A Health Systems Improvement Research Agenda for AJMC's Next Decade

Has Obamacare worked? This is the most common question that health policy “wonks” have been asked over the past 5 years by those who have not yet made up their minds on the topic. Although many asking the question would prefer a “yes” or “no” answer, the truth is, it is not so simple. For starters, key elements of the law did not go into effect until years after the passage of the Affordable Care Act (ACA) in 2010,¹ with some components, such as the individual insurance mandate, being implemented as recently as 2014.² Other components, such as the so-called Cadillac Tax, are not due to take effect until 2018.³ In addition, key elements of the law have been subject to legal interpretation, with the Supreme Court deciding on 2 cases thus far.⁴ Further, many other provisions of the law have required administrative decisions and proposed rules by numerous federal agencies such as the HHS, CMS, and the Internal Revenue Service to name a few.^5,6

Consistent with our nation’s rich federalist tradition, the impact of the ACA has also depended in great part on state-level decisions such as whether to expand Medicaid or establish a state health insurance exchange. There is also quite a bit of experimentation happening as a result of the ACA with various pilot programs, such as the accountable care organization (ACO) demonstrations being sponsored by entities like the Centers for Medicare and Medicaid Innovation,⁷ as well as comparative effectiveness research funded by the Patient-Centered Outcomes Research Institute.⁸ With so many changes in play, stakeholders involved, and different timelines for implementation, the answer to the question of whether the ACA has worked is incredibly complicated, and more definitive answers will require more time and more research.

Health Services Research

The type of research required to answer these critical questions is called “health services research” (HSR) and focuses on key topics such as how outcomes are influenced by different approaches to organizing, delivering, and financing healthcare. HSR is multi-disciplinary and interdisciplinary in nature, and brings the perspectives and tools from many contributing scientists such as economists, political scientists, sociologists, clinicians, demographers, and those who study the organization and management of institutions, to name just a few. As The American Journal of Managed Care (AJMC) embarks on its next decade, there is no doubt that the journal will be a critical resource for helping providers, payers, patients, and policy makers to understand what does and does not work in maximizing the health of populations with the most efficient expenditure of resources. HSR is different from traditional clinical research because it often requires studying key questions under nonexperimental or, at best, under quasi-experimental conditions. In addition, HSR is systems focused, seeking to understand how the behavior of organizations—including the individuals these organizations employ as well as those individuals these organizations serve—interact in the healthcare marketplace to generate outcomes.

As an example, the ACO demonstrations mentioned above provide fertile ground for HSR given that the early reported evidence on the ACO rollout is mixed; while there are many conceptual and theoretical reasons for thinking the ACO model would be successful at both delivering high-quality patient care and generating cost savings, current evidence is still uncertain about the ACOs’ impact, raising questions about the value of expanding the model.⁹ Why? We don’t know and rather than give up on the concept, we need applied research to help us understand the challenges of the model and how to improve it. There are many potential factors, and the ACOs are just a single example of areas where critical research is needed.

Other fertile areas include how best to facilitate consumer decision making and shared decision support; optimal approaches to incentivizing frontline providers, including understanding if providers are capable of accepting and managing risk for population health outcomes; and how to optimally structure benefit design and incentives to encourage the consumption of highly valuable care while reducing harmful low-value care. Another critical area of study is understanding how to productively design policies around what have been termed the “social determinants” and recognizing the influence that these factors have on population health outcomes.

The ultimate goal of the research that will be published in the pages of AJMC and elsewhere over the next decade is to provide those on the ground involved in health reform implementation and health systems redesign with critical, timely evidence in order to make mid-term corrections in the redesign of the US health system going forward. While we don’t yet know if the ACA has “worked,” we do know that the unprecedented change afforded by this healthcare law has created a valuable learning laboratory that is ripe with lessons for researchers who are comfortable dealing with the rapid, often chaotic, and seldom experimental nature of the changes occurring in our midst.

As in the past, AJMC will be there to publish this important research, and doing so will be a key part of achieving a better and more efficient health system for all.

Author Affiliations: Department of Health Policy and Administration, Center for Health Care and Policy Research, The Pennsylvania State University, University Park, PA.

Source of Funding: None.

Author Disclosures: Dr Scanlon reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; drafting of the manuscript; critical revision of the manuscript for important intellectual content.

Address correspondence to: Dennis P. Scanlon, PhD, Professor of Health Policy and Administration, and Director, Center for Health Care and Policy Research, The Pennsylvania State University, 504 Donald H. Ford Building, University Park, PA 16802. E-mail: dpscanlon@psu.edu.

REFERENCES

1. Read the law. HHS website. http://www.hhs.gov/healthcare/about-the-law/read-the-law/index.html. Updated August 28, 2015. Accessed October 13, 2015.

2. Tran A. FAQ: how will the individual mandate work? Kaiser Health News website. http://khn.org/news/faq-on-individual-insurance-mandate-aca/. Published September 3, 2013. Accessed October 13, 2015.

3. ObamaCare Cadillac Tax (excise tax on high end plans). ObamaCare Facts website. http://obamacarefacts.com/obamacare-cadillac-tax-excise-tax-on-high-end-plans/. Accessed October 13, 2015.

4. Barnes R. Affordable Care Act survives Supreme Court challenge. Washington Post website. https://www.washingtonpost.com/politics/courts_law/obamacare-survives-supreme-court-challenge/2015/06/25/af87608e-188a-11e5-93b7-5eddc056ad8a_story.html. Published June 25, 2015. Accessed October 13, 2015.

5. Redhead SC, Kinzer J. Implementing the Affordable Care Act: delays, extensions, and other actions taken by the administration. Federation of American Scientists website. http://fas.org/sgp/crs/misc/R43474.pdf. Published March 3, 2015. Accessed October 13, 2015.

6. Health care reform. Federal Register website. https://www.federalregister.gov/health-care-reform. Accessed October 13, 2015.

7. Innovation models. CMS website. http://innovation.cms.gov/initiatives/index.html#views=models&key=aco. Accessed October 13, 2015.

8. Why PCORI was created. Patient-Centered Outcomes Research Institute website. http://www.pcori.org/about-us/why-pcori-was-created. Published September 10, 2014. Accessed October 13, 2015.

9. Haywood TT, Kosel KC. The ACO model--a three-year financial loss? (published online March 23, 2011). N Engl J Med. 2011;364(14):e27. doi: 10.1056/NEJMp1100950

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