Don Hall, MPH

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When most people think about epidemics, they think of Ebola, SARS, and now, especially, the new coronavirus. But until COVID-19, when healthcare executives had thought about epidemics, they should also be thinking about diabetes, because it is growing, expensive - and deadly. 

The impact of diabetes on the lives of patients can be absolutely devastating. It is the underlying cause of serious complications, such as heart disease and stroke. Many people with diabetes are afflicted with chronic pain; it is also the leading cause of kidney failure, blindness, and amputations. Diabetes, and the complications resulting from it, ranks third behind heart disease and cancer as a cause of death in this country.  

Over 34 million Americans have been diagnosed with diabetes, mostly with the type 2 variety that is linked with being overweight or obese. Another 88 million Americans have prediabetes: They have blood sugar levels and other risk factors that could put them on the road to having full-blown diabetes. Nearly $250 billion is spent on healthcare costs related to diabetes, with an average medical expenditure of $15,000 per person with the disease. As far as drug costs are concerned, diabetes is the most expensive traditional therapeutic class on a per-member, per-month basis. 

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The causal factors of the type 2 diabetes epidemic are well characterized: poor diet, obesity, lack of exercise, and aging. Diabetes also occurs more frequently in some groups because of social determinants of health, such as unsafe neighborhoods with a lack of access to recreation.

The good news is that managed healthcare can have a significant impact on all aspects of diabetes prevention and management. Through analytics and health risk appraisals, health plans can identify members with diabetes and those who are prediabetic. Focused disease management programs, combined with value-based provider contracts, can encourage engagement of members and incentivize providers to improve outcomes. Health plans can help by, among other things,  covering smartpens that can monitor injections. The same goes for stick-free glucose monitoring, which improves adherence to blood testing and insulin management. Health plans are also well positioned to work with community organizations to support efforts to educate people about proper nutrition, exercise habits, and weight management. 

When and how is difficult to say, but COVID-19 will recede. Diabetes will not. It will continue to grow as our society struggles to control the impacts of poor lifestyle habits. However, managed healthcare plans continue to play an important part in ensuring that members receive the most impactful information and care possible to manage and ultimately stop this epidemic.

Don Hall, MPH, and Sherry Rohlfing are principals of DeltaSigma, a consulting firm that specializes in strategic problem solving for managed care.

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We recently returned from an educational summit of the Swedish healthcare system sponsored by the TPG International Health Academy. The group of 25 was made up of healthcare executives from Canadian and the U.S. organizations including Kaiser Permanente, LA Care, National Indian Health Board, Centene, Cigna, Affinity Health Plan, and others. We studied a number of aspects of Sweden’s universal, government-sponsored system including its organization, financing, access-to-care, and current challenges.

While there were a number of key points learned from the study, two things stood out to us.

First, their focus is on care delivered in a primary care setting. In the Swedish system, primary care, which does not include pediatricians or internal medicine, accounts for over 20% of all healthcare costs. As a comparison, in the United States we spend about 5% (including pediatricians and some internal medicine and non-delivery OB-GYN). Primary care in the Swedish system is largely delivered in clinic settings that include general practitioners, nurse practitioners, nutritionists, psychologists, and physiotherapists in a holistic approach to patient and family care.

Through this approach, more comprehensive care is provided in the primary care clinics and fewer referrals to specialty and other care are required. In addition, an emphasis is put on patient education and self-care. The result is lower cost and better healthcare results, which demonstrates that primary care medical homes work.
	
	The takeaway is that health plans should improve efforts to create more robust medical homes for their members to improve outcomes and lower overall healthcare costs.

Second, Swedish leadership incorporates an interesting management approach that takes an old Swedish practice called a fika (pronounced fee-ka) and turns it into a communication channel with their teams. Fika is much like our concept of a coffee break, taking time away from work to relax with a hot beverage and some food. Managers take traditional fika further by making it a time for everyone to get together for a break-management and staff. During this time, leaders have the ability to informally hear from their employees and get to know them on a more personal level. It’s like an informal focus group every day.

The takeaway is that executives should develop a similar mechanism, whether a break or lunches, to spend time with more than just the management team to better understand their employees and how to make their company a better place to work and more aligned with their customers.

As we strive to improve healthcare in the United States, it’s useful to travel to other countries to learn about their cultures and healthcare systems. Sweden’s approaches provide useful insights.

Don Hall, MPH, and Sherry Rohlfing are principals of DeltaSigma, a consulting firm that specializes in strategic problem solving for managed care organizations. They work with the TPG International Health Academy on Educational Summits and will study healthcare in Columbia and Italy in 2020. 

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It’s that time of the year when organizations begin developing their budgets for the coming year by projecting membership growth, medical loss ratio, administrative expenses as well as the investment in new initiatives. Most of these costs can and will be developed based on past trends that are adjusted incrementally for competitor, product, and market changes.

Beyond this, executives in the most successful organizations will also take a step back to think about what could go wrong and what could prevent their organization from reaching its goals. Aside from the inherent risk that all organizations have of unexpected staffing changes or poor sales performance, what are some of the biggest potential disruptors looming in 2020?

As personalized approaches to cancer treatment like CAR T-cell therapy become more applicable to wider a range of malignancies, oncology centers will face significant pressure to incorporate these therapies in addition to surgery, chemotherapy, and radiation.

