2017 Healthcare Trend #2: Unpacking the ACA
“There isn’t any way of putting the genie back in the bottle.” -Edward MacMahon
Unpacking the Affordable Care Act (ACA) and repealing coverage for millions of Americans is going to be very hard for the new administration. There will invariably be changes to Obamacare, something that is clear from Trump’s appointments. The most likely things to change will be things like the individual mandate and the requirement for ACA-approved plans for businesses. These changes will have a large impact on payers who participate in exchanges and for businesses that offer insurance for employees.
The area where there is less clarity around the direction for U.S. Department of Health & Human Services (HHS) relates to MACRA and MIPS, which I use as proxies for the new payment models (readmission, bundles, etc.) and the broad shifts of payment for care from quantity to quality. There has already been pushback from health systems about two new payment models to test in fifteen months, an indication of the pace of change for providers. It seems most likely that Trump’s HHS will continue down the path of shifting care from quantity to quality.
At the highest level, shifting from volume to value is about delivering continuous, quality care. It’s about extending the view of a hip replacement, just one example, as a point-in-time episode to a ninety-day episode. This is a major shift requiring new technology and, more challengingly, changes in workflows and internal processes. This shift will also require new partnerships. Some systems, especially integrated delivery networks like Kaiser, are aligned and organized to deliver care in this quality-care model while many others will need to partner, not just for the technology but also for the care navigators and other care team members. It’s closely related to the point I made in the [first article in this series] about offering complete, ready-to-deploy solutions. Pure technology offerings are going to fail unless they are an enabling layer, such as an API that combines some unique, proprietary sets of data to deliver a valuable new data set or resource; simply API-enabling existing standalone systems, such as EHRs, is not a long-term differentiated product.
The next level down in volume to value is purely about data, not for care but for reporting and comparison purposes. Reporting is the initial stage for new payment models like bundles. It provides HHS with new and powerful data from which healthcare providers can be compared. The reported data is compiled from multiple sources, not just the EHR, so it is not a simple matter of reporting data that providers already have available but instead is a challenging, multi-step process. The first challenge is compiling the data. The second is reporting it. The third, one which is not required by HHS but is essential for care providers to succeed in new payment models, is the analysis of reported data. All three of these challenges will see new, enabling solutions that will excel. These new data layers will power the care management platforms of the future.
Increased uncertainty and turmoil
If nothing else, the Trump election, exacerbated by the surprise nature of the outcome, increased the amount of uncertainty and turmoil in the healthcare industry. In an industry with variable margins and resources by sector, this uncertainty disproportionately will benefit life sciences companies and, to a lesser extent, payers, over health systems. Health systems will be cautious in spending on major strategic initiatives like patient engagement, while life sciences companies will accelerate efforts to own the patient as consumer.
Next week, for the third part of this series, I’ll share “The Rise and Fall of the EHR” a look at the part EHRs will play in the new guard of health IT. Be sure to follow this series by subscribing to our blog updates. Make sure to also read Part 1 and Part 4 of the series.