EXECUTIVE SUMMARY

The Affordable Care Act likely will be repealed, at least in part, with the new presidential administration. Case management experts suggest what might change from a case management and population health perspective and what might remain the same.

  • The industry probably will continue to move toward population health models.
  • The Centers for Medicare & Medicaid Services’ Innovation Center could lose funding for alternative payment model projects.
  • Despite lack of funding, fee-for-service will continue to be phased out.

More than 60 times, the U.S. House of Representatives voted, fruitlessly, to repeal all or part of the 2010 Patient Protection and Affordable Care Act (ACA). As of Jan. 20, 2017, when Donald Trump is inaugurated as the 45th president and a new Republican Congress and Senate take office, it appears likely they’ll finally succeed.

Case Management Advisor asked healthcare and case management experts to predict how a rescinded or partially repealed ACA might affect the current trend toward population health, care coordination, and enhanced need for case management.

The concept of population health began before the ACA and likely will continue after it, says Kathleen Fraser, RN-BC, MSN, MHA, CCM, CRRN, executive director of the Case Management Society of America in Little Rock, AR.

“Companies have learned the importance of population health and all aspects of preventive care,” Fraser says. “Case management used to be the best-kept secret, and the ACA helped it come onto the frontlines of notoriety.”

Medicare Programs on the Line

Whether population health and care coordination initiatives continue to receive even pilot program funding, some funding for Medicare, Medicaid, or private insurance patients is another matter. The ACA established the Innovation Center of the Centers for Medicare & Medicaid Services (CMS). Its purpose is to test innovative payment and service delivery models to reduce program expenditures — all while preserving or enhancing care quality.

For example, one of the newest Innovation Center models is the Comprehensive Primary Care Plus medical home model, a five-year model that is set to begin in January 2017. Its chief primary care goals are centered around case management-type services, including continuity of care, care management, care coordination, patient engagement, and population health.

The national model includes two primary care practice tracks and has three performance-based payment elements. It gives practices the financial resources and flexibility to improve care efficiency and reduce unnecessary healthcare utilization. It will bring together CMS, commercial insurance plans, and state Medicaid agencies.

But like the other ongoing Innovation Center projects, funding for this could disappear with the repeal of the ACA. If that happens, health systems lose financial help and incentives to make population health efforts work.

If health systems do not see where the reimbursement will be, it’s possible they’ll lay off case managers, says Connie Sunderhaus, RN-BC, CCM, vice president of CXJ Corporation in Glen Ellyn, IL.

“Will they stop reimbursing for preventive care? Who knows?” Sunderhaus says. “Fee-for-service is one of those things that Medicare has been trying to get away from, and it may not have to do with the ACA.”

Fraser says the Innovation Center might be rebranded, but might not disappear entirely.

“It is CMS that is working with it and involving case management,” she says.

Also, case managers, whether they’re called patient navigators or care coordinators — or, simply, nurses — will continue to play a role in the evolving healthcare landscape, Fraser says.

Case Management in the Spotlight

The Affordable Care Act shined a light on case management, showing the public what case managers can do, and Fraser says she is confident that case management will stay on the forefront of the minds of Congress as they restructure healthcare.

Others agree that it is very unlikely the insurance and healthcare industry will reverse course and return entirely to fee-for-service.

“Our economic system will just not sustain that, and the average Joe in America will not be able to afford the premiums, which they can barely afford now,” says Chriss Wheeler, RN, MSN, CCM, partner at Innovation Care Consultants in Independence, MO. Wheeler and Sunderhaus have spoken at national conferences about case management and public policy.

“I don’t have a glass ball to tell how much of the ACA they’ll throw out and how much they’ll keep, but I think there will be enough data to show that these initiatives have had a [positive] impact on the quality of care,” Wheeler says.

The entire healthcare industry rapidly evolved with the ACA implementation, and common sense suggests that the system could not handle a complete reversal, Wheeler says. “It would just be chaos.”

