In 2018, health care is in crisis. Here’s what you as an industry leader should know … and what you can do about it.
Health Care Reform
As we head into the second year of the Trump Administration, health care reform is on everyone’s mind. The Affordable Care Act (ACA) is dramatically different than it was this time last year. President Trump campaigned on promises to repeal Obamacare. After Trump’s inauguration, he used executive mandates to begin the ACA’s dismantlement. He expanded the use of so-called association health care plans and short-term health insurance. The same order also directs government agencies to make new rules to allow Americans to sign up for cheaper, less-regulated health insurance. Trump also eliminated the scheduled government subsidies to insurance companies. These subsidies provide lower-income Americans with much needed premium deductibles.
The Tax Cuts and Jobs Act was signed on December 22, 2017. Included in the bill is the provision removing mandatory ACA health care coverage. Starting in 2018, Americans will no longer be fined for not enrolling in an insurance plan. The provision offsets the costs of other tax cuts by reducing the amount the federal government will be forced to spend on subsidies and Medicaid. The Congressional Budget Office expects fewer consumers who qualify for subsidies or are eligible for Medicaid will enroll or seek coverage. (CNN Money)
Policy experts note that repealing the mandate could raise insurance premiums. Healthy consumers are more likely to skip enrollment, leaving only the sick and elderly, and thus driving up the price of premiums. Some insurers may drop out of the marketplace completely rather than be forced to accept a population of consumers so heavily weighted with pre-existing conditions.
The Children’s Health Insurance Program (CHIP) is only funded until March 2018. Approximately 9 million children whose parents earn too much to qualify for Medicaid but not enough to afford private health insurance qualify for CHIP. Regulations requiring employers to provide birth control coverage to employers were also scaled back.
UPDATE: Some states will start running out of money after Jan. 19, according to the Centers for Medicare & Medicaid Services. This could cause states to freeze enrollment and notify parents that the program will soon shut down. The earlier shutdown date is due to variables in state expenditure rates and reporting. Though the Senate Finance Committee reached an agreement to extend the program for five years, there is no plan on how to finance this extension.
UPDATE: On January 22, 2018, President Trump signed Bill HR 195 into law. This gives CHIP a much needed six-year extension of funding.
Complying with government requirements and mandates topped the Managed Care State of the Industry Survey for 2017. As more and more Americans are left without insurance, promoting wellness instead of treating illness is an ever-increasing challenge.
Not only that, but physicians feel increasingly helpless to influence the system. According to a Physicians Foundation 2017 survey, more than two-thirds of physicians believed they had somewhat to very little influence. That feeling of helplessness to control their own environment also contributes to physician burnout.
The Opioid Crisis
Drug overdoses using opioids are the leading cause of death for US adults younger than 50. There’s a lot of talk in Congress and the White House, the Opioid Crisis has been declared a national emergency, but there’s still no quick fix. In reality, there’s still no good plan of attack.
But as you’ve learned, the patient is now a consumer. And if the patient is worried about the opioid crisis, then as their healthcare provider, so are you.
There has been an increase in the number of opioid prescriptions over the past thirty years, though some argue this was a response to a previous period of under-prescribing. The Department of Justice under Attorney General Jeff Sessions created an Opioid Fraud and Abuse Detection Unit to sniff out physicians inappropriately prescribing opioids. But the vast majority of opioid deaths in the United States are due to illicit – not prescription – drug use. 75% of all opioid misuse begins with the non-prescription use of opioids. (Scientific American).
That means limiting opioids is doing more to keep crucial painkilling drugs from suffering patients than out of the hands of addicts. The real risk factors for drug addiction are those that can be addressed in a population health strategy targeted toward childhood trauma, mental illness, and unemployment.
President Trump suggested a “really tough, really big, really great” advertising campaign to convince young people not to do drugs. It’s reminiscent of the 1980s failed “Just Say No” campaign. (CNN) No further funding has been dedicated to the opioid crisis. Health care agencies will be directed to devote more grant money from pre-existing budgets instead.
Net Neutrality and its Impact on Health Care
The Federal Communications Commission voted on Chairman Ajit Pai’s proposal to end net neutrality. It passed (on 3-2 party lines). As early as January 2018, internet service provides, also known as ISPs, will be allowed to speed up or slow down web access according to who can pay.
What is net neutrality?
Net neutrality is the principle that prohibits internet service providers (ISPs) from speeding up, slowing down, or outright blocking any content, application, or website they want. Basically, it’s what you’re used to. In 2015, the Federal Communications Commission adopted Net Neutrality rules to keep the internet free and open.
