National Business Group on Health execs offer 2020 outlook on uptick in virtual care, impact of Amazon

When it comes to healthcare, employers aren’t willing to sit back and watch costs continue to rise without putting up a serious fight of their own.

The growth in the activities of these so-called "activists" is among the trends the National Business Group on Health (NBGH) has observed in recent years. The organization, which represents large employers’ healthcare interests, is looking to take a more activist role itself.

The organization recently announced the planned retirement of CEO Brian Marcotte. His successor, NBGH Chief Strategy Officer Ellen Kelsay, said she intends to ramp up advocacy on Capitol Hill regarding businesses' healthcare interests as she takes the reins.

The organization is also shifting to ensure it's helping companies with thinking more globally, they said.

RELATED: It's not just Amazon: Employers are turning 'activist' when it comes to healthcare

I caught up recently with Marcotte and Kelsay to talk about their insights into the future as well as where we've been, as the NBGH makes the transition.

FierceHealthcare: Brian, let’s start with you. What trends are you watching right now in healthcare? Are we still seeing employers take that "activist" role in healthcare?

Brian Marcotte: We’ve seen this tremendous growth in virtual solutions over the last several years in all facets of healthcare delivery: condition management, sleep, physical therapy, remote monitoring, virtual appointments, both virtual primary care as well telehealth—which is more about simple healthcare needs—virtual behavioral health. It’s really taking off in so many different directions and I think that is one that will continue to grow and affect the way healthcare is delivered in the future. 

Virtual care is more about bypassing the delivery system and not waiting for change to happen within the delivery system because it’s such a fragmented, market by market slog, if you will, to try and drive change. With virtual solutions, you can leapfrog that in a way that’s much more scalable and get outcomes data. That is one area where you’re seeing them play an activist role.

FH: Ellen, as you come into this position, what are some of the trends you are watching?

Ellen Kelsay: Many of our 2020 Trends to Watch were around quality and really pushing the market to transform among a number of dimensions related to quality. What are they doing directly related to value-based purchasing strategies and also what are they doing and how are they lighting fires beneath some of their incumbent partners, their health plans, to do more around quality in their network or with centers of excellence strategies?

This activist role is something we’re going to continue to see and it's borne out of the market not moving there fast enough. There’s a frustration and a need to change things faster.

FH: What impact are companies like the Amazons of the world and Walmart are having on these shifts?

BM: If you watch the stock market, whenever Amazon is mentioned about entering into a pharmacy or a relationship with Haven, or anything is discussed related to their potential reentry into healthcare, the stocks for all the health plans and the pharmacy benefit managers drop. And then they work their way back.

So there’s this threat of Amazon. What Haven will actually end up doing is still a bit of a mystery right now. You look at Amazon purchasing PillPack. You see Amazon implementing virtual primary care for its workforce. They are working on something. How it will manifest itself will be interesting. I’ve always felt that given Amazon’s footprint, their relationship with customers and them being the go-to place for online shopping today, it’s a natural place to go for healthcare.

RELATED: Large employers playing more 'activist' role in healthcare costs, dialing back push to high-deductible plans

FH: What changes, if any, have surprised you looking back?  

EK: With the high deductible health plans, I think hindsight is 20/20. I think the concept was noble several years ago. There were a lot of reasons employers were moving to the plan design to make it more affordable with the excise tax—which we now know is no longer going to be an issue. There was also the notion these plans would create better consumers of healthcare which, as we know, did not work out for myriad different reasons. They are still prevalent.

Our survey data show there are still a number of members offering them as a sole option or offer them as a choice and have considerable enrollment in them. But where we saw the shift starting three years ago was it being the only plan offering. And more employers are adding choice back in with a PPO plan now, most likely along with an HDHP.

BM: An area that hasn’t moved as fast as we hoped is the value-based care. Moving away from fee for service is very challenging and it’s a market by market push. It’s taking longer and when you see all the provider consolidation that’s going on, that’s actually slowing progress in the move to value-based care because providers have more leverage and it's harder to get them to flip.

FH: Prediction time! What should employers be keeping an eye out for in 2020?

EK: I think we’re going to see continued innovation and the emergence of startups pushing solutions around virtual capability and employers seeking more of that to address gaps in their current ecosystem of capabilities. At the same time, we’re going to see consolidation and rationalization happening in that space so I think employers will be looking for more partners to help aggregate solutions and help them manage them from their perspective as an employer but also from the consumer perspective.

BM: The other area to keep an eye on is the emergence of advanced primary care models. It’s very market-specific right now, so it’s not something you can scale across the country. But we’re really encouraged with how they are approaching healthcare delivery, moving away from fee for service and focused on total cost of care. From moving away from fee for service, it’s giving these models the flexibility to be nimble and innovative of how to best treat their populations. So it’s not tied to, ‘I don’t get reimbursed for that so I don’t really do that.’

RELATED: Large employers embrace advanced primary care in 2020: NBGH survey

FH: What about managing the costs of drugs?

BM: I don’t think importation is going to be the solution here. Obviously we have a drug pricing problem.

EK: This is one of those areas where: 'Is anything revolutionary going to happen in the near term?' No. But there will be a lot of activity and discussion on this topic for certain and a lot of desire and energy for something to change. Specialty trends are accelerating at an exorbitant rate that’s not sustainable. Now you overlay that with these multimillion-dollar,high-cost therapies that are hitting the market and increasing rates across a number of clinical conditions and therapies are very effective for the populations they serve.

But it’s not a question of clinical value, it’s a question of financing and affordability and sustainability. It’s underlying drug pricing, as Brian mentioned. There’s a lot of consternation about what needs to change there and energy and desire for something to change. But very well entrenched heels dug in deeply.

BM: The focus and spotlight on high drug costs happened because employers moved to high deductible health plans. Drug prices have always been an issue for employers, the inflation has always been an issue. When employees were paying co-pays for those drugs and were insulated from that escalation in price, no one talked about drug prices. With so many companies offering high deductible health plans today and the exposure to the consumer of drug prices and drug price inflation, not everyone is talking about drug prices.

I think you will see in 2020 different financing models. Cigna and ESI have come up with one where employers pay a small PMPM amount to cover certain drugs and it would be a giant stop-loss bucket, if you will. Just finding ways to finance really expensive drugs doesn’t solve the problem. It just mortgages our future. The problem is the drug price.