Tag Archives: PPACA

2014 Healthcare Predictions and Trends

Happy New Year!  2013 has been an interesting year in healthcare with 2014 promising many more exciting developments.  A few of the biggest stories from 2013 include:

  • Healthcare.gov – the politics, the drama, and the missteps
  • Healthcare transparency and costs – new companies, new revelations, and an entire Time magazine focused on it
  • Healthcare engagement – ongoing focus on how to get consumers to engage
  • mHealth and QuantifiedSelf – apps and devices proliferate
  • Investment – a huge jump in VC and angel funding for healthcare
  • ACOs – do they work or not
  • Big Data – so much data…so many opportunities

Here’s my predictions for 2014:

  1. Transparency – The race to bring cost data to the forefront of the consumer mindset will move from a radical concept to an expectation.  With increased out-of-pocket costs and HDHPs, consumers will expect access and information to cost data.  They will look for systems that can predict what they need and push data to them in a timely fashion using location based services and predictive algorithms. 
  2. Exchanges – With big companies trying the private exchanges and moving their employees to the federal exchange, we’ll see the market holding its breadth to see what happens.  If this drives success on both sides of the equation – employers and payers, you can expect a large jump in this direction later in the year.   
  3. Mobile – The traditional member website will continue to die a slow death without mobile optimization in place.  More and more consumers will access the healthcare system through a smart phone or device like an iPad.  This will drive healthcare companies to figure out how to embrace user design and member experience in new ways as they strive to provide the sustainable app that consumers use more than a few times. 
  4. Providers – Providers will continue to cautiously embrace pay-for-performance, value-based healthcare, and models like ACOs and PCMHs.  They will want them to work, but they will continue to look for the Tipping Point in which their overall panel is part of these programs.  Providers will also begin to modify their workflows using technology based on Meaningful Use and the ubiquity of technology. 
  5. Engagement – Consumer engagement in healthcare will continue to be the elusive Holy Grail.  Companies will try behavioral economics, incentives, and mass personalization to try and get consumers to understand healthcare and take actions to improve their health.  There will be more shifting to include caregivers and embrace social media (e.g., Facebook) and peer-to-peer networks.  We will start to see documented case studies and results in terms of improved outcomes. 
  6. Devices – While 2013 was the year of device proliferation, we will see the number of people (early adopters and QuantifiedSelf groupies) maxing out.  I expect some further consolidation and a dip in adoption rate as we move into the period of disillusionment.  Devices will be less about a standalone solution and look at how they integrate with the smart phone and existing systems (at work and home).  Like smart pills and smart clothes, this will lead to increased data and integration into daily life.  This will require collaboration with providers and employers to figure out how to come through this period.
  7. Value-based – CMS will continue to be a big driver in pushing new payment models around healthcare as they struggle to figure out how to slow the tidal wave of costs coming in Medicare and Medicaid.  This will meet up with some of the progress in the commercial space with ACO and PCMH models leading to an evolving path in terms of how drive value.  This won’t be the breakthrough year, but we’ll see meaningful progress. 
  8. Investments – I don’t see any slowdown in healthcare investments.  Our health issues aren’t going away in the US or abroad.  China is just emerging with a long list of health issues and technology is creating new solutions in 3rd World countries. 
  9. Pills Plus – With pharma struggling with how to reinvent itself, they are going to look at new solutions like Merck is doing with Vree Health.  This will cause them to look at many of these trends and how they wrap services, technology, and incentives around their medications.  
  10. Specialty Care – Specialty pharmacy will continue to be a big growth driver with novel innovations coming down the pipe.  But, these pharmacies will realize that they can’t work in a vacuum.  They have to do a better job at integrating care management into their services and partnering with Case Management companies to holistically treat the patient. 
  11. Metabolic Syndrome – The overall global issues of obesity and diabetes will become a huge weight around the shoulders of the healthcare system.  While the focus will continue to be on the complex cases requiring massive dollars, the majority of people will be struggling with a chronic disease.  Metabolic Syndrome will become a big focus for payers, employers, and health services companies as they try to find ways to prevent further complications. 
  12. Prevention – While I don’t expect a huge shift here, I think we’ll start to hear more voices on the perimeter yelling about why we only spend 5% of our dollars on prevention.  They’ll point out other models outside the US spending more with better outcomes.  Health Reform will begin to enable some change here, but it will be slow. 
  13. Community Based Care – With more people coming back into the healthcare system with Health Reform, there will be a greater need for location based access to healthcare.  This will involve clinics but will be much broader.  Companies will need to look at how they embrace community resources like churches to engage the disengaged and poor who don’t trust the system and have limited access to the traditional channels.  

