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We asked healthcare industry leaders to tell us about how their organizations are using technology-from big data to remote monitoring devices. Here’s what they said.

Managed Care Technology Survey 2019

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

The biggest issues healthcare industry leaders foresee include: 

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

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

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

Catholic Health Initiatives and Dignity Health merger

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

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

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

The Dick Tracy watches are here and are way 

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

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

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

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

The 4 Biggest New Areas to Focus on in 2019

The U.S. biosimilars market gained momentum over 2018, as more of the agents were submitted for FDA review and more regulatory approvals were granted, including additional immunosuppressive and cancer-treatment biosimilars.

Sandoz’s biosimilar adalimumab, Hyrimoz (adalimumab-adaz) injection was approved in October 2018, and Celltrion’s Truxima (rituximab-abbs), the first biosimilar to be approved in the U.S. for non-Hodgkin lymphoma and the first approved biosimilar to Rituxan, was approved in November 2018.

“We’re just seeing the cusp or initial wave of these cancer-treating biosimilars,” says Gary H. Lyman, MD, MPH, FASCO, FRCP, professor of medical oncology at the University of Washington School of Medicine, in Seattle. Lyman also serves as chair of the American Society of Clinical Oncology (ASCO) Biosimilars Work Group.

In May 2018, the FDA approved a biosimilar version of epoetin alfa (Epogen/Procrit), called Retacrit (epoetin alfa-epbx), for treatment of chemotherapy- and kidney disease-associated anemia, as well as for anemia resulting from zidovudine among HIV-positive patients. In June, the FDA approved Mylan and Biocon’s application for Fulfila (pegfilgrastim-jmdb), the first biosimilar to Neulasta (pegfilgrastim) for reducing infection risk in some patients with non-myeloid cancers who are administered myelosuppressive chemotherapy.

There are now 15 FDA-approved biosimilar products, up from nine in 2017. Of the four oncology biosimilars approved in 2018, three have already gone to market, says Rick Lozano, vice president of biosimilars and integrated business development, AmerisourceBergen. 

Additional biosimilars approvals are coming in 2019 and more applications will be submitted, as more brand-name biologics’ patent protection periods expire.

“The regulatory framework is pretty well settled now,” Lyman says. “We’re still waiting for the final rules for some of the other aspects of biosimilar approval, such as substitution and interchangeability.”

Biosimilars do not have to be declared interchangeable with their reference brand-name biologics to be prescribed, but an interchangeability determination would allow substitution by pharmacists.

“While it will take time for us to fully benefit from recent regulatory updates, the changes and communications we saw coming from policy makers in 2018 were incredibly promising and present great opportunities for 2019,” Lozano says. “Looking ahead, policy makers are seriously exploring the interchangeability between biosimilars and their reference products as part of the blueprint for lowering drug prices.”

Congress and the FDA made it clear in 2018 that biosimilars “will be part of the solution” for controlling healthcare costs, Lozano says. “That alignment is starting to better pave the way for more products to come to market, as evidenced by this year’s uptick in approvals.”

The FDA is also preparing new guidelines on biosimilar product labels, which Lozano hopes will create a “more level playing field” between biosimilars and biologics by helping to reassure healthcare providers that biosimilars are safe and effective.

Lozano expects to see continued momentum in 2019, with more approvals and increasing acceptance of biosimilars as a viable treatment option.

“We are confident that the U.S. market will continue to evolve in the direction of the European biosimilar market, as more and more obstacles, such as patent challenges and litigation, are reduced,” he

The U.S. has lagged behind Europe on biosimilars approvals and uptake, and some analysts have pointed to uncertainty about anticipated cost savings, regulatory and legal issues, contracting mechanisms, and physician unfamiliarity with biosimilars as potential barriers to uptake.

Because biosimilars are “highly similar” but not identical, on a molecular level, to originator biosimilars, some clinicians have had concerns about the idea of switching patients from well-known biologics to less familiar biosimilars. Patients have been switched to biosimilars in most cases only after brand-name biologics lost efficacy or brought intolerable toxicities.

“Europe has been ahead of the United States on biosimilar approvals for years but the good news is this: none of them have been withdrawn from the [European] market or seen red flags with major safety or efficacy issues,” Lyman says. “Nevertheless, recently, a submission for a biosimilar for rituximab for lymphoma was turned down by the FDA, for reasons they know and I don’t, and the company has decided not to challenge or resubmit.”

