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Healthcare at a Turning Point


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Table of Contents

A Vision for Tomorrow
Vision of a Fundamentally Different Future
Seeds of Disruption
Healthcare Isn't the First Industry in Transition
Where Are We Currently? Whose Agenda Controls Your Healthcare?
Why a Market-Based Model for Healthcare Is a Good Thing
How Did We Get into This Mess?
End of the Model Year
Understanding Healthcare Reform as Business Model Change
Central Role of Payment Reform
Unintended Consequences: The Hospital Example
Paying for Volume, Not Results
Real Impact of CMS on Quality of Care and Costs
Unintended Consequences: The Primary Care Example
Discouraging the Type of Care That Results in Better Outcomes
Creating a Critical Shortage of the "Right" Kind of Doctors
Healthcare Is Big Business
Recent Example
Creating a Competitive, Functioning Market
There Is Little Accountability in the Current System
There Is Little Information Available on Which to Base Responsible Care Decisions
There Is Already Enough Money in the System
There Is a Solution, and It's Closer than Some Think
Endnotes In the Eye of the Storm: The Role of Consumers and Employers
A Personal Example
Whose Agenda Controls Your Healthcare? Another Look
Perversion of the Concept of Insurance
Where Do Employers Fit into the Equation?
What Can Consumers and Employers Do?
Demand Transparency and Accountability
Move Conversation toward a Continuum of Care
Create/Become Informed Consumers
Create Incentives for Better Health Behaviors
Change Is Never Easy, but It Is Possible Comparative Effectiveness Research: Creating an Environment for Change
Drivers of CER
Role of Cost Containment
Role of Political Expediency
Why Is the Federal Government Specifically Involved?
Focus of CER
Expected Criteria for Choosing Priorities
Endnotes Redesigning Healthcare Delivery: Hospitals Were Never Meant to Be Destinations of Choice
Adapting to the Changing Landscape of Healthcare
Needed: A Transfusion of Fresh Thinking
Management Infrastructure
Misuse of IT
Comparative Effectiveness Research Is Shaping Healthcare Delivery
Development of Predictive Care Paths
Changing Quality Metrics
Impact of CER on Hospital Operations
Prudent Responses and Defensive Strategies
Accountable Care Is Needed, ACOs Are Not
Laudable Goals
Any Provider Can Provide More Accountable Care
What Are You Waiting For?
Bundled Payment: The Next Step in Improving Quality and Reducing Cost
Why Will Bundled Payment Models Do Any Better?
So How Do We Get There?
St. Elsewhere: A Case Study in Bundled Pricing
Taking a Proactive Approach to a Market in Transition
Competing with a Bundled Price
Endnotes A Brave New World for Payers
Adapting to the Changing Landscape of Healthcare Insurance
Needed Here, Too: A Transfusion of Fresh Thinking
Rethinking the Customer
Rethinking Products
Implications for Healthcare Insurers
What Payers Can Do
Develop Partnerships with Providers
Segment Providers
Focus Partnerships on the Prevention of Never Events
Require and Pay for Predictive Care Paths
Change the Basis for Paying Primary Care Physicians
Increase Consumer Engagement and Personal Responsibility, Reducing the Abuse of the System by Consumers
Reduce Fraud and Abuse by Providers
Are You Ready for Disruptive Innovation?
Endnotes Big Pharma: How to Regain Success
Vulnerabilities of the Current Model
Market-Driven Business Model
Ensuring Stakeholder Value
Strategic Marketing Capabilities
Innovation Stewardship
Pressures on Innovation
Role of CER in the Pharmaceutical Industry
Treatment Guidelines
Focus on Cost Effectiveness
End of the Placebo-Only Controlled Trial
Impact of CER on Pharmaceutical Operations
Prudent Responses and Defensive Strategies
Develop Service Wraps
Diversify Revenue Streams Away from Payers
Adopt a Rolling Blockbuster Approach
Real-World Example
Looking Ahead
Endnotes A New Day Is Dawning for Medical Device and Diagnostics Manufacturers
Getting Products to Market: Change Is in the Wind
Implications for the Industry
Commercial Challenges
CER: The Threat for Medical Devices
End of the "Last Version Plus 5%" Business Model
Increased Pressure to Rightsize Functionality
Increased Competition with Drugs
Restricted Qualification for Devices
Impact of CER on Medical Device Operations
Prudent Responses and Defensive Strategies for Medical Device Companies
Adopt Strategies Suited to the New Environment
Focus on Reducing the Cost of the Procedure
Develop Service Wraps
Embrace the Cost-Functionality Trade-Off
CER: The Opportunity for Diagnostics
Reduced Tolerance for Redundant Testing
New Commercial Model
Possibility of Mass Screening
Impact of CER on Diagnostics Manufacturer Operations
Prudent Responses and Defensive Strategies for Diagnostics
Diversify the Revenue Base
Begin to Develop Partnerships for Custom Diagnostics
Where Do Medical Device and Diagnostics Companies Go from Here?
Hospital-as-Customer Requires a New Sales Model
Endnotes Putting Value at the Center of Healthcare
Recent Legislative Solutions and Why They Won't Work
Accountability for Care Is a Good Concept
ACOs: Their Original Purpose
ACOs: Their Role in PPACA
Government-Sponsored Payment and Delivery Systems
Top-Down Approach to Complex Health Policy Problems
ACOs: Key Deficiencies
Recommendations for Policymakers: Healthcare Delivery
Enabling Markets to Create Access to Care
Creating Access to Affordable Health Coverage
Recommendations for Policymakers: Access to Care
Supporting Innovation: Finding the Right Balance at the Food and Drug Administration
Regulation's Impact on Innovation: A Two-Edged Sword
Making the Rules Clearer, More Transparent, and Simpler
Real-Life Example
Patent Life: Shooting Ourselves in the Foot
Endnotes Creating a Roadmap for Change
Revisiting the Challenge of Industry Transition
Safety in Size? The Rush to Affiliation
Consolidation and the Challenge for Manufacturers
Additional Challenges for Manufacturers
Creating Collaborations to Develop Lifetime Value
Why Now?
Reprising the Consumer
Power of Choice
Increase Perceived Quality
Creating and Sustaining a New Business Model
Harnessing Consumer Choice and Competition to Ensure Accountability: Final Thoughts for Policymakers
End Game Index
About the Authors
About NAI

