Ambulatory care and hospitals each accounted for only 22,000 new jobs. Is relief in sight for leaders?
Healthcare grew 49,000 jobs in June, down from the average 64,000 jobs over the past 12 months, but still representing nearly one-in-four (23.7%) of the 206,000 jobs created in the larger economy during the month, federal data show.
Ambulatory healthcare services and hospitals each grew 22,000 jobs, accounting for the bulk of healthcare jobs, the Bureau of Labor Statistics reports.
Job gains were also reported in government (70,000), social assistance (34,000) and construction (27,000)
The unemployment rate in the larger U.S. economy held steady 4.1%, BLS says, with 6.8 million people reporting as unemployed in June.
The average hourly earnings for all employees on private nonfarm payrolls in June rose by 10 cents (0.3%) to $35.00. Over the past 12 months, average hourly earnings have increased by 3.9%. In June, the average hourly earnings of private-sector production and nonsupervisory employees rose by 10 cents (0.3%) to $30.05.
May and June job numbers are considered preliminary by BLS, and subject to revisions.
It's the second-largest criminal financial penalty levied against a drug maker.
The now-reorganized Endo Health Solutions Inc. has agreed to pay $1.086 billion in criminal fines and $450 million in criminal forfeitures after pleading guilty to one misdemeanor charge related to the intentional misbranding of its opioid medication Opana ER with INTAC, the U.S. Department of Justice says.
EHSI pled guilty on April 18 to one count of introducing misbranded drugs into interstate commerce. The drugmaker admitted that from April 2012 through May 2013, its sales reps marketed Opana ER to physicians by baselessly claiming that the opioid was tamper- and crush-resistant and thus purportedly deterred abuse. In some cases the sales reps used hammers to strike non-medicated sample pills.
In addition, EHSI admitted it was responsible for the misbranding of Opana ER by marketing the drug with a label that failed to include adequate directions for its claimed abuse deterrence use, in violation of the federal Food, Drug, and Cosmetic Act.
EHSI stopped selling Opana ER in 2017. The drugmaker was shut down during the bankruptcy process and not allowed to continue its prior form when the company emerged on April 23. The EHSI affiliates that come out of the bankruptcy process can no longer sell or market opioids and must make public millions of documents relating to EHSI's role in the opioid crisis.
EHSI issued a statement calling the agreement "an important step in our settlement with the DOJ."
"The company has made important changes since the historical conduct of certain former sales representatives that took place from 2012 to 2013. We remain committed to operating with integrity and maintaining a culture of compliance and ethics," EHSI says.
EHSI says the settlement with the federal government included $200 million when it emerged from bankruptcy in April, "which fully satisfied the criminal fine, the civil false claims act settlement agreement, and all of the IRS tax claims, with possible additional payments up to a maximum of $100 million to be paid over five years if certain financial metrics are met."
The largest criminal penalty imposed in the sweeping opioid legal actions was levied against Reckitt Benckiser Group plc, which in 2019 agreed to pay $1.4 billion to resolve its potential criminal and civil liability for its role in marketing of the opioid addiction treatment drug Suboxone.
The EHSI settlement is a component of the broader case resolving all monetary claims held by the federal government against EHSI's new corporate entities. The new company has also funded trusts for opioid-related claims that will pay more than $450 million to state, municipal and tribal governments for opioid addiction treatment programs.
DOJ is crediting up to $450 million of these payments against the forfeiture amount.
"The opioid crisis we continue to face today originated, in part, from companies like EHSI building their business on false claims and deceptive business practices," Drug Enforcement Administration Administrator Anne Milgram says. "By intentionally misrepresenting opioid medications, EHSI prioritized profits over the health and well-being of the American people. (This) settlement reflects DEA's commitment to keep Americans safe and holding companies like EHSI accountable."
The Jacksonville, Florida-based health system self-disclosed the improper discounts to encourage patient referrals.
Baptist Health System Inc. will pay $1.5 million to settle self-reported allegations that its subsidiaries offered illegal discounts to patients to induce them to buy or refer Medicare services to the Jacksonville, FL-based provider, the U.S. Department of Justice says.
