On November 8, 2016, Donald Trump was elected to occupy the Oval Office as the 45th president of the United States while Republicans maintained control of both the U.S. House and Senate. For healthcare C-suite leaders, this administration shift brought with it new policy implications to consider in both the short- and long-term.
Now a few months into Trump’s presidency, Healthcare Informatics readers still have a myriad of questions as uncertainty lingers over the future of healthcare policy. As such, our editorial team concluded that the value-based healthcare landscape, within the current policy moment in the U.S., was well worthy of being one of Healthcare Informatics’ Top Tech Trends for this year. Within this trend are several moving parts, which could change at any point; but for health IT leaders, some of the key policy points to consider are:
- The leadership positions at two healthcare federal agencies are likely to bring with them much different mentalities than what was seen in the previous administration. Recently-confirmed Health & Human Services (HHS) Secretary Tom Price, M.D. and Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma will emphasize de-regulation and putting more decisions in the hands of doctors and patients, rather than the federal government. Both Price and Verma have talked about this in recent Senate hearings.
- The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which was passed with bipartisan support, seems safe. MACRA launched its first reporting period in January 2017 in which eligible Medicare clinicians will be reporting to a Quality Payment Program that determines a physician’s reimbursement based on the high quality, efficient care they provide that’s supported by technology. The MACRA law was enacted in order to sunset the constant “patches” to the never-funded SGR (sustainable growth rate) law; that means that any overturning of MACRA would require Congress to re-fund what could be more than $250 billion that would have to be recouped—an immense amount of federal funding that would pose challenges for anyone considering repealing MACRA.
- Other value-based purchasing and accountable care payment programs have a bit of a murkier picture. Accountable care organizations (ACOs), many of which were stemmed from the very Affordable Care Act (ACA) that Trump is trying to “repeal and replace,” have their share of skeptics. Meanwhile, Secretary Price has been outspoken in the past on not forcing providers—especially physicians—into bundled payment programs.
- Overall, there has been a strong desire from the new administration to reduce the burden that health IT puts on doctors. This was also a priority of the prior administration’s federal healthcare leaders, but coupled with the objective of Trump and his cabinet to de-regulate, it carries more teeth this time around.
- The future role of the Office of the National Coordinator for Health Information Technology (ONC), the federal government’s health IT arm, also is cloudy. While no one expects the agency to be dismantled, the administration will have to name a new National Coordinator for Health IT at some point while current ONC staffers wait for more direction. The ONC might also see major funding cuts, based on priorities of the new administration.
Different industry experts will have varying opinions on all of the above, but the sources interviewed for this story all agree on one broad concept: value-based healthcare will continue to march on. Jeffrey Smith, vice president of public policy, at the Washington, D.C.-based American Medical Informatics Association (AMIA), expects new senior federal healthcare agency officials to conduct a broad review of initiatives that are ongoing or fairly new. “I am anticipating perhaps a consolidation of a lot of work going on at CMMI [the Center for Medicare & Medicaid Innovation] and with it, potentially an opportunity to look at some of the drivers that have historically been plaguing documentation burdens,” says Smith. Indeed, CMMI has been a target of Republicans in the House in the past, who say the center, which was established as an added section of the ACA, has overstepped its definition in statutes. Brian Ahier, digital health evangelist at Salt Lake City, Utah-based Medicity, predicts that CMMI, “which many in Congress feel has not been accountable enough for the funds [they have received], will ultimately be defunded.”
As for the future of ACOs, Smith says that it’s “incredibly unlikely that any ACA repeal would include something like the [elimination of] the Medicare Shared Savings Program [a federal ACO model]. I say that because when you look at the balance sheet, the MSSP is not costing the government a lot of money and it is starting to pay dividends for those who have been in [the program] for a while.” Smith adds that there has been a big push to lower the bar for entry, in terms of what is defined as “nominal cost” for a qualifying alternative payment model (APM) under MACRA, “so you will see a push to make investments into having an ACO count as the [required] nominal cost. Whether or not HHS looks at that and will actually count it, well, that doesn’t look good on paper,” he says.
Farzad Mostashari, M.D., former National Coordinator for Health IT and current president and founder of Aledade, a Bethesda. Md.-based company focused on physician-led ACOs, agrees with Smith, noting that he recently spoke with a lead Republican staffer who said that ACOs “have been taken off of the ACA playing field and are now on a new playing field, which is called MACRA.” Mostashari says that for folks who are tangentially involved, there is an uncertainty as to what a repeal of the ACA might mean for the delivery systems part of it, but he feels that the next six months “will show an unsettling of those concerns as implementation moves forward.”
Health I.T. Considerations
Much has been made in recent months about how the new administration wants to reduce the burden that health IT puts on clinicians. The praise for electronic health record (EHR) adoption across hospitals and physician practices is there, but now it’s time to make sure these systems are not impeding patient care, they say. But what does this really mean, for health IT end users going forward?
Smith notes that people have been talking for a while about this notion of clinical documentation not getting better with technology. “I expect to see and hear organizations talking about E/M [evaluation and management] coding guidelines and looking anew at how we document care. Are we documenting for outcomes? The answer is no,” says Smith. “What do doctors hate most?” he asks. “You come out of those conversations with [complaints] around clinical documentation and quality reporting. Price and his staff were involved with the MACRA legislation, and they want to encourage organizations to move into a risk-sharing mode, so the question becomes, how do we improve the tools we have to allow for good doctors to be successful in this new APM paradigm?”
Key to anything related to health IT is ONC, amidst a Politico eHealth report in February which said that Congress had considered abolishing ONC as part of its work related to the 21st Century Cures Act, according to sources on the Hill. But, the report noted, “lawmakers gave HHS’s small health IT office more responsibility, making it more bureaucratically ingrained and harder to kill in the future.” This back-and-forth leads one to believe that ONC’s role as a convener will stay intact, but both Smith and Mostashari feel that the agency’s work will mostly be focused on specific health IT use cases, as well as moving forward with the Cures Act. “If there are specific goals that the administration has for the use of this massive infrastructure that’s now in place to achieve those goals, then they will want to have informed expertise at ONC,” says Mostashari, noting that the agency’s annual budget “has been basically frozen” for the better part of the last decade. These use cases might range from easing the quality reporting burden in MACRA, improving patients' access to their health records, and evolving the EHR certification program,” say Smith and Mostashari.
Farzad Mostashari, M.D.
In the end, with all this in mind, what kinds of plans can healthcare leaders move forward with now, in the current policy moment? John Poelman, executive director of the Accountable Care Learning Collaborative (ACLC), whose mission is to help accelerate the readiness of the industry to adopt accountable care, advises, “Do not ignore it. By not paying attention, you can really put yourself in a bad situation. Take time to learn about what’s going on. Pay attention to new programs and what’s going on in your market, and start learning from as many sources as you can,” he says.
Nonetheless, when asked if the new administration is as bullish on healthcare information technology as previous ones, Smith says that going back eight years, the promise of health IT “was just around the next bend, and you had leadership who believed that. Now, leadership is disappointed.” He adds that it would be uncharacteristic and unhelpful to not look at the progress to date, and not want to figure out ways to maximize and capitalize on that progress. “There is a feasible future in which the cheerleaders for health IT are no longer in power, and those in power are not necessarily the staunch advocates we have had in the past, but it would be irresponsible to walk away from what we have done so far, and not to look for ways to make what we have better,” Smith says. “Even if you think we have lemons, let’s look for ways to make lemonade.”