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Am Health Drug Benefits. 2015 Feb; 8(1): fifteen–20.

Key Strategic Trends that Impact Healthcare Decision-Making and Stakeholder Roles in the New Marketplace

John Santilli

Partner, Access Market Intelligence, Greenville, SC

F. Randy Vogenberg

Partner, Admission Marketplace Intelligence, Greenville, SC, Adjunct Professor of Pharmacy Administration, Presbyterian College School of Pharmacy, Clinton, SC, and Adjunct Teacher, Outcomes and Health Policy, University of Illinois at Chicago College of Pharmacy

Afterward the passage of the Affordable Care Human action (ACA) in 2010, market place changes beyond those already in play began to emerge. Traditional roles, responsibilities, and authority of diverse healthcare stakeholders could now be tested or altered every bit a outcome of some sections of the ACA. One result is that healthcare providers could at present share in the savings, have risk, and form relationships that were previously barred or were nebulously forbidden.

Amid some of the frequently mentioned trends have been answerable care organizations (ACOs), the formation of large hospital wellness systems, and the continuation of private insurance coverage past self-funded employers. Yet, the marketplace had undergone many subtle changes that began before the ACA, which only accelerated after its passage. In fact, one trend is that modify has been occurring at a rapid rate throughout the various healthcare stakeholders.

Tracking the emerging trends and tracing innovation patterns in the postal service-ACA marketplace in 2014 has led to the identification of several high-level strategic trends that are or will be increasingly pregnant. The trends that will increasingly touch on multiple healthcare stakeholders over the side by side few years (through 2018) include:

1. Patients becoming more informed consumers

2. Growth of structured quality measures

3. Acquirement-driving consolidation

4. New and alternative provider payment models

5. Specialty drug utilize driving the price of care

6. Data technology innovations driving interstakeholder communications.

The following discussion details some insights into each of these key market trends that affect multiple healthcare stakeholders and will continue to affect decision-making and human relationship dynamics.

Patients equally Consumers Making More Informed Healthcare Choices

The sometime healthcare model of treating acute illnesses is evolving into a model with increasing focus on the patient, disease prevention, and the ongoing direction of chronic diseases. Today'south healthcare market allows consumers to take charge of their healthcare in a new way. Readily accessible information and information allow patients to have open dialogues with their doctors most diagnosis and handling options. Price estimators increasingly help consumers understand the intersection of cost and quality in assessing their care options. Market exchanges for health insurance let people choose from a large variety of insurance coverage plans and options.

A movement toward personalized wellness handling is besides developing through the advancement of genetic, behavioral, and digital tools that are designed to monitor and manage personal wellness.

Health insurance products and do good structures that increase consumerism are helping to manage do good costs. With the increased fiscal responsibility, consumers are reevaluating how and when to spend on healthcare services. The 2014 Employee Benefit Research Institute/Greenwald & Associates Consumer Engagement in Health Intendance Survey found that 26 million individuals with private insurance were enrolled in a consumer-directed health plan (CDHP), a wellness plan associated with a wellness savings business relationship (HSA) or health reimbursement organisation (HRA), or an HSA-eligible wellness plan.1

This study institute show that adults in a CDHP and those in a high-deductible health plan were more likely to showroom cost-conscious behaviors than adults in a traditional plan. Specifically, CDHP members were more than likely to say that they had checked whether the plan would encompass care, had asked for a generic drug instead of a brand-name drug, had talked to their doctors about prescription options and costs, had checked the price of a service earlier getting care, had asked a doctor to recommend less plush prescriptions, had talked to their doctors about other treatment options and costs, had developed a budget to manage healthcare expenses, and had used an online cost-tracking tool provided past the health plan.

Changes in the healthcare market going forward are requiring patients to spend more of their own coin on their medications. They are no longer uninvolved players in the selection of treatment and the use of drugs or health services. The pharmaceutical manufacture is discovering that information technology is of import to empathize the behavior of its consumers if information technology wants to meet sales expectations. Drug manufacturers can no longer await to have commercial success by but proving that their drugs meet the established measures of rubber and efficacy with traditional clinical customers (ie, providers). Manufacturers must now understand consumer behaviors if they want to run across the increasing demands of patient expectations.

One expanse in particular that already has become more than expensive for consumers is specialty medications, which treat circuitous conditions. Information technology is anticipated that 2014 prescription abandonment rates will continue to ascension through 2015, forth with the growth of center-class wage earners who are facing high-deductible plans. Similarly, health systems will proceed to struggle with balancing decreasing insurance and/or direct patient-related revenues against the growing toll of diagnostics, drugs, and imaging.

