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You get what you pay for
As the pressure to control health spending increases, payers, governments, and providers are compelled to scrutinize the quality and amount of care they'll be able to deliver in the future. Health leaders around the world see the health payment system as one of the best tools in managing this challenge and achieving sustainability. However, with less than 40% of those same leaders ranking their existing payment system as good, every country has room to improve and can benefit from shared best practices. See
You get what you pay for.
Behind the numbers: Medical cost trends for 2009
From one year to the next, healthcare costs for employers and their workers always go up, but for the past five years there's been some positive news. However, the growth rate has been dropping and that trend will level off in 2009, according to employers and health plans. The new Health Research Institute (HRI) report, "Behind the numbers: Medical cost trends for 2009", addresses the cyclical nature of the healthcare industry and provides insights into the conflicting factors that are contributing to both cost increases and savings. See
"Behind the numbers: Medical cost trends for 2009".
The Price of Excess: Identifying Waste in Healthcare Spending
More than half of the $2.2 trillion spent annually on healthcare in the U.S. could be considered wasteful, according to an analysis published by PricewaterhouseCoopers’ Health Research Institute. Defensive medicine, such as redundant, inappropriate or unnecessary tests and procedures, was identified as the biggest area of excess, followed by inefficient healthcare administration and the cost of care necessitated by conditions such as obesity, which can be considered preventable by lifestyle changes.
Straight Talk: Looking at Health System Disaster Preparedness
When — not if — a large-scale disaster hits, Americans expect a carefully orchestrated and sequenced response from hospitals, emergency workers and public health officials. In their greatest time of need, the system may fail them unless disaster preparedness becomes a greater priority. In this StraightTalk roundtable, health industry leaders discuss the steps health executives should take to ensure an effective response to a disaster.
Paying for Performance: Incentives and the English Health System
Many countries are looking at ways to reform their healthcare payment systems around performance. The English system for paying primary care physicians is the only one in the world that bases a significant portion of physicians’ pay on quality metrics. For that reason, this “pay for performance” (P4P) system is worthy of study, and the PricewaterhouseCoopers Health Research Institute (HRI) report shows what is working well, what needs further refinement and what should be considered when implementing pay for performance methodologies. The learnings from this go far beyond the English system.
Top Eight Health Industry Issues in 2008
Health organizations face a pivotal year in 2008 as they anticipate the wildcard outcome of the presidential election. Meanwhile, they must prepare for impending changes — pharmaceutical and life sciences companies are adapting to a new safety agenda from the FDA including the agency's expanded authority over post-market drug safety.
Beyond the Sound Bite: November 2007 Review of Presidential Candidates' Proposals for Health Reform
Healthcare is the number one domestic concern in the US, and for the first time in history, it is a non-partisan priority. The current health care system is not built to last, and the 2008 presidential election is poised to see a significant push for major health reform. The direction it goes depends largely on the next President.
PwC Straight Talk on creating a climate of innovation: Healthcare industry leaders discuss what they're doing to nurture innovation
The United States faces another political season, and, likely, a volatile debate about what can be done to improve the current health system. Everyone agrees that the current path is not sustainable, and is fracturing around access, affordability and quality. Failure is not inevitable; in our global research report, HealthCast 2020: Creating a sustainable health system, PricewaterhouseCoopers’ Health Research Institute identified "Climate of Innovation" as one of the key features needed for sustainability.
Closing the seams: Developing an integrated approach to health system disaster preparedness
A disaster occurs every week in the US, and the numbers are increasing. Yet despite increased federal and state funding since 2001 and lessons learned following 9/11 and natural disasters like large-scale hurricanes and floods, disaster planning in the healthcare arena remains sporadic, disconnected and under-funded. PricewaterhouseCoopers Health Research Institute's (HRI's) "Closing the Seams" analyzes preparedness throughout every key element of our healthcare system, identifies gaps, and highlights emerging solutions and innovative best practices that can be leveraged to make the most of our resources and help those in the emergency response and healthcare communities deliver the best healthcare possible in the face of unknown disasters.
