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Managed Healthcare Executive polled executives from across the industry to see how they feel about the current state-and future of-healthcare. 

Managed Care State of the Industry 2018

When Americans voted in the 2018 midterm election, healthcare was a hot issue. Consider the fact that in a 

PwC Health Research Institute Consumer Survey in September 2018

, 59% of the 1,500 respondents cited healthcare as the most important issue. So now that the Democrats will control the House and Republicans will have a greater majority in the Senate, will they attempt to address the healthcare issues Americans are complaining about?

Eleven Things to Know About Healthcare in the Midterm Elections

Congress will start with a clean slate in January. “Many bill sponsors and co-sponsors from the 115th Congress are no longer Congressional members,” says Annette Bechtold, senior vice president of Regulatory Affairs and Reform Initiatives at

, which provides employers with benefit advisory services. “All old bills that were introduced will be dismissed and all previously proposed legislation will need to be reintroduced. Educating new members while finding new sponsors and co-sponsors will add to the lengthy timeline of getting things accomplished.”

Here’s how experts predict healthcare will unfold in 2019.

1. There could be more changes to the ACA 

The Democrats’ midterm wins will likely slow, but not stop, the Republicans’ pursuit of their healthcare agenda-which has focused on deemphasizing the role of the federal government in the U.S. health system, says Benjamin Isgur, health research institute leader, 

, which analyzes trends affecting health-related industries.

Democratic control of the House likely means that Republican lawmakers will not undertake another attempt for wholesale repeal and replace of the ACA. Rather, the most substantive action related to the ACA will happen as the result of regulation and executive action. Without overwhelming majorities that can grant veto power, however, Democratic lawmakers will have little room to pursue their own agenda without bipartisan support.

But Michael Strazzella, co-head, Washington office and group practice leader of federal government relations at the law firm 

, believes the Senate, having grown its majority, will make efforts to repeal the ACA as it did in the 115th Congress. “Unlike the last Congress, however, I expect them to ensure that pre-existing conditions are protected in order to ensure that the issue can be avoided during the 2020 elections,” he says. “The House will hold hearings to highlight pieces of the ACA that they consider to be successful. Moreover, they will attempt to further block executive branch efforts to impede implementation of the ACA.”

2. The Trump administration will continue to use regulatory agencies in an attempt to transform Medicaid, roll back industry regulations, and address drug pricing 

These changes can be made without congressional input. HHS will move full speed ahead with initiating block grant pilots and enabling states to reduce their Medicaid programs through premium and work requirements, reducing benefits, and raising income thresholds, in order to create savings for poorer states and reduce the federal match to help fund tax reductions, says Gerry Hinkley, JD, leader of the healthcare industry team at 

, which provides legal services that support the healthcare industry. HHS will also continue the “reducing reporting burden” approach carried forward in the 2019 Inpatient Prospective Payment System rule as a basis for accelerating the reduction in Medicare support for inpatient care.

Top 7 Healthcare Takeaways from the Midterm Elections

Regarding drug pricing, the recently-enacted 

 will improve transparency of drug pricing for patients. “I expect the president to continue to pressure pharmaceutical manufacturers to reduce drug prices, but it’s not clear when or whether further action will be taken by regulatory agencies,” says Eric D. Fader, JD, partner in the law firm Rivkin Radler LLP.

3. The Trump administration will continue to embrace value-based care models, including mandatory ones 

The administration is looking for ways to improve the affordability of healthcare and Alex Azar, HHS secretary, has affirmed that this will be the agency’s strategy. Value-based care models are predicated on success and efficiency; they focus on the best care for the best price and reward those outcomes. “More accountability on providers and education of consumers will be the key to bringing healthcare costs in line,” Bechtold says.

Hinkley notes that recent HHS initiatives around home healthcare, for example, demonstrate the administration’s continuing focus on alternate payment models that move away from payment for episodes of care.

4. Certain healthcare initiatives that Republicans and Democrats agree on could gain momentum 

Two areas that both parties agree on are prescription drug regulation and stabilizing the individual market, says Arthur Tacchino, JD, chief innovation officer, 

, a provider of healthcare reporting and compliance solutions. Prescription drugs have been targeted due to their incredibly high prices, and the country’s opioid crisis has drawn attention to them from a health and welfare perspective. “Even prior to the midterm elections there was bipartisan support to help stabilize the individual market, especially because the ACA’s individual mandate was effectively repealed with the GOP tax reform bill in 2017,” he says.

Value-Based Care: Gaining Ground or Losing Steam?

