Having looked in the last two posts at access and affordable costs of care five years after the passage of the Affordable Care Act (ACA), we now examine its impact on quality of care, the third leg of the stool that defines the structure and performance of a health care system.
The ACA took several initiatives to improve quality of care, most importantly by expanding access to care through subsidizing insurance through the exchanges and expanding Medicaid in those states that participated. Other initiatives include providing preventive services without cost-sharing, pay-for-performance (P4P) changes, accountable care organizations, expanded use of electronic health records, and establishing the Patient-Centered Outcomes Research Institute (PCORI). Let’s look at what each has accomplished.
Expanded Access to Care
While expansion of insurance coverage helps many people, we saw in our recent post on access how many restrictions are placed on that coverage, including high deductibles, narrowed networks, high co-payments, and excluded benefits. Expansion of Medicaid is generally good for those newly covered, but here again, that is no panacea. To be “covered” does not mean that you have access to care. Only 34 percent of health care providers are willing to accept new Medicaid patients, largely due to low reimbursement (61 percent of what Medicare pays for the same service, which in turn is 80 percent of what private insurers pay). (1). For-profit chains of urgent care centers are expanding rapidly, but most do not accept Medicaid patients. (2) A 2014 study found that an estimated 7,115 to 17, 104 people will die among 8 million left out of coverage in the states that opted out of Medicaid expansion. (3)
There was a good rationale for providing such screening procedures as mammography and colonoscopy without cost-sharing, since many patients forego them because of costs. But this has encouraged expanded advertising by for-profit companies providing many inappropriate and unapproved procedures of asymptomatic people. Life Line Screenings, for example, has screened some 8 million people at churches, community centers, fitness centers, shopping malls, and other locations, with 90 percent of screenings normal; the 10 percent that are “positive” typically lead to unnecessary, expensive and potentially harmful follow-up procedures in participating hospitals. (4)
Changes in Payment Systems
It is well known that the present fee-for-service (FFS) payment system encourages provision of unnecessary and inappropriate services that bring added revenues to their providers. The ACA brought forward new “value-based” initiatives that theoretically could address this problem, such as P4P report cards for physicians, accountable care organizations (ACOs) (organizations of hospitals and physicians accepting care of at least 5,000 patients for a contracted amount) and bundling of payments (whereby providers agree to accept one overall payment for an episode of care, such as for a cardiac bypass procedure).
But these were untested and unproven ideas, and the five-year experience is hardly promising. Most physicians believe that quality measures currently in use are inaccurate. Risk adjustment measures are still rudimentary, and do not adjust for socio-economic factors, leaving physicians and hospitals caring for high-risk populations, such as in poor urban areas, at risk for lower quality scores. A recent study found that of the 220 ACOs in the Medicare Shared Savings Program (MSSP), 115 did not accrue savings and in fact spent more than projected on ACO patients; only 53 earned shared savings. (5). A 2014 Rand report concluded that:
Although the past decade has witnessed a fair amount of experimentation with performance-based payment models, primarily P4P programs, we still know very little about how best to design and implement value-based payment programs to achieve stated goals and what constitutes a successful program. (6)
Electronic Health Records
In an effort to improve efficiency and coordination of care, the ACA has used financial incentives to move physicians and other providers away from paper records to EHRs. As a result, the health information technology (HIT) industry has boomed, putting out many competing systems that often do not talk to each other. Not only are these systems expensive, they have not been shown to reduce unnecessary diagnostic tests, add new efficiencies, improve quality of care, or save money. A 2014 study found that almost one-half of physicians felt that patient care was worse after shifting over to EHRs. (7) They have also changed the dynamic of the physician-patient interaction, often reducing eye contact and communication as the physician focuses more on the computer screen than the patient. Another unfortunate outcome is the increase in cyber crime as hackers target the health care sector, as recently illustrated by a cyber attack on Anthem, the nation’s second-largest health insurer, affecting 80 million insured. (8)
The Patient-Centered Outcomes Research Institute
This was an excellent component of the ACA, intended to set guidelines for urgently needed comparative effectiveness research. There is a real need to bring more rigor to the evaluation of the efficacy and cost-effectiveness of health care services. Up to one-third of all health care services provided in our market-based system are either inappropriate or unnecessary, with some potentially harmful. About 90 percent of all new drugs approved by the FDA over the last 30 years are little or no more effective than existing drugs (9), while the FDA approval process for medical devices is still too loose (recalls of defective medical devices nearly doubled from 2003 to 2012). (10) Unfortunately, however, PCORI was hobbled from the start by the ACA’s specific bans on its authority to dictate coverage and reimbursement policies, or to set clinical guidelines for federal health programs.
To sum up, these supposed “fixes” to improve quality in our market-based system , quite predictably, fail to result in acceptable levels of quality. The U. S. continues to fare poorly in quality, access, efficiency, affordability, and equity of care compared to other advanced countries around the world. The ACA built on a flawed financing system, which will be unsustainable for patients, families and taxpayers. There is an alternative—single payer national health insurance, improved Medicare for all, coupled with a private delivery system, the principles of which were laid out more than 20 years ago. (11)
3. Dickman, S, Himmelstein, DU, McCormick, D et al. Opting out of Medicaid expansion: the health and financial impacts. Health Affairs blog, January, 2014. https://healthaffairs.org/blog/2014/01/30/opting-out-of-medicaid-expansion-the-health-and-financial-impacts/
5. Heiser, S, Colla, C, Fisher, E. Unpacking the Medicare Shared Savings proposed rule: geography and policy. Health Affairs blog, January 22, 2015. https://healthaffairs.org/blog/2015/01/22/unpacking-the-medicare-shared-savings-proposed-rule-geography-and-policy/
6. Damberg, CL, Sorbero, ME, Lovejoy, SL et al. Measuring success in health care value-based purchasing programs. Rand Corporation, March 4, 2014. https://aspe.hhs.gov/health/reports/2014/HealthCarePurchasing/rpt_vbp_summary.pdf
7. Verdon, DR. Physician outcry on HER functionality, cost will shake the health information technology sector. Medical Economics, February 10, 2014. https://medicaleconomics.modernmedicine.com/medical-economics/content/tags/ehr/physician-outcry-ehr-functionality-cost-will-shake-health-informa?page=full
8. Peterson, A. Why hackers are targeting the medical sector. Washington Post, February 5, 2015. https://www.washingtonpost.com/blogs/the-switch/wp/2015/02/05/why-hackers-are-targeting-the-medical-sector/
11. Schiff, GD, Bindman, AB, Brennan, TA et al. A better outcome alternative: single-payer national health system reform. JAMA 272: 803-808, 1994. https://www.pnhp.org/publications/a_better_quality_alternative.php?page=all
Adapted in part from my new book, How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans.