Care delivery must move beyond the office and to a broader team
Anticipating less robust coverage on individual and nongroup markets due to the greater availability of insurance plans that don’t conform to ACA regulations, providers and payers should develop plans for triaging patients and members to lower-cost care options, including telehealth or in-home nurse visits. Providers also should pair patients with the most appropriate clinician to address patients’ immediate health issues. This could mean scheduling them with a nurse, dietitian, mental health specialist or social worker instead of a higher cost physician.
HRI found that a well-designed primary care team could result in savings of $1.2 million per 10,000 patients served annually.25 Providers and payers should enlist social and community supports to address the social determinants of patients’ health—such as obtaining reliable transportation or food security—and drive adherence to treatment plans with the goal of reducing avoidable hospitalizations and emergency room visits. Longer-term strategies should focus on tackling fixed costs, such as replacing certain physical infrastructure with virtual infrastructure, and creating a value line of product and service options at different price points for patients.
Attention to drug prices will increase despite a slowdown in rulemaking for manufacturers
An ACA provision that would implement monetary penalties on manufacturers that knowingly charge more than the ceiling price for a covered outpatient drug under the 340B purchasing program is scheduled to go into effect July 1. The Trump administration had previously delayed the provision. Lawmakers in 2019 will be increasingly interested in how 340B entities are using the benefit and whether or not savings generated by the program are making it to consumers or padding companies’ pockets. Government scrutiny of drug prices is expected to continue. Seventy-three percent of Americans surveyed by HRI said they want the government to do more to control the cost of prescription drugs.
The frail elderly, consumers with chronic conditions and consumers with a mental illness most strongly endorsed government action. In July 2018, after drawing criticism from President Trump, drug companies Novartis and Pfizer announced they would freeze prices on their products in the US for the remainder of 2018.26
Insurance regulations are falling to states, creating a patchwork
States will be taking more direct action to secure their insurance markets in 2019, even as the methods for doing so become more variate, creating challenges for regulatory compliance. In all states, payers will be able to sell more products in the individual and group markets, but regulations of those products will differ. States that don’t ban new products outright could still place greater restrictions on their use than federal regulations allow for.
At the same time, states will seek ways to stabilize marketplaces through federal assistance, particularly through reinsurance programs designed to reimburse payers with high-cost beneficiaries and slow individual plans’ premium increases. When making decisions in 2019, payers seeking to get the most out of new opportunities should avoid thinking of states as red or blue when they approach marketplaces and should instead closely follow state regulatory decisions.