History gives us many reasons to doubt predictions. In 1916, Charlie Chaplin famously called the motion pictures “a fad.” In 1932, Albert Einstein said that nuclear power was not possible. In 2008, Steve Ballmer predicted the iPhone would be a flop. As these cases show, smart people may see the facts, but not the environmental factors that can shift the entire landscape.
This was particularly true in 2020, a year that redefined “normal” and altered our world in ways we are only beginning to understand. In this environment, the hard job of accurately predicting future trends became that much more difficult. When I look back at my own predictions last year, almost none of them played out as I thought due to the pandemic and the complete upending of the national health care agenda.
But now 10 months in, the pandemic’s true impact is starting to be understood. For 2021, job number one for the nation will be moving ahead with the largest mass vaccination program in our history, as well as improving our rapid testing capabilities and therapeutic treatments for COVID-19, in order to build our herd immunity and allow us to safely reopen and repair our badly damaged economy. This backdrop will permeate all our decisions this year, and directional trends will largely be influenced by how quickly we make progress in these areas.
Assuming that we do make these great strides in lessening the societal impact of COVID-19 and move to a new normal, I think we will begin to make some key shifts that will ultimately improve health care’s cost, quality, reliability, and underlying data infrastructure.
What follows are the five main trends that could usher in change, and some advice about how to prepare.
Health Care’s Pax Romana
Repeal and replace or Medicare for All? A public option or an individual mandate? Drug price controls or an international pricing index? For the last 10 years, big moves in health care have largely been frozen as providers, insurance companies, investors, and others waited to see which policies would remain permanent and which would end up on the scrap heap of history.
The 2020 election largely turned the corner on the debate.
The Democrat’s extremely narrow margins of control of government and need to heal the nation by avoiding extreme polarization means that sweeping changes to the Affordable Care Act (ACA) will be off the table—probably not for 200 years, but certainly for the next two years and more likely four. That said, the Biden administration will take advantage of every administrative tool to further cement current law in place. With a legislative détente in place and more stability on implementation, private sector bets become more certain. There is every reason to assume rapid investment and modernization across the health care sector.
There will be particular momentum for programs that have bipartisan support, including payment policies that move away from fee-for-service reimbursement and toward models that drive lower-cost and higher-quality outcomes. The overall movement to value will get a shot in the arm from two principal forces in 2021: 1) the Biden Administration’s commitment to build on the ACA’s legacy by doubling down on alternative payment models and mandatory payment changes and 2) the pandemic.
When it comes to policy, the new Administration will not need convincing that value-based care improves quality and reduces costs. Ample research shows that since the move to value began, overall health spending as a percent of GDP has slowed, cutting more than $600 billion out of the budget trajectory that was predicted in 2010. Because these programs are net savers, expanding their reach will be an important and immediate objective that could be used to offset some of the COVID-19 relief spending.
To that end, we are likely to see Biden’s HHS make fee-for-service less attractive and push at least some mandatory alternative payment models. In addition, the Administration is also likely to move beyond endless testing of models, making proven programs permanent, creating added incentives to enable scale, and leading the way for private payers to follow suit with value-based programs of their own.
Juxtaposed against the government’s financial need to expand these models is a stronger desire on the part of providers to participate. During the pandemic, those left in fee-for-service models suffered tremendous financial hardships once elective volumes were curtailed. Over the course of 2020, hospitals lost an average of $50 billion in procedure revenues a month, while insurers reaped record-breaking profits over the same time period from avoided claims.
These realities have underscored the misaligned incentives in the current system and created real urgency for change. At this point, providers are now starting to see monthly per member, per month fees as a desirable alternative to unpredictable volumes. In fact, in a fall survey conducted by Premier, we learned that 40 percent of health system CFOs now believe that moving toward value-based care is a core strategy for future financial viability.
To prepare, provider organizations can either manage their own integrated, high-value network or they can make the case for partnering with an insurance company or another providers’ network by virtue of their demonstrable results related to cost and population health outcomes. Regardless of the path, systems will need sophisticated contracting abilities, experience managing risk, care management expertise, and advanced analytics to evaluate cost and quality performance in real-time.
Made In America?
COVID-19 focused the nation’s attention on the risks associated with overreliance on overseas markets for critical supplies, drugs, and equipment.
As an “easy” answer, some are now calling for manufacturers to produce a plurality of medical products domestically. While added domestic investments and expanded US manufacturing capacity are vital components of a holistic strategy for reliable supply, it will be important to strike a balanced approach—one that includes a domestic strategy, but at its core is about diversifying supply, including raw materials, pharmaceutical ingredients, and finished drugs.
Achieving this vision requires a surgical approach, starting with identifying the products that are truly needed in an emergency to ensure there isn’t undue concentration in a single country or region. In our view, that means ensuring three or more global suppliers and at least one US-based source readily available to serve the American people.