By deregulating, ISPs can slow down large data files such as videos or simply charge more for access to high-speed internet. ISPs can deny access to websites, apps, and content they don’t approve of. And there’s no guarantee that users of competing ISPs will be able to communicate with each other.
EHR software requires high-speed internet to provide quick and easy access to health records. The majority of EHRs use cloud-based storage, and that storage isn’t free. Without net neutrality, the EHR cost could skyrocket. Telemedicine would also take a huge hit. And what about systems operating on different ISPs? They might not even be able to communicate and pass patient data to one another.
The healthcare industry has repeatedly petitioned the FCC for net neutrality, and the deregulation could be a costly blow to the healthcare industry.
Total Consumer Health
The American consumer reached the healthcare industry – and found it wanting.
As patients become more technologically savvy, they change the way the healthcare industry delivers patient care. Once only found in retail, branding and customer service have become part of the healthcare lexicon. Patients are now consumers. And they expect to be treated that way. If not? They’ll take their business (and your bottom line) to the another practitioner
From first impressions, whether that’s word of mouth or in an online space, health care providers must be careful of their branding. Are you child-friendly? How about the elderly? A safe space for the LGBTQ+ community? Can a patient access a patient portal that’s intuitive and user-friendly? Is telehealth an option?
What is total consumer health?
Basically, a health care provider must provide the patient with more value, a better price, and deliver the optimum patient experience.
Outcome-Based (Value-Based) Patient Care
What is value-based care?
In a nutshell, value-based care rewards health care providers and institutions for better outcomes and lower spending. The goal is to push the focus towards quality instead of quantity. In a fee-for-service or fee-based system, the emphasis falls heavily on tests, procedures, and treatments. Unfortunately, not all of these expenses are supported by the statistical data. A fee-based system leans towards quantity instead of quality.
In value-based care, physicians must collaborate not only with one another but with the entire health care system. From the patient’s financial and social history, family input, clinical data from other sources including other health care insurers, systems, and providers, the entire network of care work towards evaluating then administering patient care. Negotiation is involved, and with such a large system to consider, open communication and the availability of information is crucial. A value-based system requires a different infrastructure and workflow system than a fee-based one. Electronic health records (EHR) collect data geared toward reimbursement rather than the wider range of data needed for effective value-based care.
Getting rid of the redundancies in patient care benefits the entire system. A value-based system inherently promotes operational efficiency, technology use, wellness, addressing social determinants of health, and population health management.
The Engaged Digital Consumer + Health Care
eHealth. Patient apps. Personalized digital information kits. Self-check-in kiosks. A social media page for your small practice.
The digital consumer is all around us. Healthcare IT has been turned on its head at an ever-increasing pace as medical technology tries to keep pace with Silicon Valley. But when your patient is accustomed to thumbing through her phone and flicking open an app, slumping in an uncomfortable lobby chair, waiting to be called, trying to keep her iPhone connected to your patchy Wifi makes for an unhappy patient before she ever sets foot in a patient room.
Telehealth is no longer a pipedream. It’s a reality. And for rural or less mobile patients, telehealth could have a major impact on their overall health.
And virtual reality (VR) isn’t just for science fiction. Hospitals across the European Union are experimenting with VR’s applications. From relaxation to physical therapy, VR proves to be therapeutic for the mind … and body. (The Medical Futurist)
Have you ever seen the analytics dashboard provided by Facebook? The demographic targeting is mindboggling. The ability to target clients based on specific health needs, say those who follow a pain management or fibromyalgia site and fall within your target age/sex window, could allow a study to expand its pool of participants a hundredfold – and at rapid speeds. But such analytics also come with ethical dilemmas. Should providers be able to show their posts to households making over $250,000 and thus increase the chance that bills will be paid? Or is that discrimination against socioeconomic groups with a lesser ability to pay? And if word got out, how would your healthcare practice react to a bad online review? What if a post or image went viral?
Health care providers should have a social media plan in place to deal with these kinds of issues.
Mobile Health Care Technology
What is mobile health technology?
Also known as mHealth, the easy definition of mobile health technology is healthcare IT you can access from a mobile device, meaning smartphone, tablet, etc. The amount of data you can receive is staggering. It includes:
- Clinical information via mobile health apps or mobile-enable EHR
- Secure message collaboration between physicians
- Patient portals
- Real-time patient monitoring
- Patient monitored apps like FitBit
- Secure messages/emails between patient and physician (must be HIPAA compliant)
Sounds terrific, right? Not quite. The biggest challenge is cybersecurity. The saying is, “you’re only as strong as your weakest link,” and in this case, it’s that mobile device. We live in a world where the Internet of Things (IoT) connects almost everything to everything else. And almost all of it is hackable. Add to that our tendency to reuse passwords, spill the answers to our security questions all over social media, and the weakest link in many healthcare systems is mHealth.
