Cover: 10 drivers of change in 2018

Monday, January 01, 2018 12:00 PM

by Kate Alfano, CMS Communications Coordinator

Physicians are constantly aware that the practice of medicine is ever-changing. This becomes even more apparent in the 10 drivers of change in 2018 that the nonpartisan Colorado Health Institute identified from a variety of sources including literature review, informant interviews and popular press. Each driver has and will continue to impact the health care delivery market and has strategic implications for Colorado physicians and the Colorado Medical Society. President and CEO Michele Lueck and Paul Presken from CHI presented these drivers to the CMS board of directors during a strategic focus weekend in November 2017 to focus the board to determine a short-term and mid-term course of action.

CMS encourages members to explore the drivers that follow, consider the questions posed and engage with your medical society to position Colorado physicians at the forefront of health care transformation.

1. Public insurance is continuing to grow.

The newest CHI data on health coverage in Colorado shows that employer-sponsored health insurance has continually decreased over the past eight years – from 57.7 percent in 2009 to 49.4 percent in 2017 – while the number of Coloradans covered by Medicare, Medicaid or CHP+ has increased – from 20.1 percent combined in 2009 to 35.4 percent in 2017. The uninsured rate has decreased by more than half, from 13.5 percent in 2009 to 6.5 percent in 2017.

Driving Medicaid growth has been the expansion under the Affordable Care Act that opened the program in January 2014 to include more adults and former foster children up to age 26. In 2012-2013, 683,000 Coloradans were enrolled in Medicaid. The Colorado Department of Health Care Policy and Financing estimates that 1.4 million will be enrolled in Medicaid in 2017-2018. Enrollment in Medicare Advantage plans nationwide has steadily increased since 2014.

The increase of lives covered by public insurance raises questions: How do these changes impact administrative burden? Is Colorado accelerating toward capitation? How can practices anticipate and leverage bonuses, clinical measures and other financial incentives or financial penalties?

2. Payment reform is advancing.

Public insurance is leading the way in payment reform. On the federal level, there is bipartisan support for reform. The Medicare and CHIP Reauthorization Act (MACRA) will impact most physician reimbursement for Medicare starting in 2019.

Colorado Medicaid will implement the second phase of its Accountable Care Collaborative (ACC), replacing Regional Care Collaborative Organizations (RCCOs) and Behavioral Health Organizations (BHOs) with Regional Accountable Entities (RAEs) in 2018. RAEs will be responsible for connecting Medicaid members with both primary care and behavioral health care. Primary care providers will be reimbursed for some behavioral health visits to encourage care integration. RAEs will be paid $15.50 per member per month and will contract with primary care providers for at least $2 per member per month. Of the $15.50, HCPF will withhold $4 per member per month for the RAE to earn back if performance goals are met.

Additional incentive opportunities in ACC Phase Two will bring more financial risk to providers, a higher behavioral health capitation rate if RAEs hit performance goals and a pay-for-performance pool to encourage higher standards.

Questions raised by advancing payment reform: How do members prepare for downside risk? What are the sticks and carrots? How can members keep up with requirements for metrics? What support can CMS provide? How can CMS train members to prepare for changes?

3. Consumers are demanding increased technology.

Technology is already part of the patient experience, with a Deloitte survey showing many consumers using the internet, apps or a device to refill a prescription; measure fitness and health improvement goals; pay a medical bill online; monitor health issues; track costs of care; receive health alerts or reminders; or measure, record or transmit data about a medication. Deloitte also shows consumers are more likely to use telemedicine for post-surgical care, chronic disease monitoring, care while traveling and minor injuries.

Questions arising from a push for more technology: Will adopting new technologies lead to higher patient trust? How will members ensure patient safety and confidentiality? How can members incorporate new technologies into a larger patient engagement strategy?

4. New models of care are emerging.

Physicians are witnessing a changing health care delivery landscape on the national, regional and local levels. Retail clinics have expanded dramatically, from 1,320 in 2010 to 3,000 in 2016, opening in grocery stores, pharmacies and big-box stores. These clinics have even developed their own advocacy group, the Convenient Care Association, which indicates they are not going away soon. This is affecting the health care workforce. Forbes reported in June 2017 that nurse practitioners are more in demand than most physicians as states allow them direct access to patients.

