How to Thrive Amid Uncertainty — Law, Policy and Growth Strategies for Health System Success in 2024

Clearway Health
March 26, 2024

A Becker’s Webinar Q&A with Health Law Strategists and America’s Essential Hospitals

 Clearway Health recently participated in a Becker’s Hospital Review webinar on How to Thrive Amid Uncertainty — Law, Policy and Growth Strategies for Health System Success in 2024.

Joining the panel were:

·       Laurice Rutledge Lambert, founding partner of Health Law Strategists, an integrated legal and strategy team partnering with healthcare leaders to help guide organizations through the ever-changing regulatory landscape.

·       Beth Feldpush, senior vice president of policy and advocacy from America's Essential Hospitals, a leading association for hospitals dedicated to providing equitable and high quality care for all, including those who face social and financial barriers to care.  

·       Nicole Faucher, MS, president of Clearway Health, a company that partners with hospitals and health systems to build or strengthen specialty pharmacy programs by eliminating barriers, improving access to care, personalizing support and ensuring ability to access timely medication.

‍Question and Answer:

Q: What are your perspectives on current policies and market influences on healthcare?

A: Laurice Lambert: The biggest challenge is the consumerism of health care. A shift away from facility level care, to care in the home, on demand care in a comfortable setting. Over the past couple of years, the big box chains and traditional technology-enabled services companies are moving into healthcare. Incubators, venture capital and founder led, owned and bootstrapped companies have emerged in the market. Hospitals have different priorities, strategic goals, risk profiles and stakeholders than publicly traded technology companies.  

A: Beth Feldpush: We have seen the expectation over the last 15 years for hospitals to go beyond delivering care within the four walls of their building. There is now an expectation that hospitals implement population and community health initiatives to ensure they are keeping people well in the community before they seek services. This means taking a larger role in mitigating social determinants of health, whether it's homelessness or food insecurity, combating structural racism or climate mitigation.

While all of these goals are certainly worthy of hospitals’ time and attention given their roles in the communities, the challenge becomes determining where their service deliveries end, and how to get reimbursed. It's challenging for hospitals to know how far out they should be reaching into their communities.

Over the last year, there has also been a public image backlash against hospitals in the wake of the pandemic. How do hospitals continue to engage with their communities, or compete against some of these other organizations, while they're dealing with challenging public image issues? 

A: Nicole Faucher: Ultimately, patients and people might be intrigued by retailers’ entrance into health care such as Amazon or Walmart, but the reality is patients rely on their hospitals and their providers as their caregivers. The important question becomes how do hospitals and health systems advance their ability to deliver care in a way that suits the expectations of the patient and the community, and leverage partners in a way that is invisible to the patient themselves.

Q: What are successful ways that hospitals and health systems have navigated challenges amid inflation and rising health care costs?

A: Beth Feldpush:  We've seen hospitals be successful in keeping a dual focus on their workforce challenges and cost pressures. These hospitals determine ways to drive costs down by investing in the pipeline for tomorrow. Examples of this are increased focus on recruitment, retention bonuses and increasing overtime hours. Hospitals have begun to be more entrepreneurial and creative in partnering with community colleges or even high schools to increase clinical workforce. Technology is also helping hospitals. Many are turning to the low hanging fruit of AI. There are simple tasks that hospitals may have at their disposal now to leverage AI without jumping in wholesale to implementing it for every clinical function.  

A: Laurice Lambert: The takeaway from AI is don't be afraid of it. As long as no one is using that data contrary to state and federal legal schemes, it can be used to help improve bottom line and patient care. AI can potentially be used to predict missed appointments, identify things like sepsis risk, stroke, malnutrition, help make bedside diagnosis, as well as identifying ways to drive revenue.

A: Nicole Faucher: More hospitals are owning their own outpatient specialty pharmacies and are able to drive a healthier financial performance, a tighter patient connection, improved provider access and patient satisfaction.

By leveraging 340B strategies, specialty pharmacy program partnerships provide an opportunity to navigate cost challenges and alleviate overall friction by making it as easy as possible for patients and providers. Lastly, it helps provide a cost containment measure and a way to help fund important services within health systems that typically might be under-resourced related to finances or staff. If a health care system understands their patient population from a standpoint of the specialty pharmacy mix and provider prescribing habits, I would highly recommend taking a look at pharmacy and specialty pharmacy as a service line to help navigate these challenges.

