The Top Five 2019 Healthcare Trends

During the 2018 mid-term elections, candidates faced off with bold claims to fix the broken healthcare system. So what is the new congress doing to improve healthcare and fix the gridlocked political system? Beyond political maneuvering, 2018 saw material changes in the business of healthcare, including the increased pace of mergers and acquisitions as well as new measures from CMS to support transparency, interoperability, and a continued shift to value-based payments. These changes have significant ramifications for health systems in 2019 as the pace of change continues to increase.

Health systems constantly have to adapt to changes in their communities, populations, politics, and reimbursement structures. Understanding the current climate and the upcoming healthcare trends can help them stay abreast of important changes and be prepared for the future in order to stay financially viable. This article examines the impacts of the biggest changes to the healthcare landscape in 2018 and predicts 2019 healthcare trends that health systems should have on their radar.

The Politics of Healthcare

Healthcare continues to be an important, but divisive political topic. Not surprisingly, 41 percent of eligible voters said healthcare was their key issue in the mid-term elections in 2018. In 2008, when the ACA became law, only 46 percent of voters supported single payer healthcare. That number has grown significantly to 59 percent approval in early 2018. While Medicare-for-all legislation is unlikely to pass both the House and Senate in its current form, there is a shift in public opinion with a solid majority now in favor.

Similarly, Medicaid is expanding. During the 2018 midterm elections, three states had ballot proposals to expand Medicaid, and two other states replaced governors who had blocked legislative attempts to expand Medicaid, resulting in a total of five new states that will expand Medicaid. Overall, the U.S. will likely increase Medicaid coverage to as many as 76 million enrollees by 2020.

Many states are also passing laws that make it easier for residents to access affordable healthcare. To that end, it seems Congress won’t repeal it–for now. Even with a Republican-majority House and Senate, there wasn’t enough support to repeal the ACA, so the ACA and the federal exchange should continue to thrive in 2019. Enrollment was down slightly in 2018 compared to 2017, but the numbers are still high. During the 2018 open enrollment period, 8.4 million people enrolled (down from 8.7 million in 2017).

However, while people are still signing up for insurance through the federal healthcare exchange, legal challenges to strike down the ACA still loom. A Texas judge ruled in 2018 that the entire healthcare law is unconstitutional because Congress had voted to remove the penalty for not having health insurance. According to the ruling, this effectively killed the constitutionality of the law because the Supreme Court had ruled that the original law (and penalty) was constitutional because Congress had the taxing authority to impose that fine. The judge’s 2018 ruling was quickly followed by legal analysts on both sides of the political aisle saying the judge’s reasoning was flawed, so it’s unlikely this ruling will stand. Regardless of the outcome, the ACA appears to be here to stay for the foreseeable future unless the Supreme Court steps in and makes changes.

Transparency

While there’s partisan divide about the ACA, both parties agree on the importance of transparency. As Figure 1 illustrates, most states are not doing well in this arena. The maps provide transparency and quality scores for each state. Grey colored states on both maps indicate a failing grade, while blue states indicate an “A” for either quality or transparency.

2019 healthcare trends

Figure 1: Transparency and Quality Scores in Healthcare in the United States

Price transparency in healthcare is another big issue to watch for in 2019. Prior to January 1, 2019, California was the only state that required hospitals to post their prices online for consumers to view. As of January 1, 2019, CMS requires all hospitals to post prices online. However, prices don’t provide the whole story as patients’ costs remain a mystery. For example, if a patient has a hip replacement surgery at an outpatient center versus in a hospital as an inpatient his costs are going to vary considerably and include a wide range of variables. To aid consumers in understanding the billing process, Maryland state hosts a website where total cost is available for some procedures. The site shows the hospital costs and a potential total cost per condition, along with some quality metrics related to that condition for individual hospitals. This is a good example of how states can help improve transparency for consumers, enabling them to make informed choices about their healthcare.

Telehealth

Another healthcare initiative with strong political support is telehealth. That support likely comes from the fact that, according to HIT Consultant, Accenture conducted a 2018 survey showing that 78 percent of consumers are interested in receiving virtual health services. In 2019, Physician Fee Schedule regulation expanded coverage for telehealth and virtual care. Thirty-four states and the District of Columbia now require private insurers to cover telehealth the same way they would cover in-office services.

