Could Medical Homes Be The Centerpiece of an ACA Replacement?
One of the great lessons learned from the implementation of the Affordable Care Act is the importance of building bipartisan support and broad support with patients and their physicians.
Because of the lack of support, every hiccup created a mini crisis. Perhaps that was unavoidable given the complexity of the problem. It’s been unsettling for our health system and business, and life-threatening for some.
Now, as President Trump’s Administration and congressional leaders consider replacing the ACA, there is little evidence they have learned this lesson.
What is puzzling to many in healthcare is that the proposals on the table overlook a viable solution already in the market. It is already doing the following:
· Demonstrates it can improve quality and contain costs.
· Allows people to choose their own doctor.
· Achieves high user satisfaction.
· Incentivizes physicians to be part of the system.
Perhaps the reason for the unintended consequences of Obamacare is that it has asked the wrong question. Expanding coverage is unquestionably a worthy goal, but it has been achieved primarily with subsidies. Obamacare has shown that the resulting coverage is often unaffordable, has forced some to lose their doctor and has led many doctors to avoid the program due to inadequate reimbursement and burdensome regulations.
So imagine if Tom Brady were the lowest paid player on the Patriots. That would make no sense, you would say, but that is the real world of primary care physicians, the quarterbacks of the healthcare system, and the lowest paid of all medical specialties. A fully engaged healthcare quarterback is crucial for coordinating care for people with chronic conditions like diabetes and heart disease that account for about 85% of healthcare costs.
What is the right question?
The replacement should address the question of how to provide everyone access to their own primary care physician – the original promise of Obamacare – and how to ensure that primary care physicians participate in the program by overcoming poor reimbursement and burdensome regulations.
The answer to this question is the patient-centered medical home. According to the Patient-Centered Primary Care Collaborative, the medical home has been implemented by over 500 healthcare organizations. This includes healthcare systems, hospitals, provider-sponsored health plans, Medicare and Medicaid plans, and health insurance companies.
With a few smart tweaks, the medical home could become the unifying principle for crafting and communicating a replacement strategy for Obamacare, without tossing out its good features like continuing coverage for young people on their parents’ policies through age 26.
At the Return on Medical Quality Institute, we have identified 10 improvements which we call the “Medical Home Advantage.” The goal is to prevent the onset and progression of chronic medical conditions by promoting patient engagement and physician participation. The key improvements include:
· Incentives to join, including tax-free Health Savings Accounts to promote and reward healthy behaviors.
· Enhanced reimbursement for participating primary care physicians, including risk-based adjustments and significant incentives tied to quality goals.
· Funding mechanisms to pay for and train nurse practitioners to function as the communication hub for this network of providers – the “Medical Home Connectivist.”
· Flexibility to pilot-test strategies without burdensome regulations.
· Increased emphasis and support for nutritional counseling and medication adherence to manage chronic conditions.
· Enhance support for Federally Qualified Health Centers to expand their initiatives to be the Medical Home for those without insurance coverage.
· Encourage states to expand the use of this approach in Medicaid and to share best practices from state to state.
· Incorporate into Medicare where it has the potential to moderate cost increases and produce savings to the federal budget without changing benefits.
· Flexibility and financial support for states to develop high-risk pools to reduce the burden on health plans for patients with extraordinarily high expenses.
How to get started? A straightforward approach would be to convene a working group of leading medical home organizations to help craft legislation build around this model and the enhancements described above. Once the core program is developed, important questions of how to transition from Obamacare to the medical home program could be addressed. The transition could begin in 2018 with the goal of being fully implemented in 2020. When fully implemented, the savings from coordination of care would more than offset any incremental costs, thus providing a substantial return on medical quality for all stakeholders.
Hank Werronen is the founder of the Return on Medical Quality Institute and the former chief planning officer for Humana. A version of this article originally appeared in the Louisville (Ky.) Courier-Journal.