THE FUTURE OF THE HEALTHCARE MARKETPLACE:WHAT’S NEXT?
Ian Morrison PhD
Outline
Looking back at the IHA
IHA Roles
Looking Ahead Political and Policy Uncertainty and Disruption
Scale, Consolidation and Disruption
Employers on the Edge
Consumerism
The End Game
No Matter What
What does it Mean for IHA
IHA Founding Retreat 1994
A group of senior executives from across the California Healthcare system gathered in Napa for a retreat to discuss the creation of a new organization called the Integrated Healthcare Association
Ian Morrison and colleagues from the Institute for the Future facilitated the retreat
The first day of discussion was lively and frank but involved a good deal of finger pointing and was not going that well
The Vision Statement Breakthrough
IHA Proposed Founding Mission Statement
To violently agree on the limited areas of overlap in self interest of our deeply divided membership……
And to keep an eye on the other guys….
So they don’t pull a fast one
IHA Early Days: The IHA DNA
A coalition of the willing who believed in managed care, capitation, integration, delegated risk, primary care, and standardizing approaches to measuring, improving, and advancing the quality and affordability of healthcare for All Californians
IHA Key Roles
Convener
Neutral Truth Teller
Champion of Standards Measurement
P4P
Clinical performance improvement
Force for Value
Atlas as Value Dashboard
Across All Models
Based on data
What the System Needs
Big Tent- All Models and All Payers
Standards
Simplicity
Reduction of Waste Clinical
Administrative
Variation Reduction
Reward Higher Performance but bring everyone up to higher standards
Improve the value of care delivery
Obstacles and Barriers
Political and Policy Uncertainty
Forces of Disruption
Value Fatigue
Recession
Fiscal Meltdown
Employers Self Insured
Institutional Inertia
Geographic variation and Terroir
Three Payers
Three Payers
But ultimately it all comes from households whether as taxes, foregone income at work, or directly as out of pocket costs and premiums paid by consumers
Business Government Households
How Americans Get Health Insurance, 2017
• ACA has impacted a small portion of the insurance market relative to how it is covered in the public debates on health care
• Medicaid is now the largest public insurance program and covers many of the neediest beneficiaries as well as expansion populations
• Medicare is highly valued and Medicare Advantage grows
• Employer-Sponsored health insurance for most Americans and it is the financial lifeblood of the delivery system
Expansion states with Republican governors outnumber
expansion states with Democratic governors, May 2018
WY
WI
WV◊
WA
VA^
VT
UT
TX
TN
SD
SC
RI
PA
OR
OK
OH
ND
NC
NY
NM
NJ
NH*
NVNE
MT*
MO
MS
MN
MI*
MA
MD
ME^
LA
KY*KS
IA*
IN*IL
ID
HI
GA
FL
DC
DE
CT
COCA
AR*AZ*
AK
AL
Independent Governor
(1 State)
States That Have Not Adopted
Expansion (17 States)
Republican Governor
(17 States)
Democratic Governor
(15 States + DC)
NOTES: Coverage under the Medicaid expansion became effective January 1, 2014 in all but eight expansion states: MI (4/1/2014),
NH (8/15/2014), PA (1/1/2015), IN (2/1/2015), AK (9/1/2015), MT (1/1/2016), LA (7/1/2016), ME (TBD) and VA (TBD). Eight states
that have Republican governors as of January 2018 originally implemented expansion under Democratic governors (AR, IL, KY,
MA, MD, NH, VT, WV), and two states have Democratic governors but originally implemented expansion under Republican
governors (NJ, PA). *AR, AZ, IA, IN, KY, MI, MT, and NH have approved Section 1115 expansion waivers. ^Expansion is adopted
but not yet implemented in ME and VA. ◊The WV governor switched parties from Democrat to Republican in August 2017.
REPEAL AND REPLACE IS LIKE BREAKING UP THE BEATLES: JUST KEEP GEORGE AND RINGO AND EXPECT IT TO SOUND GOOD
Subsidies to Medicaid and Exchanges
Guaranteed Issuance
Taxes and Fees RaisedMandates
Stay on Parents Plan
”All you are left with is Ringo” Chris Jennings“Republican policies are ideologically coherent, they just aren’t actuarially coherent.” Ian Morrison
IDEOLOGICAL REPEAL AND REPLACE
TOP STATES IN 2018 EXCHANGE ENROLLMENT
STATE ENROLLMENT (000)
FLORIDA 1,760
CALIFORNIA 1,401
TEXAS 1,227
NORTH CAROLINA 549
GEORGIA 493
PENNSYLVANIA 426
VIRGINIA 410
MICHIGAN 321
NEW JERSEY 295
MASSACHUSETTS 238
MO, WI, NY, OH 238-242
• Use Executive Orders– Association Health Plans– “Across State Lines”– Essential Benefits Erosion
• Cut CSRs (maybe we don’t want them back)• Zero out the individual mandate fine for 2019 and beyond • Cut Medicare and Medicaid Budgets• Give back Obamacare Taxes to rich people in Tax Reform• Don’t enforce the Law• “The Secretary shall”…..Maybe Not• Waiver Authority to states
– Fees for Medicaid– Work Requirements– Short term plans– Essential Benefits/Life time Caps?
• New DHHS Head • Position this as Repeal and Replace, short term• Go for Block Grants long term• Irony: 2018 Signups went well 12.2 million and 80% can
get plans for less than $75 per month, 11 million will effectuate
Sources: Charles Gaba ACA Signups, @Aslavitt, Leavitt Partners
CALIFORNIA CONTEXT
A quarter of all newly insured in the US are Californians California received $20+ billion per year of net new federal money ($15
billion for Medicaid expansion, $5 billion in exchange subsidies) these numbers are growing each year
Roughly a third of Californians are on Medi-Cal (40% in LA County, over 50% in much of the Central Valley)
California has maxed out Medicaid matching dollars using provider taxes and waivers
Currently 65% of Medicaid is paid by the Federal government (historically that was less than 50%)
California has about the lowest rate of provider reimbursement for Medicaid
Kaiser has doubled its Medicaid enrollment program wide since 2013 to 942,000 (up from 377,000 to 709,000 in California alone)
In California 40% price differential North to South on commercial rates HMO higher performing on Value than PPO Medical groups are key to value Covered California is the highest functioning exchange in the country, but
dependent on the flow of federal dollars for subsidies
Sources: KFF, CHCF, Covered California 2017, Kaiser Permanente
California Context
Signals…What Has Changed Since 2017?
• Red signals - repeal and replace failed legislatively, so the ACA lives on (for now)
• Blue signals – the electorate is looking bluer for 2018, with both houses of Congress at least possible to flip, rates will rise as much as 20+% in exchanges (on average 15%)
• Purple signals – conservative states starting to chart a course toward Medicaid expansion
• “Wonk world” is losing interest in value payment – getting impatient to see results, and federal government had put on the brakes (now back on the gas, details TBD)
• Not much pay off on costs and quality from payment reform, ACOs, EHRs etc
• Major disruptive mergers announced, but not much detail on what they will do and how
• POTUS continues to put pressure on drug pricing
• Employers continue to downgrade quality/cost of benefits, and shrink the eligibility pool despite hot economy
• Consolidation has not produced much in the way of savings – diseconomies of scale in research and care delivery
• Status quo is becoming more uncomfortable – costs are still high, but we cut tax revenue while creating conditions that will increase federal spending (i.e.: Medicaid expansion)
2018 Leavitt Partners Annual Strategy Conference
MO
RE
LESS
What is the level and intensity of
our commitment
to VALUEin health care?
2
How much is the COSTof health care creating
backlash among consumers and payers?
3
MORE GOV’T LESS GOV’T
How will we ensure universal ACCESSto insurance?
1SCENARIOS:
Maryland-ish for All
Integrated Value
Market Principles
ACA Lives On
The Scenarios “US Health Care In Mid-2022”
2018 Leavitt Partners Annual Strategy Conference
Scenarios, 2017-2022
Divided government returns, but minor “repairs” to ACA fall short. Moderate to high variation across States, with waivers
encouraging conservative principles in marketplaces and Medicaid.
Political rebound of “blue wave” elections drives partisan solution -cost control emerges as driving force, and administered pricing becomes the vehicle with a strong guiding hand from Washington.
