Inside Managed Care Today

Those working in the healthcare industry are dealing with many challenges these days as the industry attempts a complete overhaul in the wake of the Affordable Care Act (“ACA”).  Executives working in managed care are far from being immune to such challenges.  Some of the key challenges in managed care include: transitioning to value-based payment, figuring out how to better use data, addressing rising pharmaceutical costs, responding to healthcare consumerism, and adjusting to industry consolidation.

Below are some highlights of the recent 2015 State of the Industry Survey conducted by Managed Healthcare Executive.  The survey garnered responses from over 600 executives at health plans, health systems, and pharmacy benefit organizations.


  • The top two diseases respondents are focused on for 2016 are diabetes (67%) and cardiovascular (60%), followed by obesity (41%), cancer (40%), and respiratory illness (34%).
  • 55% think the ACA is mostly good, but not all good; 32% feel the ACA has been a mistake.
  • 60% are currently using business intelligence and analytics; 51% are using patient registries.
  • 47% utilize health information exchanges to share data with other organizations.
  • 34% use telemedicine. (Sadly, this is rather low.)


Value-Based Payment

  • 35% have started a few initiatives.
  • 19% have not yet started and are waiting to see what works for other organizations.


Using Data

  • 54% feel they have come a long way but still have a lot of work to do; 27% stated they do not use data very well and are confused about how to fully utilize big data.
  • 37% noted difficulty turning data into actionable information.
  • 26% cited issues with securing appropriate funding for IT initiatives.
  • 14% feel they have a problem with keeping patient data secure. (Surprising percentage.)


Drug Costs

  • 24% believe that government interference is the best way to control rising drug costs; 23% feel the focus should be on integrated pharmacy and medical benefits.
  • 19% stated the focus should be on utilization management.
  • 15% claimed that cost-effective pharmacy plan design would have the biggest impact on drug costs.


Healthcare Consumerism

  • The top two patient-centered areas respondents are focused on for 2016 are: expanding customer service improvement initiatives (60%) and increasing consumer outreach (53%), followed by expanding consumer relationship management capabilities (43%).
  • 34% are focusing on more cost transparency. (So, not much industry headway being made yet.)
  • 54% believe that incentives/wellness programs are the most effective way to increase consumer engagement in managing their own health; 16% feel the focus should be on increasing awareness of free healthcare services; 14% stated remote patient monitoring / mobile health would be most effective.


Industry Consolidation

  • 54% stated the increase in consolidation of providers and payers will lead to higher overall healthcare costs.
  • 33% believe the consolidations will lower overall healthcare costs.


More on the survey can be found here.



Contact ABISA, a consultancy specializing in solo and small group practice management.  Visit us at

Before You Get Started in Telemedicine

Many practices are hearing about telemedicine and becoming increasingly interested in how such a program could be implemented in their operations. Physicians want to start a telemedicine program quickly. Practice managers don’t want to learn by trial and error.

The biggest issue I see by far is that practices immediately focus on the technology. This often leads to two problems: they either become overwhelmed by the plethora of options available and end up not pursuing telemedicine, or they choose poorly and the technology quickly becomes unused. Consequently, I tell clients to ignore the technology that is available for starters. There are many more important things to consider in order to have a successful telemedicine program, and you will then be less likely to overspend or purchase equipment you don’t need or can’t use. Here are four items practices should carefully weigh before jumping into telemedicine by purchasing technology first.

1.  Legal requirements

Because of the way telemedicine adoption is currently happening in the United States, practices must look into a host of legal requirements, especially as the requirements pertain to applicable state law. Although there are some exceptions, physicians usually must be licensed in the state where the treatment or diagnosis is being provided. Many malpractice insurers will now cover telemedicine, but that conversation must be had with your particular carrier so they can look at the various risks involved. As with other areas of healthcare, privacy, consent, and regulatory compliance must be thoroughly evaluated by a healthcare attorney. Additionally, I would strongly suggest that your proposed telemedicine program be reviewed by a telemedicine consultant and healthcare attorney to ensure it is vetted for potential fraud and abuse.

2.  Reimbursement assessment

Currently, reimbursement (governmental and commercial) continues to be a barrier to telemedicine adoption in some (but not all) states. The type of telemedicine services you are proposing as well as the type of setting needs to be examined through the lens of the state(s) where services will be rendered, as well as the portfolio of applicable payers. Even though there may be restrictions that affect billing practices (and thus reimbursement), there are ways to get “paid” (e.g. subscriptions, etc.) for telemedicine services in lieu of reimbursement.