Questions for physicians regarding new models of care: How might practices align or partner with new care settings? What are the implications of new care settings for traditional offices? Hours? Convenience? With workforce patterns shifting, what steps can practices take to ensure quality and effectiveness?

5. Physician well-being is crucial.

Perform a quick online search on physician burnout and the number of studies, reports and articles is astounding. Medscape reports that physicians identify the leading causes of physician burnout as too many bureaucratic tasks, spending too many hours at work, feeling like “just a cog in a wheel,” the increasing computerization of practice, earning a lower income than desired, difficult patients, and insurance issues.

Stanford Medicine has demonstrated a reciprocal model where a culture of wellness, efficiency of practice and personal resilience combine for professional fulfillment.

Marti Schulte, president of Community Physician Consulting, suggests physician wellness can be improved by increased physician leadership in the workplace, cultivating community among physicians, and surveying members to understand the extent of burnout in Colorado and its reasons.

Questions to answer regarding wellness: What approaches would make the biggest impact for members? Are there specific programs or services that would prevent physician burnout? How might CMS “cultivate community?”

6. Integration of behavioral and physical health is progressing.

Colorado has a number of programs supporting the move to integrate behavioral and physical health; addressing behavioral health has been shown to be key to overall health. The State Innovation Model (SIM) grant has supported 250 practices in two cohorts with a third cohort of 150 practices to be named in 2018. The Comprehensive Primary Care Initiative supports 71 practices, Comprehensive Primary Care Plus supports 203 practices, the Colorado Health Foundation Primary Care Practices number 20, and RAEs encompass 550 practices.

Questions from this movement to integrate behavioral and physical health: What kind of training and education would be valued for integration? How can CMS better equip physicians to integrate practices? What kind of programs would be valuable?

7. Population health and public health are converging.

The literature increasingly demonstrates that social and economic factors affect health outcomes and population outcomes over the course of a person’s life. Yet, health spending often dwarfs social spending. In the city and county of Denver, $4.5 billion is spent on medical care while just $41 million is spent on public health and prevention, according to the Colorado Health Institute. Population outcomes can be improved with a greater understanding of how to address social determinants of health like economic opportunity and physical environment; health factors such as health behaviors and conditions; mental health; access and quality care.

Questions arising from the convergence of population health and public health: How should CMS position physicians to participate in this issue? Should CMS advocate for “non-health” issues in population health? Where is the opportunity for physicians, especially thinking about this in combination with payment reform?

8. Consumers are facing higher spending.

The average individual deductible has increased dramatically, from around $500 in 2002 to upwards of $1,800 in 2016, according to the Medical Expenditure Panel Survey. A Kaiser Family Foundation report similarly found that the percentage of covered workers enrolled in a high-deductible health plan increased from 4 percent in 2006 to 28 percent in 2017. Consumers increasingly skip care because it costs too much. CHI found that in 2017, one of five Coloradans did not get needed care due to cost.

This leads to three questions for physicians: If consumers are more involved in paying for care, how will physician practices adapt? Is there specialized training or programs that could benefit practices? What are potential roles for CMS around pricing transparency?

9. Consumers are demanding new (and expensive) drugs.

A fast-rising percentage of pharmacy industry revenue comes from specialty drugs. At the same time, more hospital systems are adding specialty pharmacies. One in five hospital systems have internal specialty pharmacy capabilities and nearly two in five are considering adding them. Trends in prescription drug spending show 59 percent is due to drug composition changes or price increases, 23 percent is due to overall economic inflation, 10 percent is due to an increase in prescriptions per person and 8 percent is due to population growth.

Questions arising from this driver: What role do physicians have in offering alternatives or counter-arguments to consumer demand? How can CMS help prepare practices for the complex reimbursement associated with specialty pharmaceuticals? How do practices get involved?

10. Physicians can bring a strong voice to D.C. and Denver.

Physicians who choose to be involved politically can bring their real-world experience and illustrate real-world consequences to policymakers. The current administration seeks to encourage competition in health care, while gutting portions of the Affordable Care Act and relaxing federal oversight of the health care industry.

Questions arising from this driver: Where should CMS show up in these discussions? Is this a priority area for your membership? How can you best relay the specific interests of your membership to policymakers?