Retain Republican leadership and vision of removing ACA
underpinnings, plus significant Medicare/Medicaid cut back; more
consumer shopping – less volume but more profit.
Triumph of the moderates - declare value to be the currency of health care, with bipartisan public investment to bolster faster
move to value in private sector, accelerate IT standards, empower physicians.
Maryland-ish for All
Integrated Value
ACA Lives On
Market Principles
2018 Leavitt Partners Annual Strategy Conference
HIP Surveys: Overall, how well does your health insurance plan meet your family's health needs?
1% 2% 3% 1% 1% 1% 1% 3% 6% 4%4% 8% 5% 5% 6% 7% 7% 8% 15% 13%
23%
35%30%
25%36% 32% 28%
38%
35% 42%
38%
35%39% 46% 30% 32%
30%
34% 31% 32%
34%20% 23% 23% 28% 29% 34%
17% 13% 9%
Total 2017(n = 4665)
Total 2018(n = 4419)
OriginalMedicare(n = 646)
MedicareAdvantage(n = 324)
MedicaidMCO
(n = 145)
RegularMedicaid(n = 420)
TRICARE/VA(n = 96)
EmployerSponsored(n = 2228)
Governmentexchange(n = 303)
Individual(n = 160)
Extremely well
Very well
Somewhat well
Not very well
Not at all
KEY TAKE AWAYOverall Americans are feeling less secure with their insurance, across all insurance types.
Total Insured 2017-2018 By Insurance Type (2018)
2018 Leavitt Partners Annual Strategy Conference
Employers Now Pay Just 56% Of Expected Employee Medical Costs (Family Policy)
$15,788$7,674
$4,704
Relative Proportion Of 2018 Medical Costs
EmployerContribution
EmployeeContribution
Employee OOP
SOURCE: Milliman Medical Index 2018
Among those with Employer based insurance…
20% ↓
40% ↑
19% 21% ↓
13% ↓
35% ↑
26% ↑ 26% ↓
Not at allconcerned
A littleconcerned
Somewhatconcerned
Very concerned
2017n = 2210
2018n = 2228
2018 Leavitt Partners Annual Strategy Conference
Health Care Is A “Budget Buster” At The Federal Level
SOURCE: Congressional Budget Office
CBO: “Overall the Administration’s proposals would reduce mandatory federal spending for health care by $1.3 trillion (or 8 percent) over the coming decade.”
Healthcare is Top Issue for 2018 Election
Health Care is Top Issue for Democrats and Independents
Majorities Support a National Health Plan
SOURCE: KFF Tracking Poll (March 8-13, 2018)
Even Republicans Favor Medicare As A “Public Option”
SOURCE: KFF Tracking Poll (March 8-13, 2018)
Implications For California
Healthcare: Big Picture Politics And
Policy
Prepare for less financial support from DC for Medi-Cal and exchanges
Anticipate belt tightening in the eco-system, generally as margins tighten
Expect even more consolidation as weaker players capitulate
Anticipate mixed signals on volume to value from CMS
Hope that there is no extreme retaliatory behavior toward California and the Coasts from Trump Administration if Repeal and Replace is really dead
Expect California to push ahead on reform despite all this
Anticipate health reform a big part of next Governor’s agenda
Hope we can come up with something that is simple, easy and actually works
Drivers of Disruption
Money: Private Equity and Venture Capital
Big Corporate and non-profit mergers
New Vertical Integration combinations such as CVS Health-Aetna
Volume to Value Shift and Risk Delegation to Providers
Massive and Relentless transformation to ambulatory environment leads to retailization of healthcare, focus on new players and new settings of care
Specialty Pharma ascendant over hospital inpatient
Technology enablers: AI, Machine Learning, Mobile, Cloud, Blockchain, Voice Recognition, Open Data and API
Fear of New Entrants like Amazon, Apple, Google and Facebook is causing major health systems to disrupt rather themselves rather than being disrupted
Employers on the Edge
The Rise of Consumerism
Employers on the Edge
Self-Insured Employers are the financial lifeblood of the healthcare delivery system
Not exiting in a full employment economy but steady erosion of coverage among small business and low income workers
Reaching limits of Cost-Shifting to employees ….but still doing it
Looking for alternatives
Trying many initiatives to increase value
Stitching together responses
Specialty pharma a key concern
What will they support as policy?
