Health Care Overview & ACA
“Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more.”
Massive changers have been rippling through the U.S. health care field ever since the Affordable Care Act became law. All of them in one way or another are designed to impact what Don Berwick of the Institute for Healthcare Improvement (formerly the head of the Centers for Medicare and Medicaid Services) calls the Triple Aim:
- Improving the patient experience of care (including quality and satisfaction);
- Improving the health of populations; and
- Reducing the per capita cost of health care.
One of the most talked-about topics in health care is, of course, just how the field itself is evolving to address these challenges. Each self-proclaimed expert has a theory, and no one can know for sure the full implications of the Affordable Care Act until all of the policy decisions following that play out over time. That being said, there are a few key items which few serious conversation partners would dispute:
- Most Americans will be required to purchase and/or maintain health care insurance coverage (the so-called individual mandate) to address the millions of Americans without affordable health care insurance through their employer or other access to coverage such as Medicaid
- States are required to set up insurance exchanges to oversee and regulate each market (either on their own, or with federal involvement) so that a standard set of health care benefits are offered consistently across the whole country in different tiers: Gold, Silver, Bronze
- Patients will (at least theoretically) have access to primary care providers in an effort to offer preventative health care services rather than seeking expensive episodic care in venues such as emergency rooms as the most common alternative; urgent care centers are also spreading as a lower-cost alternative for care which needs to be provided in a timely fashion beyond outpatient capabilities but less than what requires an ER
- The traditional fee-for-service model where providers are paid on a per procedure basis will be replaced by global payments where fees are paid per patient, with profits coming only after all annual medical expenditures have been taken into account. Historic US costs are far more expensive than any other industrialized country and in many cases it is difficult to prove superior quality in the U.S. compared to abroad
- Providers are adopting (willingly or otherwise) electronic medical record systems for tracking and billing health services which can require spending billions of dollars on such systems; many historically independent physician practices lack the funding base to pay for such services and also need for their systems to be compatible with the hospital’s EMR to provide effective patient care
- The expectation of increased costs likely forecasts a continued trend in consolidation among hospitals and health systems and also on the health insurance side as well
- Federal health research funding will be dramatically scaled back impacting the National Institutes of Health as well as associated research leaving new discoveries more often funded to a greater degree by private investors or pharmaceutical/medical device firms directly
Such myriad changes already unfolding nationally offer a useful window into the near future for informed consumers of relevant news coverage. Interestingly, some ‘poster boys’ with longstanding profiles in health care innovation, including the Cleveland Clinic and Mayo Clinic, have declined to take the lead on many of these initiatives. However, other systems have jumped at the chance to brand themselves as Accountable Care Organizations, and a select few have been named by the Centers for Medicare and Medicaid Services as Pioneer ACOs – the ‘Oregon Trail trailblazers’ of tomorrow.
Of the 32 health care systems originally recognized by CMS as Pioneer ACOs, it’s perhaps no surprise that 5 of them are based in Massachusetts, the state touted as the model for national care reform. Massachusetts thus represents an ideal test-bed for examining many assumptions about the sustainability of this new model. Some of the realities on the ground might suprise you. The challenge is building a comprehensive picture across multiple news sources:
- Massachusetts residents were 98% insured in 2012 but as the state was already well-insured prior to the state insurance mandate additional provider income has been limited, especially as the state’s MassHealth (Medicaid) program has been curtailed through tax revenue shortfalls.
- A 2014 estimate from the Center for Health Information & Analysis suggests that despite challenges with the MA health insurance exchange, Massachusetts has effectively achieved universal coverage.
- Many insured patients relocating to Massachusetts from elsewhere for work or school have been forced to hunt for primary care physicians still accepting new patients, and even landing a spot on the appointment calendar can be quite a challenge.
- Some hospital systems are paying as much as several hundred million dollars to build out an integrated electronic medical record.
- The courtship ritual is well under way as large systems vie for a relatively small number of hospitals, many of which are financially struggling, while others see strong potential for increased profitability with new clinical affiliations and partnerships
- Some observers fear that the collective intersection of the aforementioned trends may overwhelm state efforts to control health care spending, especially as some providers may choose to over-prescribe medical services to patients in an effort to boost their satisfaction ratings.
- More recently, the Washington D.C. budget stand-still may pull yet another brick out of the crumbling federal provider reimbursement wall.
The road ahead is challenging enough that more than half of the original Pioneer ACOs have expressed concerns to CMS that the accelerated timeline currently in place for national health care reform may require adjustments and even possibly delays. Some of the Massachusetts Pioneer ACOs have also begun talks seeking to realize improved economies of scale, which could result in their merging operations. Long-term, some experts have warned that this cost-cutting, preventative care-oriented care model could eventually transform the entire health care sector into a for-profit environment. On the other hand, some of the best models of care thus far identified are minimally profitable, if at all. Some of the latest reports are far from encouraging in terms of fiscal stability in the Massachusetts hospital landscape.
To be clear, White Coat Checklist is not opposed to the prospect of health care reform. On the contrary, we welcome and embrace the realities on the ground as opportunities for those individuals most qualified for leadership roles to overcome such challenges and turn them into strategic advantages. White Coat Checklist believes that the current ongoing revolution in the regulation and provision of health care services represents an essential paradigm for aspiring health care professionals to consider when contemplating entry into the medical profession. Many current physicians with decades of experience are struggling to cope with these relatively sudden changes, and those future doctors who have taken the time to build an accurate picture of health care’s present will be in the best position to help shape the future. After all, physicians can certainly aspire to more than just medical practice – why not begin cultivating such knowledge as far in advance of future teaching and administrative leadership opportunities as possible?
White Coat Checklist’s Member Resources section includes the free AppTrackR medical school dashboard to allow applicants to track their target schools in real-time, question prompts for composing a compelling personal statement, and real-life secondaries essays to learn from the mistakes of prior applicants who have successfully matriculated. Members are also eligible to Contact WCC to ask questions or request 1:1 Advising or Remote Editing Sessions for individual targeted support.