Healthcare Delivery Advice for 2013: Shore Up Payment Before Shifting Model

Tuesday, October 23rd, 2012
This post was written by Patricia Donovan

Eying a move to an ACO or the patient-centered medical home model in 2013? First, adjust the payment structure to support it, advises Steven Valentine, president of the Camden Group. Shifting to one of the popular post-reform healthcare delivery models before changing the payment system is courting financial disaster, Valentine warned during HIN’s ninth annual Healthcare Trends & Forecasts strategic planning session.

Valentine charted anticipated trends for healthcare providers in 2013, while Hank Osowski and Dennis Eder, both managing directors for Strategic Health Group, covered business opportunities for health plans during the 60-minute webinar.

All of the analysts agreed that the outcome of next month’s presidential election would have little impact on healthcare reform.

“Regardless of who gets elected president, many of the things I’m talking about — bundled payment, patient-centered medical home, co-management agreements, clinical integration, accountable care organizations — are all going happen due to the economics of healthcare.”

“The reform train has left the station,” agreed Eder. “Folks who are waiting around to see what happens in the election, or who waited around for the Supreme Court decision on the Affordable Care Act, are too late.”

The election results will “likely influence the pace of change to the healthcare system, but probably not the direction,” added Osowski. The continued acquisitions and consolidations evident in the industry are proof in the market’s belief in the longevity of reform-based initiatives, he said.

Common ground across the industry continuum includes potential from collaborations — hospital-physician co-management service agreements on the provider side, and strategic partnerships in population health management on the payor side. Partnership opportunities are more plentiful now than at any time in recent healthcare history, noted Eder. “I was involved in the original integrated health world in the mid-1980’s when systems were buying both hospitals and physician organizations and starting health plans. The sincerity and the desire to work as true partners are unlike any time I’ve seen before.”

The speakers identified the strategic focus for each sector, with Valentine indicating that the key investment for providers should be on growing their population — getting as large a defined population base at the bottom of the pyramid as possible, which encompasses the access points and primary care, he said.

For payors, the industry’s increasingly population-centric, value over volume sensibility offers many opportunities in coordinated care, particularly for Medicaid-Medicare dual eligibles, said Osowski. “Duals comprise about 18 percent of the state Medicaid population, and yet they account for almost a little more than a third of the total spend on Medicaid,” he said.

Duals are a complex population with unique health concerns, requiring a strong behavioral health component. “Duals tend to be very costly because they’re typically non-compliant patients and don’t really follow what is being asked of them in terms of their healthcare,” said Valentine.

“The dual population is not just frail elders; the dual population is 40 percent people under 65,” added Eder. And the vast majority of the people under 65 are disabled because of behavioral health-related issues. So for organizations considering getting into the dual market, if you’ve just done frail elderly programs and you think you’re going to be working with that same cohort of members, it’s going to be a painful learning.”

In other trends, the industry should expect delays in implementation of health insurance exchanges (HIEs), which face significant funding hurdles, said Osowski.

Healthcare may also see the reemergence of narrow networks, in which health plan members or employers benefit from lower costs when staying within their own health systems. Individuals will still have the choice of going outside the system, but face much higher copays.

“We’re leaving choice in place, but we are getting much better at directing back to a smaller, more narrow network that will help to steer volume back to the providers, and reduce the total cost of care and the out of pocket cost for the employee,” concluded Valentine.

Listen to an interview with Dennis Eder, Hank Osowski and Steven Valentine.

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