2018 Leavitt Partners Annual Strategy Conference
18%21%
27%
44% 46%
33%
49%45%
26%
45%
59%
58%
45%
55%
49%
58%53%
57% 51%
87% 88% 89% 87%
2010 2011 2012 2013 2014 2016 2017 2018
HIP Surveys: Fewer employers are looking for a way out; continue to feel responsibility for employee health needs
* Asked only of Employers with 50 or more employeesBase: All Employer Health Benefit Decision Makers; 2014-2016 data from Nielsen’s Strategic Health Perspectives (n=340); LP Surveys (2017 n=538; 2018 n=550)Q800: Please indicate your level of agreement with the following statements. Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?
Company’s Position on Employer-Sponsored Healthcare: Providing Benefits(Top-2 Box % - Describes Completely/Very Well)
It is our responsibility to ensure our employees' health needs aremet
My company is actively exploring ways to get out of providinghealth insurance to our employees
Employer-based health insurance will soon become a thing ofthe past
My company feels it is worth it to pay the penalty associatedwith not providing employee health benefits rather thanproviding health benefits to our employees.*
2018 Leavitt Partners Annual Strategy Conference
HIP Surveys: Employers a bit less sensitive about cost sharing in 2018
Base: All Employer Health Benefit Decision Makers; 2014-2016 data from Nielsen’s Strategic Health Perspectives (n=340); LP Surveys (2017 n=538; 2018 n=550)Q1715 To what extent does your company agree with the following statements about employee cost sharing?
Agreement with Statement about Employee Cost Sharing
70%
80%
57%
78%
65%
83%
73%
84%
Employees will accept paying more if wegive tools to be healthier
Cost sharing is an important tool toencourage smarter health care choices
68%63%
71%66%
77%73%76%
62%
We don’t want to burden our employees, but it is the only way to continue providing
benefits
We have reached the limit on our ability toask employees to pay more
2014 2016 2017 2018
55%57% 58%
54% 53%50% 50%
53%50%
52%49%
52%48%* 47% 46%
44% 45% 44% 43%
66% 67%69% 69% 68% 68%
66%63%
65% 66% 65%63% 64%
62% 61% 62% 63%61% 62%
62% 63% 65%63% 62% 61% 60% 59% 59% 60% 59% 59% 58%
56% 56% 55% 56% 55% 55%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
All Small Firms (3-199 Workers) All Large Firms (200 or More Workers) ALL FIRMS
Percentage of All Workers Covered by Their Employer's Health Benefits, Both In Firms Offering and Not Offering Health Benefits, by Firm Size, 1999-2017
* Estimate is statistically different from estimate for the previous year shown (p < .05).
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2017.
California Employers: Cost Sharing
2018 Leavitt Partners Annual Strategy Conference
HIP Surveys: Many more employers believe cost containment initiatives will work
Base: All Employer Health Benefit Decision Makers; 2014-2016 data from Nielsen’s Strategic Health Perspectives (n=340); LP Surveys (2017 n=538; 2018 n=550)Q1709 How well do you think each of the following initiatives will work to contain costs?
Works “Extremely/Very Well” to Contain Costs
41%
38%
34%
32%
31%
31%
31%
28%
27%
27%
26%
26%
25%
24%
23%
Increased emphasis on wellness and prevention
Focus more on primary care
Cost transparency tools for employees to make choices
Aggressive management of specialty pharmaceuticals
Negotiated reference pricing for specific conditions, hospitals
Improved management of behavioral and mental health
Better manage heavy utilizers of care
Centers of Excellence models
Private exchanges
Focus on accountable care / ACOs
Direct contracting with hospitals
Promoting greater use of bundled payments
Narrow network health plans
Expanded use of Patient-Centered Medical Home (PCMH) model
Consumer Directed Health Plans (CDHP)
60%
61%
59%
52%
50%
55%
53%
48%
47%
47%
50%
49%
45%
47%
49%
2016 2018
2018 Leavitt Partners Annual Strategy Conference
HIP Survey: Two in three employers willing to consider insurance provided by local hospital/hospital system; one in four already are.