Q: How can healthcare organizations successfully navigate changes in reimbursement and fee for service models?

A: Laurice Lambert: Value-based care hasn't been fully defined yet. It's not only a change in practice patterns of the providers, but it requires accountability and responsibility of your own health care by the consumer - the patient. If everyone's not aligned, value-based care is hard. Navigating change encompasses thinking about how to move in this direction, even if it's a small way. A hospital may not be ready to convert off a fee-for-service contract, but they may be able to do some things in their free standing clinics, or they can consider forming an ACO or set up a strategic primary care network.  

A: Beth Feldpush: When looking at patient populations, hospitals should focus on providing new care models by focusing on the patients they have, not the patients they want or don't have. If there are a lot of Medicaid patients, maybe a Medicaid ACO is where a hospital should look first. The other opportunity is to focus on health equity and social determinants and making incremental changes in the fee-for-service Medicare space that takes aim at those larger global challenges.

Q: What are the implications and opportunities for health care organizations from recent 340B program challenges?

A: Nicole Faucher: There are four things we spend a lot of time thinking about and while there are implicationsfor each of them, they create a lot of opportunities for the covered entities within the 340B Program. One is the Genesis ruling and the concept of patient definitions and the ability to leverage and understand the reach of the 340B Program within the settings of patient encounters.

Another promising opportunity is the state actions related to protecting the 340B Program. Eleven states have passed or have bills that are under review to protect 340B implications to manufacturers, as well as, protect any predatory actions by PBMs and payers on 340B covered entities.

The Inflation Reduction Act’s impact on the pharmacy space is fascinating as it relates to the risk space on the reimbursement side. Understanding a hospital’s patient populations and the implications of Medicare Part D, as well as some of the commercial care implications, will be important. Hospital leaders should focus on their population utilization management, and have an understanding of their formularies.

Lastly, the Senate inquiry earlier this year looks at how contract pharmacies are behaving and how organizations are using their 340B dollars. There's a lot of interesting understanding how patients and communities are benefiting in the hospitals, leveraging the accessibility to improve costs for medications and dispensing.

The biggest concern eligible entities ask is, “how can I keep doing this and be compliant so that my program is not at risk?” It's important to focus on the data so that decisions and actions are in alignment with the spirit of the program.

A: Laurice Lambert: The right partner will understand the risk brought to you as a health system, and the ultimate direction and control you need, ensuring everything is above board.

What I take from Genesis is the ability to be risk forward about how you define a patient, as long as it’s a patient that you are providing services to. I would still recommend engaging a lawyer to find the balance between the gray and where the line is.

Q: With focus on growth and scalability, what should hospitals and health systems consider when choosing when to build, buy or partner?

A: Laurice Lambert: There's often the thought, “well, I can build it myself,” or “why don't I just go acquire this company?” Often times, I think convincing individuals to partner can be challenging. However, it's better to have a percentage of something than a hundred percent of nothing. It can be challenging to stand something up from the ground up with limited staffing and limited budgets. Getting traction when people have competing demands on their time is also challenging. I'm seeing more traction with partnering with third party vendors to bring a new service or solution to the market.

A: Beth Feldpush: I think the number one question is, “does it make sense to have our brand on it?” If it’s something like an ACO, insurance product, new outpatient center or specialty pharmacy that are central to the patient service or community connection or mission, then I think it makes sense to build it yourself, or partner with someone.   

A: Nicole Faucher: The health care system’s brand is most important, so any decision should contemplate whether to build, buy or partner underneath their own logo to convey that these are their patients, their community and a service they provide. This concept of an invisible partner is really important for so many reasons.

Some of these programs require a level of change management or disruption. There needs to be a centralized approach to educating and engaging with different constituents to make a program as strong as possible -in the sense of the experience, which is critical, as well as performance.

If you reach out to a partner like Clearway Health, you determine what the potential to partner looks like before you decide to build. Having that information helps you make the most educated decisions around what path is best for you. It has to be a very intentional effort with the right amount of data and guidance to get started.