Trump's Impact on the ACA, MACRA, and MIPS

Robert Glatter, MD; Jesse M. Pines, MD, MBA, MSCE


December 16, 2016

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Editor's Note: This is part 1 of a two-part series of discussions on the subject of Trump's election and its impact on medical care acts and payment systems.

Robert Glatter, MD: Hello and welcome. I am Dr Robert Glatter, assistant professor of emergency medicine at Northwell Health and also attending physician at Lenox Hill Hospital in New York City. I am delighted today to be joined by my colleague, Dr Jesse Pines, who is professor of emergency medicine and health policy management and also director for the Center for Healthcare Innovation and Policy Research at George Washington University in Washington, DC.

Today we will be discussing the impact of Trump's recent election on healthcare, including the future changes to the Affordable Care Act (ACA) as well as the Medicare Access and Chip Reauthorization Act (MACRA) and the Merit-based Incentive Payment System (MIPS) that was passed in April 2015. Welcome, Dr Pines.

Jesse M. Pines, MD, MBA, MSCE: Thank you for having me.

Repealing Obamacare and the ACA

Dr Glatter: Let me start off by first, in a general way, talking about repealing and replacing Obamacare. The other concern is what the downstream effects could be on healthcare in general. What are the upsides of keeping it, the downsides of repealing it; and, if we repeal and replace it, what would be, in your mind, something that could come from it?

Dr Pines: Sure. First, I think there are a lot of upsides to keeping Obamacare in place. Over the past several years, we have seen major increases in the numbers of people in this country who have insurance and fewer people without insurance. We have seen some major changes in the way that physicians are being paid and the way that quality is measured in this country. Turning back the clock on that could have major implications to both cost and quality. At the same time—and this is from my perspective, not being a political person—there are also major concerns in this country, particularly for a lot of Trump voters and many others, about the cost of healthcare and specifically the cost of premiums and out-of-pocket costs, which continue to escalate.

The first point is: It is going to be very difficult to repeal Obamacare and come up with a suitable replacement, at least in the short term. That does not mean that millions of people will lose their insurance because a lot of what Obamacare has done has been to create programs that move people into insurance programs that they were not previously eligible for.

The second point is: There is just a lot of uncertainty, and again what this conversation is really about is trying to figure out what might happen. These certainly are only my opinions and based on information that I have now. There are a number of things that have been said that could have major implications.

Let us break it down in terms of some of the elements of the ACA. First, let's discuss specifically the provision of pre-existing conditions, where insurances cannot discriminate based on pre-existing conditions. What this did is it increased the ability for many people who previously had a lot of trouble getting insured with pre-existing conditions to be able to get insurance at much lower rates than before—if they were not affiliated with an employer. That is really backstopped by the individual mandate, where basically everyone has to have insurance or pay a penalty. The notion that one of those elements could go away without the other one staying in place is really not a possibility.

Dr Glatter: Certainly patients have been coming in and asking me, "I have my doctor; will I be able to keep my doctor?" That is something that really concerns a lot of people. Do you see that as being a continuing concern, which was a concern obviously under the initial startup phase of Obamacare?

Dr Pines: That is really a question about the networks that are allowable in these insurance plans. What we have been seeing over the last several years is that one of the ways that insurance companies have been trying to lower costs has been contracting with narrower networks of providers so that they can negotiate better rates with those providers. The current trend is going to be less access to physicians in the future, especially with changes in the insurance market, or moving to a market where the insurance companies really try to lower costs. That could actually further affect access to specific providers.

Selling Insurance Across State Lines

Dr Glatter: Exactly. With that, Trump has talked about signing insurances across state lines, being able to purchase insurance in that way. Is there any viewpoint you have about that? Is that realistic? Is that something that is unlikely to happen?

Dr Pines: There are a number of potential benefits with selling insurance across state lines. It could create increased competition in the insurance industry, potentially driving down costs for individuals. However, once you start selling insurance across state lines, or when you have insurance companies that would need to contract not only with the health systems in their state but also the health systems in neighboring states, the downside of that would be to increase the administrative complexity and the need for a lot more agreements between these insurers and more distant health systems. Again, in the short-term, I think it has some promise, but it would create a lot of administrative complexity, potentially.

Dr Glatter: I can see that effect as well. Ultimately, we are trying to decrease costs, but this may actually increase costs in the long run.

Dr Pines: It is tough to say.

Impact on Health Savings Accounts and Access to Care

Dr Glatter: Regarding health savings accounts (HSAs), that has been another area where Trump has talked about making things more accessible to patients and making it more user-friendly. Do you see the HSAs going to that?

Dr Pines: The HSA has been a political discussion for many years. It actually does have some potential benefits if you can take pre-tax money, put that in a savings account, and then use that money for healthcare expenditures, especially for young people who are in high-deductible plans. That could potentially be useful in giving people the ability to spend their own money on healthcare. The worry is that people may actually hold back on spending and actually miss needed care. Alternatively, once that money starts building up, and the discussion is to have that money be transferrable from year to year, you start generating a lot of money in the HSA. The worry there is that the people, similar to your other pre-tax accounts at the end of the year, will go on a spending spree, and they may use it unnecessarily because of the tax implications of taking that money out.

Dr Glatter: You have hit on one area that is a concern to all of us: narrow networks and these plans where people pay high amounts of money and very high deductibles and then do not use their healthcare in a meaningful way. A lot of people delay care until diseases and conditions start to really blossom (eg, cancer, other autoimmune diseases). I have been seeing this on the front lines. Do you think that we will be able to fix this issue with the narrow networks going forward?

