NEWS AND VIEWS
The Affordable Care Act: Implications for Cardiothoracic Surgery T Bruce Ferguson Jr., MD, and Joseph A. Babb, MD The Affordable Care Act legislation that was passed by the US Congress and signed into law by President Obama on March 23, 2010 is having a substantial effect throughout all of health care in the United States. Cardiothoracic surgeons, as hospital-based procedural specialists, bring unique assets and certain important liabilities into this massive restructuring of our health care delivery system. This article highlights how each of the 10 titles in the Obamacare legislation might affect our specialty; its collaborative relationship with our cardiovascular, medical specialty, and primary care colleagues; and our clinical practice roles and responsibilities in accountable care organizations and primary care medical homes. This article also addresses the unique assets in clinical data in medicine and quality improvement demonstrated by our specialty that have been used to help shape the current and future landscape. Finally, key resources are identified to allow the cardiothoracic community to monitor the ongoing progress of Obamacare as implementation begins. Keeping abreast of these rapidly changing developments will be an important role for our specialty societies and for practitioners alike going forward. Semin Thoracic Surg 25:280–286 I 2014 Published by Elsevier Inc. Keywords: Affordable Care Act, Obamacare, health policy, clinical data
In one of the most far-reaching legislative actions since the 1965 Social Security Amendments that created Medicare and Medicaid, President Obama signed into law on March 23, 2010 the Patient Protection and Affordable Care Act (ACA). Since then, “Obamacare” has been a lightening rod politically, administratively, and, more recently, medically as the first major implementation steps are undertaken. Overall approval ratings for Obamacare are split along political party lines, and politics has dramatically affected several important aspects of implementation. Since passage, public sentiment has remained stable and negative (35% pro, 43% con in June 2013) before the early stages of implementation.1 The ultimate effect of Obamacare on health care in the United States remains a considerable uncertainty. Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina Heart Institute at ECU, Greenville, North Carolina The views expressed in this article do not reflect the position of the STS or the ACC but rather reflect the authors' views of the current status of the Accountable Care Act and the potential implications for cardiovascular medicine and surgery today. Address reprint requests to T Bruce Ferguson, MD, Department of Cardiovascular Sciences, ECHI, 115 Heart Dr, Rm 3253, Greenville, NC 27834. E-mail: [email protected]
280
However, certain aspects of the legislation, particularly those related to payment reform, can be traced back to the 2004-2007 tenure of Mark McClellan as head of Centers for Medicare and Medicaid Services. The reforms instituted during that time are outlined in his 2012 Thomas B. Ferguson lecture to the Society of Thoracic Surgeons.2 These have included the transition from payment for services to payment for quality and the importance of data, particularly clinical data, on which to focus decision making, both for health care provision and payment through value-based purchasing mechanisms. The overall survival of Obamacare was assured on June 28, 2012, when the US Supreme Court voted to uphold the ACA and, in particular, the 2 most contentious provisions of the act, with exceptions. In a 5-4 opinion, the Court decided that the individual mandate could stand as a tax and that the Medicaid expansion provision, although partially subsidized by the federal government, was allowable but only as an optional new state program. Along with many of the reforms already in process, this decision by the Supreme Court of the United States effectively eliminated the possibility of overturning the entire ACA. Removing certain aspects of funding of the bill has already occurred and remains the targeted mechanism of the bill's opponents. This strategy has received considerably more attention in 1043-0679/$-see front matter ª 2014 Published by Elsevier Inc. http://dx.doi.org/10.1053/j.semtcvs.2013.12.002
THE AFFORDABLE CARE ACT recent weeks as the problems with implementation have occurred. Understanding the effect of this transformational process in US health care on subspecialty cardiothoracic surgeons has been daunting. However, with the diligent work of the Washington Office of the Society of Thoracic Surgeons (STS) supporting the Joint STS-American Association for Thoracic Surgery Workforce on Health Policy, Reform, and Advocacy, some common themes have emerged in the context of this complex legislation. This article highlights these themes and their possible influences on our specialty going forward in this new ACA health care era.
larger scale, however, this title emphasizes outpatient vs inpatient care and preventative care over therapeutic care, both with implications for hospitalbased therapeutic proceduralists. Coverage expansion and baby boomer patients entering the age ranges for ischemic heart, valve, and thoracic cancer will potentially increase the number of cardiothoracic surgical patients over the next decade. However, Title I leverages the rest of the ACA Titles to bend the health care cost curve, and the mechanisms for this may affect cardiovascular specialists disproportionately, as discussed later (Table).
OVERVIEW The framework for this is taken from John McDonough's book Inside National Health Reform.3 Dr McDonough is a DPh, MPA and a Professor of Health Policy and Management at Harvard University School of Public Health and was invited by Senator Ted Kennedy to participate in the committee that helped draft the law. Dr McDonough offers a look at the ACA that many have not seen and breaks down the law according to the 10 titles that compose it, offering an easy-to-follow guide of the changes affecting the insurance and medical industries, as well as patients, and when these changes will happen. This framework would be used to suggest how the law will or might have an influence on our specialty, its assets, and its liabilities.
TITLE II: THE ROLE OF PUBLIC PROGRAMS This title was intended to make Medicaid a program with uniform eligibility and enrollment standards, as well as quality improvement requirements for all lower-income individuals. At present, this is perhaps the most controversial aspect of ACA implementation. The Supreme Court of the United States decision to allow states to opt out of the Medicaid expansion means there are no new affordable care options for more than 5 million lowincome patients.8 Of these, 55% live in Texas, Florida, Georgia, Ohio, or North Carolina, the 5 states with the largest coverage gaps. Geographically, the southeastern United States from Texas to Virginia will remain as the states with the most number of uninsured individuals in 2016. In addition, the ACA mandated reduction in disproportionate share hospital payments, totaling $18.1 billion from fiscal years 2014-2020, in anticipation that Medicaid expansion would reduce a larger portion of uncompensated care costs.9 Although intense lobbying efforts are ongoing and the legislated implementation policy is complex, this scenario of disproportionate share hospital cuts will adversely affect safety-net hospitals in states that do not expand Medicaid programs. Many of these safety-net hospitals are affiliated with academic medical centers and their cardiothoracic training programs. Finally, this title requires coverage for “essential health benefits,” given an A or B grade by the United States Preventative Services Task Force through different mechanisms in Medicare, Medicaid, and the private insurance sectors. This will have the greatest effect on the cardiothoracic surgical community related to screening of the diseases that they treat, such as lung and esophageal cancers, and the postoperative medications for secondary prevention of stable ischemic heart disease following CABG.10
TITLE I: QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS This title fundamentally changes the nature and operation of private health insurance in the United States. Some important changes, including the banning of lifetime and annual benefit limits, were implemented in 2010. By 2014, no health insurer will be able to sell or rate coverage based on an individual's medical history, most Americans will be required to obtain health insurance, and substantial financial subsidies will be available to low-income and moderate-income Americans to help them afford the cost of health insurance. In theory, most states will operate new “health insurance exchanges” to make shopping for health insurance easier. Small businesses and individuals can shop these insurance exchanges for competitive rates. As the implicit ACA agenda is for all citizens to have health care coverage, the fundamental transition is the elimination of most of fee-for-service payment mechanisms.4-6 The transition of many private cardiothoracic surgical practices to hospitalbased employment in part anticipated this.7 On a
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
281
THE AFFORDABLE CARE ACT Table. The Affordable Care Act's 10 titles and Their Effect on Cardiothoracic Surgery Number Title I II
III
IV V
VI
VII
VIII IX
X
Effect
Quality, Affordable Health care for all Americans The Role of Public Programs
Gradual elimination of FFS vs prevention and diminish inpatient and procedure-based care State-based opt out of Medicaid, DSH cuts, requirement of “Essential Health Benefits,” and effect of disease screening on cancer and CAD Improving the Quality and Efficiency of Health care that is more efficient, effective, and patient Health Care centered; effect of health IT EHRs and integration of CV databases; medical technology targeted as primary factor for rising costs, especially technology that does not increase health care value; drive to reorganization of care (ACOs and integrated departments) will affect CV specialists Prevention of Chronic Disease and the Refocusing health care on prevention of disease, with Improvement in Public Health implications for proceduralists Health Care Workforce Currently, National Health Care Workforce Commission not funded; significant effect on cardiac surgery if not convened Transparency and Program Integrity Addressing health care cost inefficiency and fraud; Sunshine Provision for physician payment reporting; Patient-Centered Outcomes Research Institute (PCORI) support of research on comparative effectiveness Improving Access to Innovative New FDA regulatory pathways; most profound opportunity Medical Therapies is in “just-in-time” clinical research based on national databases Community Living Assistance This title was abandoned by the Obama administration on Supports and Services: CLASS October 15, 2013 Revenue Provisions This title finances approximately half of ACA; factors affecting CV are new Medicare taxes on high-income wage earners and new taxes on pharmaceutical and medical technology device manufacturers Strengthening Quality, Affordable Amendments and additions to Titles I-IX, passed as the Health care for all Americans Health Care and Education Reconciliation Act (HCERA) signed on March 30, 2010
FFS, fee for service; DSH, disproportionate share hospital payments; CAD, coronary artery disease; IT, information technology; EHRs, electronic health record systems; CV, cardiovascular; FDA, Food and Drug Administration.
