There are a lot of paths organizations can take to make healthcare more accessible, more affordable, and more equitable. Leaders need to have the courage to pick a path and do what matters most for the community they serve, their workforce, and the broader industry.
“It’s not about disrupting. It is about impact,” Tanvi Patel, Director of Amazon Pharmacy, said at the 2023 Oliver Wyman Health Innovation Summit.
The theme of this year’s Summit was Doing What Matters: The Paths to Progress. In previous Oliver Wyman Health articles, we highlighted remarks from Federal Trade Commission Chair Lina Khan on competition, detailed efforts ride the momentum of breakthrough ideas, and mapped out an agenda for the next decade. Here, we capture more of the paths to progress that were discussed during 10 Executive Sessions on topics ranging from the role of pharmacy benefit managers to the future of hospital care.
Can commercial insurers embrace value?
For employers, value is first and foremost about improving health outcomes, creating a better patient experience, and delivering evidenced-based care, Ellen Kelsay, President and CEO, Business Group on Health, said. Pivoting from a fee-for-service mindset to one focused on value requires trust and collaboration, which starts with the patient and doctor relationship, she added.
Mark Hansberry, Senior Vice President and Chief Marketing Officer, HealthPartners, said it is important to have a universal understanding of how to measure value at the community level. Healthcare organizations need to ensure that results are regularly shared with the community. In Minnesota, providers share data on how they are performing, giving healthcare purchasers more inputs to make decisions.
“Blue Cross Blue Shield of Michigan was partnering with providers well before it was popular,” Tiffany Albert, Senior Vice President of Health Plan Business, noted. She said the insurer has a responsibility — and ability — to bring stakeholders together. She also said that it is incumbent on organizations that are driving change to share best practices across the country.
Getting innovative new drugs to patients
Chris Mancill, Senior Vice President, Head of Worldwide Value Access and Payment, Health Economics and Outcomes Research, Bristol Myers Squibb, detailed existing challenges with patient navigation. The current system is fractured, he said. The industry needs to get to a point where patients are truly empowered and understand how to maneuver through a complex web of available treatments, care sites, insurance, and more. Manufacturers can do a better job of explaining what innovations are coming to market.
The first gene editing drug was approved in 2017 and the healthcare system didn’t have enough time to adjust to its success, said Angela Shen, MD, Vice President, Strategic Innovation Leaders, Mass General Brigham. “It isn’t often where you have a drug that works so well,” but at the same time, CAR-T is very expensive. The infrastructure wasn’t in place to build off the success and patients scrambled from site to site to get care. That gap will eventually be filled but it will take the involvement of a lot of players. She compared it to the current evolution of electric cars and charging stations.
Generally, people delivering care on the frontline are not the ones making purchasing decisions, said Randy Falkenrath, Founder, Epiphany Solutions and Former President, Onco360 Oncology Pharmacy. More needs to be done to extend pilot programs that have proven successful in managing care and costs effectively. There are interesting efforts underway, including value-based cancer care, that bring all parts of the industry together and use data to drive decisions.
Understanding the role of PBMs
Dan Knecht, MD, Vice President, Chief Clinical Innovation Officer, CVS Caremark, came to the PBM world as a skeptic, joining Caremark following CVS’ acquisition of insurer Aenta, where he served in clinical leadership positions. Looking at it from a new vantage point, he said PBMs are much maligned and don’t get credit for the value they bring to the market, including lowering costs, providing access to a network of high-quality pharmacies, and ensuring that drugs get dispensed at the right pharmacy. They also play a significant role in keeping the supply chain flowing.
It's not about defining PBMs as friend or foe, said Arif Khan, VP of Pharmacy Services, BlueCross BlueShield of North Carolina, rather they are strategic partners. PBMs do a lot behind the scenes like network, formulary, and claims management. The vertical integration that’s taken place in the space is similar to what’s happening across healthcare. “The system would break if we tried to get rid of PBMs tomorrow,” he said.
Health plan sponsors want control like never before, said Sunil Budhrani, MD, Chief Innovation and Medical Officer, CapitalRx. With that will come more visibility of value provided by PBMs and other parts of the industry. Patients will become better educated on their options as more layers are pulled away.
High-performing medical groups
Doing things with physicians, not to them, is critical, said Emily Young, President, Tufts Medicine Clinically Integrated Network. Value-based care is frequently more about the penalty than it is incentivizing good decisions. Part of the secret sauce at Tufts is a Physicians Bill of Rights that details what clinicians can expect from leadership. There’s an emphasis on transparency and culture, Young said.
Sean McLaughlin, MD, Physician, Board of Directors, Esse Health, agreed that change is often forced down the throats of providers instead of empowering them and making them part of the solution. At Esse, physicians operate as their own profit-loss centers with pooled risk. Since there’s a focus on total cost of care, Esse also utilizes nurse practitioners and care managers to fill in care gaps.
Operating in rural America makes it hard to create segmented care models, said Jeff Tillery, MD, CEO, OSF Medical Group. “We have to be the access point for many, not just those covered by risk-based contracts,” he added. “Our payer mix is not great spread across central Illinois. We’re 60-65% government paid.” In that environment, if OSF payment models shouldn’t be punitive. Rather, they should be designed to help clinicians be successful.