Mark Luck Olson, chief executive officer, Trainer Rx, an outcomes focused, evidenced-based, and patient-centric tele-rehab platform, says the topic of pre-existing conditions surfaced during the midterm elections, with both political parties considering it important. “They define pre-existing conditions differently, however,” he says. “While Democrats view pre-existing conditions as a necessary right, the Republicans view it as a forced purchase. Ultimately it becomes a question of whether payers think healthcare is a service to be purchased or a right that everyone should have.”

Democrats do not have enough power at the federal level to make any significant changes in the healthcare industry without bipartisan support. However, they will now have enough unilateral power to stop Republican efforts. “Any substantive change through legislation would require both the House and Senate to pass it, and now that Democrats have taken control of the House they have the ability to quash any Republican efforts they do not agree with,” Tacchino says.

Isgur says Democrats will gain more oversight authority, allowing them to hold hearings on the administration’s actions and subpoena agency leaders. These actions may hinder and slow the agency’s work. Democrats likely will question CMS as it considers the additional Section 1115 Medicaid work requirement waiver applications.

Democrats also will have a greater say in the federal budget. “One priority for them will be to include more resources to shore up the ACA individual markets,” Isgur says. “This can take the form of restoring funding for programs that connect beneficiaries to ACA navigators or pushing for restoration of ACA cost-sharing reduction payments to insurers.”

6. States will continue to become an important battleground for healthcare policy

Democratic states that haven’t done so already may seek to mimic the reinsurance programs put into place by states such as Alaska, Maine, Maryland, Minnesota, New Jersey, Oregon, and Wisconsin, which generally pay high-cost ACA claims in order to lower ACA premiums, Isgur says.

Managed Care Pharmacy’s Future: What Health Execs Should Know

Democratic-led states may also seek to recreate ACA protections that have been unwound at the federal level. States such as New Jersey, Vermont, and Massachusetts have enacted individual mandate penalties to stand in for the federal one. These states are also more likely to adopt legislation calling for greater transparency in drug price increases.

Furthermore, Democratic gubernatorial wins in the states that have not expanded Medicaid under the ACA could lead to further expansions. “Democratic wins on the state level could also slow the spread of work requirement programs for some Medicaid beneficiaries in states formerly led by Republican governors,” Isgur says. In addition to changes in statehouses, several attorney general offices flipped from Republican to Democrat. “Legal challenges to health policy have abounded in recent years, often led by attorneys general, so changes in party could shift the direction of these courtroom showdowns.”

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

Articles

Midterm Election Results: 6 Ways Healthcare Could Change in 2019

Growing up in in Limerick, Ireland, Michael J. Dowling admits his family situation was a little complicated-his mother was deaf and his father suffered from heart disease and arthritis.

“Because of that, I already had an interest in the health and human services field and I think that’s what led me to the arena,” Dowling says. “When I went to college I got involved volunteer-wise in a lot of health issues and homeless issues, and it just was natural to me. I always was drawn to it.”

That early passion for healthcare has never ebbed.

Today, Dowling serves as president and CEO of Northwell Health, the largest integrated healthcare system in New York State with more than 67,000 employees.

Under his leadership, the healthcare system has grown from an organization with 30,000 employees, 18 hospitals, and a few dozen outpatient locations to more than 67,000 employees, 23 hospitals, and over 665 ambulatory facilities. Quality has also improved. The health system’s education, awareness and clinical efforts have helped reduce sepsis mortality by more than 60% over the past decade.

“We were the first health system to be created in New York and we are currently the largest and we continue to expand,” he says.

In addition to those impressive hospitals and ambulatory location numbers, Northwell also boasts 6,675 hospital and long-term care beds, a full complement of long-term care services, a research institute, and medical and graduate nursing schools. Overall, Northwell is one of the largest health systems in the U.S., with $11 billion in annual revenue. 

“We have all components of the healthcare business, we have everything from primary care all the way to end of life,” Dowling says. “We are very committed to serving everybody irrespective of circumstance. Many organizations like to focus in on those things that only do well financially. We take care of everybody, including people with substance abuse, alcoholism abuse, etc., so you want to be an organization that is focused that way.”

Dowling earned his undergraduate degree from Ireland’s University College Cork and his master’s degree from Fordham University, picking up honorary doctorates over the years from Queen’s University Belfast, University College Dublin, Hofstra University, Dowling College, and Fordham University.

After graduation, Dowling became a professor of social policy and assistant dean at the Fordham University Graduate School of Social Services and director of the Fordham campus in Westchester County.

When Mario Cuomo was elected governor in 1983, Dowling was offered a position on his administration as deputy commissioner in the Department of Social Services, which was responsible for all welfare programs in the state. Dowling didn’t know Cuomo and had never really been involved in politics before, and he declined the position-at first.

Then he decided it was a chance to make a difference on some of the issues he cared about, and decided to give it a go.

“I’m a risk taker, and thought it would be a good new experience,” Dowling says.

Although he expected to stay about one year, Dowling ended up spending 12 in the administration. During that time, he was continually promoted, including serving as state director of Health, Education, and Human Services, and as deputy secretary to the governor and social services commissioner.

“I had all of the welfare programs, health programs, education programs, and mental health, substance abuse-all behavioral health as part of my portfolio,” Dowling says. “I worked with some very great people, we did some very interesting things, and I’m very fortunate that I was [asked to serve] because having the opportunity to work with Mario Cuomo was one of the best things that ever happened to me.”

One program Dowling is most proud of from that time is Child Health Plus.

“It was a program that provided coverage to kids who didn’t have it and it was a very innovative program at the time and still exists,” he says. “That was the one that I think I spent probably the most of my time on during those couple of years and was one I always look back on as something of a success.”

After Dowling left the government, he became a senior executive at Blue Cross Blue Shield in Manhattan, but he stayed less than two years.

“I’m not a person who likes to just sit in my office looking at paperwork; I like to be out in the field where the real action occurs,” he says. “I got a call from North Shore University Hospital asking if I would be interested in talking to them and I was excited about the possibility.”

Dowling accepted a position as chief operating officer of North Shore University Hospital, a large tertiary campus where Northwell Health’s creation began, in the early 1990s.

“I was ready to leave the insurance side to get back into the world of where I thought the real work occurred, which is to be on the provider side where you actually were dealing with patients every day and making a difference in people’s lives each and every day,” he says.

He moved up to president and CEO of Northwell Health in 2002, and not a day goes by when he doesn’t deal with people-his favorite part of the job. For instance, each Monday morning he meets with all new employees to the organization, averaging about 150 a week.

Besides meeting and mentoring staff, he deals with the press, works with politicians, offers opinions to the board, works with community organizations, and oversees the administrative, technical, and budgetary initiatives.

“Every day is a little bit different and things pop up all the time because when you’re on the provider side, when something goes wrong, if it really goes badly wrong, it’s dangerous because it’s mostly life and death situations,” Dowling says. “In healthcare, a bad decision can result in a very, very bad outcome for somebody so that’s why you’ve got to have the right people and the right physicians, officers, and administrative leaderships in the right positions, to make sure that those things happen rarely and are not a common occurrence.”

A unique program at Northwell Health replicates the show “Shark Tank,” where it holds an annual competition among employees called the Innovation Challenge in which it invests more than $1 million a year to support promising commercialization ideas that originate with the health system’s physicians, researchers, and other staff.

 “We try a lot of new things. Our medical school is very innovative, our nursing school is innovative,” Dowling says. “We do a lot of innovation programs. We’ve built up new businesses based upon ideas coming from staff.”

For instance, as part of this year’s President’s Award for Innovation, it awarded $500,000 to researchers at its Feinstein Institute for Medical Research to further develop a non-invasive approach to diagnosing endometriosis, a painful condition that affects one in 10 women and can cause infertility.

“You have to be innovative and creative in this world today. You don’t want to be a prisoner of the past,” Dowling says. “You want to be an organization that is constantly pushing the edges of the envelope and known as the place where people can get the best care, best coordinated in a holistic way, and you want to be a place where people enjoy coming to work.”

Dowling is a big believer in the team and his philosophy is to guide the ship but let the people that he puts into place do the work. He wants his employees to understand they have an obligation and responsibility, not necessarily a job.

“I try to light a fire in people rather than lighting a fire under them,” he says. “I try to inspire people, try to convince people that what we’re doing is good. I’m an optimist, I believe that we do great work in healthcare, and I think it’s important to get people to understand that they’ve got to be proud of what they do, acknowledge the great things that they do, and feel optimistic about the potential, while acknowledging the fact that they need to get better and better all the time.”

When Dowling reflects on his career and his work at Northwell Health, he is happy that he gets to come to work every day and be with a group of great people who share his views on helping people.

“When you’re in healthcare and you walk around the hospital and you walk through the children’s hospital, you walk through the oncology ward, it gives you perspective on life. You realize how fortunate you are to be working in such a place, and also how fortunate you are that you are today temporarily healthy,” he says. “By the end of the day, you can say, ‘Today we helped people, we made people better today.’ We did the right thing for those people who depend upon us for the care.”

Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years. 

