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Why value-based care will survive Republican healthcare overhaul

And most agree that MACRA will continue.

Susan Morse, Managing Editor

The Centers for Medicare and Medicaid Services' Innovation Center, the Affordable Care Act as we know it, and other federal healthcare programs may soon be wiped away as the new U.S. Congress begins its work this week, but experts predict the move to value-based care, and a continuing reduction in what providers are paid, will remain.

"The path forward will clearly involve change," said Andrei Gonzales, associate vice president Value-Based Payment for McKesson Health Solutions.

Some CEOs have publicly said that regardless of the outcome of the election, value-based care will proceed, Gonzales said. They're looking at the quality delivery of care, the quality scores, and cost of care as critical.

[Also: Task force pushes Trump administration to preserve CMMI, push to value-based care]

"Those trends tend to be pretty well established at this point," Gonzales said. "At this point, we haven't seen any significant change or trying to back out of contracts with payers. From the commercial health plan perspective, providers and payers are contracting around these arrangements."

Providers will always be expected to provide better care at a lower cost, according to Rulon Stacey, managing director for Navigant.

"I don't think we should expect anyone in Washington, D.C. is losing any sleep trying to get healthcare providers more money," he said. "Society has expected of us simultaneously to provide increased quality and decreased cost. I predict that's what the new government is going to demand."

Gonzales said his clients haven't prepared for any big changes.

"Our work with commercial plans, we haven't seen or heard any indication to stop or to take a step back," Gonzales said. "We're not anticipating that to be the case. Commercial plans have been saying in public statements they're committed to the value-based reimbursement path regardless of where CMS goes."

[Also: MACRA preparations daunting for large physician practices]

All of the experts interviewed agree that no matter what else may change, quality payment programs under the Medicare Access and CHIP Reauthorization Act, or MACRA, will continue.

"Both sides of the House and Senate had overwhelmingly great support for MACRA," said Roy Beveridge, MD, chief medical officer for Humana. "This is going to continue to move forward."

There's a clear incentive for physicians to move towards the advanced alternative payment model, one of two payment tracks under MACRA, according to Gonzales. These APMs hold the greater risk over the merit-based payment system, or MIPS, but also offer the larger share of the savings.

President-elect Donald Trump has promised to repeal and replace Obamacare. But what a replacement will look like remains unclear, as do projections about the future of Medicare, Medicaid and new payment model innovations should Congress get rid of CMMI.

"There's a lot of uncertainty where things are headed next," Gonzales said. "At a high level there's acknowledgement, the challenges the health systems face were present before the ACA, those challenges relate to rising costs, lack of transparency … a lot of those challenges are still seen as addressable in value-based care models out there."

If the ACA is repealed without a similar replacement, providers should expect greater amounts of bad debt from uninsured patients who have no money to pay, according to Stacey.

[Also: Clinical data must figure into value-based care]

Stacey predicts the ACA repeal will happen quickly and the fix will come slowly.

"I don't think anyone has the political will to pull the rug," Stacey said. "I can't imagine that happening."

Some insurers have made the exchanges a significant part of their business model, Gonzales said.

"It's one of those changes, there's still a lot of detail to be worked out," Gonzales said. Another is Trump's recommendation to relax regulations to allow insurers to sell across state lines.

Some experts have said insurers haven't really taken advantage of cross-state selling in areas where this has already been tried, but some payers could see this as a potential increase to their risk pool and that would make the exchanges more attractive, according to Gonzales.

Insurers could take advantage of the relaxed regulation to enter markets where the return is greater, said Stacey.

While Gonzales sees a growing participation in accountable care organizations, there's concern from hospital and physician groups about the mandatory nature of bundled payments.

"There's been concern about participation in mandatory models like bundled payment," Gonzales said. "The way we interpret it, providers have a lot of work to do to move forward with value-based reimbursement."

Stacey predicts accountable care organizations may also see changes.

"I see them falling out of favor because people look at them and they haven't delivered the savings," Stacey said. "ACOs are too tied in with the ACA."

This year, Gonzales and Mckesson released a study that shows payers outpacing providers in value-based models, though providers are still progressing.

Humana experienced 20 percent lower costs for members treated by providers in value-based reimbursement settings versus traditional Medicare Advantage settings, according to the insurer.

"I think there's a lot of premature discussion going on," Beveridge said. "Even if a system changes, it still takes years. Putting the patient first, keep him front and center. The rest is insignificant."

The real problem, as Stacey sees it, is that providers are having to make due with less.

"You can't make it on a 2 percent margins," he said. "I think there are some organizations out there that have become so efficient and process-driven, they've gotten all the fat out. Most organizations, I see plenty of opportunity to decrease cost and increase quality."

To do that, systems need value-based care.

"In my estimation, it means we can expect the concept of value-based care to move forward," Stacey said. "We predicted in 2017, organizations are going to have to get better at the billing process. People are going to want to know about what they're paying for. The prudent healthcare provider continues to focus on cost. They'll be able to weather the storms that come up."

Twitter: @SusanJMorse