3.  Market analysis

Telemedicine has many applications and uses, so a first task is to determine what the needs of your patients are and how telemedicine could address them. This step is a very detail-oriented process which will help identify potential telemedicine opportunities. A qualified consultant will help educate you about telemedicine technology applications which may apply to your potential goals, as well as educate you about predictors of success and best practices.

4.  Feasibility study

The implementation of telemedicine services to your existing practice will certainly impact your operations. Some items to consider are the time you could save by implementing telemedicine, how you expect the telemedicine program to tie into your regular in-person practice, and what type of clinic hours you will devote to telemedicine.

There is no such thing as a standard telemedicine program. Consequently, it is extremely important to take the time to develop a telemedicine strategic plan first, as there are many nuances to consider as they relate to your particular practice. Hiring a consultant to help guide you in the right direction will be money well spent, especially given that such an endeavor will change your practice operations, including your marketing and financial operations.


Contact ABISA, a consultancy specializing in solo and small group practice management.  Visit us at

Dental State of the Union

The U.S. economy as well as the rapidly changing healthcare delivery system has taken its toll and dentistry in the United States is in a period of transition.  “Mastering the business of dentistry is still the greatest challenge faced by today’s dentists,” stated Dr. Roger Levin.  “This lack of business knowledge and skills prevents doctors from reaching their full income potential, costing them hundreds of thousands in lost earnings throughout their career,” says Dr. Levin.

The Dental Economics / Levin Group Annual Survey and Research Report was recently published.  This ninth installment of the dental practice survey received a record number of responses.  Here are some highlights of the 2015 survey’s findings:

90% of respondents report working full time; last year that figure was 80%.

88% of those surveyed expect to be 61 or older when they retire.

74% reported using social media to market their dental practices.

64% claim to expect ending up 2015 with higher production than in 2014.

56% stated they have increased their number of active patients during 2015.

44% reported satisfaction of being their own boss.

40% of those surveyed stated they are increasing the use of third-party financing.

32% of respondents stated that their most difficult problem as a practice owner is identifying improvements for inefficient systems.

The survey also found an increase of elective treatments, which now make up over 28% of production.  Proponents of effective marketing will find interesting the analysis of social media.  The report shows that practices engaged in social media acquired nearly 38% more new patients than those practices which did not utilize social media.

Dr. Levin notes that “the dental profession as a whole is mired in a production plateau” and “practice growth now requires a higher level of business knowledge and skill than in the past.”  Correspondingly, the survey found that a mere 6% of dentists like managing the business aspects of their practices.

This year’s survey as well as past surveys can be found here.


Contact ABISA, a consultancy specializing in solo and small group practice management.  Visit us at

Healthcare Spending Review

The Centers for Medicare and Medicaid Services through the Office of the Actuary recently released detailed data on 2014 healthcare spending in the United States.  Within CMS are the National Health Expenditure Accounts (“NHEA”).  The (NHEA) are the official estimates of total health care spending in the United States. Dating back to 1960, the NHEA measures annual U.S. expenditures for health care goods and services, public health activities, government administration, the net cost of health insurance, and investment related to health care.  Here is a high level overview of the released 2014 data:

Healthcare spending grew $3 trillion in 2014, a growth rate of 5.3% after 5 years of historically low growth.  The new growth is attributed primarily to coverage expansions under the Affordable Care Act.

Over $991 billion was spent by private health insurance which accounted for 1/3 of total national healthcare expenditures.  Contributing factors include increased enrollment and faster growth in spending for retail prescription drugs, physician and clinical services, and hospital care.

Nearly 8.7 million more people had health coverage in 2014, increasing the insured share of the population from 86% in 2013 to 88.8% in 2014.

It is estimated that $9,523 was spent per person on healthcare in 2014.

Approximately 17.5% of the nation’s gross domestic product (“GDP”) was attributable to healthcare spending in 2014; in 2013, it was 17.3%.

The growth rate of retail prescription drug spending was 12.2%.  The nearly $298 billion spend represents the largest increase since 2002.

The growth rate of hospital spending was 4.1% or nearly $972 billion.  The higher growth rate is attributable in part to increased use and intensity of hospital services due to coverage expansion, which was reflected in the faster growth of Medicaid and private health insurance spending.

More detailed data behind the healthcare spending can be found here.


Contact ABISA, a consultancy specializing in solo and small group practice management.  Visit us at