Slideshows

Managed Healthcare Executive ® polled executives from across the industry to get a glimpse into the biggest challenges and opportunities healthcare executives face, along with valuable insights into how some of the top leaders plan to tackle the shifting tide of healthcare in 2020 and beyond.

Managed Care State of the Industry 2019

The year 2020 will see both new opportunities and continued challenges in managed care pharmacy. Technologies will play a major role in enhancing administrative processes while treatments will continue to become more advanced, to name a few.

Here’s a look at eight trends that experts expect will shape the industry next year:

Thomas R. Bizzaro, RPh, vice president, Health Policy and Industry Relations, FDB (First Databank, Inc.), a San Francisco-based company focused on providing trusted medical knowledge, expects to see an ongoing move in managed care pharmacy from fee for service to value-based care in 2020, with an expanded focus on quality of care and outcomes. “There’s no longer a controversy about whether the industry is moving away from fee for service-the question now is how fast the move to value-based care is going to happen,” he says.
		
		In this emerging environment, Bizzaro says payers and providers will work even more closely together, with shared responsibility for outcomes and shared risk and rewards tied to the cost of care. Meanwhile, CMS and private insurers will continue to expand these payment models to areas that traditionally weren’t covered to improve outcomes. There will be a growing focus on educating members to improve their understanding of their medication therapy (i.e., why they’re taking a drug, when they need to take it, and possible side effects). “This knowledge will ultimately improve adherence,” he says.
		
		

Opinion: Bending the Pharmacy Cost Curve with Population Health Management

Increased integration of medical and pharmacy benefits. 

Historically, medical, and pharmacy benefits have been siloed. When employers and other organizations design benefit plans, they typically use one company for medical benefits and a different one for pharmacy benefits. Because the companies are separate entities, they don’t share data or information. Therefore, there’s a disconnect.
		
		“As a result, plan sponsors are challenged to ensure that members receive coordinated care and understand the true cost of care,” says Jerry Buller, DPh, MMHC, chief pharmacy officer at Trellis Rx, a specialty pharmacy located in Atlanta that partners with health systems to enhance patient experiences. “These issues are particularly relevant for patients with chronic and complex conditions, who often require high-cost specialty medications. A plan sponsor and medical team may miss important opportunities to comprehensively manage a patient’s care.”
		Moving into 2020 and beyond, Buller believes plan sponsors will begin demanding solutions that address these siloes. Today, UnitedHealthcare’s Optum has programs that provide insight into both medical and pharmacy benefits. Other companies are attempting to replicate this via mergers and acquisitions. Finally, more integrated delivery networks are now offering comprehensive health plans as a solution to these challenges.

Drug prices will continue challenging patients, payers, and providers.

 In particular, Ryan Foster, PharmD, MBA, senior director, pharmacy

Spectrum Health, a not-for-profit, integrated health system in Grand Rapids, Michigan, expects the specialty pharmaceutical segment to keep growing, which will require novel approaches to ensure patients are able to access needed medications. Annual growth in per capita spending in this market has averaged 14% since 2013.
		
		“Many specialty drugs show great promise but have limited data because of the relatively small populations in which the medications are indicated,” Foster says. “The healthcare system simply cannot afford inappropriate use of these types of medications.”
		
		System design makes it exceedingly difficult for providers to select the lowest cost therapeutic option for their patients. “Tools to increase transparency and improve decision making (i.e., real-time prescription benefits, electronic prior authorization tools), are not well-developed and hinder providers from selecting the most cost-effective medication,” Foster says.
		
		Along these lines, as tension and attention build over drug costs, Karthik Ganesh, president, 

, a risk-bearing pharmacy benefit manager located in Montvale, New Jersey, expects increased accountability across the spectrum to bend the prescription cost curve. This includes the deployment of empirical data to empower pharmacists to disrupt ineffective treatment regimens in partnership with the prescriber; revising prescription protocols to deliver the most clinically-appropriate treatments at the lowest cost the first time; and a more disciplined approach to population risk management in order to balance drug mix in a way that rewards reduction in total costs while also improving clinical outcomes.
		 

Medication systems will gain connectivity.

 Despite substantial investments in electronic health record systems, computerized physician order entry, barcode medication administration, smart infusion pumps, and other technologies, process improvements have been small. “These technologies often work in isolation and don’t communicate with each other to form a connected system,” says Tom Utech, vice president of solution management at BD.
		
		Hospitals are using disparate systems from too many vendors, which may contribute to the problem. According to the Healthcare Information and Management Systems Society (HIMSS)’s Medication Management Technology Index, on average, hospitals use 5.8 medication management solutions from 4.5 different vendors.
		
		Faced with these disparate systems, nurses and pharmacy staff often develop time-consuming manual workarounds, which can impair workflows. “In particular, these workarounds can delay patient care, undermine standardization, and potentially jeopardize patient safety,” Utech says. “To optimize technologies, these solutions must be connected.”
		
		Fortunately, hospitals are beginning to recognize the problem. According to a HIMSS analytics study of 153 healthcare professionals, 71% of respondents see value in moving to a single medication management vendor.