Consider Contracting with…
Base: All Employer Health Benefit Decision Makers; 2014-2016 data from Nielsen’s Strategic Health Perspectives (n=340); LP Surveys (2017 n=538; 2018 n=550)Q816 Would your company consider offering a health insurance plan provided by a local hospital or hospital system rather than one offered by an insurance company?
14%
7%
6%
19%
34%
19%
2016
Yes, definitely
Yes, probably
No, don't have enoughemployees in onegeography
No, wouldn't trust anyof local hospitals
No , some other reason
Not sure
Local Hospital or System to Provide HI
Yes: 53%
9% 12%5%
4%7% 7%
12% 9%
43%40%
24% 28%
2017 2018
Yes, definitely
Yes, probably
No, don't have enoughemployees in onegeography
No, wouldn't trust anyof local hospitals
No , some other reason
Not sure
Yes: 68%
28% say they have “contracted
directly with health care providers to
lower insurance costs”
Five Dimensions of Consumerism
• Increased use of transparency and consumer navigation tools to guide choices
• Importance of consumer experience to providers and plans, both in terms of patient acquisition, retention and loyalty, as well as patient satisfaction
• Ever higher expectations of service industries driven by their positive experience with high-technology–enabled consumer offerings
• Consumers need to be more proactive and engaged in their own health and wellness
• Rising out-of-pocket cost burden
Source: S. R. Collins, M. Z. Gunja, and M. M. Doty, How Well Does Insurance Coverage Protect Consumers from Health Care Costs? Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016, The Commonwealth Fund, October 2017.
MORE THAN ONE-QUARTER OF INSURED ADULTS WERE UNDERINSURED IN 2016
1213
2223 23
28
0
10
20
30
2003 2005 2010 2012 2014 2016
* Underinsured defined as insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income.
Data: Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, 2014, and 2016).
Percent adults ages 19–64 insured all year who were underinsured*
Source: S. R. Collins, M. Z. Gunja, and M. M. Doty, How Well Does Insurance Coverage Protect Consumers from Health Care Costs? Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016, The Commonwealth Fund, October 2017.
Percent adults ages 19–64 insured all year who were underinsured*
2003 2005 2010 2012 2014 2016
Total 12% 13% 22% 23% 23% 28%
Insurance source at time of survey**
Employer-provided coverage 10% 12% 17% 20% 20% 24%
Individual coverage^ 17% 19% 37% 45% 37% 44%
Marketplace^^ — — — — — 44%
Medicaid 22% 16% 32% 31% 22% 26%
Medicare (under age 65, disabled) 39% 24% 45% 32% 42% 47%
Firm size (base: full- or part-time workers with coverage through their own employer)^^^
2–99 employees — 14% 16% 26% 26% 22%
100 or more employees — 11% 16% 16% 14% 22%
UNDERINSURED RATES BY SOURCE OF COVERAGE
* Underinsured defined as insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. ** Adults with coverage through another source are not shown here. Respondents may have had another type of coverage at some point during the year, but had coverage for the entire previous 12 months. ^ For 2014 and 2016, includes those who get their individual coverage through the marketplace and outside of the marketplace. ^^ Adults enrolled in marketplace coverage are not shown for 2014 because no one in the sample would have had marketplace coverage for the full year. ^^^ Does not include adults who are self-employed. — Data not available.
Data: Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, 2014, and 2016).
Shallow-Pocketed Consumers Create Challenges And Opportunities
• Consumer/Patient experience matters in value payment for all payers
• High Deductible Care becoming norm In employer sponsored market and exchanges
• HDHP is a blunt instrument and applies to pediatrics too*
• Consumers (particularly women) are becoming key decision-makers in selecting services under these budget constraints
• Loyalty can be bought/changed through cost sharing
• Increased Competition for the Out of Pocket dollar from worksite clinics, retail clinics, pharmacy and free-standing urgent care, ERS and micro-hospitals
• Self-Insured using new channels for employees e.g. Lemon-Aid, Book MD and Omada
• Convenience is key to many consumer choices
• Considerable competition and cream skimming potential by income and geography
• Potential disruptors from Amazon to Apple
• Retail Clinic and Urgent Care activity may be additive not substitutive
• Raise Issues: “Fragmentation of care, relevancy, loyalty, and patient flow”
* Fung et al JAMA Pediatr, 2014 Jul:168(7):649-56
CVS-Aetna becomes CVS Health
• Retail Pharmacy with Clinic Footprint acquires national insurer with ACO and data expertise
• Vision of local footprint for chronic care management and health and wellness
• Execution risk• “Beyond Pink Eye”• Health and Wellness as Substitutive
versus Additive to Medical Care• Specialty pharma and PBMs are in
cross-hairs of national employers• Intense competition for wallet share
of shallow pocketed consumers • Whose problem does this solve?
