Health system executives are finding it difficult to stay ahead of the multiple trends culminating at once-reimbursement pressures, rising drug costs, regulatory complexity (340B), and the central role of pharmacy in value-based care.

Ed Francis, a senior director of life sciences at 

, says changes in drug pricing represents a particularly important issue that health executives will need to watch out for in the coming year, starting with optimizing the drug rebate system.

“Congress and the executive branch have discussed everything from eliminating the system entirely to writing laws that increase pricing transparency,” he says. “Even without government intervention there has been movement with some new PBMs that offer rebates as 100% pass-through to consumer. Other companies have emerged that are offering online drug price comparisons in a local area. All of this will help to solve the problem.”

Here are five other policies to keep an eye on in the year ahead.

Pharmacy expert Ernie Gates, president of 

-the new workplace safety standard for pharmacy-will bedevil many healthcare organizations and the cost of non-compliance could be staggering. 

USP 800 is about protecting the healthcare worker, patient, and environment from accidental exposure to hazardous drugs and requires changes to standard operating procedures across an organization, beginning with receipt of a hazardous drug and ending with disposal.

“Many pharmacies, including those inside of institutions such as hospitals, are not prepared to comply with USP 800, which goes into effect later this year,” he says. “This could be problematic for any healthcare organization that is dependent upon pharmacies, including health plans that operate or simply reimburse pharmacies.”

2. Drug Supply Chain Security Act (DSCSA)

 was designed so an electronic system could track and trace certain prescription drugs in the United States. Katrina Harper, senior clinical manager, pharmacy for Vizient, says what’s important with DSCSA is compliance with current regulations to ensure the integrity of the pharmaceutical within the supply chain.

“We are now starting to see enforcement actions in the form of fines,” she says. “One large wholesale distributor was the FDA’s first ever warning letter for non-compliance. They also need to be preparing to comply with the new aspects of this regulation that take effect in 2020.”

By 2020, all Rx products covered under DSCSA must be serialized, and all transactions can only involve serialized product.

 on October 10, 2018 and will become effective either on or after January 1, 2020. Brian Romig, director at 

, says it blocks Medicare Advantage plan providers or providers of a Medicare Part D prescription drug plan from using gag clauses that prohibit pharmacists from alerting Medicare customers of differences between their insurance copay and what the patient would pay without using health insurance coverage.

“The act was implemented to increase price transparency for consumers covered under Medicare or Medicare Advantage,” he says. “Health system pharmacists can help patients find better pricing by advising that there are options available to them.”

4. EPA update of the Resource Conservation and Recovery Act (RCRA) standards

 were published in early 2019 to clarify an organization’s responsibility related to the disposal of hazardous and controlled substance pharmaceuticals in the waste stream.

“The good news is that there will be improved alignment to DEA requirements for disposal and the change in requirements may impact an organization’s waste generation classification which could result in lower costs,” says Joyce Thomas, associate principle, pharmacy advisory services for 

5. CMS Hospital Outpatient Prospective Payment Proposed Rule CY 2019 (OPPS)

 further expands cuts to the 340B Drug Pricing program made in 2018 and institutes a site-neutrality payment policy for hospital outpatient departments by cutting reimbursement by 40% for the most commonly reimbursed G-codes in order to match payment under the 

“The proposed rule also includes a request for information related to a potential Competitive Acquisition Program for Part B drugs and biologics, which would run through the Center for Medicare and Medicaid Innovation,” he says.

Expanding the scope of practice for pharmacists is being considered in state legislatures and in Congress. This is particularly true in states with large underserved areas.

“In Congress, a main consideration is whether Medicare should cover payments to pharmacists in these underserved areas,” Romig says. “More than half of the 100 total members in the U.S. Senate have signed on to support the 

Pharmacy and Medically Underserved Areas Enhancement Act

 [S 109). The bill has surpassed the number of votes necessary to pass this legislation in the Senate. The same bill is HR 592 in the House of Representatives.”

