2019: Another Year of Challenges for Physician Leaders

After a turbulent 2018 in the industry, we present some of the issues likely to occupy the agendas of health care C-suites in the coming 12 months.

A given in today’s health care system is constant change , albeit at a glacial pace. That reality is reflected in anticipation of the challenges awaiting physician leaders in 2019.

In 2018, the industry took major strides in the use of digital innovation, leveraging data analysis and harnessing technology to improve patient care and reduce costs. Telemedicine became virtually accepted. Yet, cybersecurity scares and population health barriers remain.

Industry disruptions remains part of the effort to make patient care more convenient and efficient with a keen eye on lowering provider and insurance costs. At the forefront, the selection of surgeon Atul Gawande, MD, MPH, to head the pioneering health care plan for Amazon, Berkshire Hathaway and JPMorgan Chase was considered a big boost to the concept of physician leadership.

At the same time, the rise of mega-mergers — such as the uniting of CVS and Aetna — along with hospital consolidations and absorptions of practices by health systems remain under scrutiny amid fears of lessening competition, increasing consumer pricing and reducing quality of care.

Dedicated clinicians and legislative action began to take significant action against the opioid crisis, which continues to take lives daily. A focus on mental health treatment is growing in the wake of an increased gun violence and a rising suicide rate in the country.

The Centers for Medicare & Medicaid Services announced new reimbursement strategies with a goal of strengthening Medicare and lowering patients’ costs. Many of the policies have been met with mixed reactions throughout the industry.

Then, as the year closed, a federal judge’s ruling put the Affordable Care Act in jeopardy, with an appeal expected to reach the Supreme Court.

This, after President Donald Trump’s administration worked to break off elements of the law. Studies estimate up to 4 million people will drop their insurance coverage with the removal of penalties for not having insurance.

All of this sets the table for what physician leaders will face over the coming 12 months. It again will be a year filled with struggles to rein in costs, concerns about a shrinking physician pool weighed down by personal wellness concerns, and considerations to become more involved in government policy.

The publishing team at the American Association for Physician Leadership, in consultation with physician leaders from around the country, came up with some of the issues that likely will occupy the time of health care C-suites in the coming months. We hope it starts conversations about best and new practices.

An expected appeal of a federal judge’s ruling that the Affordable Care Act is unconstitutional appears headed to the Supreme Court in the coming months.

THE ACA'S FUTURE

The twists and turns of the Affordable Care Act will again dominate headlines as appeals begin after U.S. District Judge Reed O'Connor ruled Dec. 14 that the law is unconstitutional. His decision in Texas v. Azar comes after years of failed attempts by a Republican-led Congress to undo and weaken the law, although Congress’ removal of the individual mandate during its 2017 tax overhaul was the crux of O’Connor’s decision.

As in 2012 and 2015, the future of the law is expected to be decided by the Supreme Court.

O’Conner’s decision came just weeks after Democrats, running on a message of preserving the government-run health care program, regained the majority in the House of Representatives in the midterm elections.

Democrats make no secret of their desire to expand the ACA, Medicare and Medicaid, and protect people with pre-existing conditions while attacking high drug prices and hospital consolidations. Decrying the O’Connor decision, they vow to play a role in the appeal.

The Trump administration plans no changes during appeals. The president is urging lawmakers to revamp the act while maintaining safeguards for pre-existing conditions.

Looking ahead, are conditions now ripe to make a new push for universal health care?

J. Gregory Jolissaint

"Medicare for all and acceptance of pre-existing conditions” will become law, predicts J. Gregory Jolissaint, MD, MS, CPE, FAAPL, the vice president for Military and Veterans Health at Trinity Health. “Both of these will be priorities” for the Democrats, says Jolissaint, who also is AAPL’s chairman of the board.

Republicans, of course, maintain control of the Senate and executive branch, and portray many of the proposals as a threat to private health plans used by most Americans.

“Regardless of which political frame we subscribe to, the debate will require that physician leaders understand the fundamental elements of access, cost and quality that are embedded in the proposals and how our patients will be affected,” says Anthony Slonim, MD, DrPH, CPE, FAAPL, the president and CEO of Renown Health and AAPL’s editor-in-chief.

Federal and state lawmakers must also take a hard look at cost containment initiatives, Jolissaint says. He anticipates they will soon formulate policies based on Maryland’s “all-payer system,” which caps annual allowable profits for hospitals. So far, the state says, savings are adding up to hundreds of millions of dollars for taxpayers, employers and others. Lawmakers are proposing an expansion of the policies into private practices.

Legal challenges are anticipated as the Centers for Medicare & Medicaid Services' final rule on site-neutral Medicare reimbursements goes into effect.

CMS EXPECTS MORE CHANGE

In 2018, CMS issued guidance to states that they are empowered to cover a broader range of mental health services. The agency also proposed revisions to improve Medicaid and the Children's Health Insurance Program Managed Care regulations.

“CMS will continue ‘motivating’ health care systems and hospitals to make positive changes (for patients) by way of regulatory guidance,” Jolissaint says.

Meantime, the debate over the implementation of site-neutral Medicare payments continues. The concept, backed by former President Barack Obama and aggressively opposed by hospitals, would allow off-campus outpatient locations and doctors’ offices to receive reimbursement at the same rate for the same procedures as hospitals. Trump continued that support and CMS announced it will implement its final rule Jan. 1.

The American Hospital Association and four other organizations followed with a lawsuit alleging the change will harm hospitals with a large Medicare population. CMS has estimated hospital reimbursements will drop about $380 million in the coming year. AHA has said the rule will lead to clinician layoffs and service reductions for Medicare and Medicaid patients.