 In conjunction with this, the pace of discovery and implementation of targeted therapies will accelerate. “While oncology has experienced the most significant shift in practice because of personalized therapies, we should expect to see a shift in prescribing patterns for chronic disease,” Foster says. “In the past, medication selection and dosing were based on broad, population-based studies.”
		
		Soon, rather than starting a medication at a dose based on population averages, providers will have the ability to select a medication and dose based on patient-specific genomic factors. “This should improve patient outcomes and medication adherence rates,” he says.
		
		The promise of precision medicine will force health plans and health systems alike to rethink formulary management strategies. “Although additional research will be needed in order to determine which genomic variations translate to meaningful outcomes, developments in this space are promising,” Foster says.
		 

Ongoing emphasis on social determinants of health (SDoH). 

SDoH, which the CDC defines as “conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes,” will continue to move to the forefront as a major issue in managed care pharmacy.
		
		“SDoH have been obvious to healthcare providers for many years, but the concept hasn’t been a focal point in the total care of the patient until more recently,” Bizzaro says. “There’s a growing recognition that not only do you need to treat physiology for disease management and prevention, but you also need to identify whether members need help with social care that can affect their well-being and clinical outcomes-including those related to pharmacotherapy.”


		When it comes to managed care pharmacy, health plans that are investing in addressing SDoH will likely see a positive impact in areas such as medication adherence, Bizzaro maintains. For example, getting members to medical appointments is important, so increasingly, health plans and other organizations are paying for ride share services when members have transportation challenges.
		
		“This type of intervention means members see their providers for regularly scheduled visits, ensuring they obtain needed prescriptions,” Bizzaro says. “Their physicians are also able to monitor drug therapy, to ensure it’s effective and that members aren’t encountering issues with adherence or side effects. By viewing members and their situations holistically, medication therapy is more effective and clinical outcomes improve.”
		 

Pharmacists emerge as primary care providers. 

More pharmacists are functioning as primary care providers, whether they are giving vaccinations at retail pharmacies or hospitals, are certified in diabetes care, or in some states, are empowered to prescribe and order laboratory tests. “In 2020, we can expect to see an expansion of pharmacists and other non-physician healthcare professionals providing this type of care,” Bizzaro says. “This approach allows pharmacists and physicians to practice at the top of their licenses; doctors can concentrate on sicker patients.”
		
		Orsula Knowlton, PharmD, MBA, co-founder and president, Tabula Rasa HealthCare in Moorestown, New Jersey, which provides medication risk mitigation technology, also foresees pharmacists taking on more primary care provider responsibilities, by playing a larger role in advising care, managing treatment, and taking responsibility to prevent adverse drug events, the third leading cause of death.
		
		“Traditionally, pharmacists and physicians have worked separately from one another. However, as a new model of patient care emerges, more hospitals and health systems will integrate pharmacists alongside physicians and nurses before prescribing decisions are made,” Knowlton says.
		
		There are multiple reasons for this change in the care team structure. First, while multiple players can be involved in decision making for a patient, none except the pharmacist have the unique education required to holistically assess medication regimens for effectiveness and safety. “Together, pharmacists and physicians can make impactful interventions that can lead to reduced hospitalizations and unnecessary healthcare costs associated with medication mismanagement,” Knowlton says. In addition, collaborative practice agreements are becoming more common, which is a proven model in the Veterans Health Administration clinical pharmacy program.
		Second, new pharmacy technologies seek to improve workflows, drive adherence, and identify medication safety and risk, which will demand improved dialogue between pharmacies and prescribers. “By leveraging the insights of pharmacy technologies, physicians will have the tools and information to better understand when to refer patients for pharmacist-driven clinical consultation,” Knowlton says.
		
		Finally, patients want a pharmacist on their care team. “They want to engage in dialogue with their pharmacist and discuss their medication profiles and safety in totality,” Knowlton says. “This could significantly reduce medication mismanagement and the risk of adverse drug events.”
		
		As this trend continues, Bizzaro expects to see more data and information sharing not only between health plans, pharmacy benefit managers, and providers, but also among retail pharmacies. “Currently, most retail pharmacies don’t have access to the breadth of patient information that they need to become a true partner to care for patients,” he says. “When interoperability finally becomes a reality, the future will need to include pharmacies having access to all of the information in a patient’s electronic health record. This team approach to care will ultimately lower costs and improve outcomes from a managed care pharmacy perspective.”
		 

Consumers will become more cautious about prescribed medications. 

In the wake of the opioid epidemic, consumers are more aware of the dangers that come with taking prescription pain medications. Knowlton expects consumers to start taking responsible measures to inquire about their prescriptions, by ensuring that they are necessary and confirming that their combination of medications doesn’t have the potential for a harmful drug interaction.
		
		“Now, more than ever, patients have access to their medical information,” Knowlton says. “Having this information at their fingertips gives patients incentives to be their own healthcare champion, and to inquire and analyze their own medication regimen or healthcare processes.”
		
		Furthermore, new technologies have helped pharmacists and physicians become more equipped to share medical information with patients in a consumer-friendly manner.
		
		

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

Articles

New administrative technology, treatment enhancements, and more.

