Lowered reimbursements are C-suite’s top fear with ACA repeal

In a survey of healthcare executives, many said they want several provisions of the Affordable Care Act to stay in place if the law is repealed, while expressing concerns over how its elimination could affect their reimbursements from Medicare and Medicaid.

The Vizient survey included 222 responses collected in December 2016, after Donald Trump won the presidential election but before he took office. At that time, Republican leaders in Congress had been planning a quicker repeal of budget-related parts of the ACA, which researchers warned could lead to a $1.1 trillion increase in uncompensated care costs for hospitals. That ambitious timeline has been noticeably slowed, with now-President Trump saying in a Fox News interview repeal could take until next year.

Assuming the law will be changed to some degree, the survey asked healthcare executives what provisions they believe should be kept and what they should be eliminated:

• Protection of pre-existing conditions: 89.5 percent in support vs. 3.5 percent for elimination.
• Medicaid expansion: 68 percent in support vs. 15.1 percent for elimination.
• Subsidies for buying insurance: 56.4 percent in support vs. 23.3 percent for elimination.
• Value-based reimbursement: 51.7 percent in support vs. 23.8 percent for elimination.
• Individual mandate: 45.3 percent in support vs. 37.8 percent for elimination.
• Alternative payment models, including bundled payments: 40.1 percent in support vs. 38.4 percent for elimination.

This largely falls in line with what physicians want, according to a recent survey published in the New England Journal of Medicine. Some 95 percent wanted to keep the ban on insurers denying coverage based on pre-existing conditions. There was more support for value-based care among practicing doctors, with 62 percent favoring more pay for value instead for volume in any ACA replacement plan.

Among pharmacy executives, there was even broader support for keeping pre-existing condition protections, with 96.2 percent in support. No other provision, however, attracted majority support, and 61.5 percent of pharmacy execs said the mandate for individuals to have health coverage should be eliminated.

With the uncertainty about policy changes, healthcare executives are most worried about finances. More than a third (36 percent) of respondents said lowered reimbursements for their facilities were their biggest concern, with 15.3 percent most worried about having fewer insured patients, 14.4 percent citing “fear of the unknown” and 11.3 percent most concerned about any policy changes making their investments in delivery system changes irrelevant.

“We believe there is broad consensus among hospital leaders that the traditional fee-for-service payment model alone is not sustainable. There have been significant investments made in the migration toward value-based care, and hospitals require a coherent direction in order for these programs to deliver on their promise,” Vizient President Byron Jobe said in a press release. “During this time of uncertainty, executives should focus on factors they can control.”

Those areas were addressed in a separate question asking those in the C-suite their top priorities for 2017. The top answer was reducing clinical variation across care delivery. The second highest priority was continuing the shift away from fee-for-service, despite the earlier answers by executives showing mixed support for value-based reimbursement and alternative payment models.