Growth of Quality Measures Increases, Becoming More Structured

Reported past many sources since 2010, the United States spends more on healthcare than any other industrialized country; nevertheless, the U.s.a. healthcare organisation is non better, and its quality is inconsistent. One reason for this is that the healthcare organisation is primarily fee for service (FFS), in which providers receive payment for each service rendered, leading to incentives to provide more, not better, services.

The federal authorities implemented the National Quality Strategy in March 2011 to increase the quality of healthcare and to decrease its toll. Quality measures are increasingly being used to determine how much providers will be paid. Mounting evidence shows that leadership date positively impacts healthcare quality.

Several organizations develop and evaluate quality measures, and an even larger number of public- and private-sector organizations use different measures for evaluating and reporting on the functioning of providers. Public measure out developers include the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality; nonprofit private developers include The Articulation Commission and the National Committee for Quality Assurance. These organizations use a transparent approach to give the public an opportunity to review and comment on their draft measures, to decline to use proprietary measures, and to make their measure-scoring mechanisms transparent.

Private sector–focused organizations, such every bit the Leapfrog Group and the National Business Coalition on Health, focus on commercial program sponsor needs to measure successful plan performance, including quality. Like their public-sector colleagues, these groups operate transparently at the local, regional, and national levels to give real-world information on provider or health plan performance to sponsors and members. These efforts are gaining momentum going into 2015, and have had successes in the market place to drive modify without publicizing or publishing like public sector agencies.

Many health professional societies also develop measures, such as the American Heart Association, the American College of Cardiology, the Society of Thoracic Surgeons, and the American Higher of Surgeons.2 These societies typically publish and promote their measures along with guidelines through membership and manufacture supporters. Although at that place accept been successes, failures and lack of significant change have remained problems going back to the use of several preventive measures (eg, the flu vaccine, aspirin, and cardioprotective agents), even in the hospital setting. Information technology is more likely that with shared savings and ACOs in the market place, more attending volition exist placed on compliance with proved clinical solutions or treatment guidelines because of the negative economic implications of not post-obit guidelines.

Overall, there is an increasing focus on single measures that are useful across care settings and are more aligned with the unabridged patient course of illness. Simplifying the large number of similar but different quality measures to more successfully implement change for ameliorate clinical and economical outcomes has become a focus going into 2015. The employ of quality measures is expanding and increasing the demand for new, innovative care-commitment measures that tin deliver desired programme performance past plan sponsors and by patients.

Revenue Pressure Driving Healthcare Stakeholder Consolidation

A fundamental shift in healthcare economic risk is taking place, driven by an crumbling population and the increasing incidence of behaviorally induced chronic conditions. Health systems, which include people, institutions, and resources that deliver healthcare services to meet the wellness needs of target populations, are evolving with the market and delivery innovations to meet the challenge of managing healthcare gamble through a growing emphasis on primary care, integrated care models, and pay-for-value reimbursement.

As operating margins continue to narrow, revenue constraints are condign a pressing result for many healthcare organizations. Partially in response, wellness systems are increasing in scale by engaging in horizontal integration through hospital mergers and acquisitions. Scale could drive more efficiency, could amend the spreading of financial take a chance across the arrangement, and could reduce operating costs across the enterprise.3

As wellness systems consolidate and demand bigger price increases, many insurers are under force per unit area to not increase premiums. A central style for insurers to keep some of the commutation plans affordable is to exclude more expensive doctors and hospitals from the network, and then many consumers will have fewer choices when information technology comes to selecting their doctor or hospital. These narrow networks have become the electric current response to expensive healthcare, along with forming ACOs or collaborations on sharing risk.

Insurers are worried because larger systems have more than ascendancy and control higher payments, and they are edifice alliances of their own. As an instance, Memorial Hermann Physician Network and Blue Cross Blue Shield of Texas are developing an ACO for 100,000 patients. Memorial Hermann Health System is hedging its bets, considering it also has an ACO relationship with Aetna and a medical dwelling model with Humana. This is happening in other states, besides as with a number of insurers beyond the land.

The good news is that these narrower networks will help keep premiums lower, just the unfortunate side effect may be unintended out-of-network bills for patients. Of plans on the exchange, lxx% have narrow or ultranarrow networks, with more than xxx% of the hospitals in the U.s. metro areas being out of network.iv This will create an increasing number of access problems for consumers, which is an unintended side effect of the ACA.

