Health Systems Advised to Tread Carefully When Considering Provider-led Health Plans 

By Claire Thayer, April 18, 2016

McKinsey & Co released an in-depth paper that explores both growth and evolution of provider-led health plans and offers key questions health systems should think about when evaluating their current plans or considering offering stepping into to provider-led plan market space. Here are some of the highlights gleaned from this paper.

The authors point out that overall, the growth in enrollment of provider led plans has increased 6% since 2010, growing from 12.4 million in enrollment to 15.3 million in 2014. While during this same time period, growth in the number of provider-led health plans was modest, increasing just 3% from 94 plans in 2010 to 106 in 2014. The enrollment growth was most pronounced in the Medicaid, Medicare Advantage and Individual Markets

The authors point to 4 important questions that are critical for health systems to consider when evaluating provider-led health plan (PLHP) offerings:

  • How can consumerism benefit a PLHP
  • When is growth through a PLHP most likely
  • Is an alternative type of administrative infrastructure possible?
  • What can be gained through granular analytics?

For further reading:

Article Summary: The market evolution of provider-led health plans [McKinsey & Company]

Full Article: The market evolution of provider-led health plans [McKinsey & Company]


Ten Things to Know About The Comprehensive Primary Care Plus (CPC+) model

By Clive Riddle, April 15, 2016

1.  CPC+ is a CMS five-year initiative starting in January 2017 to create a national advanced primary care medical home model that aims to strengthen primary care through a regionally-based multi-payer payment reform and care delivery transformation.

2. CPC+ will be implemented in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve.

3. The multi-payer approach involves Medicare partnering with commercial and state health insurance plans to support primary care practices in delivering advanced primary care.

4. Advanced primary care has five key components:

  • Services are accessible, responsive to an individual’s preference, and patients can take advantage of enhanced in-person hours and 24/7 telephone or electronic access;
  • Patients at highest risk receive proactive, relationship-based care management services to improve outcomes;
  • Care is comprehensive and practices can meet the majority of each individual’s physical and mental health care needs, including prevention. Care is also coordinated across the health care system, including specialty care and community services, and patients receive timely follow-up after emergency room or hospital visits:
  • It is patient-centered, recognizing that patients and family members are core members of the care team, and actively engages patients to design care that best meets their needs:
  • Quality and utilization of services are measured, and data is analyzed to identify opportunities for improvements in care and to develop new capabilities.

5. CPC+ lists five patient care objectives to help primary care practices:

  • Support patients with serious or chronic diseases to achieve their health goals;
  • Give patients 24-hour access to care and health information;
  • Deliver preventive care;
  • Engage patients and their families in their own care; and
  • Work together with hospitals and other clinicians, including specialists, to provide better coordinated care

6. CPC+ will include two primary care practice tracks with incrementally advanced care delivery requirements and payment options. Practices in both tracks will receive up-front incentive payments that they will either keep or repay based on their performance on quality and utilization metrics. Practices in both tracks also will receive data on cost and utilization.

7. Track 1 practices will receive a monthly care management fee in addition to the fee-for-service payments under the Medicare Physician Fee Schedule for activities.

8. Track 2 practices will be expected to provide more comprehensive services for patients with complex medical and behavioral health needs. Track 2, practices will also receive a monthly care management fee and, instead of full Medicare fee-for-service payments for Evaluation and Management services, will receive a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments for those services. Track 2 practices’ vendors will sign a Memorandum of Understanding (MOU) with CMS that outlines their commitment to supporting practices’ enhancement of health IT capabilities.

9. CPC+ was developed through the ACA enacted Center for Medicare and Medicaid Innovation, and is an outgrowth of the Comprehensive Primary Care (CPC) initiative, a model tested through the Center for Medicare & Medicaid Innovation that began October 2012 and runs through December 31, 2016

10. CMS will accept payer proposals to partner in CPC+ from April 15 through June 1, 2016. CMS will accept practice applications in the determined regions from July 15 through September 1, 2016. CMS will select regions for CPC+ where there is sufficient interest from multiple payers to support practices’ participation in the initiative.