The bill would provide for Medicare coverage and payment for certain pharmacist services that are furnished by a pharmacist in a health-professional shortage area, and that would otherwise be covered under Medicare if furnished by a physician. On the state level, many are considering allowing pharmacists to prescribe oral contraceptives, while others would allow them to prescribe treatments for flu or strep throat. Virginia is considering allowing pharmacists to perform opioid abuse counseling. Pennsylvania is discussing allowing pharmacists to counsel for tobacco cessation.

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

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These are the important policies to watch out for in 2019.

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While employees’ wages have remained mostly stagnant, family insurance premiums for employer health plans have increased 20% since 2011. Furthermore, more than 50% of individuals have a plan with a deductible of $1,000 or higher per month, says Joan Budden, MPA, president and chief executive officer, 

, a health insurer based in Grand Rapids, Michigan. Consequently, four in 10 insured adults say they struggle to afford their deductible.

Historically, the cost of health services has been hidden behind a cloak of secrecy. In some cases, people avoid getting necessary care because they don’t think they can afford it, Budden says. Other times, they pay more than necessary because they weren’t aware that lower cost options were available.

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The first step in helping consumers navigate the cost of care is to provide them with a basic understanding of what healthcare services actually cost.

“A lack of transparency is a huge problem that the healthcare industry needs to address,” Budden says. “Members deserve to have this information.”

Here are eight ways that health insurers can help patients navigate care.

The healthcare industry sits on a mountain of data in electronic health records, but the industry has yet to fully tap into the data’s potential.

“Payers and providers can leverage technology to automate analysis of historical claims data and provide patients with cost estimates before treatment or the final bill,” says Matt Hawkins, MBA, CEO, and board member of 

, a company focused on simplifying and unifying healthcare payments. “Based on similar claims that have been approved or denied by a patient’s provider, predictive analytics can give the patient a confident estimate of what they will ultimately pay for a procedure.” Price estimation technology can empower a patient with information so they understand a procedure’s cost ahead of time, check insurance eligibility, and determine their ability to pay.

Priority Health provides members with easy-to-use, digital tools to help them understand their healthcare costs. In 2015 it launched the Cost Estimator tool with the goal of providing members with estimates of their out-of-pocket costs on services and procedures. The tool provides members with pricing that is specific to their own health plan and includes their deductible and copays.

“Our effort moves beyond the traditional approach of offering historical averages and instead focuses on information tailored to a specific individual,” Budden says. Priority Health pre-processes claims, providing an accurate estimate of the member’s cost for services they’re considering. The insurer has reported millions in shared healthcare savings as a result of the Cost Estimator.

Health insurers can educate consumers on their coverage options and out-of-pocket costs in several ways. They can partner with employers to provide health benefits education at the start of employment or each year during benefits enrollment, says Mark Spinner, president and CEO, 

, which provides patient financing solutions.

Such education can be provided virtually, telephonically, or in person in a large-group setting. Some payers work with employers to ensure employees gain points for participating in online education around health benefits. These points can be applied to the employee’s wellness incentive where wellness programs exist.

To help consumers understand exactly what their benefits entail, human resource departments should revisit benefits-related documents, such as Summary Plan Descriptions (SPDs). SPDs present an opportunity to enhance and simplify benefits communications. While these documents are traditionally dense and difficult to understand, human resource departments can add charts, callout boxes, and icons to make documents more appealing and digestible. Some employers are beginning to convert their SPDs into digital, interactive documents that employees can access anywhere and anytime.

“The move to digital allows human resources to track which sections employees visit most, which terms are most often searched on, and how many employees view the document to enhance benefit communications,” says Bridget Lipezker, MBA, senior vice president and general manager, Advocacy and Transparency, 

, which provides personalized benefits education.

Employers must also leverage multi-channel engagement strategies to keep consumers informed year-round. “With today’s workforce spanning five generations, employers must rethink how they communicate benefits offerings and information to ensure that consumers are getting the right information at the right time,” Lipezker says.

Traditional forms of communications such as flyers and booklets can be reinforced and supplemented with newer methods such as webcasts, on-demand videos, and targeted texts and emails to reach both broad groups of employees and specific individuals.