Physician leaders must help their clinicians understand the benefit of increasing their knowledge of the value-based care payment model.

VALUE-BASED PAYMENTS EVOLVE

The year should continue the movement from fee-for-service to value-base payment. Adapting the replacement model remains slow-going, however, especially among physicians who still don’t understand the nuances involved. Physician leaders must help their people understand the benefit of increasing their knowledge of the payment model.

Karen Weiner

“Many leaders will need to find ways to succeed in a fee-for-service environment while simultaneously preparing their organizations to successfully compete in value-based payment models,” says Karen Weiner, MD, the CEO of Oregon Medical Group. “They will need to build the infrastructure, competencies and relationships required to succeed in an entirely different business model while simultaneously functioning in their current one.”

Value-based care ties payments for delivery to the quality of care provided, rewarding providers for efficiency and effectiveness. The transformation is supported by CMS, which has introduced numerous value-based models, and insurance companies have adopted similar reimbursement arrangements.

Raksha Joshi

“I believe that the focus on value as opposed to volume will continue, with a secondary ‘requirement’ to decrease cost, i.e., to obtain better and better outcomes with lower costs to maintain viability of our institutions,” says Raksha Joshi, MD, CMO, the medical director for Monmouth Family Health Clinic in New Jersey.

“Health care leaders at each organization will have to align all components of their operations to demonstrate that their organization can provide the best outcomes for any given condition at the lowest cost. This will be the challenge for all physician leaders into 2019 and going forward.”

Expect the industry to find even more ways to leverage data analysis and harness technology to improve patient care and reduce costs.

TECHNOLOGY STEPS UP

Health care decision-makers can expect an enhanced focus on data analytics — especially artificial intelligence — to predict, react and treat maladies.

Lawrence Nycum

“The ability to more readily use predictive analytics, in a robust fashion, will mandate that physician leaders be involved to utilize this information to better address the safety, quality, experience and cost of care for our patients — as well as outcomes for our physicians,” says Lawrence Nycum, MD, senior vice president of Novant Health, a system with 15 hospitals and more than 350 practices in North Carolina, South Carolina and Virginia.

“This will augment physician leaders’ ability to better address and course-correct around the input data for Leapfrog, Star Ratings or other CMS-focused metrics. I predict it will be a tectonic shift,” he adds.

Technology will also allow more patients to receive quicker and more efficient treatments, as telemedicine becomes a mainstream alternative.

“The drive for convenience (think Amazon) is beginning to infiltrate health care,” says Sam Cullison, MD, vice president for Graduate Medical Education at Methodist Health System in Dallas, Texas. “When added to the opportunity for lower costs, the push is irresistible.”

Momentum has been building among health care professionals to take a greater role in preventing gun violence, including suicide.

ADVOCACY GAINS PROMINENCE

Almost every piece of health care has a government component to it: insurance, licensing, accountability, ethics, abortion, end-of-life care and more. In the past, physicians wading through ethical dilemmas — or were simply too busy — avoided the public sphere. In fact, physicians historically have had low turnouts during elections, according to a 2016 report.

Not so much today. Health care professionals increasingly are asked to advocate for a variety of policy positions, from single-payer care to ending the opioid crisis. “A physician is not only a voice for other licensed professionals but for their patients as well,” Arizona State Rep. Heather Carter told AAPL in a December 2017 interview.

Recently, momentum has been building among health professionals to take a greater role in preventing gun violence, including suicide. In the wake of the Las Vegas shooting that left 58 concertgoers dead in 2017, more than 1,300 health care providers publicly pledged to ask patients about gun ownership and gun safety when risk factors are present.

In a 2014 study , 58 percent of internists surveyed reported never asking whether patients have guns at home.

Such advocacy comes amid the polarized debate between anti-gun proponents and Second Amendment supporters. Patients come from both sides, hence clinical professionals had previously taken a far more delicate approach. In 2019, however, many physician leaders believe it’s as much a public health issue as painkiller addiction or care accessibility.

Anthony Slonim

“The incredible number of mass shootings and violence that continue to threaten our country needs to be stopped,” says Slonim, of Renown Health. “For the first time in recent memory, physician leaders from a number of clinical disciplines are getting together and getting involved in the conversation.”

Slonim cites the hashtag #thisismylane, a response to the National Rifle Association’s suggestion that physicians should “stay in their lane” and remove themselves from the firearms debate. He calls the NRA’s statement “disrespectful.”

“In my mind, this debate is pivotal and potentially precedent-setting for physician leaders as we stand up for any number of important issues that impact our patients,” Slonim says. “Gun violence is likely to be the topic upon which physician advocacy for patients is tested. This is the time to make sure our voices, on behalf of the numerous patients we represent, are heard.

“Our leadership for other issues in the future may be judged by how well we perform on this critical topic.”

OTHER ISSUES

While the physician leaders we talked with were consistent in their belief that the above health care conversations will be prominent in 2019, they also saw others rising to the surface. Here’s a look at what else they see playing roles in physician leadership the near future.

Sam Cullison

Integrative medicine: “This has been on the sidelines of traditional health care, while attracting significant support from patients. I believe this is both a revenue, quality and reputational opportunity.” — Cullison

Lower costs: “Narrower networks and risk-taking by providers will be required.” — Cullison

Physician work schedules: “Senior leaders will have to champion, not just tolerate, creative work schedules that meet the needs of physicians, patients and the organization as a whole. The organizations that fail to do so will struggle to attract young new physicians entering the workforce and are at higher risk for losing the physicians they do have.” — Weiner

Rick Mayer is a senior news editor for the American Association for Physician Leadership.