Here’s where you can find out more:


52% of healthcare IT leaders evaluating cloud-based solutions for population health management

By Claire Thayer, April 12, 2016

A recent HIMSS Media survey of healthcare IT leaders identifies five key challenges in using connected health IT applications to support population health management:

  • Care Coordination – 23.5%
  • Financial investment in IT – 21.4%
  • Data Management – 18.4%
  • Patient Engagement & Adherence – 14.3%
  • Cohort identification and risk stratification – 12.2%

With the growing consumer interest in all things mobile, it’s not a surprise to see that many of these health IT leaders are giving serious considerations to population health platforms that support telehealth systems with back-end integration services.  Notably, 52% are evaluating cloud-based solutions and more than half say they intend to adopt mobile wellness monitoring apps for their population health management needs.


Identity Crisis: The Need for Improved Healthcare Identity Management 

by Clive Riddle, April 8, 2016

This week, Kathy Bardeen from LexisNexis spoke in a HealthcareWebSummit webinar on Mastering Identity Management in Healthcare.  The issue with that inaccurate and missing demographic information and inadequate authentication systems and processes threaten business integrity and success, financial outcomes, and member engagement. On top of that, there is the looming specter and fear of hacking, healthcare identify theft and fraud.

Kathy cited recent medical identity theft breaches with OPM data, UCLA Health and Anthem, along with these concerns:

  • Nearly 40% of consumers would abandon or hesitate using a health organization if it is hacked
  • 50% if consumers agreed they would find another healthcare provider if their medical records were stolen
  • Between 8-14% of medical records have erroneous information tied to an incorrect identity
  • Only about ten percent of health insurers use two-factor authentication and encryption to protect data
  • Individual can spend an average of $13,500 to resolve applicable medical identity fraud cases
  • Insurers spend $2pmpm or more for multiple years of credit monitoring for members affected by data breaches

Kathy tells us healthcare organizations need to handle identities as a journey that starts with Identity Checks, progresses with Identity Management and then Identity Insights. Here’s her definitions:

  • Identity Checks involve facilitating the authentication, verification and resolution of identities engaging with the organization, identifying possible fraud risks, and allowing for point of need identity information searches.
  • Identity Management leverages a systematic approach to maintaining, enhancing and augmenting member identity profiles with current, correct and previously unavailable information.
  • Identity Insights involves understanding individuals and their relationships within and outside of the healthcare ecosystem and gaining insight into socioeconomic factors impacting health outcomes, costs and overall risk.

Kathy shares these best practices in Risk Mitigation in Identity Checks, Identity Management and Identity Insights:

  • Risk Mitigation in Identity Checks should involve: evaluating systems and process to minimize the transmission and storage of PHI/SPII data whenever possible; executing a robust algorithm for unique ID assignment that will maintain consistency and persistence over identity evolution; and deploying a multi-layered approach for identity management that grows with business objectives as well as an ever changing identity landscape.
  • Identity Management should involve: implementing an ongoing maintenance program to ensure integrity of identity records as this data erodes; executing the identity management program with a frequency and focus that matches the business processes and programs leveraging this data; and leveraging an authoritative, reliable data source(s) to augment and update identity information.
  • Identity Insights should drive analytics from identity insights to solve for large complex problems as well as target improvements to existing programs; and maximize the value of the identity management data asset across different areas of the business.

This webinar is now available for free on an on-demand basis for qualified applicants.


The Biosimilar Opportunity

By Clive Riddle, April 1, 2016

Biosimilars hold considerable future opportunity for helping address rapidly rising prescription costs. They also hold considerable opportunity for pharmaceutical companies seeking to offer them, as well as challenges for pharmaceutical holders of brand drugs that they would impact.