Steady shifting of healthcare costs from payers to individuals not only intensifies pressure on members’ pocketbooks, but also changes their attitude toward insurance coverage and payment, Spinner says. A growing number of members who find they can’t afford the out-of-pocket expenses associated with their insurance plan have opted out of insurance altogether.

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Meanwhile, the more members owe providers, the less likely they are to return for care. One recent 

 found just 54% of primary care patients return for care when they owe their physicians $100 to $200. Just 42% seek care when their balance is more than $200.

“Given these statistics, health providers and payers have an economic stake in working together to help members navigate health insurance options,” Spinner says. These types of partnerships will become even more critical as members shoulder a greater portion of the costs of care.

Some employers are offering rewards for employees who choose lower-cost options for medical services or procedures. This incentivizes employees to shop around for healthcare treatments and procedures and through the process helps them understand price variations between services even when they’re in the same network and geographic area, says Lipezker.

Rewards programs work best when the employer communicates the program well and makes it part of the overall benefit program.

Spinner has seen examples of employers and health plans offering incentives for use of lower-cost, high-quality sites for care.

For example, Anthem Blue Cross and Blue Shield in Ohio and its affiliated health plans partner with the Cleveland Clinic Cardiac Concierge Program to provide employees from a national grocery store chain with access to cardiac surgery performed at Cleveland Clinic. The grocery store chain pays 100% of travel costs for members and one companion. Anthem helps coordinate the travel through a medical tourism facilitator.

Spinner is also seeing cash-back rewards programs for members who choose lower-cost care. In Massachusetts, a SmartShopper program offered through Anthem enables members to receive an incentive check each time they choose lower-cost options for care. Under this program, members can earn incentives monthly. Such tools also can have an impact on member care by encouraging providers to find ways to lower costs of care delivery.

As consumers take on more financial responsibility of paying for healthcare, the industry is still opaque-offering no financial guidance for patients and leading to more surprise medical bills and unpaid claims, says Hawkins. A counterparty can work with patients to evaluate financial decisions as they move through the care process and ensure that they’re putting their money in the right services and procedures at the right time.

A professional analysis of the quality and value of care available to a patient can enable smarter spending and better outcomes. It is estimated that 

 is wasted annually on unnecessary medical tests and treatment, and with healthcare spending projected to grow at a faster rate than the national gross domestic product over the coming decade, it’s important for patients to have access to an advisor to guide them through the process of evaluating care from a financial perspective, Hawkins says.

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Employers can provide enrollment services that help educate employees on how to select the right health plan based on individual situations, as well as year-round access to benefits experts who can help them choose the best options for healthcare delivery (e.g., should they go to a retail clinic, urgent care, the emergency room, or just wait it out).

“By demonstrating the range of costs associated with the plans themselves and with the point of service, consumers can begin to budget for paying out-of-pocket expenses more carefully,” Lipezker says. As a result, the costs to both the employee and employer decrease.

Some employers are beginning to offer patient advocacy services. These services are designed to help make sure that insurance is working the way it’s meant to and that consumers are engaged.

“Access to knowledgeable and experienced advocates who can help employees shop for their healthcare, answer benefit questions, locate in-network providers, and resolve claims issues helps employees make better decisions about their care and enables employers to reduce administrative and healthcare costs,” Lipezker says.

As healthcare costs continue to climb, advocacy services empower employees to be smart consumers, particularly when it comes to understanding medical bills. Advocates can help employees understand each cost included on a medical bill to ensure there aren’t any unnecessary or overpriced charges, Lipezker says. If there are errors, these advocates can work to ensure consumers only pay for what they received. Health plan designers can include references to advocacy services, so that consumers have the information on hand.

 shows that balances rose to $781 in 2018 for patients with commercial health insurance coverage-a $314 increase over 2012 figures.

“For members to successfully navigate their healthcare costs, they must have a clear understanding of their health benefits under commercial and government health plans as well as their out-of-pocket costs of care,” Spinner says. “This requires health plans to focus on ways to make it easier for members to navigate health plan choices and benefits, with simple, easy-to-understand approaches to deductibles and copays.”