Patients have an expectation of access to their own records and information. The duty to safeguard that information falls onto the provider. So how then to tighten the cybersecurity on that weakest link – the patient?
That’s a good question.
Population Health Strategy
What is population health strategy?
Population health strategy hopes to improve the health of a specific group. Large amounts of data are aggregated, analyzed as a single patient record, and actions to improve the overall health are created. Clinical, financial, and operational data from a wide variety of technological sources are used to broaden the data pool. Hopefully, physicians and administrators will identify real-time gaps in patient care that can be addressed.
The basic goal is that taking a long-term, data-driven approach will produce more positive results in addressing the needs of underserved populations. By reaching higher risk patients earlier, providers may be able to decrease expensive services, reduce preventable hospitalizations, and improve the overall quality of life.
Electronic Health Records Interoperability
Patients, physicians, and regulating agencies expect EHRs to be interoperable. When this isn’t the case, frustration ensues.
What is EHR Interoperability?
Different EHRs are unable to communicate, work together, and pass patient records to one another. Different vendors, data protection, and privacy rules keep EHRs from playing nicely together.
Cloud-based EHRs and those that used structured data capture tend to operate together more easily than other systems. (Modern Medicine) Healthcare executives should focus several key components when choosing an EHR. Matching patient records seems to be particularly challenging for many systems. EHRs that apply standardization can even out provider discrepancies. And using an HL7 integration engine is recommended for the easiest integration.
As if one EHR communicating with another EHR was challenging enough, now your EHR has to communicate with retired, or sunsetted, EHRs.
What is sunsetting of an EHR?
Sunsetting is the intentional phasing out of an old EHR system in favor of a new one. The challenge arises when the new system can’t communicate with the old system.
Legacy medical records and their archival access is a growing problem in the healthcare community. Many EHR providers charge exorbitant prices to access legacy medical records. With no other option, providers agree … and pay. That cost is ultimately passed on to the patient. While some gateway applications exist that allow for access to legacy medical records, the retirement of an EHR is still a costly and stressful process.
The Time Demands of EHR
We’ve all been in the role of patient, sitting in an exam room while the clinician spends up to half the visit interacting with the EHR instead of with us, the patient. Not only is it frustrating for the patient but for the physician.
How to overcome the EHR roadblock effect?
In a perfect world, the EHR would be invisible.
While MACRA/MIPS means either facing penalties or having an EHR, there’s no way to go without an EHR unless you’re willing to pay the financial price. For some, that might be the answer. However, you still have to balance your lost time against any penalties.
Some physicians use a scribe to enter information into the EHR. This leaves the physician free to focus on the patient. Other physicians prefer to position their laptop on a raised cart for better eye contact with the patient. If you have enough time, consider prepping your patient’s history before entering the exam room to decrease your dependence on the EHR.
Uncompensated Tasks for Health Care Providers
Up to 20% of physicians’ time is spent performing uncompensated tasks. While impossible to avoid entirely, physicians should delegate anything that doesn’t require a medical license (if possible) to another staff member. If that sounds drastic, consider the financial impact. The Physicians Foundation, a nonprofit foundation that seeks to empower physicians to deliver quality, cost-effective health care, estimates that up to $50,000 are spent per physician each year on uncompensated tasks.
Adding staff members to cover these delegated tasks will increase your overhead, but it will also free up time for physicians to see more patients. If burnout is a problem, consider taking this added time to increase your quality of life instead.
Clinical Data & Analytics: What Does It Mean for Health Care?
Big data is all the rage in the business sector. But does it apply to healthcare? Actually, it’s never mattered more.
What is big data?
Big data is the use of advanced analytic techniques against very large, diverse data sets. These include structured, semi-structured and unstructured data from different sources. Basically, it’s data so big and complex that it overwhelms traditional analytical software.
In healthcare, there’s no central authoritative source of data. Patient information doesn’t pass between providers, much less between health plans. Add in the gaps between systems like interoperable EHRs and it’s almost impossible to find data-driven insights. Why is this? Most healthcare organizations lack the proper technology for this kind of data management and analysis. A comprehensive, secure database that’s HIPAA-compliant is also necessary. But the ability to retrieve massive amounts of data, store it for future use, analyze it, and then make data-driven decisions is imperative for healthcare’s executive leadership.