“Over the past year, for the first time, we have had a number of oncology biosimilars FDA-approved for cancer treatments as opposed to supportive care agents like growth factors,” Lyman says, citing approvals since September 2017 for the biosimilars Mvasi (bevacizumab-awwb), Ogivri (trastuzumab-dkst), Ixifi (infliximab-qbtx), Hyrimoz, and Truxima.

The first biosimilar approval was for Zarxio (filgrastim-sndz), a biosimilar G-CSF myeloid growth factor used in supportive cancer care, which was approved back in March 2015. In 2018, three more filgrastim and pegfilgrastim biosimilar products were approved.

But Lyman cautions that biosimilars are still in their early days.

“Biosimilar trastuzumab and bevacizumab were approved in December 2017, but both of these met with delays and even now they are just beginning to enter the marketplace, so we really don’t yet have data on their uptake,” he says.

Oncology biosimilars have been “mainly a good-news story,” Lyman says.

“We have multiple new approvals and the approval process seems to be going smoothly-with perhaps one glitch that was part of the growing pains of a new process,” he says.

As the FDA weighs the evidence for a new approval, the agency often asks an oncology drug advisory committee to review that evidence and make a recommendation, Lyman explains.

“Usually the FDA decision is in line with the recommendation of the advisory committee,” Lyman says. “There’s public comment, a whole transparency process.”

But the agency recently skipped that step in 2018 when approving Fulphila (pegfilgrastim-jmdb), a biosimilar long-acting growth factor used in the supportive care of cancer patients, Lyman says.

“They chose not to do that this time, probably because they felt this is just another growth factor and they’ve done this before,” he says. “So, there was no public display of the evidence.”

That move might well slow its uptake, Lyman says.

“You have the issue of integration of biosimilars into clinical practice, into clinical practice guidelines or simply for uptake in health systems and clinical practices or clinics,” Lyman says. “So, this biosimilar was approved but when it came to a decision to recommend this form of growth factor biosimilar in a clinical guideline, the guideline review committee had no data available on which to base a decision because they had no data from the FDA and the company had not yet published its results from its studies.”

That episode goes to show that FDA approval is “necessary but not necessarily sufficient” for integration into clinical practice, Lyman says.

Oncologists and other clinicians-and guidelines panels-want access to all of the evidence the FDA reviewed at the time of approval, Lyman says. “Clinicians want to see trial data and results and to come to their own conclusions.”

“Hopefully this was a one-off,” Lyman says. “Whether or not the data behind these drugs are given to a drug review committee, the companies and the FDA need to make these results available to clinicians and professional organizations, and payers presumably as well want to review these data to make sure patients are being served.”

Will biosimilars deliver on cost-savings expectations?

Lyman and Lozano agree that as FDA biosimilars approvals accumulate, they should increase competition between biosimilar products to bring down cost.

“Pfizer most recently launched Retacrit at a substantial discount to the reference product Epogen,” Lozano says.

A second Neupogen biosimilar, Pfizer’s Nivestym (filgrastim-aafi), is now on the market, for example.

“Pfizer launched Nivestym at a wholesale acquisition cost [WAC) that is 30.3% lower than that of the reference product and is 20.3% lower than that of Sandoz’s Neupogen biosimilar,” says Lozano. The introduction of second entrants for a reference product, like Nivestym, within the U.S. market will give patients and their healthcare providers improved access to a high-quality, potentially lower-cost treatment option.”

“As of 2018, we have multiple supportive care biosimilar growth factors, which bring competition to that space that has for decades been dominated by the originator or innovator products, which are very costly,” Lyman says. “At the same time, the predominant growth factor used in the U.S. has been a long-acting product that requires only a single injection with each treatment cycle, and the brand-name has dominated the horizon for a couple of decades but now we will have biosimilar competition there too, in the near future.”

Biosimilar filgrastim is on the market at 10% less than the brand-name originator, Lyman says. “That’s with very early data and very little competition,” he says. “With time, we’d like to see that become 20% or 30% price reduction. It’s never going to be 80% like with generics. These are more complex molecules. But it seems to be an early trend toward a reduction in pricing.”

As biologic products’ patents continue to expire and patent litigation is resolved, 2019 should see quick approvals and market launches of more biosimilars.

