Pilgrims’ Progress
On its fifth anniversary, the ACA receives progress reports from two accomplices.
The early evangelists of healthcare reform played essential roles in getting the engines of change started in healthcare. Donald Berwick, MD, MPP, provided a sort of scripture in his Triple Aim: improve the experience of care, improve the health of populations and reduce per-capita costs of health care. Atul Gawande’s rousing 2009 article comparing the per-capita Medicare spend (and population health) in McAllen, Texas, with neighboring city El Paso provided the clarion call.1 As National Coordinator for Health Information Technology, David Blumenthal, MD, helped grease the wheels by implementing the HITECH Act meaningful use provisions—and their associated incentives.
Five years out, Blumenthal et al have penned a progress report2 on the Affordable Care Act (ACA). They review what they call the two basic thrusts of the law, briefly outlining the expansion of health insurance but focusing on healthcare delivery reform.
Though often criticized for failing to reform the delivery system, ACA is described by the authors as “one of the most aggressive efforts in the history of the nation to address the problems of the delivery system.” Consider the following examples culled from their report.
The evidence
Beginning in October 2012, hospitals with higher readmission rates for Medicare beneficiaries within 30 days of discharge were subjected to penalties. Since then, the readmission rates have dropped more than a full percentage point, from more than 19% to less than 18%. The authors acknowledge that the penalties may be unfair for safety-net hospitals.
The ACA gave CMS the option of reducing Medicare reimbursements by 1% for those hospitals in the lowest quartile on the measure of hospital-acquired conditions (HACs). Blumenthal cited HHS data that demonstrate a 17% decline in composite rates of HACs nationally between 2010 and 2013, the first documented decline. The safety improvements were estimated to have prevented 50,000 deaths and saved $12 billion.
The delivery mechanism known as accountable care organizations (ACOs) has proliferated. In the Medicare Shared Savings Program (MSSP), 405 ACOs serve 7.2 million Medicare beneficiaries, or 14% of that population. Estimated savings to date is ~$700 million. The 32 Pioneer ACOs (of which 11 switched to the MSSP and two exited completely) have achieved even greater savings for their numbers: $385 million.
Blumenthal et al are careful about attributing all of the progress of the past five years to ACA. Regarding the slowdown in the growth of national healthcare expenditures and the decrease in per-beneficiary Medicare spending, the authors merely say that ACA has “coincided” with this development.
Rabbits, turtles and birds
Atul Gawande weighed in with his own progress report3 in a recent issue of The New Yorker. To discover what had changed since his 2009 inquiry, Gawande reached out to the Dartmouth economist, Jonathan Skinner, PhD.
There was good news to report: The annual cost of treating a Medicare patient in McAllen, Texas, dropped almost $3,000 for a savings of almost $500,000 between 2009 and 2012. More generally, the cost of treating a Medicare patient across the country had flattened for a projected total savings to tax payers of $500,000,000 through 2014.
“The hope of reform had been to simply ‘bend the curve’,” Gawande wrote. “This was savings on an unprecedented scale.” The primary objective of Gawande’s appropriately titled article, “Overkill,” was to address the issue of over-treatment in the U.S. He counts the number of nuclear medicine scans, MRIs, CTs and laboratory tests. “Often these are fishing expeditions, and since no one is perfectly normal, you tend to find a lot of fish,” he wrote.
He cites echocardiograms perpetrated on healthy people, spinal surgeries performed on persons with simple degenerative disk disease and the overtreatment of breast, thyroid and prostate cancers. He acquaints your patients with the indolent cancer, explaining that every cancer has a different ratio of rabbits (swift, treatable through early intervention), turtles (slow and non-threatening) and birds (aggressive and deadly), terms introduced by H. Gilbert Welch, MD, in his book, “Less Medicine, More Health.”
Unnecessary care is the low-hanging fruit for all providers, not just radiology. With dark clouds forming over the state health insurance exchanges in the form of rate increases4 of as much as 50%, finding ways to separate the turtles from the rabbits and birds is an implicit future mission for everyone in medicine.
References
- Gawande A. The cost conundrum. The New Yorker. June 1, 2009.
- Blumenthal D, Abrams M, Nuzum R. The Affordable Care Act at 5 years. N Eng J Med. 2015: May 6 [Epub ahead of print] http://www.nejm.org/doi/full/10.1056/NEJMhpr1503614. Accessed May 22, 2015.
- Gawande A. Overkill. The New Yorker. May 11, 2015.
- Radnofsky L. Health insurers seek big increases. Wall Street Journal. May 22, 2015: A1.
Vice President, Executive Editor, Radiology Business
Cheryl began her career in journalism when Wite-Out was a relatively new technology. During the past 16 years, she has covered radiology and followed developments in healthcare policy. She holds a BA in History from the University of Delaware and likes nothing better than a good story, well told.