According to the settlement, Baptist Health subsidiaries gave discounts of 50% or more to Medicare patients from 2016 through mid-2022 "in exchange for the beneficiaries' purchase or referral of services by certain categories of Medicare beneficiaries from Baptist Health subsidiaries. The beneficiaries were chosen by Baptist Health "without regard to any financial need consideration."
DOJ noted that Baptist Health voluntarily self-disclosed the improprieties, cooperated with the investigation and took remedial measures, including discontinuing its discount policy, conducting an internal compliance review and providing federal regulators with a detailed disclosure statement and other supplemental information.
"Self-disclosures like this not only help crucial federal healthcare programs to recoup funds, but are also in the best interests of healthcare providers themselves," Roger B. Handberg, U.S. Attorney for the Middle District of Florida, says in a media release.
Baptist Responds
Baptist issued this statement. "Upon review of its payment practices, Baptist Health made a voluntary self-disclosure of outdated courtesy discount practices. The self-disclosure process encourages transparency and facilitates the resolution of matters that potentially violate federal laws, and it aligns with our commitment to do the right thing. This settlement reaffirms our dedication to compliantly delivering high-quality care."
Finance leaders take heed, your outpatient volumes dropped 5% while physician compensation shot up 2%.
The nation's hospitals booked thinner operating margins in March thanks to lower volumes and revenues combined with rising labor costs, according to Kaufman Hall's latest National Hospital Flash Report.
The consultants say that health system bean counters can expect much of the same going forward as they also contend with growing bad debt and charity care.
The Kaufman Hall Calendar Year to Date Operating Margin Index—a measure of hospital profitability—was 3.9% in March, a 0.2 percentage point drop from 4.1% in February. The index "represents the national median for hospital profitability—or operating revenue less operating expense—inclusive of allocations to hospitals from corporate, physician, and other entities," KH says.
Margins were nicked by the continued rise in labor costs, with KH's latest Physician Flash Report for Q1 2024 showing that staffing accounted for 84% of expenses. There is nothing to indicate that this trend will abate anytime soon, considering the ongoing clinical shortage nationally.
The dramatic rise in clinician labor costs is not exactly breaking news for hospital finance executives. A March survey by the Hospital Financial Management Association for that rising labor costs were by far the biggest concern for hospital CFO.
But acknowledging the problem doesn't make contending with it any easier. In what has become a game of Whack-A-Mole for CFOs, cutting labor expenses oftentimes means cutting into staffing or hours. That can lead to staff unrest and turnover and that hurts retention in a red-hot seller's market for clinician labor. Further, any cost savings seen in staff reductions often are lost in the cost of replacing those workers, or hiring temp labor, and accounting for the expected reduced productivity of replacement workers until they're up to speed.
KH reports that increases in revenues and expenses for health systems also signal increased productivity and compensation for their physicians, whose productivity grew 4% in Q1 24, when compared to Q1 2023 and whose "median investment/subsidy" grew 2% to $227,972 during the same period.
"With the high cost of labor unlikely to change, health systems must think critically about how to optimize downstream margins," Matthew Bates, managing director with Kaufman Hall, says in the report. "Organizations could lean into strategies that enable physicians to be more productive as well as prioritizing outcomes related to lengths of stay or readmissions, which impact revenue."
Outpatient Volumes Down
Outpatient volumes fell 5% in March, which KH attributed to "the competitive challenges of providing outpatient care."
"Declines in outpatient revenue mean hospitals providing outpatient care may face difficulties ahead," says Erik Swanson, a senior vice president with Kaufman Hall. "Organizations may need to reevaluate their assets and consider strategic partnerships to offset current and future challenges with volume."
The National Hospital Flash Report draws on data from more than 1,300 hospitals from Syntellis Performance Solutions, now part of Strata. The Physician Flash Report draws on data based on more than 200,000 providers, also from Syntellis Performance Solutions, now part of Strata.
Healthcare job growth in April was down about 22% from the 72,000 jobs created in March but in line with annual averages.