“In 2019, we’re hoping to see the oncology biosimilars that haven’t launched yet due to pending patent expirations and litigation-such as [biosimilar] bevacizumab-come to market as quickly and efficiently as possible,” Lozano says. “We will also continue to watch [biosimilar] pegfilgrastim and neupogen products, which are currently filing for FDA approvals.”

But there are still headwinds that will likely slow the widespread adoption of oncology biosimilars. Chief among these are concerns about reimbursement under the current “buy and bill” payment system, Lozano says.

“It’s also important to keep in mind that oncologists’ familiarity with and confidence in using biosimilars is critical to a successful formulary,” Lozano says. “As more oncology biosimilars come to market, physician education will continue to be a critical component of a product’s launch strategy, and it must start well before a therapy is in market and can be supplemented by partners throughout the supply chain. Our group purchasing organization, ION Solutions, is in the process of developing educational resources and programs that will help oncologists include biosimilars in their prescribing, specifically addressing concerns about interchangeability questions. This will be an important step in promoting biosimilar use in the coming years.”

Patients and clinicians might become more confident in biosimilars if they are granted FDA “interchangeability” status rather than only biosimilarity.

But earning that FDA designation requires biosimilars manufacturers to pay for new clinical trials, and firms have not yet pursued that option.

That could change in the 2019. Indeed, Boehringer Ingelheim is already pursuing an interchangeability trial for 

 , its candidate Humira (adalimumab) biosimilar.

Lyman believes more are likely on the way, because interchangeability could be an attractive marketing tool.

“The reason I think it will probably come is that as more of these biosimilars in a given class, like the growth factor biosimilars, all competing with one another, it’s very possible that a new one coming along will do something to distinguish themselves from the pack to give people a reason to give up using the originator,” he says. “If your patient is traveling or switching doctors or health systems, they can switch to our product because it’s interchangeable.”

As part of the federal government’s effort to address rising drug prices, the FDA is reviewing biosimilar/biologics interchangeability, Lozano says. Legislatures in 38 states have already passed bills to support the automatic substitution of biologic drugs with approved biosimilars at the pharmacy level, once the FDA starts granting interchangeability designations, he says.

While still largely a new phenomenon, biosimilars are here to stay-and this year will only bring more of them to market.

The State of Biosimilars in 2019

Nursing leaders at West Des Moines, Iowa-based 

, a network of hospitals, clinics, and home care services in Iowa, Illinois, and Wisconsin, wanted to know why patients were being readmitted within 30 days.

So they asked patients, “Why do you think you’re back?”

This approach allowed patients to speak openly, which gave nursing leaders insight into patients’ greatest challenges. 

 with a lack of access to follow-up appointments, food insecurity, or an inability to pay for medications, says Rhiannon Harms, executive director of strategic analytics at the health system.

Open-ended questions are important. It’s difficult to ask a question such as “Can you pay for your medications?” says Harms.

UnityPoint Health combines the patient narrative with retrospective data on readmissions to create a readmission risk score for the patient-and that information is communicated to the patient’s care team.

For example, Patricia Newland, MD, a family medicine physician, relied on the predictive analytics tool to prevent a readmission by one of her patients. During a follow-up appointment, Newland used the tool to determine that her patient was likely to experience an onset of symptoms within the next 13 to 18 days. She shared this information with the patient and told her to call the practice at the onset of symptoms, which could include shortness of breath, wheezing, and coughing.

Reduce Hospital Readmissions with Virtual Care Technology

The patient called the practice in that timeframe complaining of those symptoms. Newland got the patient in for a same-day appointment, consulted with her patient’s pulmonologist, and changed her patient’s medications-and thus prevented a hospital readmission.

Newland relies on her practice’s clinical care coordinator to highlight the patients who are at highest risk of being readmitted. It also helps that her practice keeps same-day appointment slots open.

Team huddles, which take place at her practice three or four times a week, allow the team to coordinate patient care. Newland, who also serves as a physician leader in the health system, is responsible for educating clinical care coordinators across the health system about the use of predictive analytics to prevent readmissions.

Once physicians realize that access to this information can help their patients, they embrace this tool, she says. In fact, Newland considers the readmission risk score as the “fifth vital sign” in her patients’ follow-up care.

Payers can support this work by paying for home-based health providers and devices to monitor a patient’s vital signs in the home, says Newland. “If we could do those things, it might keep a patient out of the hospital.”

