Effective leadership skills are best developed through direct experiences. However, in today’s dynamic healthcare ecosystem, even the most confident CEOs are drawing added inspiration from personal and professional mentors.Getting ahead of the competition is one of the primary goals that executives have in mind when they reach out for professional mentoring, according to Linda Henman, PhD, author and executive coach. She believes the realities of market competition often guide the overall leadership strategy, even among not-for-profit organizations.In other words, those focused on a mission need a healthy margin to support the ongoing fulfillment of that mission. Meanwhile, the for-profits, with their focus on revenue targets, also need to be driven by a greater good, such as building a healthy community.Organizations should define their culture by defining their passions, Henman says.“People talk about culture as if it were only tied to tradition, but that’s an outdated way of thinking that just doesn’t work today,” she says. “Traditions are important, but they’re not the reason you’re going to be successful.”Leadership as a team sportExecutives must evaluate who is making strategic decisions within the company, what decisions they’re making and why. Many boardrooms would be surprised to find out where the practical decision-making authority actually lies and how it affects the business, Henman says.For example, Henman once advised a rural provider that was struggling with claim denials. As it turned out, the physicians weren’t coding correctly, resulting in ongoing rejections and lost reimbursement, impacting as much as $10 million in revenue. But administrative employees didn’t think it was acceptable to challenge physician leadership, much less company executives.“The CEO had created a culture of fear,” she says. “No one wanted to bring him bad news.”Related article:Â Three Emerging Leader Qualities That Guarantee SuccessOnly the CEO could make the decision on how the company would hold physicians accountable for proper coding. Henman says the situation could have been avoided if the corporate culture had allowed for open discussion, rather than autocratic leadership.“Many executives have trouble changing the culture because it seems like giving up power,” she says. “In reality, they’re gaining power that way.”She recommends that executives create a culture that allows the business to innovate. Leaders should focus on a mission, be open to learning and act as agents of change within the organization.Managed Healthcare Executive recently asked several healthcare decision makers to identify personal or professional mentors who have inspired them in their careers. Executives seem to agree that the best mentors are those who provide honest feedback, instill confidence, and persist in pursuing their goals.

Slideshows

The mentors and lessons that have impacted your career.

How Mentors Inspire Health Execs

The healthcare industry is slowly starting to implement the type of consumer engagement best practices that have been hallmarks in the retail, travel, and financial industries for years: listening to individuals and designing personalized solutions to incentivize outcomes.“With the growth of consumerism and a shift to value-based care, plans today recognize that connecting with consumers is imperative to ensure the health of both their plan and their members,” says Tom Wicka, chief executive officer of NovuHealth, a healthcare consumer engagement company in Minneapolis.Consumer engagement in healthcare keeps individuals on top of their own well-being, leading to healthier outcomes. On the flip side, non-engaged consumers are often high-cost consumers, because they bypass early prevention and detection and don’t properly manage chronic conditions.“It’s incumbent upon plans to take a proactive approach to engage consumers and improve their health, which results in other benefits such as lower healthcare costs, compensation from stronger outcomes, and improved plan performance,” Wicka says.Here, experts provide 14 ways that insurers can improve their members’ experiences with them.

Experts provide 14 ways that insurers can improve their members’ experiences with them.

14 Ways Insurers Can Improve Patient Experiences

Many women in rural areas in the United States need to 

 to get to a hospital where they can give birth, according to the American College of Obstetricians and Gynecologists (ACOG). Obstetric units are often the first to close when hospital budgets get tight.

By 2010, 49% of U.S. counties-predominantly rural counties-had no obstetrician–gynecologist. In some counties, all obstetric care is provided by family physicians. And according to ACOG, the number of OBGYNs in the rural workforce could continue to decrease.

New Orleans-based Ochsner Health System supports expectant mothers with its free 

 (Maternity Online Monitoring) digital medicine program, which means fewer visits to the obstetrician.

Mothers-to-be receive a wireless blood pressure cuff and dipsticks and cups for urine protein tests, which can be used at home to test urine and securely send the results to the care team via the patient’s smartphone. They also get a wireless scale to send real-time weights to a health coach and obstetrician via their medical chart at least once a week; patients receive reminders on their smartphones if they forget.

Six Healthcare Technologies Coming in the Next 10 Years

Launched in December 2017, Connected MOM is the first such program created by a health system, according to Ochsner. As of March, 1,000 women were enrolled in the program, 

. Citing the American College of Obstetricians’ guideline that the standard prenatal care model for low-risk pregnancies requires between 12 to 14 office-based prenatal visits, the health system says the Connected MOM program connects patients with their care team while reducing the need for at least three office visits and increasing flexibility and convenience for patients.

“Digital health programs have an opportunity to create access in areas where there isn’t always access,” says Aimee Quirk, CEO of innovationOchsner, an innovation lab and accelerator founded by the health system that focuses on increasing care quality while reducing cost and improving the patient experience. Challenges for patients can include difficulty accessing transportation or getting time away from work or family responsibilities, she adds.

