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.”