Because CAR T can, in specific malignancies, deliver such dramatic and rapid results, it has the potential to be a major disruptor, forcing providers and managed care organizations to include it as a first line therapy. At a total cost ranging from $700,000 to well over $1 million, CAR T therapies could have a great impact on the cost of cancer treatment as well.

The use of integrated, distributed systems of recording, storing, and viewing information critical to providers, payers, and regulators has the potential to address problems inherent in keeping provider directories up-to-date, tracking member prescription use from multiple pharmacies, integrating patient medical records in real time, and eliminating redundant diagnostic tests.

Many of the major managed care organizations have begun efforts to employ blockchain powered approaches to provider data management, including credentialing and directories. Challenges with trusting data, lacking ownership of information, and violating HIPAA requirements will reshape how managed care organizations approach this major disruptor.

Applications for machine learning, or artificial intelligence (AI) in managed care organizations range from claims review for fraud or manipulative billing to identification of high-risk members and the development of care plans, to viewing and approving authorizations, to data quality review and interface with electronic medical records.

In short, AI has the potential to change virtually every area of a healthcare organization and have a tremendous impact on staffing skillsets managed care organizations require.

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Social determinants of health (SDoH) are the conditions in which people are born, live, and work and have been found to have a significantly greater impact on an individual's health than any clinical or genetic factor.

For most health plans, the SDoH conditions affecting their members are related to adequate housing, access to healthy food, and lack of transportation. Addressing these conditions on a member-by-member basis can have a dramatic impact on healthcare cost-but requires a new set of tools and employee skills and a transformation on how an organization defines itself and deploys its resources.

While Apple, Google, and Amazon have discussed their interest in the healthcare market, most of their activities have been relatively modest to date. That could change very rapidly.

These data-obsessed behemoths have the resources, technological capabilities, and loyal customers to be major disruptors when they enter the market in a larger way. Amazon’s purchase of PillPack is already raising significant concerns at large pharmacy chains and among PBM companies. Amazon’s Haven joint venture with Berkshire Hathaway and J.P. Morgan is starting to take form as a new intermediary focusing on outcomes-based reimbursement.

How much impact each of these or other potential disruptors will have in 2020 remains to be seen. But organizations that don’t take the time and effort to prepare for disruptors-do so at their own peril.

Don Hall, MPH, is principal of DeltaSigma LLC, a consulting practice specializing in strategic problem solving for managed care organizations. He most recently served as president and chief executive officer of a nonprofit, provider-sponsored health plan. 

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If you ignore the Sword of Damocles hanging over the industry in the form of a Texas federal judge’s ruling the entire ACA unconstitutional, 2019 could shape up as a relatively chaos-free year with little chance of legislative or regulatory upheaval. Despite the fact that the number one issue on voters’ minds during the 2018 election was healthcare, it’s unlikely that the extremely divided Congress will be able to address it in any meaningful way. Cue the 2020 election. 

The biggest issues healthcare industry leaders foresee include: 

Although it’s become clear that a person’s zip code has more impact on their health than their DNA, dealing with the 

 (or social drivers) of health that relate to where a person lives are often far outside of the scope of most health plans’ operations. That’s rapidly changing. Whether it’s food or housing insecurity, economic stability, social or environmental safety or literacy, the impacts these social drivers have on health outcomes and costs are significant. Spurred by state Medicaid agencies and CMS, finding and deploying tools to measure and address the underlying issues that drive much of the cost and utilization in healthcare will be a focus during the year. 

As hospital systems extend their reach with acquisitions, mergers and alliances (for example the $28 billion 

Catholic Health Initiatives and Dignity Health merger

), health plans will be faced with much less leverage in rate negotiation and greater challenges in establishing competitive product differentiation as providers will have more power to dictate terms for products and rates. On the other hand, plans aligned with providers will face a more favorable environment and may see significant growth over their unaligned competition. 

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Adding work requirements for “able-bodied adults” to Medicaid expansion waivers has allowed Republican states that opted out of this ACA option (and the significant federal dollars that go with it) to find a way to participate that aligns with their stated conservative values. 

Unfortunately, work requirements are much easier to put in place than to administer as some of the early-implementing states like Arkansas are finding out. Expect more non-expansion states to use this mechanism to expand their Medicaid coverage and for the health plans involved to be inundated with a whole new set of administrative requirements and challenging enrollment issues. 

The Dick Tracy watches are here and are way 

. Measuring pulse and blood sugar, breathing rate, simple ECGs, and providing emergency alerts for falls are only the beginning of what appears to be a host of clinical monitoring and alerts coming from these personal technologies. Whether and how health plans address and incorporate the application of these new capabilities to their membership will make a significant difference in the MCO’s market presence and competitive stance. 

While these were a some of the more frequently mentioned challenges, obviously other issues resonated a higher level for some execs based on their geography and product lines. Here’s hoping that 2019 sees the industry better serve the diverse healthcare needs of the country by meeting consumers’ demands for quality, affordability, and access. 

Don Hall, MPH, is principal of DeltaSigma LLC, a consulting practice specializing in strategic problem solving for managed care organizations. He most recently served as president and chief executive officer of a nonprofit, provider-sponsored health plan

Healthcare industry leaders share the biggest issues they foresee for their organizations. What can we expect in 2019?

Author | Don Hall, MPH

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