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

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Today’s healthcare consumers want a seamless digital experience, one that allows them to be an active participant in their healthcare. The problem is keeping up with the rapid changes that technology offers and making sure the capabilities you are offering to customers aren’t obsolete before they are up and running.

The question is, how do you stay ahead of the game? While it’s nearly impossible to predict what new technologies are coming up, cloud technology offers a flexible and agile solution. The key is knowing what your customers want and what kind of model your organization will be comfortable with.

 shows that 53% of healthcare businesses take many months to a year to integrate technology changes into their existing systems. That’s because 62% of them report using between two and 10 different customer-facing software systems. Roughly one-quarter of healthcare leaders responding to the survey weren’t even sure how many software systems they utilized.

For these reasons and many more, healthcare companies are looking to simplify their digital solutions and create a better experience for consumers, and one that can change more swiftly with the rapidly changing technology landscape. The report goes on to note that 58% of companies in the survey planned to consolidate technology platforms for simplicity, 49% were looking to improve agility, and 43% were looking to migrate to cloud-based applications to achieve these goals.

With so many cloud-based services to choose from, the question then becomes, how does one choose the right fit and stay ahead of the game?

What is cloud technology and why do I need it?

Cloud technology is used in so many customer-facing systems across industries and is a way for a company or service provider to interface with consumers using web-based tools and applications, rather than through an in-house server. Building and maintaining in-house technology can be expensive, time-consuming, and quickly become obsolete.

Kevin Riley, senior vice president and general manager at 

, a developer of industry-specific cloud and mobile software, in San Francisco, says cloud technology is the key to digital transformation.

"You're going to have to adopt a technology, and that technology should be cloud,” Riley says. "Regardless of what problem you're solving for, if you're not buying cloud technology, you're buying an expensive problem."

Cloud technology takes away the burden of maintaining an in-house system by letting someone else with probably more expertise build and host the system not to mention deal with security.

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Digital transformation is being driven by several factors, Riley explains, and all of these set the stage for the healthcare industry to adopt cloud technology. The first is customer experience. Bad customer experiences have put the health insurance industry in particular at the bottom of the customer experience scale, Riley says. That doesn't mean, however, that the healthcare industry should rush into creating a lot of technical debt to improve their customer service experience.

"Modern day vendors already have customer experience people on staff," Riley says. "Work with vendors that are telling you they can change your customer experience."

The second driver of digital transformation is product innovation. It's important to be able to stand out in the products you offer, and to have the technology to bring those new products to market quickly, Riley says. Top startups use lean technology to bring new products to market and test distribution channels without high overhead costs, Riley says. Utilize vendors who have these systems in place rather than recreating the wheel.

Another key to digital transformation is making sure that you are using a vendor who offers straight-through automation or processing Riley says.

"Can the vendor help prevent partner fatigue? Is the process tedious or attractive? Is it end-to-end and does it look unified?" are key question to ask when reviewing a vendor's process, Riley says.

Finally, companies should seek out cloud vendors that provide application consolidation, Riley says. Some health plans have hundreds of apps to manage, and a good cloud vendor will be able to help with that.

Each cloud vendor offers similar services, yet each have their niche, as well. Some might have stronger customer service elements, while others might excel in healthcare-specific services.

Riley says it’s important when seeking out a cloud vendor to find one who has customers with similar service lines to yours. The ideal vendor will have worked with other companies within your industry and are well-established and well-funded enough that you can be sure they will stay in business and aren't a fly-by-night startup.

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It’s also important to find out how willing and able that vendor is to create new products and services to meet your unique needs. For this reason, Riley says leaders should always question accessibility when choosing a cloud vendor.

"How much access do you have to the people that think about and create the product, and can you drive product design?" Riley says. "People are building software now using agile technologies. The software never stops being developed. The only way to judge that is to see whether you have access to influence the people who control what gets built." 