Dr Pines: The question is really about access to care and whether the new trend in insurance is going to increase or decrease access to care. I certainly think that narrow networks decrease access to care. Also, anything that happens to repeal the ACA and not replace it with something that allows the same people to still have insurance is going to reduce access and exacerbate the exact problem that you talked about, where people are going to wait longer to seek medical attention. They may come in sicker and potentially have preventable illnesses that could have been managed had they actually had insurance in an outpatient environment. Now we are shifting a lot of those costs to the inpatient environment.

Dr Glatter: Is there any way this could be sort of mandated into the new product that is produced? Do you see that happening to avoid the issues and improve upon the product we currently have?

Dr Pines: It all comes down to access and creating products that allow people to access healthcare in the ways that they want, such as seeing their own doctor whom they have a relationship with. The problem again with narrow networks is that when we restrict that for some people, they may be less likely to seek care and may be in the position you talked about where they are coming in with something potentially preventable late in the game.

MACRA, MIPS, and the Sustainable Growth Rate

Dr Glatter: I am going to shift a little bit into what MACRA is and what this means in light of Trump and the sort of evolving products we are talking about, especially how physicians are paid. Can you talk a little bit about the sustainable growth rate (SGR) and, now that we have MACRA and MIPS, what this means in terms of value-based care? Actually, will the care improve under this new type of setup?

Dr Pines: MACRA, which was legislation that came out in 2015, replaced and is certainly better than the SGR. Actually, a lot of the elements really focused conceptually on having physicians report data on quality measures—making sure that they are doing care coordination and actually doing clinical practice improvement. A lot of what conceptually is in MACRA I think is a good thing. How it actually gets implemented is really a question of how effective it is going to be to actually change the quality of care out there.

One of the questions that comes up is whether MACRA and MIPS are going to be on the table. Specifically, are a lot of the programs within the Centers for Medicare & Medicaid Services (CMS) Innovation Center going to be on the table to cut? Recently, the congressional budget office actually scored what it would take to actually cut the CMS Innovation Center. In order to cut something that actually saves money, you have cut other things in the government to make up for those costs. The upshot of that is, I think it is going to be very difficult in the short term to really change what the CMS Innovation Center is doing, and the center is really taking a lead role in implementing a lot of what is in MACRA. If you look at the support that MACRA had, it was really bipartisan support.

I think that there is good agreement on both sides of the aisle that we should be measuring quality of care and that physicians should be participating in quality improvement efforts.

Dr Glatter: In terms of case mix in the emergency department, that will have some role in deciding whether an alternative payment model or MIPS might be more beneficial to some physician groups or even healthcare systems. If you practice in an urban environment vs a little bit more upscale environment where the payer makes changes, would you say that is going to affect your bottom line?

Dr Pines: One of the issues that needs to be addressed in MACRA, and I think in a lot of the CMS measurement programs and measurement in general, is making sure that we are adequately risk-adjusting for populations. For example, the Medicare star rating system that was put out recently that measures a number of quality measures at the hospital level gives hospitals a 1- to 5-star rating. When you actually look at one of the major factors that influences that star rating, it is what neighborhood they are in. Hospitals, especially big academic medical centers that deliver care to safety net populations, tend to be really disadvantaged by some of the quality measurement systems. The science is not necessarily there yet to make sure that we are really comparing apples to apples. This has direct relevance to what is happening with MACRA because a lot of what is contained in MACRA is going to be a comparison of how a hospital, health system, physician, or whatever the entity, is compared to other groups. If one of the major things that really determines how you perform is your population, you have got to really figure out how to adjust risk.

For groups that are working in big academic settings and taking care of populations where there are a lot of social determinants that influence whether or not they get ill or can receive care, those systems are really at risk in a lot of the legislation in terms of how things are going to be measured and who is ultimately going to be rewarded.

Dr Glatter: The composite performance score really needs to look at how resources balance with advancing care information. That part of the pie is going to change in the next decade based on what I have read. I think adjusting that appropriately might be something the government needs to look at. CMS really needs to explore that.

Dr Pines: The key element there is going to be making sure that we attribute costs appropriately to the right providers who can actually control them, so it is similar to the CMS star ratings. If I am working in a disadvantaged neighborhood where I cannot really control the neighborhood economics, and that unfairly gives me a lower score because, for whatever reason, that population is going to have worse outcomes or worse quality of care, that really needs to be taken into account. One of the major focuses of MACRA is resource use and total cost per beneficiary. When you think about the average emergency physician, we may see a patient only for a short period of time, but if that patient's overall cost of care is somehow attributed to us, it really is an unfair comparison.

Dr Glatter: That works into the Medicaid block grants that they are going to allow to states, and that is part of the equation to really consider going forward. That is going to be a key determinant.

Dr Pines: The question is: What is going to happen with Medicaid and particularly Medicaid expansion? In the short term, I think that Medicaid expansion has really done a lot to improve access to care. We did a study that was published in Health Affairs back in August that showed no differential impact of Medicaid expansion in expansion states vs nonexpansion states on emergency department use. This is actually really good news for the Medicaid expansion. People are not flowing into emergency departments as was expected.

On the block grants, if you start giving power to states to decide which patients are covered and what services are covered, what you are going to start seeing is a lot of inequity and a lot more variation across states.

Dr Glatter: It seems like that would be the key point—the states that are certainly more well off with different effects than those who are economically disadvantaged.

Dr Pines: One of the big factors in state budgets is Medicaid costs. Depending on what the overall state budget looks like, and if you are getting a block grant, you may decide to use those resources differently.

Dr. Glatter: Thank you again for you time; it's much appreciated.

Dr. Pines: Thanks for having me.

Editor's Note: To continue watching part 2 of this discussion, please click here.


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