Growing up in in Limerick, Ireland, Michael J. Dowling admits his family situation was a little complicated-his mother was deaf and his father suffered from heart disease and arthritis. Read more about his early life and what led to his rise in healthcare.

Featured Exec Michael Dowling: CEO of Largest Integrated Health System in New York 

When Gregory Kane, MD, chair of medicine at Thomas Jefferson University’s Sidney Kimmel School of Medicine, started his career in pulmonary medicine in Philadelphia 30 years ago, he quickly noticed that patient outcomes were not solely dictated by the patient’s medical condition. Two patients with similar cases, who were treated in comparable ways, could-and often did-respond to those treatments differently.

“Early on, I recognized that my patients’ neighborhood and their domicile was a major contributing factor to flares of their disease,” he says. “Those who work in healthcare understand that poverty level, access to healthcare insurance, and social situation contributes to disease and outcomes. We see it every day.”

With the passing of the ACA in 2010, and a greater focus by payers and providers on value-based care, such social determinants of health (SDOH)-defined by the World Health Organization as “the conditions in which people are born, grow, live, work, and age”-have become a major public health concern.

Julia Andrieni, MD, vice president of Population Health and Primary Care at Houston Methodist, an eight-hospital health system with more than 6,700 physicians, in Houston, says research shows that SDOH-related inequities don’t just impact access to care-but overall health outcomes. In fact, according to Healthy People 2020, a report put out by the CDC, social and economic factors play an integral role in whether a patient can or will engage in behaviors known to promote health or follow a doctor’s recommendations or treatments after being diagnosed with a chronic condition.

“Social determinants of health affect every aspect of healthcare, says Andrieni. “We’re learning that we have to address not only clinical factors that affect a patient’s health but also the nonclinical ones if we are going to successfully treat patients. Patients may have the same conditions, but they are not the same. If you have one patient with diabetes who has a good education and predictable income, and another who has food insecurity, an inability to pay for medicine, and a lack of transportation, there are disparities there that require more than a prescription to address. This is a major public health concern.”

Across the United States, a growing number of programs and initiatives are tracking SDOH-and exploring how it can inform effective, evidence-based patient care. While it’s not easy, it’s important, says Bita Kash, PhD, director of the Center for Outcomes Research at Houston Methodist Hospital.

“The overall goal is to achieve the same outcomes for every patient regardless of their income, where they live, or education level,” she says. “The problems that arise from these factors are often manageable-if we understand them and their effect on care-and healthcare payers and providers should be able to come up with pertinent interventions to reduce variations and outcome disparities due to socioeconomic factors.”

It’s well known that the United States’ healthcare spend greatly surpasses other first-world nations. Yet, despite spending 17.8% of its gross domestic product on healthcare, patient outcomes are no better-and, in fact, are often poorer-than other high-income countries. As noted by a recent Commonwealth Fund report, “

Health Care Spending in the United States and Other High-Income Countries

,” lower rates of insurance coverage and mixed levels of population health programs likely play a role.

A lack of investment in social services that could help mitigate many of the SDOH that negatively impact health-and, as a consequence, drive up healthcare costs-also need to be tackled, says Krista Drobac, chairwoman of Aligning for Health, a payer coalition that advocates for better integration of social service programs into the healthcare system.

“We’re spending a lot of money on clinical care that would be better spent if we invested it upfront to help deal with these inequities,” she says. “There’s been a lot of research about how SDOH impact healthcare. It’s well-documented at this point. But they don’t answer the really critical question: What is the next step? What is it that we have to do to actually integrate SDOH into patient care in a robust and meaningful way?”

Aligning for Health believes it starts by breaking down funding silos in federal programs and testing community pilot programs that address specific SDOH issues. As a federal advocacy organization, the coalition is lobbying the federal government to allow for “lending and breeding of funding” across different departments like the United States Department of Agriculture, Housing and Urban Development, and HHS.

“Right now, there isn’t transfer or waiver authority across programs,” says Drobac. “We’re trying to create county level pilots that would be able to get across all of these different departments and really address the whole patient-because that’s what’s needed to really address these disparities.”

To do so, the coalition is relying on data from payers and providers about SDOH, as well as other federal or community programs that patients may be utilizing. But that data can only take them so far, says Drobac. Without the right connections between healthcare and community problems to address these issues, healthcare costs will continue to rise and patient outcomes will continue to decline.

“Providers are collecting data about whether or not a patient has adequate nutrition or lives in a safe home but often they just don’t know what to do with it,” says Drobac. “Unless that provider has the ability to actively refer the patient to a program, the data really just sits there-we can’t reduce costs and we can’t improve care. We need more opportunities for providers to take action on SDOH so patients can be connected with the social services they need.”