Assessing risk will require new transparency initiatives, requiring manufacturers of critical products to share vital information with government, including supply sources, centers of manufacturing, redundancy and contingency protocols, etc. And all this new information needs a technology backbone that helps government better track product availability, supply chain performance, and sources of supply to predict potential trouble spots in real time during another emergency.
While a balanced approach is important, there is no question that US-based sources for many products are lacking to non-existent. To remedy this imbalance, we may see tax incentives and low-cost loans that would enable American manufacturers to invest in new automation technologies, to help level the playing field with overseas companies that have access to cheap labor and fewer regulatory barriers. There may also be new requirements that government purchasers such as the Veteran’s Administration and Department of Defense purchase at least a portion of the medical products they use from domestic suppliers. More, too, should be done to incent our health care providers to purchase domestically.
Such moves would go a long way to creating the demand necessary for added domestic investments.
When added incentives are required, the private sector will continue to step in to reward manufacturers that place a premium on geographic diversity for their supply chains.
For instance, after learning that 90 percent of all face masks were produced in China, leaving the US highly susceptible to shortages, Premier and 16 leading health systems pooled resources to take a minority stake in Prestige Ameritech, one of the nation’s only domestic producers of face masks and other personal protective equipment. In exchange for the cash infusion and long-term purchasing commitments, the company is now making 3.5 million masks per month that it ordinarily would have had little incentive to make. In November, we followed that initiative with a partnership with 34 members to invest in DeRoyal Industries for the domestic production of isolation gowns that have increasingly been difficult to find.
Such a model could easily be extended to create other joint ventures for drug supply diversity, either for raw materials, pharmaceutical ingredients or finished goods.
Overall, in 2021 we expect more of these and other types of diversity initiatives to start bearing fruit.
Public Health Infrastructure 2.0
If there’s one thing that COVID-19 has exposed, it’s the antiquated and siloed nature of public health data systems and technologies. Today, our public health system relies on technology from the last century, including manual data entry and faxed forms. Not only does that ensure that the data collected is flawed and delayed, but it also means that we are completely unable to accurately track current and suspected cases of COVID-19 and other diseases, risk-stratify patients, or monitor disease progression and predict future spread.
This is why Dr. Deborah Birx of the coronavirus task force said in a recent article in the Wall Street Journal that it’s easier to get AIDS data from clinics in Africa than it is to get actionable COVID-19 data from US health care providers.
The irony is that the infrastructure needed to greatly improve our ability to monitor for disease outbreaks and predict spread is right at our fingertips—it just needs to be activated. Almost every provider in the nation uses electronic health records (EHR) technology; many also rely on clinical decision-support apps that operate across the different EHRs to help guide their adherence to the evidence. Combined, this means that there is a window into nearly every patient-provider interaction in the United States at the moment that care is delivered.
Using these technologies, public health officials could conduct symptom surveillance at the initial point of care using machine learning and artificial intelligence to interpret physician notes, where much of the symptom information resides. Early detection allows quarantining and contact tracing to begin much earlier to stymie spread. As an added advantage, symptom surveillance within clinical decision support can help guide risk stratification and treatment pathways for specific patients. Last, because these systems are automated using natural language processing and machine learning to understand physician notes, they can be leveraged to aggregate data nationally, pinpoint new hot spots and make predictions about future spread.
In preliminary tests of this technology with a large health system in the North East, Premier was able to validate a fourfold increase in the number of COVID-19 symptoms identified, more than doubling the number of symptomatic patients found—effectively rendering symptom surveillance faster and more accurate than diagnostic testing alone.
For 2021, there will be critical discussions about how to improve the government’s access to reliable public health data using syndromic surveillance via modern systems, as opposed to faxed paper forms. In part, it means a total overhaul of the CDC’s systems and data collection methods to better track the spread of disease, as well as the vaccination process and long-term side effects.
But the conversation also needs to consider the government’s technology systems overall, which today are largely “old school” or non-existent – leaving public health officials to the equivalent of flying a plane with no instrument panel. For instance, we need to invest in technology systems that could improve the government’s ability to monitor the supply chain for trouble spots that could quickly turn into shortages of both drugs and devices. A successful technology modernization effort will be critical, not just to manage the COVID-19 pandemic but also to improve our responses to seasonal influenza, foodborne illnesses, and other disease outbreaks. Moreover, this system modernization could propel greater interoperability within our health information systems overall.
The Doctor Will See You Now
Long described as a gamechanger in the delivery of care, telehealth remained underutilized in most markets, largely due to policy that limited reimbursement for telehealth services to rural providers and those in two-sided risk models. But the pandemic has fundamentally shifted the ground beneath our feet.
New policies designed to pay for telehealth services for a broader array of ambulatory services, regardless of geography, led to dramatic uptake. In fact, Premier data shows that as a result of COVID-19, virtual visits in the ambulatory setting during the third quarter of 2020 were up by a factor of 30 year over year. Employers have also started to reap the benefits of virtual care now that more providers and employees are willing to engage in this way.