TITLE III: IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE This title establishes new mechanisms to improve the quality of medical care in the United States by making it more efficient, effective, and patient centered. This title has perhaps the most far-reaching implications for specialty medicine and specifically for cardiothoracic surgery because of our specialty's particular attributes and liabilities. The first component of the efficiency mechanism is information technology. The digital information revolution is finally beginning to take hold in health care. By May 2013, more than 50% of all the eligible providers, including nearly 80% of hospitals, were using electronic health records (EHRs).11 Although the promise that this digital infrastructure will generate the data in real time to increase transparency, improve quality, and lower costs remains unrealized, it is not an unrecognized need. Thomas
282
Friedman12 has commented that Obamacare has “… created a new marketplace and platform for innovation—a new health care Silicon Valley—that has the potential to create better outcomes and lower costs by changing how health data are stored, shared, and mined. It's a new industry.” The challenge this creates for specialty organizations, such as the STS and the American College of Cardiology (ACC) with established clinical data information investments, is daunting. There is near-complete agreement that clinical data should be the resource for quality evaluation, decision making, and payment for quality; our efforts in continuous quality improvement nationally13 and at the state level through the Virginia Cardiac Surgery Quality Improvement and the Washington State Clinical Outcomes Assessment Program initiatives have provided considerable evidence for this.14,15 The challenge is that there is considerable anticipation that these new technology
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
THE AFFORDABLE CARE ACT approaches will provide better business models for acquiring these quality data than the legacy STS and ACC systems, as they currently exist. The STS has worked tirelessly to get the National Databases designated as Qualified Clinical Data Registries, and these databases are a data source for the Physician Quality Reporting System. Evolutionary infrastructure transformation of these remarkable assets to meet these parallel and exciting new developments as described in the Institute of Medicine Report “Best Care at Lower Cost: the Path to Continuously Learning Health Care in America”16 and by Friedman will be necessary. For example, a Health and Human Services “Health Datapalooza” was held in 2012, where 1600 health information technology entrepreneurs and innovators met to hear presentations from 100 selected companies, almost all of which had been started in the last 24 months.12 A more sobering reality, however, is that to date EHR interoperability is mostly lacking, the definition of eMeasures is in its infancy, the ability to extract data from EHRs remains a very real challenge, and cross-platform interoperability between EHRs and clinical data registries has been difficult to engineer. New incentives need to be developed to accomplish these critically necessary goals. The second efficiency component is medical technology. The introduction, expansion, and diffusion of new technologies are credited with having the single largest effect on the growth of health care spending.17-19 Technologies in this context include a new intervention or treatment, changes in procedures or processes, and changes in the appropriate population for a treatment. The implications for cardiovascular medicine are clear. The 2-decade era of achievements in cardiovascular medicine described by Thomas Lee20 in Eugene Braunwald and the Rise of Modern Medicine has plateaued in the reality of health care fiscal accountability. Recent progress in cardiovascular medicine and surgery, both pharmaceutical and technological, has been more incremental than transformational when examined from the context of health care efficiency and value. Only a few cardiovascular technologies have met the transformational “…a dramatic improvement in healthcare quality, while radically reducing health care costs” benchmark set forth by Dr Harvey Feinberg (Feinberg HS: personal communication, January 11, 2011) of the Institute of Medicine (IOM). The importance of these 2 efficiency components for cardiovascular medicine is because 17% of every health care dollar spent in the United States is related to cardiovascular disease.21 In 2008, the costliest quartile of beneficiaries (many with cardiovascular diseases) accounted for 81% of Medicare spending.22
In 2010, federal spending on Medicare and Medicaid was $793 billion, and this amount is projected to grow to $1.608 trillion by 2021.18,23 This ACA Title III will lower Medicare's rate of growth to provide $450 billion in savings between 2010 and 2019, accounting for about half the cost of the ACA. The Independent Payment Advisory Board (which organized medicine feels would be even less representative than Medicare Payment Advisory Commission has been) is specified to make recommendations to reduce the Medicare growth rate where per capita spending exceeds certain targets set in the ACA. Clearly, a disproportionate share of this savings will need to come from cardiovascular services relative to the rest of medicine. The opportunities for health information to influence nonpayment for never events, readmissions, and other hospital-based revenue cuts based on quality differentiation are emerging.6 For example, as much as $12 billion could be saved by eliminating half of the 25% of the 30-day readmission rate in patients with heart failure.24 Moreover, recent data described by Secretary Sebelius indicate that the Medicare spending per beneficiary grew just 0.4% per capita in the fiscal year 2012, much lower than predicted by Medicare Payment Advisory Commission.11,25 The larger savings will be from drastically limiting new technology introduction and better, more costeffective use of the technologies in play now. The developing controversy over robotically assisted surgery is an example.26 Another example is coronary artery bypass graft (CABG), where despite the dramatic improvements in mortality outcomes for CABG over the past 2 decades, risk-adjusted mortality has remained at 1.8%-2.0% for the last 3 years nationally. Assessing CABG from a different, nonhistorical perspective, as has been done with percutaneous coronary intervention, might create the paradigm shift to continue improvements in mortality.27,28 Despite the randomized trial-documented late mortality benefits of CABG vs percutaneous coronary intervention in a multivessel disease, the lack of long-term financial data to accompany these outcomes data are limiting. This is particularly true because periprocedural complication rates have not decreased, and thus the cost of a perioperative CABG episode of care has remained stagnant. As has been argued by the STS and the ACC, these limitations can be better addressed through novel scientific collaboration and evaluation, rather than through regulatory practices both at the local and at the national level. As cardiothoracic specialists and as cardiovascular medicine providers, we should challenge ourselves to objectively and effectively address these issues.
