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Where, Oh Where, Will Our Healthcare System Go?

Where, Oh Where, Will Our Healthcare System Go?

With President-elect Donald Trump’s inauguration now about a month away, we can expect a flurry of activity surrounding Obamacare and the potential remake of both the Medicare and Medicaid systems. As we stated in our last blog, we believe a vigorous debate on all of our healthcare entitlements is not a bad thing at all. The alternative is lawmakers burying their heads in the sand as they have these past many decades and having the healthcare system continue down its dysfunctional road – where costs rise and quality remains low.

Whether lawmakers make a decision to strip away the defined benefit and entitlement nature of the exchanges, Medicaid and Medicare is anyone’s guess at this point. There are merits and pitfalls to such reform in each system. But we feel that there are far more important considerations in health reform than the exact framework in which the various benefits are delivered and the programs function. While stripping away entitlements would indeed be transformational in nature, these recommendations below likely will do more to fundamentally shift how the system operates, especially from a quality and efficiency standpoint.

Maintain the emerging public-private partnership nature of our healthcare system

We know it sounds statist, but we see a reasonable centralized role for the federal government overseeing and coordinating smart healthcare policy, with “reasonable” being the key word. Given the threat healthcare costs have on our economic future, a central guide is not a bad thing. With the help of state regulators, consistent health policy across lines of business would emerge to ensure the greatest accountability, quality, and efficiency. The current fragmented system we operate in creates haves and have nots and massive cost-shifts between lines of business.

At the same time, we believe leveraging private sector innovation is key. The failure of the Medicare and Medicaid traditional fee-for-service systems are well known. While more needs to be done, the recent successes of private Medicare and Medicaid plans, driven by smart public policy, is a case in point why private delivery and not public systems should be endorsed.

Emphasize accountability, quality and efficiency

Many plans take issue with the recent accountability and quality dictates coming from the Centers for Medicare and Medicaid Services (CMS); however, it is hard to argue with the results. CMS’ compliance regime, while sometimes over-reaching, does ensure plans adopt a consistent, equitable and timely approach to authorizing services and considering appeals. It helps establish strong faith on the part of both providers and members in the health plan system. Over time, the transparency of such a system will also change member and provider behavior and create efficiencies.

Private Medicare also has been witness to a meteoric rise in quality outcomes. It is only a start and more needs to be done to refocus the system on prevention, quality and care management. Ultimately, a shift from simply scrutinizing individual services to treating members holistically must occur in full. This promotes prevention and management of disease states and conditions, thereby reducing utilization of urgent and emergent high-cost services. Then, we should see the absolute cost of healthcare and inflation reduced.

CMS has had it right over the past few years. Policy-makers and lawmakers should not short circuit these achievements.

Emphasize personal responsibility

While not everyone in America has the same economic wherewithal, it seems to us strategies must be built in each line of business to ensure all Americans have a stake in their health care. It is the old “skin-in-the-game” argument. Human nature dictates that, without it, players are neither honest nor active.

Benefit design is one good way to ensure this. Cost-sharing and copays can incentivize members and patients to think about what, when and how they access the health system. And where cost sharing and copays are not effective due to the limited means of individuals, incentives, penalties and additional services can be an adequate substitute to change behavior.

Pay attention to the social determinants of health care and work to break down these barriers

We don’t expect health plans to be social workers, but they probably should have them on staff. While we don’t want our health plan to be Mom or Dad, the literature is clear there are a myriad of socio-economic and other such social determinants that create barriers to good health outcomes. It seems to us health plans likely know more – or should – about these issues as they seek to ensure the right health care is delivered. Health literacy and access to transportation, food, and housing all play important roles in health outcomes.

So there is a legitimate role for health plans to help break down these barriers by referring individuals in need to key community and governmental programs and agencies. In this case, an education and coordination role is needed.

Use the latest technology to reach out to members, motivate them and improve behavior and outcomes

Even the most health literate among us need reminders and motivation to take stock in our healthcare. We need those reminders that we have missed an important prevention test or appointment or have become lax with our medication adherence. The bigger the economic and social barriers, the more reminders and interventions are needed.

Technology today gives health plans the unprecedented opportunity to engage members via various innovative means and media. Behavioral analysis and predicting the best intervention techniques has become a cottage industry in all areas and has its place in healthcare too. Tailoring interventions to known individual preferences or even predicted ones can add demonstrably to the personal responsibility focus above and drive outcomes. More important, technological interventions seem to become cheaper by the day.

Don’t forget providers

Providers need as much attention as members. Providers are facing a sea of change in how they are reimbursed and engage with health plans. Just a few years ago, it was all about filing a claim and disputing underpayments. Today, providers will need education and coaching to truly transform the system from one centered on transactions to outcomes. Building collaborative models between health plans and providers – with free exchange of real-time data – is essential to move to an outcome-based system. Incentive-based reimbursement models and use of the same engagement and technology strategies will be key.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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