“This gets back to the fundamental lesson of political survival that Bill Clinton taught me, which is if you make it about the American people’s lives instead of your life, you’re going to be okay.” — Paul Begala
It’s March, 2015. Healthcare reform has now been active for over five years with the majority of reforms kicking in as of January 1, 2014. Several amendments have been proposed and passed in the interim period including the All-Payer Act normalizing reimbursement rates for hospitals between Medicare, Medicaid and private insurance.
The American Family Practice Reimbursement Act promulgated minimum reimbursement levels for primary care providers acting as part of accountable care organizations and included a package of incentives for medical graduates and nurse practitioners to practice primary care. A particular emphasis was paid to establishing federally qualified health centers in urban and rural areas where Medicaid statistics reveal high rates of chronic illness and minimal levels of compliance with requisite preventive care to arrest the erosion of chronically unstable patients into catastrophic illness.A final legislative action – passed in December 2014, increased the individual mandate penalty for failure to purchase healthcare to be equal to the average of the lowest cost plans within state health exchanges. The amendment was borne out of actuarial forecasts that health exchange healthcare plans were experiencing adverse selection – with younger, healthier workers choosing to pay the de minimus annual penalty of $ 695 in lieu of purchasing coverage whose costs exceeded this amount.
Healthcare costs continue to rise but are projected to moderate with Medicare forecasting its lowest trend in five years. Private healthcare trend has moderated substantially for small business and individuals but it still plagued by rising expenses as employers resist adopting more aggressive lifestyle based population health management plans.
After hitting a high water mark for overall medical trends in 2012, hospital trends are forecast to be increasing only 4%, specialty moderating to 3%, prescription drug costs are still hovering at 10% and are a source of great debate among those in Congress who are arguing for more efficacy and value based reimbursement. Primary care costs have risen sharply but have been more than offset by less inpatient and specialty services consumption.
As we glance across the field of stakeholders, we can see how each is faring in a brave new world that is emphasizing prevention and consumer engagement:
Insurers – Insurers have ceded higher profit margins realized in the individual, Medicare Advantage and small group business as a result of the gradual reduction of their 14% Medicare subsidy and their participation in profit margin controlled health exchanges. Insurer market share has increased overall but is more distributed as all payer reimbursement legislation removed barriers to entry for new consumer focused insurers to enter the marketplace. Insurers have shifted from opaque and complex provider contracting to focus on consumer activation, public health improvement and patient advocacy and satisfaction.
Insurers are now better branded and enjoy a more trusted role as a healthcare system ombudsman. Aetna’s purchase of Athena Health and United’s acquisition of Web MD and Revolution Health demonstrate the commitment that insurers are making as the invest in health information technology and consumer/provider data management services. Carriers are striving to drive value to be considered worthy of margins beyond utilities. A key strategy has been the hiring and engagement of B2C business professionals solving for the compromises that have frustrated consumers for years.
Insurers have worked with CMS to aggregate clinical data on quality and efficiency of doctors and hospitals to create a credible, non-partisan consumer report to help patients make more informed choices of providers. High performance networks have become the norm to ensure optimal value over an entire episode of care. Primary care reimbursement has increased over 30% for family practice providers as insurer medical home and population health improvement incentive programs reimburse family practice providers to keep patients well or stable when chronically ill. Insurers have become better community stewards recognizing that healthcare is local.
Brokers/Consultants/Agents – Total transparency marks the year 2015 as broker, agents and consultants remuneration is shared with all employers. As small group purchasing consortia reduce administrative costs, brokers and agents consolidate creating four dominant brokerage and consulting firms representing employers as they structure their benefit programs. Consolidation is a prerequisite to affording the resources necessary to add value to employers.
Insurance brokerage and consulting becomes less about relationship management, and annual marketing of insurance and more about serving clients as an extension to their Human Resources and benefits department. Many brokers and agents have failed to justify their role as an intermediary that impacts medical trend and have disappeared. Those that have survived are distinguished less by the marketing of insurance and more by harnessing clinical, underwriting, administrative, compliance and population health management programs to advise small, medium and large employers on how to best manage and finance healthcare risk.
Hospitals – our most expensive delivery systems have endured substantial turmoil and change as all payer legislation and market forces have pushed facilities to focus heavily on outcomes and value. Hospitals have accepted value-based healthcare and risk transfer through global case rates – helping actively manage the assembly line of care to patients being delivered by multiple providers within the inpatient setting.
Intensity of services have declined as well as inpatient days. Survivor hospitals have invested in outpatient treatment centers and now triage patients through a more coordinated disease management process. Tied to accountable care organizations, hospitals remain integral partners but are less likely to be the first point of entry into the health system for critically ill patients. Waiting times increase in some markets as occupancy increases. A private, non network of concierge hospitals begins backed by private equity firms expecting demand for private elective surgery to increase. Consumers continue to consider non US centers of excellence for elective procedures using medical tourism benefit plans that supplement traditional hospital coverage.
