Aims of ACA Get Better Reviews Than Implementation at Cardiologists' Meeting

Wendell Primus, PhD, the veteran legislative aide for US House Minority Leader Nancy Pelosi, D-California, got right to the point when he asked those gathered for the 63rd Scientific Sessions of the American College of Cardiologists if, so far, the Affordable Care Act (ACA) was helping them, as opposed to their patients.

Only a pair of hands out of several hundred in the hall went up.

“So, we have our work cut out for us here,” Dr Primus said, to a sprinkle of laughs.

But for Dr Primus, who has spent his entire career battling over healthcare, the bickering in Washington, DC, where the cardiologists held their annual meeting, and beyond the beltway is no joke. Dr Primus, who famously dueled with then-White House Chief of Staff Rahm Emmanuel over the fine points of the ACA to the point that the 2 could not be in the same room,¹ today deals with its ongoing fallout—the botched implementation of HealthCare.gov, the possible loss of seats in the upcoming midterm elections, and the refusal of many governors to expand Medicaid.

Dr Primus, the first of a roster of speakers in Saturday’s featured presentation, “Affordable Care Act Implementation: Impact on Patients and Providers, A Town Hall Forum,” began with an observation that the ACA, as a concept is not the far-left construct that is portrayed by its opponents. Its core elements, especially small business subsidies and the individual mandate, were featured in every Republican healthcare proposal going back to the Nixon Administration, Primus said.

Some of Dr Primus’ points were well-received; there were nods at his prediction that 12 to 14 million of the nation’s uninsured will end up with coverage when marketplace, Medicaid, and young adults on their parents’ plans are taken into account. But the cardiologists had issues with implementation, and they had plenty of questions. In particular, they asked about items left out of the ACA, such as tort reform; questioners insisted the legal environment and insurers’ red tape force continue to force them to practice defensive medicine and waste time and money.

That said, there was optimism for the changes coming in medicine among the perspectives of a physician, a hospital executive, a patient, a payer, and a representative from the Centers for Medicare & Medicaid Services (CMS). All agreed that the revolution in healthcare, which demands a change to payment models that reward quality, were in motion already, and that ACA is just part of that change. Thomas M. Priselac, president and CEO of Cedars-Sinai Health System in Los Angeles, California, said the ACA is far from a “national system;” rather, it set up 50 state systems.

“The ACA was not implemented in a vacuum,” Mr Priselac said. “It really reflected the broader economic circumstances that are still with us today.” The ACA, he said, put in place the “levers and dials” to achieve the goals of the triple aim: lower cost, population health, and patient satisfaction.

Sean Cavanaugh, deputy director of CMS’ Center for Medicare and Medicaid Innovation, is charged with giving those new payment models a try within the biggest payer of all, and he said there have been some good signs. He agreed that the rollout of ACA has not been perfect, but he said that the prior situation could not stand. In a former job at a Brooklyn hospital, many of his day were spent trying to figure out “how to keep the doors open,” while taking care of high numbers of uninsured patients.

Already, Mr Cavanaugh said, CMS is seeing a drop in Medicare readmission rates because of quality improvement initiatives in the new accountable care organizations. These were rates that had been stuck at 19% for a very long time, and have dropped to 17%. “This improvement is being driven by many factors; some of it is by payment changes, some of it is by public reporting,” he said.

Patient representative Jonathan Rintels, a longtime member of the Writers’ Guild of America and a former member of its board, riveted the audience with his tale of what life was like when he lost eligibility for his union insurance and had to shop for individual coverage in the years before the ACA took effect. With an autistic son, insurance costs consumed 25% of the family income. He avoided seeking care for a cardiac condition until he collapsed on a tennis court. He worried how he would pay his daughter’s college costs.

When the infamous HealthCare.gov site went live in October 2013, Mr Rintels said of trying to sign up: “My own experience is that those reports were inaccurate. It was worse.”

And, yet, after the site was overhauled, he did manage to get through and use his credit card to sign up on Christmas Eve, in time for a policy to take effect New Year’s Day. He will spend 40% less than he did before. He did have to change to a new orthopedist for his tennis elbow, but he said he would do it all again.

“For all the hours I spent...” he said, “you cannot put a price on peace of mind.”

Richard Salmon, MD, PhD, who is national medical executive for Performance and Improvement at Cigna, said there are elements of the ACA that he said are making the triple aim a reality:

• Patient engagement is requiring employers to go after opportunities to encourage employees to engage in healthy behavior, especially quitting smoking.
• Financial incentives are part of the equation.
• The change from “volume-based” to “value-based” incentives is real, but if the healthcare system is going to transform, it’s going to require aligning payment incentives to bring health insurance technology to hard-to-reach places, as well as quality-improvement collaboratives.
• Training of new physicians is essential.

Dr Salmon said there’s a big difference between today’s reform movement and that of the HMO movement of the 1990s, which was just about transferring risk without really changing the way medicine was practiced. “Today, the technology is better, the federal stimulus is better, and the collaboration is better,” he said.

J. James Rohack, MD, former president of the American Medical Association, offered his thoughts in what he called “the good, the bad, and the ugly.” What’s good about the ACA? Getting rid of the ability to let insurers exclude the people who need insurance because they are sick. What’s bad? Lawmakers have to figure out what to do about those who sign up for healthcare but don’t pay the premium, leaving the unwitting doctor or hospital on the hook down the road. What used to be charity care is going to become bad debt, Dr Rohack said. “If I don’t have cash coming in, how do I keep the doors open?” he said.

And then there’s the ugly. “We have states refusing to expand Medicaid, which doesn’t cover childless adults. I come from Texas, so we have 1.6 million Texans who won’t have health insurance.”

Where should doctors stand on these issues? “A physician should support medical care for all people,” he said.

Reference

1. Akers MA. In the speaker’s office, a quiet liberal lion: Wendell E. Primus. The Washington Post. http://www.washingtonpost.com/wp-yn/content/article/2010/06/20/AR2010062003442.html. Published June 21, 2010. Accessed March 30, 2014.