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Healthcare Change Is Coming … But What Does That Mean for Me?

Robert Sepucha, Senior VP of Corporate Affairs for FMCNA

bobby-sepucha_web-headshot_247x247These days, the question I hear most often is, “Who is going to win the election?” In my mind, whether we know (or think we know) who is going to win is secondary. What is more important is what’s going to happen after the election. Will we see major shifts in policy? Can we come together as a nation to end the increasingly divisive political discourse? And, perhaps most important, what will the White House look like with gold trimming?

Joking aside, these questions are all the more pressing when you consider the state of American healthcare. As an industry and a nation, we are at an inflection point, moving headlong towards value but with at least one foot still planted in traditional fee for service. A new president – complete with a new Secretary of Health & Human Services and a new administrator at the Centers for Medicare & Medicaid Services (CMS) – will have the potential to enact wide-sweeping change or solidify the status quo. With so many patients’ lives in the balance and so many dollars invested, the stakes are enormous.

Change is coming

Trouble is, no one is exactly sure what kind of change that is. Conventional wisdom says it all depends on which person – Hillary Clinton or Donald Trump – ends up in the White House. And given how little people think of the two finalists, it’s no wonder that many dinner conversations around the country these days are focused on whether to move to Canada after the election.

So, where are we headed?

On the surface, there is a significant divide among the candidates and the parties: Democrats are committed to Obamacare but Republicans just want to repeal and replace. But is this really the case? To understand that, we have to look a little deeper.

Have you heard about this shift from volume to value yet?

You’ve heard time and again how CMS is moving to a value-based system, with providers on the hook for quality and cost. CMS is so focused on this shift that they have already hit many of their targets for 2016. The fact is, value is coming … whether we like it or not.

But it’s not just CMS and the Obama Administration. It’s also Congress. And – this is the key point – it’s both parties in Congress.

As you know, Congress passed a law last year that no one – and I do mean no one – saw coming. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) did the unthinkable: It finally got rid of the dreaded Sustainable Growth Rate (SGR) formula that threatened to cut Medicare reimbursements to physicians by more than 20 percent each and every year.

Put in place in 1997, SGR was an attempt to control costs as fee-for-service payments started outstripping the growth of the overall economy. But year in and year out – for 17 years, in fact ­– Congress stepped in to delay the SGR cut once doctors complained about the possibility of reimbursement dips. Things got so bad, delaying the SGR cut became an annual rite of passage. Is it March in DC? Must be SGR season.

But after 20 years of this madness, Congress finally shaped up. In a moment of bipartisanship that has unfortunately become the exception rather than the norm, John Boehner and Nancy Pelosi came together to pass MACRA and repeal SGR once and for all.

But it also did something else, something that in the long run will be far more profound than repealing SGR. In its place, Congress created two new payment systems and said that, henceforth, every doctor in America must decide which system to be in. One payment track is the Merit Based Incentive Payment System, or MIPS. The other payment track is the Alternative Payment Model, or APM.

The dirty little secret of American politics

The details of each system are not important for this discussion except for this general point: From the way in which Congress crafted the MIPS and APM payment tracks, it is clear that Congress wants to move every doctor in America (or at least every doctor who is able) into an alternative payment model with very clear incentives (in the form of both sticks and carrots) to improve both the quality and cost of care.

MACRA was and is a huge kick in the pants for doctors to move towards value. It is tempting to believe that this is the work of the Democrats, given that the ACA, the exchanges and accountable care organizations are viewed as the hallmark of the Obama Administration. But MACRA wasn’t partisan. In fact, it sailed through the Senate by a vote of 92-8. Even by today’s twisted political standards, this is an overwhelming majority and a remarkable display of bipartisanship.

And here lies the dirty little secret of the American political system: Democrats and Republicans can agree on something. In fact, when it comes to healthcare, they agree on far more than they disagree.

I know, I know. I can hear the clamoring already. Are you nuts? Haven’t House Republicans voted more than 60 times to repeal Obamacare? Doesn’t this reflect at least a hint of fundamental disagreement?

I hear you, but those votes are Washington at its worst: a whole lot of sound and fury signifying absolutely nothing.

Obamacare has become a political lightning rod, but the fight around it long ago lost all semblance of substance. The fact is that Democrats and Republicans alike agree on the fundamentals of how we need to change healthcare:

  • the move from volume to value;
  • the desire to make physicians and providers accountable for not just the service they provide, but also the quality and cost of that service;
  • and the need to move away from fee-for-service towards alternative methods of payment such as capitation and bundling.

Yes, disagreements remain at the margin. For example, many Republicans object to the administration’s decision to make parts of the recently announced orthopedic and cardiac bundles mandatory. But even in this disagreement, you won’t find many Republicans in Congress who think that bundles themselves are a bad idea. No, the fight over whether we need changes like bundling have long been settled. Everyone agrees we do. Now the conversation is about how we should make those changes.

So … what will happen in healthcare after the election?

Heretical though it may sound, I don’t think the election will bring much change at all, at least when it comes to healthcare. Policymakers on both sides of the aisle agree we need to radically rein in spending and devise new ways to make physicians and providers more accountable for quality and cost. With so much momentum, I don’t see that effort slowing down, no matter who is in the White House.

Does that mean the next four years will be exactly the same as the last four? Not at all. At a minimum, the players and personalities will change, but the underpinning of their efforts and their ultimate goals – continuing the move toward value-based care – will undoubtedly remain the same.

The good news, from where I sit, is that we are moving in the right direction. The challenge now is to see if we can get out of our own way as a nation and overcome the rancor and vitriol that has invaded our political discourse so we can continue to make positive steps forward.

And if we can’t manage to do that?

Well, then. I guess I’ll see you in Canada.