Marco's Morning Report — Wednesday, August 26, 2026

A · Top Stories

Measles

Two unvaccinated Pennsylvanians dead — first US measles deaths of 2026

Pennsylvania's health department confirmed Tuesday that two unvaccinated residents in Lancaster County died of measles, the state's first measles deaths in 35 years and the first reported anywhere in the US this year. Pennsylvania is now at 393 confirmed cases, 86 of them diagnosed in the past week alone, with 70 hospitalizations. Nationally the CDC counted 2,777 confirmed cases as of Aug 20 — the worst year since 1991, with roughly 94% of cases outbreak-associated. PAHO is expected to rule this fall on whether the US keeps the elimination status it has held since 2000.

Why it matters to you: the mortality here is landing in adults, not just kids, and adults are who you admit. Your practical exposure is the febrile-rash adult who sits in the ED waiting room for three hours before anyone says the word "measles." Also worth knowing which of your elderly patients are actually protected: born before 1957 is presumed immune, but the 1963–1968 cohort got a killed-virus vaccine that doesn't count and needs revaccination — that's people in their late 50s and early 60s now, well inside your admitting population.

Action: ask infection prevention what actually triggers airborne isolation in your ED for a febrile adult with a rash, and whether the trigger fires before or after the ID consult. Worth two minutes at the next group meeting.

Washington Post · CNN · PA DOH statement · CDC case data

Update · Dengue

Local dengue keeps moving north — now signals in Hillsborough and Pinellas

Update on yesterday's Citrus County item: WUSF reported Tuesday that Hillsborough and Pinellas are showing further signs of locally acquired dengue. Florida is at 23 locally acquired cases this year across five counties, and Hillsborough alone accounts for 15 of them. The serotype data is the part worth reading twice — it points to sustained local circulation in Hillsborough rather than a scatter of separate travel-linked introductions. Citrus County remains the northernmost case of the year.

Why it matters to you: a negative travel history no longer rules dengue out anywhere on this coast. For an elderly admit, the tell is the combination you'd otherwise attribute to something else — fever with a falling platelet count, rising hematocrit, and a transaminase bump — and the danger window is defervescence, not the fever itself. NSAIDs and prophylactic anticoagulation decisions change if this is on your differential.

Action: if you haven't already, confirm whether your lab runs dengue NS1 antigen and IgM in-house or ships to the state lab, and what the real turnaround is. A five-day send-out is not a usable test for an admitted patient.

WUSF Health News Florida · Citrus County background · CDC dengue data

B · The Debate

Should traditional Medicare use prior authorization — with AI in the review loop — to police low-value care?

Why it's live right now: comments on CMS's CY2027 Hospital Outpatient proposed rule close Sunday, August 31, and the rule would add eight more service codes to prior authorization in fee-for-service Medicare starting July 2027. That lands on top of the WISeR pilot, which has been running AI-assisted prior authorization in six states since January and which the Senate declined to repeal earlier this year.

The case for

Brian Blase, Paragon Health Institute

Traditional Medicare is the one large payer with essentially no utilization review, and the improper-payment numbers show what that costs — an HHS OIG audit found $580 million in improper psychotherapy payments in a single 12-month window. Congress already gave CMS the authority to require prior authorization for outpatient services showing abnormal volume growth, and GAO recommended in 2018 that the agency use it more, not less. Targeting the specific codes where utilization has run away from clinical need is narrower than a blanket policy and cheaper than chasing the money after it's out the door. Paragon's comment on the 2027 OPPS rule

The case against

Sen. Ron Wyden (D-OR), Rep. Suzan DelBene (D-WA)

The mechanism, not the goal, is the problem: seniors in six states are finding that care their own physician ordered has been slowed or stopped by what Wyden called "a shadowy, AI-driven third party," and the vendors running those reviews are compensated in part on the volume of care they deny. An AMA survey found 89% of physicians say prior authorization sometimes or often delays care and roughly a third have seen it contribute to a serious adverse event. Importing that machinery into the program specifically designed to avoid it inverts the trade patients made when they chose fee-for-service. DelBene et al. letter to CMS, June 2026 · STAT on WISeR delays

Where it might land: the comment window shuts August 31; a Ban AI Denials in Medicare Act has been introduced in the House but the Senate already voted down a repeal resolution, so the near-term decision point is the final rule rather than legislation.

