As the U.S. Congress swirls with discussions over, and some level of contention around, the legislation introduced Monday afternoon by Republican leaders of the House of Representatives, including Speaker of the House Paul Ryan (R.-Wis.) to replace, or at least modify, the Affordable Care Act (ACA), one very important aspect of the bill introduced into the House Energy and Commerce Committee is what is, and what is not, in it. For the readers of Healthcare Informatics, the key point of what was revealed is this: 100 percent of the bill focuses on some of the health insurance elements in the ACA; there is nothing at all that is not insurance-related; there is nothing at all in the legislation connected to the internal health system reform provisions of the law.
In other words, the mandatory value-based purchasing, readmissions reduction, and healthcare-acquired conditions-related provisions in the ACA are here to stay. The same is true of the voluntary programs, including the now-several accountable care organization (ACO) programs being administered by the Medicare program.
And though the new bill received a stormy mix of support and criticism from members of both parties, and faces an uncertain future, it seems clear now that any future repeal legislation is unlikely to encompass the internal health system reform elements in the ACA.
And that means that the leaders of patient care organizations across the United States can now prepare more effectively for the future, in terms of the health system reform-based demands in the law. What’s more, those in the know on Capitol Hill feel confident that the MACRA (Medicare Access and CHIP Reauthorization Act) law—which was passed in 2015 and is a piece of legislation completely separate from the ACA—is quite safe from being overturned, for a number of reasons (not the least one being that the passage of MACRA “fixed” once and for all the problem of the constant “patches” that had been necessary to manage the SGR (sustainable growth rate) problem that had been created through legislation a decade ago—and repeal of MACRA would force Congress to ante up as much as $300 billion in what would then become a new federal revenues gap). And because MACRA is safe, the MIPS (Merit-based Incentive Payment System) program for physician payment, will essentially be safe in its broad outlines. And even as some moderate changes might be made to MIPS, Seema Verma, last month in her confirmation hearings to be administrator of CMS (the federal Centers for Medicare and Medicaid Services), praised MACRA overall, saying of the law, “It was an important step forward to provide stability for providers and move us toward better outcomes. The most important thing we can do is engage stakeholders not just on the front end, but all the way through,” Verma said of MACRA. And while she hinted that some minor changes might be made to MIPS—and Tom Price, now Secretary of Health and Human Services (HHS), has in the past as a congressman criticized the over-regulation of physician practice in particular—it appears that even elements of MIPS and MACRA that might undergo modification will likely be at the level of detail, not at the level of legislative repeal.
The one area that both Price and Verma have spoken somewhat openly about is the subject of mandatory bundled payments for total joint replacement and cardiac care, which have been unveiled and implemented under the aegis of the Center for Medicare and Medicaid Innovation (MCCI), a division of CMS that Price roundly criticized while a congressman. When it comes to mandatory bundled payment models, said told senators that she supports “efforts around innovation, as it’s important that we are trying to climb the highest mountain. Innovation is important, as we look at testing new ideas. That process has to be sure of a couple of things,” she cautioned, “like making sure we are not mandating people to participating in something there is not consent around.”
Verma also referred to the meaningful use program, which as readers know comes out of yet another law, the HITECH (Health Information Technology for Economic and Clinical Health) Act, part of the 2009 ARRA (American Recovery and Reinvestment Act), aka, the federal stimulus. Of course, physicians’ obligations under meaningful use have already been shifted entirely over into the MIPS program. Speaking of physicians and mandates, she told senators last month that “We need to talk to doctors and have open collaboration and communication with them to identify regulations and provisions that are [leading] providers to consider not participating in the program.” She also added that she likes the potential of electronic health records (EHRs), but that she has been around doctors “where they're staring at the computer instead of looking at me."
Still unknown is the precise fate of Stage 3 of meaningful use for hospitals; but, given Secretary Price’s past expressions of hostility towards meaningful use, it is highly likely that, if Stage 3 comes into being at all, it will most likely be minimized in terms of requirements for hospitals.