After testing the model to largely positive reviews through 10 months of the pandemic, more than half of all employers (53 percent) plan to offer more virtual care options in their benefits packages, making it the top initiative for change in 2021. Given this, it’s no surprise that telehealth payment waivers ranked as the top regulatory flexibility that providers want made permanent.
Studies have long demonstrated that telehealth, remote monitoring, and care at home can reduce the time patients spend in the hospital for chronic illness management, and we anticipate providers will be more savvy about using telehealth to reach at-risk populations in 2021. Telehealth can extend access to those living in rural areas, seniors, and low-income and high-risk individuals—populations that are more likely to have chronic health conditions and be in the top spending tiers for health care expenditures. In 2019, more than half of seniors had suggested they were open to telehealth, and during the pandemic, CMS data says telehealth adoption increased 50 percent for primary care visits with Medicare beneficiaries. The same trend holds in the private sector, where a recent survey from the Business Group on Health found that 96 percent of large, self-insured employers intend to offer virtual health services—including behavioral health—by 2023.
Telehealth is also becoming an integral strategy for population health management, as providers experimenting with Medicare’s Primary Care First model use technology to flip in-person annual wellness visits to virtual events. Not only does this improve access and adherence, but it also allows providers to get a look inside the patient’s home to draw out additional factors that may affect overall wellbeing.
While in-person services will gradually increase as the pandemic abates, it’s unlikely that brick-and-mortar encounters will return to pre-pandemic levels. Medicare is also likely to continue to incent telehealth within risk-based payment models to ensure that both telehealth and alternative payment methods continue to gain steam. Given the momentum, the question for 2021 is less about whether telehealth will proliferate, and more about how the competition shakes out.
There are hundreds of independent telehealth organizations in the market today, some of which are rapidly approaching the depth and breadth of services provided by traditional health systems. For instance, this summer’s announced merger of Teledoc and Livongo won’t just extend virtual visits, but also access to specialty care, remote patient monitoring, and direct-to-consumer engagement.
As this deal shows, the competition is real. If health systems are to succeed, they must be more strategic in how they develop their virtual offerings and participate in alternative payment models, as well as how they then create next-generation clinical models, target specific consumer needs and preferences, and attract new payer partners. Simply slapping a virtual veneer on the traditional model will not a sufficiently better mousetrap make.
Maternal Health At Last
It’s no secret that the United States has the worst maternal health outcomes of any developed nation, and that we are the only such nation with maternal mortality rates that have steadily increased since the 1980s. But hidden within in that statistic is an even more troubling trend—racial and ethnic disparities.
According to the latest research conducted by Premier, there are wide variations in maternal health outcomes, with disparities across age groups, income and payers. But racial disparities are perhaps the most glaring, as black women are 39 percent more likely than whites to experience a severe event that can lead to mortality. The gap is even wider for indigenous women, who are 41 percent more likely to experience severe events during pregnancy.
Many of the factors contributing to severe events are complicating factors that are present before or exacerbated by pregnancy, such as advanced maternal age and comorbidities like hypertension, diabetes and/or obesity. These factors, more than anything else, can add risks to pregnancy and can result in complications that continue to affect a new mother’s health after giving birth.
Closing this gap needs to be a national priority, especially since these same communities and co-morbidities disproportionately affect a range of other health outcomes, including those for COVID-19. But, we have to start by understanding what is really going on and how to best fix the problem.
After years of talk, we are finally acting on this. Earlier this year, the Department of Health and Human Services (HHS) finally took steps to address this issue by improving the data collected around maternal health outcomes. HHS began to create broad-scale learning networks to help providers improve maternal health overall, but specifically to reduce disparities. This is a milestone, particularly since, historically, the data collected on maternal mortality was embarrassingly limited, inconsistent, and rarely acted on. The hope is that we can achieve improvements here that rival what was done during the Obama years for hospital readmissions and harm through the Partnership for Patients program, which finally cracked the code for how to impact the “immovable” readmissions statistic.
But maternal health is more than just the labor and delivery process, and going forward, we need to think more expansively about how to provide health care services to women of all races and ethnicities before pregnancy, and how we continue to care for them after they give birth. This requires more population health-type solutions that get at social determinants and other barriers to quality care, such as lack of access to qualified providers, transportation problems, draconian rules about paid time off, food deserts, poor health literacy, unsafe communities, and more.
Historically, maternal care has been riddled with bias and looked at through a highly political lens. My hope is that, in 2021, we finally get the facts so that we address the true problems and create whole person care models that move the needle on maternal health disparities. There is a long journey ahead, but it is important that we begin to take our first steps.
The pandemic has been a tragedy that has tested us all. But COVID-19 has shone a bright light on systemic issues that have stymied progress in health care. With an expansion of value-based care, improvements in both our manufacturing and data collection infrastructure, expansion of access and enhanced maternal outcomes, we can usher in a series of important changes and overcome the entrenched status quo.