Question

The role of the U.S. court system has become increasingly important over the year for healthcare leaders. In this assignment, you will explore the critical points at which the U.S. courts may serve as a referee and the role of the federal and state courts impact healthcare policy. List what you believe to be the top 2 biggest challenges facing healthcare leaders as it relates to the involvement of courts in healthcare.

Answer 1

Challenge #1: Complying with government requirements and mandates

Adhering to government requirements and mandates tops all challenges. Addressing this question at this point requires more precision because the government is deconstructing the broader legislation and taking on various components of it. We actually know quite a bit about where things are headed; we just don’t know exactly what form they will take. Most importantly, customers (i.e., consumers, employers, and both state and federal government entities) are not willing to absorb continued increases and are being proactive about pulling every lever at their respective disposal to manage costs. On the payer side, the public exchange is an important channel, but it will require continued government support to be sustainable. For providers, must be focusing on delivering consistent, integrated, high-quality care. In the short term, the economics will have some volatility but over time, the rewards (i.e., customer loyalty, strategic partnerships, and expansion opportunities) will accrue to organizations demonstrating the greatest value propositions.

Challenge #2: Implementing value-based reimbursement

One reason organizations struggle in this area is that today’s fee-for-service system is not well aligned to deliver true value-based care, and for most provider and payer participants, most business remains fee-for-service. The country continues to tolerate fee-for-service and annual reimbursement increases. “Until that changes, we can’t really expect payers and providers to make the change.

Secondly, delivering value-based care requires different infrastructure, work flow, and information than what has been in place historically, all of which require investment. Some examples of this include physicians needing to collaborate, integrating clinical and financial data, and having the capability to evaluate, negotiate, and administer risk-based contracting arrangements. To date, the return on such investments has been elusive.

Thirdly, even after a decision is made to move a business model to value-based pay, data and insights needed are not easy to obtain and often considerable lag time occurs when compiling it.

For years, major national carriers have served as the administrative and network partner for employers’ self-funded plans. They typically have deep knowledge and extensive relationships with employer decision-makers, and have been the first to introduce value-based arrangements to employers. “However, value-based care requires intensive clinical collaboration and a patient-centered focus, and carriers have been challenged to effectively drive these changes at health systems within their networks,” he says. “While there have been some success stories in driving value by carriers, through their experience in fully insured markets as well as with specialized buy-up care management programs, their role as intermediaries limits their ability to drive the clinical and operational changes required at the health system level.”

To succeed in the value-based world, health plan leaders need to develop a frank, honest perspective on where they have a unique, sustainable advantage for both payers and providers in the value-based world, and build their services and solutions around their strengths, says Bresler. For example, in some markets carriers may have an extremely well-developed network of hospitals and providers that offer high-quality, low-cost care. Their network depth and breadth can be leveraged in developing value-based offerings.