Big is no longer necessarily better. Outcomes are marketed over capabilities. It has been a turbulent time for the SEIU 1199 health workers union as hospital closures and restructuring resulting from reimbursement reforms linked to quality and efficiency have reduced over-saturation of services in certain markets.
Those hospitals once perceived to be most at risk due to their dependence on Medicare and Medicaid reimbursement have become models for business transformation as bigger systems struggle to change. Total transparency of costs of services and clinical outcomes have become the norm.
A controversial but equally effective decision to regulate rates for certain types of admissions at academic medical centers ( teaching hospitals ) has also better aligned disparities in charges where improved clinical outcomes could not be proven.
Specialists – Specialists have reluctantly yielded to a brave new world of reduced reimbursement, consolidation and the first decline in new practice growth as medical graduates redirect back to family medicine. For the first time in 2015, family practice rates of graduation gain on pathology, radiology and anesthesiology from historic lows of 2% in 2009.
Specialty remuneration is now more closely managed as medical home plans reassert control of care, pre-empting self-referrals and over-treatment more characteristic of the early 2000s. The expanded role of nurse practitioners and physician assistant further narrows the scope of specialists as basic care and triage for routine conditions returns to a medical home setting. Tension has increased between specialists and family practice only now the resentment has been reversed. Specialists portend a huge capacity problem as Americans live longer with chronic illness and fewer providers are available to treat them.
Government – Federal and state agencies have made modest strides to controlling the cost of existing entitlement through clinical and medical management services, not just through serial underpayment. With improved oversight Medicare and Medicaid, States and the Federal government has successfully clawed back up to $35B a year in fraud and waste. The additional savings coupled with higher payroll taxes for higher wage earners, global case rates for hospitals, effective disease management and fee cuts aimed at over-treatment has helped finance subsidies for the expansion of primary care. Government will enforce Certificates of need and moderate the medical device and specialty care arms race of medical device purchases and redundant care delivery.
States have redirected additional saving to increase Medicaid reimbursement rates improving the circle of providers willing to accept expanded roles of Medicaid based patients for treatment. As more patients find a medical home and are stabilized, emergency visits reduce and incidence of preventible catastrophic illness improve. States have adopted interest free medical school loans to students electing to practice primary care as part of the companion legislation in The American Family Practice Reinvestment Act.
The government finally amends its weak individual mandate penalties and ties the minimum tax to the cost of the lowest price market option so that no incentive exists for individuals to game the system. States are still struggling with obligations for retiree healthcare – specifically long term care obligations that were not addressed in prior health reform legislation.
Skilled nursing is costing states as much as $80,000 per participant. State budgets comprised primarily of education and healthcare spending continue to look to the federal government to increase subsidies to cover sun-setting Medicaid support and increased cost of labor as unions have turned their focus to increasing wages to offset expected taxes on cadillac plans designs.
The $ 40B of investments appropriated during the 2009 fiscal stimulus package in health information technology and physician and hospital practice transformation has paid huge dividends in coordination of care and the reduction of waste. After digesting CMS and ONC regulations on ‘Meaningful Use’ and standards for the Electronic Health Record Incentive, an impressive 65% of medical records are maintained by providers and hospitals with outliers paying penalties of reduced reimbursement for failure to comply with 2011 HIT regulations. While 15% short of the legislated goal of 80%, the information technology transformation has drawn the US closer to other industrialized nations for digital medicine and is hailed as an unmitigated success by the White House.
Government has finally struck middle ground with the all powerful plaintiff’s lobby to modify medical liability law focusing on practical changes designed to reduce the frequency and size of medical liability awards. Particular attention has been paid to creating tighter controls over punitive damage claims when physicians have followed proven clinical best practices in the treatment of care.
Health tribunals and caps on punitive damages have become mandatory for plaintiff complaints where providers have been proven to follow evidence based guidelines. Liability premiums have fallen 40%. The additional insulation from risk affords doctors greater confidence in avoiding expensive overtreatment and reduces clinical variability which results in billions in unnecessary care each year.
Congress has promulgated all payer reimbursement reform blending rates paid for Medicare, Medicaid and private insurance. The National Reimbursement Parity Act was initially met with huge resistance from traditional fee for service hospitals but has helped eliminate cost shifting, create a more unified public/private focus on clinical outcomes, reduced variability of care, encouraged population health management and reduced barriers to entry for new insurers to compete for individual and small business.
The projected net present value of the Medicare deficit has been moderated by this reimbursement legislation and the projected savings has extended the life of the Medicare trust as well as bent the medical inflation cost curve. US debt standing has improved which in turn, has reduced yields on treasuries – improving credit availability for many businesses, especially those restructuring old debt covenants forged during the tighter times of the 2011-2012 credit crunch. The dollar is slowly strengthening.
Consumers – Medicare recipients now accept medical home models as a necessary access point to the healthcare system. Focus is on personal responsibility and the elimination of barriers to care (reversing years of peanut butter spread increased co-pays and deductibles that characterized employer sponsored care in the late 90s and early 2000s).
