TrustWorks On Call: Requiem for ACIP

Behind the Headlines

Unpacking the forces driving healthcare's biggest stories.

1. RFK fires vaccine panel as measles cases approach 30-year high.

On Monday, Secretary of Health and Human Services (HHS) Robert F. Kennedy Jr. removed all 17 members of the Advisory Committee for Immunization Practices (ACIP), a panel which influences Centers for Disease Control and Prevention (CDC) vaccine policies.
In his op-ed justifying the decision to “retire” the panel members, Kennedy said he was taking this “bold step in restoring public trust” because it would take too long for Trump appointees to constitute a majority on the panel; he also made misleading statements about the panel’s policies on conflicts of interest and transparency.
At the time of Kennedy’s decision, there have been 1,168 confirmed measles cases across 33 states this year; case counts could surpass 2019’s recent high of 1,274 as soon as this month, which would make this year have the worst measles outbreak since 1992.
According to the Centers for Disease Control & Prevention, 95 percent of cases are either unvaccinated or have an unknown vaccination status, and three deaths have been recorded so far.

TrustWorks Take: In 1989, during the last major measles outbreak, ACIP issued a recommendation that all children receive a second MMR vaccine dose, which in conjunction with a campaign for better first-dose coverage, led measles cases to plummet 92 percent in two years and achieve elimination status within a decade. Now, as measles cases are surging again, our health secretary has mass fired the very same panel, further undermining the public’s trust in science that Kennedy claims he wants to restore. Kennedy has been as much a symptom as a cause of this mistrust in public health and anti-vaccine sentiment, but this coup against scientific expertise is his most harmful and dangerous decision to date, one that could pave the way for a major regression in childhood vaccinations. He is stripping away not just people’s trust in public health but the infrastructure—the experts, advisory bodies, and funding—of public health itself. All healthcare professionals, not just those working in public health, will feel the ramifications of Kennedy’s decision here, as the impact of medicine is always limited by the public’s willingness to trust in the care they receive.

2. Payers ask Congress to limit MA home payments amid Senate bill debate.

Last Thursday, UnitedHealth Group (UHG) posted a statement calling for reform to Medicare Advantage (MA) in-home clinical assessments, while Humana is reportedly lobbying lawmakers to restrict MA reimbursements associated with in-home assessments and chart reviews.
UHG and Humana, the largest and second largest MA payers respectively, are pitching payment reforms as Senate Republicans are reportedly considering MA reforms as a pay-for in the reconciliation tax bill.
One such reform could resemble a bipartisan bill, the No UPCODE Act, that would reduce incentives for MA plans to exaggerate the health problems of plan members by extending the risk-adjustment diagnostic period, limiting payments to relevant treatments and conditions, and better aligning patient assessment under traditional Medicare and MA.

TrustWorks Take: With several Republican Senators expressing concerns over the amount of deficit spending authorized by the funding bill, the Senate GOP has gone back to the drawing board to find new sources of “waste, fraud, and abuse”. MA payment reform actually fits the bill, as up to 14 percent of MA spending over the next decade, or $1.2T, is projected to qualify as “overpayments,” largely due to upcoding and favorable selection. One key difference between the Medicaid and MA reforms considered for this bill is that the Medicaid cuts would target beneficiaries directly, by adding work requirements and altering enrollment standards, while these MA changes would directly impact private payers first (although premium increases and benefit reductions would be sure to follow). That UHG and Humana, who together cover nearly 50 percent of MA enrollees, are floating modest limitations to MA upcoding suggests they know reform is coming and want to stay ahead of it. They can afford to lose in-home assessments, as long as the core components, like benchmarks and risk-adjusted revenues, remain. By working with lawmakers, UHG and Humana are hoping to find an acceptable minimum level of regulation that preserves, if not reverses, their declining profitability in the program.

3. Omada Health marks second successful health IPO of the year.

Omada Health, a digital chronic health management company, enjoyed a successful initial public offering (IPO) on Friday, opening at 21 percent above its public offering share price.
Omada follows in the wake of Hinge Health, a virtual musculoskeletal (MSK) company, which went public in late May for 23 percent above its public offering price, although its stock price has fallen slightly since then.
Health IPOs had entered a dormant period following the post-IPO struggles of several prominent digital health startups in 2022, but the public debuts of Omada and Hinge are seen as promising bellwethers and tailwinds for the resurgence of health IPOs, albeit not to the fervent levels of 2021.