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
283
THE AFFORDABLE CARE ACT The effectiveness mechanism in this title has equally important implications. The ACA incentivizes the structural reorganization of health care delivery through accountable care organizations (ACOs) and a much greater emphasis on the primary care medical home as the driver for health care utilization. Currently, more than 250 organizations are participating in Medicare ACOs, serving approximately 4 million (8%) of Medicare beneficiaries.11 ACOs are expected to save up to $940 million in the first 4 years. ACOs are encouraging providers to invest in redesigning care for higher quality and more efficient service delivery.29 The role of medical specialists in ACOs, and cardiovascular providers in particular, is still being evaluated. ACOs are initially interested in providers who treat recurrent conditions because these patients provide the opportunity for the ACOs to reduce expenses.30 As ACOs manage the continuum of a patient's care across different delivery settings (inpatient, outpatient, and home care) and facility structures (hospital, outpatient, local and regional clinics, and home), selected specialists will be included to provide services, in many circumstances without much leverage or ability to partake in shared savings. Having quality and cost information will be critical in the future for specialists groups, who may find themselves competing with each other for inclusion in dominant ACOs in their geographic area. With respect to primary care, the American College of Physicians has recently outlined their somewhat narrow perspective of health care professional collaboration going forward.31 Through this and other mechanisms, the ACA intends to transition much of the direction of care for the major long-term conditions of patients toward prevention and toward management from specialists to the Medical Home context.32,33 The effect on specialty care has already begun. The Sustainable Growth Rate stopgap legislation from 2012 increased primary care reimbursement by reducing payments to specialty care providers. Controversy exists as to whether primary care or cardiovascular medicine providers are best qualified to manage patients with existing cardiovascular conditions, such as ischemic heart disease and heart failure.34 The largest opportunity for specialists may be to integrate themselves (so the primary care medical home does not have to do this), and then to provide the knowledge and educational opportunities to the medical home and their shared patients. The final consequence of Title III will be much closer collaboration with other providers. The relative isolationism of cardiac surgeons compared with thoracic surgeons and many other providers has been positively affected by the Heart Team developments of the past few years, most notably by placing
284
the patient at the center of the delivery process. This patient-centered approach is the core of the Best Care at Lower Cost IOM report, which is increasingly recognized as the road map for achieving an ideal health paradigm based on continuous learning.16 Across the broad continuum of care in cardiovascular disease (ischemic heart disease, structural heart disease, and electrophysiology), the academic, administrative, and financial integration of cardiovascular providers engaged in this patient-centered care will have the greatest opportunity to reengineer care to improve quality and lower costs and meet one of the primary expected outcomes of the ACA. TITLE IV: PREVENTION OF CHRONIC DISEASE AND THE IMPROVEMENT OF PUBLIC HEALTH Title IV is the most ambitious law ever passed to promote healthier lifestyles for all Americans and to prevent disease and disability. Evidence-based clinical preventive services will be provided in most public and private health insurance policies without cost sharing. A National Prevention, Health Promotion, and Public Health Council will devise a national prevention strategy, backed up by a $13 billion trust fund. For cardiothoracic surgeons, despite being proceduralists, they must engage in this prevention process with data and education and research efforts to ensure that the demonstrated benefit of multivessel CABG remains a long-term superior outcome in the setting of stable ischemic heart disease, or that lung cancer resection is the most effective therapy for certain types of accurately staged lung cancer. TITLE V: HEALTH CARE WORKFORCE This title establishes a National Health Care Workforce Commission to analyze and plan for workforce needs and to make recommendations to the Congress and the administration. The workforce issues in cardiothoracic surgery have been effectively presented to the government entities, and hopefully, some, if not all, of the solutions proposed will be enacted to assure a sufficient number of cardiac and thoracic surgeons in the future.35 This is among the provisions of the ACA that have not been funded. The members of the Commission have been empaneled but, without appropriated funds, they are unable to convene. TITLE VI: TRANSPARENCY AND PROGRAM INTEGRITY The Best Care at Lower Cost report from the IOM estimated that as much as one-third of the $2.7 trillion spent on health care in 2011 was wasted
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
THE AFFORDABLE CARE ACT through inefficient, unnecessary, or illegal spending.16,36 Title VI provides new authority to federal and state agencies to combat fraud and abuse in US health care. The Physician Payments Sunshine Provision requires drug companies and medical suppliers to report most gifts and other gratuities to physicians for public release on a federal Web site.37 The Patient-Centered Outcomes Research Institute is supporting research on comparative clinical effectiveness. At both an individual and specialty society level, these developments will variably have an influence on cardiothoracic surgical providers. TITLE VII: IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES This title directs the US Food and Drug Administration to develop new regulatory pathways to permit the development, manufacture, marketing, and sale of innovative medical therapies. Engagement in this process is critical for cardiovascular medicine. Perhaps the greatest opportunity would be establishing “just-in-time” clinical research based on the ACC NCDR and STS National Database. The recent Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia trial has clearly illustrated the exciting opportunities for “registrybased randomized trials.”38 Although this will require some reengineering of the infrastructure of the NCDR and the STS National Database, the opportunity for partnership with industry for new technology evaluation, reduction in trial costs, and collaboration with the new Food and Drug Administration regulatory pathways is paradigm shifting. This approach would also leverage the unprecedented commitment to clinical data that has been made by the cardiovascular specialty society community and provide considerable value added to ongoing investments in these data. TITLE VIII: COMMUNITY LIVING ASSISTANCE SUPPORTS AND SERVICES The Obama administration announced on October 15, 2013 that it was abandoning plans for Community Living Assistance Supports and Services. Congress is expected to quickly draft legislation to repeal the provisions of this title. TITLE IX: REVENUE PROVISIONS This section covers the financing for slightly less than half the cost of the ACA. Key provisions establish new Medicare taxes on high-income wage earners, as well as new taxes on pharmaceutical manufacturers, health insurance providers, and medical device manufacturers.
TITLE X: STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS The final title in the ACA is the “Manager's Amendment,” which includes amendments and additions to Titles I-IX, reflecting the unusual legislative process leading to passage of the ACA. These changes were approved in a separate measure called the Health Care and Education Reconciliation Act signed into law by President Obama on March 30, 2010. COMMENT The ACA remains very much a work in progress. Concomitant with the current rollout, the Senate Finance Committee and the House Ways and Means Committee have drafted a bicameral, bipartisan bill to collaboratively address the Sustainable Growth Rate debacle. Both the STS and the ACC Washington offices have worked tirelessly with the staff of these congressional Committees, and because of the leadership demonstrated by both the organizations in clinical data and quality improvement, their collective influence on the proposed legislation has been substantial. However, there remains much work to be done.39 Burke and Kamarck40 of Brookings have authored a useful User's Guide to Implementation of the ACA. It is an excellent overview, and the benchmarks proposed, although mostly market driven, are important for the cardiovascular community to monitor, both locally and nationally, as we continue to address the unique attributes and resources that we collaboratively bring to our nation's health care. SUMMARY STATEMENT The ACA is transforming medicine in the United States, even as it is a work in design and progress. In all its iterations, it will have a specific and perhaps profound effect on cardiovascular providers, because of both therapeutic procedural specialists and the enormous cost of cardiovascular care overall. Making sure that our strengths and unique resources are incorporated into these iterations will necessitate a thorough understanding of the legislation and its consequences on our specialty. ACKNOWLEDGMENT We would like to express our deep gratitude to Cortney Yohe, MPP, Assistant Director of Government Relations, Society of Thoracic Surgeons. Our multiple conversations have provided navigation for the STS-American Association for Thoracic Surgery Workforce on Health Policy, Reform, and Advocacy and for a number of concepts in this article.