Employers and providers now understand that they must engage consumers to keep healthy. Consumers participate in health plans that can offer up to a 50% “incentive ” to participate and comply with expectations for regular care and maintenance. Electronic Medical records allow providers to better manage the treatment of patients with co-morbidities such as diabetes, cardiovascular disease and chronic pulmonary complications.
Compliance with tests such as A1-C tests for blood sugar are being embedded and monitored. Home healthcare is delivered through accountable care organizations and federally qualified family practice centers that seek to reach under-served, high risk populations using telemedicine and nurse practitioners whose roles have been broadly expanded in family practice.
Patients have slowly been socialized to routine compliance calls from nurse practitioners and physicians urging them to follow up with tests, maintenance drugs and check ups. Patients understand their physicians will be rewarded for health maintenance and catastrophic cost risk mitigation restoring trust in reimbursement incentives and payers.
72% of Americans in 2015 are now accessing healthcare through a primary care provider and employers are seeing a steady reduction in ER visits for routine non-emergency treatment that characterized the early years of health reform where newly insured accessed care through hospitals due to an absence of primary care. Individuals now check their biometric health indicators through work site and public kiosks, health clubs and primary care provider offices to measure progress on key health management indicators. Reductions in heath risks are rewarded with higher subsidies for individuals and lower costs of contributions to employer based plans.
Consumers are encouraged to engage in end of life care discussions with providers who are graduating medical schools with a greater focus on life quality versus life extension. The hospice and alternative home healthcare industries have expanded to accommodate a new set of incentives designed to give patients greater control and dignity through the process of coping with catastrophic illness.
With healthcare guaranteed, job mobility increases as job lock due to healthcare is eliminated. Small businesses develop in myriad industries and the economy begins to see a new generation of cottage industry workers evolve out of a model that offered the best protection for employees covered under employer sponsored plans.
Employers – Perhaps the most engaged stakeholders, mid-sized and larger employers have now accepted their reluctant role as the catalyst for market reforms. In striving for low single digit medical trends, employers have finally elected to focus on population health improvement, compliance, value based plan designs, medical home, specialty services for key chronic illnesses such as diabetes, cardiovascular disease and orthopedic care.
Partnering with CMS and private insurers, employers have taken a front seat as the market force advocating the adoption of gate keeper, medical home models and high performance networks to reduce, streamline and re-balance secondary and tertiary care in America. The C-Suite has finally realized that healthcare can be managed similar to workers compensation with loss control programs designed to eliminate, reduce and manage health risks in their population. Improved productivity, lower medical and controlled workers compensation costs through a healthier workforce begin to roll into employer’s operating income helping improve GDP. States compete for businesses through tax incentives and by advocating a healthier worker population.
Pharmacy – Big Pharmacy and intermediaries such as Pharmaceutical Benefit Management firms have slowly seen margins squeezed. $ 4 generics through Walgreens, CVS, Walmart and others have narrowed margins considerably. Specialty drug costs have been finally identified as a source of low value, high inflation expense and are being held to a higher standard based on value based efficacy. A new piece of bi-partisan legislation, The RX Reimbursement and Parity Act will strive to normalize CMS and private insurance RX reimbursement and develop a common formulary for brand and generic average wholesale pricing.
Providers will no longer be able to buy drugs wholesale and sell them at as much as a 50% retail mark-up to patients as was the practice of oncologists in 2012. There will be a slow push to close the gap between US retail pricing and non US wholesale pricing – mitigating the artificial subsidy that US healthcare patients finance for other countries consumption of US drug products. Legislators with large concentrations of bio-pharma industry are wary of this level of intrusion in the bio-tech markets.
Patent protection is now prioritized by social need and based on evidence of impact. Pharma salesforces have been pruned substantially to partially offset margin declines as physician decision support tools ushered in by a new generation of electronic medical records and health information technology has transformed doctors offices and better coordinated on and off label use of medications.
A False Positive ?
As we stare into our crystal ball, we wonder whether this vision is but a dream or a potential reality borne out of a confluence of public policy and market forces. In a free market economy, balanced symbiosis can be accomplished through a variety of careful interventions. When ecosystems become wildly imbalanced, calculated adjustments are necessary to restore equity and efficiency.
2015 is about balancing public and private responsibilities. There are no victims or villains in this discussion. The conversation needs to shift back from politics to policy. Everyone has their fingerprints on the problem and can contribute to its solution. We need to excuse from the discussion those who choose to remain too committed to the status quo and those whose angry populism has compelled them to advocate massive public policy interventions without understanding the downstream impacts on quality and our economy.
It is unlikely that we there will be only one winner. In this fight for the future, we all win or lose together.
Mike Turpin is frequent speaker, writer and practicing benefits consultant across a 27 year career that spanned assignments in the US and in Europe. He served as the northeast regional CEO for United Healthcare and Oxford Health from 2005-2008 and is currently Executive Vice President for Benefits for the New York based broker, USI insurance Services.