Means to the Same End?
March 3, 2026
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Welcome to TrustWorks On Call, here with your healthcare business and strategy 411 for the week. If you enjoy our work, please consider forwarding it along to a friend and encouraging them to subscribe.
This week, we go Beyond the Whiteboard to show the generational impact on healthcare demand, and we’re Dialing In on Medicare’s fickle payment pilots. But first the news, starting with President Trump’s second nominee for surgeon general, Casey Means, facing serious questions about her lack of credentials after his first nominee, Dr. Janette Nesheiwat, was withdrawn for exaggerating her own:
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Behind the Headlines
Unpacking the forces driving healthcare's biggest stories.
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1. Surgeon general nominee faces uncertain confirmation.
- Last Wednesday, the Senate health committee held its confirmation hearing for Casey Means, a Stanford School of Medicine graduate turned social media influencer who is President Trump’s nominee for surgeon general; after the hearing, at least two Republican Senators, whose votes she needs to advance to a full confirmation vote, said they remained undecided.
- Issues holding back Means’ confirmation include her lack of an active medical license, noncommittal stance on vaccines, and potential conflicts of interest from her career as a Make America Healthy Again (MAHA) influencer.
TrustWorks Take: The GOP-controlled Senate has pushed back only minimally on President Trump’s nominees, but healthcare has caused him the most trouble. His original nominee for surgeon general, Dr. Janette Nesheiwat, was withdrawn after she was found to have misrepresented her medical credentials. And Dr. Dave Weldon’s nomination for Centers for Disease Control and Prevention (CDC) director was sunk over his past statements on vaccine safety, leaving the CDC still without a permanent director. The steps taken by Health Secretary Robert F. Kennedy Jr. to upend vaccine policy have also been a source of tension for pro-vaccine Republicans, like Senator Bill Cassidy (R-LA), a medical doctor and the chair of the Senate health committee, who has refrained from publicly criticizing Secretary Kennedy’s leadership.
Casey Means’ long-delayed (partly due to having recently given birth) nomination for surgeon general now arrives as the Senate GOP is reevaluating how the MAHA agenda will impact the midterms. Once again, vaccine policy has taken center stage. Senator Murkowski (R-AK) questioned Means on her criticism of childhood hepatitis-B vaccinations, and remains a pivotal, undecided vote. Means’ significant lack of experience and inactive medical license, which President Trump’s first surgeon general believes should disqualify her from assuming the position, could also provide cover for Senators looking to oppose her nomination. And if she does earn the Senate’s confidence, she will be obliged to evolve her messaging from individual choice and “shared clinical decision-making” toward a societal understanding of public health. Her vision ought to forefront the people who do not have time to discuss everything with their doctor. |
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2. Major payers undergo leadership shakeups.
- Last Thursday, Elevance Health announced several changes to its top management: CFO Mark Kaye is now overseeing Carelon, Elevance’s health services division, after its president announced his planned exit; and Felicia Norwood, who headed up government benefits, will now be responsible for all insurance operations as Chief Health Benefits Officer.
- Former Optum CEO and longtime UnitedHealth Group (UHG) executive Heather Cianfrocco shared on LinkedIn last Friday that she was leaving the company after 24 years; Cianfrocco was Optum CEO from April 2024 to April 2025, when she was replaced by current Optum CEO Dr. Patrick Conway.
- Breaking the news on Tuesday (just before this newsletter publishes), Cigna announced that David Cordani, its CEO of 17 years, will be transitioning to executive chair of its board of directors, with COO Brian Evanko succeeding him as CEO.
TrustWorks Take: Elevance and UHG both forecasted revenue declines for 2026, offering yet another bump in the road for these for-profit payers looking to regain investor confidence. In the last year, Elevance’s stock price has fallen 27 percent, and UHG's has dropped 38 percent, as the payers’ profits have declined thanks to higher-than-expected care utilization and stingier payments in Medicare Advantage (MA). From 2024 to 2025, Elevance’s operating margin on health benefits dropped from 4.2 to 2.5 percent, and UHG’s fell from 5.2 to 2.7 percent. In an effort to limit exposure to high-cost enrollees, UHG and Elevance, which cover the largest and fourth-largest MA enrollment populations respectively, both significantly reduced their enrollment in 2026.
Payers originally pursued vertical integration strategies to diversify revenues in the face of capped insurance profits, but their health services arms are struggling with profitability, too. Elevance’s provider business, Carelon Services, has posted a declining operating margin for two years, but its rapid revenue growth, roughly doubling since 2023, justifies a small decline in efficiency. Optum, on the other hand, saw its margin nearly cut in half, from 6.6 percent in 2024 to 3.5 percent in 2025, including its provider arm, Optum Health, losing money on operations last year. With MA's “golden goose” era ending, payers need their health services businesses to deliver profits more than ever. These leadership changes are part of a larger realignment to focus on company-wide margin improvement in place of their previous strategy of growth at (nearly) any cost.
