Change is happening on multiple fronts and at a faster pace than ever before. Stakeholders that ignore or minimize it will do so at their peril. To be clear, addressing organizational change or purpose internally, as well as external positioning today, is the more likely path to success.
The need for a strong pricing strategy is a foregone conclusion. Hospitals and health systems have a window of opportunity now to craft a thoughtful approach to pricing that avoids common pitfalls and ultimately creates a competitive advantage in the market.
The American College of Emergency Physicians pushes a payment model that would have ED doctors tracking patients for 30 days after discharge. CMS may adopt it for Medicare. Meanwhile, emergency medical groups interested in participating will need to learn the ropes of care coordination.
The Emergency Triage, Treat, and Transport, or ET3, pilot would empower EMS crews to treat patients at the scene of a call (sometimes with the help of telehealth) or take a patient to an alternative site like an urgent care facility or a doctor's office.
Insurers and some drug manufacturers are turning to the Institute for Clinical and Economic Review (ICER) as the arbiter of drug prices, especially as prices soar and value is sought. But questions persist about the cost-effectiveness calculations of the Boston not-for-profit and its dependence on QALYs.
Several factors are at work. Group health insurance got more expensive when the ACA mandated essential health benefits and no-cost preventive care. Some small companies dropped coverage altogether, but now they are coming back into the fold as the employment market has tightened up, say brokers. Starting fresh, they have a chance to consider self-insurance.
When patients and their medical records are out of whack, it causes harm and wastes money. It gets worse when organizations try to share patient records. Even if two facilities share the same EHR system, match rates may be as low as 50%. Privacy concerns makes this problem difficult to fix.
A newspaper series and a state audit put a spotlight on PBM practices in Ohio. PBMs may not like it, but it seems that much more may come to light about what used to be an obscure corner of the business of American health care.
The law is supposed to keep physicians from unduly profiting from referrals. But CMS Administrator Seema Verma thinks that it "may prohibit some relationships that are designed to enhance care coordination, improve quality, and reduce waste," and thereby become an obstacle to ACOs and value-based care.
The two CAR-T therapies approved for certain blood cancers have price tags of $475,000 and $373,000-and those prices don't include other costs for services that are integral to the treatments, such as harvesting a patient's T cells. Moreover, patients typically have a lengthy hospital stay after treatment.
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