Cybersecurity threats and rising costs are some of the greatest challenges facing payers and accountable care organizations, according to executives.
The eight leaders featured in this article, part of an ongoing series, are speaking at upcoming Becker's Payer Issues Roundtable events. The fall roundtable will take place Nov. 4-6 at the Swissotel in Chicago. The spring roundtable will take place April 28-29 at the Hyatt Regency in Chicago.
If you have any questions about attending the event in November, contact Heidi Simon at hsimon@beckershealthcare.com.
Note: Responses have been lightly edited for length and clarity.
Question: What is the most dangerous trend for payers and ACOs right now?
Abdou Bah. Senior Vice President of Medical Management and Chief Health Equity Officer of EmblemHealth (New York City): At EmblemHealth, we see the most dangerous trends for payers and consumers involving a lag in preventive care coming out of the pandemic. During the pandemic, regular checkups and chronic disease management declined. It has not fully recovered. Consequently, we are not detecting disease early enough and crucial intervention is being postponed. We are addressing this problem by partnering with primary care physicians to move our efforts more upstream. We are focusing on the social determinants of health that, if not addressed, prevent timely care. We are working with physicians to introduce coaching support alongside their important efforts. Postponement of care and a de-emphasis on primary care has significant deleterious consequences for patients and the health system itself.
Tenbit Emiru, MD, PhD. Executive Vice President and Chief Medical Officer of UCare (Minneapolis): The cost of drugs. The cost of drugs has been directly related to increases in premiums. Advancements in pharmaceuticals are changing many lives. There are now gene therapies for serious conditions that didn't have many treatment options. It's not just GLP-1s. There are several life-altering medications such as vaccines, biologics and gene therapies that are more expensive than we are accustomed to. It is anticipated that we will continue to see new gene therapies and biologics come to market. While this is good news for society in general, there is an increasing concern that the cost of these therapies may prohibit many people from accessing them. In addition, the cost of drugs is continually adding to the cost of healthcare in this country in a way that may not be sustainable in the long run.
Rick Goddard. Vice President, Head of Commercialization and Strategy at Lumeris: One of the longest-running and most concerning trends for payers and providers is friction between them around contracting, reimbursement and payment denials. With increasing frequency, tough negotiations and disputes over care appropriateness erode trust and undermine the potential for successful collaboration.
A similar worrisome trend is over data sharing. Some providers are reluctant to share detailed patient data with payers, fearing it will be used to justify denials of coverage or lower reimbursement rates. Conversely, payers argue that access to comprehensive data is essential for managing population health and ensuring cost-effective care. A perceived or real lack of transparency fuels suspicion between the groups, damaging trust.
Unaddressed - and without a common commitment to transparency and the assumption of positive intent – these issues could irreparably undermine the cooperative spirit required to make ACOs and value-based care models work effectively for everyone. Aligned goals and incentives between payers and providers are essential to ensure all parties are focused on delivering high-quality, patient-centered care that all beneficiaries deserve.
Harlon Pickett. President of Eagle Care Health Solutions (Austin, Texas): One of the most dangerous trends currently facing payers and [accountable care organizations]s is the escalating threat of cybersecurity breaches and data vulnerabilities. Cyberattacks on healthcare entities have been increasing in both frequency and complexity. Ransomware attacks, where malicious actors encrypt critical data and demand payment for its release, have targeted numerous healthcare organizations, with over 700 reported in the last 18 months. While cybersecurity is the most pressing threat, several other trends also pose significant risks to payers and ACOs, including regulatory and policy uncertainty, transitioning from fee-for-service to value-based models, and rising healthcare costs such as the escalating costs for treatments, medications and administrative expenses.
Alessa Quane. Chief Insurance Officer of Oscar Health (New York City): Healthcare costs continue to rise at unsustainable rates and are straining both employers and employees. Small and mid-sized businesses, in particular, are disproportionately impacted, often struggling to provide health insurance at reasonable costs. We need a fundamental shift in how health insurance is financed and offered in America to address this issue. Individual coverage health reimbursement arrangements are a promising part of the solution. Oscar sees a sustainable path forward through the individual market and believes ICHRA can play a significant role in driving the change needed in the health benefits experience.
Jen Truscott. Senior Vice President of Aetna Clinical Solutions (Hartford, Conn.): According to the National Council on Aging, 80% of adults aged 65 and older have two or more chronic conditions. Many older adult patients seek care for health complications long after they have arisen. Care management can improve outcomes for health plan members when these programs are proactive and personalized, yet coordinated care is not utilized to its full extent across the U.S. To combat this, health plans should increase their emphasis on holistic care, effective care management programs and the power of value-based care. Our data show that four in 10 Aetna members changed their behavior — including reducing avoidable emergency room visits, improving medication adherence and choosing more cost-effective sites of care — due to our care management programs proactive outreach.
Shelley Turk. Divisional Senior Vice President of Illinois Health Care Delivery at Health Care Service Corp. (Chicago): There is a widespread reach and cost of cyberattacks that are occurring across the healthcare marketplace which can have an impact on patients, employer groups, providers, payers and ACOs. Change Healthcare, and more recently the CrowdStrike outage, as well as a number of attacks on hospitals, have illustrated the systemic risk these situations can create. Large-scale disruptions that occur in a complex ecosystem can affect operations, reimbursement, benefits, and provision of care at a myriad of entities; even those with indirect pieces of the healthcare puzzle. Viewing preparedness through the lens of our interconnected industry will help organizations better position themselves to operate through disruption.
Troy Williams. Vice President of Hospital Partnerships at First Choice Health Network (Seattle): One of the most dangerous trends right now might be ignoring the commercial market segment for value-based payment methodology. ACOs have done a good job of preparing the processes and ongoing workflow for largely Medicare-focused populations, but have been less sensitive and interested in evolving those models in the commercial space. Aligning organizations to adapt, operate competitively and encourage continuous improvement for the commercial sector has been more challenging. Still, many systems and practices have found that value-based care is inevitable and potentially more efficient and rewarding within employer populations as well.