If E-Prescribing Doesn’t Have All The Data…Is It Helpful?

This is an interesting dilemma.  At this point, I think everyone is pro e-prescribing even if it’s simply for the benefit of reducing errors.  But, I think the original intent of the solutions were to do a lot more than reduce errors.

The hope was to improve adherence (which I think may have been too lofty).  The idea was that e-prescribing would reduce the abandonment rate at the pharmacy.  I’m not sure picking up a prescription is the same as taking a prescription.  And, taking a prescription once isn’t the same as staying adherent over time.

Another hope was that the use of e-prescribing would drive formulary compliance and increase generic utilization.  The idea was that putting this information in the hands of the prescriber would allow them to make more real-time decisions that were aligned with the consumer’s interests (i.e., lower out-of-pocket spend).  The latest report doesn’t seem to support this at all.  It also echos my prior posts about whether e-prescribing was aligned with pharma at all.

Fewer than half (47.5%) of the 200 PCPs polled said they have access to formulary information when e-prescribing, and fewer than a third said they have access to prior authorization (31.0%) or co-pay (29.5%) information. Among physicians with formulary information access, that information was available 61.1% of the time and was said to be accurate 68.6% of the time.

Physicians with an EMR (54.1%) were more likely to have access to formulary information than physicians without an EMR (29.6%). And differences were seen depending on the EHR vendor: Allscripts physicians (32.2%) were less likely to have access to this information than “All Other” software suppliers (60.5%), Epic physicians (62.5%) and eClinicalWorks (68.8%). 

Another big effort that e-prescribing and integration with EMR was going to have was to push utilization management (UM) to the POP (point of prescribing) rather than having the pharmacy and the PBM dealing with it.  I never really thought this would work.  If the information isn’t there or they don’t trust the information, the prescriber isn’t going to want to deal with this.  It’s already work that they let their staff handle and isn’t something they want to deal with during the patient encounter.

While e-prescribing is definitely here to stay and becoming the norm, the question is whether it’s creating simply a typed “clean” Rx to transmit electronically or whether it’s actually an intelligent process which will enable better care.

Given multiple studies and surveys recently about transparency in healthcare billing and the general push with Health Reform to drive to outcomes, I’m not sure the “dumb” system process can be a sustainable value proposition.

The 15 Year Old Technology Missing From Healthcare.gov

I talked about my experience trying to use the site day one. I honestly hoped it was an anomaly but it doesn’t seem to be.

But, as I think about Healthcare.gov and the general benefits selection process, I see two huge gaps.

Back in 1999, I was working with a company called Firepond. The had what was called a product configurator. At the time, I was at E&Y and Empire BCBS and several other Blues hired them to build a tool for brokers. The tool sat behind a really slick web interface which allowed the broker to ask a consumer less than 10 questions. They would move a sliding bar across the screen and it would dynamically rank their plan options to tell them what was the best option for them to buy. It seems like that wold be great for Medicare.gov and Healthcare.gov.

What we were missing then which Big Data might actually help us solve now is individual claims data. This is what drives me crazy when you have to pick your benefits at work. Why can’t I upload my benefits information and have a tool actually tell me what to buy? If I had my claims history plus a predictive model, I could make smarter decisions about how to select my benefits.

Interesting Survey Results About Obamacare

Given all the buzz about healthcare exchanges (much of it echoing what I talked about last week), I thought this was an interesting study from Coupa Software.