UnityPoint Health has reduced all-cause readmissions by 40% within 18 months of using the predictive analytics tool. The health system’s home health team also used it to determine their most vulnerable patients when the community was hit by a blizzard. With this insight, home health providers could tailor their visit schedules to see patients who were in most need of care, says Harms.

Preventing readmissions for diabetes patients

In his quest to reduce readmissions at Kansas City-based 

, David Wild, MD, vice president of lean promotion, discovered that patients with diabetes were more likely than other patients to be readmitted three times within 90 days at the nonprofit, academic medical center.

Wild used predictive analytics to comb through variables such as total length of stay, number of chronic conditions, whether the hospital admission was planned or unplanned, smoking history, the age of the patient, and payer type (public or private).

Inability to access follow-up care, patient discharge disposition (the presence of a family member in the home or a stay at a skilled nursing or rehabilitation facility), and the total number of chronic conditions were the biggest drivers of readmissions for 

With this insight, all patients who have been readmitted to the hospital three times in 90 days-not just those with diabetes-are connected with a case manager who helps them secure follow-up care. On an average day, five to nine inpatients meet that criteria, says Wild.

In May, when Wild started this project, the readmission rate for diabetes patients was 25%.

Currently, the readmission rate for diabetes patients is 13.9%. Wild attributes University of Kansas Health System’s success to improved engagement with nurses on inpatient units and incorporating diabetes educators for daily information sessions with patients on medications.

He welcomes support from payers. For example, coverage of diabetes education in the outpatient setting could help prevent readmissions.

Physician engagement helps reduce readmissions

, a nonprofit healthcare facility in St. Augustine, Florida, has 400 physicians, according to Michael Sanders, MD, its chief medical information officer. With that number of physicians, wide variation in clinical practice is likely. That’s a pet peeve for Sanders, who also laments the impact of waste on healthcare spending in the United States. (Wasteful spending in healthcare exceeds $1 trillion each year, an amount that two experts writing in 

 “could fund the entire Medicaid program twice over.”)

To address this, Sanders decided to reduce variation in care for patients with pneumonia. After looking at more than 16,000 patients over four years, he discovered that many patients with pneumonia were getting daily X-rays and blood tests, which increases the cost of care without improving outcomes.

He also learned that introducing nebulizer treatments for patients with pneumonia and chronic obstructive pulmonary disease early in their hospital stays improves clinical outcomes.

Nine Ways to Reduce Hospital Readmissions from Hospital Executives

Sanders had the proof in hand, but changing how physicians practice medicine is tough. To tackle this, he taps his longstanding relationships with physicians involved in Flagler Hospital’s EHR deployment, which started in 2012. These physicians act as “ambassadors” for adhering to the care path designed for pneumonia patients, says Sanders.

Flagler Hospital has reduced pneumonia-related readmissions from 2.9% to .4% since March. In addition, the hospital has saved $1,350 per patient and reduced the length of stay for pneumonia patients by two days. Going forward, Sanders expects the hospital to save $726,300 annually because of this work.

Payers should care about this, he says. They’ll benefit from the elimination of unnecessary tests and the reduction in cost.

“They should be looking at ‘same cause’ readmissions and rewarding hospital systems that can not only reduce cost, but also readmission and mortality as well. They must recognize that this effort costs hospital systems in dollars and work effort, and reward them accordingly.”

Insurance companies could also pass on those savings to members who use hospital systems that reduce cost while improving outcomes, adds Sanders.

From diabetes to pneumonia, how hospitals are eliminating waste and creating healthier patients.

How Three Hospitals Use Predictive Analytics to Reduce Readmissions

Having grown up in a “medical family,” Marc Harrison, MD, never had much doubt that he would follow in the footsteps of his father and grandfather and carry on the legacy as a third-generation physician.

“My dad’s a general surgeon and a really good dad. I didn’t see very much of him when I was young, so I used to go on rounds with him on Saturday mornings at one of the small hospitals in Pittsburgh, where most of the poor people got taken care of in his practice,” Harrison says. “I got to see him interact with these patients and it inspired me. So, all I ever wanted to do was be like my dad and be a good doctor.”

Today, Harrison serves as president and CEO of 

, an innovative, not-for-profit system that operates 22 hospitals and nearly 200 clinics in Utah and Idaho.