Eight Trends Expected to Shape Managed Care Pharmacy in 2020

 (OCPs) have been part of a growing trend for providers and payers.  The American Society of Clinical Oncology (ASCO) reported a 

 increase from 2014 to 2016 in practices compliant with a pathway program based on an annual census of oncology practices.  Protocols for OCPs include a wide variety of important aspects of delivering cancer care including anticancer drug treatment based on the stage and disease type. Oncology pathways balance various aspects of care including clinical efficacy, safety, toxicities, cost, and scientific advances. Additionally, ASCO is continuously raising awareness about high-quality OCPs among oncology providers, patients, and other stakeholders. This article will focus on OCPs and high-quality, value-based reimbursement models.

, approximately 60 individual health insurance plans in the United States are establishing OCPs. More than 170 million individuals covered by these plans are potentially being treated under a plan-sponsored pathway, with many receiving treatment for active cancer. In January 2015, 

 established the Task Force on Clinical Pathways to review OCPs and provide guidance on developing and using OCPs in cancer care.

Robin Zon, MD, FACP, chair, ASCO Task Force on Clinical Pathways, president, Michiana Hematology Oncology Advanced Centers for Cancer Care, in Mishawaka, Indiana, has been instrumental, through her publications and research, in developing criteria to evaluate OCPs and educating on the use of these programs to improve patient care. The use of OCPs can also play an important role as a collaborative approach with various practice settings or through participation in accountable care organizations that don’t share a common electronic health record (EHR). High-quality OCPs can serve as an important tool to improve care quality and reduce costs. According to a study published in the 

, outpatient costs were 35% lower for non–small cell lung cancer patients treated on OCPs compared with those treated off pathways, while there was no difference in overall survival. Another study published in the 

 demonstrated that overall costs from the national claims database, including total cost per case and chemotherapy costs, were lower for patients treated on-pathway compared with patients not treated according to the OCP. Other key study findings include that patients treated on-pathway required a shorter therapy duration, and there was a lower rate of chemotherapy-related hospital admissions.   

, also known as Criteria for High-Quality Clinical Pathways (Criteria), to serve as a guide for evaluating OCPs that focuses on the following important areas: development, implementation/use, and analytics. High-quality programs should be expert driven, include a clear process and methods for development, be patient focused, and have an evidence-based approach as part of the development criteria. Also, programs should have clear and achievable expected outcomes, cost-effective technology, and clinical decision support (e.g., EHR) for the implementation and use component. The analytics area should include performance metrics, have outcomes-driven results, and promote research and continuous quality improvement. According to Zon, there were concerns with OCP program quality, so the Criteria help to ensure that pathway programs “focus on efficacy first, then toxicity, and lastly cost.” Zon played an important role in helping to develop the Criteria for OCPs.        

Zon and Robert Daly, MD, MBA, Memorial Sloan-Kettering Cancer Center, New York, along with the ASCO Task Force on Clinical Pathways, 

 the national pathway vendors using the Criteria and included OCPs in their analysis that provided treatment management tools to standardize and promote evidence-based care and enhance treatment quality. The various vendors involved in the 

 included different characteristics. For example, New Century Health consists of two levels of pathways. Oncology pharmacists draft the initial Level 1 Pathways in collaboration with medical oncologists to determine whether the regimen is safe and effective first and then evaluate the cost. The Level 2 Pathways include oncology treatment regimens used by CMS. Other interesting findings are that some OCPs like Anthem/AIM enable providers to retrieve their pathway adherence performance reports, and it uses a panel of eight to 12 physicians from community and academic practice settings to develop the pathways. Not all pathways have fully integrated their programs into the EHR, and Zon says that continuous work is needed to facilitate implementing this into the daily workflow.

Daly emphasized the importance of “having information at the point of care.” He says that the two types of OCPs are provider and payer pathways. Payer pathways are usually developed by health plans, while provider pathways are established by physician disease committees. Their study serves as a guide for clinicians to ensure that OCPs are high quality, rather than a recommendation to use a specific pathway.   

OCP education, evidence-based resources, and future research 

Zon says that education about OCPs is key, and she has been instrumental in the process. After attending a recent Oncology Clinical Pathways Congress meeting, Zon reported that there were many educational sessions with a variety of stakeholders including physicians and payers.  “More groups are implementing OCPs to achieve value-based care,” Zon says. She has provided education to oncologists through podcasts and at meetings.

Zon discussed the importance of a hierarchy of evidence-based resources for selecting treatment regimens. The ASCO and National Comprehensive Cancer Network guidelines should be used as part of the decision-making process along with newly FDA-approved medications and the latest evidence. Ultimately, “assessing how the patient is doing is the goal,” Zon says. Oncologists should ask the quality of life questions that include whether the patient is able to work and participate in daily activities. Daly says that more research is needed on value-based payment models and their impact on quality of care. He adds, “Physicians have little control over cost but can control how patients are treated.”

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

A program that balances scientific advances and cost, oncology clinical pathways can be an important tool for improving quality of care.

Oncology Clinical Pathways: A Growing Trend for Value-Based Care

As value-based care initiatives continue to drive healthcare decisions, it’s no surprise that mobile applications are being used by providers and payers as a way to connect with patients and connect silos within the healthcare community.

