Although the ACA is still the law of the land, only bits and pieces of it remain intact as President Trump continued to take actions to dismantle it in 2018. Meanwhile, it’s unclear if and when Congress will resume its quest to implement a new healthcare law.
In light of this, it’s hardly surprising that according to Managed Healthcare Executive’s 2018 State of the Industry Survey, complying with government regulations and policies top health executives’ list of challenges for 2019. Implementing value-based reimbursement is another top concern, with addressing rising pharmaceutical costs and using big data to improve healthcare quality and reduce healthcare costs rounding out the top four concerns. Nearly 200 executives from provider organizations, benefit management organizations, health plans, long-term care organizations, and group purchasing organizations responded to the survey.
Here’s a closer look at the top industry challenges, and what industry experts advise organizations to do to overcome them.
Complying with policy changes
In MHE’s survey, 32% of respondents listed complying with government regulations and policies as their top concern. In addition to efforts by President Trump and the Republican Congress to get rid of the ACA, this challenge has a lot to do with the fact that some state agencies change rules and requirements yearly, while others issue multiple notices of changes to Medicaid managed care plan operations during the year.
At the federal level, CMS issues more than 400 Health Plan Management System (HPMS) memoranda a year. Some of these communications require operational, reporting, and information technology changes. CMS also issues National Coverage Determinations that may require a health plan to pay for procedures or prescription drugs that they previously didn’t have to cover. “All of these changes require analysis, planning, budgetary and staffing analysis, and implementation,” says Shelley Stevenson, director, Government Programs Practice, Change Healthcare, which leverages technology to improve patient care. “Many changes impact profitability, provider relationships, and member communication.”
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Insurers who offer state or federally regulated lines of business are directly impacted by any change in regulations. “Payers that have hospital systems and integrated healthcare systems in their networks are always affected by any policy changes,” Stevenson says. “While integrated health plans often have access to hospital and physician [EHRs], non-integrated plans have to do outreach to access clinical data, such as that to support a prior authorization request. Hospitals and integrated healthcare systems are challenged by regulatory changes that only pertain to medical institutions, such as billing requirements.”
How to deal
C-suite executives need to stay on top of challenges associated with regulation changes, and then rely on experts in those areas to help them navigate those changes in light of their business goals. “Regulatory considerations need to be front and center as business decisions are made,” says Joe Geraci, partner, Husch Blackwell, an industry-focused law firm.
Susan Feigin Harris, JD, a partner in the law firm Morgan, Lewis & Bockius LLP, says lawyers and compliance officers can be helpful in preventing violations by identifying any weaknesses that require attention as well as performing periodic reviews in order to show a proactive focus on compliance or identify areas that need improvement.
Joe Paduda, MS, principal, Health Strategy Associates, LLC, advises working with an established and connected association or lobbying group that can demonstrate consistently accurate insights into potential changes to policy and regulation. “When planning, build flexibility and adaptability into systems, contracts, and work processes so significant alterations in policy don’t require wholesale revamps or revisions to key business operations and systems,” he says.