The Business of Healthcare: 2019 Healthcare Trends

As healthcare grows and changes, new business models are taking shape. One of those models is personalization of healthcare services. Consumers are taking advantage of personalized healthcare options that provide a concierge model of service, accommodating the care they want at the time and location that’s convenient, such as the expansion of telehealth services. New models also means new market entrants and shifting strategies are driving changes in the healthcare landscape, with Amazon, Berkshire Hathaway, and JPMorgan’s foray into the healthcare space at the forefront. They’re not the only ones, however. Companies are seemingly entering the healthcare market from all directions and industries; Google is hiring physicians, including former executives of Geisinger Clinic and the Cleveland Clinic; Apple is investing in their Wellness Monitoring App; and even Uber is getting in on the action with the launch of Uber Health to help increase patient access.

Mergers and acquisitions are the norm with partnerships forming everywhere. For example, CVS is working with Aetna to combine 10,000 stores, 1100 clinics, and 22 million enrollees. The CEO of CVS, Larry Merlo, said about the move, “We are hard at work creating a plan to differentiate CVS Health in these patient journeys with the goal of making them simpler and more personalized while making care more actionable.” Cigna and Express Scripts combined to create insurer and pharmacy benefit company, and UnitedHealth Group’s OptumCare and other insurance companies are buying physician practices to try to control the first input into the healthcare system.

The list of partnerships and mergers of health systems seems endless. Meanwhile, many hospitals have closed their doors–a total of 21 in 2018 alone. While hospitals are closing, existing health systems are expanding their facilities. According to the American Hospital Association’s (AHA) 2019 Hospital Statistics report, 71 percent of respondents said their hospitals will be acquiring off-site outpatient locations. Looking at volume trends reported by the AHA, it’s clear that inpatient admissions are trending down, while outpatient care centers are increasing, which points to a change in the way healthcare is delivered.

Bridging Healthcare Disparities

According to National Research Council, the United States is among the lowest in terms of life expectancy out of 17 of countries with similarly high income. Health disparities take part of the blame. Variation in life expectancy across the county is dramatic. Access to healthcare services, education, early childhood development, and work conditions vary greatly. New York City is a perfect example of these disparities. In a presentation at the Institute for Healthcare Improvement in December 2018, Don Berwick stated that people who live on the upper east side of Manhattan have a life expectancy that is 10 years longer than those who live five miles north in the south Bronx. A breakdown of this shows that life expectancy declines by six months for every minute someone travels on the subway or 2.3 years for every mile driven.

Addressing these complex disparities is challenging, but some organizations are trying to do just that. For example, Rush University Medical Center in Chicago is taking ownership of the disparities. The organization’s stated goal is to work toward improving life expectancy, not only for students and employees, but for nearby communities as well. They are working towards this goal by hiring and developing local talent and increasing their minimum wage to roughly $22 per hour, which they believe is the minimum pay rate to support health. They also source and buy products locally rather than on a national level, and they’re investing in their communities with the goal of improving the quality of residents’ health and increasing life expectancy in the surrounding neighborhoods.

This visual below from the Democracy Collaborative provides more details about Rush’s aim to address healthcare disparities.

Episodes of Care

Episodes of Care have taken healthcare organizations on a wild ride. These are bundled Medicare payments that started out as voluntary, then were mandatory, but are now again voluntary. The new voluntary episodes of care bundle, which began in October of 2018, is called Bundled Payments for Care Improvement (BPCI) Advanced. There are 1,547 physician organizations and hospitals signed up for BPCI, which includes quality scores as part of the program.

Some examples of bundling payments include major joint replacement, congestive heart failure, and sepsis. This program gives health systems an opportunity to get their feet wet, so to speak, and try out an episodes of care model before going all in.

Looking to the Future: 2019 Healthcare Trends

With all of these changes afoot, there are several keys for health systems to stay ahead of the game in 2019. Health systems should have a clear understanding of their goals and develop a strategic plan based on current knowledge of the healthcare landscape. When it comes to ACOs, bundles, and risk-based contracts, health system leaders should be ready for a growing data burden and make sure there are analysts on board who know how to analyze claims data. Building capacity to integrate claims and clinical data is also critical. Another trend that’s worthy of following is collaboration with community partners to improve healthcare delivery and reduce disparities.

Health systems must be agile enough to adapt to changes in the industry including new healthcare business models, mergers and acquisitions, and reimbursement structures. Understanding this landscape and the new expectations can help keep them viable for the future of healthcare.

A poll of a 2019 Healthcare Trends webinar attendees showed that nearly half of attendees believe that consolidation and changing business models will be the top healthcare story in 2019, with big market share gains in new care delivery models and consumerism coming in second and third, respectively. No matter what happens in 2019 and beyond, one thing is certain: healthcare organizations will have to change and adapt in order to meet the challenges of the evolving healthcare landscape.

