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Value-Based Payments Likely to Survive Affordable Care Act Repeal
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Coverage, Patient Protections May Be at Risk
As Republicans in Congress advance their plans to repeal and replace the Affordable Care Act (ACA), there is much uncertainty about how cardiologists and their patients may be affected. So far, 2 key questions are emerging among cardiologists: What will happen to coverage? And how will the changes affect value and quality initiatives?
The 2 questions get to the heart of some of the difficult trade-offs legislators will face in this latest round of health reform. The ACA extended coverage to >20 million US individuals, including 6 million at risk for cardiovascular disease and 1.3 million with heart disease, hypertension, or stroke, according to an American Heart Association (AHA) study published last year.
"The first priority is that we have 22 million lives that attained coverage in the first round of the ACA," said Vince Bufalino, MD, an Illinois-based cardiologist and chair of the AHA's Expert Panel on Payment and Delivery System Reform committee. "However it gets reshaped, we need to cover those people on the other side."
Bufalino also noted the need to expand coverage further to help the 28 million who remained uninsured even after the ACA was implemented.
Republicans in Congress took the first steps toward repealing parts of the ACA in January through the budget reconciliation process. This process allows them to alter parts of the law that have budgetary impacts, but will not allow a complete repeal of all ACA regulations or related legislation.
For example, the 2015 Medicare Access and Reauthorization Act (MACRA), which repealed the Medicare Sustainable Growth Rate formula in favor of value-based payment programs for physicians, is in many ways intertwined with the ACA's value-based payment initiatives. "It would be very difficult to repeal the ACA in one fell swoop in part because of follow-on legislation like MACRA," explained Karen Joynt, MD, a cardiologist and health policy researcher at Brigham and Women's Hospital in Boston.
In addition, MACRA had broad bipartisan support, so its efforts to boost value and trim health spending are likely to survive.
"There is a lot of support on both sides of the aisle for value-based payments," said Joynt.
Preserving MACRA and its value-based payment incentives would be good news for clinicians who have already begun implementing changes in anticipation of the law. Among them is William Borden, MD, a cardiologist and director of Healthcare Delivery Transformation at George Washington University, who has been gearing up for his group to participate in MACRA's Merit-based Incentive Payment System (MIPS). The MIPS consolidates 3 Centers for Medicare & Medicaid Services (CMS) quality-reporting programs into one and ties Medicare payment incentives to quality.


Whatever shape the ACA replacement takes, there is broad agreement clinicians and policy makers must work together on designing a better healthcare system.
"We are moving ahead with MACRA as the law and rule are [currently written] because we don't know what the future will bring," said Borden. The CMS rule outlining what clinicians have to do to comply with MACRA was published in November 2016.
There are also concerns about what will happen to the Center for Medicare and Medicaid Innovation (CMMI), which was created under the ACA to test quality improvement and value-based payment models. The center is also involved in implementing MACRA. "I'm not sure how MACRA would proceed without CMMI," said Borden. "There would have to be some sort of replacement and I hope there would be because CMMI is creating a wide range of new models that are trying to provide an evidence base on how to better deliver care." The CMMI has drawn ire from some Republicans in Congress including former Rep Tom Price (R-GA), who the Senate confirmed as Secretary of the Department of Health and Human Services in February. Price was among a group of representatives who signed a letter to CMS arguing that CMMI had overstepped its authority by requiring participation in some value-based incentive programs. For example, CMS announced last year that it would be launching a mandatory cardiac care bundled payment program in select areas across the country in mid-2017.
"That may be one of the areas that could change under new leadership," Joynt said. Already, President Trump has signed an executive order that could delay or halt new regulations, including the mandatory bundles, noted Joynt.
Much uncertainty remains about the timeline for repealing and replacing the ACA. Some Republican Congressional leaders have pushed for a very rapid repeal, by March or April, but President Trump said the process could take a year in an interview on Fox with Bill O'Reilly in early February.
Preexisting Conditions
Much rests on the Republican replacement plan and which parts of the ACA Republicans chose to keep intact.
"Where we are likely to see the most change is on the insurance side," said Joynt. Changes that directly affect clinical care are less likely, but changes in patient insurance coverage are expected, she explained.
Several competing Republican proposals have been released. Some common features in the proposals include changing Medicaid into a block grant program to states, establishing high-risk pools for individuals who are denied coverage on the private market, purchasing insurance across state lines, tax breaks for purchasing insurance, and greater use of health savings accounts.
How these various changes could affect cardiologists will depend on the patient mix they see in their practice, said Joynt. For example, practices with large Medicaid populations would be disproportionately affected by a roll back of Medicaid expansion, which could drop as many as 12.9 million from coverage, according to a letter from AHA CEO Nancy Brown to congressional leaders. The individual insurance market is also likely to be disrupted, Joynt emphasized.
"The effects of changes to the insurance market will be seen for certain groups of patients, rather than being targeted at clinicians," Joynt explained.
A roll back of patient protections included in the ACA could also affect patients with heart disease. President Trump has promised to preserve a ban on preexisting conditions and to continue to allow children to stay on their parents' plans until age 26. Those provisions, and a ban on lifetime coverage limits, as well, are critical to patients with heart disease, noted Brown in her letter. For example, a patient born with a congenital heart defect may have had 2 to 3 surgeries by age 10 and could easily hit a lifetime limit or be unable to get adequate health coverage in their first job, noted Bufalino. Whatever shape the ACA replacement takes, there is broad agreement clinicians and policy makers must work together on designing a better healthcare system.
"There is a tremendous need for clinicians to participate in thinking through what we want our healthcare delivery system to look like," Joynt said. "Regardless of your political persuasion, and regardless of what happens in the insurance market, on the delivery system side there is widespread agreement we can make the system work better for our patients. We can deliver better care."