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By Monica E. Oss

Our team spends a lot of time thinking about strategy, competitive advantage, and sustainability—and the likely disruptors that will upend strategy. As we look ahead, I think there are three big disruptive forces that executive teams of specialty provider organizations should pay attention to—the implications of continued “integration”, the changing political and regulatory landscape, and a new wave of disruptive partnership.

A continued push for “integration”—It was really the Patient Protection & Affordable Care Act (PPACA) that started the “integration movement” in motion. No preexisting condition exclusions permitted with no annual/lifetime limits. The first accountable care organizations (ACO) and health homes. Payers discovered that “integrating” consumer management improved health and reduced costs. And, at the same time, they realized that fee-for-service (FFS) reimbursement wasn’t an optimal model for integration and started the push to value-based reimbursement. Since then, we’ve seen adoption of ACOs by commercial health plans, the use of specialty medical home concepts across all payer types, and lots of pay-for-performance initiatives. All these market changes eliminate, in one way or another, a separate “specialist” market, and drive financial, clinical, and data systems to merge (or at least, collaborate). Depending on the geographic and consumer markets of any particular program, “integration” can be a big threat.

For more on the integration trend, check out these resources from the OPEN MINDS Industry Library:

  1. Health Plan Relationship Building Skills Key To VBR Success
  2. Watch Out For Elephants
  3. The Pace Of VBR Is Picking Up
  4. Pay For Value-The Glass Half Full, The Glass Half Empty?
  5. Preparing For Value-Based Reimbursement-Even Before The Contracts Are Signed
  6. Defining ‘Value’ Is Key To Provider/Health Plan Conversations
  7. State Medicaid ACO Programs Ranked By Percent Of Medicaid Enrollment
  8. Louisiana To Test Subscription Model For Hepatitis C Drugs
  9. Final Rule Creates Pathways To Success For The Medicare Shared Savings Program

Accountable Care & The Complex Consumer—The changing political and regulatory landscape for health and human services are a front-and-center political issue. In fact, the last polling showed that health care was the “number one” issue for voters—which makes it the “number one” issue for politicians. There are big changes proposed: the end of pharmaceutical rebates, the end of prohibitions on pre-existing conditions, the end of parity, the concept of essential health benefits, additional funding for addictions, and more. Every organization needs to have a plan for the political and regulatory scenarios that could affect their sustainability. And, in case you missed it, be sure your team is on top of these issues:

  1. Medicaid Eligibility & Work Requirements – Another Pending Strategy Issue
  2. The Beginning Of The End Of Parity
  3. Why New Medicare Rules For ‘Non-Medical Benefits’ Matter
  4. CMS ‘Pathways To Success’ Medicare ACO Overhaul Limits ACO Time Without Risk
  5. Florida Faces ADA Lawsuit Over Medicaid HCBS Wait List
  6. Medicare Modifies Plans To Change Evaluation & Management Coding
  7. Federal Nursing Facility Case Mix Payment Changes Planned For October 2019
  8. CMS Launches Civil Money Penalty Reinvestment Program
  9. CMS Guidance To State Medicaid Directors Recommends Leveraging Managed Care To Improve Services For Dual Eligibles
  10. PPACA Open Enrollment Through HealthCare.gov Website Falls 4% From 2017, Totaling 8.4 Million Enrollees

A new wave of disruptive collaborations/partnerships—Competition isn’t what it used to be. Unusual combinations of stakeholders are reshaping service delivery and financing: combinations like CVS/Aetna, Beacon/Walmart, and Otsuka/Magellan. The combinations are creating a new “value chain” (see Unlikely Bedfellows and The ‘Melting’ Value Chain) with some great threats for specialty provider organization strategy. For more on the new disruptors, check out our recent coverage:

  1. Health System/Insurer Combos Gain Steam-& More To Come With ACO Changes
  2. CVS Health Completes Aetna Acquisition
  3. S. Department Of Veterans Affairs, Walmart Team Up To Offer Telehealth Services
  4. Amazon To Launch ‘Choice’ Brand Of Consumer Medical Devices Created By Arcadia Group
  5. UnitedHealth’s Optum To Acquire A Stake In The Polyclinic
  6. PEAR Therapeutics & Sandoz Launch reSET-OT Mobile Digital Therapeutic For Opioid Use Disorder
  7. CVS Health Invests $100 Million Over 5 Years In Community Health Initiatives
  8. Beacon Care Services Launched With Texas Walmart Mental Health Practice
  9. Reckitt Benckiser Group & Walmart Launch First-Of-Its Kind Partnership With Doctor On Demand
  10. Otsuka Collaborates With Magellan Health To Launch ABILIFY MYCITE®

For a deeper dive into all three of these trends, be sure to check out my article, The 2019 Health & Human Service Landscape: 2018 Legacy Sets Stage For Opportunities & Challenges. And for more advice on the coming year, check out The Three Trends That Are ‘Top Of Mind’ In 2019 For The OPEN MINDS Team. And, for a deep dive into strategy , mark your calendars for June 5 at The 2019 OPEN MINDS Strategy & Innovation Institute, and my keynote session, What Does It Take To Outlast The Disruptors? Building A New Strategy For A New Market.

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