Moving care outside of the hospital
David Cook, MD, Senior Vice President, Strategy and Innovation, United Health Group, and Former Executive, Mayo Clinic, outlined four trends that are driving care away from the hospital: consumer preference toward convenience, the high cost of care, new entrants, and advances in technology. Going forward, it’s critical that all stakeholders come together to answer some fundamental questions: what defines your market, what is the actuarial risk of the population, and what is the breadth and depth of market at play?
Houston Methodist is embracing technology and other operational changes to move lower-cost and lower-acuity care to the home, said Roberta Schwartz, the system’s Executive Vice President and Chief Innovation Officer. Mass and scale are needed in communities where healthcare systems are also expected to address social care, she said, adding that innovation will require changing regulations and setting new expectations of what services are offered in a hospital and what is done elsewhere.
Greater cooperation and collaboration are needed to reduce redundancy in the system, said Rich Snyder, MD, Executive Vice President, Facilitated Health Networks, Independence Health Group. That includes rethinking what the payment structure looks like to drive new models of care. The health plan works with hospitals to adopt total value of care contracts that include upside-downside risk. He also sees a unique opportunity to better manage care as it moves between the hospital and home.
Paging doctor AI
Although there are new generative AI tools are being built at a rapid pace, the number being deployed in clinical care are very small, according to Brigham Hyde, PhD, Co-Founder and CEO, Atropos. He said roughly 184 algorithms are trained and certified to do diagnosis but only 10% are deployed. Understanding how these systems get deployed and physicians interact with them will be key moving forward.
Suchi Saria, PhD, Founder and CEO, Bayesian Health, said that the current understanding of artificial intelligence is one of the industry’s biggest problems. There’s ample confusion over what AI can and can’t do. Healthcare organizations need to build the right interfaces to ensure that AI is interacting with data correctly and in a trustworthy way.
Don’t lose sight of core IT needs
It’s difficult to leapfrog to new technologies without the right infrastructure in place, argued Sara Vaezy, Executive Vice President, Chief Strategy and Digital Officer, Providence. Before they adopt a new technology, including AI, organizations need to understand what problem they are trying to solve. Having the shiny new object isn’t valuable if it doesn’t tie back to a business case and revenue driver, she noted.
Nick Coussoule, Senior Vice President, Enterprise Business and Technology Solutions, Horizon Blue Cross Blue Shield of New Jersey, identified two ways organizations can future proof their technology deployments: find a trustworthy partner who can help with technical specifications and scale the solution; build as little internally as possible so the partner can maintain the technology, relieving pressure on your team. Additionally, data governance must be a priority. Innovative technologies won’t yield results if the data is flawed or of there are security gaps that jeopardize privacy.
Caring for the Elderverse
Two sessions examined ways to improve care for seniors. One focused on what improvements can be made in Medicare Advantage. Suzanne Hansen, Chief Operating Officer of Iora Health; Renee Buckingham, President, Primary Care Organization, Humana; and Monica Engel, Senior Vice President and President of Government Markets, Blue Cross Blue Shield Minnesota; shared strategies for improving services for MA enrollees by making purpose-built investments in things like primary care and technology, including virtual care and automation to relief administrative burden on clinicians. The other session focused on improving care for seniors experiencing cognitive decline. Kemi Reeves, Lead Dementia Care Specialist, University of California, Los Angeles; and Kristen Clifford, Chief Program Officer, Alzheimer’s Association; discussed the need to incorporate cognitive screening into more patient visits. It’s also important, they said, to develop toolkits to help families identify early signs of cognitive decline.
The Affordable Care Act as a testing ground
Matt Bartels, MD, Individual and Family Plan National Medical Executive, Clinical Performance and Quality, Cigna Healthcare, said the insurer is investing in technology that will empower patients to manage their care, including diabetes and weight loss education. He added that as a national ACA Exchange player, it is important to track results and use data to bring what works to different markets.
Pete Marino, President and CEO, Neighborhood Health Plan, said the insurer zeroes in on improving the member journey and being customer focused. Baked into that approach is a concerted effort to address health equity. The insurer has also bolstered outreach to Medicaid members who may lose coverage as the state ramps up redeterminations. Part of that education includes informing members what it means to move to the ACA, he said.
The ACA has opened opportunities to build flexible and adaptable offerings, said Loretta Lenko, President, ACA Exchange, AmeriHealth Caritas. She noted that the No. 1 thing driving behavior for members is price and No. 2 is the clinical network. Understanding these consumer behaviors can help inform what insurers do in other markets, like small group.
Bill Tuthill, Vice President, Market Strategy, Affordable Care Act and Medicare, Highmark, agreed that understanding consumer behaviors can help inform decisions in other product areas, like individual coverage Health Reimbursement Arrangements. He noted that nearly one-third of the ACA market is new every year.
Kristen Hefferan-Horner, Hayley Reta, and Jacob Ziller contributed to this article.