About the Author

Rita E. Numerof, Ph.D., President of Numerof & Associates, Inc., is an internationally recognized consultant and author with more than twenty-five years of experience in the field of strategy development and execution, business model design, and market analysis. Her clients have included Fortune 500 companies such as Johnson & Johnson, Eli Lilly, Pfizer, Westinghouse, AstraZeneca, Merck, Abbott Laboratories, major healthcare institutions, payers, and government agencies. The focus of her consulting addresses the challenges of maintaining competitive advantage in highly dynamic and regulated markets. Dr. Numerof has been a consistent advocate for the importance of strategic differentiation, organizational alignment of structure, competencies and metrics to ensure effective implementation, and anticipating, rather than reacting to industry trends. She's been a pioneer in the area of economic and clinical value, anticipating the impact of changing global payer attitudes on the fundamental business model of the healthcare industry. Her work across the entire healthcare spectrum gives her a unique perspective on the challenges and needs of manufacturers, physicians, payers, and healthcare delivery institutions. Under her leadership, NAI has developed proprietary approaches that provide precise insight and practical solutions to some of the industry's most complex business challenges. Taking a systemic approach, Dr. Numerof has addressed such diverse issues as comparative effectiveness research, accountable care, bundled pricing, consumer engagement, operationalizing compliance and transparency, portfolio management and the identification of growth platforms that provide sustainable differentiation through economic and clinical value, and effective commercialization based on value propositions that matter to key constituencies. Dr. Numerof is widely published in business journals and has authored five books. She serves as an advisor to members of Congress on healthcare reform and comparative effectiveness research. She was a senior advisor with the Center for Health Transformation, a regular contributor to the Manhattan Institute, and wrote the Heritage Foundation's policy paper, "Why Accountable Care Organizations Won't Deliver Better Healthcare-and Market Innovation Will." She led a tri-partisan, cross-industry work group on payment reform and developed recommendations for new payment models that incent better health outcomes at lower cost. In addition, Dr. Numerof provides guidance to policy organizations and agencies on the relationship between innovation and regulation, working to support innovation and ensure responsive regulatory oversight. Dr. Numerof graduated magna cum laude from the Honors College, Syracuse University and received her MSS and PhD from Bryn Mawr College. Michael N. Abrams, M.A., Cofounder and Managing Partner of Numerof & Associates, Inc., has served as an internal and external consultant to Fortune 50 corporations, major pharmaceutical and medical device companies, healthcare delivery institutions, the financial services industry, and government agencies for over twenty-five years. He has worked extensively in the areas of strategic planning and implementation, product strategy and portfolio development, market analysis, consumer engagement, and operational improvement. Abrams is well known for his expertise in the design and implementation of strategies for building competitive differentiation, defining sustainable value, identifying market influence mechanisms, and translating white space analysis into the creation of innovative solutions to meet unmet needs. His ability to identify market opportunities and to effectively improve organizational performance has been an invaluable resource to client companies on a global basis across industries. Abrams has structured and managed innovative programs to evaluate care delivery and payment models, thereby defining the internal change processes necessary to translate business opportunities into effective market position, operations, product portfolio management, and new product design consistent with changing regulatory requirements. He has provided solutions to healthcare delivery systems to improve the management of care transitions, thereby reducing unnecessary hospitalizations, and reduced length of stay by identifying and managing factors causing extended stays, changing admissions and patient care management processes, and managing across the continuum of care while maintaining or improving clinical outcomes and reducing costs. He is experienced in the design and execution of econometric modeling and analysis and decision support systems for a variety of science-driven industries and applications. He has designed technology solutions to meet a wide range of needs, including strategic account planning and management, thought leader interface, and key opinion leader management. His ability to manage the process of technology integration to support business objectives across multiple business environments ensures return on investment (ROI). Abrams has written extensively on economic and clinical value creation and the need for integrated, systemic solutions to the challenges facing the global healthcare industry. His articles have appeared in more than a dozen leading business journals, and he coauthored the book Solving the Healthcare Crisis. As an adjunct faculty member of Washington University in St. Louis and LaSalle College School of Business Administration in Philadelphia, Abrams has taught MBA courses in strategic management, product planning and evaluation, quantitative decision making, and market analysis. Michael Abrams completed his doctoral work in Business Policy at St. Louis University. He received his MA from George Washington University in Washington, DC.


