Doctor with diagnostic imaging

STRATEGY Regulating change: healthcare policy trends spur innovation

From mega-mergers to website usability, federal healthcare policy trends continue to trigger innovation in the industry. As the new year begins, I visited with healthcare leaders and technologists about new areas of change that may influence their work in 2016. In each case, evolving public policy is anticipated to require health networks and organizations to design and change healthcare within these new circumstances.

Here are four key healthcare policy trends to watch.

1. An antitrust check on supersized healthcare organizations

The Affordable Care Act (ACA) started an extended wave of consolidations which have merged competing hospitals in horizontal mergers, as well as integrating physician groups, rehabilitation services, and even payers through vertical deals.

While organizations may say this is part of preparing for accountable care by growing in order to spread risks across larger populations, or pushing to achieve savings through economies of scale—self-preservation is also at play. Size is increasingly seen as essential to gaining bargaining traction to sustain prices and profitable operation.

But as the year ended, the FTC began to tamp down on mergers such as the consolidation of North Shore University Health System and Advocate Care which would create the dominant healthcare organization on Chicago’s North Shore. Meanwhile in Boston, Partners HealthCare, the largest network of doctors and hospitals in Massachusetts, appears to have grown as large as it can locally without running afoul of antitrust laws.

Individual markets seem to be finding a new balance of consolidation and competition, which is a mix of marketplace forces arbitrated by policy.

Forbes: Antitrust showdown next after Aetna, Humana shareholders approve merger
Merger mania in the healthcare industry draws scrutiny of federal regulators.

In just a few weeks this past summer, nearly $100 billion in mergers were proposed, including Aetna’s purchase of Humana ($37 billion), Anthem’s play for Cigna ($54 billion), and Centene bidding for Health Net ($6 billion).

But is bigger really better? Often not, argues professor Thomas Greaney, contending that Sumo-sized competitors may divide markets among themselves and then combine forces to manage regulators.

Paradoxically, limits on local expansion may bring healthcare marketers to address patients in new more distant markets and accelerate the use of telemedicine. Communications and strategy teams may find they are supporting organizations such as UPMC, which operates facilities in a surprising number of countries, or such as Mass General, which is recruiting patients traveling internationally.

2. Big lists of providers can be big liabilities when they’re wrong

For people buying health insurance those lists of providers showing which doctors will take your health coverage are like ingredient lists for food or drugs. Except the provider lists contain something unexpected: lots of errors.

Imagine being diagnosed with cancer, only to find that 80% of the surgeons listed on your insurance company’s website as providing the procedure you need don’t actually take your insurance. Worse still, of the 20% remaining half are unavailable, and the other 10% actually don’t perform that procedure at all. That’s the exact scenario a real breast cancer patient faced when seeking reconstructive surgery through her Health Net plan in California. Once the errors were removed from her insurance company’s list, there were exactly zero providers approved to provide her surgery.

Complaints like this got California’s Department of Managed Health Care to study this problem, and they found that nearly 20% of providers listed in Blue Cross’s directory were not even practicing in the locations their websites said they were. A Blue Cross representative said they paid $38 million in claims adjustments during the past two years to write off what would have been surprise out-of-network charges for patients. This shows these errors are frequent—and already costly in terms of frustration and extra costs.

Medicare.gov website physician comparison page
Look for a new focus on keeping provider listings and physician profiles up to date.

Starting with the new year, new regulations allow the Centers for Medicare and Medicaid services to fine insurers as much as $25,000 per beneficiary for errors regarding Medicare Advantage providers, and up to $100 per beneficiary for insurance plans sold through federal exchanges. If other systems have problems similar to the Blue Cross system in California, then there is a new ongoing need for content validation and correction.

Of course, regulation isn’t the only external spur to action. Close to a dozen consumer groups and individual plaintiffs are suing payers over alleged inaccuracies in provider directories. While many organizations “kick data integrity down the road,” expect a new focus on creating service designs to better connect provider listings on insurance sites as well as their hospital physician profiles.