“This is a really powerful way to help address some of the access issues and disparities we see,” says Quirk.

Ochsner also supports patients with chronic conditions such as hypertension and diabetes with digital health programs including wearables, says Quirk. “We recognize that the acute care model, which is the model of care today, is changing. We’re seeing it change because of payment incentives.”

To support patients and non-patients, the health system launched 

, retail locations where patients and non-patients can purchase activity monitors, wireless blood pressure monitors, and weighing scales. Shoppers also have access to technology specialists who help them choose the appropriate digital health app, while providing technical and set-up support.

The first O Bar opened at its medical center in Baton Rouge in May 2018, and there are now seven O Bar locations at health system facilities. Available to serve community members in other locations is the mobile O Bar, which travels to Ochsner hospitals. Expectant mothers can pick up materials for the Connected MOM program at an O Bar, says Quirk.

UnitedHealthcare Motion uses wearable devices to capture members’ required 10,000 daily steps to help them earn as much as $1,095-or $3 per day-toward their health savings account each year. The program is available to members in more than 40 states.

Launched by the payer as a pilot program in 12 states in 2016, the program started because there’s a “significant body of evidence that movement and motion can have a meaningful impact on the quality of life,” says Paul Sterling, vice president of emerging products.

While physicians have been recommending for years that patients should be active, starting that activity and remaining engaged can be challenging, he adds.

Activity trackers and smart watches available through the program include devices from Samsung, Garmin, Fitbit, and Apple. For members in the program, UnitedHealthcare subsidizes $55 toward the cost of an activity tracker or smart watch. Participants who already have a device receive $55 worth of credit in the program.

Collectively, members who participate in the program have walked more than 180 billion steps and earned just shy of $30 million in rewards since the program’s inception.

People with chronic conditions are 20% more likely to participate in Motion than people not managing these conditions, according to UnitedHealthcare. Specifically, people with diabetes are 40% more likely to participate in the program than people without the condition. 

Members’ participation in the program can translate into cost savings for employers, according to the payer. Members who participate in Motion have been shown to cost $222 less than members who don’t participate.

Consumerism, crunching data, managing costs

Hypertension, heart failure, and diabetes. Those are the conditions typically tracked by wearable technology, says Andrew Rebhan, consultant with Advisory Board’s Healthcare IT Advisor. One of the biggest drivers behind these programs-certainly for payers and providers-is the need to monitor patients in the home and keep them out of the hospital, he adds.

But Rebhan also attributes the interest in wearable technologies to the rise in the consumerism in healthcare. “It’s the idea that consumers have more ‘skin in the game’ with high deductibles. They’re trying to become more engaged in their own care. That’s while their employer or payer is trying to manage costs.”

Healthcare Technology in a Post-Digital Age

The challenge for providers is the need to turn large volumes of clinical data into actionable information, says Rebhan. That requires the collection and analysis of the data, and getting it into clinicians’ workflow to intervene if, for example, a patient’s heart rate spikes.

, 87% of consumers were using a digital health platform in 2017 (the latest year data was available)-that’s an increase from 80% in 2015.

As the technology that powers these devices continues to become more powerful and less expensive, Karl Ulfers, chief product officer at Rally Health, which develops digital health platforms that educate employees about their healthcare-related decisions, expects that the return on investment of using these devices more broadly in the population will grow. He also anticipates a shift from chronic disease management to chronic disease prevention.

Articles

How payers and health systems are using wearables to monitor patient health and encourage healthy behaviors.

The Future of Healthcare Wearables 

As cardiac disease, diabetes, and other chronic illnesses rise worldwide, and as the population ages and the U.S. faces a predicted physician shortage, many health systems and health plans have embraced 

 as an option to grow their markets and continue care to patients remotely.

 on health insurance claims from across the country found that between 2016 and 2017 telehealth claims increased by 53%-more than both urgent care centers (14%) and retails clinics (7%) combined.

“From a business perspective, if I can keep you healthier and more compliant with your physician recommendations, hopefully your health outcomes are going to be more positive. That means where we can potentially reduce readmission disease exacerbations and emergency room visits,” says Marya Vande-Doyle, director of workplace wellness and telemedicine for 

 (BCBS). The health plan recently reported that nearly 15,000 telemedicine claims were filed in 2018. “We see telemedicine as a way to ensure that members feel like they have access to care wherever they go.”

Combined with market factors, CMS also accepted 

 in 2019 allowing for providers to be paid for remote patient monitoring, e-visits, and e-consults.

But even with a ripe market and more CMS support, experts believe that healthcare organizations still have a long way to go before telemedicine and e-visits are commonplace. Zynn says state regulations can still be a hurdle to telehealth adoption.

“If you asked anybody in the industry, they would say licensing and changes in the regulations at the state level are probably the biggest hurdle or hindrance to faster growth,” says David Zynn, president of Infectious Disease (ID) Connect, a telemedicine company recently spun off from the University of Pittsburgh Medical Center (UPMC).

