce inpatient burden on hospitals. A recent study shows that use of a patient portal through the EHR can improve patients' self management of healthcare services, which results in increased outpatient appointments and reduced emergency room visits and hospitalizations. Around 70 percent of hospital and health system executives polled in a 2019 survey about their organizations' main IT priorities for 2020 said that they plan to invest in patient portals.

Patients also have more access to clinician notes via online portals, which enables them to be more engaged in their care. OpenNotes, an international movement focused on increasing patient access to their clinical notes on online portals, announced in July that more than 40 million patients now have access to notes written by their providers. More than half of patients consider access to visit notes through patient portals an important factor when searching for a new healthcare provider, a study published in the Journal of Medical Internet Research shows. EHRs also helped solve the issue of poor handwriting on the part of providers, which led to inefficiencies, errors and delayed care. Today, the EHR allows hospital staff members and patients to more easily decipher clinician notes. 

EHR data has also been mined for research. For example, Boston-based Massachusetts General Hospital researchers developed a machine learning-powered software that can scan EHRs to predict dementia risk, while Penn State Clinical and Translational Science Institute developed a research population discovery tool that can examine and validate the feasibility of clinical studies using EHR data.

While EHRs have made patient information more accessible and have improved the quality of care, they have also been cited as a major source of burnout among clinicians. Researchers from Albuquerque-based University of New Mexico found that increased data entry requirements for medical malpractice, quality assurance initiatives, support for billing processes and government policy oversight have added extra administrative work, causing added stress and burnout.

Additionally, a market for EHR add-ons has proliferated in the healthcare industry, which ultimately increases the cost of EHR adoption and optimization. Add-ons include data analytics tools, clinical documentation software, communication tools and artificial intelligence solutions. In 2017, EHR vendor Epic launched its "App Orchard," a marketplace for third-party developers to showcase pre-approved reporting, visualization and content apps to its customers. 

Looking to the next decade, EHR vendors will have to work on making their EHRs more user friendly, allowing clinicians to spend more time with patients and less time in front of a computer screen. Additionally, Cerner, Epic and other vendors may face questions about the EHR industry's lack of interoperability and competition. 

 

Healthcare rankings proliferate

By Angie Stewart, Mackenzie Bean and Andrea Park

It’s human nature to want medical care from only the best, yet this determination is hardly easy. In the 2010s, agencies, for-profit companies and analysts attempted to get us closer to answering this question via their proprietary rating and ranking systems, all of which spurred larger discussions about consumer transparency and data accuracy and intensified competition between hospitals for the must-have marketing material of grades and ranks.

The most coveted ranking among hospitals today is that of U.S. News & World Report, which launched its hospital rankings in 1990 and continues to refine its methodologies. In 2011, the magazine rolled out regional rankings as part of its annual Best Hospitals list to recognize healthcare facilities outside major urban hubs, according to Kaiser Health News. As a result, the rankings became more useful to Americans with average medical needs seeking information on their local hospitals. Additionally, in 2012, U.S. News updated its Best Hospitals methodology to place more weight on clinical data than on more subjective reputational scores.

Healthcare rankings hit another major turning point in 2012, when the Leapfrog Group launched its Hospital Safety Grades. Twice a year, the group assigns letter grades to more than 2,500 hospitals nationwide based on their patient safety performance. While 36 hospitals have earned straight A's in every safety grade update since 2012, the ratings system is a point of contention for many others. Several healthcare organizations, including Chicago-based Saint Anthony Hospital and Naples, Fla.-based NCH Healthcare System, have sued Leapfrog over poor letter grades, alleging that the organization offers healthcare consumers inaccurate depictions of quality performance. 

The Leapfrog Group isn't the only healthcare ratings system to undergo scrutiny for its methodology and data accuracy. After launching its Surgeon Scorecard operational outcomes database in 2015, ProPublica was accused of “public shaming” and flawed ratings, even as supporters praised the news outlet’s commitment to increasing transparency for patients. CMS has also faced a tangle of challenges since unveiling its overall Hospital Quality Star Ratings program in 2016, citing methodology issues as the reason for a handful of ratings update delays and postponements. Less than a year after the Star Ratings program launched, the American Hospital Association called it "deeply flawed" and publicly called on CMS to suspend it. In December 2019, the Veterans Health Administration discontinued its internal star ratings system to boost transparency and allow veterans to more easily compare VA hospitals. 