3. Patient reviews will be protected; hospitals may stay under gag rules

A nationwide ban of non-disparagement terms in consumer contracts is making its way through Congress. According to TechDirt, the bill seems to have the support necessary for passage. (I’m surprised that TechDirt is now handicapping legislation, but perhaps this is a sign of the reach of technology or that the regular political pundits are all fixated on national elections, which are nearly a year away.)

If passed, the Consumer Review Freedom Act would enable state attorneys general and the FTC to take action against businesses that attempt to deter complaints about poor customer experiences. Many hospitals are working on ways to incorporate consumer reviews as part of their websites, and although that’s not required, doctors and hospitals would be blocked from making patients sign over their freedom to comment on their treatment.

Unfortunately, this bill won’t apply in a similar way to contracts between hospitals and the businesses that serve them, specifically electronic medical records (EMR) providers. I picked up on this topic from Naomi Fried at Children’s Hospital in Boston, who called out this practice as reported over at Forbes.

A Politico investigation used public records requests to gain copies of 11 contracts between some of the biggest firms marketing electronic medical records and taxpayer-subsidized healthcare organizations. These contracts carried terms forbidding healthcare providers from talking about their experiences using these systems. Of the six biggest EMR vendors, all but one added clauses to restrict what users of these systems may say about them. Healthcare Dive extended this theme, suggesting that EMR gag orders compromise the professional ethics of physicians and the academic independence of researchers.

Yelp reviews for Boston hospitals
Yelp adds hospital reviews featuring ER wait times, patient reviews and more.

Expect health systems to embrace transparency at many levels, including reviews from patients. While many providers are already increasing their customer satisfaction research, some will merge this with opportunities to share their perspective on provider sites.

4. Section 508 accessibility will re-emerge as a priority

You may recall that Section 508 is the part of federal law requiring agencies to make their information technology accessible to people with disabilities. Its goal is to make sure that staff and members of the public who are disabled receive comparable access to electronic information and interaction with the government as the general public.

The digital world has changed since Section 508 was enacted in 1998. The first major revision of Section 508 began its way through the federal rule-making process in 2006, and it’s expected to be finalized this year, a full decade after the refresh effort began. Federal agencies will be given a fixed number of months to make all web systems conform to these revised standards, as well as other parts of the federal government’s connected internet of things.

If anything, the importance of accessibility has grown as mobility and the internet of connected things makes the ability to navigate digital interfaces essential for even basic living. The prospect of driverless cars holds huge promise to many disabled people. Increasingly, managing devices from refrigerators to thermostats requires the use of digital interfaces, which are likely to be subject to this act.

The popularity of mobile devices may provide a design alternative to baking accessibility in to a wide range of connected devices. Mobile technology can conceivably be used as an accessible interface to a wide range of devices. This arrangement of consolidating interfaces to a device may be more convenient for both users and developers. As an example: an oven’s setting can be voiced through a mobile phone speaker, and once a cooking time has been reached the same mobile device can provide an audio or haptic (vibrational) alarm.

Further, organizations that have taken a mobile-first approach to their development will be a step ahead because their data is structured and flexible for use across a variety of devices and application environments.

MyChart smartphone app
Focus on accessibility will go beyond websites and span healthcare IT ecosystem.

While the implementation of refreshed Section 508 rules is over a year away, larger IT organizations will want to stay ahead of this priority. Accessibility expert Tim Springer points out that large departments such as Homeland Security have developed trusted tester programs to help ensure agencies receive reliable and consistent advice from advisors. Many healthcare organizations respond to federal accessibility guidelines, so expect a renewed focus on accessibility beyond websites and across the healthcare IT ecosystem.

Innovation and disruption will continue as usual, but these four high level trends may spur new growth and activity—which smart digital healthcare innovators can anticipate and include in their plans.

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