Know what you want and what's being offered

, an international process transformation company, says there is a lot of confusion around cloud-based services in the healthcare industry. The first step to knowing what you need is to really understand first what you want to achieve, and second what level of service is offered by a vendor. Hughes says he often shares with his customers an analogy about pizza.

"If you want pizza, you've got choices. You can make it from scratch with flexibility and control, but not with scale. You have to pick a kind and stick with it," Hughes explains. "That model is like an on-premise model where you have everything in-house to manage technology and infrastructure."

The next option, Hughes says, is to buy your pizza from a store. "Frozen pizza has everything you need, but you still have to cook it," he says. "That is more like infrastructure as a service. It's the most basic way, where you just use technology for storage and computing."

The next service level is delivery pizza. With that model, someone else does all the work and delivers it to you, but you still have to arrange for cleanup. That is more like a platform-based service, he explains, where you use a vendor's infrastructure to do more than the basic functions.

Finally, there is going to a restaurant for pizza. "You have your choice and it's full service," Hughes says.

The key is knowing how much you need, how much control of flexibility you want, and how involved you want to be.

"There's so many different flavors of cloud that you can adopt, and we encourage customers we work with to think through what they are trying to do and which of these models they want."

Ken Cahill, chief executive officer of SilverCloud Health, a global health technology company, says whatever vendor you choose, it’s important that they be vetted, and that you take care in how you are selecting that vendor.”

“There’s something to be learned from the old adage, ‘You can’t be fired for buying IBM,’” Cahill says. “The fundamentals of business have and haven’t changed.”

Whatever vendor you choose, you must be conscious about who is leading that organization, how it is being led, what colleagues are saying about that vendor’s services, and make sure that the product will hold the same level of regard as whatever it is replacing, Cahill says.

“We’ve seen a number of vendors who can come into a marketplace and look slick and shiny, but we have to see what’s behind that,” Cahill says. Ask for case studies and testimonials, he suggests.

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Some newer vendors might not be able to compete with the sheer scale that vendors like Google or Microsoft have, but maybe they have had contracts with larger health systems or government entities, he adds. Then again, those bigger vendors have proven track records when it comes to things like security. It can be tempting to jump into transitioning to cloud services, and to jump into the next big thing. But Cahill warns that first or fastest isn’t always best.

“The caution I would raise is to move at pace, but make sure you’re doing the right things in terms of due diligence and vetting,” Cahill says, adding you have to be able to show your board the steps and processes you went through in making your vendor selection. “Fast has to be at pace, but it can’t be at a reckless one.”

There are so many options when it comes to cloud vendors and services. This is a good thing-and it’s not.

"You have to plan it, understand what you are trying to accomplish, and what roles you need, and that culminates in a three-year transformation blueprint," Hughes says of the way cloud transitions work through Sutherland.

Anticipate surprises and be prepared to have lots of questions about your organization's needs, he says.

"No one should start knowing the journey they are on," Hughes says. "Think, what do I need the cloud to do for me? Understand the customers' needs, what the clinicians need, and design it. Think about the end-to-end journey and what it means to users."

Leadership may also want to review what other applications they are using in the planning phase of a cloud transition, and plan for restructuring in a measured pace.

"The big bang approach is typically not a great recipe for success," he says.

The move to cloud services and any related restructuring should be done in phases, with considerations about what to do with data and how to phase out old tech, Hughes says.

Keep in mind, Hughes says, that cloud isn't necessarily the cheapest option-depending on which options you choose, cloud could be costly.

"It will probably give you the best total cost of ownership over a three- to five-year period as capabilities evolve," Hughes says. "The thing that you get with cloud services is instead of every individual hospital trying to keep up with and maintain the latest technologies and security measures, you can just push all of that to people who are managing it for tens of thousands of other organizations."

The nice thing about cloud, Hughes adds, is that there is a fit for every need. From basic storage to computing, you pay for how much you use-and that might mean using more than one vendor.

Cloud vendors are also working to distinguish themselves from one another, developing specific capabilities tailored to healthcare. Each vendor may have their own specialty, such as algorithms for managing diabetes patients, and many healthcare companies may look to hybrid models to best meet their needs, Hughes says.

