Look at the world of healthcare! Everything seems to be changing, by the day and in all sectors! One thing’s for sure, best stated in the unchanging (and dead) language of Latin: “Non tamquam dies hesterna,” which translates to “it was not like yesterday.” Nowhere is this more true than in healthcare. I like change but am having a tough time keeping up with the pace of healthcare change! When you look at key healthcare service sectors, the amount of change just on the surface is astounding. Here are just a few lightning strike, top-line, non-exhaustive views from key industry sectors.
If you are following insurers, good luck! Just look at the current models in play, HMO, PPO, PCMH (patient centered medical home), ACO and private ACO-like models, CMS Pioneer ACO models, state health exchanges and many more. Not to mention the changes occurring in Medicare and Medicaid rules, eligibility, payment and care inclusions and exclusions. Today, almost all insurers are staffing in-house integrity and compliance units to help minimize fraud and abuse. Quality of care units are testing the adequacy of existing quality controls and testing quality in care management, care coordination and claims payment. To keep health plan administrators up nights, are the payment outflows timely and consistent with the income previously projected based on the current medical loss ratio? Has the plan charged the right premiums and incentivized its network of care providers with pay for performance quality of care measures? Do we have enough members, especially healthy ones?
If you are a physician today you’ve got to worry about building your practice. Your key nightmares are: if, how and what you got paid, and what plans do you continue to accept in the office? And new pressures are mounting, including: what networks to belong to; what health plan contracts to accept and reject; what hospital(s) to affiliate with, and the benefits of solo or small practice vs. part of a large group practice. Oh and by the way, how is your practice supposed to afford all this technology, fill out these required reports and still manage to give patients quality personalized care with excellent health outcomes?
If you’re managing a hospital, the questions are whether or not to have hospitalists, affiliates, or staff specialists. How to diversify, integrate and manage our clinics, and what sorts of clinics to operate? Should we buy physician practices, and if so, which ones? Do we affiliate with other hospitals, systems, or an academic medical center? How do we negotiate reasonable contracts with insurers for the best payment rates? How do we effectively balance insured and under-insured populations? Are we effectively serving the health care needs of our community? How do we maintain a talented and dedicated professional staff?
If you are in the pharmaceutical industry, the use of generics is now the rule of the day. Brands better be innovators to survive and recoup their research investments. Specialty and biotechnology drugs are on the upward trend and are very costly to develop, distribute and monitor for safety. Formularies and prior authorizations are everywhere. Hold it, 340b drug reimbursement is expanding and that’s below market reimbursement designed for low income patients. This was a program that was only supposed to be in 90 locations; now there are 1700 340b locations and growing. And the ACA brings a host of new rules that are starting to come online for example, industry now must report any payments to hospitals or physicians in order to assure integrity.
In the 21st century, a key to success in medicine and in business will be getting patients to adhere to their medications and to take their drugs safely and correctly. That means properly educated patients. Is there a new role for sales forces here, especially in light of the growth of managed care?
If you are in pharmacy practice, be prepared for more prescriptions as health plan rules on medications change and access improves. Walgreens, CVS, and others are already deep into in-store health clinics. Big or small, partnering with other healthcare providers for medication management, patient education, adherence, and persistence will be the hallmark of the best and most innovative pharmacies.
My head spins when I think of all the changes that are occurring today and wonder what things will look like tomorrow or next month!!! Nothing, to me, is more important, and more worthy of following, than the fast-paced changes occurring every “tomorrow” in healthcare.
By Philip P. Gerbino, PharmD, President Emeritus, University of the Sciences