PwC listed Biosimilars as one of their top ten health industry issues of 2016. They stated that “Finally entering the US market, biosimilar drugs have the potential to be as disruptive as generic drugs following the Hatch-Waxman Act of 1984. The first US biosimilar - Sandoz’s Zarxio, which prevents infections in cancer patients – received FDA approval in 2015, and entered the market at a 15% discount. At least four biosimilar applications are pending FDA review in 2016, with another 50 in the FDA review process.”

PwC also another challenge in that U.S> consumers don’t know what the heck a Biosimilar is: citing a survey in which only 17% of consumers chose a correct definition of Biosimilar when offered multiple choice answers.

Biosimilars are of course much further along the path in Europe, but in addition to consumer confusion and provider and purchaser lack of familiarity as well, there is of course continued regulatory morass as well as lobbying from pharmaceutical companies trying to protect specific brand drug turf. The NCSL (National Conference of State Legislatures) has a page dedicated to the topic of State Laws and Legislation Related to Biologic Medications and Substitution of BioSimilars.

In addition to monitoring and summarizing this activity, NCSL provides easy to understand background information. They tell us “Biologic medicines are much more complex than traditional chemically synthesized drugs. Biologics are manufactured from living organisms by programming cell lines to produce the desired therapeutic substances and consist of large molecules….Regulating biologics raises new issues for both state and federal policymakers. Because of their complexity, biologic drugs are much more difficult to replicate than the chemically produced generics for other drugs. The cell lines used and modifications in the manufacturing process affect biologic medicines. As a result, truly identical “generic” versions are currently virtually impossible to produce. However, once patents expire for the existing brand-name biologic drugs, “biosimilar” medicines can be produced, which is an occurrence that raises regulatory issues in the states. Currently, there is concern that traditional statutes regulating ‘generic drugs’ may be misapplied to new products that are not identical. This has led to a recent move to amend older state laws to address the medical and chemical characteristics of these ‘biologics,’ as well as any future generic-style ‘follow-on biologics’ or ‘biosimilars.’ “

This week the IMS Institute for Healthcare Informatics released a 36 page report: Delivering on the Potential of Biosimilar Medicines -The Role of Functioning Competitive Markets, telling us that “Greater acceptance of biosimilar medicines in a growing number of therapy areas and an active pipeline of 56 new products in clinical development are expected to deliver total savings of as much as $110 billion to health systems across Europe and the U.S. through 2020.”

IMS offer considerable research into Biosimilar adoption and issues in Europe, and counsels that “As these medicines also become available in the U.S., stakeholder education and incentives will play a vital role in ensuring biosimilars deliver their full potential.” Their report finding include:

  • Considerable variations across the EU in payer policy approaches are limiting the biosimilar opportunity.
  • Biosimilars use in the EU and U.S. may yield total savings of $56-110 billion over the next five years.
  • Patient access to biologic treatments has grown by as much as 100 percent following the availability of biosimilars.
  • Intensifying competition and greater choice are expected as new biosimilars reach the market.
  • Capturing the benefits of biosimilar medicines requires a balance between controlling price and ensuring a sustainable, competitive marketplace.

IMS emphasizes the need for education and incentivization in order for Biosimilars to fulfill their potential.  They tell us that “Payers need to ensure that they are keeping themselves informed. The variation in policies adopted, as well as in biosimilar prices and uptake, across the EU, suggests that some payers do not understand the potential offered by biosimilar medicines. Physicians need to trust that biosimilar medicines offer a safe and efficacious alternative to original biologics…..Patients are expected to accept new technologies, about which they may have only limited information….Payers need to ensure that doctors see a tangible benefit to prescribing biosimilar medicines. Physicians need to understand that prescribing biosimilar products delivers clinical benefits across the market as a whole, and that the cost-savings that result from biosimilar uptake enable more patients to access needed treatment.”