Rising Costs of Healthcare and a Government’s Squeeze

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Healthcare reform was only a matter of time. Today healthcare reform is coming in all shapes and sizes and from all forces. Patients, payers, providers, judicial rulings, legislative changes, and costs are all changing the future of the healthcare system.

In the past 12 years, we have seen some of the biggest changes to healthcare, and those changes are only a starting point of what we shall continue to see. The Patient Protection and Affordable Care Act (ACA) started this revolution in the industry with the biggest changes since HIPAA. It opened up the opportunity for Medicaid expansion and public exchanges where more people can obtain healthcare coverage. However, in doing so it also leads to greater costs through the high deductible plans with high maximum out-of-pocket expenses for many individuals. More people became insured but many also ignored the protections of the ACA and the subsidies due to the higher out-of-pocket costs associated with the various plans. Most people never meet their annual deductible or maximum out-of-pocket costs, leading some to question if healthcare insurance is affordable or worth the costs.

As some states expanded Medicaid others looked to place work restrictions on it. Not all states expanded and some even obtained waivers to test alternative approaches that are different than what is required by federal law. Some states, such as California, have even begun creating a state Medicaid-type plan for undocumented immigrants, recognizing that true Medicaid has eligibility restrictions under federal regulations that prohibit undocumented migrants from receiving Medicaid.

Within the past couple of years, the No Surprises Act, Transparency in Coverage, and The Inflation Reduction Act have further changed the future of healthcare. Out-of-network visits for patients for some types of service, provider specialties, or facilities may be treated as in-network for purposes of determining a member’s cost share. Contracts between payors and providers will no longer be confidential as hospitals and payers need to post their contracted rates online. Payers need to create shoppable services along with hospitals to help patients shop around for the best-priced healthcare options. COVID-19 expanded subsidies for individuals to obtain coverage under the exchanges, and additional subsidies will make insurance on the exchange may increase the number of individuals with insurance in the country. Medicare will even have the ability to negotiate drug prices in a few years and cap the out-of-pocket drug costs for Medicare prescriptions.

This comes at the same time that some major rulings have happened at the United States Supreme Court in recent years. The Court has upheld the legality of the expansion of healthcare in this country and other provisions within PPACA, creating mixed reactions on both sides of the political spectrum. Then the Court ruled Medicare twice violated the law through the Administrative Procedures Act with hospitals receiving a disproportionate share as well as a misapplication of the law to treat 340B hospitals differently for purposes of outpatient hospital reimbursement. Finally, the court overturned Roe v. Wade and sent the topic of abortion back to the states to address.

Each of these legislative changes and court rulings has implications for the future of healthcare and costs. Utilization, benefits, reimbursement methodologies, transparency, and drug pricing. The future of healthcare reimbursement includes alternative payment models, such as value-based care, qualifying payment amounts, Medicare solvency and expansion, and public healthcare options. Combine this with a greater need for artificial intelligence and predictive analytics, and the future of healthcare is looking at massive changes. Companies are exploring artificial intelligence to aid business operations, diagnostic testing needs, and treatment options. Predictive analytics are helping better prepare payers and providers for the future needs of patients, chronic condition treatment and testing, and utilization costs.

Are you prepared for the major transformation healthcare as a business is undergoing?

Learning Objective:

• Review the past legislative and policy changes that brought us where we are today in healthcare.
• Explore some of the legal cases and their implications on the future of the healthcare system.
• Uncover some of the future policy and legislative actions currently taking shape.
• Understand what payers and providers are doing and considering to prepare for the future of healthcare reform.
•  Learn about some of the reimbursement methodologies, predictive analytics, and artificial intelligence options available to payers and providers.

Areas Covered in the Session:

• The Patient Protection and Affordable Care Act
• The No Surprises Act
• Transparency in Coverage
• Inflation Reduction Act
• ACA Exchanges and Medicaid Expansion
• Section 1115 Waivers in Medicaid
• State programs for undocumented migrants
• Azar v. Allina Health Services
• American Hospital Association v. Becerra
• Dobbs v. Jackson Women’s Health Organization
• Medicare Solvency and Expansion
• Alternative Payment Models
• Qualifying Payment Amounts
• Artificial Intelligence
• Predictive Analytics and Data Analytics
• Live Q&A session

Suggested Attendees:

• Professionals rendering services in a facility (e.g., hospital, ambulatory surgery center, independent clinical lab, freestanding ER)
• Revenue cycle management (RCM) companies
• Hospitals
• Ambulatory Surgery Centers
• Payers
• Practice Managers
• Collection Companies
• Air ambulance providers
• Ground ambulance providers
• Practice Management

Presenter Biography:

Mike Strong has been working in healthcare for nearly 20 years with payers and providers. He is a former healthcare fraud investigator for the payers with millions in recoveries, a former EMT-B, and a certified coder. His experience includes commercial, Medicare, Medicaid, workers’ compensation, and auto medical claims. With publications and presentations in healthcare coding and billing, Mike has a diversified background in healthcare reimbursement and payment integrity.

At Exponent Health we harness the power of technology to eliminate cost inefficiencies and maximize the value of every healthcare dollar. Driven by an entrepreneurial spirit since 2001, Exponent Health has been challenging the status quo to provide innovative cost containment solutions that improve our clients’ bottom line. Our medical cost containment business utilizes a dynamic cost optimization approach designed to find the best discount, not the first discount. This is supported by industry-leading person-to-person negotiation perfect for high-touch situations. Our pharmacy cost containment business driving lowest net cost strategies through active formulary management, channel optimization, enhanced purchasing power. Everything is supporting with our leading-edge data analytics platform that gives you clarity and insight to actively optimize your business.

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