"The whole world is likely to evolve over the next five to 10 years in a hybrid cloud model," Hughes says. "That's where the idea of plan it and design it comes in, so you can keep your flexibility."

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Using multiple vendors allows an organization to keep their options open with the ability to be more flexible, Hughes says. Larger organizations may be able to manage using multiple vendors in a hybrid model, where smaller organizations may want to pick one vendor with the best fit and stick with them.

"You've really got to think about the size of your organization and the skillset you've got," Hughes says. "Technology is getting too complex to have all the talent needs in-house, whether it's infrastructure services, cloud service, platform, or software.

Organizations just absolutely are going to have to leverage more and more of these services or they won't be able to keep up with the rate of change. Our customers are looking for someone to make it easy."

Rachael Zimlich, RN, is a writer in Columbia Station, Ohio.

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It’s like “dÃ©jÃ  vu” all over again! This phrase summarizes the world of pharmacy in 2019.

As the cost and use of pharmaceuticals is now on the front page of newspapers and a top priority for employers, government, and individuals, some people think that this is a new phenomenon. However, drug costs have been discussed and analyzed for decades. As you plan for 2020 and beyond, here are some key questions to consider:

1. Who is the customer for pharmaceuticals and pharmacy services?

The customer is changing from a physician-centric to a patient-centric world. 

2. What are appropriate pharmaceutical pricing strategies?

Employers are questioning the value of new drug treatments and their price. As patients pay more of the cost of these expensive therapies, drug companies are trying to develop value-based contracting ties to outcomes to address the cost problem.

Drug companies are also launching more “specialty drugs” that are covered under the medical benefit, so these drugs cannot be managed.

The current conversation around the future of rebates is interesting, but drug companies will always discount their products or purchases that can drive market share.

As prescription dispensing is increasingly handled by automation and pharmacy technicians, pharmacists will need to manage a patient’s drug therapy and be connected to others on the healthcare team (e.g., physicians and homecare providers). Using information technology can enable timely communication.

Yes. As companies like Amazon impact the drug distribution model for pharmacy and reshape the consumer experience in buying prescription drugs, pharmacy needs to invent care models to remain relevant.

5. What is the value of pharmacy benefit management (PBM) companies? 

Created in the 1990s to consolidate purchasing power for employers and health plans, PBMs have done a nice job getting discounts from pharmacies and drug companies to lower the cost of the pharmacy benefit. Serving as the middle man between drug companies and pharmacies, PBMs have also amassed large databases of pharmacy claims data to analyze drug utilization and track financial performance. They used this role to “manage” the cost of the pharmacy benefit while simultaneously creating new ways to create profits for themselves.

PBMs are currently selling commodity services (e.g., pharmacy claims processing, pharmacy network contracting,  and drug rebates) to employers and health plans.

As the focus for drug cost management moves to the drugs covered under the medical benefit, PBMs will try to position themselves to manage these medications.

6. What technology enabled services will impact pharmacy?

As pharmacies strive for greater efficiency, two technologies are emerging that ensure every patient is receiving the right medication in the prescribed dosages: (1) using digital imaging makes it much easier and faster for the tech and pharmacist to verify the prescription and (2) improvements in machines specifically engineered to count dosages ensures that the pill count is correct.

Technology such as telemedicine extends pharmacy services to the internet. Individuals in remote locations can fill prescriptions that can then be mailed to their location.

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Pharmacies will increasingly use analytics such as EHR (Electronic Health Records) systems to gain a better picture of the overall health of the patient and in turn provide better services to its customers. In addition, pharmacies will use business analytics to identify customer choices and take action to improve its brand.

Pharmacies will be impacted as consumers embrace technologies (devices and applications) that give them greater access to relevant information. For example, technologies that provide consumer awareness of drug pricing disparities between retail pharmacies will impact their decision on where to get the prescription filled.

7.  What is a managed healthcare executive to do?

A forward-thinking healthcare executive should have a process to scan the industry for innovative applications for consumer-centered healthcare and be willing to make incremental strategic investments that can benefit their members.