Creating a climate of innovation: the health industry's most challenging paradox
Innovation is one paradox of healthcare - tremendous strides forward within a system that overall doesn't work well. Can innovation transform healthcare? The annoyingly complex answer is that it does and it doesn't. Effective incremental, sector and local innovations are everywhere, but the breakthroughs that would make the entire health system workable remain elusive
Keeping Score: A comparison of pay-for-performance programs among health plans
In order for providers to improve quality and make sustainable changes in the delivery of care, they must have specific incentives to do so. Pay-for-performance programs are an important tool to link financial payment with quality improvement. If P4P is to succeed in significantly moving the needle on quality, we ultimately need an all-payer approach, wherein providers face the same metrics and incentives for all their patients, regardless of their insurance coverage.
Behind the numbers* Healthcare cost trends for 2008
The nation's employers can expect a return to single-digit increases in health benefit expenses in the year ahead. Unlike health plan premium forecasts, medical cost trends reflect the underlying numbers for actual medical costs by plan design. They are used by private insurers and employers to compare health plan costs year over year, ultimately to set premium levels and design the benefit packages that will be offered to employees in the fall.
Pharmacy Benefit Management Savings In Medicare and the Commercial Marketplace
The Pharmaceutical Care Management Association (PCMA) retained PwC to estimate the value of pharmacy benefit management as well as the potential impact of enactment of proposed legislation that would restrict pharmacy benefit management (PBM) activities for consumers, private employers, health plans, unions, and state and federal governments> download report.
Collaboration Fosters Connected Health
The system of caring for people.the chronically ill, the elderly or even the fitness buff.is reactive, expensive and cumbersome. But a new paradigm of care, called connected health, promises to reduce costs and improve quality by working with patients proactively.
Tailoring the approach: Employer attitudes and healthcare strategies address distinct issues
Employers are still debating how to stave off future healthcare cost increases and incent employees to take on more responsibility for their health. In describing emerging employer attitudes and healthcare strategies, a tailoring of approaches can be observed, in which distinct issues, such as chronically ill employees, are being addressed through specific tools, incentives and disease management programs. The newest results released by the Health Research Institute of PricewaterhouseCoopers and Management Barometer demonstrate the evolution of employer attitudes on benefit design, consumers and quality.
A Sustainable Framework for Achieving Transparency in the Health Industries
Transparency is having a transformative effect on the health industry. The following report: Seeing is Believing* A Sustainable Framework for Achieving Transparency in the Health Industries, looks at transparency from three separate viewpoints: the health industry, government and non-health sectors, such as transportation and financial services. Understanding the power of transparency from these different viewpoints will be important as organizations traverse the future.
TGen: Translational Genomics Research Institute
Translational research generates tremendous benefits. The nexus between basic research and its commercial applications is too often neglected yet it can attract players on both sides, creating a true hub of scientific and business activity.
The quality conundrum: Practical approaches for enhancing patient care
More than a year in development, "The Quality Conundrum" is a compilation of essays by PwC subject matter experts, discussions with selected clients and insights from our interviews with health industry leaders in the United States and around the world. It explores the barriers that have made healthcare quality improvements difficult to achieve, and outlines a clear path to progress. It includes a discussion of quality from the patient's perspective, in the journey across the health care system.
Recapturing the vision: Restoring trust in the pharmaceutical industry by translating expections into actions
This report provides an in-depth analysis of one of the most pressing issues facing the global pharmaceutical industry today -- its reputation and how it deals with perceptions about its business and operational models. This report (along with the first in the series "Integrity Driven Performance in the Parmaceutical Industry") was co-developed by the Pharmaceutical Industry Group and the firm's Health Research Institute.
New Federal Leadership on Healthcare Transparency: What Will It Mean for Patients, Payers and Providers
On August 22, 2006, President Bush signed an executive order mandating that four federal agencies that administer or sponsor several of the largest federal healthcare programs compile information about the quality and price of the healthcare services they pay for and communicate that information to their consumers and each other. The executive order builds on previous administration efforts to expand the transparency of pricing in support of consumer-directed healthcare, an innovative approach to controlling healthcare costs by empowering patients as the consumers of healthcare. This PricewaterhouseCoopers report reviews the president’s executive order and its implications for patients, payers and providers.
