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.
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.
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: email@example.com. 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.