This book is a compelling and thought provoking analysis of critical choices facing health care leaders. It offers a detailed prescription for stakeholders on how to proceed and how to implement genuine accountability at each stage of care management. ... Numerof and Abrams offer a road map for sustainable market reform with remarkable clarity and vision.
Book review by Peter Boland, PhD, appearing in The Journal of Ambulatory Care Management, Vol. 37, No. 1, pp. 38-41

Everyone complains about the state of healthcare in this country-patients feel uninformed, mistrustful and lost; clinicians and hospitals are frustrated in their efforts to improve the quality of care while meeting demands for lower costs; employers are burdened with the rising expense of employee health insurance; payers who provide the coverage are pushing for greater evidence before approving reimbursement for new drugs, technologies, procedures and tests; the medical product industry is struggling under the weight of increasing costs, longer development timeframes, shifting regulatory requirements and resistance from the other stakeholders to pay for new products; and politicians and state and federal government agencies are mandating a patchwork of fixes that seem to only make things worse. What we have lacked are tangible solutions that can actually work-until now.

Rita Numerof and Michael Abrams in their new book, Health Care at a Turning Point: A Roadmap for Change have offered a fresh look at the current state of healthcare in America, providing a detailed diagnostic assessment of what's wrong, and importantly offer a comprehensive strategy to fix the problems. They begin with a vision of what a viable future state could look like in 10 years for providing affordable, accessible healthcare that promotes innovation in business models, products and services. Numerof and Abrams identify clearly and objectively the obstacles that must be overcome and gaps that must be closed by each of the important participants in the healthcare ecosystem, and then as the book's title implies, they deliver a roadmap, which is not only plausible, but if followed, will undoubtedly succeed in getting all of us there.
Harlan F. Weisman, M.D., Former Chief Scientific and Technology Officer, Medical Devices and Diagnostics, Johnson & Johnson

Numerof and Abrams have crafted a thoughtful, and often provocative, analysis of the challenges and opportunities facing the healthcare industry today. At its heart is a clarion call for the sector to become much more patient and consumer-centric -- before their existing business models become obsolete.
-Paul Howard, Director and Senior Fellow, Center for Medical Progress, Manhattan Institute for Policy Research

A pair of strategic management consultants intelligently scrutinize America's healthcare industry. ... The authors' blueprint for healthcare redesign is impressively conceived yet decidedly business-minded. Chapters defining their proposed remedies emphasize a market-based approach that objects to recent legislation and ideas of federally financed accountable care organizations (ACOs) while promoting models of bundled payment systems in which services are funded through a fixed-price schedule. ... they offer fresh, clear approaches to restructuring the healthcare system and place appropriate emphasis on the fostering of informed, accountable consumers. ... Numerof and Abrams' ambitious study succeeds in illuminating problems within the multifaceted system ... . An elucidating, relevant discourse on the precarious future of medical care.
-Kirkus Reviews, August 2012

The authors present thought-provoking ideas for the 'disruptive innovation' needed to uncover pragmatic solutions for our country's healthcare delivery system. ... this suggested blueprint for market-based action is a must-read for all sides of the healthcare reform debate.
-Marc Boutin, Executive Vice President & Chief Operating Officer, National Health Council

Everyone agrees that the American healthcare system needs to change, but there is little agreement about how it should change. Abrams and Numerof paint a picture of how healthcare could look in an ideal future, and offer to manufacturers, payers, and providers a way to get there. Examining the healthcare system today, changes already taking place in attitudes towards innovation and medical education, ... they show how the key players in healthcare must change their thinking to survive. ... The main, and certainly provocative, message: if we move to a value-based system based on patient choice, rather than a cost-based system that assumes one size fits all, the consumer of health care is the ultimate beneficiary.

