US Healthcare Industry Blog Series Part 2: Emerging Trends& Models

In order to reign in healthcare costs and bring in greater number uninsured citizen under the healthcare fold, the Government has initiated reform measures like the Affordable Care Act, Health Information Exchange, and State level Health Insurance Exchanges. On high level all the reforms point towards 4 Key principals.

Value based incentives

Greater Engagement of Consumers in Decision making

Promotion of Wellness and Preventive Care

Transparency and Seamless Information exchange to facilitate lesser administrative overheads.

These 4 principals will not only drive the structural changes in the healthcare industry but bring in innovations in processes and technology increase the accessibility of right care at affordable costs.

Value Based Incentives

The Patient Protection and Affordable Care Act made law by the Obama administration, often referred to as Obama Care, hinges on the central theme of introducing value based incentives in the industry structure in the form mandates, subsidies and tax credits.

The PPACA provides guidelines for Accountable Care Organizations as voluntary groups of Hospitals, Physicians and other care providers to come together to accept the responsibility of healthcare delivery and wellness of a set of Medicare beneficiaries. The ACOs will provided co-ordinated care to the beneficiaries and be accountable of the overall healthcare expenses and wellness of the beneficiaries.

The ACOs are incentivized on the basis of overall savings achieved as compared to CMS (Center for Medicaid and Medicare Services) set benchmarks which will be reviewed periodically.

In order to provide co-ordinated care and reign in the overall healthcare costs, the ACOs will be required to incorporate processes and technologies to allow seamless exchange of information.

This will primarily mean utilizing patient clinical and claims data for predictive modeling of care, and decision support for physicians.

Great Engagement of Consumers in Decision Making

The creation of State Level Health Insurance Exchanges will bring in more transparency with respect to the pricing and benefits of health plans. In order to grow in this market driven scenario the private insurance players will have to engage Consumers actively to the basis of differentiated value driven services which augment the basic plan coverage. This will encompass more target marketing campaigns based on the patient data analytics, self-help and wellness management portals for consumers to help ACOs bring down the overall cost of healthcare delivery.

On the healthcare provider side as well, personalized services like pr-emptive scheduling of appointments, pill and procedure reminders will be have to be incorporated to move the care delivery to prevention paradigms as described in the next point.

Promotion of Wellness and Preventive Care

The Affordable Care Act has created a Prevention and Public Health Fund for investment in promotion of wellness, disease management and public health. Several incentives have also been planned for Payers, Providers and Employers who provide wellness management services to members.

In a cascading effect of incentives, the employers are incentivized by the payers for greater engagement of employees in the wellness management programs and employees are incentivized by the employers to join wellness management programs.

Transparency and Seamless Information exchange to facilitate lesser administrative overheads

Lack of transparency and seamless information exchange have been some of the biggest factors for the fragmented state of the US healthcare system , driving up administrative costs and leading to inefficient decision making.

Several key regulations like HIPAA 5010, ICD 10 Transition, and HI-TECH Act of 2009 intend to strengthen the underlying infrastructure for transparency and informed decision making. With common standards for information exchange and increasing obligation to reduce administrative expenses, payers and providers will be expected to bring in advanced data handling technologies, process and predictive analytics to bringing in efficiency in operations.

The impact of health insurance exchanges will be seen mainly on how health insurance players cope with the open market structure to determine innovative ways to engage and attract customer loyalty.

This blog post gave an overview of the trends which are shaping imminent threats and evolving opportunities in the healthcare industry.

Date Published: January 18, 2013





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