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
285
THE AFFORDABLE CARE ACT 1. Kaiser Family Foundation. Available at: http:// www.kkf.org. Accessed November 10, 2013. 2. Naunheim K: Forth-ninth Annual Meeting of the Society of Thoracic Surgeons: Report from the STS Board of Directors. Ann Thorac Surg 96:361-374, 2013 3. McDonough JE: Inside National Health Reform. UC/Milbank Books on Health and the Public. September, 2011. 4. Shatto JF, Clemens MK: Projected Medicare expenditures under an illustrative scenario with alternative payment updates to Medicare providers. Memorandum from the Centers for Medicare and Medicaid Services. Office of the Actuary. May 13, 2011. 5. Lee JL, Maciejewski ML, Raju SS, et al: Valuebased Insurance Design: Quality improvement but no cost savings. Health Affairs 32(7): 1251-1257, 2013 6. Eddy DM, Shah RA: Simulation shows limited savings from meeting quality targets under the Medicare Shared Savings Program. Health Affairs 31(11):2554-2562, 2012 7. O’Malley AS, Bond AM, Berenson RA: Hospital Employment of Physicians: Better Quality, Higher Costs? Issue BriefWashington, DC: Center for Studying Health System Change; 2011 8. Mullin J: Which states will have the biggest coverage gaps next year? Available at: http:// www.advisory.com/Daily-Briefing/2013/10/21. Accessed November 10, 2013. 9. Mullin J: For states not expanding Medicaid, DSH cuts will deal a tough blow. Available at: http://www.advisory.com/Daily-Briefing/2013/ 9/23. Accessed November 8, 2013. 10. Williams JB, DeLong ER, Peterson ED, et al: Secondary prevention after coronary artery bypass graft surgery: Findings of a National Randomized Controlled Trial and Sustained Society-Led Incorporation Into Practice. Circulation 123(1):39-45, 2011 11. Topol EJ, Sebelius K: Topol asks Sebelius 5 ACA Questions. Medscape, June 27, 2013. 12. Friedman TL: Obamacare's other surprise. The New York Times, May 25, 2013. Available at: http://www.nytimes.com/2013/05/26/opinion/ sunday/friedman-obamacares-other-surprise. html?r=2&. Accessed November 9, 2013. 13. Ferguson Jr. TB, Peterson ED, Coombs LP, et al: Use of continuous quality improvement to increase utilization of preoperative betablockade and internal mammary artery grafting in patients undergoing coronary artery bypass surgery: A National Randomized Controlled Trial. J Am Med Assoc 290:49-56, 2003 14. Spier AM, Karirajan V, Barnett SD, et al: Additive costs of postoperative complications for isolated coronary artery bypass grafting in
286
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
patients in Virginia. Ann Thorac Surg 88: 40-46, 2009 Aldea GS, Mokadam NA, Melford R, et al: Changing volumes, risk profiles and outcomes of coronary artery bypass grafting and percutaneous coronary interventions. Ann Thorac Surg 87:1828-1838, 2009 Institute of Medicine (IOM). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2012 McKinsey Global Institute. Accounting for the cost of US health care: A new look at why Americans spend more. New York, McKinsey and Company, 2008. MedPAC. Report to the Congress: Medicare Payment Policy. Chapter 1: Context for Medicare payment policy, 2012. Cutler DM, McClellan M: Is technological change in medicine worth it? Health Affairs 20(5):11-29, 2001 Mandrola J: Progress in cardiology? A sobering second look. Comnmet on Lee T: Eugene Braunwald and the rise of modern medicine. Medscape, Oct 30, 2013. CDC. Heart Disease and Stroke Prevention: Addressing the Nation's Leading Killers. At a Glance, 2011. Available at: http://www.cdc. gov/dhdsp. Accessed November 11, 2013. Keehan SP, Cuckler GA, Sisko AM, et al: National Health Expenditure Projections: Modest annual growth until coverage expands and economic growth accelerates. Health Affairs 31 (7):1600-1612, 2012 Keehan SP, Sisko AM, Truffler CJ, et al: National health spending projections through 2020: Economic recovery and reform drive faster spending growth. Health Affairs 30(8): 1594-1605, 2011 Basoor A, Cotant J, Patel K, et al: Decreased readmissions and improved quality of care with use of inexpensive checklist in heart failure. J Am Coll Cardiol 59:E1026, http://dx.doi.org/ 10.1016/S0735-1097(12)61027-4 Martin AB, Lassman D, Washington B, et al: Growth in US health spending remained slow in 2010: Health share of gross domestic product was unchanged from 2009. Health Affairs 31(1):208-219, 2012 Burton TM: Report raises concerns on robotic surgery device, 2013. Available at: http:// online.wsj.com/news/articles/SB100014240527 02304672404579186190568061568. Accessed November 11, 2013. Pijls NH, et al: Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (Fractional Flow Reserve Versus
28.
29.
30.
31.
32.
33.
34. 35.
36.
37.
38.
39.
40.
Angiography for Multivessel Evaluation) study. J Am Coll Cardiol 56(3):177-184, 2010 Ferguson TB, Babb CC, Efird JD: FFR-guided CABG: Can intra-operative physiologic imaging guide the decision making? J Thorac Cardiovasc Surg 146:824-835, 2013 Yox SB: Implementing the Affordable Care Act —What clinicians should expect. Medscape. Sept 27, 2013. Page L: 8 ways the ACA could affect your ophthalmology practice. What the ACA means to ophthalmologists. Medscape Sep 11, 2013. Doherty RB, Crowley RA, for the Health and Public Policy Committee of the American College of Physicians. Principles supporting dynamic clinical care teams: An American College of Physicians position paper. Ann Intern Med [Epub ahead of print] Auerbach DI, Chen PG, Friedberg MW, et al: Nurse-managed health centers and patientcentered medical homes could mitigate expected primary care physician shortage. Health Affairs 32(11):1933-1941, 2013 (et al) Frellick M: Emerging care models may east primary care doc shortage. Medscape, Nov 08, 2013. DeMaria AN: The primary care cardiologist. J Am Coll Cardiol 58:881-882, 2011 Shemin RJ, Ikonomidis JS: Thoracic surgery workforce: Report of STS/AATS Thoracic Surgery Practice and Access Task Force—Snapshot 2010. Ann Thorac Surg 93:348-355, 2012 Solomon MZ, Bohham A, (eds): Ethical oversight of Learning Health Care Systems. Hasting Center Report Special Report 43, No 1, 2013. doi:10.1002/hast.132. The Physician Payments Sunshine Act. CMS. Open Payments. Available at: http://www.cms. gov/Regulations-and-Guidance/Legislation/ National-Physician-Payment-Transparency-Pro gram/index.html. Accessed August 1, 2013. Forbert O, Lagerqvist B, Olivecrona GK, et al: Thrombus aspiration during ST-segment elevation myocardial infarction. New Engl J Med 369:1587-1597, 2013 Klar R: Medicare physician payment reform: An analysis of the New Congressional Proposal. Available at: http://healthaffairs.org/blog/2013/ 11/08/medicare-physician-payment-reform-a n-analysis-of-the-new-congressional-proposal/? utm_source=rss&utm_medium=rss&utm_ campaign=medicare-physician-payment-refor m-an-analysis-of-the-new-congressional-pro posal. Accessed November 9, 2013. Burke S, Kamarck E: The Affordable Care Act: A user's guide to implementation. Available at: http://www.brookings.edu/search?start=1&q= Burke. Accessed November 10, 2013.