Cybersecurity and Health Care
2017 was the Year of the Hacker. Russia. North Korea. China. WannaCry. Petya. NotPetya. Ransomware. Wipers. Nuance. Merck. Baptist Hospital. Peyton Manning Children’s Hosptial. The list goes on and on, both of malware, cyber attackers, and victims.
The health care industry finally woke up enough to the very real threat of cyberattack and created a cybersecurity task force.
Yet most health care providers are unaware of the breaches in their systems. As patients require more access to their data, providers access EHRs from more locations, more emails are sent with private health data, those breaches continue to widen. Patient data is worth $1,000s on the dark web’s black market – far more valuable than your credit card number. (Forbes) Credit card numbers can be canceled. Health records are forever. That’s a lifetime supply of material for blackmail and identity theft.
Rising Prescription Drug Costs
By 2018, specialty drugs will account for 50% of all drug spending. Why is this important? Because health care plans have to choose between paying for these specialty drugs – and the innovative cures they promise – versus more cost-effective yet less powerful drugs.
What is a specialty drug?
Specialty drugs usually require special handling, administration, or monitoring. Often, they also need prior approval from your insurance plan. And they’re often what you need to treat complex, chronic disease like cancer, rheumatoid arthritis, and multiple sclerosis.
Nearly half of the new drugs in development are specialty drugs meant to treat conditions that previously had no known treatment. The down side? These specialty drugs can cost into the five or six figure range.
According to a November 2017 poll by the Biosimilars Council (a division of the Association for Accessible Medicines), nearly 9 out of 10 seniors and 8 out of 10 taxpayers believe the government has a responsibility to lower our health care costs. (Biosimilars Council) The poll showed national support for congressional action to lower out-of-pocket costs for patients and reduce federal spending for the Medicare Part D prescription drug benefit that covers most of America’s seniors. Currently, Medicare Part D encourages more expensive brand-name medications over FDA-approved, lower cost biosimilars.
Physician burnout has reached epidemic levels in the United States. Unfortunately, technology use has become a major hurdle and source of stress for many clinicians. A recent Mayo Clinic study reported that only 36% of physicians are happy with their EHR use. Hard to use or poorly functioning technology not only causes anxiety for physicians but it takes them away from what matters most – time spent with patients.
Burnout is both preventable and treatable. And fortunately, burnout awareness is on the rise.
If you’re feeling overly tired or want to leave medicine all together, consider taking our free Physician Burnout Assessment.
The Frustration of Dealing with Insurance Companies and Prior Authorizations
Interference from insurance companies is an ongoing headache for clinicians and patients both. Plus it takes extra time (and that means extra cost) to navigate what can be a complicated and lengthy process.
Best practices for dealing with prior authorizations
Document, document, document. Educated staff members on the importance of documenting the details of symptoms and prior treatments. The more detailed your notes, the less likely a payer is to challenge your decision or ask for more details.
Keep a running list of priory authorization medications. Check the list before prescribing and save yourself, your staff, and the patient the frustration of dealing with prior authorization if it’s not necessary.
Communicate. Stay in the loop about which medications, tests, and procedures are getting pushback.
Work with the payer, not against. Know how each payer prefers to handle prior authorizations. Keep administrative and clerical errors to a minimum. Keep records so you can analyze what’s accepted versus what’s denied.
Share what you know. Consider assigning a staffer to a payer so each request is handled the same way each time. This will keep mistakes to a minimum and increase your chances of an acceptance.
Health Care and Profit Margin
No matter what standard of personal ethics you hold yourself too, philanthropist or realist, Republican or Democrat, the profit margin is the ultimate equalizer in healthcare today. Because if your practice or hospital can’t pay the bills, your doors will close. There will be no more patients. No more prescriptions. No more intellectual property applications or mHealth apps to capitalize upon. The lights will be off, your staff will be putting out resumes, and you’ll be looking for a new place to hang out your shingle.
In the cut-throat world of healthcare today, the profit margin might feel like the only factor that matters. And in reality, everything else on this list factors in some way either to increase or decrease your profit margin. If you can embrace technology that increases staff efficiency, you stand a chance. But if you alienate your patients when you do so, you’re back to square one. It’s a balancing act but instead of a two-sided lever, you’ve got a thousand. Administrative and supply costs. The pros and cons of alternative staffing models. Shifting patients to outpatient when possible. Revenue sources from intellectual property (IP). Outsource or in-house. Cloud-based technology versus a cyber attack.
What do you do? And when you do decide, will Congress change it all again, sending you back to square one?
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