“Healthcare as a field is rewarding because you truly make a difference in the lives of people,” he says. “Not only can we help people get better, we have the opportunity to help them stay well.  In fact, Intermountain’s mission statement is ‘Helping people live the healthiest lives possible.’”

Harrison is an influential leader in healthcare and is responsible for the creation and execution of Intermountain’s strategy to transform healthcare through best clinical and operational practices designed to advance its mission.

Under his lead, Intermountain is doing a number of interesting things to not only advance the healthcare industry, but to continue to provide their patients with the highest quality care at the lowest possible cost.

Adrienne Boissy: Chief experience officer of Cleveland Clinic Health System

For example, Intermountain Healthcare has launched one of the nation’s largest virtual hospital services-called Intermountain Connect Care Pro-bringing together 35 telehealth programs and more than 500 caregivers to enable patients to receive the medical care they need, regardless of where they are.

Additionally, to help patients by addressing the often-unwarranted shortages and high costs of lifesaving generic medications, Intermountain Healthcare initiated a collaboration of other leading health systems to form a new, not-for-profit generic drug company called 

 which will bring products to market in 2019.

“Dan Liljenquist, the brilliant chief strategy officer for Intermountain, was the one who conceived this idea several years ago,” Harrison says. “With all health systems facing chronic shortages of vital life-saving drugs, and often capricious increases in the cost of these medications, we saw that action was needed to remedy the situation.”

It was back in August 2017 that Intermountain committed to cutting the number of opioids prescribed for acute pain across its entire system by 40% by the end of 2018 and Harrison notes it was close to achieving this goal. He attributes the success to a comprehensive, 360-degree approach that includes public education, and physician training and education regarding prescribing and payer limits. 

“This means that there will be about two million fewer pills prescribed in 2018 for acute conditions,” he says. “Utah is one of only a handful of states that has seen a decrease in opioid deaths in 2018.”

There’s also a new collaborative called the 

Utah Alliance for the Determinants of Health

 (The Alliance), formed to promote health, improve healthcare access and decrease healthcare costs. The Alliance-a collaboration in Ogden, Utah, and St. George, Utah-is led by Intermountain Healthcare and involves a number of community organizations. 

“It seeks to improve health by focusing on non-medical factors that affect health, such as housing instability, utility needs, food insecurity, interpersonal violence, and transportation,” Harrison says. “Intermountain will be investing $12 million over three years-$2 million annually in both Ogden and St. George-which will sustain the three-year demonstration project.”

Harrison holds a medical degree from Dartmouth Medical School. Upon graduating from medical school, he was a resident at Intermountain 

 in Salt Lake City, then went to Maine to run a small PICU in Bangor, before heading back to Utah to complete a fellowship in pediatric critical care. 

“I then joined the Cleveland Clinic as a pediatric intensivist,” he says. “I was then offered the chance to become the CEO of Cleveland Clinic’s 

, which was still under construction when I got there.”

While there, he oversaw the establishment of 12 Institutes, five centers of excellence, and more than 30 medical and surgical specialties.

In 2016, after nearly five years in Abu Dhabi, Harrison returned to Utah as the president and CEO of Intermountain Healthcare, where he has thrived.

“There are leadership principles I follow,” he says. “Be purposeful-leadership is a high calling, advance the greater good. Be courageous-do what’s right, even in the face of adversity. Be agile-focus relentlessly on the goal and be ready for anything. In all matters, leaders should save our greatest intensity for human beings. Putting people at the center leads to the best decisions.”

When not at work, Harrison is a big fan of family time with his wife, Mary Carole, a pediatrician herself. He also enjoys keeping fit through participation in endurance sports, and is an All-American triathlete and seven-time Ironman.

Intermountain has a long history of bold moves and innovation and that’s not expected to stop anytime soon.

In 1983, Intermountain created its own health insurance plan called SelectHealth, which covers approximately 850,000 lives in Utah and Idaho, something that has expanded under Harrison’s leadership.

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In 1994, the Intermountain Medical Group was formed, and now employs about 2,300 physicians and advance practice clinicians. It also created an IRxMatch program, where patients and their providers have the opportunity to use a patient’s DNA to guide the prescribing of medications. Its Partners in Healing program helps patients recover quicker so that they can go home earlier, by allowing family members to be a part of the care and recovery.