For example, you need to focus on lowering drug costs by having a “state of the art” fraud, waste, and abuse program.

Redefine the role of the PBM in your organization and focus on total cost care benefits when approving new drug coverage.

Perry Cohen is an editorial advisor for 

 and is Chief Executive Officer, The Pharmacy Group.

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Priority Health is a $4 billion Michigan-based health plan that is nationally recognized for improving the health and lives of the people it serves-and leading the efforts is Joan Budden, its president and CEO.

“I really see my responsibilities as being threefold. First, it’s dealing with the current real-world healthcare issues and figuring out how to provide affordable care product and services that our members need to get healthy, be healthy, and stay healthy,” she says. “Second, it’s developing strategies for the future to understand what will be needed and anticipating how the industry will continue to evolve to make sure that Priority Health is well-positioned to take on the challenges of tomorrow.”

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And the third, which Budden has done to a tee, is to be a leader and champion of culture and talent within the organization.

“Underlying all of that, my most important responsibility is truly to our members, figuring out how we can provide value to the people and communities we serve,” she says.

 has reported growth across all business lines for the past five years and is now the second largest health insurer in Michigan, impacting nearly one million lives across the state each year. Priority Health was also the only insurer in Michigan to reduce rates on the individual market for 2019.

With over 30 years of healthcare experience, including leading the individual consumer division, project management office and corporate strategy departments for Blue Cross Blue Shield of Michigan, Budden came to the health plan in 2009 looking for a change.

“After many years of experience in a standalone insurance company, I was interested in exploring the complexities and advantages of a fully integrated health system that included a health plan, a medical group, and a hospital,” Budden says. “The opportunity to address complex healthcare issues from multiple perspectives and collaboratively debate the challenges and develop solutions was something that fascinated me.”

Today, she is a fierce advocate for Priority Health members and is committed to ensuring that they have the tools and resources they need to help them play an active role in managing their own health.

Under her leadership, Priority Health has designed affordable health plans that meet the needs of individuals across Michigan, which has resulted in a 35% increase in the number of people being covered.

“Many integrated delivery systems often have the heart of the member through the provider ties, but may lack some of the expertise from an insurance perspective to really soar,” she says. “We’ve always been known for being member focused, but recently we’ve also focused on strengthening our financial discipline and expertise to make sure we had a solid foundation from a business perspective. In addition, we have also made a commitment to really understand our members and their needs across all of our key market segments.”

For instance, she notes the needs of a 67-year-old Medicare member are significantly different from that of a 28-year-old shopping for insurance on the ACA exchange. So, by customizing the approach and focusing on the unique needs of each segment of membership, Priority Health was able to design plans and services that met the specific needs of every member.

Over the years, Budden has spearheaded numerous programs that reflect her commitment to transparency and passion for helping members engage in their healthcare.

“When trying to lift the cloak of secrecy surrounding cost of care, many people have resorted to price-shaming providers,” she says. “We took a very different approach. We recognize that it’s not about passing the buck or blaming others, it’s about giving consumers the information they need to be proactive and make an informed decision about their care.”

Priority Health’s Cost Estimator provides members instant access to cost information for hundreds of health care procedures in a way that’s personalized to their individual health plan-specific to their location, prescription, and benefits-to help them make truly informed decisions about their care.

Hundreds of procedures are available in the tool, and earlier this year, more than 6,000 prescriptions were also added.

“We also enhanced our Cost Estimator with a provider view to allow doctors and other healthcare providers to work together with their patients to find the best value when seeking care,” she says. “Priority Health is the only health plan in Michigan to deliver one comprehensive experience with a transparency tool, offering cost information for healthcare procedures, services, and prescriptions.”

Launched late last year, the Priority Health Wellbeing Hub offers a personalized online health and well-being experience. The Wellbeing Hub is intended to help members get and stay healthy by providing content and tools tailored to their specific health and well-being needs. The Wellbeing Hub uses predictive analytics, or “smart” learnings, to evolve the member’s experience-so it becomes more customized as they engage with the platform.