Individual health systems are looking for ways to create those opportunities through innovative research programs. With Medicare-related avoidable hospital readmission penalties on the rise, Kash and her colleagues at Houston Methodist and at the Texas Medical Center, a confederation of 60 medical institutions in the Houston area of which Houston Methodist is part, wanted to see how much social and environmental factors might influence the likelihood that different patients might be readmitted.

“Our ultimate goal is to close the disparity gap in hospital readmissions-because, unsurprisingly, there is a big gap. More disadvantaged populations are at a much higher risk of being readmitted to the hospital after a health issue,” she says.

To start, Kash and colleagues conducted a meta-analysis of studies that compared different readmission reduction strategies to see how they intersected with SDOH. They then took a detailed look at patient-level data regarding SDOH from EHRs and health information exchanges to get a better understanding about different patient populations and any correlated reasons for readmission. Then they used predictive modeling techniques, including their own data and data from the area deprivation index (ADI), which is census data that looks at common socioeconomic factors, to determine the factors that were most likely to predict an avoidable hospital readmission.

“We found that being a Medicaid patient is the best indicator of an avoidable readmission. Even with all the other ADI data, it seems to be a good proxy for disadvantaged populations,” Kash says. “The other factors included patients who are older than 45 years of age, patients who are discharged to a skilled nursing facility or discharge themselves against medical advice, patients who have a diagnosis of chronic obstructive pulmonary disease, and patients who have severe illness. But when it comes to reducing readmissions, it seems to come back that simple insurance status really is a predictor of outcomes.”

Kash hopes that studies like hers will encourage payer organizations to consider SDOH when calculating readmission penalties. But she also hopes that more healthcare systems will find ways to incorporate the findings into clinical care.

“We want this to result in some kind of actionable strategy,” she says. “And this is something that could be easily implemented with some kind of alert or reminder in the EHR. We recommend that patients who meet these criteria get more detailed and comprehensive discharge instructions, especially around self-care and symptom recognition and management. And we also recommend follow-up phone calls and home visits. They work-and they don’t cost all that much in the long run.”

While it would be easy to add a few checkboxes to a patient record on an EHR, Kash is quick to point out that every hospital and health system needs to develop their own approach to addressing SDOH.

“Each hospital really caters to a different type of patient population,” she says. “We’ve learned, if you really want to close these gaps, it’s important to come up with strategies that are very specific to your region and the needs of the patients within that region. And that means understanding, at the patient level, the SDOH that may interfere with positive outcomes.”

Kane agrees, using the community in Flint, Michigan, as an example. “They have very specific community issues that affect the health of all their residents,” he says. Because of infrastructure issues in that community, he explains, children in that area have a much greater chance of experiencing learning disabilities, of chronic kidney disease, and potential growth retardation-all because that community has struggled with providing basic human services like water, transportation, sewage, and safe housing to everyone. “Even the opioid epidemic, in some ways, could be considered a byproduct of SDOH, because of an environment with jobs with more physical demands that led to injuries, to higher rates of prescriptions, to targeted pharmaceutical advertising.”

Kane contributed to a position paper on SDOH for the American College of Physicians in April 2018, “

Addressing Social Determinants to Improve Patient Care and Promote Health Equity

.” In it, he and his colleagues called for “health in all policies.”

“Payers and providers can’t do this alone,” Kane says. “Legislators need to consider the health of the population when they implement policies in their city, state, or region. It really is an important first step,” he says.

Yet, he acknowledges that dealing with SDOH must be a team effort.

“We also believe there should be greater attention for SDOH among trainees in medicine. We can do a much better job of teaching our students so they know what to look for when caring for individual patients,” he says. “Healthcare systems need to think creatively about how to address all those little things that can influence care-how patients get transportation to their facilities for follow up, how the neighborhood may contribute to exacerbating an underlying condition, or how to make sure that patients have access to fresh fruits and vegetables. Payers should recognize that patients who are affected by a number of SDOH may require more time to treat, and reimbursement might need to be adjusted so we can deliver that care. It’s going to take a lot of different things, many of them little things that add up over time, to get the insights we need into how SDOH affect our patients and how we, across our communities, can effectively plan and deliver interventions that will address them.”

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

Evidence grows that these nonclinical factors have a large influence on patient outcomes. Here’s what hospitals and payers can do about it.

Social Determinants of Health Play Growing Role in Hospital, Payer Strategies 

When patients start searching for a new doctor, they typically click through online results on a payer’s website or ask friends and family members for recommendations. But even the best online searches only provide minimal information, such as a physician’s gender, age, educational qualifications, practice locations, specialty, or board certifications.

