The Road Ahead

With the election season now thankfully behind us, we can look back and ask what does the outcome of the election mean for the nation’s health-care systems and our HME provider community? For all providers, another veil of uncertainty has been lifted regarding the future of the Affordable Care Act (ACA): its payment reforms such as accountable care organizations (ACOs) are here to stay and the Obama Administration is committed to continued rollout of the health reform law’s provisions over the next four years.

Post-election, the president and Congress have focused their attention to near term deadlines on major issues including expiring tax cuts, the sequestration and the Medicare physician payment fix. That’s the legislative package we are focused on; our aim is to incorporate the H.R. 6490 Market Pricing Program legislative language into this end-of-year bill. (Note: Call your Representative and ask him/her to sign on as a co-sponsor of H.R. 6490!) It is still unclear if the parties can reach agreement on a larger framework by year end, or whether they will cobble together a short term package for now, leaving the bigger and more contentious issues to resolve in the next Congress. At press time, however, the odds of a year-end package were looking better than ever.

Either way, late this year or very early next year current law is most likely to be extended at least through August 2013 to give the new Congress time to develop the large package of tax, entitlement and deficit-reduction reforms. Final passage of this measure would be targeted for late 2013. In either scenario, Medicare and Medicaid likely will be part of the deficit discussion, and formerly untouchable elements of the Medicare program—e.g. changes to beneficiary cost-sharing as well as eligibility age—will be discussed alongside additional provider cuts.

As the administration continues to implement the various provisions of the ACA, it’s worth noting that some aspects are rolling ahead faster than others. The Department of Health and Human Services has released rules regarding payment reform pilots (ACOs and other shared savings programs and bundled payments) as well as pay-for-performance initiatives: e.g., value-based purchasing and readmissions penalties.

Coverage expansion will be more of a mixed bag. Over the next few months we will see how many states meet deadlines for establishing health insurance exchanges, and whether governors and legislatures choose to opt into or out of the ACA’s Medicaid expansion following the Supreme Court’s decision earlier this year. For most providers, the election’s outcome represents a confirmation of the twin efforts of controlling costs and improving quality of patient care. A few implications stand out:

Controlling costs and shifting management of cases to more efficient (read home care) and higher quality settings remains critical in advance of potential Medicare payment reductions. National attention has already shifted to resolving the “fiscal cliff.” With health care representing nearly a quarter of the federal budget, any attempts to resolve the sequestration cuts or reduce long-term deficits will almost certainly include incremental reductions to federal health-care programs.

The transition toward new payment models will continue. The new payment models established by the ACA are here to stay. Contingent payment will become the “new normal” as CMS expands the Hospital Value-Based Purchasing Program and targets both readmissions and hospital-acquired conditions in upcoming pay-for-performance programs. Further, expect focus on bundled payment and ACO models to intensify as CMS looks to improve Medicare’s affordability, efficiency and quality.

All eyes are on the states as coverage expansion looms. With the president’s reelection, lingering questions surrounding the employer and individual mandate should be resolved.

The conversation now shifts from the federal level to state capitols where providers must closely track and influence progress on Medicaid reform and expansion as well as development of state health insurance exchanges, two key enablers of anticipated coverage expansion. Also watch as state Medicaid programs experiment with increased home and community based programs.