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
The Affordable Care Act: Implications for Cardiothoracic Surgery T Bruce Ferguson Jr., MD, and Joseph A. Babb, MD The Affordable Care Act legislation that was passed by the US Congress and signed into law by President Obama on March 23, 2010 is having a substantial effect throughout all of health care in the United States. Cardiothoracic surgeons, as hospital-based procedural specialists, bring unique assets and certain important liabilities into this massive restructuring of our health care delivery system. This article highlights how each of the 10 titles in the Obamacare legislation might affect our specialty; its collaborative relationship with our cardiovascular, medical specialty, and primary care colleagues; and our clinical practice roles and responsibilities in accountable care organizations and primary care medical homes. This article also addresses the unique assets in clinical data in medicine and quality improvement demonstrated by our specialty that have been used to help shape the current and future landscape. Finally, key resources are identified to allow the cardiothoracic community to monitor the ongoing progress of Obamacare as implementation begins. Keeping abreast of these rapidly changing developments will be an important role for our specialty societies and for practitioners alike going forward. Semin Thoracic Surg 25:280–286 I 2014 Published by Elsevier Inc. Keywords: Affordable Care Act, Obamacare, health policy, clinical data
In one of the most far-reaching legislative actions since the 1965 Social Security Amendments that created Medicare and Medicaid, President Obama signed into law on March 23, 2010 the Patient Protection and Affordable Care Act (ACA). Since then, “Obamacare” has been a lightening rod politically, administratively, and, more recently, medically as the first major implementation steps are undertaken. Overall approval ratings for Obamacare are split along political party lines, and politics has dramatically affected several important aspects of implementation. Since passage, public sentiment has remained stable and negative (35% pro, 43% con in June 2013) before the early stages of implementation.1 The ultimate effect of Obamacare on health care in the United States remains a considerable uncertainty. Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina Heart Institute at ECU, Greenville, North Carolina The views expressed in this article do not reflect the position of the STS or the ACC but rather reflect the authors' views of the current status of the Accountable Care Act and the potential implications for cardiovascular medicine and surgery today. Address reprint requests to T Bruce Ferguson, MD, Department of Cardiovascular Sciences, ECHI, 115 Heart Dr, Rm 3253, Greenville, NC 27834. E-mail: [email protected]
280
However, certain aspects of the legislation, particularly those related to payment reform, can be traced back to the 2004-2007 tenure of Mark McClellan as head of Centers for Medicare and Medicaid Services. The reforms instituted during that time are outlined in his 2012 Thomas B. Ferguson lecture to the Society of Thoracic Surgeons.2 These have included the transition from payment for services to payment for quality and the importance of data, particularly clinical data, on which to focus decision making, both for health care provision and payment through value-based purchasing mechanisms. The overall survival of Obamacare was assured on June 28, 2012, when the US Supreme Court voted to uphold the ACA and, in particular, the 2 most contentious provisions of the act, with exceptions. In a 5-4 opinion, the Court decided that the individual mandate could stand as a tax and that the Medicaid expansion provision, although partially subsidized by the federal government, was allowable but only as an optional new state program. Along with many of the reforms already in process, this decision by the Supreme Court of the United States effectively eliminated the possibility of overturning the entire ACA. Removing certain aspects of funding of the bill has already occurred and remains the targeted mechanism of the bill's opponents. This strategy has received considerably more attention in 1043-0679/$-see front matter ª 2014 Published by Elsevier Inc. http://dx.doi.org/10.1053/j.semtcvs.2013.12.002
THE AFFORDABLE CARE ACT recent weeks as the problems with implementation have occurred. Understanding the effect of this transformational process in US health care on subspecialty cardiothoracic surgeons has been daunting. However, with the diligent work of the Washington Office of the Society of Thoracic Surgeons (STS) supporting the Joint STS-American Association for Thoracic Surgery Workforce on Health Policy, Reform, and Advocacy, some common themes have emerged in the context of this complex legislation. This article highlights these themes and their possible influences on our specialty going forward in this new ACA health care era.
larger scale, however, this title emphasizes outpatient vs inpatient care and preventative care over therapeutic care, both with implications for hospitalbased therapeutic proceduralists. Coverage expansion and baby boomer patients entering the age ranges for ischemic heart, valve, and thoracic cancer will potentially increase the number of cardiothoracic surgical patients over the next decade. However, Title I leverages the rest of the ACA Titles to bend the health care cost curve, and the mechanisms for this may affect cardiovascular specialists disproportionately, as discussed later (Table).
OVERVIEW The framework for this is taken from John McDonough's book Inside National Health Reform.3 Dr McDonough is a DPh, MPA and a Professor of Health Policy and Management at Harvard University School of Public Health and was invited by Senator Ted Kennedy to participate in the committee that helped draft the law. Dr McDonough offers a look at the ACA that many have not seen and breaks down the law according to the 10 titles that compose it, offering an easy-to-follow guide of the changes affecting the insurance and medical industries, as well as patients, and when these changes will happen. This framework would be used to suggest how the law will or might have an influence on our specialty, its assets, and its liabilities.
TITLE II: THE ROLE OF PUBLIC PROGRAMS This title was intended to make Medicaid a program with uniform eligibility and enrollment standards, as well as quality improvement requirements for all lower-income individuals. At present, this is perhaps the most controversial aspect of ACA implementation. The Supreme Court of the United States decision to allow states to opt out of the Medicaid expansion means there are no new affordable care options for more than 5 million lowincome patients.8 Of these, 55% live in Texas, Florida, Georgia, Ohio, or North Carolina, the 5 states with the largest coverage gaps. Geographically, the southeastern United States from Texas to Virginia will remain as the states with the most number of uninsured individuals in 2016. In addition, the ACA mandated reduction in disproportionate share hospital payments, totaling $18.1 billion from fiscal years 2014-2020, in anticipation that Medicaid expansion would reduce a larger portion of uncompensated care costs.9 Although intense lobbying efforts are ongoing and the legislated implementation policy is complex, this scenario of disproportionate share hospital cuts will adversely affect safety-net hospitals in states that do not expand Medicaid programs. Many of these safety-net hospitals are affiliated with academic medical centers and their cardiothoracic training programs. Finally, this title requires coverage for “essential health benefits,” given an A or B grade by the United States Preventative Services Task Force through different mechanisms in Medicare, Medicaid, and the private insurance sectors. This will have the greatest effect on the cardiothoracic surgical community related to screening of the diseases that they treat, such as lung and esophageal cancers, and the postoperative medications for secondary prevention of stable ischemic heart disease following CABG.10
TITLE I: QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS This title fundamentally changes the nature and operation of private health insurance in the United States. Some important changes, including the banning of lifetime and annual benefit limits, were implemented in 2010. By 2014, no health insurer will be able to sell or rate coverage based on an individual's medical history, most Americans will be required to obtain health insurance, and substantial financial subsidies will be available to low-income and moderate-income Americans to help them afford the cost of health insurance. In theory, most states will operate new “health insurance exchanges” to make shopping for health insurance easier. Small businesses and individuals can shop these insurance exchanges for competitive rates. As the implicit ACA agenda is for all citizens to have health care coverage, the fundamental transition is the elimination of most of fee-for-service payment mechanisms.4-6 The transition of many private cardiothoracic surgical practices to hospitalbased employment in part anticipated this.7 On a
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
281
THE AFFORDABLE CARE ACT Table. The Affordable Care Act's 10 titles and Their Effect on Cardiothoracic Surgery Number Title I II
III
IV V
VI
VII
VIII IX
X
Effect
Quality, Affordable Health care for all Americans The Role of Public Programs
Gradual elimination of FFS vs prevention and diminish inpatient and procedure-based care State-based opt out of Medicaid, DSH cuts, requirement of “Essential Health Benefits,” and effect of disease screening on cancer and CAD Improving the Quality and Efficiency of Health care that is more efficient, effective, and patient Health Care centered; effect of health IT EHRs and integration of CV databases; medical technology targeted as primary factor for rising costs, especially technology that does not increase health care value; drive to reorganization of care (ACOs and integrated departments) will affect CV specialists Prevention of Chronic Disease and the Refocusing health care on prevention of disease, with Improvement in Public Health implications for proceduralists Health Care Workforce Currently, National Health Care Workforce Commission not funded; significant effect on cardiac surgery if not convened Transparency and Program Integrity Addressing health care cost inefficiency and fraud; Sunshine Provision for physician payment reporting; Patient-Centered Outcomes Research Institute (PCORI) support of research on comparative effectiveness Improving Access to Innovative New FDA regulatory pathways; most profound opportunity Medical Therapies is in “just-in-time” clinical research based on national databases Community Living Assistance This title was abandoned by the Obama administration on Supports and Services: CLASS October 15, 2013 Revenue Provisions This title finances approximately half of ACA; factors affecting CV are new Medicare taxes on high-income wage earners and new taxes on pharmaceutical and medical technology device manufacturers Strengthening Quality, Affordable Amendments and additions to Titles I-IX, passed as the Health care for all Americans Health Care and Education Reconciliation Act (HCERA) signed on March 30, 2010
FFS, fee for service; DSH, disproportionate share hospital payments; CAD, coronary artery disease; IT, information technology; EHRs, electronic health record systems; CV, cardiovascular; FDA, Food and Drug Administration.