But as mobile apps on smartphones are commonplace for many consumers, it can be overwhelming to decipher what apps are the most useful. There are more than 318,000 healthcare mobile apps available to download, according to 

At this point of market saturation, mobile apps in the healthcare space are expected by patients and consumers, says Benjamin Kanter, MD, FCCP, chief medical information officer of Vocera, a healthcare technology company with more than 20 years of experience in developing mobile apps and digital communications, in San Jose, California.

“The real question is how can we improve our clinical and operational efficiency? And you can't do that without a modern communication and collaboration platform,” Kanter says. “I would suggest that executives should not differentiate between the applications that help them communicate from the applications that also help them process, mobilize, and act on data.”

Though many consumer-facing healthcare apps have become more robust in their data collection by using cloud and machine learning technology, executives still have to wade through apps’ capabilities in order to find the ones that are the most effective, says Paul Cerrato, MA, author of 

Realizing the Promise of Precision Medicine.

Mobile Apps Bridge the Patient-Provider Gap

“Physicians and healthcare organizations that are making financial decisions have to find those apps that are really well supported by the evidence, not just conceptually well-supported but in terms of actual experiments to show that these apps work,” Cerrato says.

Static apps that offer just education and information aren’t as useful as those that can help patients with specific health issues, Cerrato says.

“If you have a patient who wants more out of his or her healthcare app, then you have to start thinking about investing in interactive programs,” he adds.

New mobile app technology shouldn’t be a one-off investment but part of an overall digital strategy, says Vincent Martino, chief product officer and co-founder of VisitPay, a mobile patient portal solution.

“The investments health systems need to make in mobile development will depend on how they think about mobile strategy within their larger service offerings,” Martino says. “In our experience, health system leaders should think about mobile no differently than they think about web in terms of importance. In fact, we encourage our clients to rollout their web and mobile strategies concurrently. Any features that are on the web should be mobile-optimized.”

More than 40% of working adults have problems with medical debt-amounting to more than 72 million Americans, according to 

 by The Commonwealth Fund. As high deductible healthcare plans are on the rise, and patients are more financially vested in costs, healthcare organizations have to be more agile in fitting patients’ needs.

“Consumers’ perceptions of the overall healthcare experience are heavily influenced by the level of transparency, control, and convenience provided by the billing experience. A one-size-fits-all billing strategy lacks the flexibility and personalization required to meet people where they are in their lives,” Martino says.

After surveying more than 1,700 patients that use VisitPay, the company found that a number of variables can determine how patients manage their billing obligations and the best way to engage with them.

“People manage their lives through their mobile devices. They schedule appointments, plan their social lives, order products and services, and manage their money through their phones. More consumers are expecting to be able to manage their healthcare needs anywhere, anytime, and on their own terms,” Martino says. “Most industries, including healthcare, are investing considerable resources to reach and engage consumers through mobile devices.”

Martino says ongoing communication about mobile app offerings is important in order to boost and maintain adoption.

“Four years ago, our clients were reporting that 20% of the patients who used our platform to manage their billing did so through their mobile device. Today, that average is 40%,” Martino says. “By comparison, web-based logins average 56% across our health system clients. The gap is quickly closing, and I expect mobile payments to exceed web-based payments within two years.”

Kanter says that mobile apps can be an integral part of an internal communication strategy for practitioners. He estimates that less than 15% of nurses use smartphones as a part of their workday routine.

“If you make communications easier, you're not only improving the tasks of the caregivers, you actually improve the lives of the patients as well,” Kanter says.

He adds that practitioners can choose between providing staff with their own devices or creating a “bring-your-own device” policy where staff can add a secured app to their smartphones. Kanter says each way is affected depending on the company’s culture.

“I think that by making communication easier, it actually makes somebody's job easier,” Kanter says. “It also makes hospitals and healthcare environments safer because when communications are hard to accomplish, they tend not to occur. We know that the majority of healthcare issues are almost invariably traced to a problem in communication.”

Vocera has created a mobile app, Vocera Vina, that helps clinicians make decisions in real time by prioritizing the most urgent information to the top of the inbox and delivering patient context as part of an inbound phone call, so they know what to focus on instantly. That means they get a meaningful picture of a situation quickly, when a patient’s status declines. The app also gives nurses the ability to communicate with others on the care team instantly.

Ultimately, Kanter says, internal apps that can offer real-time triage information is a part of a broader initiative to help healthcare organizations digest data properly.

“When we have mobile apps and software available to us all of the time because of the device in our pocket it isn't really a phone, it's just a mobile computer,” Kanter says. “I don't differentiate any longer between mobile apps and the apps that sit on the computer. The question is, what are we going to do with all this computing power that's available to us in relationship to healthcare?”