So what parts of the ACA might continue? Fraser, Wheeler, and others suggest that provisions that protect people with pre-existing conditions and those that allow adult children under age 26 to be on their parents’ health insurance might be retained.

“What I’ve heard is they would keep the aspect where young adults can be on their parents’ insurance until age 26, and that’s been so positive,” Fraser says. “Personally, I have a daughter who graduated from college and needed to waitress and sub-teach for a year before getting a full-time job.”

Young adults like Fraser’s daughter have benefited from that ACA provision. “I think that was a wonderful part of the ACA, and from what everyone has heard, the future President Trump said he’d keep that,” Fraser says.

Predicting how the ACA might change is trickier. “I think we’re all wondering what those changes might be,” says Cheri Lattimer, RN, BSN, government affairs specialist for CMSA.

“I’ve been in healthcare for over 50 years, and I’ve seen change after change,” Lattimer says. “It’s just too bad that we’re constantly in this flux of change, and that it’s always a huge pendulum swing rather than looking at what we can learn from [evidence-driven data] to make it better.”

Will Value-based Purchasing Survive?

The future focus likely will continue to be on improving quality through value-based healthcare. This includes better communication and engagement with patients through case management, Lattimer adds. (See story in this issue about the future of case management lobbying.)

There’s even a possibility that the demise of the ACA will upend the private healthcare insurance market and eventually lead to a single-payer system, says Joseph Feinglass, PhD, a research professor of medicine in the division of general internal medicine and geriatrics at Northwestern University Feinberg School of Medicine in Chicago. (See story in this issue about Feinglass’ study about ACA reducing uninsured ER visits.)

“The big issue in healthcare is that the insurance industry is based on skimming off low-risk patients, and that’s how you make money,” Feinglass says. “Insurance is driven by the ability to get rid of higher-risk patients and dumping them somewhere else.”

The medical industrial complex has been pushed in the direction of a high-tech medicine intervention for the very sick who have insurance or Medicare, making its money that way, he explains.

“I don’t see that changing in a Trump administration,” Feinglass says.

The ACA and population health measures have pushed providers — through case management — to focus on the social determinants of health, he says.

“The ACA has many provisions that people don’t know about that are in that vein of prevention and public health, all funded in the direction of population health, and I don’t see that funding continuing as much [under a Trump administration],” Feinglass says. “I expect the worst.”

From Wheeler’s perspective, it’s difficult to imagine how the government and health systems will handle all of the people with chronic and/or catastrophic illnesses who were uninsured before the ACA and still need extensive health services. “I don’t know how you fix that problem other than through case management, which is one of those ways we know has a positive impact on the economics of healthcare,” she says.

Some say it’s questionable that the value-based healthcare initiatives, involving care coordination and promoted through the ACA and Medicare, would be completely abandoned.

“Care coordination at some level in population health is going to contribute to payment and reimbursement,” Sunderhaus says.

‘They Can’t Pull the Plug on the Whole Thing’

One of the Affordable Care Act’s positive attributes was its focus on preventive care through funding incentives. One of the ACA’s goals was to prevent people from using the ED as their family doctor, Sunderhaus says.

For example, Medicare’s quality initiatives that involve 30-day readmissions had several years to become ingrained. Health systems developed care coordination and case management services based on Medicare’s financial incentives to keep people from returning to the hospital. It’s hard to imagine these initiatives being reversed, Sunderhaus says.

“They can’t pull the plug on the whole thing,” Sunderhaus says. “Care coordination is mentioned in the ACA several times, so whether it will stop, who knows? Will they stop reimbursing for preventive care, who knows?”

If legislators look at data, they’ll see that case management benefits patients and helps reduce healthcare costs in the long term, Wheeler says.

“Case management has a proven track record,” Wheeler says. “Their focus is around that triple aim of quality, cost effectiveness, and patient satisfaction.”

Around 80% of healthcare dollars go to medical care for people in the last 30 days of life, Wheeler notes.

“That’s where my mother would say Obamacare is going to have a death panel, but it’s a societal thing where we have to acknowledge that we’re born and at some point we’re going to die,” she adds.