Health plan leaders began the year 2019 just as they did in 2018 with uncertainty over the future of the Affordable Care Act (ACA). RISE turned to industry experts for their thoughts on the ACA and what other challenges the industry may face this year. Here are five predictions from Sean Creighton, managing director of the healthcare consulting firm Avalere; John Criswell, CEO of health care data analytics and technology company Pulse8; and John Broderick, M.D., FACEP, CPE, chief clinical officer-East for the risk-based provider group Landmark Health.
1. The ACA is here to stay but components may change
Despite a federal judge’s recent ruling that the ACA is unconstitutional, John Criswell, CEO of Pulse8, a health care data analytics and technology company, predicts the health care reform law will remain in place after the legal dispute makes its way through the court system.
Neither political party really wants the ACA to go away, he says. “I think at this point they’ll be reinventing and changing the components of ACA that would enable lower costs and offer different benefit design with more metal levels,” he says.
A new Avalere 2019 Healthcare Industry Outlook report noted that while the ruling will have no impact on coverage in 2019, it will reopen Congressional debate about ACA alternatives for 2020 and in the future. Elizabeth Carpenter, policy practice director for the health care consulting firm, said in a webinar about the report findings that as the debate rages on at the federal level, some states may act to shore up the insurance market in case the judge’s ruling stands.
Sean Creighton, managing director, Avalere, a RISE board member and chair of our risk adjustment policy advisory committee, agrees with Criswell that the ACA will likely remain the law of the land. However, he expects the current administration will continue to take actions to sabotage the ACA and make it harder for people to enroll, such as not funding marketing campaigns about the open enrollment period. Like Carpenter, he believes it’s important to see what steps states take to either strengthen or destabilize the insurance markets.
“States that are pro-ACA, like California, or more actively opposed to aspects of the ACA, like Idaho, will do things that will differentiate themselves from the national program. Pro-ACA states will take steps to bolster their enrollment, and those that oppose aspects of the ACA will move in the opposite direction through waivers and encouraging short-duration plans,” says Creighton, who will be a speaker at the 13th Annual Rise Nashvillle Summit in March.
2. Disruption in the pharmacy benefit management (PBM) market
The PBM market will continue to feel pressure as new players, like Amazon, enter the health care space and consumers push back on rising prescription drug costs and insist on pricing transparency and lower costs. Criswell believes this leaves the payer space ripe with opportunities. He expects that the recent acquisitions of PBMs will only serve to drive down cost for the acquire while increasing cost for everyone else.
The Avalere report also notes that policies that change the current drug rebate model may be disruptive to pharmacy benefit managers and some health plans because these rebates are a revenue source. The current rebate model is complex and may be difficult to unwind and replace, according to the report
3. New, creative benefit designs, partnerships that address social determinants of health
Criswell also expects that payers who offer Medicare Advantage programs will evaluate benefits that address social determinants of health.
“We will see new innovative benefit design from payers that will offer more regional and state services to their membership,” he says. For example, he predicts more payers will look for new innovative solutions to address social determinants of health factors, such as transportation, nourishment, and housing.
“We’ll see payers developing partnerships with Lyft and Uber on the transportation side,” Criswell says, adding that he expects payers will increasingly rely on data from wearables to help uncover and support membership engagement.
Avalere experts agree, noting in the annual outlook report that in 2019 regulatory changes will allow Medicare Advantage plans to expand the scope of supplemental benefits that they can offer beneficiaries. They also predict that these plans will spend the upcoming year evaluating additional benefit changes that are not primarily health related but will address personal comfort or social determinants of health.
But the report cautions that it is essential for health plans to identify and link existing patient databases to provide the necessary information to effectively address social determinants of health drive improvement in outcomes and reduce health care costs for high-need patients.
John Broderick, M.D., FACEP, CPE, chief clinical officer-East for Landmark Health, one of the nation’s largest risk-based provider groups that care exclusively for complex, chronic populations, urges health plans to take advantage of the expansion of benefits under Medicare Advantage and include delegated provider groups in writing benefits.
“Value-based groups have been dealing with these complex issues for years,” says Broderick, RISE’s 2016 Martin Block Award winner. “Expanded benefits to deal with these complex issues is welcome, but these efforts need to be coordinated with medical groups, so the greatest patient value can be realized.”
4. Efforts to make better use of data to improve patient outcomes
Broderick also expects its plan partners to continue to provide the medical group with more patient data this year. But the key to improving patient outcomes, he says, is to make sure that the data is used with bedside data that is in real time and more meaningful.
He envisions integrating existing claims data with real-time data that comes through the electronic health record, phone calls, patient visits and other means of engagement. “This will allow us to react sooner to patient needs and moves us away from sick care and closer to health care,” Broderick says. “We are good with sick care. But health care means we can get ahead of a problem that could potentially occur.”
For example, perhaps the data may suggest an uptick in medications being prescribed for behavioral health. That information, coupled with data from the EHR that focuses on screenings for behavioral health risk assessments, may mean the group needs to evaluate the current staffing of its behavioral health providers and whether it needs to hire additional staff.
5. Steps to broaden coalitions with community partners
Broderick also says that efforts to address social determinants of health require medical groups and health plans to work more closely with community businesses and organizations that have an impact on their patients’ everyday lives. Landmark Health has started to work more closely with grocers to help patients make better food choices through education, encouragement and incentives. The provider group has partnered with Inland Empire Health Plan to address these needs on the west coast and with Capital District Physicians Health Plan to make inroads with patients who live on the east coast.
Many of the group’s patients are dual eligible and many of those within the population are food insecure, according to Broderick. The community partnerships include foodbanks in the area that can provide patients with no-cost foods and work with the group’s dietitian who can recommend plant-based, healthy food. The provider group has also identified a cohort of patients with diabetes who live in upstate New York and who likely get their medicines from a pharmacy that is part of a grocery store. The patient population has been invited to take part in a six-month program that will allow dietitians to help them with their food purchases and coach them to change their behaviors and make better choices that may help their underlying health since food drives much of the chronic diseases in the U.S.