, which provides streamlined licensure for physicians who offer telemedicine services through multiple states.

“In the next five years, we'll lose the term ‘tele’ because it will just be healthcare,” says Zynn. You will make an appointment to see your doctor and either go to the hospital or get that service via telemedicine. You will also get follow ups via telemedicine. So, it’s more efficient, more effective, and better for the patient.”

Using telehealth to expand specialists’ reach

UPMC saw telehealth as an opportunity to offer its expertise in infectious disease to communities across the country. The hospital launched a telemedicine company, ID Connect, to help other hospitals improve outcomes and reduce transfers for patients who need infectious disease treatment.

Currently, the program is being used by several other hospitals and outpatient clinics, with plans to expand in the upcoming months. A shortage of physicians who specialize in infectious disease, coupled with the constantly-evolving nature of the field were other catalysts to UPMC’s decision to create a technology company focused on providing services more broadly.

ID Connect incubated at UPMC for the past five years, and Zynn says that through that trial they were able to prove that telemedicine could contribute to a decrease in 

, patient hospital stays, and mortality. Currently, 12 doctors are providing services on the platform to other doctors who need assistance or second opinions, and to patients who are recommended to a specialist.

“Our doctors schedule tele-physical exams and we train our customers to use a tele-presenter. It is still is a very comprehensive exam, with questions, history, and a physical exam. The tele-presenter also has a video, so that our doctors can see and hear everything as if they were physically present,” Zynn says. “Our doctors can diagnose, treat, order labs and prescriptions, all documented in the EHR. They will follow up with that patient to make sure everything is working out as planned. They can make any changes to the diagnosis or treatment plan if necessary. And upon discharge, a telehealth appointment would be part of the discharge order and follow up.”

Zynn says that because there are more than 4,000 hospitals with 300 beds or less, it is increasingly important for smaller providers to have easy and affordable access to specialists. The U.S. could be short up to 122,000 physicians by 2032, with possibly half of them projected to be specialty care providers, according to 

 from the Association of American Medical Colleges.

“I’ve talked to our customers and the number one thing that we bring to them is, without our service, they would have to transfer a lot of patients out to a larger tertiary. That’s not good patient service,” Zynn says. “It's not good for the local hospitals because they lose that patient. You don't want to take someone who is very sick with an infection and transport them from one facility into another. That alone is a tremendous opportunity to improve care.”

Health plans increasing telehealth outreach

Health plans are also seeing positive impacts to increased telehealth adoption. A recent claims review from Excellus BCBS in New York found that telehealth services have tripled in the past two years. The health plan’s review found that nearly 15,000 telemedicine claims were filed in 2018, up from 5,100 in 2016.

A survey of more than 2,000 Excellus BCBS members conducted in 2019 found that more than half of members knew about telemedicine and 43% said they would consider using it in the future. Though only 5% reported using telemedicine services, 93% who used it rated their experiences favorably.

An increase in community outreach and provider education are factors that led to the increase in telemedicine claims, Vande-Doyle says.

“We provided a public service campaign to help spread awareness using local media and partnering with community events, to help the community understand what a telemedicine visit is,” Vande-Doyle says.

New Payer-Technology Partnerships Could Be Telehealth’s Future

The second approach Excellus BCBS took was to work with network partners, health systems, and primary care providers based in the community and the local and state medical society to share why telemedicine is important. Excellus BCBS services Medicare, Medicaid managed care, commercial, and employer-based health plans.

“A vast majority of our population is located in either health professional shortage or metropolitan shortage areas as designated by HHS. We recognize that for those members it's very difficult for them to travel during a snow storm or find a caregiver to drive them to a doctor's appointment. We reached out to the medical community understanding these common challenges and how can we increase awareness of telemedicine,” Vande-Doyle says.

The Excellus BCBS survey results found that 78% of telehealth services were related to heart disease, hypertension, skin disorders, diabetes, and pneumonia. Another 22% of services were related to behavioral health, including anxiety, depression, attention and bipolar disorders. Behavioral health visits via telehealth were the fastest growing areas of treatment, according to the claims review.

“In order to be successful, we have to ensure that our providers feel comfortable in offering telemedicine. We have to encourage our providers to innovate. And at the same time, we have to share what we're learning,” Vande-Doyle says. “It's not focused on one specialty, healthcare provider, or one visit type. Telemedicine is for all types of applications. It's part of a solution of increasing access to care and using our healthcare services.”

In the last decade, PipelineRx has grown its telepharmacy business to serve more than 600 hospitals and provider organizations, with 150 telepharmacists working from a call center or remotely. Brian Roberts, CEO of 

, says that remote dispensing and medication management, along with counseling patients and providers delivers education and efficiency that is lacking in the healthcare system.

“Telepharmacy increases access to facilities or organizations that either can't afford or can’t find the right pharmacy personnel. We can provide that remotely so that everybody has 24/7 care,” Roberts says. “I can take one telephone pharmacist working from home or from our call center, and they can cover between four and seven facilities at the same time. You can bring the overall cost of managing those facilities down by using telepharmacy.”

