As we enter a new year, certain trends will have a significant impact on the healthcare sector in 2025.
In particular, health care advocates say they are watching closely to see what the new Trump administration and Congress have in store for the industry, particularly as it relates to the Affordable Care Act (ACA) and Medicare and Medicaid reimbursement rates. are.
Given the financial health of Connecticut's 27 acute care hospitals, any change could have a dramatic impact on their bottom line.
According to an analysis prepared by New York state health management consultants Kaufman Hall & Associates for the Connecticut Hospital Association, operating margins for all hospitals in the state will be -0.5% in fiscal year 2023. Total operating loss was $76. Million.
This is only a slight improvement from fiscal 2022, when total operating margin was -1% and operating loss totaled $164 million.
Other trends will also impact the industry, experts say, including the growth of value-based care and the increased use of artificial intelligence.
Focus on DC
Kurt Barwis, president and CEO of Bristol Health, said several major federal programs have a “near-term funding cliff” that could be negatively impacted by the incoming administration and the 119th Congress. He said there is a possibility of receiving it.
“The two big ones are the extension and funding of the (ACA) subsidy and…the ACA Marketplace subsidy, which is set to expire at the end of 2025,” said Barwis, who oversees the 154-bed Bristol Hospital. “The first could have an adverse impact on state Medicaid program funding, and the second could have an adverse impact on the insurance exchange, Access Health CT.”
A total of 129,000 people enrolled in Access Health CT-qualified health plans in 2024, the highest enrollment since the state-based marketplace opened in 2013.
Meanwhile, in 2021, the state Legislature approved expanding Medicaid, known as Husky in Connecticut, to children 8 and under, regardless of immigration status. One year later, eligibility expanded to include children 12 and under, as long as the family met the income limits to qualify for Medicaid.
The ACA provides a sliding scale of subsidies to reduce premiums.
“As an expansion state whose eligibility criteria makes it easier for low-income families and individuals to qualify for Medicaid, the impact on state budgets will be significant at a time when we already see Medicaid consuming an increasing amount of state budgets. “It could be,” Barwis said. “If marketplace subsidies are reduced, some people may no longer be able to obtain health insurance through Access Health CT.”
That could overwhelm the state's already overburdened Medicaid budget, but Gov. Ned Lamont has called Medicaid an area of concern, calling Medicaid costs “the new cancer on the budget.” It is specified that
The state's Medicaid program had a $220 million deficit in October, according to the Governor's Budget Office.
Lisa Trumbull, president and CEO of Southern New England Health (SoNE Health), agrees that this is a volatile time for the ACA.
“While it is unclear what the new administration will do with the Affordable Care Act, efforts to restructure or repeal the Act without careful consideration will destabilize the market and provide options for patients and employers. “There is a possibility of narrowing the scope,” he said.
Trumbull said changes to essential benefits, such as domestic partner and pre-existing condition coverage, could increase costs, result in reduced access to care and increase the number of uninsured people.
He added that “the Biden administration's efforts to prevent further consolidation in the health care industry, including through private equity acquisitions, could face setbacks and result in increased costs.”
payment reform
Although uncertainty surrounding potential changes in the federal government is causing concern, 2025 is expected to see an increase in one positive trend in health care.
This goal, known as value-based care, is a hot topic in the healthcare industry, and efforts to implement it are likely to continue.
The fundamental purpose of value-based care is to move away from the traditional “fee-for-service” model and instead compensate health care providers, such as doctors and hospitals, based on patient health outcomes and quality of care.
“Connecticut's leading primary care and specialty medical groups, along with the nation's leading primary care brands, are demonstrating true leadership by embracing payment reform and care transformation, thereby increasing accountability at lower costs. “It will meet the demand from employers who are looking for a certain level of care,” said President Jeff Hogan. Upside Health Advisors in Farmington;
Lou Junquinto, president of Anthem Blue Cross and Blue Shield of Connecticut, agrees.
“Over the past decade, and especially since the COVID-19 pandemic, employers and insurers have begun to recognize the benefits of prioritizing 'value over quantity' through value-based care models,” Janquinto said. . “At Anthem, we see the continued expansion of these performance-driven payment models in Connecticut, especially in primary care practices.”
Patients work with their doctors to develop a treatment plan that “benefits not only from a clinical perspective, but also from an emotional, spiritual, social and financial perspective,” he said.
He added that this collaboration tends to improve members' overall health and ultimately reduce costs.
Trumbull said many physician practices will need to “adapt their workflows, implement advanced data analytics and shift their financial models” to align with value-based care models.
“Payers and regulators are increasing their oversight of patient outcomes and quality measures, and are encouraging investment in population health management, data analytics, and preventive care,” she said.
artificial intelligence
Another trend expected to grow in 2025 is the use of AI in healthcare.
Hogan said AI will become “widely used in healthcare delivery to help clinicians identify, better coordinate and manage treatments, and drive and measure better patient outcomes.” “Deaf,” he said.
Using AI in this way can reduce not only fragmented care but also wasteful services and spending, he said.
Trumbull said AI will improve diagnostic accuracy in radiology, pathology and other specialties.
“AI tools save time and help physicians discover abnormalities that might otherwise be missed, which can lead to cost savings for patients and the system,” she said. Said.
AI can also help predict patient needs, “reducing reactive treatments, improving patient outcomes, and lowering costs,” she added.
Medicare scrutiny
Another trend cited by Barwis, who is also a director of the American Hospital Association and chair of the New England Regional Policy Committee, is increased scrutiny of Medicare Advantage plans.
Medicare Advantage (Part C) is a Medicare-approved plan offered by a private company that provides an alternative to Original Medicare.
“The focus on fixing these plans for enrollment is not a partisan issue in D.C., which is great news,” he said. “Due to the high percentage of seniors in Connecticut covered by these plans, these improvements primarily focus on prior authorization delays and denials of needed care, increasing access, Timeliness will have a huge positive impact on results.”
Meanwhile, Trumbull said such plans and original Medicare could face rapidly rising costs in 2025.
As a result, “low-performing plans are being pulled from the market even as the Centers for Medicare and Medicaid Services and the new administration aim to encourage more beneficiaries to enroll in such managed care products.” “It's possible,” she said.