CMS, U.S. News and other ratings organizations have spent the latter half of the decade refining their methodologies based on this type of industry feedback. CMS collected more than 800 comments on its hospital star ratings during a public comment period in 2019 and plans to update its methodology in 2021. U.S. News also updated the methodology for its 12 data-driven Best Hospitals specialties in 2019 to incorporate more patient-centered measures, better account for differences in patient populations and address constructive feedback from healthcare professionals.

In spite of these issues, however, hospitals and health systems still rely heavily on third-party rankings as a measure of their performance, a source of competition with their peers, and perhaps most significantly, a launching pad for widespread marketing campaigns. In fact, a New York Times investigation found that, due to major discrepancies between the most prominent ratings systems, results are best used primarily as a marketing tool, rather than an objective and quantitative ranking of healthcare organizations.

Despite some of the major challenges they've faced this decade and an ongoing debate over their usefulness, one thing is clear: Ratings systems aren't going away anytime soon.

 

Health system C-suites reflect organizations' growing complexity and scope

By Alia Paavola and Jackie Drees 

If the business of healthcare was ever just about the CEO, CFO and COO, it surely isn't now. 

The healthcare industry is constantly changing as new federal payment rules are adopted, costs for medicines rise, new technologies are implemented and consumers demand a seamless care experience. As a result of the changing landscape, new C-suite positions emerged throughout the last decade. Today, those hires have added up, creating a diverse C-suite that better reflects health systems’ growing complexity and scope.  

Below are 10 of the newer roles that became more common in the 2010s: 

1. Chief Diversity Officer. The chief diversity officer is responsible for cultivating diversity and inclusion in the workplace. This individual plays a crucial role in recruiting, retaining and developing diverse healthcare leaders and executing inclusion initiatives, like diversity training.

2. Chief Experience Officer. The CXO heads up patient experience strategies and often oversees a team responsible for tackling complaints, compliments and performance improvements for the organization’s services and products. 

3. Chief Innovation Officer. The chief innovation officer role has emerged in the wake of technology’s intersection with healthcare. However, the position encompasses more than deploying health IT initiatives; the chief innovation officer is responsible for creating a culture of creative thinking systemwide that supports staying ahead of industry trends and market disruption. 

4. Chief Medical Information Officer and Chief Nursing Informatics Officer. The CMIO and CNIO roles broadly serve as liaisons to physicians and nurses when it comes integrating clinical informatics and IT systems with their daily workflows.

5. Chief Pharmacy Officer. The chief pharmacy officer is responsible for strategic and operational oversight of a health system's pharmacy services. This executive can affect several crucial fronts in an integrated delivery system, including patient safety, cost containment and standardization.

6. Chief Quality Officer. Responsible for patient safety efforts, the CQO oversees quality data collection and ensures clinicians meet specific quality indicators. The executive establishes a culture of continuous improvement by setting goals to enhance efficiency and identifying key performance indicators. 

7. Chief Revenue Officer. The chief revenue officer oversees the hospital or health system's revenue cycle and revenue-related processes, including payer relationships, government reimbursement and chargemaster operations.  

8. Chief of Staff. The chief of staff, also called the right hand of the CEO, ensures that the executive is not bogged down by the details of daily operations. The role of a healthcare chief of staff depends on the CEO's needs and the organization's demands.

9. Chief Strategy Officer. While CEOs are increasingly tasked with responsibilities, the CSO role emerged to help develop and execute strategic initiatives among clinical and hospital staff.    

10. Chief Wellness Officer. As clinician burnout rates soared, health systems started carving out a new role in the C-suite to address the issue. Stanford Medicine was the first academic medical center to hire a chief physician wellness officer in 2017, and others have since followed suit. The role focuses on promoting a culture of well-being and addressing factors of burnout to benefit clinicians and improve patient care.  

 

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