“As an integrated system, we can effectively coordinate best care for patients,” Harrison says. “Intermountain’s focus will always be on doing what’s right for the patient. We are embracing consumerism, as many patients are becoming more price sensitive because of high-deductible plans. Providing high-quality care at the lowest appropriate cost is always going to be a winning strategy and is best for patients.”

Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years, on topics as diverse as sports, business, and healthcare

As a third-generation physician, Marc Harrison, has become an influential leader.

Featured Exec Marc Harrison: President and CEO of Intermountain Healthcare

As the new year marches on, four trends that are helping to shape healthcare stand out.

These include consolidation of payers and providers, a rise in consumerism, technological advances, and integrating care based on population health. Managed healthcare executives will need to embrace these trends in order to survive in the healthcare landscape. Here, experts discuss what these trends entail, what’s giving them momentum, and how executives can get on board with these trends.     

Tools That Promote Payer-Provider Collaboration

The trend of health insurance companies and providers such as health systems, hospitals, and pharmacy chains consolidating began in 2013 with the passage of the ACA. “This legislation initiated a massive industry shift away from volume-based reimbursement toward value-based reimbursement,” says Ben Kraus, CEO and founder of 

, which helps insurers and providers improve the long-term health of managed care beneficiaries. The number of practices owned by big health systems 

 since 2012; many would have gone out of business otherwise due to financial pressures. Similarly, health insurers have been buying up providers to consolidate vertically rather than horizontally, at an historical rate.

“For the first time ever, insurers (and indirectly, providers) are on the hook for keeping people healthy (i.e., avoiding additional medical services) rather than encouraged to provide more services,” Kraus says. “This fundamental change is forcing industry players to reinvent themselves. Providers are consolidating to create an integrated clinical network that is more coordinated and well-positioned to keep a large population of members healthy and therefore perform well financially in the new system or because they lack capital and scale to survive in an industry that requires a fundamental overhaul of the provider business.”

Similarly, health insurers are buying up providers because from the 

’ perspective, everything has changed-their business is no longer an underwriting exercise that they price and then passively observe outcomes. Rather, their new business model is actually impacting the risk, rather than simply pricing and managing it. The health insurers that will win this new game are companies that can increase their provider networks’ efficiency and make their populations healthier. Post 2013, insurers rely heavily on providers managing their members in a certain way (i.e., focusing on prevention, coordinating transitions, avoiding expensive over-hospitalization) in order to remain profitable as insurance companies.

Despite the benefits, the combined integration of insurers and providers has not, and will not, be easy, says Steve Jackson

, a healthcare customer experience solutions provider. For most of the last 60 years, the two entities have been on opposing sides. “For these new combinations to truly achieve their desired potential, it requires a focus on consumers,” he says. Consumers want ease; 

 that they would switch providers for convenience factors alone. “Benefits will be achieved if healthcare is made more affordable, accessible, and cost transparent as well as less administratively burdensome for clinicians, affording them more time to spend serving patients and families.”

A starting point for any insurer looking to partner with a health system would be to understand the hospital’s current and historical focus on customers. “Health systems that already deliver a great customer experience will be predisposed to build upon that foundation through a vertical integration with insurance partners,” Jackson says. “Measuring progress against these efforts must extend beyond a segmented, episodic view of patient experiences to one that more holistically encompasses the consumer relationship with the healthcare organization and measures their loyalty. The 

 gives healthcare organizations a single metric to assess consumer loyalty-taking into account brand awareness, Net Promotor Score, access, needs, engagement, motivation, and experience.

Today’s consumers increasingly want to interact with the healthcare industry as more than just passive patients. “Just like any other purchasing decision they make-from cars, to clothing, to hotel choices-they want to be in control and are demanding more choice than ever,” says Ross Goldberg, president, 

, an agency that helps healthcare clients with marketing communications challenges.

“This trend has emerged because of the rise in digital tools and the incredible amount of data that is now available at the click of a button to help consumers make intelligent decisions and better manage their health,” Goldberg says. “Access to information gives consumers a feeling of empowerment and a belief that not only can their opinions be heard, but that they can also have the ability to influence matters more than ever before.”

Furthermore, health plans are accountable for achieving financial outcomes for 

 reporting, and receive financial incentives when they attain certain population health outcomes, says Paul Meyer, president of the public and community market at Welltok, a software as a service company for consumer health.