The healthcare sector grew 56,000 new jobs in April, a 22% drop from March, but in line with monthly averages over the past year, and still among the most robust job-creating sectors in the overall economy, new federal data show.
Ambulatory care and hospitals lead in job creation within the healthcare sector in April, accounting for 33,000 and 14,000 new jobs, respectively, while nursing and residential care created 9,000 new jobs, according to the Bureau of Labor Statistics April jobs report.
Despite the slowdown, the healthcare sector accounted for nearly one-in-three (32%) of the 175,000 jobs created in the larger economy in April, BLS data show.
The healthcare sector has created an average of 63,000 new jobs every month for the past year.
The unemployment rate in the larger U.S. economy held steady at 3.9%, BLS says, with 6.5 million people reporting as unemployed in April.
Big job gains in April were also seen in social services (31,000), and retail (20,000).
The average hourly earnings for all employees on private nonfarm payrolls in April rose by 7 cents (0.2%) to $34.75. Over the past 12 months, average hourly earnings have increased by 3.9%. The average hourly earnings of private-sector production and nonsupervisory employees rose by 6 cents (0.2%) to $29.83.
March and April job numbers are considered preliminary by BLS, and subject to revisions.
The warning letters don't specify how the drugmakers are flouting patent regulations, or what criteria the FTC uses to make that determination.
The Federal Trade Commission on Tuesday challenged the legitimacy of more than 300 "junk patents" for drugs treating a range of conditions from diabetes to COPD and including Novo Nordisk Inc.'s weight-loss drug Ozempic.
In warning letters to 10 pharmaceutical companies, the FTC disputes the accuracy or relevance of the patent listings across 20 brand name products, as listed in the FDA's "Approved Drug Products with Therapeutic Equivalence Evaluations," a.k.a. the Orange Book.
None of the warning letters specify how the drugmakers are flouting patent regulations, or what criteria the FTC uses to make that determination.
"By filing bogus patent listings, pharma companies block competition and inflate the cost of prescription drugs, forcing Americans to pay sky-high prices for medicines they rely on," FTC Chair Lina M. Khan says. "By challenging junk patent filings, the FTC is fighting these illegal tactics and making sure that Americans can get timely access to innovative and affordable versions of the medicines they need."
The warning letters were sent to:
AstraZeneca and Novo Nordisk for obesity and type-2 diabetes injectable drugs.
Boehringer Ingelheim, Covis Pharma, Glaxo-Smith Kline, Novartis Pharmaceuticals Corp., Teva Pharmaceutical Industries Ltd. and some of their subsidiaries for asthma and COPD inhalers.
Amphastar Pharmaceuticals Inc. for a glucagon nasal spray to treat severe hypoglycemia in type-1 diabetics.
The drug makers will have 30 days to withdraw or amend the listing or certify – under penalty of perjury -- that the patent is legitimate and complies with regulations.
"It is the responsibility of branded drug manufacturers to ensure that Orange Book submissions contain information only on the types of patents for which information should be submitted to FDA," says FDA Commissioner Robert M. Califf, MD. "The FDA will continue to engage with the FTC to identify and address potential efforts to impede competition so that consumers can get access to the medicines they need."
In November, the FTC challenged more than 100 patent listings for medications specific to asthma and other inhaler devices, Restasis multidose bottles, and epinephrine autoinjectors.
Those challenges led to Kaleo Inc., Impax Labs, GlaxoSmithKline, and Glaxo Group delisting patents. In addition, AstraZeneca, Boehringer Ingelheim, and GlaxoSmithKline capped inhaler out-of-pocket costs at $35, the FTC says.
These recent actions follow a September 2023 FTC policy statement that warned drugmakers that the commission would be scrutinizing the improper patents in the Orange Book. The FTC says junk patents can lead to costly legal battles over patent rights that disincentivize investments in alternative and cheaper generics.
In a response to a query from HealthLeaders, Novo Nordisk acknowledged that it had "received the letter from the FTC and are currently reviewing it."