Healthy choices: The changing role of the health insurer
Health insurance is pivotal to healthcare financing. In most parts of the world, governments are looking to enlarge, or at least to encourage, the contribution of private sources of healthcare funding.
Rethinking postretirement benefits
The FASB’s proposal, its impact on companies and capital markets, and the changing pact with the American worker
Consumerism in Healthcare: An Initiative of the HFMA Patient Friendly Billing Project
PricewaterhouseCoopers provided the research for this report, published in July 2006. It is is designed to help all of the stakeholders understand the goals, roles, and responsibilities inherent with consumerism, with an emphasis on the effect on revenue cycle activities of providers. The report lays out the strategies that must be considered, adapted, and implemented for the healthcare industry to take advantage of the opportunities and challenges consumerism offers.
Louisiana Recovery Authority Endorses PwC Healthcare Report
The Louisiana Recovery Authority Board of Directors endorsed a sweeping health care report on June 15 as a blueprint for health care reform in Louisiana. It urged health care reform leaders to use the reportīs findings in effectively rebuilding and redesigning the vast health care systems crippled by last yearīs hurricanes and created a subcommittee of board members to help guide the progress. The report, by PricewaterhouseCoopers LLP, was sponsored with private funds by the LRA Support Foundation, on behalf of the LRA. It includes recommendations addressing both the immediate and long-term recovery of the health care systems in the hurricane-affected areas, as well as the redesign of health care systems in all regions of Louisiana.
See related Roundtable
Rebuilding Healthcare In Louisiana - A Blueprint for the Nation
Rebuilding Healthcare In Louisiana - A Blueprint for the Nation
Executives from Franciscan Missionaries Of Our Lady Health System, Baton Rouge, and Ochsner Health System, New Orleans, discuss the present and future state of healthcare in Louisiana and how they have struggled to cope with day-to-day challenges while also preparing for the future.
See related report
Louisiana Recovery Authority Endorses PwC Healthcare Report.
The Trends and Benefits of Providing Healthcare Quality Data
In this latest HealthBrief, PwC discusses the results of a recent survey of top executives at large U.S.-based multinational companies. The focus of the HealthBrief is on healthcare quality data that firms provide to their employees as a way to influence the utilization of healthcare through better education of their employees on cost and quality issues and improvement of their own health behaviors.
Assessing Quality-Based Benefit Design
Quality-based benefit packages take traditional benefit design one step further by emphasizing coordination of health care, support services, and the importance of providing useful information to consumers. But are they effective? And do they really improve the quality of care and boost the value of benefit dollars? This report was prepared by PricewaterhouseCoopers for the Pacific Business Group on Health and the California HealthCare Foundation.
Factors Fueling Rising Healthcare Costs 2006
The Factors Fueling Rising Healthcare Costs 2006 examines the causes of rising health care costs and analyzes how health insurance premium dollars are being spent. Health insurance premiums are growing at a reduced rate, despite increased utilization and higher costs, while health insurance plans' efforts are easing drug cost increases.
The study which was prepared by PricewaterhouseCoopers (PwC) on behalf of America's Health Insurance Plans (AHIP), " found that premiums increased 8.8 percent between 2004 and 2005, which is 36 percent lower than the 13.7 percent increase a similar report found in 2002.
Higher utilization of services accounted for 43% of the increase, fueled by factors such as increased consumer demand, new and more intensive medical treatments and defensive medicine, as well as aging and unhealthy lifestyles. Price increases in excess of inflation accounted for 30% of the increase and were impacted by movement among purchasers to broader-access health plans, provider consolidation, increased costs of labor and higher priced technologies.
The report found that 86 cents out of every premium dollar go directly towards paying for medical services. Embedded within the 86 cents are the costs of medical liability and defensive medicine, which are estimated to be ten cents of the premium dollar. The report also breaks down the extent to which each major utilization service is being affected by medical liability and defensive medicine.
HealthCast 2020: Creating a Sustainable Future
In this groundbreaking report, HealthCast 2020, PricewaterhouseCoopers looks at solutions and responses from around the world to the globalization and industrywide convergence of healthcare. What insights, best practices and policy lessons can be learned from experiences in various countries to create a globally sustainable health system? Who, or what, is driving the solutions?
