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?"
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.
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.
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
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
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.
Better Health Technologies, LLC
The ACA's provisions promoting ACOs and accountable care are
showing the greatest promise to transform the US healthcare
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
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
(innovation.cms.gov). 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
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
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.
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.
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
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.
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.
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).
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...
R. Kongstvedt, MD, FACP
Principal, P.R. Kongstvedt Co., LLC
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
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
To see expandable version of the graphs and table,
please visit Peter's blog at
http://kongstvedt.com/kvedtblog/?p=81 . 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
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.
Video White Paper: Utilizing Analytics to Deliver Coordinated,
On-Demand: IBM Patient Care and Insights: Four Videos
On-Demand: Managing Complex Billing Environment in Advance of
Health Care Reform
Strategies for Readmissions Success: HealthPartners' Regions
Hospital Initiatives, May 7, 2013
Facilitated Exchanges - A Status Report and Implications, May 8,
Depression in the Workplace: Why it Matters and What You Can Do
About it, June 6, 2013
Modeling Web Summit, June 13, 2013
Readmissions Web Summit, August 22, 2013
Accountable Care Web Summit, December 12, 2013
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