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plans, many people have been switching to high-deductible health plans with comparatively low premiums. Mr. Baumgarten says high-deductibles lower the demand for services. "When you have to pay everything out-of-pocket until the deductible is met, you're less likely to seek care," he says. He believes it's unlikely people will switch back from high deductibles even if healthcare inflation subsides. 8. Hospitals forced to become more efficient. Hospitals have long complained about insufficient Medicare payment levels, but as rate hikes cool off, Mr. Baumgarten thinks hospitals may decide Medicare rates aren't so bad after all and that these rates could be enough if hospitals learned to be more efficient. One way this can be done, he says, is to collaborate very closely with physicians and other providers to reduce the total cost of a particular episode of care both inside and outside of the hospital. 9. Payors move to bundled reimbursements. Mr. Clarke says CMS has launched several pilot projects that explore paying providers for the whole episode of care, such as the Acute Care Episode (ACE) demonstration. Instead of reimbursing for volume, he predicts payors will move toward reimbursements for outcomes, or "payment for value." Expect more pilots, soon followed by some permanent changes in reimbursements from both public and private payors, he says. 10. Providers coalesce into integrated systems. Facing declining income and changing payment methodologies, hospitals will need to fundamentally restructure the way they deliver care, Mr. Clarke says. "Organizations will need to pull together in a different way," he says. "The old incentive to admit more patients will be replaced by the new incentive to improve outcomes." He thinks hospitals will have to approach healthcare from a new perspective: keeping patients out of the hospital. 11. Physicians fall in with hospitals. Despite bad experiences with acquiring physician practices in the 1990s, hospitals are back at it, Mr. Baumgarten says. He sees this as a win-win situation in many cases. Hospitals need physicians to increase admissions and to coordinate care, and group practices need hospitals to access capital for projects like EMR. Some analysts believe a group practice of less than 350 doctors cannot amass the necessary capital and cannot be sustained. 12. Small hospitals seek shelter with larger ones. "The number of small, freestanding hospitals will decline fairly significantly in the next five years," Mr. Clarke says. "In many cases smaller institutions will not be large enough to address upcoming challenges, such as taking a bundled payment." He thinks they will join larger institutions that have the means to organize hospitals and doctors into integrated systems. 13. Capital needed for IT introductions. Mr. Clarke says hospitals will need to buy more equipment and redesign facilities to change patient flow, but the biggest investment will be in healthcare IT, a very expensive proposition. 14. Non-profits' debts stay comparatively small. While many nonprofit hospitals face debts, they tend to have much lower debt loads than those of privately held organizations, Mr. Clarke says. Because nonprofit hospitals can't go into private equity markets, their ability to develop capital is more constrained and they can't amass huge debts, he says.
15. Discounts for construction become available. With overall demand for construction in the basement, Mr. Baumgarten sees outstanding discounts for hospitals that want to build and have the money to does so. The cost of materials is down and contractors will negotiate price just to get the business. However, hospitals face the risk of overbuilding caused by the downward trend in patient volume. Already some new projects are being scaled back, with unfinished space set aside for future expansion. Contact Leigh Page at leigh@beckersasc.com .
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