The ACA played a key role in the rise of consumerism when it launched the online marketplace. “More than ever, consumers are shopping for their health insurance and are weighing their options and purchasing decisions,” Goldberg says. Non-traditional players entering the market are also giving the trend momentum, because they offer consumers even more choices on how they will access and pay for their healthcare.

Another reason that consumerism is growing is that consumers have lost trust in the healthcare system. “This is because costs continue to soar, defining quality remains mysterious, moral debates have morphed into political rhetoric, reports on medical errors continue to emerge, and unencumbered access remains elusive to many,” Goldberg says. “Consumers don’t believe that that those steering the healthcare ship-including health plans-put members first. Until trust is restored, consumers will want more control over decision making.”

To embrace this trend, Meyer says that healthcare executives need to continue to employ technology. “Consumers expect a digital experience first, but healthcare is still largely relying on paper and the postal service in an attempt to reach members,” he says. Using ingrained communication channels such as texting to engage Medicaid beneficiaries in their health and wellbeing has been successful. For example, 

 read text messages within three minutes and 

 of low-income Americans have used their phone to access health information.

Four Ways the Healthcare Industry Can Regain U.S. Trust

Along these lines, Goldberg says, “Healthcare organizations will need to embrace digital health, telemedicine, wearable monitoring and fitness devices, online resources, social media, and other technologies to develop effective consumer engagement strategies.”

One example of consumerism at the federal level is the newly proposed 

 requiring drug companies to give list prices for their products in television ads. “The HHS proposal will require direct-to-consumer television advertisements for prescription drugs and biological products paid for by Medicare or Medicaid to include the list price in certain situations,” says Carolyn L. Mitchell, JD, MHA, senior counsel, Jackson Walker LLP, a law firm that advises businesses, including healthcare entities. “If a manufacturer’s list price for a prescription drug is greater than $35 for a one-month supply, or the usual course of therapy, then TV ads must include the price.”

As an industry that’s often viewed as antiquated, the opportunity for digital transformation in healthcare is great. Administrative burdens account 

 of the multi-trillion-dollar healthcare spend; much of this was caused by inefficient data entry processes, says Peter Kirk

SERMO, a global social network for physicians. A recent 

 found that despite the United States spending about twice what other high-income nations do on healthcare, U.S. health outcomes are still inferior.

In light of this, health insurers face immense pressure with rising costs, evolving consumer demand, and changing industry dynamics. Out-of-pocket costs are growing, with 63% of employees seeing single-coverage deductibles rise from 

 struggling to navigate the health system on their own. “When you combine that with demographic shifts-an older population and more chronic disease-the cost and complexity of healthcare is only expected to increase,” says Kaveh Safavi, MD, JD, head of global health practice, Accenture, a global professional services provider.

Consumers' expectations are also changing, driven by experiences and perceptions outside of healthcare. This is evidenced by observations such as 

 being willing to switch a health plan to get personalized benefit options. “People expect a personal touch-round-the-clock service, easy-to-use, wherever they are, on their terms-in all areas of their lives,” Safavi says. “Healthcare is no exception. This means transparent pricing, more frequent communications, and personalizing service options to individual needs.”

In order to lower a healthcare company’s costs while meeting consumer expectations, companies must tap into digital technologies to increase productivity while making care more personalized, Safavi says. “To make care more productive, we must find ways to move elements of care to machines as well as on to the patients themselves,” he says.

By staying on top of how other industries leverage technology to solve key pain points, Kirk says healthcare executives can be better equipped to implement technological solutions into their own organizations or be inspired to build technology that meets specific needs.

The biggest obstacle to technological adoption can often be an organization’s company culture, as employees may be reluctant to adopt new technologies for fear of change. “When rolling out new technology and processes company-wide, it’s crucial to highlight not only the benefits for the business, but also for each individual,” Kirk says. “SERMO has seen success by emphasizing how technology will free up time spent on manual tasks and allow employees to focus on business initiatives which may have fallen by the wayside, therefore empowering talent to rise through the ranks.”

4. Integrating care based on population health

Integrated care involves complementary care and coordination across a patient’s entire care needs and provider network, starting with the primary care provider (PCP) and extending across all specialists. “It is a vehicle to treat the whole patient, comprehensively addressing their care needs, while aligning financial incentives to do the right thing for the patient,” says Hank Schlissberg, president, DaVita Health Solutions

which provides comprehensive, integrated care for high-risk, poly-chronic patients. Those care needs often vary and span clinical, social, palliative, and behavioral, among others.