Roberts says that telepharmacy can allow on-staff pharmacists the ability to focus less on administrative tasks and work more closely with patients.

“We provide increased safety because a telepharmacist has his or her head down focusing on processing orders and making sure that the prescriptions are right,” Roberts says. “We actually counsel the patient during and after discharge to help them understand their medications and how adhere to their program.”

As rural pharmacies close across the country, and the importance of prescription drug management continues to rise, Roberts says telepharmacy can fill gaps in continuity of care.

FCC considers $100 million for rural telehealth program

“Transitions of care are such a big problem for the U.S. When a patient gets out of the hospital, information stops. If they have to pick up medications at the pharmacy, 40% of patients who leave the hospital either have a wrong prescription or they never pick up their medications,” Roberts says. “That 40% causes readmissions, it causes people to get sicker. We really like the impact that we can have by following patients out of the four walls of the hospital and allowing for the data streams to continue to follow them.”

The nationwide network developed through telepharmacy also allows for better tracking of medication abuse and misuse, Roberts says.

“Our data analytics and our pharmacists identify those that have a history of drug abuse or have been identified as a person who could be of high risk,” Roberts says. “We have access to see patient records across multiple settings and multiple hospitals. So, we can actually identify those who have gone to different hospitals trying to get opiates or other drugs.”

Donna Marbury is a writer in Columbus, Ohio.

The state of telemedicine and remote patient monitoring.

Telemedicine and E-Visits: An Update

Multiple sclerosis (MS) is a chronic inflammatory condition that affects the central nervous system (CNS), and it can result in significant disability and death. According to the 

, more than 2.3 million people are living with MS worldwide, and disease-modifying therapies (DMTs) are considered the mainstay of therapy to help to reduce the frequency and severity of relapses. However, these medications are also associated with adverse effects ranging from mild to life-threatening. Current phase 3 studies are investigating new ways and novel approaches to prevent MS relapses.

Healthcare executives are concerned about the cost, quality, and outcomes of MS drugs, making it a top priority for patient care and expenditures. According to a study published in 

 out-of-pocket monthly costs for MS medications increased from approximately $15 to about $309 over 12 years. According to the 

, the average median price of MS DMTs in 2013 was less than $60,000 while the price in 2018 was $80,000. Patients with MS also face co-insurance that could be as high as 40%, which translates into a monthly cost of over $2,500 for their DMTs.

Legislation that makes MS medications more affordable is needed to alleviate patient costs. Healthcare professionals can play an important role through an interdisciplinary approach to managing patients with MS and identifying financial options such as patient assistance programs to alleviate costs.

Erin Lopata PharmD, MPH, Senior Director, 

Access Experience Team at Precision for Value

 points out that Tecfidera (dimethyl fumarate) is approaching the end of its patent exclusivity, and there are several similar medications that are anticipated for FDA drug approval. Lopata adds that Vumerity (diroximel fumarate) is a prodrug for monomethyl fumarate, which is the active metabolite of Tecfidera and may cause less gastrointestinal adverse events.

Interim efficacy and safety results from the 

 study were recently presented at the AAN Annual meeting, and showed that after 48 weeks, relapse rates decreased by about 79% relative to baseline. Biogen has submitted the new drug application (NDA) and approval of Vumerity is expected sometime in 2019.

 for Bafiertam (monomethyl fumarate) for relapsing forms of MS. Lopata discussed that Bafiertam is the active metabolite of both Tecfidera and Vumerity, and its launch is anticipated for June 2020. 

 has submitted its NDA for ozanimod for the treatment of adults with relapsing forms of MS. The FDA previously rejected the NDA based on insufficient data, but it is expected to receive approval based on the new submission on March 25, 2020. Data is based on the 

 trials, which demonstrated that ozanimod was effective at preventing MS relapses.

The Latest Autoimmune Disease Treatment Advances

Ozanimod is an oral sphingosine 1-phosphate (S1P) receptor modulator. “With a mechanism of action similar to the recently approved Mayzent (siponimod) and an optimal pharmacokinetic profile, ozanimod hopes to demonstrate an improved safety profile to Gilenya (fingolimod),” says Lopata. Ozanimod has only been studied in relapsing forms of MS; however, Mayzent is FDA approved for both relapsing and secondary progressive populations.

“With the success of Ocrevus (ocrelizumab) for MS, additional CD20-directed monoclonal antibodies are likely to follow,” says Lopata.

Another candidate on the horizon is ublituximab (TG-1101), which is being studied by the biopharmaceutical company 

. Ublituximab is a monoclonal antibody that targets the CD20 antigen, and anti-CD20 antibodies have been shown effective in treating various conditions including MS. The company recently announced 

 at the AAN annual meeting showing that the drug is well tolerated. Phase 3 trials known as 

 (NCT03277248) are currently being conducted to assess the safety and efficacy in patients with relapsing MS.