Hospitals and health systems continue to acquire physicians. They have the ability to immediately escalate physician charges to the higher hospital rate, which will probable trigger a rise in wellness programme spending in the next financial year. Hospitals and health systems are making these purchases to gain local marketplace share and to develop monopolies.five Although some of these payment dynamics will shift once again belatedly in 2015 and 2016, the "besides large to fail" scenario may evidence a valuable lever to utilize with politicians, because healthcare withal remains a local issue.

Employers have been increasingly self-insuring, taking on the claims run a risk that insurers previously held. Even small employers with as few as 50 to 100 employees are switching to this model in the hopes that they tin defray costs and manage their employees' healthcare spending more effectively on their own. The Kaiser Family unit Foundation and Wellness Research & Educational Trust's Employer Health Benefits 2013 Almanac Survey and Access Market Intelligence analysis of commercial trends shows that at that place were 89.1 million fully insured commercial health plan members in 2008, which decreased to 68.8 million members in 2013. At the aforementioned fourth dimension, the number of self-funded commercial health plans increased to almost 60% of plans ( Figure ).6

Self-Funded Commercial Wellness Plans

Source: Admission Market Intelligence. Data on file; 2014.

New and Culling Provider Payment Models

New provider payment models are emerging as increased cost pressures are driving payment models away from FFS approaches to those that ameliorate align incentives for cost control and high-quality delivery of patient care.

In the next two to 5 years, the shift from FFS to value-based reimbursement will exist fifty-fifty more dramatic. According to a 2013 Wolters Kluwer Wellness Survey, 9 of 10 physicians cited shifting reimbursement models and the fiscal management of practices every bit their top challenges.7

Contest among providers and increasing pressure from public and commercial payers to lower costs and to amend care are driving them away from long-standing book-based healthcare models and toward value-based care models. These models seek to more fully align payment and objective measures of clinical quality.

The concept of pay for performance (P4P) emerged as a more popular tactic for aligning provider payment with value. Nether the typical P4P model, fiscal incentives or disincentives are tied to measured performance; they may also involve performance thresholds, improvement thresholds, or relative performance cutoffs.

The arranged payment or episode-of-care model provides a single negotiated payment for all services for a specified process or condition, such as pregnancy and birth, knee and hip replacement surgery, and certain cardiac procedures.

As a primary care–driven initiative, the medical home focuses on building a team of professionals, such as physicians, registered nurse case managers, medical administration, and in some cases, pharmacists, that is responsible for coordinating the care of patients across the healthcare continuum.

Shared-savings arrangements represent a potentially higher level of advantage for providers. Although per-member per-month payments and FFS charge per unit increases mostly comprehend only the added infrastructure and staff resource, shared savings tin be an enticing incentive because providers who offer patient-centered medical homes are often challenged to maintain their previous productivity levels.

Oftentimes combined with FFS, P4P, bundled payments, global payments, or capitation, shared-savings programs reward providers who reduce their total healthcare spending on patients below an expected level ready by the payer. The provider is and so entitled to a share of the savings.

Shared-adventure models could be described as the "adjacent level" of risk system that will be seen in the marketplace, under which providers receive operation-based incentives to share cost-savings combined with disincentives to share the excess costs of healthcare delivery. Await 2015–2017 to exist a menses of continued risk experimentation, especially in private-sector commercial insurance arrangements.

Although these new models have the potential to encourage care coordination, ameliorate quality, and control costs, there are many challenges in implementing them. Many of the new models are being implemented by adjusting the FFS payment rather than replacing information technology, and their potential to exist truly transformative may be express. The success of new payment models will depend in part on identifying and incorporating lessons learned by early on adopters.viii

Specialty Drug Use Is Driving the Toll of Intendance Trend

Innovations in biologics and so-chosen specialty drugs are beginning to enter the market at a more rapid pace equally the enquiry pipeline continues to grow. Only approximately 4% of patients utilize specialty drugs, but those drugs account for 25% of the total United states of america drug spending.9

The current trends in increased utilization and spending for specialty drugs are expected to continue, placing burdens on all healthcare stakeholders. In detail, insurers or other third-party payers and manufacturers volition be challenged to develop novel approaches to formulary design and pricing practices that ensure patient admission. Diagnostics, drugs, and devices continue to drive the overall care spending. In the short term, in the midst of uncertainty regarding the biosimilars market and the rapid innovation in personalized medicine beyond 2015, plans and chemist's benefit managers will continue to focus on unit toll-savings. The longer-term impact of the current trends is at present being recognized by commercial and self-funded plan sponsors, along with how best to manage the economic risk over time. This outcome alone could change the structure of insurance product offerings and consumer coverage past 2017.