C · On My Radar

Hospitalist burnout, measured. SHM's 2026 Hospital Medicine Workforce Experience Report (released this month) found more than 45% of 900+ hospitalists surveyed are burned out and only 24.3% feel professionally fulfilled — still among the highest burnout rates of any specialty. SHM

Mets 3–2 over Milwaukee in 10. Lindor made a bases-loaded diving stop in the ninth and scored the winner on a throwing error in the tenth; his homer was his 154th as a Met, tying Dave Kingman for sixth on the franchise list. Benge notched his 11th three-hit game, most among big-league rookies. Mets are 60–72 but 13–6 since the deadline sell-off. ESPN recap

Iran: "Operation Economic Outcast." Treasury sanctioned 60+ entities, individuals and vessels Monday in what officials billed as an economic D-Day; Tehran vowed a "seismic" response. Al Jazeera's analysts read the package as pressure without much remaining leverage, six months into the war and past the expired ceasefire window. Al Jazeera

Puerto Rico's water emergency grinds on. Roughly a quarter of the island is in severe drought with another third moderate; 500,000+ people remain on rotating 48-hour shutoffs, and AAA still loses about 65% of the water it produces to leaks. Connecticut is assembling technical and financial aid. González spent Tuesday pitching the island as "open for business" from the NYSE. Al Jazeera · CT Public

Cuba's grid. The state utility projected a 2,170 MW shortfall against peak demand for Tuesday, after a 2,211 MW deficit the night before — service disrupted all 24 hours. Solar parks contributed 4,632 MWh. This follows the sixth full national grid collapse of the year on Aug 2 and an 80%+ drop in Venezuelan oil deliveries since January. Unión Eléctrica figures via Cubadebate

Watchlist, screens. The Whisper Man hits Netflix Friday (De Niro, Adam Scott, Michelle Monaghan) — no reviews posted yet, so file it as a maybe. Dark Matter S2 also lands Friday on Apple TV+ with Joel Edgerton back. RT

Golf tech: no new developments in the last 48 hours — 25th straight day. Pipeline unchanged: Shot Scope LM1 at $200, Par Breaker Swing Pulse X10 under $800 with dual-camera tracking. GBN roundup

D · Trends to Watch

Vaccine-preventable mortality is becoming a bedside problem, not a policy abstraction. For two years the measles story was case counts and elimination status; this week it became two death certificates. The lagging indicator has caught up to the leading one, and the clinical consequence is that hospitalists in states with soft coverage now need airborne-isolation reflexes they haven't used since residency.

Travel history is doing less diagnostic work in Florida every season. Aedes-borne disease is widening its footprint north — five counties with local dengue, sustained circulation in one — which means the screening question that used to sort dengue in or out is now close to useless west of I-75.

Utilization control is migrating into traditional Medicare just as it's driving providers out of Medicare Advantage. Becker's is now tracking 25 health systems that dropped or narrowed MA contracts in 2026, most citing prior-authorization denials — at the same moment CMS is importing the same mechanism into fee-for-service. Watch whether "traditional Medicare has no prior auth" survives as a reason patients choose it. Becker's

Infrastructure failure is showing up as a health-system variable. Puerto Rico's water rationing and Cuba's rolling generation deficits both cash out the same way — dialysis schedules, refrigerated medications, oxygen concentrators at home, and dehydration admissions in heat indices near 110°F. Worth watching if the Caribbean drought persists into hurricane season.

E · Ideas & Opportunities

Comment on the CY2027 OPPS rule before Sunday. The window closes August 31 and hospitalist perspective on prior authorization in fee-for-service is thin in the docket compared with specialty societies. Even a short comment on discharge delay is on-record input. Federal Register

Benchmark your group against SHM's numbers. 45% burned out / 24.3% fulfilled is now a published reference point. Knowing where your nocturnist block sits relative to that is a better opening at a group meeting than an anecdote — and the report's addendum breaks it out by census and clinical FTE.

Two-minute audit worth doing: does your admission template capture MMR status for adults, or only for pediatrics? The 1963–1968 killed-vaccine cohort is now squarely in your admitting age range and nobody is asking them.