What's on the Horizon for Healthcare Changes in 2018?

Flexibility, innovation, and data—especially to deliver patient-specific care—are just a few buzzwords marking impending change in the 2018 healthcare landscape.

Experts from Avalere talked about their main predictions of what to watch for this coming year, mainly in the areas of experimentation with Medicare and Medicaid, other new approaches to value-based payment, and increasing pressure for greater drug competition. Their analysis was presented in a webinar and in a report issued Thursday.

For example, expanding use of real-world data to deliver high-value care is just one of the continued shifts observers can expect to see.

“More widespread availability of real-world data will enable new entities to leverage analytics and insight to benefit patients and their providers,” the report stated.

One Data Example

As one example, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) Thursday announced a collaboration with Quartet, a technology start-up seeking to marry mental health care with primary care.

Quartet receives and analyzes Horizon claims data, and when the analysis reveals potential patterns suggesting an unfulfilled need in behavioral health for adult patients, they contact the patient’s primary care doctor, who decides whether to ask Quartet to conduct an assessment of the patient, according to Thomas Vincz, a Horizon spokesman.

Patterns might include frequent emergency room trips, nonadherence to prescription medications, gaps in care, or patterns that may suggest a substance use disorder, Vincz said. If the assessment discovers the patient would benefit from mental health care, Quartet connects the patient to local behavioral health services providers. The primary care doctor also gets tools to better manage patients’ care, such as live consults with psychiatrists.

Substance use disorder (SUD) will be one of the patterns used to identify candidates for the assessment, Vincz said. “Ideally, the Quartet system will help us better identify patients with SUD risks early—before their conditions become acute,” wrote Vincz in an email to The American Journal of Managed Care^®.

Patients could also contact Quartet on their own.

“The beauty of the approach is ease of use—Quartet does outreaches to providers for patients, makes appointments for them and connects back to the patients’ PCPs. These are steps usually left to patients to handle on their own, often when they need help the most,” he said.

In addition, real-world data is bringing together plans and manufacturers to focus on improving outcomes and lowering costs in targeted disease areas.

Avalere cited a 2017 example, when Amgen and Humana announced a partnership to include a range of serious conditions. Avalere said additional partnerships are likely in 2018.

The company said the impact of using real-world data can be seen in different ways among health plans, manufacturers and providers.

• Health plans—develop high-performing provider networks; map members’ utilization patterns to develop care management programs; manage risk-based programs; support value-based contracts
• Manufacturers—support product label expansions; refine clinical development programs; support innovative contracting arrangements; target approaches to addressing unmet needs using Medicare data.
• Providers—manage the cost and quality of care of their patient population, especially as they take on more risk themselves.

Better use of data will also be essential in value-based contracts and helping providers with alternate payment models.

Other predictions

With public programs such as Medicare and Medicaid, expect to see Medicare Advantage (MA) continue to grow, especially as tailored benefits for specific populations in Special Needs Plans deliver better outcomes for patients. Last year, for example, an Avalere analysis found that patients with diabetes were hospitalized less when enrolled in such plans.

CMS has proposed expanding these programs, which would give health plans operating in the MA market room to innovate and experiment.

However, there may be a renewed focus on entitlement spending overall. While “conventional wisdom” says most politicians would not touch Medicare during the 2018 midterm cycle, we are not in conventional political times, noted Elizabeth Carpenter, senior vice president for policy at Avalere.

Moreover, if there is anything that the 2017 debate on curtailing the Affordable Care Act showed, Medicaid is a popular program, she noted. Efforts by Congress to impose cost caps failed, but states are moving ahead with waivers that allow them to make their own changes, such as increasing beneficiary premiums and cost sharing, requiring individuals to participate in job search programs, limiting the duration of coverage, and reducing benefits.

In pharmaceuticals, the discussion around affordability has shifted to patients, with efforts focused on supply-chain transparency and rebate pass-throughs, both of which have an impact on the out-of-pocket cost borne by the consumer. Premiums could increase for patients as pharmacy benefit managers face new pressure to be more transparent in their arrangements, as a result of 2 things: 1) efforts to implement rebate pass-through arrangements in Medicare Part D; and 2) redirected savings to consumers who use high-cost specialty medicines.

In the battered individual insurance market, different proposals to help stabilize rising premiums could include reinsurance, higher subsidies, and changes to rating rules. But getting a bipartisan legislative agreement will be difficult.