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3. FDA wants to bring drugs to market faster.
- Last week, the Food and Drug Administration (FDA) proposed creating a new standardized pathway for drugs that treat rare diseases to be approved, since these treatments are not suited to large clinical-trial studies.
- Earlier in February, the FDA lowered the number of rigorous clinical trials it required to approve a new product from two to one, hoping to prompt a “surge in drug development” by shortening the approval process.
- Separately, the Commissioner’s National Priority Voucher Pilot Program (CNPV), announced last June and intended to provide “ultra-fast” approvals for “companies supporting US national interests," has reportedly caused alarm among FDA staff, some of whom have felt pressured to meet unreasonable review deadlines.
TrustWorks Take: Under Commissioner Dr. Marty Makary’s leadership, the FDA has pursued a deregulatory approach that should reduce the time and money it takes to bring a drug to market, at the expense of some consumer safeguards. Less thoroughly reviewed drugs will reach patients in need faster, but there will be heightened risks of undetected side effects making it into the market. For rare and serious diseases with few-to-no treatment options, this tradeoff is likely to be worth it.
The concern over the CNPV, on the other hand, is that the criteria by which the drugs are selected, as well as the expedited timeline by which they are approved, are opaque and possibly subject to political influence. If a CNPV drug that makes it to market is later revealed to have serious side effects or safety concerns, it could severely damage the public’s faith in what it means for a drug to be FDA-approved, which to this point has been a gold standard. |
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Beyond the Whiteboard
Visualizing key trends from the healthcare industry
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Millennials May Finally Save an Industry
Millennials, the generation of people born between 1981 and 1996, have been accused of “killing” every industry from restaurants to gyms, as cover for these industries failing to adapt to the consumption habits of what is now America’s largest generation. In an ironic twist, healthcare providers’ continued reliance on commercial plan revenues to “cross-subsidize” services “underpaid” by Medicare and Medicaid may remain viable for longer than expected, all thanks to Millennials. By 2030, all Baby Boomers will have turned 65 and aged into Medicare, and Generation X is too small to sufficiently replace the commercial volumes of Baby Boomers. However, the eldest Millennials are now turning 45, perhaps the unofficial start of the human body’s “breakdown years,” during which time a person’s healthcare needs and spending rapidly escalate. This presents significant revenue opportunities for providers able to meet this demand, but only if they meet Millennials where they like to receive care.
For example, Millennials are far less likely to have a primary care provider (PCP) than previous generations, in part due to having come of age in the era of high-deductible health plans. Inspired by these plans to seek care reactively rather than proactively, Millennials have a higher reliance on urgent care clinics and emergency departments, as well as a preference for going straight to specialists. A lifetime of paying for care out-of-pocket has led Millennials to internalize the logic that they are consumers first and patients second. The providers who can offer this generation the highest-value experiences will be the ones to retain their business, whereas those that refuse to evolve may go the way of napkins, formal dress codes, American cheese, and doorbells (and the list goes on).
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Dialing In
Sharing insights from our work with clients
Against “Acronym Du Jour” Policymaking
A physician I have known for decades decided a few years ago to step away from his large, suburban multi-specialty practice, move to the Finger Lakes in upstate New York, and practice primary care in an underserved area—his way of “giving back” while easing into semi-retirement. When we caught up recently, he had a bone to pick with CMS policymaking. “Have you heard about the latest acronym du jour? REACH is out, and LEAD is in. I cannot keep up with this anymore.” He was referring to a succession of Medicare accountable care organization (ACO) models, and I knew part of his frustration stemmed from his local community hospital having lost federal funding when CMS announced the early termination of “Making Care Primary,” a CMS pilot that was supposed to last ten years and was cancelled within two years. They have been encouraged to apply for LEAD, which he bemoaned as a “completely different model.”
After more than a decade of pilots, demonstrations, and rebrands, ACO participation is uneven, provider fatigue is real, and aggregate savings are incremental at best. Each new “acronym du jour” arrives with ambition and exits with a press release, scattered like seeds on barren soil. The models change faster than practices can retool their workflows, making it virtually impossible for communities and providers to invest in and deliver a different kind of care. But acknowledging underperformance of the models does not require declaring the entire project of value-based care a failure. The underlying premise that, by giving providers accountability for total cost and quality, we should reward outcomes over volume remains directionally right. What has been wrong is the tempo and the tenacity. Value-based care requires a different operating system, but instead we have been layering patches onto fee-for-service and wondering why performance remains unstable. You cannot redesign healthcare within a two-year demo window. Rather than chasing the next acronym, providers want commitments toward longer-term program stability, benchmark longevity, and sustained investment in care redesign.
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