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End of ACA Won't Stop March Toward Value-Based Care, Experts Say


President-elect Donald J. Trump’s upset win almost certainly means the end of the Affordable Care Act (ACA) as we know it, but experts who spoke at Patient-Centered Oncology Care Thursday and Friday said the movement toward value-based payment will continue. The fifth annual meeting, presented by The American Journal of Managed Care, took place in Baltimore, Maryland.


BALTIMORE, Md.—The arrival of a Trump administration will mean the end of the Affordable Care Act (ACA), likely through a budget reconciliation bill early in his term. But along with ACA elements that President-elect Donald J. Trump has said he wants to keep, like guaranteed issue, expect the transition from fee-for-service toward value-based care to continue.

That’s what experts predicted during the discussion, “Oncology Care 2017,” the final session of Patient-Centered Oncology Care, an annual multistakeholder gathering presented by The American Journal of Managed Care Thursday and Friday in Baltimore, Maryland.

The panel featured experts in both oncology and in the ways of Washington: Robert W. Carlson, MD, CEO of the National Comprehensive Cancer Network (NCCN); Scott Gottlieb, MD, of the American Enterprise Institute, who held senior posts at the US Food and Drug Administration and the Center for Medicare and Medicaid Services in the George W. Bush administration; Kavita Patel, MD, MS, of the Brookings Institution and a former senior advisor in the Obama administration; and Ted Okon, MBA, executive director of the Community Oncology Alliance. Bruce Feinberg, DO, of Cardinal Health Specialty Solutions, served as moderator.

Gottlieb predicted, as others have, that the Republican Congress will use the budget reconciliation process to get rid of most of the elements of the ACA, as well as its name, while allowing a two-year transition period to work on a replacement. Some of the changes might include a loosening of the essential health benefit requirements, and fewer restrictions on what Gottlieb called the “very tight actuarial banding,” that he said, “doesn’t allow for experimentation in benefit design.”

There might even be “relief” to fund risk mechanisms, Gottlieb said, which Feinberg noted Republicans refused to do for the Obama administration.

The key, Gottlieb said, is to address the broader problems within the insurance market so the country won’t change course on healthcare every time the party in power changes in Washington. To Carlson, that means ensuring access—and not cutting off access to the 20 million individuals who have gained coverage under the ACA. But Gottlieb and Okon said that the quality of coverage for many, especially in cancer care, falls far short of what is needed.

While the panelists split on the merits of the ACA as it has functioned, they agreed that healthcare would keep moving away from fee-for-service toward value-based payment, though that is necessarily more complex in cancer care. “Everyone wants value,” said Okon. “It’s just a matter of how.”

Feinberg framed the session around observations from keynote speaker Roy A. Beveridge, MD, chief medical officer of Humana, who said that the transition to value-based care has taken payers from worrying about the “ceiling,” which is how much they would have to pay, to the “floor,” which is the minimum quality of care.

Because the time frames of government regulation can’t keep pace with scientific advances, NCCN’s guidelines can offer a foundation for value-based reimbursement in cancer care, for Medicare and beyond. When asked what constitutes value, Carlson said, “It’s what the patient tells me it is.”

For Patel, one key to a value-based healthcare system of the future is improved patient literacy. Even Gottlieb, an acknowledged critic of the ACA, said the HealthCare.gov website improved its consumer navigation tools between its debut and the current year.

Said Patel, “I still practice medicine, and I’ve never had more people asking me how to buy insurance.”

On the first day of the meeting, Beveridge explained that before the ACA, health plans relied on underwriting, a practice in which actuaries determined that some people would not be covered because they presented too great a risk. The ACA ended this, Beveridge said, “which is a good thing. And I think the industry applauds that.”

President-elect Trump has said he wants to continue this part of the ACA, known as guaranteed issue. To do so, Beveridge said that plans will have to work with providers on population health. “If you can’t make the population healthier, then financially you’re not going to do well,” Beveridge said.

In the world of cancer care, there will be more attention paid to areas like palliative care, data sharing, transparency, and nurturing stronger relationships between physicians and patients. Ultimately, the move toward value-based care means removing the historic antagonism between payers and providers and getting the two to work together. “Help your payer figure out who the good folks are, and who the not-so-good folks are,” Beveridge said.

About the Journals and AJMC.com

The American Journal of Managed Care is the leading peer-reviewed journal dedicated to issues in managed care. AJMC.com distributes healthcare news to leading stakeholders across a variety of platforms. Other titles in the franchise include The American Journal of Accountable Care, which publishes research and commentary on innovative healthcare delivery models facilitated by the 2010 Affordable Care Act. AJMC’s Evidence-Based series brings together stakeholder views from payers, providers, policymakers and pharmaceutical leaders in oncology and diabetes management. To order reprints of articles appearing in AJMC publications, please call (609) 716-7777, x 131.

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