Ten Contrarian Predictions for Healthcare in 2019

After a spending years in the health reform wilderness as commoditized “providers,” doctors will reassert their hard-earned professional designation.  Large health systems will see an uptick in physician-administrator tensions, physician-owned entities that honor the profession will have less trouble poaching talent and the ratio of employed to independent physicians will stabilize.  Contrary to expectations, independent physician entities will cater to millennial doctors’ underappreciated skepticism about corporate healthcare.

As their fee-for-service (“volume”) income wanes and payments are shifted to reward quality (”value”) the independent physicians take advantage of advances in information technology to organize into clinically integrated networks (CINs).  Declining costs and increasing sophistication of these information systems is lowering the barriers to market entry. This will enable the best of both worlds: local independence and regional interdependence.  These entrepreneurial doctors will be the surprise alternative to  health system consolidation, hospital market  dominance and one-size-fits all approaches to care. Financial savings from other group purchasing arrangements will be icing on this cake.

As hospitals scramble to get even bigger by buying one another, constructing new wings and launching slick branding campaigns, these glass and steel behemoths will begin to contrast with unflattering local stories about inability of patients to get a timely appointment and a convenient care plan. These noisy patients will use more social media to point out something that elected officials, regulators and academics are missing: that these complex mega-health care organizations cost more than they give. Unfortunately, this alone won’t be enough to lead to change, but…..

The Wall Street Journal confirmed what many physicians suspected about hospital-insurer collusion. 2019 will show how prevalent this is: enterprising local reporters will find that their health system has been using its local market dominance to dictate terms to health insurers.  No longer just a matter of fat fee schedules and lavish quality bonuses, terms of these contracts will leak and inform local markets, showing anti-steering clauses, secretive pricing arrangements, extra fees and the exclusion of lower-cost alternatives.  As news of these arrangements spreads, embarrassed health insurers will pull back from these agreements and look for network alternatives.  Combined with #2 above, patients will be willing switch to these alternatives and large health systems will begin to see declines in the rate of increase in their outpatient revenue. 

Health insurers are ultimately in the business of “risk transfer,” in which the potential cost of a future healthcare event is accepted in exchange for money.  This monetized risk increasingly being sliced, sorted, allocated and re-transferred. While this innovative area of insurance has been dominated by large systems, increasing actuarial sophistication and growing risk appetite of smaller networks – including physician CINs –  will lead to limited and profitable risk transfer arrangements.

As risk transfers to providers grow, awareness of underlying socioeconomic threats to patient claims expenses will evolve in a Stages of Change arc from “precontemplation” in 2018 to “action” in 2019. An impatient mandate to “do something!” to manage social determinants will prompt frontline healthcare workers will begin to use some of the upfront premium revenue from their risk arrangements to mitigate the impact of determinants, such as poor social supports, low education, and insufficient income. Unencumbered by an insurer mindset, there will be investments in community-based supports, patient education and non-medical services.

The allure of artificial intelligence, connected health, the human genome, block chain, consumerism, making the inefficient more efficient and more will drive another run at finding “The Innovation” thatwill finally transform healthcare.  Alas, this is less a function of the potential of market change than the lack of investment opportunities elsewhere.  Good luck!

An accommodating posture in CMMS will enable the leadership of state Medicaid programs – and their managed care insurance partners – to innovate.  One area ripe for change are quality metrics, which have been dominated by entities such as the NCQA, NQF and AHRQ. Criticized for being disconnected from what patients really value, state Medicaid Directors will show a willingness to adopt new measures and reward health systems that can move these new needles.  Physician-led CINs will lead the way and they’ll start by arguing that a number one priority should be measures of social determinants of health.  By the way, venture capitalists (see 7 above) will miss this bus.

Didn’t these companies’ ERISA plans already exploit the low hanging fruit?  Between Warren Buffet’s hardnosed actuaries, blockchain’s unreadiness for prime time, the limits of Alexa-style healthcare consumerism, and Atul Gawande being the Peter Principle personified, this three-way alliance will remain stuck in countless video conference rooms in Seattle, New York City and Omaha.

The Donald will demonstrate once again that he has no ideological moorings, no respect for fiscal responsibility and no embarrassment from co-opting his opponents’ ideas. Once the fight over The Wall has been squeezed for every possible advantage, the President will shamelessly signal he’s open to a version of “Medicare for All.”  Why not?  Insurers will see opportunity in the expansion of government-paid managed care business, employers will welcome a way out of paying for commercial health insurance, voting Boomers’ may be grateful for being fast-tracked to Medicare eligibility and the House Democrats’ momentum will become ten times more complicated. To the chagrin of his detractors everywhere, Mr. Trump will give the impression he really has a chance at a second term. MFA might even pass.