Value-Based Health Care in Limbo

Repeal and Replace, Part Deux

A return to the dark days of unaccountable care?

One thing lost in the din about repealing the Affordable Care Act is that the ACA gave value-based health care the biggest shove forward it’s ever gotten. The health care reform law set standards for the development of quality measures and, through more than a dozen programs, tied Medicare payments to performance on those measures and others related to readmission rates, safety standards, and patient satisfaction. The ACA forced the kind of accountability that had been mostly talk, with little action, for the better part of two decades. CMS, as the federal government’s prime health care payer, has taken the lead, but the ACA has emboldened private payers to push accountable care.

Title III of the ACA created the Medicare Shared Savings Program, the Hospital Value-based Purchasing program, and the Bundled Payments for Care Improvement Initiative; cut reimbursement to hospitals with high 30-day readmission rates; and ended payments for readmissions related to hospital-acquired conditions. Seventy thousand pages of regulations followed, detailing how all of this accountability would be carried out. But if Congress dumps the whole ACA, can CMS enforce any of those regulations?

“If you toss out the legislative authority, then no,” says Robert I. Field, professor of health management and policy at the Dornsife School of Public Health at Drexel University. “It would cause chaos for hospitals, which have adjusted their financial model and a lot of their operations to deal with this.” Repeal would also mean massive uncertainty for ACOs, which would linger in a sort of no-man’s land if their enabling legislation was repealed.

For years, as the ditch-Obamacare beat drummed on, few people challenged the law’s detractors to explain how they would keep the quality movement rolling. The exchanges became the face of “repeal.” Says Field, “I have been surprised at how inept the Obama administration has been at explaining what else is in there.”

But depending on what “replace” looks like in 2017, the quality movement might not be entirely dead in its tracks. “They can get rid of the name Affordable Care Act and call it something different,” says Field, “but it’s hard to imagine that most of [the ACA] won’t remain pretty much intact.”

As an example, Field says, House Speaker Ryan’s “A Better Way” alternative to the ACA would retain several of the provisions of Title III. A few more of its provisions live on in new forms in the Medicare Access and CHIP Reauthorization Act (MACRA). So we may not be doing a 180 to the bad old days of unaccountable care.

But we might be stuck at a 90-degree turn. Even if Title III is salvaged, it’s an open question as to whether the leading edge of payment reform will come out of Baltimore any more. The Center for Medicare and Medicaid Innovation (CMMI) has developed and test-driven 34 alternative payment models, from Next Generation ACOs to the Oncology Care Model. CMMI has few friends on Capitol Hill, and Ryan’s “A Better Way” calls for putting it out of business. Field doubts it can survive. “It would be pretty easy to defund it,” he says, adding that if Medicare were turned into a voucher program, as Ryan proposes, CMMI progeny like value-based purchasing and bundled payments would become irrelevant. Without a champion in CMS for payment reform, it might fall to private insurers to keep the volume-to-value ball rolling. — Michael D. Dalzell


• Center for Medicare and Medicaid Innovation (CMMI)
• ACA exchanges
• ACA subsidies

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