PPACA’s impact on future health care delivery systems
The new legislation1 does attempt to stimulate health care innovation in order to absorb the impact of the expansion of coverage and shifts in funding. PPACA contains provisions for hospitals to receive federal incentive payments for "meaningful use" of Health Information Technology and hospitals are embracing electronic medical records systems and e-prescribing.1 However, the costs of these technological transitions are substantial and may not be affordable for small group practices or for AMCs stressed by the developments described above. These costs could force physicians into employment within large group practices or financially secure hospital systems. AMCs that lack the necessary finances will be placed at a competitive disadvantage as they will not be able to compete for new government funding based on meaningful use of health information technology. These AMCs will also be poorly placed to take advantage of new revenues from clinical research that will be built around the ready accessibility of clinical outcomes data. They will be further financially disadvantaged based on their inability to collect the required quality data that will determine a significant component of their reimbursement under PPACA.
PPACA establishes the Medicare Shared Saving Program (MSSP) for Accountable Care Organizations (ACOs), an approach that many AMCs will undoubtedly attempt to pursue.1 The stated goal of MSSP is to achieve better care for individuals, better health for populations, and slower growth in costs through improvements in care. An ACO must assume responsibility for the care of a clearly defined population of Medicare beneficiaries and if it succeeds in delivering high-quality care while reducing costs, it will share in the cost savings with Medicare. However the ACO will receive less monies than it would have under the old fee-for-service reimbursement. If the ACO saved 10% of the prior year’s cost of caring for this defined population, it would only receive a proportion of the savings as a bonus at the end of the year and would in reality experience a reduction relative to the reimbursement it received in the prior year. AMCs will be forced to decide whether assuming financial risk if they do not reduce costs is a financially viable option for them. The cultural barriers inherent within AMCs that will have to be overcome if the AMC is to provide high-quality patient-focused care while assuming financial risk are substantial.1 One fear is that government and private payers will shift the financial risk of taking care of the sickest and most expensive patients to ACOs.
The American Hospital Association estimates1 that it would cost between $11.6 million and $26.1 million to build the ACO infrastructure and run it for the first year. In contrast, CMS estimated these costs to be only $1.8 million. CMS’ ACO proposal is based on the results of a demonstration project1 in which the participating organizations were predominantly large medical centers with well established infrastructures. Despite this, only half of the participants were able to share in the financial incentives under MSSP. Furthermore, none of the participants were able to recoup their initial investment by the third year. CMS\' proposal appears to transfer too much risk to the ACO relative to the potential rewards, and CMS may need to consider providing capital to fund the infrastructure required to establish physician- or hospital-led ACOs. However, this seems unlikely given the level of the national debt and the current era of national austerity.
In contrast to these concerns, Berkowitz and Miller3 see PPACA as an opportunity for AMCs "to modernize their approaches to research, education, and care." They believe AMCs are "well positioned to spearhead efforts to develop, pilot, and disseminate new patient-focused measures and models of care." They point to new sources of funding that PPACA brings within the Patient-Centered Outcomes Research Institute ($500 million in research funding annually by 2015) and the Center for Medicare and Medicaid Innovation with $10 billion to spend over 10 years to support innovation grants to develop new care delivery models. However, the authors3 also stress that each AMC will have to assess whether it is positioned to assume the financial risk associated with becoming an ACO. They emphasize that AMCs will have to abandon departmentally based care in favor of multidisciplinary centers to promote patient-centered care. In addition, they believe AMCs’ promotion and tenure system will need to change so that it appropriately recognizes faculty’s contributions to high-quality, cost-effective patient care.
PPACA’s impact on subspecialists
A recently released federal report4 demonstrates that 1% of Americans accounted for 22% of all health care costs in 2009. The average cost of care of these individuals was $90,000 per person that year according to the Agency for Healthcare Research and Quality. Furthermore, just 5% of Americans account for 50% of all health care costs in 2009 or about $36,000 each. The monumental challenge for the nation is to stop the steady rise in health care costs by providing good quality health care for all Americans at an average cost of $10,000 per person per year for a total of approximately $3 trillion a year in national health care expenditures. We would argue that this goal can only be achieved by controlling the costs associated with the care of these very complex patients and that this will necessitate involvement and even a primary role for subspecialists. Furthermore, the profession and the nation must address the ethical issue of futile interventions which inappropriately prolong the process of dying, denying patients the right to a dignified death when such an end is inevitable.
