Question

What are the major forces shaping health insurance and managed care today? Provide examples and references.
Describe the forces that shaped health insurance and managed care in the past.
How did managed care and insurance come into the United States marketplace?

Answer 1

What are the major forces shaping health insurance and managed care today?

There are significant regulatory, cultural, and business-related trends that are changing the face of healthcare in the U.S. today. To ensure that continuing medical education (CME) remains relevant to today’s healthcare professionals and their patients, CME providers must first understand the forces that are driving change in the way healthcare is now perceived and delivered in the U.S.

As the Affordable Care Act has taken effect, healthcare organizations must become performing accountable care organizations (ACOs), to be competitive. Those who plan medical and healthcare meetings are feeling the impact of that altering landscape and its new requirements. Simultaneously, healthcare professionals must deal with cultural and business-related forces that also are reshaping healthcare.

All medical meeting planners need to take a hard look at these six forces changing the healthcare industry in the U.S. “Use them to shape your executive decision-making,”.

Here are the six major factors driving healthcare from a transactional industry to a wellness model:

1. Costs
With the Affordable Care Act in place, more than half of the 40 million previously uninsured Americans have affordable access to healthcare — resulting in greater demands for healthcare providers. The rising cost of U.S. healthcare is a significant factor driving change, with Americans projected to spend $3 trillion on healthcare this year. The United States spends more than any other developed country in the world on healthcare. “We are the only developed country in the world that does not have some flavor of a single-payer model, and we have a fairly strong lack of transparency of pricing in this country,”.

2. An Aging Population
According to the Pew Research Center, there are 79 million baby boomers, which is estimated to account for 26 percent of the population of the United States. These 79 million people are expected to live longer than any previous generation, with many of them needing continuing medical care for the rest of their lives. A report published by the University of Albany’s Center for Health Workforce Studies shows that as people age, they use a disproportionately large share of healthcare services. A larger population of all ages also translates into a greater demand for healthcare providers.

In 2010, the population of people age 65 or older was 39.4 million; fast forward 10 years to 2020, and that number could rise to 53.2 million. It’s been forecasted that by 2020, there will be 3 million jobs in nursing and senior care alone, compared to only 2.4 million today. So, what does this all mean? Well, healthcare talent management professionals will continue to battle head-to-head with their peers in the “war for talent.” “As a result, the biggest growth areas for employment will be home health aides, geriatric nurses, physical therapists and similar jobs,”.

3. Changing Relationships
Consumerism in the healthcare industry is an inescapable growing trend. In fact, a study from Wolters Kluwer Health shows that a whopping 86% of consumers believe proactivity on their part is critical in ensuring high quality care and outcomes. Patients are increasingly taking an active role in their care experience and are evermore empowered to choose their own care alternatives. “Patients are becoming more like consumers due to the decreasing levels of direct contact with medical professionals,”. Patients can order refills, schedule appointments, consult with their primary care physicians, and more, all through online patient portals.” This growing connection to technology will likely increase demand for medical assistants, medical secretaries, and IT staff.

4. Drugstore Clinics
The United States currently has about 1,600 small clinics in drugstores, such as CVS and Walgreens, and that number is projected to increase to 3,000 in the next five years. These clinics provide a growing number of services, treating sprains and shingles, administering pregnancy tests, doing diabetes monitoring, and much more. “I was talking to a VP of HR about a month ago, and she was telling me that she is directly competing for nurse practitioners against CVS and Walgreens in her community,”. “It’s a direct competitive threat for the labor pool, and it’s only going to increase over time.”

5. Technology
Growing advances in medical technology (i.e. brain implants controlling epileptic seizures, colonoscopies done with a pill camera, and medical staff remotely monitoring a patients’ vital signs) will significantly impact healthcare recruitment and employee education and training due to the specific skill-sets needed to carryout these advanced methods of care delivery. And technology us only going to continue to evolve.

6. Opposing Models
The current fee-for-service model is in direct conflict with the growing patient-centered, or population wellness, model. “With one, you get more money for more tests, more procedures, more admissions; the other, you get more money for keeping people out of the hospital, getting tests, procedures, and so forth,” Segall said. “They are in direct opposition to each other, and the CFOs are trying to create this balancing act.” But the general consensus, he said, is that in five to 10 years, the balance will reverse dramatically, across the board.

“We are moving from a transactional model to a wellness model, and we can’t stop it,” adding that while the Affordable Care Act is behind some of these changes, in general it has nothing to do with them. “The insurance companies, which are a major payer today of our salaries, were forcing provider organizations into bundled payments or population management even before the Affordable Care Act, and it’s continuing to happen today.” The future model will transform hiring in healthcare, with changes in existing jobs, substantial increases in the need for certain jobs, and additions of emerging jobs such as population health navigators and data analysts.

Strong employee professional development programs, the transformation of learning and performance management, and the optimization of processes are key areas where healthcare providers make a difference. Perhaps the most important focus area and where healthcare talent management professionals can have a tremendous impact is in employee engagement by acting on the results of their employee engagement surveys. It’s up to talent management professionals to develop future leaders who have the right healthcare competencies for the new wellness-based model of healthcare – people who have clear visions, are innovative and strategic, communicate well, and are persuasive and inspirational. These attributes and competencies should exist throughout the healthcare organization. If healthcare providers can transform their organizations to fit the wellness model, “beautiful things will happen.”

Describe the forces that shaped health insurance and managed care in the past?

In the past, health care spending has grown more rapidly than any other sector of the economy. Another way to view the rapid growth in expenditures, is to examine national health care expenditures in relationship to the GDP. For the past 40 years Americans have seen steady cost increases in excess of the growth of the rest of the economy. Health care's share of GDP went from 5 percent in 1960 to nearly 14 percent in 1990. Though stabilizing somewhat, the figure is anticipated to reach 15.6 percent or higher in 2010.

A variety of factors have influenced this rapid and significant growth. They include:

• Growth in the U. S. population, as well as an increasing number and percentage of elderly people in the population;
• Increases in key health care technologies and related costs;
• Growth of allied health care professions;
• Increased reliance on drugs and related pharmaceutical costs;
• Rising cost of individual and family health care insurance; and
• Higher malpractice insurance, case settlements, and jury awards.

Data on rising costs indicate the need for some type of action. The action taken by a health care system seeking correction and balance has been to look for ways to contain costs.