Tom Price's departure as head of Health and Human Services on Friday leaves a question mark for providers on the future of Medicare and Medicaid payment policy.
Price, an orthopedic surgeon, tried to ease Obama-era burdens on physicians by scaling back mandatory bundled payment models and compliance with the merit-based incentive payment system rules under the Medicare Access and CHIP Reauthorization Act.
During his short tenure, his focus was the smaller, independent physician practices, in policies that moved payment models from hospital-centric to physician centric, according to health policy expert Jeff Goldsmith, president of Health Futures.
Under President Obama, it was the larger insurers and providers that were thought would bring about the biggest changes in electronic health records and other mandates. But independent physician sponsored ACOs were found to show great success.
Seema Verma, administrator of the Centers for Medicare and Medicaid Services, leads the list of likely candidates to take over as HHS secretary. Whether she would continue Price's policies is unclear.
Goldsmith believes her appointment is unlikely as the Trump administration will want another physician. Verma has Medicaid experience. She helped Vice President Mike Pence, as governor of Indiana, craft the waiver for ACA Medicaid expansion.
Other candidates reportedly include Scott Gottlieb, commissioner of the Food and Drug Administration and a proponent of speeding up approval for generic drugs, former Louisiana governor Bobby Jindal and Sen. John Barrasso of Wyoming, a physician.
Price resigned due to controversy for spending over $400,000 in taxpayer money to charter private jets for business trips.
Price's leaving amounts to a firing over his inability to lead healthcare policy for the Trump administration, according to Goldsmith.
"I think part of the problem is this firing -- obviously that's what it was -- was an expression of frustration on the part of the White House over lack of coherence on health policy," Goldsmith said. "There was no strategic direction for this administration's health policy."
Price was in a perfect position to concentrate on repeal and replace legislation, he said. The former House Budget Committee chairman had written his own ACA replacement bill called the Empowering Patients First Act.
In the Trump administration, Price was the senior expert on healthcare policy and for whatever reason, didn't take on that role, according to Goldsmith.
"There was no script," Goldsmith said, "no strategic direction."
Under Price, the ACA has been weakened and the marketplace remains unstable for insurers. Promotional funding for open enrollment has been gutted by 90 percent, the enrollment period shortened, Navigator funding drastically cut in many areas and Healthcare.gov will be closed for 12 hours on Sundays.
Price was also a big proponent for states to use Section 1332 waivers to repeal mandates of Obama's healthcare law.
"The central challenge remains," Goldsmith said, "how do you pay for healthcare through Medicare and Medicaid?"
Carolyn Magill, CEO of Aetion, said she's optimistic that the direction towards value-based care will continue in HHS. Magill has worked in numerous leadership roles, including within the Medicare and Medicaid business of UnitedHealth Group. HHS will continue to build policies that create the greatest impact for outcomes, she said, rather than those that create unnecessary assessments and tests.
Instead, policy is looking at what clinical intervention led to a specific result, or an unnecessary hospitalization.
"I'm optimistic," she said.