The 'Edge Report Blog

Three take-aways from AHIP's National Conferences on Medicare, Medicaid & Duals 2018

Healthcare executives from all walks of Medicare and Medicaid assembled in Washington D.C. from October 15th through the 18th to discuss and learn from each other a variety of challenges facing government programs. The audience heard from members of various administrations both past and current, and there were three things that all parties could agree on: coordinated care is better than uncoordinated care; we need data that can be analyzed and scored for budget purposes and pay-for-value is better than fee-for-service. Below are three recurring themes from the conference.

More Stakeholder Are Opening Their Eyes to Social Determinants of Health

The industry has been talking about social determinants of health (SDoH) for over twenty years, but payers are just now starting to incorporate it into their member’s health predictions. Blue Cross and Blue Shield of North Carolina’s CEO, Patrick Conway, sees the promise of SDoH and spoke about their organization’s $50 million investment in the initiative. Conway cited investments in issues such as the opioid epidemic in North Carolina, early childhood development and preventing child abuse, and providing social and legal aid to those in need. A number of healthcare leaders from the private sector and government officials spoke about the need to dig our heels in, as a country, to the non-clinical areas that affect health. We all know that malnutrition and lack of transportation can affect a person’s health, and if neglected, will lead to more costly care. But only recently are payers and providers working together with community resources to fill these gaps in non-clinical care. Of the various factors contributing to risk of death, individual behavior accounts for 40%, and social and economic factors account for 20%. To compare nature versus nurture, genetics accounts for 30%, and health care accounts for 10%[i]. Although payers are now well entrenched in SDoH, the industry still has a long way to go in terms of partnerships between payers, providers, and community resources.

Payers and Providers Still Not on the Same Page

A tale as old as time. We know aligned incentives between payers and providers improve care, but some are still hesitant to come to the table and agree to downside financial risk contacts. The fee-for-service system puts these two parties at odds. Providers depend on high volume, while payers aspire to reduce utilization for costly care. Contrary to the fee-for-service world where payers and providers were adversaries, and providers would look to payers “for permission”, in the value-based world payers and providers must tear down those walls and develop trust. Mike Leavitt of Leavitt Partners and former Secretary of Health and Human Services and former Governor of Utah, said from the main stage, “Providers are only tiptoeing into taking on risk. At the same time payers are reluctant to give up and share risk. There should be a balance between compassion and economic reality. Focus on primary care as the central pillar of an integrated health system in the US.” Only when payers and providers truly come together to create win-win contracts can we make progress in healthcare. But payers and providers need additional stakeholders to assist with their collaboration. Government/regulators, employers/purchasers and members must also have their voices heard. If payers, providers, and their stakeholders can create value-based downside financial risk contracts focusing on improving primary care, the output will be the achievement of downstream savings.

Data Data Everywhere, But How Should We Leverage It?

Panelists at the conference discussed the mountains of data available, with more still being requested. Data can’t be the answer in and of itself, but data can help with SDoH and improved payer/provider relationships. The latest burning need is data and analysis for identifying how social determinants of health can impact high utilizing members. Electronic health record vendors are being asked to collect this data because both payers and providers are requesting it. Bringing data systems together and allowing for better information exchange can help to enable the trust necessary in payer and provider relationships. Better data alignment will help the industry look at more quality measures, cost measures, and provide much needed transparency across payers, providers, pharma, medical devices, etc. in order to manage patient populations.



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