Addressing Heath Insurance Business Challenges with Core Transformation: Managing Complex Billing Environment in Advance of Health Care Reform
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Today's Topic

Which provision of the Affordable Care Act do you feel has had the greatest degree of success thus far with regard to implementation and achieving its objectives?"

   William J DeMarco MA, CMC
 William J DeMarco MA, CMC

William J DeMarco MA, CMC
Pendulum HealthCare Development Corporation

If I can point to any one provision or set of rules I would have to say that the way reimbursement has changed and IS changing is motivating people to think differently about delivering care but also the preparation to deliver care. I believe patient engagement and population health measurement are here to stay because they support the idea of helping patients become better consumers of care, which is what a medical home is intended to do. For the first time this is being linked to payment with a financial incentive to help the patient navigate the labyrinth we call the care system. In treatment we are also changing trying to build better pathways and follow guidelines with a reward attached if we can reduce cost as an ACO is intended to do. Finally we are no longer leaving the patient at the curb but are taking up the slack with technology, social media and on hands follow-up by care coordinators who  did not even exist 3 years ago. This post discharge and transitional care process saves money by lowering readmissions and more importantly improves care. Would any of this have happened without financial incentives? Probably. But it would have been slower and more protracted in getting at the implementation of these common sense innovations. Now we see grants, structures, best practices and data flowing everywhere to really transform this reimbursement system, not merely transition it to the next status quo.  The federal  government and, to a great extent, the purchasers like Kaiser and Dean Care are proactively involved in setting the platform for the next generation of care system delivery AND financing.

 Mark Lutes
 Mark Lutes

Mark Lutes
Member of the Firm, Epstein Becker & Green, P.C.

One of the ACA's "success" stories, in the eyes of its proponents, has been the requirement that insurers refund to groups/beneficiaries, that portion of premium that falls below a new percentage expenditure on claims and health care quality related activities (the "medical loss ratio" or "MLR").  Of course, like most things in Washington, the requirement has had unintended consequences.  Thus, the celebration of "success" evidenced by MLR generated refunds needs to be tempered by a realization that the requirement limits the amount of retrospective and concurrent medical management (aka cost control) activities that can be taken by insurers thus working directly against any cost control goals associated with the ACA.  Moreover, the "success" establishes profit controls on insured business thus making the ASO/self-funded book increasingly more attractive to carriers and thus contributing to the flight to self-funding among employers.  Of course the flight to self-funding drives increasing percentage of coverage beyond the strictures that the ACA has imposed on insured products including premium increase regulation.

While not the reason that MLR requirement was enacted -- a silver lining is that the MLR regulation encourages insurers to seek enhance medical management by delegating responsibility to provider organizations with the function supported by capitation and other bundled payments.  Those who believe that provider incentivization is a preferable medical management solution to remote medical management should find solace in this unintended consequence.  However, it is clear that the "success" of MLR regulation under the ACA has had unintended consequences that dwarf those that the provision was intended to produce.

 Vince Kuraitis
 Vince Kuraitis

Vince Kuraitis

Better Health Technologies, LLC

The ACA's provisions promoting ACOs and accountable care are showing the greatest promise to transform the US healthcare system.

Medicare's initial ACO programs are the Medicare Shared Savings Program (MSSP) and the Pioneer model. The MSSP has attracted 220 ACOs to sign up and there are 32 Pioneer participants.

Many other accountable care program demonstrations and pilots are being developed under section 3021 of the ACA - enabling legislation which established the Center for Medicare and Medicaid Innovation ( That section lists 18 different models for possible testing, e.g, payment and practice reform in primary care, contracting directly with groups of providers, and many others. We should expect to wait 4-5 years for final results while these programs are planned, conducted and evaluated.

The reason these programs show the greatest promise for transformation is that they begin the migration away from fee-for-service payment--a root cause of inefficiencies, over-utilization, and minimal attention to system quality.

The most often heard (and valid) criticism of the ACA is that the legislation did not focus on fundamental health delivery system reform and cost control. Surprisingly, the provisions described above are increasingly showing promise for fundamental shifts in delivery of care.

I'm using the term "promise" cautiously. While these initiatives show promise, it's important to understand that the jury is still out on deciding the verdict for long-term success.

For example, the MSSP is as "fragile" as it is promising. While the MSSP has 220 participants, only 8 are participating in the option to assume downside risk in return for greater upside potential. We don't know how many of the MSSP participants will stick around after the initial 3 year contract period. Expect to see some initial results from the MSSP program this summer.

  Michael J. Thompson
 Michael J. Thompson

Michael J. Thompson
Partner, PricewaterhouseCoopers

The biggest and most complex parts of ACA are in front of us. Some of the early provisions were implemented with delays or transition plans to mitigate the short term impact (eg elimination of annual maximums, automatic enrollment) while others were eliminated (voucher program, CLASS Act). The most successful provisions to date have been the Age 26 rule and elimination of lifetime maximums but the success of the overall legislation will largely ride with the 2014 implementation when the most transformative changes take place.