The book will stimulate the thinking of industry across functions, and should be read not only by management but by R&D, Strategic Planning, and Sales. Sections on the need to form partnerships and alliances can change the way industry, payers, and providers think about each other. By examining the four forces they see as dominating our healthcare environment today, namely changes in the regulatory environment, a changing competitive landscape, shifting technology, and changing market expectations, Abrams and Numerof have indeed provided an insightful guide to how the industry needs to change its strategic thinking.
-David L. Horwitz, MD, PhD, FACP, Chief Medical Officer, Johnson & Johnson Diabetes Institute

Here it is in Healthcare at a Turning Point healthcare must restore control and accountability for intimate, personal decisions to each of us as our own consumer. No one else can define our quality-value-price equation, and discipline our providers ... Such is the economics, humanity, history, and even politic of western is time for the Renaissance of those principles, just as articulated here in Healthcare at a Turning Point.
-Steve Bonner, President and Chief Executive Officer, Cancer Treatment Centers of America (R)

Numerof and Abrams have conducted a thorough analysis of the implications of market and non-market forces on all players in the health industry -- carriers, care providers, governments, consumers and employers. They have hit the nail on the head that it will take disruptive innovation and a collaborative approach across all these stakeholders to drive solutions to the fundamental problems of high cost and poor quality in health care.

I appreciate that Numerof and Abrams focus in on three major principles: 1.) Rethink the customer: It's really the consumer, the end-user of health care services. The consumer needs to be at the center of the work that we are undertaking. It is imperative that we provide them transparency to cost, quality and value. 2.) Watch out for non-traditional competitors: There are many other industries which have been historically very close to the consumer. The players in our industry are changing, and all of those who serve the consumer need to rapidly evolve ourselves in order to differentiate and succeed. 3.) Segment care providers: We need to apply the discipline of market segmentation to our relationships with care providers. That is, we cannot assume that a one-size-fits-all approach on paying for value or outcome will succeed with each and every physician or hospital. Rather, we must segment our networks and identify which care providers are most likely to succeed in a partnership to reform payment in a particular way, work with them closely and then allow that success to breed other success in the market place.
-Elena McFann, VP Network Strategy and Implementation, UnitedHealthcare

For every professional engaged in the financing and delivery of medical care, this book is essential. Like it or not, sparked by the renewed debate over the controversial Affordable Care Act, we find ourselves in the midst of a major transformation in the health care sector of the economy. The convergence of biomedical breakthroughs, new medical technologies, new organizational structures is upon us. But the authors got it right: change will be frustrated, and energies will be diverted into unproductive channels, unless and until we change health care financing and put the patient in the center of the process as the key decision-maker.
-Robert E. Moffit PhD, Senior Fellow, Center for Policy Innovation, The Heritage Foundation

Congratulations on the publication of Healthcare at a Turning Point. ...[You] really hit the ball out of the park with this book. First, you identified the real root problem in our healthcare system [payment], and then provided the key solution, a consumer-driven market model. This book should be the new reference text for healthcare reform and should be read by every healthcare provider, administrator, insurer, product developer, and lawmaker. Thank you for delivering such remarkable insight and strategic guidance to a very complex and polarizing issue in the U.S.
-Kurt Weingand, D.V.M., Ph.D., Chief Science Officer, Central Garden & Pet

Have there ever been three not-so-little words that turned an industry upside down, virtually paralyzed the planning process and left providers and consumers alike adrift as much as "health care reform"? The authors bring a calm, dispassionate tone to the dialogue, underscoring the unsettling nature of transition (a much more palatable word than change) and offer reasonable strategies that override politics. I found the emphasis on collaboration especially comforting and doable.
-Ellen Sherberg, Publisher, St. Louis Business Journal is important to have a clear bridge between the issues of today and the possibility of a much brighter future. Without glossing over serious issues...this book describes a way forward for those inside and outside the Healthcare system.
-Jeff Thompson, MD, Chief Executive Officer, Gundersen Lutheran Health System

I appreciate that Rita and Michael call out the "ultimate objective" in the debate-to improve health outcomes at lower cost. It would seem that all sides can agree we save money when we decrease and change the demand for services. There are two approaches that allow us to do it. Approach 1 is to ration care. Approach 2 is that we incentivize and align consumers AND providers toward a plan for health which the authors rightly refer to as the consumer-driven market model.
-Amanda L. Adkins, General Manager and Executive, Healthcare Information Technology, Cerner Corporation

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