Jennifer Gershman, PharmD, CPh is a pharmacist and medical writer residing in South Florida.

MS is in need of new medications-these could be the future.

What’s New in the MS Drug Pipeline

President Trump jump-started some proposals for reducing the cost of prescription drugs when he created his American Patients First Blueprint in May 2018.

Unfortunately, drug costs are continuing to affect adults taking prescription medications-especially those who are uninsured. The 

 that 19.5% of uninsured adults in 2017 asked their doctors for a lower-cost medication, 11.4% didn’t take their medications as prescribed, and 5.4% used alternative therapies.

Most people taking drugs say they can afford their treatment, but about 25% have a difficult time paying for their medications, according to 

Here are four areas of reform touted as solutions to the problem:

Lowering OOP payments for Part D beneficiaries

This year saw changes to the Medicare Part D standard benefit in an effort to lower OOP payments paid by Part D beneficiaries.

Under the Bipartisan Budget Act of 2018 (BBA), Part D enrollees’ OOP costs for brand-name drugs in the “donut hole,” declined from 35% of total costs in 2018 to 25% in 2019, while the manufacturer discount increases from 50% to 70%. The Congressional Budget Office (CBO) estimates that these changes will reduce Medicare spending by $11.8 billion over a 10-year period (2018-2027).

Plans’ share of costs for brands decreased to 5% in the donut hole; however, insurers are responsible for 63% of the cost of generics while enrollees pay 37% for them in the gap.

Beneficiary OOP costs before moving into the catastrophic phase jumped from $5,000 in 2018 to $5,100 in 2019 and are expected to rise again in 2020 to $6,350.

The bulk of insurer responsibility is in the initial coverage period-75%-while Medicare is on the hook for 80% of total costs under catastrophic coverage after beneficiaries reach a threshold of $8,140.

Four Ways Hospitals Can Deal with Rising Drug Costs

“While this does create a perverse incentive, payers are still careful about the number and types of drugs they make available on their Part D formularies primarily due to concerns about adverse selection and its impact on overall drug spend,” says Brian Duffant, vice president, BluePath Solutions, a health economics outcomes research consulting firm in Los Angeles.

He acknowledges that insurers have limited ability to move beneficiaries into the donut hole and Medicare to keep them out of the catastrophic phase, based on the standard Part D benefit design (see graphic) that allows a patient to move through the phases of coverage based on total drug and patient OOP costs.  

Legislation has not yet been introduced to modify the BBA coverage gap provisions; however, efforts are underway.

Pharmaceutical manufacturers are pressuring Congress to roll back the manufacturer discount from 70% to 63%, increase Part D plan-sponsor liability, and block an increase in the total amount beneficiaries must spend OOP on their prescription drugs before catastrophic coverage kicks in.

According to the Commonwealth Fund, these proposals would financially benefit drug manufacturers more than Medicare beneficiaries. Beneficiary spending in the coverage gap would be slightly reduced (far more for manufacturers), and Medicare spending under Part D would increase to cover the savings to beneficiaries and manufacturers.

 by the Kaiser Family Foundation states that increasing plans’ shares of costs in the coverage gap, reducing the manufacturer discount to something less than 70% for 2019 and beyond, and modifying the scheduled increase in the OOP spending threshold would result in higher Medicare spending, resulting in a substantial increase in beneficiary OOP cost and fewer Part D enrollees qualifying for catastrophic coverage.

Bipartisan efforts are indicating support for capping OOP spending and shifting more responsibility to insurers by increasing their share of costs in the catastrophic phase, and to manufacturers to lower drug prices.

At the beginning of 2019, CMS green lighted permission for Medicare Advantage plans to use step therapy for Part B drugs covered under Part C to reduce costs and provide more coordinated care.

“The ‘step therapy’ proposal, which was previously not allowed, enables negotiation by manufacturers for discounts related to step therapy for Part B covered under Part C,” says Andy Parece, vice president, life sciences practice, Charles River Associates in Boston. “Approved in 2018 and renewed in 2019, there was limited participation last year, but we expect more in 2019 for 2020 formularies.”

In addition, HHS will test a new payment model to substantially lower the cost of prescription drugs and biologics covered under Medicare Part B. The new model would, for the first time, base Medicare payment for Part B drugs on the typically lower prices paid in 14 other industrialized countries, known at the International Pricing Index.

Medicare’s current payment to physicians for Part B drugs, which is based on the average U.S. sales price for these drugs and biologics, is 47% higher on average than prices paid by these countries for the same products, according to the Administration.

The administration is experimenting with value-based programs for drugs, including indication-based pricing and long-term financing. The Center for Medicare & Medicaid Innovation will test a value-based insurance design model for 2020, including a reduction in cost sharing or additional supplemental benefits for enrollees based on condition, socioeconomic status, or both; awards and incentives; use of telehealth services; and coordinated approaches to wellness and healthcare planning.

