Industry Restructuring
ECONOMIC AND STRATEGIC CONTEXT FOR CHANGE
Defined contribution is replacing defined benefits as a cost management strategy. I address how this development dramatically affects consumer choice, utilization patterns, and business strategies. I point out how acute care services for employees stands in stark contrast to the chronic care requirements of Medicare beneficiaries—and why providers may have to choose which market to serve based on economics.
TEN MAJOR CHANGES DRIVING MARKET CHANGE
In order to understand how market forces are shaping business models and finances, I describe how 10 factors are driving change: demographic tsunami, cost escalation, government intervention, employer competitiveness, technology and medical informatics, market-defined value, health plan reimbursement, hospital hegemony and medical group disintermediation, consumerism and choice, and social media.
IS MANAGED CARE DEAD?
Financial risk is being transferred from employers and insurers to individuals through high deductibles and catastrophic coverage options. Patients now assume the role of the bank. I explain the profound implications of how this new model disintermediates managed care networks and upends traditional benefits design strategies. I also challenge the audience to develop post-managed care business models to remain competitive.
Healthcare Reform Implications
UNINTENTIONAL CONSEQUENCES OF THE AFFORDABLE CARE ACT
Access to insurance coverage was extended to millions of new beneficiaries, but little was done to ensure access to providers. I explain how high deductible options offered by state and federal exchanges may limit access because many patients will be unable to meet their deductibles. This will result in denied care, increased emergency department use, and pervasive beneficiary stratification, a practice that is little understood by providers or employers.
IMPACT OF REFORM MANDATES ON PROVIDER PAYMENTS
With the advent of much higher deductible levels, few employees will each their out-of-pocket thresholds. In addition, most workers do not have enough liquid assets to cover the cost of unexpected healthcare expenses. This means that many patients will not have sufficient funds to pay the deductibles necessary for care. I suggest practical options for providers to deal with non-paying patients and aging receivables, and suggest ways to amortize consumer debt.
LEGAL AND OPERATIONAL CHALLENGES OF IMPLEMENTING BUNDLED PAYMENT
Episodes are currently focused on single specialty services and diagnostic procedures. More complex procedure bundling will include documenting and pricing all relevant codes for professional, institutional and technical services—a daunting task for most providers. I explain how to overcome the operational and legal barriers to episode-based pricing through patient-initiated bundles and analytic resources offered by third-party vendors.
Leading Change
QUESTIONING CONVENTIONAL WISDOM AND CHALLENGING INDUSTRY ASSUMPTIONS
While uncertainty over the Affordable Care Act has dominated healthcare decision-making, deeper structural reform driven by the economy is already a reality. I clarify why two factors—increased financial risk of beneficiaries, and disintermediation of medical groups and hospital services—carry as much weight going forward as ACA. I stress that accurate forecasting, based on understanding how the market is changing, is essential for delivery systems success.
REFRAMING STRATEGIC THINKING WITH STRATEGIC INSIGHT
Crosstown rivals are no longer as big a threat to hospitals as asymmetric competition coming from new market segments. I point out that new market entrants bypass traditional revenue streams and that hospitals must reframe their strategic thinking accordingly. Defensive consolidation is not a sustainable strategy. I emphasize why structural shifts in the industry demand a ruthless focus on lower costs and customer service as the key to competition.
POST-REFORM BUSINESS MODELS
As the healthcare industry undergoes restructuring, business models and strategic decisions must be calibrated to keep pace. Leaders can see restructuring as either detrimental to their vested interests and resist change, or they can capitalize on new opportunities brought about by new market realities. I give examples of business models, distribution strategies, and pricing approaches used by successful consumer services companies as a guide.
CHANGING ROLE AND CLOUT OF CUSTOMERS
Consumers now have financial incentives and technology tools to drive change and reshape payment mechanisms. Boomers are driving utilization patterns and millennials are redefining how and where to access care. I tell the audience that hospitals and physicians must do two things: become more consumer-centric rather than remaining provider-centric, and operationalize value in terms of customer expectations rather than provider norms and priorities.
Healthcare Financing Wild Card
THE INEVITABILITY OF CASH PRICING
As major market segments shift from wholesale to retail, many providers are opting for discounted cash payments. Cash pricing at the time of service enables consumers to negotiate directly with providers and arrive at market-based prices that are often lower than Medicare rates. I point out why providers value cash pricing as a strategic revenue stream that bypasses managed care overhead costs of 40% and eliminates accounts receivables problems.
