Working as a managed care executive in today’s healthcare environment is a demanding role. According to Managed Healthcare Executive's 2016 State of the Industry Survey, challenges abound. Government requirements and mandates, such as implementing value-based reimbursement, are difficult to meet. Meanwhile, employing new technologies, such as electronic health records and data analytics, is no easy task. Pharmaceutical costs continue to rise dramatically, burdening the entire system.
The survey findings, based on 160 responses, show the biggest challenges that executives at health systems, health plans, pharmacy benefit organizations, and more anticipate next year. Here's a closer look at the survey results, and what industry experts say organizations can do to overcome them.
Challenge #1: Complying with new government requirements and mandates
When asked about the biggest challenge healthcare organizations face, a whopping 36.3% of survey respondents cited complying with new government mandates and requirements. Among these regulations, is the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which industry experts predict will be one of the biggest hurdles.
“Its payment methodologies are complex; it will require a large investment in time and resources to sort through it,” says Lauri Miro, MBA, RN, vice president, consulting services, Halley Consulting Group. “As MACRA combines elements of programs, including the Physician Quality Reporting System, the value modifier (or value-based payment modifier), and meaningful use into one program, healthcare providers and payers who have invested in earlier program infrastructure are left wondering what will come next. While changes are meant to address previous program deficiencies, the chaos created by frequent changes can make both providers and payers hesitant to invest in infrastructure changes needed to make timely transitions.”
For health plans, Gregory Scott, vice chairman and U.S. health plans leader, Deloitte LLP, views requirements associated with Medicare Advantage as a top concern. “Medicare Advantage comes with challenging and fluctuating operational and compliance requirements, and with unavoidable financial uncertainty—given the complexity and annual surprises surrounding CMS payment rates,” he says.
Furthermore, healthcare executives are struggling with lower reimbursement rates for services rendered under Obamacare plans. “The exchanges often have high deductibles, leaving patients to shoulder more of the upfront costs of care,” Miro says. “When patients can’t afford to pay their deductibles, providers are often not paid for services and patients may not seek preventive care that could avoid future disease escalation.”
Due to the unpredictability of populations served under the Affordable Care Act (ACA), current actuarial models are less reliable to accurately predict premium revenues, utilization levels, plan expenses, and expected profits and losses, Miro says.