The future of voice-activated apps in healthcare

Cerrato says many hospitals are considering voice-activated assistants, such as Amazon Alexa, to enhance internal communications for nurses and other staff. In April 2019, Amazon issued an 

 to create HIPAA-compliant healthcare skills for Alexa, after a trial at Cedars-Sinai Medical Center in Los Angeles. In August 2019, Amazon released 

 with six healthcare providers, including:

Scheduling same-day appointments (Atrium Health)

Post-operation information and appointment management (Boston Children’s Hospital)

Employees managing health goals and wellness incentives (Cigna)

Prescription home delivery status (Express Scripts)

Connecting blood monitoring device and voice-command glucose readings (Livongo)

Helping patients locate nearby urgent care facilities and schedule same-day appointments (Providence St. Joseph Health)

“Hospitals should be thinking about embedding Alexa, Google Assistant, or some of the other mobile assistants into the hospital environment so they can, not only improve the patient experience but also give the clinicians less of a work load,” Cerrato says.

Voice assistants that recognize speech can be used for medical transcription and chart searches during patient appointments. And hospitalized patients can use them to request services and information from on-site staff.

Cerrato adds, “Instead of a patient hitting a call button to request the nurse, he or she can simply ask, ‘Alexa, when am I going to get my next medication?’”

The healthcare industry is investing considerable resources to reach and engage consumers through mobile devices.

Finding the Most Effective Healthcare Apps

Pain management has become a trending topic, especially as the opioid crisis has reached epidemic proportions. According to a recent 

, 67.8% of drug overdose deaths that occurred in 2017 in the United States involved opioids. There are currently about 

 with chronic pain who are receiving opioid therapy. Balancing treatment options as well as preventing prescription drug abuse can be challenging. Chronic pain can lead to increased healthcare costs and 

. This article will discuss pain management drugs that are in phase 3 development as well as the financial impact of these medications and potential alternatives to opioid therapies.

One first-in-class opioid analgesic studied by 

, has received fast-track designation by the FDA for the treatment of moderate-to-severe pain. This drug is expected to have low permeability across the blood-brain barrier, which should result in less abuse potential. The new drug application (NDA) has been filed with the FDA; however, approval may be 

 as the benefit-risk of new opioid medications is being carefully evaluated based on 

 study evaluated the efficacy, safety, and tolerability of NKTR-181 in more than 600 patients with chronic low back pain (CLBP), and it demonstrated that NKTR-181 was effective, as it resulted in an average pain score reduction of over 65% during the dose titration period. Additionally, NKTR-181 had a favorable safety profile and was well tolerated.

 study examined the long-term safety and tolerability of NKTR-181 in 638 patients with moderate-to-severe CLBP or chronic noncancer pain over 52 weeks of treatment, which revealed that pain intensity decreased from baseline. The most common adverse effects were constipation and nausea, with no deaths reported.

CCA Shows Success in Managing Members’ Pain and Opioid Use

“As opioids are still a mainstay of pain management despite the abuse concerns, abuse deterrent formulations [ADFs] have been entering the market at a rapid pace,” says Michelle Krichbaum, PharmD, assistant professor, pharmacy practice, pain management specialist, Memorial Primary Care, Dania Beach, Florida. One 

 showed that over a five-year time period, using ADF opioids prevented an additional 2,300 new cases of opioid abuse but resulted in approximately $535 million in healthcare costs.

 is studying CNTX-4975 for the treatment of moderate-to-severe pain for osteoarthritis (OA), which was granted fast-track designation by the FDA in January 2018. CNTX-4975 is a trans-capsaicin injection that targets the TRPV1 receptor that selectively inactivates the local pain fibers. There are currently two ongoing phase 3 studies examining CNTX-4975 for OA. 

 is expected to be completed in 2020, and it is a placebo-controlled, single-injection, 52-week study evaluating the efficacy and safety of CNTX-4975 in patients with chronic, moderate-to-severe OA knee pain. 

 is a randomized double-blind, placebo-controlled, two-injection, 52-week study evaluating the efficacy and safety of repeat doses of CNTX-4975 for OA knee pain, with an estimated completion date of 2020.

 is studying Zalviso for moderate-to-severe acute pain in the hospital setting as a novel approach to patient controlled analgesia (PCA). Zalviso is a noninvasive sublingual dosage form that is delivered through a novel hand-held, pre-programmed, PCA system that could be an alternative to intravenous PCA. The FDA previously rejected the NDA for Zalviso citing concerns over system errors. One recent phase 3 

 evaluated the overall performance of the Zalviso system in 320 hospitalized, postoperative patients, revealing a device-dispense failure rate of 2.2%, which is a significant improvement over previous clinical trials.

With future opioid therapies on the horizon, it is important for healthcare professionals to monitor for prescription drug abuse. Krichbaum discussed that prescription drug monitoring programs can be a useful tool, but they may not paint a complete picture. “One of the ways I believe practitioners can make an impact is through the use of validated questionnaires to help better identify patients who may be at higher risk,” Krichbaum says. She explains that the Opioid Compliance Checklist is a promising five-item, self-reported questionnaire to help monitor patients as well as identify possible prescription drug abuse behavior.

Pain management drugs in phase 3 development show promise as abuse-deterrent formulations of opioid therapies.

Managing Pain Drugs Requires a Delicate Balance

Although managed care has changed dramatically over the last 30 years, its essential value proposition is the same: deliver higher quality and lower costs compared with fee-for-service arrangements.

We refuse to accept a tradeoff between quality health outcomes and affordable care. Governments and taxpayers demand both. Patients deserve both. And it is a constant challenge to deliver both.