The patient-primary care doctor relationship is an important one that can span for decades, so helping members find a doctor who is a good fit and who meets the member’s health needs is critical.

To help its members find a physician who understands them, Pittsburgh-based Highmark Health, one of the country’s largest payer/provider organizations serving people in all 50 states and the District of Columbia, developed a Doctor Match tool.

 to determine the characteristics that are the most valuable to individual members. For example, whether the member would prefer a friendly, chatty physician or one who gets right to the point.

Participating primary care and OB/GYN doctors must also complete a 10-minute quiz and provide a photo and a two-minute video clip to introduce themselves and their approach to care to prospective patients. This is facilitated by members of Highmark Health’s provider relations team, who set up video cameras and captured photos of physicians in their practices, says Stacy Byers, vice president of digital strategy at Highmark Health.

Highmark Health’s internal data show that 7% of patients have switched providers because of a negative customer experience-and that number is twice as high among digitally-savvy consumers. Twenty-six percent of patients will “shop” providers to determine personal compatibility.

Doctor Match is available to members in Western Pennsylvania and Delaware, according to a spokesperson. Highmark Health may add pediatrics and orthopedic surgery to the online tool in the future, says Byers.

Here are four more ways payers are improving the member experience:

When a patient is sick, they don’t want to be just a number to the insurance customer service representative who answers their call.

That’s why when a member reaches out to New York City-based Oscar Health, they connect with one of five staff on the concierge team at the health insurance company. The team also includes a registered nurse, says Chelsea Cooper, senior vice president of strategy and operations. The member can communicate by phone, secure messaging, or email with any staffer on the concierge team, or they can request to speak to a specific staffer.

When a member calls their concierge team with a clinical question-such as one pertaining to pink eye or whether they need to schedule a flu vaccine-they can also be connected with a doctor for a virtual visit through Oscar’s 

 feature. During the virtual visit, the member is asked about their symptoms and health history; in return and if appropriate, the member receives a diagnosis and plan, and prescriptions can be sent to their pharmacy.

The information gleaned about virtual doctor visits is stored within the member’s profile, which allows the payer to know more about each individual member, according to Cooper.

In addition, members have access to the Oscar web, Android, and iOS apps, where they can search for care based on the reason for visit, type of doctor, and location. They can also book appointments and pay their bills. Also available on the app is a pre-selected network of hospitals and physicians.

Members with more complex health needs-such as diabetes-are assigned to the complex case management team; this assessment is based on claims data, says Cooper. This team includes doctors, nurses, and social workers, who can go into members’ homes to do assessments and set up medical devices.

Oscar Health launched the concierge team model to some of its members in 2016 and transitioned all members by the second quarter of 2017, says Cooper.

2. Increasing access to medication-assisted treatment recovery 

More than half of the estimated 2.5 million people with substance abuse disorders in the United States are without dependable access to medicated-assisted recovery options, according to Boston area-based Neighborhood Health Plan, a payer arm of Partners HealthCare. The nonprofit payer, which will become AllWays Health Partners on January 1, 2019, highlights that nearly 2,000 people in Massachusetts died due to opioid-related overdoses in 2017.

That’s why Neighborhood Health Plan is trying to improve the experience for members and non-members by offsetting the cost for providers to dispense buprenorphine products-such as Suboxone, which is used to treat cravings and withdrawal symptoms related to opioid dependency-and other medication-assisted treatments.

Specifically, the payer will pay providers $1,000 to support a provider’s training, which is required by the Drug Enforcement Agency (DEA) to prescribe and monitor patients during these treatments. In addition, once providers have been certified and have treated at least 10 patients, they will receive a $4,000 honorarium. The patients treated by the trained providers don’t have to be health plan members to qualify for payment, says Tony Dodek, MD, chief medical officer.

Additional efforts to support Neighborhood Health Plan members struggling with opioid dependence include:

No pre-authorization requirements for Suboxone.

No copays for Narcan (naloxone), which is used to revive people who have overdosed on opioids; in addition, pharmacists inform members about their eligibility for free supplies of Narcan when they receive a prescription for high-dose narcotic painkillers.

Two trained and certified recovery coaches who work with at-risk patients and, hopefully, prevent life-threatening relapses. According to its announcement, Neighborhood Health Plan is the first payer in the country to hire recovery coaches for this purpose.

Neighborhood Health Plan’s strategy is to optimize access to treatment, says Dodek.

“The problem is related to access to medication-assisted therapy,” he says, noting that evidence shows the most effective way to treat opioid addition is with medications such as Suboxone, in conjunction with counseling.