Employers Embrace Consumerism to Control Healthcare Costs: New PwC White Paper
With double digit health insurance cost increases affecting the business bottom line, employers are turning to consumerism and consumer directed healthcare to provide a solution. HRI's latest research gets behind this trend to find out how employers are coping with rising healthcare costs and the promise that consumerism may bring.
Recapturing the vision: Integrity driven performance in the pharmaceutical industry
Pharmaceutical companies face increasingly regulatory scrutiny and highly critical media coverage of the industry's R&D, marketing and manufacturing practices. This report explores the reputation issues and compliance challenges facing the industry.
Impact of the Medicare Prescription Drug Benefit on Catastrophic Spending by Beneficiaries
Beginning in 2006, the Medicare program will offer coverage for outpatient prescription drug spending. Enacted by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the voluntary prescription drug insurance program will provide coverage through two related benefits: front-end coverage for spending below median levels, and catastrophic coverage related to high out-of-pocket spending. The latter benefit is significant in that the Medicare program will now provide catastrophic coverage for spending on prescription drugs.
Venture Capital Investment in Health Industries Report - Q3 2005 Results
Health industries companies once again led all sectors in venture capital investment in the third quarter of 2005, accounting for 32% of total VC dollars invested during the quarter, according to a report produced by PricewaterhouseCoopers Health Research Institute. Even though the health industries sector maintained its lead, funding dipped slightly in the third quarter to $1.68 billion, down 5% from $1.77 billion in the previous quarter (Q2 2005) but up from $1.43 billion in the same quarter a year ago (Q3 2004).
Venture capital investment in the health industries has now held steady at around 25%-30% of total VC capital for 10 consecutive quarters, indicating that the industry has reached a sustainable level of investment. No longer have the boom-or-bust gyrations of five or six years ago, and that stability - while not exciting - is better suited to developing companies that will be successful. The health industries sector's 32% share of all venture capital dollars invested during the quarter was up slightly from both the previous quarter's 30.6% share and also from the 31.4% share of a year ago (Q3 2004). Biotechnology and pharmaceutical companies accounted for 19.2% of total venture capital investment in Q3 2005, while medical devices & equipment accounted for 10.6% and health services and health information technology accounted for 2.2%.
Protecting Healthcare Companies Against Fraud, Reputation & Misconduct Risk
At the end of the 20th century and the beginning of the 21st century, several high profile corporate fraud scandals jolted the financial markets and led to decreased investor confidence. The scandals that rocked corporate America over the past few years will have a lasting historical impact. Will historians dub these the frauds that changed America's Healthcare Sector? Public outrage over corporate fraud has resulted in new legislation, regulations and professional standards, which focus on prevention and timely detection. For the first time, corporate fraud is a key agenda item for boards of directors, senior management, and independent auditors.
Pay-for-performance
Commercial and government payers are taking parallel paths, some of which intersect, in developing metrics and reward systems. The lack of consensus, however, is creating confusion.
Personalized Medicine: The Emerging Pharmacogenomics Revolution
The latest report from PricewaterhouseCoopers' Global Technology Centre and Health Research Institute provides insights into the challenges and opportunities afforded by pharmacogenomics.
Personalized Medicine The Emerging Pharmacogenomics Revolution
Each revolutionary change in human medicine, from antibiotics to painkillers to vaccines, has moved the practice of healthcare toward improved patient treatment. Pharmacogenomics, the next fundamental development in this area, promises to usher in an era of individualized patient care or personalized medicine.
Pharmacogenomics uses markers in individuals' genetic code to pinpoint the underlying causes of disease. The science is enabling researchers to better identify drug targets and the mechanisms of action of investigational new drug candidates. Genomics-related technology facilitates the elimination of unfavorable products at earlier stages of development than is currently possible. It also could guide companies
in designing clinical trials that would more definitively prove drug efficacy, in turn decreasing the time, costs, and risks of drug development. In the clinical setting, pharmacogenomics will help physicians better define long-term health risks patients face, more precisely diagnose the stage of patients' diseases, and more accurately predict their responsiveness to specific drugs or the likelihood for adverse events.
