Entering 2014, key elements in the external environment for hospitals are clear …

  • Medicare will continue to cut reimbursement to hospitals. The Congressional Budget Office has forecast total health spending to increase 6 percent in 2014 vs. 4 percent annually for the past three years. But on a per capita basis, Medicare will be flat (vs. 0.4 percent in 2013) as a result of the sequester and expanded enrollment in the program.
  • Medicaid will expand dramatically. Through mid-December, new enrollment in Medicaid via HealthCare.gov tops 900,000. At the same time, 26 states are expanding enrollment in sync with the Affordable Care Act. For hospitals, the Medicaid payer mix will increase exponentially, cutting into already stretched operating margins. Complicating matters, private health plans are lining up to convert Medicaid to managed care for states — a huge growth engine for their investors premised on lower payments to hospitals and limits on access to specialists.
  • Employers will be active shoppers. Three in four employers will limit employee choices of local hospitals and doctors via high-deductible plans that offer narrower networks of hospitals and doctors. They’ll push for hospital price transparency and use reference pricing to base their payments. With the employer mandate delayed to 2015 and health spending spiking up, cost will be the employer’s issue. Some will play; others will pay the penalty and walk away. Hospital direct-contracting with employers, therefore, will be based on competitive pricing and a willingness to share risk for improved value in specific high-volume, high-cost clinical categories like joint replacement and open-heart surgery. Employers in certain industries and markets will contract for services with nonlocal hospitals and physicians to garner a value advantage.
  • Medical device and drug companies will make new deals with hospitals. Drug and device manufacturers will pursue gain-sharing arrangements with hospitals that protect their volumes, wholesale margins and share of mind with physicians. As a result, the hospital supply chain will be re-engineered as manufacturers look for deals, which will face intensified scrutiny from regulators and the media as incentives must not induce unnecessary utilization or unusual financial gain to the parties.
  • Bad debt will increase as margins from patient care will shrink. Hospitals will see increased severity of their patient populations, fewer with commercial coverage, and tougher negotiations with private insurers. Medicare will expand its policy of site-neutral reimbursement for outpatient tests and services, further cutting margins. The compound impact of slower-than-expected uptake of coverage via Healthcare.gov, reluctance in states to expand Medicaid, medical inflation anticipated at 3 percent, higher cost of capital and intensified competition means thinner margins in core patient care businesses and increased reliance on diversified businesses and unrestricted gifts to institutions.
  • Insurers will play hardball with hospitals. Private insurance operators have had a good run since the ACA passed: Margins are strong even as enrollment shrank. They successfully passed through their costs of compliance with its new requirements in higher premiums, but those days are ending. Margins in their core business will shrink in coming years, prompting significant consolidation in the sector, and tougher negotiations with providers. For many plans, the gradual erosion in their group business will be replaced by strong retail and government businesses, but these growth markets bring lower operating margins to their businesses.Some insurers will seek to partner with hospitals via ACO agreements and narrow network agreements; others will compete directly with hospitals, acquiring medical practices and delivering outpatient services. And all expect the next few years to be challenging; thus, they’ll play hardball with hospitals — their primary target for health cost-reduction.
  • Physicians will seek cover. Two-thirds of primary care and one-third of specialists currently depend on an exclusive relationship with a hospital for some or all of their incomes. Many of these are employed. But private health insurers and large medical groups are options for physicians seeking cover, and the terms of their deals dis-intermediate traditional hospital referral relationships. Medicare cuts and expansion of Medicaid enrollments will stress physicians forcing hospitals, in some cases, to make up the difference in lower payments to keep referral networks in tact.

Daunting as these seven are, many questions impacting hospital strategy remain unanswered going into 2014:

  • Will Healthcare.gov and state exchanges be successful in reducing the ranks of the uninsured?
  • Will private exchanges become the transitional bridge facilitating an employer’s transfer of financial risk to employees via high-deductible insurance programs?
  • Will the results of key ACA demonstration and pilot programs — accountable care, patient-centered medical homes, et al. — justify their continuation or expansion?
  • Will consumers push back from narrower networks of doctors and hospitals as insurers and employers advertise their advantages in prices, safety and quality?
  • Will the political leaders in Red states not expanding their Medicaid programs change their minds?
  • Will the Federal Reserve’s gradual easing of its inflation controls result in economic recovery that will not cause interest costs to soar?
  • Will mergers among hospitals catch the ire of antitrust regulators?
  • Will the backlash about the National Security Agency’s role in data-gathering activate public anxiety about the compromise of their personal health information?
  • And what will happen in Campaign 2014 with 435 House seats, 33 Senate seats and 36 governors’ races to be decided? And how will changes in the composition of Congress and statehouses impact the ACA, budgets for Medicare and Medicaid, and more?

Against this backdrop, hospital leaders and boards must brace for the worst and hope for something better, and learn to live in uncertainty. The management dashboard, therefore, must carefully address these strategic imperatives:

Radical cost-reduction. Hospitals are labor-intense, capital-intense, and highly regulated at state and federal levels. In the immediate future, they’re also retailers for wellness, healthy living and over-the-counter self-care, managers of a professional network of physical and mental health providers, operators of long-term care services and facilities, and sponsors of health insurance plans sold to local and national employers and plans. Lowering operating costs across this complex system while deploying capital to targeted opportunities is key to survival: Core clinical programs must operate at Medicare rates. Diversified (non-third-party reimbursable) services must operate at levels that allow for value-based pricing. Radical cost-reduction will mean more than clinical program redesign and supply chain efficiency gains. It requires tough decisions about structure, people and processes, efficient acquisition of capital, and tough choices about which clinical services might be reduced or eliminated for institutional stability and sustainability.

Risk management. Hospitals must focus on three areas of risk: fraud, performance risk and payer-contracted risk. Fraud-related risk is well-understood and compliance efforts generally structured to avoid penalties. Performance risk — i.e., avoidable readmissions, overutilization of tests and procedures, medical error and safety — are nowhere near acceptable levels of preparedness in hospitals. And payer-contracted risk — i.e., the transition from volume to value via accountable care, medical homes and bundled payments et al. — is only modestly under way. The pace of the three is quickening, and the potential for revenue losses to competitors or penalties from regulators is increasing.

Physician alignment. Whether through employment or contractual means, exclusive relationships with a high-performing “group” of clinicians unafraid of risk, receptive to team-based delivery and accomplished in the use of clinical and administrative information technologies is the most difficult challenge facing hospitals. Clearly, transitioning from a facilitycentric brick-and-stick operating model to a regional care management organization with a wide scope of products and services requires physician input and active engagement. But conflicts with physicians take a toll: Physicians are increasingly dispassionate about their hospital loyalties. They want financial security and professional autonomy, and they’ll listen to any party that can deliver.

Growth. Scale in hospital operations is key. ‘Go big or get out’ is an imperative for most hospitals. Opportunities in adjacent sectors — like retail health, Medicare Advantage and population health — require new competencies that smaller, stand-alone players often are ill prepared to build or buy. And capital markets — lenders and investors — are skeptical about the sector’s ability to reinvent itself.

2014 is a pivotal year for hospitals. Boards and management must navigate the uncertainty while pursuing growth and re-engineering in their core business of patient care.

Paul H. Keckley is a health economist and leading expert on U.S. health reform and its impact. He recently retired as executive director for the Deloitte Center for Health Solutions, where he directed the center's nonpartisan studies that are prominently featured in congressional testimony and industry publications. His H&HN Daily column appears the first Monday of every month.