TITLE III: IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE This title establishes new mechanisms to improve the quality of medical care in the United States by making it more efficient, effective, and patient centered. This title has perhaps the most far-reaching implications for specialty medicine and specifically for cardiothoracic surgery because of our specialty's particular attributes and liabilities. The first component of the efficiency mechanism is information technology. The digital information revolution is finally beginning to take hold in health care. By May 2013, more than 50% of all the eligible providers, including nearly 80% of hospitals, were using electronic health records (EHRs).11 Although the promise that this digital infrastructure will generate the data in real time to increase transparency, improve quality, and lower costs remains unrealized, it is not an unrecognized need. Thomas
282
Friedman12 has commented that Obamacare has “… created a new marketplace and platform for innovation—a new health care Silicon Valley—that has the potential to create better outcomes and lower costs by changing how health data are stored, shared, and mined. It's a new industry.” The challenge this creates for specialty organizations, such as the STS and the American College of Cardiology (ACC) with established clinical data information investments, is daunting. There is near-complete agreement that clinical data should be the resource for quality evaluation, decision making, and payment for quality; our efforts in continuous quality improvement nationally13 and at the state level through the Virginia Cardiac Surgery Quality Improvement and the Washington State Clinical Outcomes Assessment Program initiatives have provided considerable evidence for this.14,15 The challenge is that there is considerable anticipation that these new technology
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
THE AFFORDABLE CARE ACT approaches will provide better business models for acquiring these quality data than the legacy STS and ACC systems, as they currently exist. The STS has worked tirelessly to get the National Databases designated as Qualified Clinical Data Registries, and these databases are a data source for the Physician Quality Reporting System. Evolutionary infrastructure transformation of these remarkable assets to meet these parallel and exciting new developments as described in the Institute of Medicine Report “Best Care at Lower Cost: the Path to Continuously Learning Health Care in America”16 and by Friedman will be necessary. For example, a Health and Human Services “Health Datapalooza” was held in 2012, where 1600 health information technology entrepreneurs and innovators met to hear presentations from 100 selected companies, almost all of which had been started in the last 24 months.12 A more sobering reality, however, is that to date EHR interoperability is mostly lacking, the definition of eMeasures is in its infancy, the ability to extract data from EHRs remains a very real challenge, and cross-platform interoperability between EHRs and clinical data registries has been difficult to engineer. New incentives need to be developed to accomplish these critically necessary goals. The second efficiency component is medical technology. The introduction, expansion, and diffusion of new technologies are credited with having the single largest effect on the growth of health care spending.17-19 Technologies in this context include a new intervention or treatment, changes in procedures or processes, and changes in the appropriate population for a treatment. The implications for cardiovascular medicine are clear. The 2-decade era of achievements in cardiovascular medicine described by Thomas Lee20 in Eugene Braunwald and the Rise of Modern Medicine has plateaued in the reality of health care fiscal accountability. Recent progress in cardiovascular medicine and surgery, both pharmaceutical and technological, has been more incremental than transformational when examined from the context of health care efficiency and value. Only a few cardiovascular technologies have met the transformational “…a dramatic improvement in healthcare quality, while radically reducing health care costs” benchmark set forth by Dr Harvey Feinberg (Feinberg HS: personal communication, January 11, 2011) of the Institute of Medicine (IOM). The importance of these 2 efficiency components for cardiovascular medicine is because 17% of every health care dollar spent in the United States is related to cardiovascular disease.21 In 2008, the costliest quartile of beneficiaries (many with cardiovascular diseases) accounted for 81% of Medicare spending.22
In 2010, federal spending on Medicare and Medicaid was $793 billion, and this amount is projected to grow to $1.608 trillion by 2021.18,23 This ACA Title III will lower Medicare's rate of growth to provide $450 billion in savings between 2010 and 2019, accounting for about half the cost of the ACA. The Independent Payment Advisory Board (which organized medicine feels would be even less representative than Medicare Payment Advisory Commission has been) is specified to make recommendations to reduce the Medicare growth rate where per capita spending exceeds certain targets set in the ACA. Clearly, a disproportionate share of this savings will need to come from cardiovascular services relative to the rest of medicine. The opportunities for health information to influence nonpayment for never events, readmissions, and other hospital-based revenue cuts based on quality differentiation are emerging.6 For example, as much as $12 billion could be saved by eliminating half of the 25% of the 30-day readmission rate in patients with heart failure.24 Moreover, recent data described by Secretary Sebelius indicate that the Medicare spending per beneficiary grew just 0.4% per capita in the fiscal year 2012, much lower than predicted by Medicare Payment Advisory Commission.11,25 The larger savings will be from drastically limiting new technology introduction and better, more costeffective use of the technologies in play now. The developing controversy over robotically assisted surgery is an example.26 Another example is coronary artery bypass graft (CABG), where despite the dramatic improvements in mortality outcomes for CABG over the past 2 decades, risk-adjusted mortality has remained at 1.8%-2.0% for the last 3 years nationally. Assessing CABG from a different, nonhistorical perspective, as has been done with percutaneous coronary intervention, might create the paradigm shift to continue improvements in mortality.27,28 Despite the randomized trial-documented late mortality benefits of CABG vs percutaneous coronary intervention in a multivessel disease, the lack of long-term financial data to accompany these outcomes data are limiting. This is particularly true because periprocedural complication rates have not decreased, and thus the cost of a perioperative CABG episode of care has remained stagnant. As has been argued by the STS and the ACC, these limitations can be better addressed through novel scientific collaboration and evaluation, rather than through regulatory practices both at the local and at the national level. As cardiothoracic specialists and as cardiovascular medicine providers, we should challenge ourselves to objectively and effectively address these issues.
