We are in the midst of exchange implementation-the centerpiece of the affordable care act-and it seems a good time to take stock of where we are and need to go. The ACA has validated and spurred on existing efforts. We are making progress on many fronts but fundamental changes are still needed to deliver on the promise of better value.
Published Online: December 12, 2013
Sarah Thomas, MS
The Affordable Care Act Reinforces and Supports Work Already Under Way
The Affordable Care Act (ACA) built from the experience of many pioneers in working toward better value—from business, states, local initiatives, multipayer initiatives, and private organizations, as well as some federal initiatives like the Physician Group Practice demonstration. In many cases, these initiatives are benefiting from funding and reinforcement from the federal government through implementation of the Affordable Care Act.
Regional initiatives have been working on safety and quality improvement together with payment reform, all intended to get to better value for the healthcare dollar. Even before the ACA passed, many local initiatives got serious about improving quality and payment reform. There are many examples of initiatives around the country—many spearheaded by business leaders committed to getting better value from the healthcare system in places like Memphis, Tennessee, and Maine. One example of these initiatives is the Pittsburgh Regional Health Initiative. Focusing first on improving hospital quality and safety (eg, reducing rates of medication errors by 86%), then moving on to reducing hospital readmissions through myriad strategies, its work is grounded in analysis of data to identify opportunities for making care better. ACA funding through the Center for Medicare & Medicaid Innovation and the Agency for Healthcare Research & Quality (AHRQ) has supported some of this work.
The ACA drew from the work of private organizations like the National Committee for Quality Assurance (NCQA). NCQA has proven approaches to defining and promoting quality improvement through accreditation of health plans, evaluating clinical practices (eg, through the patient-centered medical home [PCMH]), and standardized collection and public reporting of quality measures results. With ACA implementation, funding has been made available for developing new quality measures for children, for people with behavioral health problems, and for use in electronic health records. The number of clinicians recognized as PCMHs has grown to over 30,000 and record numbers of health plans are seeking accreditation because of participation requirements for Exchanges called for in the ACA.
We are seeing many health plans getting serious about sponsoring payment reforms. Carriers like Aetna, CIGNA, and United are entering into new types of arrangements with provider groups to form Accountable Care Organizations (ACOs). The ACA does not support these initiatives directly, but may have helped to stimulate their development together with employers’ push for better results.Promising Results From ACA Initiatives
The ACA passed in March 2010. The last 3½ years have been a long road for the legislation, which has faced multiple hurdles— the presidential election, the Supreme Court ruling, multiple votes from the House to repeal and defund, and now website problems. Despite these many tests, implementation has moved forward and we are seeing some positive results.
The ACA transformed the Medicare Star Rating program from a report card program (where results for the plans were posted to a website) to a pay for performance program that—with the addition of demonstration funds—has resulted in new attention from health plan leadership and acceleration in results. NCQA reported last year that Medicare plan performance on measures like colorectal cancer screening, body mass index assessment, and controlling high blood pressure had improved.1
Centers for Medicare & Medicaid Services (CMS) authors reported that Medicare beneficiaries appear to be using quality information to help choose a health plan2
; this is a major breakthrough for consumer engagement.
CMS is also reporting some positive results in the trends in hospital readmissions and improved quality in the first year of the ACO program. The agency has laid the groundwork for many potential improvements through supporting state and multipayer initiatives around primary care (including PCMH initiatives), integrating care for people with Medicare and Medicaid coverage, and delivery system transformation. The Office of the National Coordinator for Health Information Technology is reporting increased rates of health information technology adoption covering many important elements of “meaningful use.” While promising, it is too soon to see the results of these initiatives. Healthcare spending growth is slowing down and while all economists attribute this to, at least in part, the recession, some credit the new incentives in the ACA with some effect.3 Where We Still Need to Go
Although we are making good and steady progress toward better value, we need more.
Exchanges need to realize their potential. Although there was a lot of discussion around active versus passive purchasing models for exchanges in the early days of the ACA, most states and the federally facilitated exchanges have put their energiesinto offering choice of plans and negotiating over premiums. This is natural given the goal of getting these programs up and running, but we want to see more emphasis on quality and driving plans to sponsor initiatives to change the delivery system in the next couple of years.
We need to move away from fee-for-service payment to physicians. Researchers surveying large multispecialty group practices found that even these organizations that are most likely to be positioned for better value are still using fee-for-service payment, which rewards volume over value.4 The Catalyst for Payment Reform reported that in 2012, only around 11% of payments were based on value.5 Pending legislation to address physician payment by Medicare would move in the right direction by promoting alternative payment models.
Engaging patients. Changes to align incentives in the paymentsystem and provider transparency and accountability initiatives are important, but getting to the best possible results in health outcomes will require helping consumers to take better care of themselves, whether this means diet and exercise or management of chronic conditions.
Improving the system for furnishing long-term servicesand supports. As the US population ages, we will need to fix the current financing system for long-term services and supports and for post acute care. The program established by the ACA for addressing this was not actuarially sound. The commission established to make recommendations on how to improve care broke down when it tried to figure out how to improve financing. We hope that some of the new initiatives around providing better care for people with Medicare and Medicaid are successful, but there are many challenges to surmount.
Integrating behavioral health with medical healthcare. State governments have long separated the financing and delivery of care for behavioral health issues from physical health. Experts realize that some of the “high fliers” in healthcare spending are people with both types of healthcare problems; they also realize that treatment for behavioral health conditions can lead to physical health problems. The ACA created the “health home” program in Medicaid as a way to bring primary care and behavioral health together, but it is too soon to see results. Furthermore, the funding for this program is limited to just 24 months.
Getting to transparency on price and quality. Despite manyall-payer database initiatives and report cards, we are a long way from real transparency about prices and quality. Private sector innovators like Castlight are leading the way in engaging consumers in information about cost and quality at the point when they need and can act on the information. But we are a long way from this type of information being widely available. Some states are hamstrung by political factors from providing useful information on healthcare prices. Robust transparency and other steps to spur competition are needed to pull down prices for both plans and hospitals with too much market power.
Author Affiliation: From Public Policy and Communications, National Committee for Quality Assurance, Washington, DC.
Author Disclosure: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Address correspondence to: Sarah Thomas, MS, Vice President, Public Policy and Communications, National Committee for Quality Assurance, 1100 13th St NW 1000, Washington, DC 20006. E-mail: firstname.lastname@example.org.
1. State of Health Care Quality. http://www.ncqa.org/Portals/0/State%20of%20Health%20Care/2012/SOHC%20Report%20Web.pdf.
2. Reid RO, Deb P, Howell BL, Shrank WH. Association between Medicare advantage plan star ratings and enrollment. JAMA. 2013;309(3):267-274. doi:10.1001/jama.2012.173925.
3. Cutler DM, Sahni NR. If slow rate of health care spending growth persists, projections may be off by $770 billion. Health Aff. 2013;32:841-850. doi:10.1377/hlthaff.2012.0289.
4. Mechanic R, Zinner DE. Many large medical groups will need to acquire new skills and tools to be ready for payment reform. Health Aff. 2012;31:91984-91992.