At the same fourth dimension, these trends are affecting pharmacy practice. Specialty chemist's shop is transforming from a drug distribution model to an integrated system that coordinates many aspects of patient care, enabling wellness plans to manage populations across all benefits and distribution channels. In parallel, the emergence of personalized medicine is revolutionizing the treatment paradigm for a growing number of illness states. As a result, at that place is a demand for a sophisticated agreement of treatment plans and pathways, a need that can be filled by specialty pharmacy programs. This also changes relationships across stakeholders as roles shift, blend, or modify from traditional practices in the next few years.

With the increasing availability of tools and mobile applications, new avenues for patient engagement and new healthcare commitment roles are emerging or are chop-chop changing. The location of intendance is shifting from the hospital to the home, and the focus on improving patient wellness and well-being is increasingly condign a community-broad endeavor. Applied science and calculating trends are quickly embraced by younger consumers, equally well as by new-age health providers who assist older populations in making decisions about their healthcare options. The improved access to data, including price, has been identified as a "game changer" that will affect all care provider roles through the end of this decade.

Considering infused drug therapies can be administered in a hospital, physician's office, infusion center, or fifty-fifty in the patient'southward home, costs related to where the drug is administered can vary significantly. For example, the costs for a standard dose of a treatment for rheumatoid arthritis tin can vary from $3259 for the drug and $148 for administration when infused at the patient's home to $5393 for the drug and $425 for administration when infused every bit an outpatient procedure at a hospital. In fact, the hospital setting is typically the least cost-effective site of treat infusions.

According to a recent CVS report, infusions are increasingly beingness done in a hospital setting, where the costs for the drug and its administration can be the highest of all potential sites of intendance.10 As previously mentioned, this is unlikely to keep in the long-term, and the market will drive other behaviors past providers or systems through altered revenue dynamics. Nosotros have already seen this phenomenon with diagnosis-related groups, ambulatory visit groups, and Surgical Care Comeback Project payments to hospitals, to name a few.

Newer oral and self-injected drugs will also be irresolute the costs that are associated with the site of care.

Information Applied science Innovations Drive Interstakeholder Communications

Innovations in calculating and big data services are changing the manner wellness data is recorded and delivered between patients and providers. Electronic health records (EHRs) and electronic medical records (EMRs), clinical documentation tools, and telemedicine devices are changing the way that providers collect and consume wellness information regarding their patients.

United states physicians and consumers are increasingly ready to embrace a dramatic expansion of the "high-tech" personal medical kit. Vesture engineering, smartphone-linked devices, and mobile applications will get increasingly valuable in the delivery of care. A proliferation of approved and portable medical devices in patients' homes and on their phones makes diagnosis and handling more convenient, redoubling the demand for potent information security systems.eleven

Electronic activity monitors (as well known as trackers or wearables) are apace gaining popularity with consumers for tracking physical activity, heart rate, slumber patterns, calorie consumption, and more. Companies such equally Nike, Fitbit, Jawbone, and Garmin currently offer a range of wearables, with varying features and toll points. The Apple Sentry, which is expected to launch in 2015, will include the HealthKit software, which collects data from the user's health and fitness applications for centralized access to health data. It is estimated that betwixt ten% and 15% of consumers in the U.s. own wearables, with 61% of those devices being activity trackers.12

Outset-up companies that offering applications for iPhones or Android devices are proliferating in healthcare. Providing a new solution or a new approach to managing a disease (eg, diabetes or asthma), and integrating general health with the early direction of a illness or status (eg, heart disease, loftier cholesterol) are primed areas for growth in the side by side few years. This is a result of the consumer adoption of the technologies, besides as investment in information engineering applications for healthcare past angel investors or venture capital groups.