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
283
THE AFFORDABLE CARE ACT The effectiveness mechanism in this title has equally important implications. The ACA incentivizes the structural reorganization of health care delivery through accountable care organizations (ACOs) and a much greater emphasis on the primary care medical home as the driver for health care utilization. Currently, more than 250 organizations are participating in Medicare ACOs, serving approximately 4 million (8%) of Medicare beneficiaries.11 ACOs are expected to save up to $940 million in the first 4 years. ACOs are encouraging providers to invest in redesigning care for higher quality and more efficient service delivery.29 The role of medical specialists in ACOs, and cardiovascular providers in particular, is still being evaluated. ACOs are initially interested in providers who treat recurrent conditions because these patients provide the opportunity for the ACOs to reduce expenses.30 As ACOs manage the continuum of a patient's care across different delivery settings (inpatient, outpatient, and home care) and facility structures (hospital, outpatient, local and regional clinics, and home), selected specialists will be included to provide services, in many circumstances without much leverage or ability to partake in shared savings. Having quality and cost information will be critical in the future for specialists groups, who may find themselves competing with each other for inclusion in dominant ACOs in their geographic area. With respect to primary care, the American College of Physicians has recently outlined their somewhat narrow perspective of health care professional collaboration going forward.31 Through this and other mechanisms, the ACA intends to transition much of the direction of care for the major long-term conditions of patients toward prevention and toward management from specialists to the Medical Home context.32,33 The effect on specialty care has already begun. The Sustainable Growth Rate stopgap legislation from 2012 increased primary care reimbursement by reducing payments to specialty care providers. Controversy exists as to whether primary care or cardiovascular medicine providers are best qualified to manage patients with existing cardiovascular conditions, such as ischemic heart disease and heart failure.34 The largest opportunity for specialists may be to integrate themselves (so the primary care medical home does not have to do this), and then to provide the knowledge and educational opportunities to the medical home and their shared patients. The final consequence of Title III will be much closer collaboration with other providers. The relative isolationism of cardiac surgeons compared with thoracic surgeons and many other providers has been positively affected by the Heart Team developments of the past few years, most notably by placing
284
the patient at the center of the delivery process. This patient-centered approach is the core of the Best Care at Lower Cost IOM report, which is increasingly recognized as the road map for achieving an ideal health paradigm based on continuous learning.16 Across the broad continuum of care in cardiovascular disease (ischemic heart disease, structural heart disease, and electrophysiology), the academic, administrative, and financial integration of cardiovascular providers engaged in this patient-centered care will have the greatest opportunity to reengineer care to improve quality and lower costs and meet one of the primary expected outcomes of the ACA. TITLE IV: PREVENTION OF CHRONIC DISEASE AND THE IMPROVEMENT OF PUBLIC HEALTH Title IV is the most ambitious law ever passed to promote healthier lifestyles for all Americans and to prevent disease and disability. Evidence-based clinical preventive services will be provided in most public and private health insurance policies without cost sharing. A National Prevention, Health Promotion, and Public Health Council will devise a national prevention strategy, backed up by a $13 billion trust fund. For cardiothoracic surgeons, despite being proceduralists, they must engage in this prevention process with data and education and research efforts to ensure that the demonstrated benefit of multivessel CABG remains a long-term superior outcome in the setting of stable ischemic heart disease, or that lung cancer resection is the most effective therapy for certain types of accurately staged lung cancer. TITLE V: HEALTH CARE WORKFORCE This title establishes a National Health Care Workforce Commission to analyze and plan for workforce needs and to make recommendations to the Congress and the administration. The workforce issues in cardiothoracic surgery have been effectively presented to the government entities, and hopefully, some, if not all, of the solutions proposed will be enacted to assure a sufficient number of cardiac and thoracic surgeons in the future.35 This is among the provisions of the ACA that have not been funded. The members of the Commission have been empaneled but, without appropriated funds, they are unable to convene. TITLE VI: TRANSPARENCY AND PROGRAM INTEGRITY The Best Care at Lower Cost report from the IOM estimated that as much as one-third of the $2.7 trillion spent on health care in 2011 was wasted
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
THE AFFORDABLE CARE ACT through inefficient, unnecessary, or illegal spending.16,36 Title VI provides new authority to federal and state agencies to combat fraud and abuse in US health care. The Physician Payments Sunshine Provision requires drug companies and medical suppliers to report most gifts and other gratuities to physicians for public release on a federal Web site.37 The Patient-Centered Outcomes Research Institute is supporting research on comparative clinical effectiveness. At both an individual and specialty society level, these developments will variably have an influence on cardiothoracic surgical providers. TITLE VII: IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES This title directs the US Food and Drug Administration to develop new regulatory pathways to permit the development, manufacture, marketing, and sale of innovative medical therapies. Engagement in this process is critical for cardiovascular medicine. Perhaps the greatest opportunity would be establishing “just-in-time” clinical research based on the ACC NCDR and STS National Database. The recent Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia trial has clearly illustrated the exciting opportunities for “registrybased randomized trials.”38 Although this will require some reengineering of the infrastructure of the NCDR and the STS National Database, the opportunity for partnership with industry for new technology evaluation, reduction in trial costs, and collaboration with the new Food and Drug Administration regulatory pathways is paradigm shifting. This approach would also leverage the unprecedented commitment to clinical data that has been made by the cardiovascular specialty society community and provide considerable value added to ongoing investments in these data. TITLE VIII: COMMUNITY LIVING ASSISTANCE SUPPORTS AND SERVICES The Obama administration announced on October 15, 2013 that it was abandoning plans for Community Living Assistance Supports and Services. Congress is expected to quickly draft legislation to repeal the provisions of this title. TITLE IX: REVENUE PROVISIONS This section covers the financing for slightly less than half the cost of the ACA. Key provisions establish new Medicare taxes on high-income wage earners, as well as new taxes on pharmaceutical manufacturers, health insurance providers, and medical device manufacturers.
TITLE X: STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS The final title in the ACA is the “Manager's Amendment,” which includes amendments and additions to Titles I-IX, reflecting the unusual legislative process leading to passage of the ACA. These changes were approved in a separate measure called the Health Care and Education Reconciliation Act signed into law by President Obama on March 30, 2010. COMMENT The ACA remains very much a work in progress. Concomitant with the current rollout, the Senate Finance Committee and the House Ways and Means Committee have drafted a bicameral, bipartisan bill to collaboratively address the Sustainable Growth Rate debacle. Both the STS and the ACC Washington offices have worked tirelessly with the staff of these congressional Committees, and because of the leadership demonstrated by both the organizations in clinical data and quality improvement, their collective influence on the proposed legislation has been substantial. However, there remains much work to be done.39 Burke and Kamarck40 of Brookings have authored a useful User's Guide to Implementation of the ACA. It is an excellent overview, and the benchmarks proposed, although mostly market driven, are important for the cardiovascular community to monitor, both locally and nationally, as we continue to address the unique attributes and resources that we collaboratively bring to our nation's health care. SUMMARY STATEMENT The ACA is transforming medicine in the United States, even as it is a work in design and progress. In all its iterations, it will have a specific and perhaps profound effect on cardiovascular providers, because of both therapeutic procedural specialists and the enormous cost of cardiovascular care overall. Making sure that our strengths and unique resources are incorporated into these iterations will necessitate a thorough understanding of the legislation and its consequences on our specialty. ACKNOWLEDGMENT We would like to express our deep gratitude to Cortney Yohe, MPP, Assistant Director of Government Relations, Society of Thoracic Surgeons. Our multiple conversations have provided navigation for the STS-American Association for Thoracic Surgery Workforce on Health Policy, Reform, and Advocacy and for a number of concepts in this article.
