An ACA appeal would be a serious threat to value-based care

The surprise of Donald Trump’s presidential victory was not lost on healthcare leaders, even during a busy RSNA 2016 in Chicago.

At an administrators’ symposium, I heard practice leaders and physicians repeating the same conversations you probably experienced everywhere in the past few months: “What is he going to do?” “What happens now?”

To hospitals and health systems, those questions are probably centered around the Affordable Care Act (ACA). Trump has promised to repeal it and got the ball on that process rolling with an executive order on his very first day.

But it’s not just the insurance exchanges and minimum coverage standards which could go away. The transition to value-based care, and the initiatives facilitating it, like the Medicare Access and CHIP Reauthorization Act (MACRA), could come to a screeching halt.

If the ACA is totally eliminated—which isn’t a given, considering the number of proposals on when and how to do so—the Centers for Medicare and Medicaid Innovation (CMMI) goes with it. It’s been the mechanism through which CMS developed several alternative payment models, like Next Generation ACO and mandatory bundled payment programs.

The ACA directly created one value-based model: the Medicare Shared Savings Program, which generated $429 million in Medicare savings in 2015.

One problem: Trump’s pick to run HHS isn’t a fan of these initiatives.

During his time representing Georgia in Congress, Tom Price, MD, has been a skeptic on MACRA, a supporter of ACA repeal and opponent of mandatory programs created through CMMI. In a September 2016 letter to CMS, Price equated mandatory bundled payments enacted under the Obama administration with “experimenting with Americans’ health,” demanding any future CMMI initiatives remain voluntary.

Current mandatory programs are likely to become voluntary under Price’s watch, Archway Health CEO Dave Terry told me in a recent interview. Even though he expects the Trump administration as a whole to be receptive to value-based care as it searches for “market-based solutions” to reducing healthcare costs, the transition to value over volume will inevitably be slowed if Price, an orthopedic surgeon, is more focused on making his fellow specialists comfortable.

The majority of physician compensation continues to be based off fee-for-service payments or salaries, not value-based arrangements, according to a Deloitte survey. Thinking back to that RSNA symposium, I saw very few hands go up when the assembled physicians were asked if their practices were involved with value-based arrangements like those CMMI models. So maybe an end to these “experiments,” as Price may say, wouldn’t be so bad in their eyes.

To opponents of his nomination, however, he and the Trump-led ACA repeal may reverse important progress in value-based care.

“Rep Price's policy proposals and statements, along with the Trump administration's own, voicing disregard for evidence-based medicine and practices also are deeply concerning and we feel are a clear threat to value-based care,” says Manan Trivedi, MD, president of the National Physicians Alliance, which is against Price’s nomination and the American Medical Association’s endorsement of him. “At a time when we should be moving forward with efforts to expand value-based care, enacting Rep Price's plans would set us back in ensuring effective, high quality, and affordable healthcare for all.”

This all leaves healthcare executives wondering whether several years of work on transitioning to value-based care will go to waste. That same Deloitte survey I referenced earlier said 94 percent of execs at provider organizations are “on the path to value-based care.”

Unless administrators are OK with scrapping those efforts, they should make sure their concerns are heard as the ACA repeal debate heats up.