It’s traditional this time of year to take stock of where we’ve been and to look ahead to where we are going. A lot of consultants and organizations have already dusted off their crystal balls and opined about the healthcare trends that will be important in 2013. Most everyone can rattle off a bunch of them: meaningful use; accountable care organizations (ACO); state health insurance exchanges; electronic health record (EHR) implementation; the transition to ICD-10; and the Medicaid expansion resulting from the Affordable Care Act (ACA). To be sure, these are worthy trends to pay attention to.
But there are a number of other trends that will come to the fore—if not become equally important—as 2013 rolls on. So here is our list of the top ten under-the-radar trends in healthcare for 2013.
Rise in specialty pharmacy. As we’ve mentioned in previous issues of HIT Perspectives, specialty pharmacy services are rapidly on the rise due to a number of factors, including the upswings in chronic illness and approvals of new specialty medications. According to a health plan executive, nearly half of all prescription drug sales will be for specialty medications by 2016. Plan sponsors will need to better understand the appropriate use of specialty pharmaceuticals as well as develop effective tools to manage their use, such as ePA. Watch for health plans and ACOs to acquire specialty pharmacies as a way to control costs, reduce inappropriate utilization and better manage patient care. This will require increased specialty pharmacy automation.
In addition, adding specialty pharmacies will help plans diversify their portfolios and create synergies with their pharmacy benefit managers (PBM) to enhance the bottom line. Let’s face it—health plans can no longer keep their stockholders happy by just selling and managing insurance policies.
Standards: ePrior authorization leading the way. The industry has been hard at work to create more and better standards that will enhance interoperability and data exchange. Watch for the release sometime later this year of the new electronic prior authorization (ePA) standard from the National Council for Prescription Drug Programs. States in particular have been waiting for this standard’s release so they can develop legislation requiring its use or beef up the mandates already on the books. Payers are just beginning to think about ePA. Some are even seeing the strategic potential of using ePA in other contexts, such as a replacement for formulary.
While that may appear extreme, formulary does not pack the same punch as patents on branded small molecule drugs expire and generic dispensing rates continue to advance toward saturation. Pharmacy benefit managers will be looking to deploy new tools such as ePA to further contain costs and ensure the efficacy of treatment.
Spotlight on medication reconciliation. What with regulatory requirements for medication reconciliation and new Medicare payment penalties for high readmission rates, hospitals are focusing on medication reconciliation and adherence to keep patients from ping-ponging to and from their facilities. And this is paying off. An example is Hennepin County Medical Center in Minnesota. After a year as an ACO, its pharmacy medication management program has helped cut admissions by 42 percent and emergency room visits by 37 percent, which adds up to savings totaling $24 million, Drug Topics reported. This means that more and more organizations will be leveraging pharmacy power to improve outcomes and reduce costs. Watch for partnerships between hospitals and pharmacies. As an example, about a dozen hospitals are partnering with Walgreens, which will oversee medication delivery while patients are still in the hospital.
Called WellTransitions, the program includes pharmacists’ review of medications and prescription therapy planning. They also participate in follow up care with primary care providers, counseling patients on medication regimen, and increasing patients' connection with the extended care team immediately after discharge—all of which could boost adherence.
Privacy and security. The federal government is really getting serious about privacy and the security of health information. The Office for Civil Rights (OCR) just issued a four-part rule that updates federal privacy and security protections for health information established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and two other laws. It is another indication about the seriousness of the government’s intentions and its losing patience with non- or half-hearted compliance by stepping up enforcement and fines. About half of privacy and security breaches are attributable to insider negligence, such as the loss of a laptop. Covered entities—which now include business associates (BA)—need to pay attention to the new rule, or face government fines as breaches occur and are disclosed.
Sadly, hardly a day goes by without stories in the media about healthcare data breaches. Among other things, covered entities must update their BA agreements and HIPAA risk analyses to comply with the new OCR requirements. Mobile health policies are a definite ingredient that must be folded in.
Data mining. Yes, data mining is a negatively charged term, and, yes, many prefer other, more positive terms. Whatever you call it, it will be increasingly important in 2013. More predictive modeling will be used to detect fraud and abuse and identify patients who are at risk for preventable hospitalizations. Data analytics will be key to accounting for quality, gaps in care, and patient outcomes as well as addressing patient needs sooner—the keys to reimbursements for ACOs and other payment arrangements by public and private payers. Look also for more data analytics in clinical trials, where it can help identify patients who are eligible to participate as well as better help researchers aggregate and analyze findings across large-scale, complex populations.
This will help keep costs down and produce a more accurate, better quality study.
