Bill FeraThis week marks another pivotal moment in the evolution of government-sponsored health insurance exchanges (HIXs). On Dec. 14, states will have reached the deadline to inform the federal government on whether they intend to set up their own exchanges or have the federal government do so.

To date, a majority of discussions have focused on national and state-level political dynamics involved in the advancement of HIXs. However, with an implementation date of Jan. 1, 2014, forward-thinking payers and providers are well under way in their efforts to meet the challenges and opportunities that will result from the entry of an estimated 25 million new patients to the U.S. healthcare system.

Although payers will initially be on the front lines of interacting with these new consumers and in meeting the technical requirements to operate in these exchanges, the onus will ultimately fall on providers to effectively manage and deliver the best care possible to these newly insured patients.

I recently had the opportunity to participate in a webcast focused on the new competitive landscape for payers and providers under HIXs. As part of that discussion, several core challenges that providers can expect repeatedly rose to the forefront.

Exchanges will have a tremendous impact on how providers interact with payer organizations. New payment models such as bundled payments, global payments, and gainsharing are becoming increasingly prevalent in the market. Providers that are successfully adopting patient-centered medical homes and accountable care tenets are being preferentially sought out. Are you attractive to payers? Will you be a coveted member of their network?

Driving behavioral change of patients will be a critical component for success under HIXs. For example, uninsured patients have habitually utilized the emergency department for primary care treatment; how can providers break that habit and guide them to go through normal care channels?

Providers will need to explore innovative ways to collaborate with payers to effectively manage the HIX population. Similar to what we have seen in the early stages of accountable care organizations, the ability of providers to effectively and safely exchange a growing and increasingly diverse array of patient data with payers will be a competency that no provider can be without.

Ultimately, success for providers in this new HIX landscape will inextricably hinge on their ability to meet the greatest demand of the new healthcare ecosystem: reducing costs while improving quality of care. Although the challenges of managing and delivering care under HIXs appear daunting, this influx of new participants into the healthcare system has the potential to accelerate significant improvements in healthcare outcomes. It will also provide vast growth opportunities to those providers who are willing to be both creative and aggressive in applying new solutions and aggressively partnering with payers.
Bill Fera, MD, is a principal, health care advisory services, Ernst & Young LLP.

The views expressed herein are those of the author and do not necessarily reflect the views of Ernst & Young LLP.


Publication Date: Thursday, December 13, 2012