 State of the Industry Survey finds that nearly two-thirds (64%) of responding healthcare executives have made improving quality and lowering costs their organizations’ prime focus-but barely more than one in six (18%) think that healthcare quality and costs are improving. Nearly half (48%) believe that quality and costs are getting worse.

But managed care is up to the challenge. Our ‘secret ingredient’ is the ability to craft creative solutions to address quality and cost. Value-based payments are a big part of the equation; they align financial incentives in the direction of paying for health outcomes instead of encounters and procedures.

Five Ways to Integrate Social Care into Healthcare

Social determinants initiatives contain cost, improve outcomes

However, health plans have been going even further upstream and working to address social determinants of health. In many ways, our health is the sum total of our lived experience-what we eat, where we live, and how we work all contribute. These social determinants often have a more profound influence on a person’s health than medical care itself. And unlike our genes, these social determinants of health are not set in stone. They respond to outside influences and incentives.

States and federal policy makers have recognized the value in addressing social determinants of health, especially in Medicaid and Children’s Health Insurance Program (CHIP). A 

 of managed care contracts or requests for proposal in 40 states, in addition to 25 approved § 1115 demonstrations, found that many included requirements and incentives for managed care organizations (MCOs) related to social determinants of health in contracts or requests for proposals. At the same time, 

 Medicaid MCOs provide services to improve social determinants of health.

Health coverage helps people find, keep jobs

Employment, for instance, is a social determinant of health. In many ways, Medicaid is a jobs program, and statistics bear this out: More than six in 10 able-bodied Medicaid recipients (nonelderly, non-dual eligible, non–Supplemental Security Income recipients) already have full-time or part-time employment. Among able-bodied adults covered under Medicaid expansion, about eight in 10 are similarly employed.

Enrollees report that coverage helps them find and keep jobs. In Michigan, 69% of working adults said coverage through Medicaid expansion made it easier to work or made them better at their jobs. In Ohio, three-quarters of non-working adults said such coverage made it easier to look for work.

How health plans are addressing employment


	Safety net health plans that are members of the Association for Community Affiliated Plans (ACAP) have invested heavily in innovations to address social determinants of health, even if they fall outside the traditional bounds of Medicaid health benefits. Medicaid prohibits tax dollars from being spent on social determinants of health, so safety net health plans provide for such programs at their own expense, because they have been proven useful time and again.

 has developed two programs to help its Medicaid members keep and find jobs. The Workforce Initiative Network is a partnership with two community organizations that provides job skills to members to pursue careers as community health outreach workers or administrative staff. The Consumer Workforce Innovator Project, supported with funds from healthcare providers and the city council, provides technical support to the hired enrollees and to contracted community providers that employ them.

 has invested heavily in its JobConnect program. Members who opt into the program are assigned a life coach, who helps to identify a member’s strengths and assure that immediate needs-such as food, shelter, physical health, childcare-are met. Members are then connected with employment opportunities, or education opportunities to open a wider range of doors to employment. Life coaches also help the member prepare for life in the workforce-and the eventual loss of publicly supported assistance.

Ten or 15 years ago, the idea of employment assistance initiatives at health plans would have sounded strange indeed. But plans have found that filling a gap in employment assistance doesn’t just help people find good-paying jobs; these programs can enhance member engagement and keep folks engaged with their healthcare and their health plan.

Stakeholders are coming together on the issue of social determinants of health. Managed care plans are creating innovative approaches to realign incentives and advance value-based care.

As health plans step in to mend the frayed edges of the safety net, it is incumbent on plan leaders to make a clear case for plans to engage in areas that go beyond health care's traditional boundaries. State and federal Medicaid agencies are eager to improve health outcomes while containing expenses and support these efforts. It’s up to us to make the connection between health coverage, social determinants programs, and better outcomes for all.

Jennifer McGuigan Babcock is vice president for Medicaid policy and director of strategic operations at the Association for Community Affiliated Plans.

Healthcare organizations have been going further upstream and working to address social determinants of health, including investing heavily in employment programs.

How Employment Impacts Healthcare

We are seeing a new era in healthcare. Gone are the days of the all-knowing doctor and the passive patient. Consumerism is driving changes in medicine, with Americans demanding higher-quality care, better cost management, and a greater focus on preventive medicine.

How can you use these trends to your advantage? One option is to make routine vision care work harder for you.

Few people realize that a routine eye exam can detect and diagnose more than 25 different medical conditions-including those that are most feared by Americans, such as stroke risk, Alzheimer disease, diabetes, and heart disease. Better yet, an eye exam often identifies the condition long before the patient even knows they have the disease.

Take a minute to think about that. A routine vision exam is noninvasive; takes 60 minutes or less; often occurs at convenient times of the day; and can be used as screening for diseases like diabetes and heart disease.

, which found that a routine eye exam detected signs of chronic disease long before any other health professional had noted the condition. Specifically, the researchers found signs of high cholesterol 65% of the time, high blood pressure 30% of the time, and diabetes 20% of the time.

This was seen in another study, this time from the 

, where researchers reported that 21% of patients tested during an eye exam had high blood pressure, yet two-thirds (67%) of them had no idea they had elevated levels.