Value-Based Model Engages Provider Specialists

Under new guidelines, an indication-based formulary will be available in 2020, allowing Part D plans to choose a different drug for an indication by using step therapy and prior authorization to promote the most cost-effective option. CMS policy currently requires Part D plans to cover a drug for every one of its indications approved by the FDA even if a plan would otherwise have covered a different drug for a particular indication.

Joe Paduda, principal, Health Strategy Associates, a consulting firm in Skaneateles, New York, supports patient-specific formularies as the norm because patients might respond differently to the same therapy. He is concerned, however, that PBMs will use financial measures as a key component of formulary decision making. “Given the need for therapies to reflect each patient’s needs and genetics, patients and prescribers must have access to the right drugs without financial penalty,” he says.

 of employer-sponsored health plans, 60% of employers surveyed believe that permitting importation of less-expensive drugs from abroad is one of the most effective ways to reduce drug prices.

 agrees that importation has the potential to lower healthcare costs for two primary reasons: 1) Patients could access some medicines at lower prices because brand name drugs are generally more expensive in the United States than in other high-income countries; and 2) increased competition from imported drugs could put pressure on drug companies to reduce the price of their products in this country.

The Affordable and Safe Prescription Drug Importation Act, introduced in 2017, would allow pharmacies, wholesalers and patients to purchase drugs and biologics from sellers in Canada who are certified by the HHS secretary.

On a state level, Florida Gov. Ron DeSantis 

 a bill that would allow his state to import drugs. The bill cites a 2003 federal law that allows federal agencies to authorize states to import drugs. DeSantis says that state officials are working with HHS at high levels, and says he has the support of President Trump.

Lower Drug Prices Aren’t Worth Higher Health Risks

Ed Schoonveld, managing principal, ZS Associates, a Chicago-based biosciences consulting firm, supports differential pricing (up to the level that variable cost allows), but notes it has some hurdles. “The critical factor in enabling differential pricing is the willingness of high income countries to accept it. Recent initiatives in the United States and Canadian pricing reform (the Canadian government is changing its basket of reference countries by removing the United States and Switzerland and adding lower priced countries such as Australia and those in Eastern Europe) are part of the challenge,” he says.

While some worry about the loss of R&D funds for pharmaceutical manufacturers, Schoonveld sees new opportunities to recoup potential losses. “There is a lot of pressure to make drugs available at affordability levels in low- and middle-income countries. In most cases, it would likely be in the interest of all patients worldwide (and the industry) if prices could be adjusted to affordability levels as higher volumes of patients, now enabled to use the drug, would add at least some marginal contributions to the global cost of R&D,” he says.

Two more Trump administration proposals to decrease drug costs-mandating that drug manufacturers disclose list drug prices in TV ads and an overhaul of the drug rebate program-are off the table as of July 2019.

Opportunities to lower drug prices, as promised by President Trump’s American Patients First Blueprint, are picking up steam, some progressing more quickly than others.

Drug Price Reform Takes Off in 2019

Think of a recent consumer experience that you’ve had and odds are it is not related to your use of the healthcare system or related or your health insurance. More often than not, we cite examples from the retail, banking, hospitality or travel industry where elements of transparency, convenience, and reliability combine to generate a memorable and lovable experience. Surrounded by these examples every day, consumers have come to expect the same level of experience in all aspects of their life including healthcare.

Our members also tell us this. Ultimately, they are seeking our help in making their experience simple and affordable. This is no small task. However, we have taken it on with a focus to develop trust, engagement, and activation with those who use our health plan.

An easy-to-navigate web page and mobile experience that provides personalized information (easy access to information about current spend against deductible and OOP limits, finding a high-quality, in-network provider, and more affordable along with access to EOBs) is table stakes these days. Creating relatable, relevant ,and timely communication and tools that demonstrate the value of a health plan to the consumer is where the opportunity lies.

Two key ways to enhance experience are making cost and quality information easily accessible and supporting coordination and navigation of care through consumer personalization and empowerment.

Who enjoys getting a colonoscopy? The idea of prepping for and having the test is a barrier to even going to have a physical at a certain age. In an effort to enhance colorectal cancer screening (CRC) rates, we identified individuals not up to date with screening recommendations who also had no primary care visits in the prior year where a recommendation for screening might occur.

10 Ways to Improve the Patient Experience

Understanding these individuals were not engaging with the care system and knowing a big barrier to CRC screening is fear of colonoscopy, we mailed FIT kits-a home based screening test for CRC-to over 30,000 members along with information on CRC screening and the value of establishing a primary care relationship. The communication was timely and relevant to the audience as just over 24% completed the test and returned the kits. Those with positive findings were all referred for further assessment and screening leading, in some cases, to early cancer diagnoses or identification of polyps requiring more frequent monitoring. Personalizing the campaign increased CRC screening and engaged members with primary care.

Healthcare can be complicated, right? Shopping for prescriptions shouldn’t be. Recently, we launched a pharmacy price transparency tool in our web and mobile experience that provides pricing at any pharmacy. Through a real time benefit check, a consumer can see their OOP cost and plan liability for individual drugs or total cost for all of their prescriptions at a given pharmacy. If a lower cost pharmacy is nearby, they can initiate a transfer of prescriptions with the push of one button.

