As the landscape of healthcare changes at lightning speed, stakeholder organizations from every group in the constellation—the public and private purchasers and payers of healthcare, pharmacy benefit management (PBM) companies, providers of all types, and consumers—are being affected by constant disruptions.
One has been unprecedented business deals, such as the announcement Dec. 5 that mega-pharmacy retailer CVS is acquiring the Hartford, Conn.-based Aetna, one of the nation’s largest health plans—deals that are potentially reordering the contracting and operational landscape for employer-purchasers, health insurers, PBMs, retail pharmacies, hospitals, physicians, and consumers, alike—in unanticipated ways.
Meanwhile, organizations like the Berkeley, Calif.-based Catalyst for Payment Reform are working to prod forward the journey towards value in healthcare, as evidenced by an announcement Dec. 4 that the organization had created a new vehicle for understanding accountable care organization (ACO) contracting terms. A press release on that date stated that, “Catalyst for Payment Reform (CPR) today called on employers and other health care purchasers to unite in holding health plans accountable for the performance of their accountable care organizations (ACOs) by asking them to report a consistent set of performance metrics to their employer-purchaser customers—as easy to read as a nutrition label.”
As the Dec. 4 press release explained it, “To drive this change, CPR released a unique set of resources called Standardized Plan ACO Reporting for Customers (SPARC) that employers, state Medicaid, employee and retiree agencies and other health care purchasers can use to assess their health plans’ strategies to use ACOs to improve the delivery of care and make it more affordable. CPR developed SPARC in conjunction with Willis Towers Watson and major health care purchasers to answer growing purchaser demand for greater transparency into ACO design and performance. Purchasers put the onus on health plans because they rely on them as their agents in the market place.”
The press release quoted Suzanne Delbanco, Ph.D., CPR’s executive director, as saying that “Purchasers want better, more affordable care for their employees, and ACOs offer a potential way to bend the cost curve while also addressing patient needs more holistically. Unfortunately, they lack a standard, meaningful way to measure and compare ACO performance, which makes it difficult to justify the additional fees and potential disruption for employees that ACOs can generate,” Delbanco said. “SPARC offers a robust way to dissect and evaluate a health plan’s ACO arrangements so that purchasers know whether they are getting good value for their populations and for their health care spending.”
Suzanne Delbanco, Ph.D.
Dr. Delbanco spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding both subjects, following the release of the SPARC announcement on Monday. Below are excerpts from that interview.
Let’s begin by discussing the CVS-Aetna deal. What are your perspectives on it, and on its potential disruption to established patterns of activity among the various healthcare stakeholder groups?
At the heart of it, the question is whether or not this relationship will be good for those who use and who pay for, healthcare. And I always worry on behalf of employers when consolidation occurs, because it rarely leads to lower costs or a better healthcare system. That said, this is not a typical horizontal merger or acquisition within the same space. So it’s possible that there could be better continuity or coordination of care, by bringing together a health plan with a retailer and PBM; only time will tell.
Consolidation has not necessarily led to greater value, then? That is a perspective held by many—when speaking of health plan and provider consolidation.
We know for sure in the healthcare provider space, that when there’s consolidation, that prices go up, and there’s no evidence that quality gets better; in fact, there’s some evidence that it gets worse. In the health plan space, there’s some evidence that consolidated health plans can do a better job at negotiating for lower prices; but what ultimately is a problem for both the employer and consumer, is that there are fewer and fewer choices—when you chose a PCP [primary care physician], specialist, or treatment, that there’s less and less competition involved that can lead better choices and offer lower prices. That’s what I worry about here; hopefully, they’ll create a nirvana of healthcare. But based on past evidence, unfortunately, this is not guaranteed.
One of the aims of Aetna leaders, according to news reports, is the potential for better pharmacy benefit management, based on a closer integration of health plan, pharmacy benefit management, and retail pharmacy operations interactions. What do you think about that potential?
I think we have a mess right now in the pharmacy space. Everyone likes to point fingers: it’s the pharmaceutical companies, it’s the PB managers, it’s direct-to-consumer advertising. But whether or not this creates greater value, will depend on relationships that CVS has with manufacturers, among other factors. So I don’t know that it’s a done deal, that they’ll instantly move to the highest level of value in this context.