It’s the same story with Alzheimer disease and stroke, as well. A study from 

 found that eye doctors can detect small alterations in retinal blood vessels that are known to be a biomarker for Alzheimer disease years before it begins to affect memory. Similarly, a study from the journal 

 found that retinal microvascular measurements can predict risk of stroke.

In other words, one can learn a lot about whole body health from a routine eye exam 

 there are symptoms of bodily damage. Now that’s the kind of high-quality, low-cost preventive care Americans are demanding.

Early prevention equals cost savings with routine vision

Speaking of cost savings, let’s consider for a moment the fact that many of the very diseases detected in an eye exam are the most costly.

Stroke-the leading cause of long-term disability in the United States-alone costs the United States an average of $34 billion each year, according to a report from the American Heart Association. But that’s a drop in the bucket compared with diabetes, which the American Diabetes Association estimates totals $327 billion annually, with $237 billion coming from direct medical costs and $90 billion coming from decreased productivity.

Yet, employers considering routine benefits often give ancillary benefits, like vision, little attention. The good news is that some health plans administering Medicare and Medicaid plans are ahead of the trend and are turning their attention to vision plans to increase their members’ access to preventive screening. In fact, some are considering telemedicine and mobile units for vision screening to address barriers to access.

Routine vision is a low-cost benefit, which is why it is sometimes overlooked. But savvy health plans are paying attention-because it is also a low-cost screening method that helps identify members at risk for costly medical conditions-and measuring the positive impact on health outcomes.

While routine vision may be relatively low cost, medical care associated with eye and vision diseases are not. Eye disease costs are on the rise, with ophthalmology and optometry ranking as the second highest cost specialty for Medicare expenditures. Specifically, eye-related costs drive 7.2% of total Medicare expenses ($102 billion) and in fact, eye care costs have been growing at a faster rate than total Medicare costs-three times as fast to be exact.
	
	Health plans may not be aware of this trend, but for those of us in managed vision care, we are watching it constantly, often taking the temperature on these costs three times a day.

Routine vision, preventative care, lower costs

Managed vision benefits provide preventive care, support whole body health, improve outcomes, and manage costs-precisely what Americans want from their healthcare.

It’s time we all start paying attention.

Kirk Rothrock is chief executive officer of Versant Health, a next-generation managed vision care company dedicated to 

helping members enjoy the wonders of sight through healthy eyes and vision. He has nearly three decades of experience leading healthcare services companies, with a proven track record of growing organizations and enabling better access to care. Previous roles span the continuum of care, including positions with leading provider and payer organizations in both the public and private sectors

A routine eye exam can detect and diagnose more than 25 different medical conditions.

Vision Care: Front-Line to Whole Body Health

With an election year just about upon us, there are a number of changes coming from the current administration that are going to impact the managed care industry in 2020. Changes in allowable benefits, home health, hospice carve-ins, and new CPT codes for remote home monitoring are just a sample of these. 

There are an additional set of fundamental changes coming from the administration affecting clinicians related to payment models. For example, earlier this year, CMS announced five new primary care payment models designed to incentivize the entire healthcare system to transition to value-based care, especially for patients with complex, chronic, and high-need conditions. 

Here are eight policy changes that could make a huge impact in 2020.

Michael Abrams, managing partner of the global healthcare consulting firm Numerof & Associates, a global healthcare consulting firm based in St. Louis, says there will be no ignoring Medicare for All in 2020.

“It’s already a hot policy topic among presidential candidates, and I suspect the debate around its potential pros and cons will only continue to intensify; some arguing that the significant expansion of healthcare coverage is worth the incredibly expensive price tag, and others arguing there’s no way today’s providers will be able to respond to its ramifications,” he says.

Specialty Medications and Managed Care Pharmacy

Emily Felder, senior policy advisor and counsel with D.C.-based Brownstein Hyatt Farber Schreck, a lobbying firm specializing in healthcare, notes HHS is rewriting the rules for the Stark Law, or physician self-referral, and will issue a proposed rule later this year. That will set up 2020 as the year to debate the proposed changes and a broader discussion about the role of Stark in managed care.

CMS Administrator Seema Verma has called Stark “outdated” and said while it makes sense in a fee-for-service (FFS) system to prevent inappropriate financial incentives, it doesn’t apply the same way to managed care and value-based systems.

“Changes to Stark will be largely positive for two reasons,” Felder says. “One, the administration is aware that the 30-year-old law needs to be updated and adapted for today’s evolving system, and two, there is commitment and action to make it reflect the intent of the law. The administration sees these changes as part of the larger ‘Regulatory Sprint to Coordinated Care.’”

John Nicolaou, healthcare expert at PA Consulting, a global healthcare consultancy with U.S. offices in New York, says the price transparency regulation proposal, started by executive order earlier in the year, and now part of a CMS proposed rulemaking, is currently in comment period.

“This would require hospitals to publish gross and negotiated rates for services in an accessible format, including commonly used ‘bundles’ of services,” he says.   