TrustWorks Take: Despite a slightly smaller stock price pop, Omada’s IPO is more bullish for digital health than Hinge’s because Omada, unlike Hinge, is not profitable yet. Investors used to frequently encourage digital health companies to pursue growth over margin, but rising interest rates and the declining fortunes of public digital health companies contributed to a period of risk aversion for healthcare investors. We’re not here to give financial advice or speculate on the future profitability or stock performance of either of these companies, but both Omada for diabetes and Hinge for MSK have massive addressable markets where effective preventative care programs could quickly and measurably impact self-insured employers’ bottom lines. They represent a new form of care supplementation. This model, emerging across many next-wave healthcare start-ups, aims to work alongside treating providers, not around them. If coordinated effectively, these niche, tech-enabled solutions could help primary care and specialty practices offload targeted services to improve efficiency. What once looked like fragmentation may instead prove to be focused specialization and a potentially valuable evolution in how care is delivered and scaled.

Beyond the Whiteboard

Visualizing key trends from the healthcare industry

The Tension Between Care Management and Profit Optimization
The health insurance industry in 2024 experienced its least profitable year since 2015. Just as care avoidance in early COVID brought insurers a record-high profitability in 2020, high utilization rates and medical costs were responsible for payers’ financial struggles in 2024. In fact, the industry was only profitable in aggregate due to investment income, as cash flow from operations was -$1.4B in aggregate. As profit margins have shrunk, payers’ use of utilization management tactics has increased. In 2024, almost 12 percent of hospital claims were initially denied or delayed by insurers, even though 97 percent of these claims were eventually paid following appeal. This represents a 2.4 percent increase in denials from 2023, even though (much-maligned) prior-authorization-related denials fell almost 8 percent. In their place, more claims were denied for lacking medical necessity or faced requests for more information, which even after successful appeal, can result in difficult payment delays for providers.

At the heart of this dynamic is the persistent tension for payers between utilization management and profit optimization. On the one hand, insurers use utilization management to control costs and ensure appropriate care through deploying tools like prior authorization, denials, step therapy, and case reviews to prevent unnecessary or duplicative services. On the other hand, these same tools can be leveraged to delay or deny care, raising concerns that profit motives are overriding clinical judgment. When financial incentives reward reduced utilization, payers risk prioritizing cost containment over patient outcomes, fueling distrust among providers and their patients, while inviting increased regulatory scrutiny. And as cost pressures mount and public funding recedes, premium increases are likely to follow, placing additional financial strain on employers and individuals alike. Providers, meanwhile, bear the brunt of delayed reimbursements and growing administrative burdens, further destabilizing their already thin margins and contributing to workforce burnout.

Dialing In

Sharing insights from our work with clients

Three AI Solutions that Solve Defined Problems
Last week, we touched on how AI is being used to automate non-clinical workflows, especially in revenue cycle and administrative ops. This sparked a few interesting conversations with clients and colleagues that set this topic up for a deeper dive. As with any new and promising tech, there’s a glut of AI solutions looking for problems to solve, and the challenge is figuring out where to begin. Most people we’ve spoken to, both vendors and clients, are more focused on nonclinical applications today. AI-powered clinical decision support, predictive alerts, and diagnostics are all rapidly advancing, but those warrant a separate conversation.

Nonclinical AI is still a wide field, so as AI vendors continue to pitch tools, we have learned to ask: Does this fix a defined pain point? Do we have the data, process, and people in place to use it well? Can we measure ROI within 6 months? Based on these conversations, we’ve identified three emergent applications and areas of immediate promise for AI:

Patient Access and Scheduling—AI chat tools are increasingly being used to triage incoming appointment requests and schedule, freeing up call center bandwidth. One client called it “the first real win” in their digital front door strategy.
Denials Management—One health system CFO told us that using AI to pre-screen claims for error codes and payer-specific rules dropped their denial rate by nearly 20 percent in just 3 months. Nothing revolutionary, but it builds well off some practice management applications. The bar for usability is just to be slightly more accurate and responsive in suggesting how to address the error than current procedures.
Coding Optimization—AI is beginning to close the gap between documentation and billing by suggesting CPT and ICD codes based on encounter notes. Some groups are piloting tools that integrate directly with the EMR and reduce coder burden by up to 30 percent. Again, somewhat duplicative, but it can stack well with existing efforts to optimize revenue cycles.

AI may be automating the revenue cycle process one component at a time, but none of these are “plug and play.” Success depends on workflow integration, internal ownership, and a clear change-management plan. One CMO we spoke to summed it up well: “The tech is fine. It’s our operations and workflows that are messy.”

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Requiem for ACIP