Johns Hopkins Health Plans serves more than 470,000 members across managed care and commercial health plans.
Becker's sat down with President and CEO James Holland to discuss how the Hanover, Md.-based organization is driving growth in 2024 and delivering a balanced strategy with prior authorization requirements.
You can listen to the full podcast with Mr. Holland here.
Question: How are you thinking about growth and development at Johns Hopkins Health Plans moving forward?
James Holland: We have four health plans and a health solutions ventures segment. We serve Medicaid, Medicare Advantage, TRICARE/military, and commercial members. Our health services venture arm is where we commercialize great ideas from Johns Hopkins and bring them to employers and government, including Johns Hopkins ACG system, the world's leading population health analytics software.
At our core, we're focused on growing where we have a unique and competitive advantage in the market and can bring real value to the members we serve. Based on the deep, world-leading expertise from Johns Hopkins Medicine, we bring industry-leading expertise to our members, including the most in need, frail and disadvantaged people in our society. Navigating healthcare is hard, and even more so if you're facing other challenges at work and home — everyone deserves to have affordable, effectively-coordinated and member-centric healthcare.
For us, that means a specific focus on government programs. We are extraordinarily effective at coordinating care for Medicaid, Medicare Advantage and military members.
Headwinds
We are concerned about a few headwinds. Rising healthcare costs and an aging population, along with increased demand for services are great financial pressures. These aren't new and healthcare costs have been aggressively rising for decades, but we're approaching a level of unsustainability in terms of total cost in healthcare. Managed care organizations like us are increasingly being asked to reduce the cost trend and make healthcare more affordable, as we should be. But the means in which MCOs promote and insure evidenced-based care is increasingly subject to scrutiny.
A prominent example is prior authorization, which has sort of become a dirty term as of late. One example is with lower back pain, which is a relatively common condition, especially as adults age. For patients with low-risk lower back pain, about 30% are exposed to unnecessary imaging early in their treatment, which really offers no improvement in health outcomes. There's also clearly a cost to this unnecessary exposure, from thousands of dollars for an MRI to tens of thousands for a CT scan. Society overall bears those costs, and it could also expose patients to unnecessary high doses of radiation, which can have health implications in the future — not to mention lost productivity and other harms from prescription opioids or more invasive treatments like spinal fusion. Evidence suggests that alternatives such as physical therapy, exercise and stretching, and OTC anti-inflammatory medications are more effective and appropriate. After treatment, those patients have a lower rate of prescription opioid use and their rate of pain score is lower than those who have had early imaging.
That being said, MCOs have an obligation to use prior auth as a tool to ensure evidence-based care and not as a barrier to care. The process for provider partners to obtain authorization should be clear, streamlined, fast, and preferably electronic. I also think it's important to waive prior authorization requirements for providers that demonstrate a strong track record of consistently delivering evidence-based care.
MCOs are increasingly focused on measuring and improving quality outcomes, member experience and health outcomes. Meeting performance metrics, reporting requirements and implementing those quality improvement initiatives can be resource-intensive for MCOs, but it's important to our mission to provide high quality care to the members and communities we serve.