In a recent editorial, US Department of Health and Human Services Secretary Sylvia Mathews Burwell gave a broad overview of the achievements of the Affordable Care Act (ACA), touching on everything from health insurance exchange to accountable care organizations and health IT.
The timing of Burwell’s Health Affairs editorial comes a little over a month before president-elect Donald Trump—who has vowed to repeal the ACA—is sworn into office January 20.
Burwell starts by first addressing the volume and rates of newly insured Americans under the health insurance exchanges and through the law’s massive Medicaid expansion. For example, according to Burwell, the law gave insurance to 20 million new individuals and now, almost nine out of 10 Americans has insurance for the first time in history. Additionally, the Centers for Medicare and Medicaid Services (CMS) projects the US is on track “to spend $2.6 trillion less over the ACA’s first decade than was projected without the ACA back in 2010.”
Delivery System and Payment Reforms
While HIM professionals may well have been tasked with coding and processing more claims as more people became insured, their professional involvement with the ACA came as a result of the numerous Medicare reforms developed by the Center for Medicare and Medicaid Innovation (CMMI). That Center launched accountable care organizations (ACOs), the medical home model of care, and bundled payments/reimbursement for procedures such as joint replacements. It is programs from CMS and CMMI that are helping to move the healthcare system away from fee-for-service reimbursement to pay-for-performance methods.
“Just as important to the future of payment reform is that we are starting to see similar shifts in the private sector and in states. In October, we joined many of our private and state partners to announce that they have also shifted a significant proportion of their health care payments to flow through alternative payments models in 2015 and expect this number to increase for 2016,” Burwell wrote. “Thanks to the efforts of the Health Care Payment Learning and Action Network to track this progress, we know that plans and states that cover approximately 200 million Americans are now spending almost a quarter of their health care dollars through alternative payment models.”
In order for ACOs to thrive, and Burwell argues that they are, provider members of the ACOs need to be able to share and exchange information—such as when and where a patient underwent a diagnostic test, thus reducing duplicates—in order to improve outcomes in numerous quality measures.
“By tying the amount of potential savings earned to measurable outcomes, ACOs’ financial incentives are designed to drive care improvements instead of higher volume. In 2015, Medicare ACOs saved $466 million and resulted in improvements across key quality measures. Over 100 new ACOs have joined in the last year, bringing the total to 477 serving nearly 8.9 million people,” Burwell wrote.
HIM professionals, especially clinical documentation improvement specialists, are on the frontlines of bundled payment initiatives since it means reviewing a higher volume of charts—a task that often requires technologies such as natural language processing.
As Burwell notes, the “Comprehensive Care for Joint Replacement model now holds participating hospitals accountable for the costs and quality of care for the full episode of a hip or knee replacement from the time of the surgery through 90 days after hospital discharge. Providers who administer high-value care share in the savings and otherwise share in the costs.”
She also notes that none of these changes to the system are possible without robust health IT systems, including EHRs. While the “meaningful use” EHR Incentive Program was not a part of the ACA, it contributed to a boom in EHR adoption while the ACA was being implemented.
“Easily accessible and portable electronic health records (EHRs) not only help patients move seamlessly between their providers, but they also offer patients the agency to take an active role in their care,” Burwell wrote.
Click here to read the editorial in full.