Obamacare: Separating Politics From Practicalities
The Affordable Care Act is President Obama's legacy, but it didn't start with his administration. While politicians can create gridlock, health IT pros must deal in reality and compromise.
Lately I've been trying to talk about Obamacare without talking politics, to the extent that such a thing is possible.
This is research for a digital issue we'll publish in February on Health IT in the Obamacare Era. While the HealthCare.gov fiasco has been the big story of the past several months, arguably the more significant structural change (with big implications for data management and analytics) is the rise of Accountable Care Organizations. ACOs are being driven to greater prominence by government-funded ACO programs associated with Medicare and Medicaid. The ACO concept is that healthcare organizations get paid based on how well they maintain the health of a population rather than on volume -- the fee-for-service tradition now roundly criticized for driving up costs rather than driving up quality. I'll have more to say about the practical IT implications of this for data gathering, analysis, and responsive service in that February feature.
One of my sources for the piece is Joe Ketcherside, a neurosurgeon turned healthcare technologist who serves as chief medical officer at a startup called Quire. He interrupted me when I used the popular nickname for the Affordable Care Act -- the one invented by opponents of the law and now adopted by President Barack Obama.
"I don't like to call it Obamacare," Ketcherside told me. "I like a lot of things about the law, but I don't like Obama all that much, so I kind of don't want to give him credit for it." At the same time, when people working in the healthcare system blame Obama for changes in the system that they dislike, the blame is often misplaced. "Doctors tell me the reason they're having to put these electronic medical records in is because of Obamacare. And I'm like, the hell it is -- that was George Bush!"
Ketcherside said his politics don't fit neatly into any left- or right-wing category, except that he sees plenty of reason for people of any persuasion to be angry about the aspects of the healthcare system that don't work as well as they ought to. In regard to Obamacare, he just wanted to set the record straight.
The new regulatory regime is not the work of one leader or the result of one law, but taken as a whole, Ketcherside said, it provides "some structure and some financial incentives to give people power to go do what [they have] talked about doing for the past 30 years. [Healthcare organizations are starting to] create an infrastructure that makes it easy for doctors to have the right information at the right place at the right time, so they can do the right thing for their patients," he added. If that can be achieved, he said, "good things will follow."
The reality is that presidents don't write the laws or regulations, and they often don't get to finish what they start. The Obama administration wound up following through on initiatives that started under George W. Bush with the establishment of the Office of the National Coordinator for Health IT within the US Department of Health and Human Services. Bush popularized the idea that electronic health records (EHRs) could improve the efficiency and quality of healthcare delivery, giving the idea a shout out in his 2004 State of the Union address. President Obama came into office in the midst of an economic crisis and wound up funding his predecessor's initiative by building incentives for meaningful use of EHRs into his economic stimulus plan.
Meanwhile, the ACA may be popularly known as Obamacare, but it might be more accurately labeled Compromise-care -- squeaking through Congress by the narrowest of margins after many rewrites and concessions to interest groups. One of its central features is the individual mandate that kicks in this year, requiring citizens to get insurance or pay a fine. That was a conservative idea that Obama originally opposed when it was being promoted by Democratic primary opponent Hilary Clinton. Compromise is not necessarily the best way to make policy, but sometimes it's the only way. (As Churchill's quip stated, "Democracy is the worst form of government, except for all those other forms that have been tried.")
Of course, then the balance of power changed to the point where Obamacare could never pass Congress today. Yet the Republican opposition doesn't quite have the votes to override a presidential veto. One of the consequences of this gridlock is that fine-tuning of the law is nearly impossible.
Dan Haley, VP of government and regulatory affairs for Athenahealth, said that when he lobbies for changes his firm believes should be made to the law, "we get almost universal agreement... except that Democrats can't admit that there's anything wrong with the Affordable Care Act and Republicans can't admit that there's anything that could be fixed in the Affordable Care Act."
The trend toward ACOs and other value-based reimbursement structures predate Obamacare, but elements of the Affordable Care Act enshrine the direction, Haley said. The objection Athenahealth has raised (which was also discussed in my interview with CEO Jonathan Bush) is that the law goes on to dictate how Medicare ACOs should be structured, requiring that they be 75% physician-owned. Bush argues that one way Athenahealth might help the small to midsized physician practices that make up the bulk of its customers would be to use its data management and business process services to function as an ACO -- except that as a public company, it doesn't qualify under Medicare rules.
Haley pointed out that one of the unintended consequences of the ACA may be to force greater consolidation of physician practices that may be unable to compete with larger health systems in a future dominated by ACOs that, by definition, must be involved in every aspect of a patient's care.
David Muntz, who recently left a post as deputy director at the Office of National Coordinator for Health IT, said that consolidation is already happening. "Providers who are weary of the changes or who don't want to take the time to understand all the changes are lining up with hospitals," he said, and it's only natural that they'd want to be part of an organization with more IT and administrative resources in this environment.
"We're still supposed to be focused on the patients," Muntz pointed out. "It's not all about the money -- it's how do you get the patients engaged in their own care?" If the structural changes in the market achieve a better quality of care, he said, then the transition will have been worthwhile.
Muntz now serves as senior VP and CIO at GetWellNetwork, an online service focused on boosting patient engagement. His time in government was mostly focused on the Meaningful Use program, and as a former hospital CIO he said he regrets the collective effect of piling so many requirements onto technology managers at once. "If all they had to do was Meaningful Use, it would be fairly straightforward," he said, but Meaningful Use Stage 2 is hitting at the same time as many other requirements, such as the shift to ICD-10 coding and the demands of ACO models.
"If it were my call, I would have liked to have seen us spend more time at Stage 1 before we moved to Stage 2," Muntz said, "because Stage 2 is a very, very steep step [in terms of EHR implementation and interoperability]." Big hospitals may be up to it, but smaller and more rural healthcare organizations are likely to struggle. "On the other hand, if we hadn't put a stake in the ground, would they have moved at all?"
While the programs for digitization of healthcare and accountable healthcare come out of separate laws and initiatives, they dovetail to the extent that ACOs require the data that EHRs can provide. The proliferation of electronic health data also creates opportunities for the kind of business-model change ACOs represent.
"The ACO model was a logical outgrowth of the challenges we were seeing on the financial side of the business," Muntz said, as well as social demands for a better healthcare system. When hospital CIOs talk to him about the pressures they are under, Muntz said they talk less about Obamacare than about the trend for their organizations to have to assume more risk in general, whether dealing with public or private payers. That means they need to do a better job of coordinating care across all the doctors and nurses in their networks, as well as with the patients themselves.
"If Obamacare does anything, it encourages people to get coordinated more quickly," he said.
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