Privacy, despite HIPAA/HITEC violation concerns, volition lose ground to convenience in 2015, as patients prefer digital tools and services that get together and analyze wellness information. Although numerous positive applications of these electronic action monitors be, in that location is always the possibility for unintended adverse consequences or ethical dilemmas. The potential for the sharing of global positioning system location data and personal health information produces clear privacy concerns. Surveillance of the collected data past healthcare providers may also lead to situations where intervention is deemed ethically necessary. Articulate protocols volition be necessary to guide provider behavior in such cases and to reduce the risks associated with potential privacy breaches.thirteen

The application of data and analytics to patient care provides novel opportunities for improving care effectiveness and efficiency. Withal, the full potential for data-driven insights to revolutionize care is hampered past the current data input and output limitations of medical record systems, the lack of a robust business organisation model for interoperable information exchange beyond organizations, and broader organizational barriers that require coordinated solutions across stakeholders. Addressing those barriers and alternative acquirement for a sustainable solution has become an increased focus of attention for many investors and public health advocates alike. This trend will likely intensify during the side by side couple of years to be in place when EMR and EHR software selections are finalized.

The Medicare and Medicaid Electronic Health Care Record Incentive Programs provide incentive payments to eligible professionals, eligible hospitals, and critical access hospitals as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology.

In 2013, 59% of hospitals have adopted at least a basic EHR organisation. This represents an increment of 34% from 2012 to 2013 and a 5-fold increase since 2008. In 2013, 93% of hospitals possessed certified EHR engineering science, increasing by 29% since 2011.14

Information technology is an area within healthcare that clearly crosses many disciplines while offering some of the greatest return on investment for healthcare commitment solution implementation. Main information officers and their chief medical officers in systems and plans are very focused on finalizing the implementation of EMRs, at the aforementioned time that employer plan sponsors are seeking access to that information in real time. Patients are now jockeying for a seat at the tabular array, considering in that location is a light at the end of the information technology tunnel in this decade.

Going forward, new technologies will more than apace empower patients and providers to raise practices for managing and coordinating healthcare. The effective widespread employ of new technology tools may crave increased data transparency, patient education, and the coordination of tools beyond the growing range of technology options.

Conclusion

Alter and the more than rapid, broad-based effect of change have impacted all healthcare stakeholders since 2010 and the passage of healthcare reform in the United States. Although many early changes in the healthcare marketplace accept been widely published, trends that are tracing locally early or are however emerging nationally demand to be identified to better set for success in the healthcare market. High-level trends identified here will impact healthcare roles and controlling. These trends accept the ability to continue the market place transformation and to impact relationships among multiple stakeholders.

Personal or business consequences related to these trends will be important for all stakeholders to remain aware of and to gear up for their impact. Individual stakeholders will have to innovate or conform to these trends, and understand their impact on clinical intendance decision-making.

The clinical care decisions that are increasingly shared among the various stakeholders will take to balance the economic and the clinical consequences among stakeholders. Already occurring in oncology care, this new reality cannot exist avoided, and change is hard. Being enlightened of tracing early on, as well as of emerging trends, can aid each healthcare stakeholder to exist better prepared and can drive innovation that could alter an adverse motion of a trend.

Biographies

Author Disclosure Argument

Mr Santilli and Dr Vogenberg reported no conflicts of interest.

Contributor Information

John Santilli, Partner, Access Marketplace Intelligence, Greenville, SC.

F. Randy Vogenberg, Partner, Admission Market Intelligence, Greenville, SC, Adjunct Professor of Pharmacy Administration, Presbyterian College School of Pharmacy, Clinton, SC, and Adjunct Instructor, Outcomes and Health Policy, University of Illinois at Chicago College of Pharmacy.

References

1. Fronstin P, Elmlinger A. Findings from the 2014 EBRI/Greenwald & Associates Consumer Engagement in Health Intendance Survey. Employee Benefit Research Found; December 2014; Issue Brief 407. www.ebri.org/pdf/briefspdf/EBRI_IB_407_Dec14.CEHCS.pdf. Accessed January 29, 2015. [Google Scholar]

half dozen. Access Marketplace Intelligence. Data on file. 2014.

13. Lyons EJ, Lewis ZH, Mayrsohn BG, Rowland JL. Behavior change techniques implemented in electronic lifestyle activity monitors: a systematic content analysis. J Med Internet Res. 2014; sixteen:e192. [PMC free commodity] [PubMed] [Google Scholar]

14. Office of the National Coordinator for Health It. Adoption of electronic health tape systems among U.S. non-federal acute care hospitals: 2008–2013. Data brief. No.16; May 2014. world wide web.healthit.gov/sites/default/files/oncdatabrief16.pdf. Accessed January 29, 2015.

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Articles from American Health & Drug Benefits are provided here courtesy of Appoint Healthcare Communications, LLC

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415172/

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