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Specialty Care Transformation
In addition to episode-based payment models, CMMI has made gains through specialty models that focus on conditions—specifically for oncology and kidney disease, including the Oncology Care Model and the new Enhancing Oncology Care Model and Kidney Care Choices and the comprehensive ESRD model. New care models in orthopedics, cardiology, and maternity will reshape how high-cost conditions are treated, managed, and reimbursed.
Primary Care Transformation
Payers can advocate for primary care transformation by instituting strong metrics and emphasizing patient-centered care. Providers can invest in advanced primary care capabilities and restructure the physician compensation model to one more focused on value. Additionally, the Consolidated Appropriations Act of 2023 allotted over $1B in spending on chronic disease prevention and health promotion. These will continue to push payers and providers will be driven toward new models of primary care, anchored around value-based agreements.
Membership Models
In the past, individual consumers have been steps-removed from the direct purchase of healthcare. A popular model in 2023 will be the Membership where individuals and families can pay a fixed monthly or annual fee for unlimited access to a defined set of services.
Total Cost of Care
Value-based business models have evolved over time from basic pay-for-performance arrangements to partial and full-risk. 2023 will be the year that provider organizations get more aggressive in accepting risk for populations.
Retail Healthcare
The emergence of the new "Big Four" in healthcare (i.e., Walmart, Amazon, Walgreens, and CVS), plus pilots by others (i.e., Dollar General) are built around offering services in retail settings that are more accessible and convenient to many traditional healthcare providers. Healthcare conducted at retail outlets will accelerate in 2023, eroding the legacy positioning of incumbents.
Vertical Integration
Vertical integration continues to blur the lines between payers and providers. Payers will use acquisitions to expand their services and become well-rounded in their offerings, including home healthcare, expanding medical services, etc. Providers will continue to acquire physician practices, and create and build out Clinically Integrated Networks (CINs) to ensure in network revenues.
Omnichannel Healthcare
An increase in alternative site-based and virtual care has had a positive effect on patient outcomes and is more cost-efficient compared to inpatient care, includes telemedicine, remote surgery, and virtual hospital wards. More consumers and employers will align with vendors that offer omnichannel capabilities to help drive down healthcare costs.
Medicare Advantage
Medicare Advantage (MA) enrollment continues to grow rapidly. Despite MA plans being under scrutiny in 2022 due to overcharging and marketing practices, MA will continue to grow, and plans with supplemental benefits—specifically cash benefits—will become more valuable and attractive to members.