The program has demonstrated savings but legal challenges threaten its future.
Medicare Part D saved nearly $15 billion over six years with the use of "skinny label" generics, a new report says.
However, the program is imperiled by a lawsuit claiming patent infringement, researchers at Brigham and Women's Hospital and Harvard Medical School said in a research letter published on Monday in Annals of Internal Medicine.
The researchers are urging Congress to "reinforce the skinny-label pathway by creating a safe harbor that protects manufacturers engaged in skinny labeling from induced patent infringement laws."
Skinny labels permit the use of generics for conditions that are not specified by brand-name drug makers and allow the cheaper generics to enter the market before the patent of the brand-name drug expires.
The Brigham and Women's / Harvard Med School researchers analyzed 15 name-brand drugs and their "skinny label" counterparts, compared actual spending on each brand-name drug and its skinny-label generics, and projected spending had the generics been unavailable.
The researchers determined that Medicare Part D spending on these 15 drugs and their skinny-label generics was $16.8 billion, while projected spending without generics was $31.5 billion, saving Medicare $14.6 billion from 2015-2021.
The savings were the greatest for rosuvastatin (Crestor, AstraZeneca; $6.5 billion), pregabalin (Lyrica, Pfizer; $4.2 billion), and imatinib (Gleevec, Novartis; $3.1 billion).
Legal Landmines
A Delaware jury in 2017 awarded $235 million to GlaxoSmithKline for patent infringement by Teva Pharmaceutical Industries Ltd.'s generic version of GSK's beta-blocker Coreg.
A federal appeals court in 2021 upheld the award and rejected Teva's claim that it had followed Food and Drug Administration mandates to "carve out" a patented use for the drug to treat heart failure.
The appeals court affirmed GSK's complaint that Teva's labeling and marketing encouraged physicians to prescribe the generic for patent-protected conditions.
"This court's decision may discourage the marketing of skinny label generics," the brief notes.
CEO Sam Hazen says the for-profit hospital chain is 'encouraged by our performance.'
HCA Healthcare, Inc. credited robust patient volume growth in Q1 2024 for revenues of $17.3 billion, an 11% increase over the $15.5 billion booked in Q1 2023, the company says.
The Nashville-based for-profit health system reported a year-over-year 6.2% increase in same-hospital admissions and same facility equivalent admissions grew 5.2%.
As a result, adjusted EBITDA totaled $3.35 billion, up from $3.1 billion in Q1 2023, cash flow totaled $2.4 billion, and net income totaled more than $1.5 billion, or $5.93 per diluted share.
The HCA board of directors declared a quarterly cash dividend of $0.66 per share on common stock, which will be paid to stockholders on June 28.
"The strong fundamentals we saw in our business this past year continued into the first quarter of 2024," HCA CEO Same Hazen said during a conference call on Friday. "This momentum generated strong financial results that were driven primarily by broad-based volume growth."
"As we look to the rest of the year, we remain encouraged by our performance, the overall backdrop of growing demand for our services and our enhanced stability across our networks to serve our communities," Hazen said.
The Q1 report also booked $201 million ($0.57 per diluted share) from the sale to UCLA Health of the 260-bed West Hills Hospital and Medical Center in West Hills, CA.
HCA's balance sheet finished the quarter with $1.3 billion in cash and cash equivalents, total debt of $41 billion, and total assets of $57 billion. Capital expenditures totaled $1.1 billion, excluding acquisitions. Cash flows provided by operating activities totaled $2.4 billion, compared to $1.8 billion in Q1 2023. HCA also repurchased 3.9 million shares of common stock for $1.2 billion.
HCA operates 188 hospitals and some 2,400 ambulatory care venues in 20 states and the United Kingdon, including surgery centers, freestanding emergency rooms, urgent care centers and clinics.
Spending on weight-loss drugs will continue to climb in 2024 and beyond as drug makers catch up with the huge global demand.
Eric Tichy, PharmD, MBA, division chair, supply chain management at Mayo Clinic, is lead author of a new study detailing how and where the U.S. spent $772 billion on drug in 2023, up 13.5% from 2022, and what's in store for 2024.