This has helped save countless dollars for consumers and plan sponsors. This same capability is being piloted in our providers offices to allow the prescriber to see and share with their patient what the real drug costs are based on negotiated rates and current benefit status.

Communications and plan tools must feel relevant and demonstrate value to the consumer if we wish to gain trust and deliver on our members expectations of a simple and affordable experience.

Patient experience should take a front seat at healthcare organizations, but what does that entail?

What Does Simple and Affordable Healthcare Look Like?

More and more, payers and providers are realizing the value of integrating patients’ social determinants of health (SDoH) data into patient care initiatives. With the industry looking toward a value-based care future, it’s becoming clear that finding ways to incorporate what the World Health Organization defines as “the conditions in which people are born, grow, live, work, and age” is vital to improved health outcomes-and a healthy society, in general.

This includes using SDoH data to help guide the development and implementation of successful population health strategies, says Ali H. Mokdad, PhD, chief strategy officer for population health at the University of Washington School of Medicine. He argues that healthcare professionals can develop excellent, evidence-based population health initiatives-but unless a particular population’s SDOHs are considered, such programs will not be as effective as desired.

“A patient’s environment plays a critical role on whether or not they can actively participate in their own health and wellness,” he explains. “If a family is struggling to pay their rent, they are not going to spend money on preventative care. If a family can’t find fresh fruits and vegetables that are affordable in their neighborhood, they won’t eat a healthy diet. If they are in a neighborhood that isn’t so safe, it may be hard for them to be physically active. It is very important that we address all of these aspects early on so we invest in the right kind of population health approaches-and don’t waste time and money with trial and error type programs.”

Dion Sheidy, a healthcare advisory leader with KMPG, a professional services firm, says that while adding SDoH data into population health initiatives seems like it should be a fairly simple thing to do, it’s much harder than one might expect in practice.

“The biggest challenge to using this information to help deliver care in an appropriate setting and an appropriate way is actually the data itself,” he explains. “Providers may not even collect this kind of information about a patient. If they do, the data exist in lots of different places and are saved in lots of different formats. The ability of any organization to successfully pull that data into a single location to help drive data-driven care is very difficult to do.”

, a leading healthcare payer organization, has made strides in incorporating SDoH into their population health strategies with their Bold Goal initiative, a unique program to help better care for patients with chronic medical conditions. Humana aims to improve the health of the communities they serve by 20% by 2020. Part of that strategy is considering SDoH factors like food insecurity and social isolation in their population health programs.

“We understand that food insecurity, social isolation, transportation security, and housing are all directly related to health,” says Andrew Renda, MD, MPH, associate vice president of population health at Humana. “This program allows us to bring those things into the mainstream of healthcare so we can start treating SDoH for what they are-clinical gaps in care.”

Caraline Coats, MHSA, vice president of Bold Goal and Population Health Strategy, says healthcare has been too medically focused for too long. “Today, as an industry, we only spend 4% of every healthcare dollar on social health. Everyone knows it’s important to health outcomes, particularly the clinicians. But we needed to find a way to provide the data and resources providers needed so they could treat social health factors too.”

It was a challenging undertaking. But Renda said they started by simply standardizing their SDoH data collection.

4 Ways Health Plans and Communities Can Address SDOH

“We needed to agree on common definitions and a way to codify those definitions,” he says. “For food insecurity, we decided to use the United States Department of Agriculture (USDA) Vital Signs screener, a two-question survey, and for social isolation and loneliness, we used a three-question scale from the University of California Los Angeles (UCLA) called the Loneliness Scale.”

By using these validated screeners, Humana was able to more effectively incorporate the data into their different well-being and direct clinical platforms. In 2018, the health plan screened 50,000 of their members in San Antonio, markets on these particular social determinants. And, in doing so, they were able to bring that information into their data ecosystems to not only help their providers make appropriate referrals to their patients for different resources, but also to assist Humana in their development of more effective population health programs.

After only a few years, Bold Goal is seeing clinical gains. The integration of SDoH information helped to increase the number of self-reported “healthy days” by Medicare Advantage members in Humana communities by 2.7 days. While 2.7 days might not seem like much, 

 beneficiaries in communities who did not participate in the Bold Goal program saw a decrease of 0.6 healthy days for the year. While Coats said Bold Goal program is still in its early stages, she is buoyed by the results so far.

“I firmly believe there is a return on both health and financial investment in social determinants,” she says. “We have incredible qualitative data and feedback from our members. It is going to take time to prove all this out but, with the space and time to prove the importance of social health on the overall quality of life, we will get there.”

Renda agrees. “We see that the program is moving in the right direction with both the healthy days numbers as well as other improvements we’ve seen in physical and mental health in our members,” he says. “We see SDoH as an opportunity for us to get deeper into our communities and understand the unique issues each may face and how we can rally around those to improve overall health. And our results so far give us hope that if we continue this work-and scale things that we are now learning are effective to improving health outcomes-we can have a bigger and bigger impact for our members over time.”

