Presented by James D. Fortenberry, MD, MCCM
Dr. Fortenberry the pediatrician-in-chief was the keynote speaker at the Society for Pediatric Sedation (SPS) Conference 2018 in Atlanta.
Dr. Fortenberry’s keynote addressed the following issues in healthcare:
- The Healthcare Reform Landscape
- Reimbursement-Medicaid
- Behavioral Health Tsunami
- Pharmaceutical Industry
- Imaging
- Hope
The Healthcare Reform Landscape
In 2014 an estimated 22 million Americans received healthcare under the Affordable Care Act (ACA). The expanded coverage cost the US ~46 billion dollars in 2014-2016. Additionally the health and human services (HHS) estimated the US national health expenditure to be ~ 5,000 billion dollars by 2025. While ACA expanded coverage it really didn’t bend the cost curve for providing healthcare. The new era of healthcare under the administration of President Trump was designed to reduce the price of healthcare. The reduction in the amount would be enabled by payers pulling pricing levers to decrease healthcare spending, driving providers to reduce the cost of care. Dr. Fortenberry briefly touched upon alternative models including value-based and risk-based proposals. In December 2017, the ACA was repealed and American Healthcare Care Act (AHCA) was passed. The Congressional Budget Office (CBO) estimated that coverage would increase by 13 million and result in a saving of 338 billion dollars. The AHCA would also eliminate individual mandate policy by 2019. About 47% of Americans are provided healthcare through an employee shared program, whereas 19 % received healthcare through Medicaid and CHIP. Only 4% received healthcare through public exchanges.
Dr. Fortenberry touched very briefly on Medicare Access and CHIP Reauthorization Act (MACRA), which would replace current reimbursement schedule and many value-based care incentives into single Merit-based Incentive Payment System (MIPS). The MACRA increase participation in accountable care organizations (ACO’s). All this means is the consumer is will have to be willing to accept higher deductibles to keep cost down.
Dr. Fortenberry also discussed the Children’s integrated network and its quality evaluation program. Despite consolidation by hospitals, prices were still on the rise and forcing some hospitals to provide innovative scheduling, virtual visits, use of apps, etc. for the provision of primary care. As people look for options, there has been a substantial increase in retail clinics since 2012, which could potentially decrease revenue for hospitals.
Another big shocker slide was the revelation that there was an increasing number of administrators in healthcare and a decrease in physicians. In the future, the fee for service model could potentially change to a value-based care model. The majority of children are covered by private insurance, whereas as 42% were covered by a government program such as Children’s Health Insurance Program (CHIP) or Medicare. The CHIP is based on a state-federal partnership. As of 2017 October, only 31 states and DC have approved for expansion of CHIP.
The Pharmaceutical Landscape
There has been and will be shortages of drugs used for patients including sedatives (e.g., Ketamine) in the future. Facility quality issues, as well as drug quality issues, were the most cited reasons for the shortage. A majority of pharmaceutical manufacturing occurs in Puerto Rico, which was recently hit by hurricane Irma. The disaster caused considerable problems with drugs manufactured in there, feeding into shortages even further. Some pharmaceuticals are fighting to prevent generic agents from being produced by suing to expand patents, which can also increase cost and create shortages.
Behavioral Health Tsunami
There is an increasing need to provide healthcare for children with behavioral issues. Adding to this is the opioid crises epidemic.
Changes in Imaging
The majority of the radiology imaging is slowly shifting towards an outpatient model rather than being attached to hospitals. The impact of the radiology imaging moving towards outpatient model on sedation services reimbursement is unknown.
In the end Dr. Fortenberry emphasized that the future of healthcare is bright. Every obstacle can be an opportunity. Detecting new disease indicators, powering evidence based decisions and precision medicine will transform healthcare.