From the press release they sent me…

The results highlight just how divided the healthcare community is over the new law:

93% believe there will be negative outcomes from the new law, including:

  • Quality of insurance policies will suffer (53%)
  • Quality of healthcare will suffer (51%)
  • Americans will die earlier (19%)

74 percent felt there would be also be positive benefits for patients, including:

  • More Americans will have some level of coverage (57%) 
  • Increased preventative care services (36%)
  • Lower hospital bills for patients (21%)

78% identified spending inefficiencies in their workplace, including wasteful spending

66% believe Obamacare will eliminate some of those inefficiencies

    • More Americans will have some level of coverage (57%)
    • Increased preventative care services (36%)
    • Lower hospital bills for patients (21%)

Here’s a look at the raw data: https://www.instant.ly/report/52386bb2e4b0c02bc208a937

Healthcare.gov Registration Process – My Experience…Not Good

I was up and ready to try the new healthcare exchanges at HealthCare.gov this morning.  While it started well with a nice GUI (graphic user interface), it went downhill from there.

Once I got in, it was busy so I had to hold.  

Then, when I tried to create a username and followed the directions, it wouldn’t accept my username.  

And, finally, when I got through it all, it wouldn’t accept who I was to let me proceed.  

If everyone else has a similar experience, this is either going to be a miserable failure or the call centers are going to be lit up with phone calls and huge waits.  I guess to answer the question that the CEO of BCBS of NC poised the other day…this won’t reflect badly on the plans because I can’t even get far enough into the process to see what plans participate.  

The one positive (other than the design) was that the terms and conditions were ridiculously simple!







What Will Really Happen October 1st For Health Reform?

10/1/13…That is the date that the healthcare exchanges will go-live (or at least are supposed to go live).  As of a week ago, the testing hadn’t even begun.  Will they actually get through all the testing and go-live in time?  It will be a huge failure if they don’t.

On the flipside, if they go live but the experience is horrible and pricing is wrong, will that reflect poorly on the exchanges or on the health insurance companies?  I know several of the large health insurance companies who are ready (or as ready as they can be) are worried about that.  

There are other issues to be sure:

  1. Do people even know that the exchanges exist?  (A recent survey said only 27% of young people did.)
  2. If people know, will they come to buy insurance?  Will they understand the exchanges and that they can get a subsidy?
  3. Will exchanges end up with only the sick or will there be a mix of healthy and sick?  (This will eventually be an issue, but plans will have to underwrite for 2015 exchange pricing before they really understand this.)


Is Wellness Really Just About ROI?

Al Lewis and Tom Emerick posted a great article on the HBR blog about the Danger of Wellness Programs.  It reminds me a lot of what my old boss published after she left Healthways, but as the old expression goes – don’t throw the baby out with the bathwater.

I’ve talked about this before in my post on why CVS asking for their employees weight was a good thing, but let me elaborate more.  While the HBR article makes some great points about ROI, the reality is that companies don’t just jump into wellness for the ROI.  It’s about creating a better workforce.  What Al Lewis and his partner ignore are other realities like:

In general, only 12% of people are fully health literate.  Most people are unengaged with their healthcare and overwhelmed with work and life.  That’s why programs like biometrics and health risk assessments are important.  They try to create teaching moments for us to pay attention to our health and realize our risks.

A New Approach To Care: Health Incentives In The Affordable Care Act (Guest Post)

Preventative Care is a key aspect of the Affordable Care Act that stands to benefit millions of Americans, in ways that you might not expect.

The term describes an array of services, programs, and incentives that are funded by the government in order to make people healthier. Contrary to what you might think, however, the funds are not limited to impacting care on the individual level.

Rather, the reforms will include everything from building public health centers to creating bike lanes and walking paths. Not to mention, free immunizations for individuals and families.

It’s important for consumers to understand what these changes could mean for them, in every respect. With this thought in mind, let’s explore the ways in which individuals, families, and communities will be impacted by these new reforms.

Individual and Family Health

Individuals and families will benefit tremendously from a host of preventative services that will be offered free of charge by insurance providers, regardless of pre-existing conditions.