More than half of all U.S. hospitals report over-crowding in the Emergency Department (ED), one-third report an increase in ambulance diversion, and 90 percent report they frequently operate at or over capacity, risking the ability to effectively provide emergency care to those who need it and contributing to patient dissatisfaction. Overcrowded EDs cause problems for both hospital patients and staff, such as increased wait times, length of stay (LOS), medical errors, and mortality rates, as well as financial losses to hospitals. A data-driven systems approach can dramatically improve every aspect of emergency care, improving wait times and throughput, reducing left without being seen rates, and improving patient satisfaction.

Common Problems with Emergency Care

Crowding in the ED has become a widespread problem in hospitals across the country for two primary reasons: emergency medicine is the only specialty with a federal mandate to provide care to patients seeking treatment, and a shortage of primary care providers has forced more sick people to seek treatment in hospital emergency rooms. This overcrowding leads to a number of common problems with emergency care that can be seen as markers of hospital health.

These include the following problems with emergency care:

Patients walking out of the emergency department without being seen. When customers vote with their feet, this presents three risk factors for the organization:

Customer satisfaction – anytime a patient walks out the door without having received the service she came in for, customer satisfaction suffers.

Health – The patient did not see a provider to be evaluated for the health problem that brought him to the ED leading to potential negative healthcare outcomes down the road.
Financial – Each patient that leaves without being seen represents a missed financial opportunity to provide a needed service.

Excessive wait times. In May 2014, the Centers for Disease Control and Prevention (CDC) reported average emergency department wait times were roughly 30 minutes.

Volumes negatively impacting throughput and patient experience. Hospitals need a coordinated system effort in order to improve throughput, however Emergency Departments can focus on some specific metrics such as Median LOS for discharged patients, Median LOS for admitted patients, and Median LOS for behavioral health patients to improve throughput and patient experience. However, factors such as operating room schedules, inpatient capacity, and increased behavioral health problem affect volumes and throughput and need to be addressed on a system-wide level.

Redesigning the Delivery of Care Through Emergency Department Quality Improvement

As the crisis of emergency care grows, hospitals have more pressure to make improvements in addition to the many other pressures facing the healthcare industry. Redesigning the delivery of emergency care involves a four-step approach.

Begin with the bigger aim and ask “What do we need to best deliver emergency care?” Improving emergency care ties into the Triple Aim of healthcare improvement: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare.

Create a vision and support for a data-driven systems approach to improving emergency care. Many times, a department will embark on an improvement project, but don’t think about how it will affect the flow of other teams or departments. Instead, it can be helpful to create an ED Joint Practice Team where anyone who touches the patient is part of the care team. This helps improve communication between departments to avoid unforeseen consequences of changes to other departments.

Using an analytics platform, develop an ED analytics application that provides insight into performance. If an ED with 65 beds has 130 patients come through the doors on any given day, but the OR doesn’t know, nor does the hospital care control center, the ED is operating in isolation without the ability to resolve issues or foresee them in advance. Using an analytics application such as ED Explorer, frontline leadership and executives have the ability to track throughput, and obtain actionable data necessary for demand/capacity management.

Engage frontline staff, key stakeholders, patients, and families in improvement. Improving ED throughput is much more than an emergency department initiative. It must include the entire system of care for real, lasting change to occur.

Understanding ED Performance

To prevent the ED from operating in isolation, it’s necessary to involve hospital leadership and other frontline leaders in the improvement process. One way to do this is utilizing executive dashboards that show a snapshot of the ED performance on a regular (perhaps daily) basis. Dashboards might show the C-suite how many patients are in the ED, how many are waiting to be seen, wait times, and the number of behavioral health patients. One of the most telling metrics used in an executive dashboard is the longest wait time recorded or the longest wait time for a bed to be assigned to an admitted patient in the last 24 hours. Using executive dashboards can help keep stakeholders informed and involved. Increased leadership visibility and engagement can greatly contribute to success.

In addition to the daily snapshot, executives might be given access to look ED goals, past performance, patients left without being seen percentage, and admission trends. Using an emergency services application such as ED Explorer can help provide the data necessary to track, trend, and predict resources need in the delivery of quality emergency care. Additionally, a robust ED analytics application allows users to identify and quantify areas of opportunity in throughput, ancillary resource allocation, utilization, and quality.

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