Kayt Sukel is a science and health writer based outside Houston.

How can healthcare organizations better overcome the challenges involved with integrating social determinants of health data into their population health initiatives?

Uniting Determinants and Data for Population Health

Hospital executives face a myriad of challenges in today’s ever-changing healthcare landscape. 

 asked some chief executives what their biggest challenge has been, and how they have worked to overcome it. Here’s what they had to say.

Alex Hellinger, DPT, MBA, executive director, 

, New York, says his biggest challenge has been bringing healthcare back to a community that had recently lost a major hospital and lacked sufficient medical resources.

“When a hospital closes, the vast majority of health providers leave the area, ultimately creating a medical desert,” he says. “My team and I addressed the challenge by building a comprehensive medical network throughout downtown Manhattan in phases, initially opening Manhattan’s first free-standing emergency department and then gradually adding essential services including imaging, ambulatory surgery, orthopedic and rehabilitation programs, as well as primary and specialty care.”

Top 4 Challenges Healthcare Executives Face in 2019

When building a comprehensive medical center from scratch, Hellinger had to step back and take a fresh look from a patient’s perspective at how healthcare should be delivered. “We fulfilled this objective by implementing services such as telehealth, and a personalized website for physician referrals and home-based healthcare programs,” he says. “The center has positioned itself as a vital community resource by partnering with longstanding neighborhood organizations and offering free public services, such as immunizations and health screenings.”

, Edison, New Jersey, has found navigating two different payment models to be a big challenge. “We’re moving from a volume-based environment to a value-based environment,” he says. “Our 17 hospitals need to remain solvent, so we are still reimbursed on a fee-for-service basis to a large extent. If I had to pick a definitive path-to either stay in fee-for-service or go into the value-based world-I would vote for going into the value-based world. That’s because all the incentives are aligned and physicians and hospitals are rewarded for achieving the best outcomes for the people we serve.”

Garrett has found this to be the best strategy when looking to lower the overall cost of care delivery. “To keep the needle moving toward value, we are growing our accountable care organizations (ACOs),” he says, adding that the health system’s best performing ACO saved about $145 million over five years and is among the nation’s top performers. “Beyond ACOs, we are investing in more patient-centered models including bundled payments, shared risk arrangements, and value-based purchasing.”

Teaneck, New Jersey, which has 351 inpatient beds, has found it challenging to provide patients with high-quality, affordable care in a transparent, cost-effective manner in light of its small size.

“With individuals demanding to play a much more active role in choosing where and how they spend their healthcare dollars, we need to ensure that patients receive high-quality, patient-focused care,” Maron says. To provide this, Holy Name is moving away from a procedure-driven model toward a relationship-building model that is more patient-centric, focusing on every individual’s unique needs. These include linguistic, dietary, cultural, religious, familial, financial needs, as well as personal and social considerations. 

Holy Name’s outreach programs and culturally-sensitive initiatives such as Asian Health Services, Familia Y Salud, and its faith-based services have become national models for addressing the diverse needs of various populations. 

As the healthcare market continues to change, Holy Name will continue to work with policymakers, insurers, and other stakeholders to accomplish its goals.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.

Managed Healthcare Executive asked some chief executives what their biggest challenge has been, and how they have worked to overcome it. Here’s what they had to say.

Top 3 Issues for Hospital Executives

Each year there are more than 17,000 deaths nationally from prescription opioid overdoses, 

 that 75% of U.S. employers say their workplace has been directly affected by opioid usage but only 17% feel well prepared to deal with the issue.

In response to the local and national ongoing opioid epidemic, 

 (FCH), a provider-owned health benefits company, which serves over 1 million people in Washington and the Northwest, wanted to do its part to help.

Launched on July 11, 2019, FCH’s Workforce Prescription Opioid Use Report, is offered free of charge to employers in the Puget Sound area with over 200 employees until Sept 15, 2019. The report will help identify high rates of opioid use, which can be associated with potential misuse and addiction among employees.

Once initiated, the employer will instruct their pharmacy benefits manager (PBM) to send their pharmacy claims to FCH to be analyzed. This extracted information will be de-identified with no personal health information and is completely HIPAA-compliant.

The Impact of Preoperative Opioid Use on Patient Outcomes

 tackling opioid abuse in the workplace.

“We are constantly innovating our application of data to help create healthier workforces, while responding to our society’s most serious health concerns,” says John W. Robinson, MD, chief medical officer, FCH. “Opioids are at the top of that list. We are implementing this workforce prescription opioid use report as a community service to help employers recognize if they have an opioid problem in their workforce.” 

, which was established so that public and private healthcare stakeholders would have the opportunity to identify specific ways to improve healthcare quality, outcomes, and affordability in Washington State.

The first step to addressing opioid abuse for employers is to identify potential misuse and addiction.

Managed Healthcare Executive August 2019 Issue