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Three game changers threaten the industry in 2015


In the healthcare industry, most executives have placed huge caveats on their organization's plans for 2015. Looming this year are three potential game changers: the United States Supreme Court's King v. Burwell decision, a new Republican-controlled Senate's actions on the Affordable Care Act (ACA) and the implementation of ICD-10.

In most organizations, January marks the beginning of a new budget cycle and a flurry of activity surrounding the implementation of growth and diversification activities.

In the healthcare industry, most executives have placed huge caveats on their organization’s plans for 2015. Looming this year are three potential game changers: the United States Supreme Court’s King v. Burwell decision, a new Republican-controlled Senate’s actions on the Affordable Care Act (ACA) and the implementation of ICD-10.

Supreme Court challenge

The King v. Burwell case challenges U.S. Treasury regulations related to individual subsidies provided through healthcare exchanges as part of the ACA. The lawsuit contends that the Treasury department exceeded its authority in providing subsidies to individuals enrolled through the 36 state healthcare exchanges run by the federal government, when the law, as written, indicated that subsidies would be provided only through state-run exchanges.

Should the Supreme Court agree, a major financial underpinning of the ACA could be removed, leading to a significant destabilization of the individual health insurance market. While some states may elect to bring the exchanges under state control, conservative states like Florida and Texas may allow the ruling to undermine their exchanges.

Election results

The election of a Republican majority in the U.S. Senate, joining the Republican-majority House of Representatives, inevitably  will bring more votes to repeal the ACA. On the other hand, there’s a real possibility that Republicans may elect to amend the ACA with changes supported by Congressional Democrats  and President Barack Obama. While most changes would be relatively minor, it’s possible that Congress will provide some latitude in allowing states that have resisted Medicaid expansion to do so under state-customized programs.

It’s also expected that Congress will try to weaken the insurance mandate on small employers and tweak the language regarding full-time employees. The resulting changes could have a major impact.

NEXT: Coding changes, provider access


Coding changes

While many countries already have implemented ICD-10, some as long ago as 1998, the U.S. has repeatedly delayed implementation due to software and provider concerns.  If the current implementation deadline of October 1 holds, it would mean significant challenges for both health plans and providers, not the least of which will be the impact on provider contracts, claims processing and payments. On the positive side, ICD-10 will greatly enhance data collection and analytics and improve clinical research opportunities and provider contracts.

As if those weren’t enough changes…new ways to access providers

The year ahead likely will see a continued shift in provider types and a rise in consumerism.

Led in large part by healthcare consumers’ dislike of waiting for care, telemedicine is surging in popularity. Currently confined largely to primary and urgent care, it will evolve into specialty areas as diverse as dermatology and psychiatry through an expansion of capabilities on mobile devices.

At the other end of the provider spectrum, we will see a rise in the use of residentialists, providers delivering care in the home in lieu of hospitalization. Spurred on by an emphasis on reducing hospital readmissions, residentialists will become an essential element of managing clinical care for homebound individuals with multiple morbidities.

While it has become cliché to describe each new year as one of great change, 2015 may rank as one where it’s most appropriate. For those of us who have seen the ups and downs of managed healthcare in this country, the challenges in front of the industry this year are significant, to say the least.

Don Hall, MPH, is principal of DeltaSigma LLC, a consulting practice specializing in strategic problem solving for managed care organizations. He also is an editorial advisor for MHE. 

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