During the past election season, much of the discussion we heard about health care focused on the Patient Protection and Affordable Care Act, better known as the ACA — and most often what is wrong with it. Now that we know that our executive leadership and both the House and Senate are Republican, with a pledge to repeal and replace the ACA, what should really happen?
Without question, some things have not worked out so well as a result of this landmark legislation, but there is a lot that is right with the law. President-elect Trump’s new health care team should carefully weigh the good and the bad.
The ACA broadly sought to create a high-value system by improving access to health care, and to change the U.S. health care delivery system so that costs are reduced and outcomes of care are better. A new Congress can address what was wrong and keep what makes sense. This is a great opportunity we would not have had if not for a dramatically disruptive election.
Access to health care has improved for many Americans as a result of the ACA’s dramatic reduction in the number of people without health insurance. At MD Anderson Cancer Center, some patients tell us that getting insurance through the exchanges allowed them to get treatment for their cancer. Patients with preexisting conditions cannot be denied insurance. Children can stay on their parents’ insurance longer. These advances have to mean something to even the most severe critic of the ACA.
Yet there remain uninsured people, and the costs of health insurance are increasing even on the exchanges. Rising insurance prices and the rapid emergence of narrow networks keep patients from getting care with better providers. These issues must be addressed. All Americans need access to providers who offer the best outcomes. Market forces should not drive consumers only to low-cost providers because — as much as we do not want to admit it — you get what you pay for, even in health care.
While details of Republican plans to replace the access portions of the ACA have yet to emerge, two principles need to be emphasized:
- There should be significant incentives to Americans to be insured.
- The narrow network concept, which benefits only the insurance industry, should be eliminated.
Accelerating Value in Health Care Delivery
Beyond the access provisions of the ACA, perhaps the greater opportunities lie in the framework created to improve care delivery and control cost. These are critically important concepts in redesigning America’s delivery system. One of the real opportunities in a repeal-and-replace scheme is to place an even greater emphasis on value creation in our system, and to try even harder to hardwire approaches that improve outcomes that matter to patients and control costs.
The ACA has accelerated the movement to value-based health care. The term “value” was used several hundred times in the bill. The push to reimburse hospitals based on quality measures gave credibility to the value concept, and has led to multiple other value initiatives coming from CMS, culminating in the 2015 goal to move the majority of CMS payments to value-based payments over the subsequent three years. The emphasis on value also resulted in the replacement for the SGR bill, MACRA, to further accelerate alternative reimbursement models and the use of outcome measurement, including patient-reported outcomes, for quality assessment.
Preserving ACA Successes: The Innovation Center and PCORI
Of all the programs in the ACA, a major success is the Center for Medicare & Medicaid Innovation. CMMI was created to test new and innovative reimbursement and delivery models. It has supported the testing of accountable care organizations, which may not be living up to their expectations to control cost and improve quality — which is exactly why these programs are being tested. CMMI has rolled out multiple evaluations of bundled reimbursement to see what works to control cost and improve quality. The law also stipulated that if CMMI shows that a particular program works well, the Health & Human Services Secretary can implement it straightaway, eliminating delay. CMMI has also turned America’s largest provider of health insurance, CMS, into its most progressive. It is also piloting programs to transform primary care.
Of course CMMI could do more. At the current rate of testing these reimbursement models, it could take decades to get us out of the fee-for-service system into new reimbursement models that reward good results. A replacement bill should keep CMMI and accelerate its testing and implementation of alternative payment models (like bundling) to many more conditions. Once CMMI demonstrates the success of these programs and physicians see that they can be rewarded for achieving good outcomes that matter to patients, then other insurers will get out of the fee-for-service business and be more willing to implement bundled reimbursement.
Another tremendous success of the ACA has been the creation of the Patient-Centered Outcomes Research Institute (PCORI). For the first time, there is peer-reviewed funding for testing of health care issues that matter to patients. Looking at patient-centered outcomes has transformed comparative effectiveness research (CER) into a robust field that answers questions about care delivery overlooked in other forms of clinical research. Traditional funding agencies did not address how to help patients make decisions about the care they need, and how to include patients in the research team that designs and executes these studies.
PCORI can also do more. It should fund more CER studies. The National Academy of Medicine has identified over 100 high-priority areas for CER, of which PCORI has touched only a fraction. Additionally, the ridiculous, politically motivated stipulation that PCORI-funded research cannot consider costs of care needs to be erased, so that health care decision-making becomes transparent. How can one assess outcomes without addressing cost?
Numerous other provisions of the ACA have important impact, such as the requirement for insurance coverage of patients on clinical trials and the introduction of a broad-based program to support disease prevention programs. Their ultimate impact has yet to be fully realized.
Clinical Leadership Is Critical
A final consideration: If the federal government is to truly lead the needed transformation of health care, there must be more coordination between Congress and the Department of Health & Human Services from the outset of the new Administration. President-elect Trump needs a clinician in his cabinet to lead that effort as HHS Secretary. Credibility will come from someone who has actually cared for patients and understands value in health care. Congressional leaders need to work collaboratively with the new Secretary to pass a replacement law that will work for patients and will be embraced by clinicians as a new path forward in health care. Using the value framework of the original ACA, the new Administration can make American health care great again.
