Leonard Lichtenfeld, MD: There are all sorts of things in the Affordable Care Act that many people don’t know about, or don’t pay attention to, that certainly don’t have big constituencies. One of the issues is accountable care organizations and the concept of paying for care in a different way, and that’s still a work in progress. There are some that have been successful, and some that are not as successful. I’m familiar with one practice in particular, in which they made a concerted effort to implement the ACO model, and they ended up having to back out because they were already a high-performing practice and the rewards of doing that didn’t work—and there are all sorts of innovative models. They may be virtual ACOs. There’s a lot going on.
But there are some practical questions. What about the Center for Medicare and Medicaid Innovation? Now, some people will say, “I don’t like what the CMMI does; I don’t want them anyway.” But a lot of people happen to like what they’ve done. What about the CCMI Oncology Care Model, which has been trying to figure out a better way to pay for cancer care? What if that goes away? What do you do? I was sitting in a meeting a couple of months ago, just after the election, and started to scratch my head and say, “Well, if CMMI goes away, what happens to the Oncology Care Model?” I’ve heard nobody address that. Most people say, “Well, the CMMI model won’t go away, but it may have more Congressional oversight. It’s all part of the legislative process.”
It’s the old sausage making issue—you don’t want to watch it being made, but eventually somebody will make a decision. But there are also other agencies that may not be part of the ACA specifically, like the Agency for Healthcare Research and Quality, which looks at patient-centered outcomes research—to try to foster that. That may not be an immediate part of the ACA, but it is on the radar screen. Is that going to go away? Will we lose some of the organizations and institutions that we need to be able to understand what quality care is?
So, there are a lot of pieces to this puzzle. It was a very long act. I’ve never read it, I have no intention of reading it, and I won’t get into the famous quotation—“You’ll know what’s in it after you pass it”—but we’re still in that process: the absolute repeal coming and saying that it’s all gone. It would be a lot of work to put it back together, and there are always going to be problems. Legislation is not designed to be perfect. There’s always the regulatory piece, and then there are always the pieces that need to be fixed. We need to pay attention to all those below the radar screen issues, because they have an impact on the way that we give care.