In this HealthLeaders interview, Tichy explains how weight-loss drugs pushed double-digit increases in drug expenditures last year, even as drug price increases were relatively modest.
Tichy projects that spending on weight-loss drugs will continue to climb in 2024 and beyond as suppliers catch up with the huge global demand. That growth will continue as new and similar drugs come to market and as the FDA approves the medications for more conditions.
HL: What are some of the big take-aways from your report?
Tichy: It was very impressive how much the diabetes medications that are used for weight loss have grown over the last year. Last year, we had seen that they were growing at a very high rate, and this year they continued to grow at a very high rate. It was just very impressive. And now those are the number one expenditure drugs in the U.S.
People are sensitive to prices of drugs and there's like this public perception that drug prices are driving our expenditures, but prices have been below inflation. It's more about utilization. We have this whole category of weight-loss drugs that we didn't have a couple of years ago. The drug industry is very good at innovating and developing new areas of care that grow our drug expenses.
HL: Is the public conflating drug spending and drug costs?
Tichy: Yes. In our, in our report there are three categories of spending. There's the price, there's brand new drugs that didn't exist last year, and there's utilization. Those get all conflated into price but price is just one driver of expenditures. It's not so much price, at least in the recent five years or so. It's more about utilization and utilization of new drugs.
People are sensitive to prices of drugs and there's a public perception that drug prices are driving expenditures, but prices have been below inflation. It's more about utilization. The pharmaceutical companies would like this to be more widely known, but it takes a long time to shift that narrative. Think about patients spending so much on insulin, but that's a five-years-ago problem. Insulin expenditures have decreased over the last couple of years. Now it's the GLP-1s that have taken off, so it takes society time to catch up.
HL: Have these weight-loss drugs sufficiently demonstrated ROI to the point where private insurers would include them in their formularies?
Tichy: We know people have struggled for years with weight have now dropped weight and they're doing great. But it takes years to accrue health benefits would influence an insurance plan. It's yet to be determined if GLP-1s are "cost effective" from that standpoint. But there's more evidence every day showing that these drugs help with sleep apnea, cardiovascular diseases, joint replacements and other chronic conditions.
HL: Do you think the cost of weight-loss drugs will go down? Would any savings be offset by volume expenditures?
Tichy: Because the use is growing so fast, even if the price comes down, it's not going to show up because the utilization is just so large. In fact, the demand for these products is so strong that manufacturers can't even make them fast enough. They’re doing everything they can to meet that demand because it’s a permission slip to print money.
HL: What about the opportunities for cheaper, generic weight-loss drugs?
Tichy: We're aways off from that because of the patents. These drugs are relatively new so we're not going to see a meaningful generic competition in the next couple of years. What could happen is that there's more and more of these other drugs in development that do similar things. That'll create competition. Wegovy competes with Zepbound; different companies making a drug that has the same mechanism. We will see if there's another drug that's approved that does the same thing. So, we might see some competition in that way.
But that doesn't show up in the expenditures because a lot of times the discounts or rebates go to the PBMs. HUMIRA is the No. 2 drug spend and it has biosimilar competition, but the expenditures are still very high because there's a lot of rebates. We use purchase data, so it does get inflated with rebates that show those discounts.
HL: What effect did 340B have on hospital drug expenditures?
Tichy: 340B was a big factor that kept hospital expenditures almost flat, unlike some of the other sectors. Another factor is that the pandemic is very much over and we're no longer using the drugs that we were spending a lot of money on in the hospitals to treat COVID. And that's because people aren't ending up in the hospital with COVID and now we have oral medications and vaccines. So that has totally changed, and it's really impressive how in just a short couple of years that has shifted.
HL: We’re hearing about widespread drug shortages. Why is this happening?
Tichy: With the GLP-1s it's the insatiable demand. But most of the shortages are generic injectable drugs. A big part of the cause for that is there's just not a lot of money in those for manufacturers and there's a lot of regulatory burdens and a lot of competition. They run into quality issues that lead to recalls so there are a lot of market forces at play.