This post originally appeared in NEJM Catalyst on November 18, 2016.
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Solomon Varghese
Your headline for the article is very misleading, and sounds like the author is already taking a partisan stance- the content reads otherwise. Repealing ACA in its entirety would be a disaster. Working to repair the ACA
November 18, 2016 at 10:50 am
Tom Feeley
My intent is to be non-partisan but if reality is that it is to be repealed and replaced with something, let's preserve the good parts of the ACA and make it better with something else.
November 18, 2016 at 12:22 pm
Richard J Perry MD
Narrow networks benefit provider systems more than insurers by growing captive market share in exchange for very modest reductions in cost of services.
And that is the fundamental flaw in the ACA that needs repair: there are no significant controls on prices (drugs, devices or provider systems etc). Until then, it is accessible but not affordable.
November 23, 2016 at 8:25 am
Jeff Lowenkron, MD, MPP
Thanks for the article. Innovation is important, yet the main reason healthcare in the United States is not great is the gaps in basic blocking and tackling. There are some core issues that could and, probably should, be fixed with legislation. The idea of leading the transformation or controlling it will be the challenge for the Federal Government. Control is a major mistake. The concepts of PPACA that are positive are easy to enumerate: portable insurance including for people with preexisting conditions, expansion of coverage options that allow the vast majority to have insurance, etc. The rules to accomplish this should not be 2000 pages long. The idea of MACRA should be simple to state and not 1000 pages of rules. This is why there is such resistance to the concepts. There are simple design flaws in our current reimbursement model that drive perverse decisions and negatively impact patients: we value procedures and tests, but not physician time and coordination of care. We value emergency department visits but not primary care visits (just based on what we are willing to pay for them). Some simple concepts have been making their way into CMS, so expect these will continue: if we put others at risk they will make more consumer driven decisions (Medicare Advantage); patients with chronic illnesses should cost more to care for than healthy patients (risk adjusted payments); coordinating care helps patients achieve better outcomes than fragmented care (chronic care management program); etc. The fundamental design flaw for most of our care: if you pay one group of doctors more for procedures and tests and a second group of doctors based on how well their patients do, which group of doctors will do more procedures and tests and which group of doctors will have patients with better outcomes? This should become the design question, followed by implementation. Legislation can absolutely help migrate this design. Legislation will have major challenges putting in the detail if we want to get to meaningful measurement of improvement in patient outcomes. The commitment to direction and then commitment to iteration is key. As a profession we have to accept that 50% of our colleagues will be in the bottom half of performance. Identifying this continuum should help us direct patients to physicians more likely to help them achieve better health.
November 23, 2016 at 11:58 am
Paul Nelson, M.D.
The fullest expression of improvement for our nation's healthcare will not occur through tinkering with the payment process. Obviously, the importance of uniform health insurance is paramount, but without equitably available and culturally accessible Primary Healthcare for each citizen, Parkinson's Law will continue to dominate the cost and quality of our nation's healthcare. Currently, the excess cost of our nation's healthcare dominates the annual deficit of the Federal government: 60% in 2015 or $300 Billion. To be justly efficient and reliably effective, our nation's Healthcare reform must begin community by community. The Design Principles for managing a Common Pool Resource should apply with a VISION of "Stable HEALTH for Each Citizen."
November 23, 2016 at 11:59 am
Jeff Lowenkron, MD, MPP
Appreciate the comment of Dr. Nelson. It is hard for me to follow if this is outside in or inside out as a suggestion. Does your suggestion begin community by community or with equitably available and culturally accessible primary care for each citizen?
How do you account for living in a capitalist country and driving uniform health insurance? Do you really believe Barack Obama will accept the same insurance coverage and health delivery service as the undocumented worker in California? Do you expect everyone in the country to contribute to paying the bills? Who should pay for the increased lifetime costs for teenagers who choose to start smoking or skiers who break their legs? What if Bill and Melinda Gates want to pay out of pocket for better access to care? Would we let them? The achilles heel of PPACA is the requirement that hard working healthy people have to commit to paying more for care than they will need or use to cover others who care needs are more expensive. Not participating is a rational decision, as they could argue they are doing their part by keeping health care costs down. Bottom line is, this is a complicated challenge. When we commit to the change and follow through, there will be winners and losers with the change.
November 23, 2016 at 1:37 pm
Michael Gould
Great post Tom. All these years later, I am still learning from you! In my view, we need incentives that are better aligned to encourage innovations that not only improve outcomes but also reduce costs. This is a given in any industry other than health care. The ever-expanding selection of low-value/high-cost specialty pharmaceuticals (for cancer and other diseases) is exactly the kind of innovation that we can no longer afford.
November 30, 2016 at 7:58 pm
Meredith Alger
Excellent insights for the current administration. Especially relevant now in the "design phase" of repeal + replace.
March 01, 2017 at 5:19 pm
Chris Efthymiou
I didn't find Dr. Feeley's heading to be misleading or partisan, though I can see where a politically obsessed "eye" could read otherwise (of which I do not possess). As a matter of fact Dr. Feeley's content was anything but, praising the new administration of the last year (while I understand this post occured in late 2016), so well done Dr. Feeley.
February 22, 2018 at 11:44 pm