Development and use of quality measures. Two quality-related trends will be front-and-center in 2013: development of better quality measures and wider-spread use of them as a tool for payers. As an example on the development side, the Centers for Medicare and Medicaid Services (CMS) recently issued a request for information to assess hospital readiness for Inpatient Quality Data Reporting beginning with calendar year 2014 discharges. Goals include reducing the burden associated with hospital collection and submission of patient-level data on clinical quality measures (CQM) and exploring ways that hospitals might be able to align quality measurement and reporting among quality reporting programs.
Quality reporting and penalties non-reporting will also be on the minds of payers and providers. According to recent surveys, physician pay is becoming increasingly linked to performance measures, with an estimated 20 percent or more of providers’ pay being dependent on meeting quality metrics. Then there is CMS’ Physician Quality Reporting System (PQRS), which has paid incentives based on reported quality measures. Now the penalty phase is about to kick in. To avoid the 2015 payment adjustment, an eligible professional must satisfactorily report PQRS quality measure data during the 2013 reporting period (January 1, 2013 – December 21, 2013).
Training. It’s not rocket science to know that purchasers of technology must spend some time learning how to use it successfully—and that goes double for advanced features. And technology is disruptive in the early stages, so there’s a learning curve to be overcome. This means that various groups focused on physician practices—such as regulators and plans—must adjust their approaches according to the type of electronic health record (EHR) in place, the length of time it has been in place and how well the providers use their system. Practices in the early stages of EHR use are far less likely to use advanced features that improve patient care. Training, consulting and time improve practices’ use of EHRs. Mature practices and recently adopting practices must be addressed differently based on their capabilities; capacity is needed to successfully communicate and influence practices. It's worth the effort because there are tremendous opportunities to increase the quality of care and improve practice efficiency—all of which translate into cost savings all around.
We also need to keep in mind that training needs are broader than health information technology, and that providers and members in ACOs and patient centered medical homes in particular will need a lot of education in order to effectively transition to this new way of doing business. Look for continued innovation by the Regional Extension Centers in helping practices make the most of their EHRs. Vendors and others will be stepping up to fill the knowledge void and enhance skill sets.
Population health. Population health is the orphan stepchild of meaningful use. Yes, we’re supposed to be doing or figuring out how to do it better. Unfortunately, it seems to have fallen to the bottom of the heap except for the folks in public health and at the Centers for Disease Control and Prevention (CDC). The federal government is likely to view 2013 as the year to get more serious about it. We expect to see new federal requirements to make health information technology vendors, payers and providers connect the dots and figure out how exchange a variety of disease- and population-specific information—both sooner and later. Medicare ACOs and patient centered medical homes create a foundation for improving population health, but other partnerships will arise and use this base, thus stimulating growth of population health management.
Demographics. Healthcare business plans and strategies will need to take a harder look at demographics. Our nation is getting more diverse, but that diversity is getting more complex. According to the 2010 Census, about two-thirds of our population is non-Latino whites, and the largest minority group is Latino, followed by African-Americans. That has plenty of implications for health care beyond birth rates and prenatal care. For example, specific population groups have specific genetic predispositions to certain disease that must be diagnosed and treated. Community profiles are changing due to minority birth rates, internal migration and the aging of baby boomers. This means that insurers and providers must get a better fix on who they are really serving. This will allow them to make adjustments to provide better quality and lower cost care, and more efficient customer services.
Cultural competencies are even more important and directly relate to the patient engagement requirements of meaningful use.
Exchange of mental health data. Sadly, recent events have brought the importance of mental health to the top of the public’s consciousness. Heavy-duty conversations about reforming the nation’s mental health system are likely to begin soon at the federal and state levels. Part of the conversations will address the assessment of mental health status and how that information can be shared while protecting patients’ rights and privacy. The need to coordinate such data and share it is evidenced by depression, for example.
Because depression is a frequent comorbid condition with chronic disease, effective treatment requires attention to both conditions. With so much focus on chronic diseases elsewhere, it behooves all of us to consider it holistically and address the mental health components at the same time. Medication reconciliation will be critically important as patients transition to and from inpatient and outpatient settings. Medication adherence is crucial for mental health patients, and we will see creativity in the use of mobile health applications and interactive personal health records to help keep compliance on track. Vendors will need to work on the technical issues, such as the perpetual conundrum of opt in/opt out, while policy makers will need to revisit and realign data sharing requirements.
Organizations, most running on leaner and leaner margins, will need to monitor the healthcare landscape and translate what intelligence they gather into action and strategic planning.
Edited by Braden Becker