While the new administration has brought uncertainty to what the Affordable Care Act will look like in the coming year, industry experts believe that the healthcare transformation will continue.
Four experts shared their insights into trends, opportunities and challenges for the coming year for physicians and provider networks.
Don Crane, President and CEO, CAPG:
“We may have a different administration, but the value movement is non-partisan and will continue apace. Changes will likely be around the margins, and underneath will be continued pursuit of care that’s delivered at lower cost at equal or better quality. We have to move from fragmented care to coordinated care. To physicians out there, our message is ‘stay the course.’ Medicare Advantage remains a very good opportunity because so many of the health plans are prepared to capitate downstream. That population has more chronic disease and represents a real opportunity for improving care and enjoying higher profits and saving money.”
James (Larry) Holly, M.D., CEO, SETMA:
“One trend is that in the face of geometric technological advances in healthcare techniques, increased emphasis must focus on rediscovering human values and human relationships as manifested in trust and dialogue between all participants in the healthcare dynamic. The second trend is that as an extension of refocusing healthcare expenditures on quality, safety and outcomes, the market will demand the adoption of the elements and principles PCMH. But that focus must not be in checking boxes but in dynamic collaboration. Unfortunately, MACRA and MIPS have systematized the deficiencies of the old system which will prevent true transformation. The biggest challenge is to understand that healthcare transformation is an organic outcome, resulting from the blossoming of the nurtured plant -- the organizational organism -- which springs from the nature of the patient-centered dynamic collaboration between healthcare professionals and healthcare participants.”
Roger Kathol, M.D., URAC Board Member representing the American Psychiatric Association (APA); President, Cartesian Solutions, Inc.:
“There is increased interest by URAC in better supporting behavioral health (BH) issues as part of total healthcare in the medical settings. This is because: 1) 60% of medical patients with BH conditions receive no BH care; 2) medical patients with BH comorbidity purposely avoid care in standalone BH settings; and 3) the impact of #1 and #2 is that total healthcare costs for medical patients with BH conditions is double that for patients without BH conditions, and much higher in the 2% subset with chronic comorbid conditions. This average doubling persists over time because needed BH treatment is not accessed.
“Based on these industry-wide findings, URAC is moving to support for a system in which BH services increasingly become a part of total health. While this involves a core transition in the delivery of BH services, i.e., BH services become a part of medical benefits provided in medical settings, the long term consequences of this transition could have a substantial positive impact on patient health and total cost of care. As a result, a number of URAC clients are gradually transitioning to care delivery systems in which BH is becoming a part medical services, such as endorsed by CMS’s Collaborative Care model. While this transition is challenging, it also creates an opportunity which could lead to substantially improved total patient health at considerably less cost.”
Michael Hunt, M.D., CMO/CMIO, St. Vincent’s Health Partners:
“I think there will be a lot more visibility around the business and the monetization of healthcare in the next few years. … [In the coming year] from an economic perspective, we’re going to start really defining what the cost of healthcare is. When you come down to actually providing healthcare and the choices the consumer makes and the demands within [the system], there’s a cost to it. We’ve not really had a very good national conversation on the value of healthcare and what it costs to deliver it.
“I run a clinically integrated network that is moving toward an organized delivery system. A lot of hospitals and health systems have developed a system around a hospital. We are looking at what an organized delivery system is that goes beyond a hospital system, because we feel that hospitals are going to become cost centers. … What we’re trying to focus on in the next couple of years is, what does an organized delivery system look like, and how do you create that model so that all of the members find success under that umbrella?”
“We have to band together and educate our patients. … What we are seeing already is that the consumer has been left behind in the knowledge of what’s about to change. … There are many models of care that are being more intrusive in a positive way than in the past, and they don’t understand it. … So there’s a lot of unintentional and intentional inequities in this healthcare model, and that is the challenge that we’re going to have to manage.”
Clearly, there’s a huge challenge looming for providers — especially smaller practices — to adjust to new reimbursement models and the logistics they require. But, experts agree, physicians and provider networks can’t lose sight of another important challenge: educating patients to help them understand the changes they’ll be experiencing as their physicians shift from fee-for-service to value-based care.
Read more on this topic:
- Clinically Integrated Networks: A Framework for Clinical and Financial Success
- 3 Tips to Prepare Your Practice for PCMH Certification
- Small Physician Practices: How to Successfully Go It Alone
- URAC's complete, detailed PCMH Certification Standards (PDF format, 101 pages)
- URAC’s Provider Integration and Coordination Programs