Offered services will include: Breast cancer screenings, wellness checkups, domestic violence screenings, contraception, and breast-feeding supplies. Immunizations, counseling services, and depression screenings will also be made available as a result of the new legislation.

For many Americas, this change will mean first time access to potentially life-saving services that work in turn to promote further wellness among individuals, families, local and regional communities.

Public Health and Prevention

Without funding, reforms are simply laws on the books that don’t have any real-world import.

In 2010, The Prevention and Public Health Fund was created in order to ensure that care actually gets to the people who need it, through the development of programs that mobilize entire communities toward the goal of better health.

The fund’s initial budget has been compromised since 2010, but local governments have already received an estimated $290 million to put towards the development of healthy eating programs that are aimed at some of our nation’s deadliest health issues, such as child obesity and diabetes. Funding has also been put to work through infrastructure development to create sidewalks and bike paths, in an effort to encourage daily exercise.

Although the Prevention and Public Health Fund has met some opposition from congressional republicans, the potential for positive impact is clear.

Smoker’s Penalty: Two Sides Of The Same Coin

The Affordable Care Act takes a bold stance on smoking.

The Smoker’s Penalty, as it’s come to be known, has to do specifically with plans offered in the state health insurance marketplaces, which will open for business this October.

Under the ACA, insurance providers are allowed to charge smokers up to 50% more for their coverage than non-smokers, due to the associated health risks.

However a recent, highly publicized computer error has delayed this possibility. This is due to the fact that the computational system in place cannot differentiate between price inputs for smokers of differing ages. The glitch may take up to a year to fix.

Although this may seem like good news to smokers, no one knows how insurance companies will respond to the penalty issue come October.

Some view the smoker’s penalty as discriminatory, while others see the benefit in a hard-nosed incentive to get people to quit.

The good news is that the ACA will provide access to quitting services and products at no charge to consumers, and you can’t be denied coverage for having been a smoker.

All of these incentives, controversial or otherwise, are clear indicators of a much needed change in government thinking. Healthcare reform is doing more to help Americans avoid potential problems altogether. Let’s hope this is just the beginning.

Michael Cahill is the Editor of the Vista Health Solutions Blog. He writes about the health care system, health insurance industry and the Affordable Care Act. Follow him on Twitter @VistaHealth and @VistaHealthMike 

Presentation – 2nd Annual Bio/Pharma Retail Summit – Discount

I’m excited to be presenting in the Fall with Adam Fein and lots of other great speakers at the 2nd Bio/Pharma Retail Strategy Summit to be held September 18-19 in Philadelphia, PA.  

I get to talk about one of my favorite topics which is how health reform is driving change in the industry and enabling new opportunities for the pharmacy / pharmacist.  

You get to listen to me for 90-minutes so I’m hoping to find some great examples, data, and insights to get you thinking hard about your business and the white space here.  I hope to see some of you there.  If interested, I’m passing on a discount code they offered to me as faculty.


2013 PBMI Presentation On Pharmacy Need To Shift To Value Focus

Today, I’m giving my presentation at the PBMI conference in Las Vegas.  This year, I choose to focus on the idea of shifting from fee-for-service to value-based contracting.  People talk about this relative to ACOs (Accountable Care Organizations) and PCMHs (Patient Centered Medical Homes) from a provider perspective.  There have been several groups such as the Center For Health Value Innovation and others thinking about this for year, but in general, this is mostly a concept.  That being said, I think it’s time for the industry to grab the bull by the horns and force change.

If the PBM industry doesn’t disintermediate itself (to be extreme) then someone will come in and do it for them but per an older post, this ability to adapt is key for the industry.  While the industry may feel “too big to fail”, I’m not sure I agree.  If you listened the to the Walgreens / Boots investor call last week or saw some of things that captive PBMs and other data companies are trying to do, there are lots of bites at the apple.  That being said, I’m not selling my PBM stocks yet.

So, today I’m giving the attached presentation to facilitate this discussion.  I’ve also pre-scheduled some of my tweets to highlight key points (see summary below).


Planned PBMI Tweets

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