HL: What is the effect of this ongoing drug shortage on drug spending or costs?
Tichy: With the GLP-1s, if there weren't shortages this spending would have been even higher. The manufacturers are doing everything they can to make those products. It's in their best interest but the demand is so insatiable that they can't meet it. Eventually, maybe this year, they'll get to where they're meeting market demand. We did factor that in because we think that expenditures for GLP-1 are going to continue to increase at a high rate because the demand is very strong, and we know that they'll ramp up supplies.
But with generic drugs, we don't think that that has much of an impact because generic drugs are such a small percentage of our expenditures and they're just using a different drug if they can't get the drug they’d would prefer to use.
HL: What’s the next blockbuster drug?
Tichy: Alzheimer's was one of those drugs that we thought was going to take off and it has not yet, but they have the potential to be a very big market and an expensive drug. A lot of our spending growth has been with cancer drugs, and we expect that to continue. One of the hot areas of study in cancer is vaccines, whether they're therapeutic or preventative. They’re in clinical trials at this point. Nothing's FDA approved yet.
Prescription drug spending grew by 13.5% in 2023, but drug cost inflation was lower than the CPI.
The United States spent $772.5 billion on prescription drugs in 2023, a 13.5% increase from 2022, driven largely by the proliferation and popularity of blockbuster weight-loss drugs, a new report today shows.
Spending for semaglutide doubled in 2023, making it the top-selling drug in the nation, replacing the autoimmune disease drug adalimumab, which also saw sales growth despite the availability of cheaper biosimilars. Spending on the diabetes drug tizepatide grew 373% even though Food and Drug Administration approval for weight loss came in November, 2023, the report says.
Retail pharmacies accounted for $307.8 billion (42.6%) of total expenditures, mail-order pharmacies accounted for $206.6 billion (28.6%), clinics $135.7 billion (18.8%), and nonfederal hospitals $37.1 billion (5.1%).
Study lead author Eric Tichy, PharmD, MBA, division chair, supply chain management at Mayo Clinic, projects that spending on weight-loss drugs will continue to climb in 2024 and beyond as supplies catch up with the huge global demand. That growth will continue as new and similar drugs come to market and as the FDA approves the medications for more conditions.
In sharp contrast, hospitals' drug spending fell by 1.1%, continuing a steady period of falling expenditures that was interrupted during the COVID pandemic. This ongoing decline was credited to the transition from expensive COVID medications such as Remdesivir to cheaper oral treatments, the increased use of biosimilars, and the growth of the 340B program allowing hospitals to buy drugs at a discount.
"Hospitals and health systems are doing a commendable job using available tools to manage drug expenditures, which typically represent about 10% of their budgets," Tichy says. "Pharmacy and health-system leaders should persist in their proactive management and continue to anticipate disruptions that may affect drug spending."
The Inflation Reduction Act had a modest effect on drug spending in 2023, but the full effect of its savings won't be felt until 2026 for retail and mail order pharmacy and 2028 for hospitals and clinics. Tichy says Medicare drug price negotiations mandated by the IRA will reduce prices on some drugs but could also drive up spending on some drugs as more people use them.
The report also found that:
Drug expenditures in clinics grew 15%, driven by high-cost injectable medications for cancer, immunology, and neurology.
Biosimilar use in hospitals and clinics remains strong and helps contain total expenditures. However, biosimilar uptake in retail and mail-order pharmacies was more limited.
The top 25 drugs by expenditures in the U.S. in 2023 were Semaglutide ($38.6 billion), adalimumab ($35.3 billion) and apixiban ($22.1 billion).
Strong growth was booked for tirzepatide (373.1%), risankizumab (106.3%), semaglutide (100.1%), dupilumab (44.9%), dapagliflozin (41.8%), and empagliflozin (34.0%).
Sitagliptin (–9.4%), insulin glargine (–4.6%), insulin aspart (–3.5%) and insulin lispro (–1.8%) were the drugs in the top 25 with lower expenditures in 2023 than in 2022.
