Amid all the rhetoric over ACA re­peal and re­place, agenda must build on gains al­ready achieved

Modern Healthcare - - COMMENT - By Su­san DeVore

With the tran­si­tion to a new ad­min­is­tra­tion well un­der­way, the fate of the Af­ford­able Care Act is weigh­ing on ev­ery­one’s mind. We’ve all heard the rhetoric of re­peal and re­place, but what will a new sys­tem look like? One thing re­mains clear: The chal­lenges haven’t changed. Healthcare costs con­tinue to soak up bud­gets in fam­i­lies, states and the fed­eral gov­ern­ment.

We must come to­gether to find ways to con­tinue to im­prove qual­ity while safely re­duc­ing costs and build­ing on gains achieved over the past sev­eral years. Here are a few things to con­sider:

Congress needs to hit the ground run­ning. The new Repub­li­can-con­trolled Congress will be sworn in on Jan. 3. Look for both cham­bers to be­gin work im­me­di­ately on healthcare-re­lated is­sues—start­ing with Se­nate hear­ings on Cab­i­net nom­i­nees, in­clud­ing Dr. Tom Price for HHS sec­re­tary. Once con­firmed, Price will be among those work­ing on a re­peal-and-re­place strat­egy for the ACA fo­cused on vouch­ers to pur­chase high­d­e­ductible, cat­a­strophic plans, cou­pled with health sav­ings ac­counts.

It is likely he will ad­vo­cate keep­ing the re­stric­tion on pre-ex­ist­ing con­di­tions, pro­vided cov­er­age is pur­chased and main­tained. While broad strokes are clear, the de­tails will be more com­plex. Like a game of Jenga, Repub­li­cans will need to bal­ance the pieces to en­sure any­thing they jet­ti­son doesn’t cause un­in­tended con­se­quences.

Cov­er­age ex­pan­sion limbo can’t go on for long. Be­cause most of the ACA is in place, it will be dif­fi­cult to roll back ben­e­fits—and Repub­li­cans cer­tainly are not united around the best path for­ward. We can ex­pect at least a year of con­sen­sus-build­ing around cov­er­age ex­pan­sion is­sues, e.g., in­di­vid­ual and em­ployer man­date, Medi­care Ad­van­tage, Med­i­caid ex­pan­sion, ex­changes, sub­si­dies, high-risk pools and insurance reg­u­la­tions. There will also be de­bate around elim­i­nat­ing or re­duc­ing de­vice, phar­ma­ceu­ti­cal, insurance and other taxes that fund the ACA ex­pan­sions. How­ever, Congress can’t wait too long. In­sur­ers will be hes­i­tant to par­tic­i­pate in the ex­changes for 2018 with­out some cer­tainty.

The move to pay-for-value will con­tinue. The move to­ward al­ter­na­tive pay­ment mod­els and provider ac­count­abil­ity in the shift to­ward a value-based sys­tem is bi­par­ti­san. MACRA, which passed with sup­port from both sides of the aisle, so­lid­i­fies and ex­tends the move to new con­stituents. This means there is a vested in­ter­est in see­ing these mod­els suc­ceed. The fis­cal im­per­a­tive to rein in healthcare spend­ing while im­prov­ing qual­ity will re­quire law­mak­ers to con­tinue to press for changes that pay for value, pro­mote in­creased con­sumer re­spon­si­bil­ity and in­crease trans­parency of costs and qual­ity. This is not up for de­bate—it’s clear that value is the new healthcare econ­omy and mea­sures are the cur­rency.

In­creas­ing pharma com­pe­ti­tion must be a top pri­or­ity. The pres­sure to con­tain health spend­ing will only in­crease. At this time, Repub­li­cans don’t ap­pear to be look­ing to curb spend­ing by plac­ing reg­u­la­tory con- straints on phar­ma­ceu­ti­cal or de­vice pric­ing. How­ever, we do need solutions that drive mar­ket com­pe­ti­tion to keep phar­ma­ceu­ti­cal and other costs down, such as faster ap­provals from the Food and Drug Ad­min­is­tra­tion, more biosim­i­lar ap­provals, end­ing pay-for-de­lay and turn­ing to­ward value-based con­tracts. With­out greater choice and com­pe­ti­tion, providers could be caught be­tween in­creas­ing costs and con­strained re­im­burse­ment.

More power to the states. Look for Congress to em­power the states to de­ter­mine lo­cal­ized di­rec­tions for Med­i­caid and their healthcare sys­tems. Gov­er­nors will be im­por­tant ad­vo­cates for change, and we ex­pect more states will seek Med­i­caid waivers. This is an op­por­tu­nity to move Med­i­caid pay­ment to align with other pop­u­la­tion health mod­els such as ac­count­able care or­ga­ni­za­tions. More­over, pro­vid­ing states with in­creased author­ity will help con­ser­va­tive gov­er­nors ad­vance Med­i­caid ex­pan­sion us­ing more in­cen­tives for peo­ple to take bet­ter care of them­selves.

Healthcare re­mains the top so­cial and eco­nomic is­sue fac­ing our coun­try. We must con­tinue to ad­dress pres­sures in our sys­tem through de­liv­ery sys­tem trans­for­ma­tion. This in­cludes reg­u­la­tory re­lief from poli­cies that pre­vent in­te­grated, co­or­di­nated care; in­creas­ing ac­cess to data for providers in al­ter­na­tive pay­ment mod­els; in­tro­duc­ing a stream­lined hos­pi­tal pay-for­per­for­mance pro­gram; and fix­ing the short­com­ings in the ACO pro­grams. Now is the time to in­tro­duce changes that will pro­vide a bet­ter chance at a health­ier life for all Amer­i­cans.

Su­san DeVore is pres­i­dent and CEO of Char­lotte, N.C.-based Pre­mier.

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