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
285
THE AFFORDABLE CARE ACT 1. Kaiser Family Foundation. Available at: http:// www.kkf.org. Accessed November 10, 2013. 2. Naunheim K: Forth-ninth Annual Meeting of the Society of Thoracic Surgeons: Report from the STS Board of Directors. Ann Thorac Surg 96:361-374, 2013 3. McDonough JE: Inside National Health Reform. UC/Milbank Books on Health and the Public. September, 2011. 4. Shatto JF, Clemens MK: Projected Medicare expenditures under an illustrative scenario with alternative payment updates to Medicare providers. Memorandum from the Centers for Medicare and Medicaid Services. Office of the Actuary. May 13, 2011. 5. Lee JL, Maciejewski ML, Raju SS, et al: Valuebased Insurance Design: Quality improvement but no cost savings. Health Affairs 32(7): 1251-1257, 2013 6. Eddy DM, Shah RA: Simulation shows limited savings from meeting quality targets under the Medicare Shared Savings Program. Health Affairs 31(11):2554-2562, 2012 7. O’Malley AS, Bond AM, Berenson RA: Hospital Employment of Physicians: Better Quality, Higher Costs? Issue BriefWashington, DC: Center for Studying Health System Change; 2011 8. Mullin J: Which states will have the biggest coverage gaps next year? Available at: http:// www.advisory.com/Daily-Briefing/2013/10/21. Accessed November 10, 2013. 9. Mullin J: For states not expanding Medicaid, DSH cuts will deal a tough blow. Available at: http://www.advisory.com/Daily-Briefing/2013/ 9/23. Accessed November 8, 2013. 10. Williams JB, DeLong ER, Peterson ED, et al: Secondary prevention after coronary artery bypass graft surgery: Findings of a National Randomized Controlled Trial and Sustained Society-Led Incorporation Into Practice. Circulation 123(1):39-45, 2011 11. Topol EJ, Sebelius K: Topol asks Sebelius 5 ACA Questions. Medscape, June 27, 2013. 12. Friedman TL: Obamacare's other surprise. The New York Times, May 25, 2013. Available at: http://www.nytimes.com/2013/05/26/opinion/ sunday/friedman-obamacares-other-surprise. html?r=2&. Accessed November 9, 2013. 13. Ferguson Jr. TB, Peterson ED, Coombs LP, et al: Use of continuous quality improvement to increase utilization of preoperative betablockade and internal mammary artery grafting in patients undergoing coronary artery bypass surgery: A National Randomized Controlled Trial. J Am Med Assoc 290:49-56, 2003 14. Spier AM, Karirajan V, Barnett SD, et al: Additive costs of postoperative complications for isolated coronary artery bypass grafting in
286
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
patients in Virginia. Ann Thorac Surg 88: 40-46, 2009 Aldea GS, Mokadam NA, Melford R, et al: Changing volumes, risk profiles and outcomes of coronary artery bypass grafting and percutaneous coronary interventions. Ann Thorac Surg 87:1828-1838, 2009 Institute of Medicine (IOM). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2012 McKinsey Global Institute. Accounting for the cost of US health care: A new look at why Americans spend more. New York, McKinsey and Company, 2008. MedPAC. Report to the Congress: Medicare Payment Policy. Chapter 1: Context for Medicare payment policy, 2012. Cutler DM, McClellan M: Is technological change in medicine worth it? Health Affairs 20(5):11-29, 2001 Mandrola J: Progress in cardiology? A sobering second look. Comnmet on Lee T: Eugene Braunwald and the rise of modern medicine. Medscape, Oct 30, 2013. CDC. Heart Disease and Stroke Prevention: Addressing the Nation's Leading Killers. At a Glance, 2011. Available at: http://www.cdc. gov/dhdsp. Accessed November 11, 2013. Keehan SP, Cuckler GA, Sisko AM, et al: National Health Expenditure Projections: Modest annual growth until coverage expands and economic growth accelerates. Health Affairs 31 (7):1600-1612, 2012 Keehan SP, Sisko AM, Truffler CJ, et al: National health spending projections through 2020: Economic recovery and reform drive faster spending growth. Health Affairs 30(8): 1594-1605, 2011 Basoor A, Cotant J, Patel K, et al: Decreased readmissions and improved quality of care with use of inexpensive checklist in heart failure. J Am Coll Cardiol 59:E1026, http://dx.doi.org/ 10.1016/S0735-1097(12)61027-4 Martin AB, Lassman D, Washington B, et al: Growth in US health spending remained slow in 2010: Health share of gross domestic product was unchanged from 2009. Health Affairs 31(1):208-219, 2012 Burton TM: Report raises concerns on robotic surgery device, 2013. Available at: http:// online.wsj.com/news/articles/SB100014240527 02304672404579186190568061568. Accessed November 11, 2013. Pijls NH, et al: Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (Fractional Flow Reserve Versus
28.
29.
30.
31.
32.
33.
34. 35.
36.
37.
38.
39.
40.
Angiography for Multivessel Evaluation) study. J Am Coll Cardiol 56(3):177-184, 2010 Ferguson TB, Babb CC, Efird JD: FFR-guided CABG: Can intra-operative physiologic imaging guide the decision making? J Thorac Cardiovasc Surg 146:824-835, 2013 Yox SB: Implementing the Affordable Care Act —What clinicians should expect. Medscape. Sept 27, 2013. Page L: 8 ways the ACA could affect your ophthalmology practice. What the ACA means to ophthalmologists. Medscape Sep 11, 2013. Doherty RB, Crowley RA, for the Health and Public Policy Committee of the American College of Physicians. Principles supporting dynamic clinical care teams: An American College of Physicians position paper. Ann Intern Med [Epub ahead of print] Auerbach DI, Chen PG, Friedberg MW, et al: Nurse-managed health centers and patientcentered medical homes could mitigate expected primary care physician shortage. Health Affairs 32(11):1933-1941, 2013 (et al) Frellick M: Emerging care models may east primary care doc shortage. Medscape, Nov 08, 2013. DeMaria AN: The primary care cardiologist. J Am Coll Cardiol 58:881-882, 2011 Shemin RJ, Ikonomidis JS: Thoracic surgery workforce: Report of STS/AATS Thoracic Surgery Practice and Access Task Force—Snapshot 2010. Ann Thorac Surg 93:348-355, 2012 Solomon MZ, Bohham A, (eds): Ethical oversight of Learning Health Care Systems. Hasting Center Report Special Report 43, No 1, 2013. doi:10.1002/hast.132. The Physician Payments Sunshine Act. CMS. Open Payments. Available at: http://www.cms. gov/Regulations-and-Guidance/Legislation/ National-Physician-Payment-Transparency-Pro gram/index.html. Accessed August 1, 2013. Forbert O, Lagerqvist B, Olivecrona GK, et al: Thrombus aspiration during ST-segment elevation myocardial infarction. New Engl J Med 369:1587-1597, 2013 Klar R: Medicare physician payment reform: An analysis of the New Congressional Proposal. Available at: http://healthaffairs.org/blog/2013/ 11/08/medicare-physician-payment-reform-a n-analysis-of-the-new-congressional-proposal/? utm_source=rss&utm_medium=rss&utm_ campaign=medicare-physician-payment-refor m-an-analysis-of-the-new-congressional-pro posal. Accessed November 9, 2013. Burke S, Kamarck E: The Affordable Care Act: A user's guide to implementation. Available at: http://www.brookings.edu/search?start=1&q= Burke. Accessed November 10, 2013.
Seminars in Thoracic and Cardiovascular Surgery Volume 25, Number 4