  Henry Loubet
 Henry Loubet

Henry Loubet
Chief Strategy Officer,

Accountable Care Organizations (ACOs) are the most significant outgrowth of the Affordable Care Act (ACA) to date, and have been successful in beginning to change the paradigm for delivery and financing of health care. By shifting the emphasis from volume purchasing to quality of outcomes, rewarding wellness over morbidity, and facilitating an integrated delivery system, ACOs are demonstrating the potential for improving care while lowering the cost trend.

Visionary and innovative providers have a great opportunity to create a competitive market using the ACO model to attract patients as long as they are successful in their quality metrics and pricing structures, and provided they are transparent with both their ratings and costs. Transparency and better availability of consumer information is another positive result of the ACO provision and this will further drive competitiveness in the marketplace.

Physicians who have established high medical reputations can partner with ACOs to help enhance outcome/quality ratings of the organization. This approach could help to drive up the overall quality as ACOs seek out the best talent among providers in building ACOs.

Finally, I believe Accountable Care Organizations can successfully drive innovation in the areas of access and efficiency for patients, treatment and monitoring of complex disease conditions, organization of both individual and population medical data, and research advancement. ACOs, if successful, can enable the migration from Pay to Perform (P2P) to Pay for Performance (P4P).

Cindy Nayer
 Cyndy Nayer

Cyndy Nayer
Founder, Center for Health Value Innovation

With what seems like daily "rules clarification," this question is one that can change rapidly. However, I believe the greatest degree of success so far has been the emphasis on prevention and wellness. This is high praise from someone who has been in the field of health promotion and healthy aging for over 25 years. I remember the days when prevention and wellness (a crudely-defined term, and therefore I do prefer health promotion, but, "wellness" is now part of the nation's healthcare fabric) were dismissed before the words were even out of our mouths.

Now, there is an abundance of wellness programs, apps, and opportunities to get involved in managing one's health and healthy outcomes. The objectives of getting people to focus on preventing disease and managing the conditions that already exist has grown to a national priority. But the definitions of success and how we measure it? Ah, there's the rub...

Peter Kongstvedt
 Peter R. Kongstvedt, MD, FACP

Peter R. Kongstvedt, MD, FACP
Principal, P.R. Kongstvedt Co., LLC
Peter's Blog

The answer to this or any other question must always be preceded with a question: Who's asking? In other words, how successful or effective something is depends on who is defining success or effectiveness. The following table illustrates this:

To do so for every provision would require about 80,000 words though, so for ten different constituencies we'll score ten provisions currently in effect and six not yet in effect. The ten in effect will be made up of five coverage-related provisions and five non-coverage related provisions, while the six future provisions are mixed. The scale for perceived level of success goes from -5 (the least successful) to +5 (the most successful).

There are good reasons behind all of these scores, but to do this in the confines of a blog means we'll skip that part and assume omniscience on my part, even though you will think I severely miss the point on one particular element or the other depending on what constituency you are in. But never mind that for now. Here goes.

To see expandable version of the graphs and table, please visit Peter's blog at . Please click on the images If you'd like to see enlarged graphics.

Despite the rigorous methodologies applied to creating the results displayed on these charts (and by rigorous methodologies I mean I scrunched my eyebrows and scowled in thoughtful concentration) they miss something big, something that trumps most other elements. So what's missing from these charts? Instead of me telling you what it is, how about you think about it for a few minutes.

Ooh, doncha just hate that? Really gets you irritated, just like that professor you had for comparative biomusical theology class used to. But not as mad as when Ted, who has a corner cubicle and seems to think that means he can leave just 1/4 inch of coffee in the pot and never, ever make a fresh pot and it's always me that makes the new pot and never Ted and he always leaves his dirty coffee cup in the sink and his leftover food on the break table and never cleans it and what does he think I am, his servant?

Hmmm...Maybe there's a clue there. Your emotions are not simple binary feelings, like pure happy, pure sad, pure angry, etc. There are degrees, and that's the missing element: Emotional charge, and when it comes to health, there's only one thing that carries more emotional weight then does your health, and that's the health of loved ones.

Try this thought experiment. Imagine how you feel if your 14 year olds' English teacher gives him or her a B on what you consider to be a beautifully written essay on the  influence of Kierkegaard on the music of the British band Muse. OK, got it? Now imagine how you feel if Greatte Bigge InsureCo(R) denies coverage for treatment of your child's cancer at The World's Most Famous Cancer Center(R) on the basis of it not being a contracted hospital. I know I'd have steam coming out of my ears like Yosemite Sam when he's riled by some flatlander, and I'll bet you would too.

For people who are sick or who have loved ones who are sick, and who are either uninsured or reached their coverage limitations, the emotional charge associated with getting coverage is beyond any possible emotional weight by any company or person not facing medical Armageddon. If we used some type of emotional weight element into the graphs, the value bars for the uninsured would be so high you wouldn't even be able to see any of the others. This will never change. Not even if Ted in the corner cubicle cleans the coffee a thousand times.

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