The results of last week’s presidential election were extremely unexpected to many, and in the days that followed, debates in media and social circles took front and center for many of us. Those discussions will likely not cease any time soon, but in a time of great uncertainty, it’s important to focus on what we know rather than what’s now behind us. What we know: Donald Trump is the 45th president of the United States while Republicans maintained control of both the U.S. House and Senate. This will have a profound impact on healthcare’s already-changing landscape.
At a broad level, we also know what Trump and many Republicans think about the Affordable Care Act (ACA, or Obamacare). On the campaign trail, President-elect Trump spoke about repealing the ACA which would mark a significant shift in healthcare policy. While it remains unclear on what exactly “repeal and replace” means, as Trump has said, there will be major changes in store. In a story last week, Healthcare Informatics spoke to multiple healthcare policy experts who had varying opinions on what this could mean for value-based purchasing and healthcare IT, with an underlying theme being that most of what our industry has been accustomed to will likely not be altered in any great way.
With that said, I think it’s important for health IT and healthcare policy stakeholders to deliver a message to the President-elect and to a Republican-controlled Congress that the path healthcare is currently on must not go far off course. Within this changing healthcare landscape are two key developments that are critical to bending the cost curve (total healthcare spending is projected to reach $5.631 trillion in 2025, according to Medicare actuaries): a shift away from fee-for-service, and towards value-based care delivery and purchasing under the Medicare program; and the continued adoption and optimization of health information technology. Let’s tackle each of these.
The Medicare Access and CHIP Reauthorization Act (MACRA) is, of course, set to launch its first reporting period next year 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. It’s important to remember that MACRA is supported by most members of Congress, regardless of political party; last year, the House of Representatives approved the bill by a vote of 392 to 37, while the Senate voted 92-8 in approval. Also, very importantly, 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 in funding that would have to be recouped—an immense amount of federal funding that would pose challenges for anyone considering repealing MACRA. Thus, not surprisingly, MACRA appears to retain broad bipartisan support.
Interestingly, in last week’s story, Jeffrey Smith, vice president of public policy at the American Medical Informatics Associations (AMIA), did say that a Trump administration and a Republican-controlled Congress could provide an opportunity to scale back some of the law’s minimum necessary requirements if they are deemed too difficult. After all, Smith said, “de-regulation” is something that the new administration might be in favor of. Nevertheless, most policy wonks expect MACRA and its Quality Payment Program to go on as expected.
There are other major federal value-based purchasing programs to consider as well. For one, there has been rumblings that the new administration could represent a chance to rethink federal accountable care organization (ACO) initiatives. According to a perspective from The Advisory Board, a Washington, D.C.-based healthcare consulting firm and technology company, “The Medicare Shared Savings Program (MSSP) program was established by the ACA itself and as such would theoretically be eliminated by a full repeal. And the existing ACO programs' disappointing early results (they haven't generated significant savings to CMS) mean that CMS and Congress could be moving to emphasize bundled payments over ACOs as a clearer and simpler driver of savings.”
Their perspective continued, “While some Republicans have expressed discomfort with the mandatory Comprehensive Care for Joint Replacement (CJR) and proposed Episode-Based Payment Model (EPM) programs, that has had more to do with the mandates emanating from the ACA-created Centers for Medicare and Medicaid Innovation (CMMI) rather than from Congress. But as with bundled payments, there currently is no proposed replacement for alternative payment models (such as MSSP) per se, and little near-term indication that they would be targeted in more specific repeal efforts, though the situation bears watching.”
As The Advisory Board mentioned, yes, the government’s federal ACO programs have garnered at best, mixed results so far, there are still reasons for optimism. While the financial savings have not been significant of date for most federal ACOs, the quality outcomes improvements are praiseworthy. At the same time, those ACOs who have been in these programs since their inception tend to do better than new entrants. This indicates that the process is working; but it takes real time to see results.
There is also the ACA’s Hospital Readmissions Reduction Program, designed to make hospitals pay closer attention to what happens to their patients after they get discharged. Since this program kicked off in 2012, national readmission rates have dropped, but too many hospitals are still getting hit with penalties. Kaiser Health News reported in August that the government will punish more than half of the nation’s hospitals — a total of 2,597 — having more patients than expected return within a month. The report revealed that Medicare will withhold approximately $528 million—about $108 million more than last year—as a result of hospitals failing to lower their rehospitalization rates in 2015. While there are valid points against how the rates are calculated and measured, I think most would agree that this program, like the ones above, are key to making sure that hospitals continue to work towards keeping patients from being readmitted so soon when it can be avoided. This alone will help lower that scary $5.631 trillion healthcare spend projection.
Meanwhile, health IT must plunge forward as well in the new administration, as it’s a core element of these value-based programs. It was in 2004 when President George W. Bush created the position of National Coordinator for Health IT. It was then under President Barack Obama in 2009 when Congress mandated the Office of the National Coordinator for Health Information Technology (ONC) in the Health Information Technology for Economic and Clinical Health Act (HITECH). In this time period, electronic health record (EHR) adoption has taken off; a recent ONC report to Congress confirmed that 96 percent of hospitals and 78 percent of physician offices use certified EHRs. Beyond that, HITECH funding spurred health information exchanges (HIEs), and now, ONC and other federal agencies are prioritizing the free flow of health data through agreed-upon standards, preventing information blocking, and have placed more of an emphasis on responding to cybersecurity threats.
There’s no reason why any of these priorities should change under a Trump presidency. As Leslie Kriegstein, vice president of congressional affairs, College of Healthcare Information Management Executives (CHIME) told us in last week’s story, “I don’t see many health IT surprises in this space, as there is a recognition that patients and clinicians alike are empowered with the use of technology.” Here’s hoping that indeed will be the case.
Another angle at play here is awaiting who will be the federal leaders that will take on new roles to continue to lead healthcare’s transformation under Trump. It’s critically important that the President-elect chooses people who have deep knowledge in healthcare policy to replace the senior leadership currently in place. When speaking to Healthcare Informatics, AMIA’s Smith wasn’t too confident in this being the case. “I just can’t imagine a more stark contrast between most of Obama’s Cabinet and political appointees and what will be Trump’s Cabinet and political appointees. It’s not at all clear to me that the same talented and intelligent people will turn up for the job,” Smith said, adding that current U.S. Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell is “a technocrat who understands the complexities and how difficult change is.”
To this end, the future of ONC remains unclear and what direction Trump’s administration sees for an agency that has been crucial to health IT progress is anyone’s guess. But again, an elimination or severe reduction of ONC resources would only raise more questions about direction and leadership going forward.
In the end, while Trump has talked about a repeal and replace of the ACA, the current trajectory for value-based purchasing and health IT must stay on track. Hospital and health system leaders have worked hard to get to where they are today, and reversing course would only cause chaos. Innovation in healthcare needs to continue in order for the sector to get to the level of advancement we have seen in other industries. With so much uncertainty in American government now, it’s critical that we stay on the path that has been laid out for us by previous administrations.