WASHINGTON — Healthcare companies that offer integrated care services are the ones most likely to succeed in today’s business climate, Sheryl Skolnick, PhD, said at the annual “Wall Street Comes to Washington” conference.
For example, Optum, a division of health insurer UnitedHealth Group, “is looking at the patient in totality and seeing what services need to be delivered, where they need to be delivered, and what’s the appropriate price to pay for that,” Skolnick, managing director of Mizuho Securities USA, said at the event, which was sponsored by the USC-Brookings Schaeffer Institute for Health Policy and the Jane Koskinas and Ted Giovanis Foundation for Health and Policy.
Optum and its parent company offer a health insurance plan and a pharmacy benefit management (PBM) service, “so some of the contract wins of its OptumRx [division] are precisely because they’re able to do the synchronization of the health event with the pharmacy event, and the data around it,” she said. “They’re not just trying to price the treatment; they’re trying to price the [entire] episode of care efficiently.”
Optum’s advantages could be bad news for other competitors, she added. “Anthem is behind the 8-ball on the PBM … and if you’re a PBM and don’t have the health plan integration aspect, you’re really missing the boat on data and integration, and the way you gain market share is by [integrating more].” Anthem, which owns a number of Blue Cross Blue Shield health insurance plans, recently announced it had created its own PBM, IngenioRx.
Ana Gupte, PhD, managing director of Leerink Partners, agreed there is an “Optum wannabe thing going on.” In particular, CVS is facing a lot of challenges in its business, she added. “CVS’s sales have been extremely challenging” in its brick-and-mortar stores.
But Matthew Borsch, managing director of BMO Capital Markets, was a little bit more cautious. “For OptumRx, their account wins have mostly been a type of carve-out pharmacy PBM accounts,” he said. “It isn’t clear that large employer purchasers have necessarily yet embraced the model of, ‘OK, we want everything in one basket, one carrier managing the medical and pharmacy side.’ That could very much be where we’re going, but we haven’t seen evidence yet that it’s resonating in the marketplace.”
In terms of what employers are looking for, “anecdotally, I’ve heard less appetite for a higher deductible” in a health plan, said Gupta. “There is some sympathy for workers and what they pay out-of-pocket … Most employers will [still] offer you a choice of a preferred provider organization (PPO) versus a high-deductible health plan.”
Moderator Paul Ginsburg, PhD, director of the USC-Brookings health policy organization, noted that narrow networks were another tool being used to lower employers’ costs.
But that solution can create problems, Gupta said. “The biggest constrain for the managed care organization is that although they’re tasked with bending the cost curve, employers [still want] employees to have access to [highly rated] facilities like Cedars Sinai and UCLA [University of California Los Angeles],” she said.
Skolnick said she’d prefer to call the current movement a “narrowing of networks as opposed to true narrow networks,” noting that they often get a lot of resistance.
“United had the embarrassing situation of having some of the worst star [ratings] of publicly traded companies, and they discovered they really had to assess physicians, and encourage them to follow protocols and narrow gaps in care,” she said. “When they started to kick doctors out of the network, do you know what the doctors did? They sued. Pushback on narrow networks is a real issue in some cases. Ultimately, they were were able to narrow networks a lot, and outcomes did improve.”
New alternative payment incentives are now beginning to appear on the gerontology front in Medicare Advantage, and they are incentivizing hospice care to improve quality of life for terminally ill patients, she said. “The doctor is choosing to make that [hospice] choice even 2-3 weeks earlier when they know the patient is terminal, and it can have a dramatic impact on cost. If you give the doctor some structure that rewards them for quality of life — not necessarily cost savings — you can achieve that outcome.”
But health plans that are considering changes in the way they pay physicians don’t always say much about it. “Every time you change how you pay doctors, they tend to yell and scream a lot,” Skolnick added. “So you research the model very intensively and select a forward-thinking group of physicians to pilot with, and then announce it after the pilot is done. So these pilots may be going on, and we don’t know it.”
On the other hand, there are some areas of care that are not on the healthcare companies’ minds as much, including the opioid crisis, Borsch said. “It is obviously something that has taken a great human toll and is a national emergency, but at the level of impact on healthcare costs and utilization, it hasn’t been that much of a mover of anything at a fundamental level for either providers or insurers, so that’s why it’s gotten less attention from investors in those sectors.”
Healthcare reform and repeal-and-replace also aren’t hotly discussed subjects, said Skolnick. “We don’t talk about reform on conference calls any more … The publicly traded companies on Wall Street have essentially moved on from this issue — not because it’s not important what happens here, but because they’re helpless and [can just] stand back and watch the chaos.”