Currently, there aren’t enough providers in Massachusetts with this training, which means patients don’t have access to medical-assisted recovery from opioid dependence, he says.

In Massachusetts, physicians with DEA-required training can prescribe these medications, 

 to the state’s board of registration in medicine. Advanced practice registered nurses, physician assistants, and pharmacists can also prescribe some medications. Physician assistants and advanced practice clinicians must be supervised by a physician licensed in the state.

According to DEA rules, providers who receive training on medication-assisted treatment of opioid dependence can treat up to 100 patients.

Struggling to come to grips with a recent cancer diagnosis or trying to adhere to a diabetes care plan are stress-inducing circumstances. That’s why members want to hear a friendly, calm, informed voice at the other end of the phone when they call their health insurer.

To support its members during stressful times, Minnetonka, MN-based UnitedHealthcare trains its customer service personnel on what it calls its “compassion code.”

The payer defines this as taking an empathetic approach to members’ needs by paying attention to their voices and the language they’re using during the phone interaction, says Rebecca Madsen, chief consumer officer. This approach allows a customer service representative to understand the member’s state of mind.

Customer service representatives learn about the compassion code during extensive training, which features soft skills, technical skills, and operational policies and procedures.

Customer service representatives are evaluated based on an improvement in member satisfaction, says Madsen. These variables include:

: Was the issue resolved correctly on the first call?

: Was the member treated with care, concern, and respect?

: Did the interaction meet privacy and regulatory requirements?

: Did the call adhere to operational policies and procedures?

4. Supporting members’ weight loss goals

Weight loss is difficult. And most people who lose weight are 

 in the long term. Being overweight is also dangerous since it 

 of developing diabetes, heart disease, hypertension, and other chronic diseases.

To help its members lose weight, UnitedHealthcare developed Real Appeal, which is a personalized, interactive online weight-loss program. The program uses personal coaches and well-known celebrities-such as Dr. Oz, actor Tom Arnold, and actresses Jennie Garth and Vivica A. Fox-to support members in their weight-loss journey.

At its core, Real Appeal combines social support, entertainment, and science to support members. The program includes a web program that features segments on fitness, cooking, stress management, and sleep.

Program participants receive exercise DVDs and resistance bands, along with measuring cups and a food scale to help control portion size. Also included are booklets with weight-loss information and a measuring tape to track waist size and a weighing scale.

Since the program was launched in late 2015, more than 100,000 enrolled members have collectively lost more than 1 million pounds or an average of 7% of their body weight, according to United Healthcare. The program has saved employers up to 16% in annual medical costs, when program participants are compared to nonparticipants.

MCOs are stepping up their game to ensure members are highly satisfied with their services. Here are some strategies to consider.

Five Ways to Improve the Member Experience

After the midterm election votes were tallied, pundits and thought leaders began offering their perspectives of what the results mean for citizens, taxpayers, and businesses. In some ways, the results offer more clarity about what we can expect for America’s healthcare future. In other ways, they raise more questions.

This month we revealed the results of our annual State of The Industry Survey. They provide insight into how our peers are responding to major industry changes, and what challenges they see coming in 2019. While we all want to predict the future so we can avoid obstacles, we cannot allow our desire for clarity to become an obstacle itself. As healthcare leaders, we have tremendous control over our own destinies-and countless opportunities to improve American health and wellness.

Over the past two years in particular, healthcare has been the focus of several high-profile-and sometimes heated-policy debates. 

 (AHIP) has been at the center of many of them. In responding to the immediate, urgent policy questions on the table, we are also looking for the opportunities to drive healthcare improvements:

As we engaged in the repeal-and-replace debate, we put forth recommendations at the federal and state level for improving costs in the individual market, promoting access to affordable, comprehensive coverage for everyone.

As we responded to the 2019 annual rate notice for Medicare Advantage plans, we advocated for greater flexibility that would permit plans to offer more choices for beneficiaries.

As states consider the future of their Medicaid programs, we continue to offer studies and resources that demonstrate the benefits the managed care offers for enrollees and taxpayers.

As lawmakers debate the value of private-market health care coverage, our 

 initiative demonstrates how insurance providers protect the health and financial security of the 180 million people who receive coverage through their jobs.

As Congress developed legislation to battle the opioid epidemic, we advocated for changes that would help keep people safe from the risks of addiction. We also launched the Safe, Transparent Opioid Prescribing initiative to support the widespread adoption of clinical guidelines for pain care and opioid prescribing.

