Affordable Care Act Celebrates its Second Anniversary

March 23, 2012, marks the two-year anniversary of the signing of the Affordable Care Act – the sweeping law that is/will be impacting health care for years to come. Much of the law focuses on health insurance reform, but some elements of it also impact the health care delivery system.

It is important to remember that the biggest impact on Electronic Health Record (EHR) usage was contained in the 2009 ARRA law (the American Recovery and Reinvestment Act), which contained the HITECH title that defined the EHR Incentive Program (Meaningful Use). The definition of Stage 1, Stage 2, etc., of Meaningful Use, as well as the incentive moneys that fund this program, were defined by that 2009 law, not the 2010 Affordable Care Act (ACA).

The ACA has elements that phase in at different stages, projecting out 10 years from its inception. The health insurance proposal of the “individual mandate” – which has been controversial and opposed by a number of politicians, and is currently awaiting review at the Supreme Court – is only one element of the ACA, scheduled to go into effect in 2014.

It might be helpful to look at the roll-ins of the ACA, and separate the elements into “insurance reforms” and “health delivery system reforms.” Though not exhaustive, this is an abbreviated chronology:

The Center for Medicare and Medicaid Innovation is a new department within CMS that governs ACOs (accountable care organizations), and multiple other initiatives. It was created in January 2011, and is responsible for the following programs:
− ACO
− Bundled Payments
− Comprehensive Primary Care Initiative
− FQHC Advanced Primary Practice Demonstration
− Health Care Innovation Challenge
− Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents
− Innovation Advisors Program
− Medicaid Emergency Psychiatric Demonstration
− Medicaid Incentives for the Prevention of Chronic Diseases
− Partnership for Patients
− State Demonstrations to Integrate Dual Eligibles
− Strong Start for Mothers and Newborns

ACOs originally were seen as a shared-savings mechanism for Medicare fee-for-service, but has been expanded to be more prospective (rather than retrospective), similar to how managed care networks have functioned for private HMO patients in the past. The final regulations governing ACOs were published 11/12/11, and can be reviewed here. A good description and overview, including a video by former CMS chief Don Berwick, can be found here.

Overarching themes
There are some overarching themes that emerge from the language in ACA. These themes define the changes in the wind for medicine, regardless of what the Supreme Court determines around the “individual mandate for health insurance coverage.”

One theme seen throughout is that healthcare is changing from a more one-after-another transaction model based in fee-for-service compensation to a new paradigm where whole populations are managed by a coordinated delivery network, supported by a performance-based compensation system. Will this mean that the small and solo practices of the past will disappear? There are certainly trends that indicate the reduction in this kind of practice, in favor of mid-sized (5-50 clinicians) single-specialty practices. Regardless, a “brick and mortar” or a virtual coordinated network that can deliver population-based care will be a dominant theme in the future. Practices that recognize this, and prepare for this, will do well. Those that don’t will fade (through attrition and retirement), driven mainly by economic necessity.

Another theme is focusing on the total cost of healthcare. The delivery system needs to offer primary care services to everyone, focus on the whole delivery network, and avoid unnecessary “catastrophe rescues” in the Emergency Department. That means more coordinated care, again – maybe ACOs will be that vehicle, maybe Patient Centered Medical Homes, maybe other novel organizational forms that have not been tested yet. But creating an environment (a payment environment) that supports and grows primary care services is in the wind – including more robust home health, virtual on-line health care, and other non-traditional ways of serving the public.

In addition, ways to minimize the variability of care is another theme. This includes normalization of geographic variability (as documented by the Dartmouth Atlas), as well as normalization of racial, ethnic and socio-economic variability that are a persisting fact of life.

Role for health IT
Given the kinds of structural changes embedded in the ACA, and the changes happening in health care in general, health IT (including EHRs) are a necessary platform for facilitating such change.

EHRs can support the move to populations management in several ways. (1) Clinical Quality Measures, collected from within the EHR directly, can be the basis for prompting at the point of care (CQM-based Clinical Decision Support). (2) More advanced Clinical Decision Support, such as crowd-sourcing treatments frequently used for given conditions, can make “smart expert systems” never before seen. (3) Advanced reporting for practices, or even groups of practices (the “circles” concept) can help identify individual patients who are at risk, or needing pro-active outreach – a very important element of population management.

Further, health data derived from EHRs can be used to advance Comparative Effectiveness Research (also funded by ACA). EHR data is generally more accurate than traditional billing-based data, which is what had been relied upon in the past.

Web-based EHRs represent a wide network of practitioners, and this can be used to disseminate the Health Promotion and Prevention Promotion efforts (also funded by ACA) both to clinicians (via the EHR) and also directly to patients (via the PHR).

We are at a time of change in health care. The way in which health care is organized and paid for is in the midst of fundamental change – regardless of what happens with the “individual mandate” element of ACA. Modern EHRs, and health IT in general, are a fundamental platform required for such change to take place.