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Good morning from Colorado, where I'm at Aspen Ideas: Health, a festival organized by the Aspen Institute. Say hello if you're here as well!

Today's word count: 755 words, <3 minutes.

1 big thing: The corporatization of hospital systems

Illustration: Lazaro Gamio/Axios

Not-for-profit hospital systems increasingly operate more like corporate titans on the stock exchanges than the charities they promote themselves to be, Axios' Bob Herman reports.

The big picture: As hospital systems have gotten larger, they have hosted more investor calls, released more financial data and attended more conferences and roadshows to attract banks and municipal debt buyers — all while health care spending continues to soar.

Where things stand: Almost 60% of community hospitals are private and nonprofit, and therefore don't pay income or property taxes. But hospitals are more on par with pharmaceutical giants and insurance companies than soup kitchens.

  • Most hospitals are part of larger systems after years of frenetic merger and acquisition activity.
  • Kaiser Permanente ranks just behind Johnson & Johnson in revenue — which would make it one of the 50 largest corporations in the country.
  • More than two dozen private, not-for-profit hospital systems would sit in the Fortune 500 rankings.

The intrigue: Hospitals that want to erect new buildings or buy new technology issue debt in municipal bond markets instead of the public markets.

  • And more hospital systems "increasingly are trying to sell themselves to investors as they expand and become more complex to ensure they get the best rates when they borrow," the Wall Street Journal reported in 2016.

The bottom line: "Not-for-profit" does not mean "no profit."

  • Hospitals are swimming in cash, which has attracted investors to them. But hospitals' financial pursuits have raised concerns about whether they are continuing to chase revenue and inflate health care costs at the expense of patients.

Go deeper.

2. Transparency order coming Monday

President Trump will issue an executive order on Monday requiring more transparency around negotiated health care prices, WSJ reports.

  • The order will direct agencies to begin the rulemaking process, which could impact insurers, doctors, hospitals and other groups.
  • It's not clear how aggressive the measure will be, especially following industry pushback.

Go deeper: Washington's favorite health policy isn't a silver bullet

3. Providers vs. surprise billing proposals

Hospital and provider groups may hate the leading House and Senate proposals for ending surprise medical bills, but the largest providers will likely be least affected, according to a Moody's analysis.

Driving the news: The Federation of American Hospitals, the American Hospital Association and the American Medical Association all oppose tying payments for out-of-network care to the median in-network rate for the service.

  • "That approach would eliminate incentives for plans to contract — and likely encourage plans to drop contracts — with providers who are currently above that amount," the AMA said in a statement.

What they're saying: This wouldn't be bad for all providers, according to Moody's — just the ones that collect higher-than-average payments.

  • If median rates are low, insurers may not have as much incentive to build provider networks, as they may end up paying less for an out-of-network claim than an in-network one.
  • Large providers, thanks to their scale and negotiating leverage, are already more likely to be in-network than smaller providers.

Overall, resolving surprise medical bills for patients is "mostly credit negative" for the industry, according to Moody's — which implies that the industry benefits from the ability to balance bill patients.

What we're watching: The change could lead to further provider consolidation, Moody's predicts.

  • The proposal "would make it more attractive for smaller group providers of anesthesia, emergency and other services to be part of a larger, in-network group," the authors write.
4. Why CVS is worried about Amazon

A lawsuit filed by CVS against a former employee suggests that major industry players are more worried about Amazon's foray into health care than they initially let on, CNBC reports.

  • Amazon gained a pharmacy arm when it acquired PillPack, and it's also part of the trio that has formed Haven.
  • UnitedHealth has also sued a former employee for attempting to join Haven.

The incumbent companies are worried that Amazon could negotiate directly with insurers, cutting out the need for pharmacy benefit managers.

  • CVS' PBM arm made up about 60% of its overall revenues in 2018.
  • "Given its robust infrastructure, operational capacity, and distribution reach, Amazon-PillPack is uniquely positioned to negotiate directly with payers (insurers) and displace CVS Caremark's mail-based services," CVS argued in a lawsuit to prevent a former employee from working for PillPack.
  • CNBC reported last month that there have been talks between PillPack and Blue Cross Blue Shield.

The other side: "It is important to keep in mind that what's being reported here is another company's speculation about our business strategy for a lawsuit to which neither Amazon nor PillPack is a party," a PillPack spokesperson told CNBC.

Read CVS' lawsuit.

5. Intensifying debate over vaccine exemptions
Expand chart
Data: Immunization Action Coalition; Map: Aïda Amer/Axios

As measles spreads, a debate is heating up nationally over whether to mandate vaccines or keep in place laws that allow for more individual choice, my colleague Eileen Drage O'Reilly reports.

Driving the news: Trust in government and in the health care system tends to be linked to people's belief that vaccines are safe, according to Imran Khan, Wellcome Trust's head of public engagement, who discussed their Global Monitor Report on a panel on Wednesday.