President Bush's Second Term: Prescribing Private Solutions for the Nation's Healthcare Problems
PwC's Health Research Institute (HRI) developed a comprehensive 360 degree view of President Bush's health plan, the challenges and opportunities for industry, and an analysis on the likelihood of implementation.
Impact of the Medicare Prescription Drug Benefit on Catastrophic Spending by Beneficiaries
In December 8, 2003, the President signed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), which added a prescription drug benefit as part of the Medicare program. Under the new law, Medicare will offer complete prescription drug coverage to qualifying low-income beneficiaries with minimal cost sharing and no premiums. The Alliance to Improve Medicare retained PricewaterhouseCoopers (PwC) to examine the impact of the prescription drug benefit of the MMA on low-income Medicare beneficiaries.
Although the MMA provides subsidies to ensure that all Medicare beneficiaries are able to purchase affordable prescription drug insurance, the most generous subsidies are reserved for those who have income below 150 percent of the federal poverty level (FPL).1 The legislation provides two forms of low-income subsidies: a premium subsidy that will eliminate the premium for most low-income individuals, and cost-sharing subsidies that will significantly limit the out-of-pocket spending for low-income beneficiaries. Some low-income Medicare beneficiaries will pay as little as $1 per prescription.
Implications of the Medicare Modernization Act: Healthplans
New white papers from PricewaterhouseCoopers explain the implications and opportunities of the new Medicare reform law for each of the largest sectors of the healthcare industry.
Implications of the Medicare Modernization Act: Pharmaceutical
New white papers from PricewaterhouseCoopers explain the implications and opportunities of the new Medicare reform law for each of the largest sectors of the healthcare industry.
Impact of the Medicare Prescription Drug Benefit
Three new reports from PricewaterhouseCoopers show how the new drug benefit will affect low-income seniors and catastrophic spending by all seniors.
HealthCast Tactics: A Blueprint for the Future
This report suggests tactics for the healthcare industry to employ over the next three to five years. According to HealthCast Tactics, there are significant gaps between what healthcare executives, policy makers and employers rate as important and what is being implemented performance-based reimbursement, privacy, and clinical excellence. The report draws on a survey of more than 650 top executives of hospital systems, payors, governments, medical supply vendors, physician groups and employers.
HIPAA's Myths, Practical Realities and Opportunities The Work Providers Need to Perform For Standard Transaction and Code Sets
PricewaterhouseCoopers HIPAA Practice leaders dispel some of the popular myths circulating about HIPAA and shed light on the scope and magnitude of the effort providers will need to undertake to achieve even basic compliance with HIPAA's TCS Requirements.
Final Revisions to HIPAA Privacy Rule
HHS published in the Federal Register on August 14, 2002 the final revisions to the HIPAA privacy rule. (67 Fed. Reg. 53182). The final revisions largely track the proposed revisions released by HHS on March 27, 2002. This brief summary largely focuses on group health plan sponsors.
PwC's Consolidated and Redlined HIPAA Administrative Simplification Rules Guide to the Complete HIPAA Administrative Simplification Regulations (as of 8/14/02)
PwC created the Guide as a reference source for those who must interpret the HIPAA Administrative Simplification regulations. It covers Parts 160 through 164 of Title 45 of the Code of Federal Regulations.
PricewaterhouseCoopers' Guide to the HIPAA Privacy Regulations
PricewaterhouseCoopers (PwC) is pleased to provide this Guide to the HIPAA Privacy Regulations to its clients and the healthcare industry. Developed by the HIPAA privacy specialists in its Healthcare Advisory practice, The Guide provides significantly greater detail and usefulness than "highlights" documents that began appearing shortly after release of the final regulations. We anticipate that the document will serve you as a reference resource during assessment, planning and implementation work relating to the HIPAA privacy regulations. In preparing The Guide, we have kept the document concise by summarizing the significant elements of the new regulations and the implications for healthcare organizations, rather than creating an annotated version of the entire regulation.
HealthCast 2010: Smaller World, Bigger Expectations
Our survey group included a mix of policy makers, health system executives, employers, physicians, insurers and medical supply vendors. In addition, PwC practice leaders interviewed more than 50 thought leaders from seven countries at length about future trends and their implications for the industry's stakeholders.