Comprehensive, coordinated care might include transportation assistance, social services, support navigating multiple doctors and care plans, medication management, and after-hours support. “The additional resources built into integrated care models help time-limited PCPs ensure that their patients receive the extra attention needed to successfully manage their health,” Schlissberg says.

As the industry moves to value-based arrangements, many health systems are evolving their approach to care. “This includes managing populations to keep them healthy, aligning incentives for everyone who has a stake in healthcare, creating care process models that further define how care and services should be provided, improving access to care by addressing the social determinants of health, and working to make care more affordable,” says Steven Barlow, MD, senior medical director, 

Schlissberg expects this trend to gain momentum because as healthcare costs continue to skyrocket, they are unsustainable. “Savvy healthcare leaders are finding success with integrated care models that deliver high-quality care and generate lower costs,” he says. “Keeping patients healthy and out of the hospital or emergency room is the goal.”

Health Execs Struggle to Keep On-Pace with Population Health Goals

, an Allscripts company that provides care coordination software solutions, says there’s a huge upside to payers investing in population health and creating tighter financial and clinical alignment with providers, particularly around their high-risk patient populations. “These strategies demonstrably improve patient engagement, resulting in higher member satisfaction and retention, and they also yield better clinical outcomes,” he says. The tremendous growth of Medicare Advantage-an entire insurance program developed around appropriately meeting the needs of the Baby Boomers in a cost-efficient way-is clear validation of population health approaches.

At a high level, the primary thing that health insurers need to do is set reasonable and achievable population health goals that are calibrated over time. “For some, it’s a significant change to deliver integrated care and to enter into risk-sharing agreements with providers,” Brown says. “Population health should be viewed as an ongoing process, not a one-time event.”

As plans set their population health strategies, they should be mindful of the need to build integrated processes that scale, Brown cautions. “Today we see plans sending case workers into post-acute care settings to check on patients and when necessary, intervene, and redirect their care,” he says. “The intention is good, but it’s not scalable. Insurers that are offering Medicare Advantage plans need to devise strategies that support the exponential growth of that population.”

Experts discuss what these trends entail, what’s giving them momentum, and how executives can get on board.

Four Trends Health Execs Need to Follow in 2019

Experts agree that forecasting the future of healthcare technology isn’t difficult-machine learning, artificial intelligence (AI), cloud technologies that apply to clinical, workplace, and financial processes will have better and richer incorporation into the industry.

But to get there, healthcare executives need to be laying the cultural foundation today for upcoming technology changes in the next decade.

For example, investing in AI over the next five years could cost, on average, more than $30 million per organization, according to 

 of 500 healthcare executives by OptumIQ published in November 2018. However, 38% of employers and 20% of health plans believe they would see a return on that investment in four years or less. Ultimately, 94% of respondents see investments in technologies, such as AI, as the clearest route to affordable, accessible and equitable healthcare in the future.

Real-World Applications of Artificial Intelligence in Healthcare

But in order to realize those future possibilities, a culture shift needs to happen in healthcare today, says Tom Lawry, director of worldwide health for Microsoft. He adds that the future of healthcare technology relies more on the culture and framework being created by clinical and business leaders today.

“What really is going to be needed in the future is not just the breakthroughs in technology, but breakthroughs in creative thinking and the ability of leaders to think differently when redeveloping their processes to leverage the power of the technologies rather than trying to insert these new technologies into a framework,” Lawry says.

Anil Jain, MD, vice president and chief information officer for Watson Health at IBM, says that healthcare organizations will need to shake the stigma of being bureaucratic and slow to adapt in order to be agile enough to adopt future technologies.

It’s an exciting time for healthcare technologies. Here are the ones you need to look out for in the next ten years.

Managed Healthcare Executive February 2019 Issue

Managed Care Technology Survey 2019

The 4 Biggest New Areas to Focus on in 2019

The State of Biosimilars in 2019

How Three Hospitals Use Predictive Analytics to Reduce Readmissions

Featured Exec Marc Harrison: President and CEO of Intermountain Healthcare

Four Trends Health Execs Need to Follow in 2019

Six Healthcare Technologies Coming in the Next 10 Years

The Impact of Big Data on Medical Decisions

The Biggest Barrier to Home Healthcare