Three Ways to Better Address Social Determinants of Health

Individually, health insurance providers have been making their own bold moves to improve what’s working, and to fix what isn’t. They are improving care access by leveraging telemedicine and other on-demand technologies. A deeply held personal favorite, they are investing in social determinants of health, to help entire communities get healthier faster and stay healthier longer. Rethinking their approach to negotiating lower costs for patients, they are adopting new value-based models to bring down prices of prescription drugs and medical treatments. They are introducing new measures to better understand and drive member satisfaction; creating new collaborative relationships with doctors, nurses, and hospitals to break down barriers to care and find real solutions that will work in their communities; and launching new education initiatives to help people understand how healthcare works, and how to get the most out of their coverage and care.

It is important to take part in the policy debates. At the same time, I encourage managed care leaders to lean in to how we differentiate ourselves as a private market industry in very tangible ways. Focus your strategies relentlessly on patients and consumers. Invest in initiatives that will make sustainable improvements in health and living. Find new ways to offer more choices and value. Consider hiring executives in charge of social determinants of health. By driving innovation for more affordable choices that help people maintain their health without breaking the bank, we can truly make a difference for a better American healthcare system.

 editorial advisor, is chief operating officer of AHIP,  the national trade association representing the health insurance community. AHIP’s members provide health and supplemental benefits to millions of Americans.

While we all want to predict the future so we can avoid obstacles, we cannot allow our desire for clarity to become an obstacle itself.

What Every Healthcare Executive Must Remember as 2019 Approaches 

Major blockbuster drugs slated for launch in 2019 are expected to have a significant impact on treating certain cancers, diabetes, peanut allergies, and other conditions.

Many medication launches will treat a variety of cancers, says Christopher Peterson, PharmD, director of Emerging Therapeutics for Express Scripts. “Cancer therapies represent about one-third of all specialty drugs in the pipeline, so a significant number of cancer drug approvals is expected into the future,” he says.

 (Immunomedics), a novel, first-in-class antibody-drug conjugate (ADC) for treating breast cancer, was granted priority review by the FDA in July 2018. It is one of the top cancer medications expected to receive FDA approval in early 2019, according to Aimee Tharaldson, PharmD, senior pharmacist with Emerging Therapeutics at Express Scripts.

FDA clears new type of leukemia treatment

 (Elzonris, Stemline Therapeutics), for treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN) cancer, is also expected to receive final approval in February.

Other expected major cancer drug launches include oral 

(Karyopharm Therapeutics) to treat multiple myeloma and oral 

 (Janssen), which received breakthrough therapy designation in March 2018, for urothelial cancer.

 (Loxo Oncology), received breakthrough designation from the FDA for patients with metastatic RET-fusion-positive non-small cell lung cancer (NSCLC) as well as a last-line treatment of RET-positive thyroid cancer, is another cancer therapy to watch, says John Santilli, president of Market Access Intelligence.

 (Ozempic, Novo Nordisk), a GLP-1 agonist for type 2 diabetes approved in 2018, may achieve blockbuster status in 2019, Santilli said. “Ozempic has been gaining market share during this year in Canada and Denmark, in addition to the United States.”

 (Zynquista, Lexicon), has a PDUFA date of March 22, 2019. The oral dual inhibitor of SGLT-1 and SGLT-2 is used in combination with insulin to improve blood sugar control in patients with type 1 diabetes, Peterson says.

The projected big new drugs for inflammatory conditions in 2019 include 

 (Boehringer Ingelheim and AbbVie) for psoriatic arthritis, Crohn’s disease, and other inflammatory conditions, according to Tharaldson.

(DBV Technologies), which has a PDUFA date of June 22, 2019, is a novel allergy immunothearpy, administered daily via transdermal patch for desensitizing pediatric patients with peanut allergies. “Around three out of 500 patients in the United States have an allergy to peanuts,” Tharaldson said. “This could be a blockbuster medication.”

 (Ketanest, Janssen) nasal spray, which received breakthrough designation and is expected to be approved by FDA in early May 2019. Esketamine treats major depressive disorder, which affects around 16 million Americans, with imminent risk for suicide. “In a clinical trial, within 3 days, more than 60% of patients receiving esketamine saw improvement in depressive symptoms,” Tharaldson said.

bictegravir/emtricitabine/tenofovir alafenamide

 (Biktarvy, Gilead Sciences), launched in 2018, will “continue to provide strong growth for the company in 2019 on its way to becoming a blockbuster drug,” Santilli says. “This HIV ‘triplet’ medicine, combining different treatments into a single formulation, recently demonstrated high efficacy, high barrier to resistance, and long-term tolerability, re-affirming the drug as a first-line treatment option for suitable adult HIV patients who are starting therapy.”

FDA adds key label expansion to blockbuster anticoagulant