Robbie Hughes, founder and CEO of Lumeon, a digital health company leveraging Care Pathway Management, based in Boston, expects that heading into 2020 there will be more movement around Trump’s order on price transparency, aimed at lowering rising costs of care by showing prices upfront to patients.

“The executive order describes the concept of price transparency as the means to creating a ‘shoppable’ experience-the idea that there could be packages of care at understandable, logical prices,” he says. “Not only will this force providers to package their care into ‘shoppable’ products for consumers, but it will also ultimately drive down prices through market forces.”

The ideas in this executive order will likely be reflected in a bigger policy package that will need bipartisan support and approval from both houses in Congress.

“Nobody will disagree on making it easier and more affordable for Americans to consume healthcare,” Hughes says. “The challenge I anticipate we’ll see is around industry agreement on an approach that ensures the consumer sees the benefit of reduced healthcare costs.”

4. International reference pricing for therapies paid for by Medicare

Both political parties have proposed plans that involve some form of reference pricing, and a recently released study by the Senate Ways and Means Committee found some therapies may cost fourfold more in the United States than other comparator countries. 

Meg Alexander, managing director, reputation and risk management practice for Syneos Health, a healthcare research organization based in Morrisville, North Carolina, says some reference pricing proposals, such as the version posed by the administration, may enable payers to more closely “manage” certain drug categories. However, reference pricing could also deliver several un-intended consequences that may have the opposite effect of making drugs affordable and accessible for Americans.

“For example, some reference pricing proposals involve vendor ‘middle men’ for drug management, increased payer management strategies, and could involve a flat physician administration fee for therapies offered under Medicare Part B,” she says. “This may translate into fewer physicians offering such therapies due to administrative and reimbursement hassles; thereby leading to American patients potentially struggling to find doctors to administer the medicines they need.”

Bryan Becker, MD, chief medical officer for DaVita Integrated Kidney Care, a Fortune 500 healthcare provider based in Denver, Colorado, says following an executive order signed in July- Advancing American Kidney Health-the Center for Medicare and Medicaid Innovation (CMMI) announced voluntary and mandatory payment models, though the details of the voluntary models, which have some general features that mirror the primary care payment models, have not been released yet.   

“The mandatory model, otherwise known as the ESRD Treatment Choice [ETC] model, would take effect in 2020,” he says. “The ETC as proposed extends to half of the Hospital Referral Regions [HRRs] in the country and includes the patients in the dialysis clinics in those HRRs and the nephrologists who work with patients in those clinics.”

The claims from both nephrologists and clinics will be adjusted based on home and transplant rates for chronic kidney disease stage 4/5 or ESRD Medicare FFS patients in areas identified by CMS as an ETC region.

Sami Inkinen, CEO and founder of Virta Health, a San Francisco-based health tech company specializing in type 2 diabetes reversal through nutritional intervention, believes in 2020, there will be policy changes roll out to help address the rising cost of insulin, which the FDA Commissioner Scott Gottlieb, MD, has called unacceptably high for a decades-old drug.

“Insulins are biologic drugs, and they will be regulated as such for the first time in 2020. The transition will spur generic competition in the insulin market and impact costs,” Inkinen says. “The shift has been long planned, but it comes amid growing public outrage and media stories focused on patients having to ration their insulin, travel abroad to buy cheaper insulin, and make choices between buying insulin or putting food on the table.” 

HHS is aggressively pushing forward with new requirements to hasten the adoption of interoperable electronic health records and utilizing brand new legal authorities to do so. In its February 2019 Interoperability and Patient Access proposed rule, CMS requires all Medicare, Medicaid, and federal exchange plans to share claims data information electronically with enrollees.

“While this is an important policy objective to further the administration’s goal of giving patients access and control over their own data, it could create a burden for plans to operationalize this new rule and ensure it complies with data safety standards,” Felder says. “This rule is set to be finalized by the end of the year, and plans will be charged with implementing it in 2020.”

Lee Barrett, executive director and CEO of Electronic Healthcare Network Accreditation Commission, the nonprofit standards development and healthcare accreditation company, says to the extent to which managed care companies manage drugs, as well as other healthcare service delivery, the current focus on bringing drug costs under control is relevant.

House Speaker Nancy Pelosi’s bill to lower prescription drug prices would save Medicare $345 billion over 10 years, according to a preliminary analysis from the nonpartisan Congressional Budget Office.

The main thrust of the plan would allow Medicare to negotiate lower prices on up to 250 of the most expensive drugs-including insulin-per year and apply those discounts to private health plans.

“If Medicare were to move in the direction of the Pelosi proposal, in which drug prices would be indexed against foreign prices and the government would negotiate prices downward, we would expect that drug prices in the commercial market would fall as well,” Barrett says. “While a political agreement on an approach to lowering drug prices will be difficult, we think there is a reasonable chance that drug manufacturers and PBMs [pharmacy benefit managers] will be squeezed considerably in 2020, and managed care organizations, like other payers/controllers of care, should benefit.”

This past summer, the Trump administration dropped the proposed drug rebate rule aimed at PBMs, then introduced a plan to import drugs from Canada. As the public is still searching for a solution, 2020 will undoubtedly see more discussions about how to reel in drug prices. 

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

A look at what will impact the managed care industry next year.

MHE December 2019