Cigna Buys Express Scripts
• CIGNA agree to buy Express Scripts for a total of $76 billion ($52 billion in cash and stock , $15 Billion in assumed debt)
• “When we think about Express Scripts, it has PBM capabilities, but it has 27,000 individuals and a significant number of consumer touchpoints around health and well being,” Cigna CEO David Cordani said in an interview Thursday morning. “It expands our service portfolio beyond that of a PBM.”
• Cigna began exploring the tie-up seriously late last year, Mr. Cordani said. One of the drivers for the deal is its ability to broaden Cigna’s offerings and reach. “Having the capabilities to serve an individual whether they are healthy, healthy at risk, chronic or acute is important,” he said.
• Cigna shareholders will own about 64% of the combined company, which will retain Cigna’s name, and Express Scripts shareholders will own about 36%.
Source: WSJ, March 8th, 2018
Amazon, Berkshire Hathaway, JP Morgan Chase
Big Brands come together and announce joint venture to disrupt healthcare for own employees, insurers stock price hit immediately
But….. 1 million lives is less than 1% of privately insured spread all over the
country Can they really scale technology and innovation in an industry that has
resisted it? What can they do about price, absent concentrated local clout?
JP Morgan CEO reassured banking clients in health insurance this is just a GPO deal
Long history of “Cranky, Confused, Aimless and Spineless Employers”
Employers own the margin in healthcare
But they struggle to apply power in collective action and reluctant to risk their own brand in being tough on healthcare
They can innovate and pilot
Atul Gawande will attract followers and partners
You need CMS as the big dog changing the game at scale
OPTUMIZE
Source: The Healthcare Blog, Dec 13, 2017 Tory Wolff, Recon Strategies
The End Game
Integrated Care Integrated Health Systems of different flavors built around Medical Groups “Fair share” of Medicaid and the Uninsured allocated through auto-enrollment Targeted total cost of care targets tied to economic growth Increased focus on population health Large Self-Insured Employers given flexibility
Medical Darwinism 50+ million uninsured Best care in the world based primarily on ability to pay Doctors walk away from the poor Widening performance disparities within and between states
Single Payer “You are not Canadian” FFS Hamster Care Massive transfer of income from rich to poor Reduce the prices and incomes of all actors through government monopsony “Balloon in a Box” Change the mix: Get Rid of the Specialists Good Luck With That
No Matter What: Pursue The Value Agenda
Focus on getting the cost structure down in healthcare delivery Culture: Make it everyone’s problem
Engagement with medical staff on physician sensitive preferences
Cost Discipline as a strategic priority
Waste avoidance, clinical standardization and variation elimination
Labor substitution such as scope of practice extenders, telehealth and alternate sites
Partnering for Long Term Risk Delegation Gov. Leavitt “25 Years in to a 40 Year Journey to Value”
Medicare Advantage for All?
Managed Medicaid for more?
Self Insured Employers: Will they go direct?
Focus on 5/50 Segmentation and Analytics
Social Determinants of Health
Scale Scale matters in health insurance, PBMS, Supply Chain, Capital Creation but is it key for
providers?
For providers: You need to be big where you are but be prepared to partner with others
Local Terroir varies
What does it mean for IHA?
Key Opportunity for All Payer Value Measurement and Improvement infrastructure
The Prisoners Dilemma: A Better outcome is possible with collaboration
How do you standardize when no one is in charge?
Self-Insured Employers need to be on board
Measurement and Performance Improvement in retail healthcare
Disruption is real Elections
Market disruption
IHA DNA still matters