“I’m also proud of new care model programs like Home-Based Primary Care that allows us to meet members where they are, and provide personalized care-which improves outcomes and reduces costs,” Budden says. “Our program offers the patient a full support system of individuals dedicated to their health care and overall wellbeing.”

This team includes a physician, nurse practitioner, registered nurse case manager and a social worker who work collaboratively to provide routine and preventive care-as well as direct access to care when the patient has a serious health concern or is managing multiple chronic diseases. 

Budden likes to think of herself as an inclusive leader and hopes her team agrees with that assessment.

“I’ve always tried to encourage a culture of collaboration and innovation, and I think one of the best ways to do that is to try and provide as many opportunities as possible for every employee to feel like they have a voice,” she says. “Over the past year, I held 17 listening tours across Priority Health’s multiple campuses throughout the state to receive feedback from all employees, personally.”

In the meetings, there are open discussions about what is going well and what needs improvement. She also encouraged employees to share their ideas about how Priority Health might be able to better execute on the company’s vision.

“Feedback was analyzed from every one of the sessions for our executive team to consider-leading to improvements to today’s operations, as well as new opportunities,” Budden says. “My philosophy on innovation has always been ‘think big, start small, adjust fast, grow to scale’ and that’s the approach I’ve tried to instill in my team.”

When not at her job, Budden likes to spend as much time with family and friends as possible. An empty nester at home with her husband Doug, with their children Megan and Mitchell off working on their own education and careers, the couple likes to golf, hike, and enjoys all types of outdoor activity.

“One of the things that I really enjoy is mentoring. I personally benefitted from having a couple of wonderful mentors over the course of my career, so I try and work with young women each year- offering advice and support, hoping to provide them with some guidance to help them along in their careers,” she says. “One of the pieces of advice that I share from my own experience is that sometimes you have to be bold and take a chance.”

That’s what Budden herself did when she made the risky decision to leave a good job at a large insurer, after many years with the same organization, to pursue an opportunity with Priority Health.

“There were certainly challenges along the way, but I’ve never regretted that decision and every day I’m thankful that I had the courage to make that move,” she says. “The future is very bright for Priority Health. We have a great team and a fantastic culture and I genuinely believe that we are helping people improve their health. We’re financially stable and well-positioned for continued growth.”

Joan Budden has created a culture at Priority Health, the No. 2 health insurer in Michigan, that encourages and rewards innovative thinking.

Featured Exec Joan Budden: President and CEO at Priority Health

The drug approval process is infamous for its complexity and the length of time to develop. But as complicated as standard drugs are to develop, biologics-such as vaccines-are more complicated.

vaccines take about 10 to 15 years to develop

 for a standard drug. In addition to the longer development period, vaccines also have a lower success rate-

 ever reach the market, compared to about a 

That long lead time and high failure rate means that a large number of needed vaccines are still missing from healthcare’s armamentarium.

Cancer Vaccine to Prevent Breast, Ovarian Cancer Recurrence Could be Close

One study from the Duke Global Health Institute’s Center for Policy Impact in Global Health 

. Analyzing over 500 vaccine candidates for 35 neglected diseases in the pipeline, the study found the chances of efficacious vaccines gaining approval over the next five years is “unlikely.” This study concluded that there is a significant gap in funding.

However, not all of the pipeline news is as bleak. From improved flu vaccines to the first

) vaccines, there are many exciting recent and upcoming developments in vaccines.

close to half a million Americans every year

, according to the CDC. A large reason for the spread of 

The vaccines that could make a big impact on healthcare, from radical new flu vaccines to simplified meningococcal vaccine regimens.

Managed Healthcare Executive June 2019 Issue

Seven Pharmacy Regulations Health Execs Must Watch

Eight Ways to Help Patients Navigate Healthcare Costs

Cut Through the Cloud Vendor Clutter

Seven Pharmacy Questions to Consider for 2020 and Beyond

Featured Exec Joan Budden: President and CEO at Priority Health

What You Need to Know About the Vaccine Pipeline

Managed Care Pharmacy Survey 2019

Hospital Pharmacist Role Expands in Patient Care