Campaign rhetoric does not always equate with what happens after an election, and Charlene Frizzera, president of CF Health Advisors, an independent policy and regulation consulting firm, believes that may just be the case with the fate of the Affordable Care Act.
Even though President-elect Donald Trump and Congress seemed to be set on undoing the ACA, there’s more likely to be a review of the law that seeks to preserve the portions that have worked, tweaking parts that can be optimized, and eliminating portions that have either not worked or have been opposed by Republicans since the law was enacted six years ago.
The winnowing process should benefit value-based care initiatives that have shown promise. The fate of the ACA is important for healthcare providers, and particularly as they seek to make strategic plans for how they’ll operate and the kinds of information technology they’ll need to support those plans.
Frizzera should know about teasing out what really happens from political posturing. She worked within the Centers for Medicare and Medicaid Services for 30 years, from 1980 to 2010, serving in an amazing variety of roles, from auditing cost reports, to writing regulations, to serving as a regional administrator, deputy director and ending her public service stint as acting administrator and chief operating officer.
Over her career at CMS, the agency handled a variety of radical shifts in approaches, ranging from the prospective pricing system and the implementation of diagnosis-related groups of illnesses in the early 1980s to early work to implement the ACA. “All of those seemed overwhelming at the time,” she admits.
Now, with a new administration entering the White House, CMS likely will be dealing with changes to ACA. Those are likely to come in areas that have not been successful, such as trying to mandate health insurance coverage for all and Medicaid expansion “that didn’t happen in some states,” Frizzera says. “One thing that ACA didn’t do very well was that it didn’t get everyone covered.”
However, ACA has introduced new approaches that the government is using to pay for care, such as accountable care organizations and bundled payments.
Developed by the Center for Medicare and Medicaid Innovation (CMMI), “many of the new models have been transferred to the regular Medicare program,” says Frizzera.
CMMI brought on some controversy when it asked for mandatory participation in a Part B drug demonstration program; previously, it had used a model of seeking voluntary participation in demonstration projects. Frizzera believes that CMMI won’t repeat the mandatory participation approach again, which resulted in a formal letter of protest signed by 178 congressmen, almost all of them Republicans.
To its credit, CMMI’s new approaches are estimated by the Congressional Budget Office to save $40 billion over 10 years, Frizzera says, and those types of savings are important in meeting zero-sum budget requirements. “It’s hard to come up with those kinds of savings, which makes it hard to get rid of the innovation center,” she adds.
Expansion of bundled payments hold particular promise, Frizzera says. For example, the bundled payment program for knee and joint replacements “has created a whole new dynamic way of providing care for patients,” causing providers to work together, from before admission for the procedure (so-called pre-habilitation), the procedure itself and post-procedure care.
With pre-habilitation, “patients go into surgery much more healthy than they had been previously, and as a result, rehabilitation is much faster,” she says. “That’s a great example of how a bundled initiative can work, and how it can care for a patient more holistically.” She cites the experience of PeerWell, a company that specializes in prehab services that assist patients getting knee and joint replacements in bundled payment initiatives.
Similarly, federal agencies are gaining experience with and refining ACOs, learning from each iteration in the program, and that’s helping to adjust the program to increase the likelihood that ACOs will succeed and stay in the program.
So what does Frizzera expect after inauguration day? She doesn’t believe Trump or the Republican Congress will take worst-case drastic action immediately. “I keep reminding people, the Republicans and the president-elect are not kings or dictators; even within the Republican Party they just have general ideas and really haven’t come in with any significant plan,” she says.
Even as Republicans eventually move to more reliance on health savings accounts, high-risk pools and catastrophic health care coverage, Frizzera doesn’t believe the movement to get patients more involved with their care will fade.
“Under any scenario, the idea of a patient-centered continuum of care is at the center,” she says. “The government can help providers behave differently by the way they pay, but for this all to work, patients are going to have to behave differently, too. Moving forward, they have to be more engaged.”
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