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Health system reform moves forward despite controversy and legal challenge

This article first appeared in the St. Louis Beacin, Dec. 8, 2011 - The federal government's decision to open access to Medicare data so groups can compare practice patterns of doctors and hospitals is the latest indication that certain major health reforms will move forward no matter how the Supreme Court rules on the Affordable Care Act.

The recent decision on Medicare data is welcomed by members of the St. Louis Area Business Health Coalition, a group of more than 40 local employers. In a report issued earlier this year, it called once more for giving consumers more access to health-care information that can help them "make informed choices about treatments and providers."

The federal government is doing just that. Opening the vault to its Medicare data will allow data compilers to identify high quality health care providers and set up online sites to help consumers make informed health care choices.

"This is a giant step forward in making our health care system more transparent and promoting increased competition, accountability, quality and lower costs," says Marilyn Tavenner, acting administrator of the Center for Medicare and Medicaid Services or CMS.

While portions of the health reform law are controversial, and under legal challenge, such as the requirement that people pay a penalty if they refuse to buy health insurance, the Obama administration has used rulemaking and federal funding to move ahead on major health care changes. Among other things, the administration has:

  • Required hospitals and doctors to meet certain quality measures connected with what's known as value-based purchasing in caring for patients. Hospitals that don't improve certain quality health indicators will face financial penalties.
  • Embraced the medical home model of care through which teams of providers work to better coordinate and improve a patient's care in and out of the hospital.
  • Used part of the money from the federal stimulus package to jump start the shift to electronic health records. Electronic records can help providers avoid medical errors and unnecessary duplication of medical tests and services.

Parts Make Up the Whole

The reform law and other health care changes hold lots of potential, says Susan Kendig, a nurse practitioner and professor of nursing at the University of Missouri-St. Louis. She says the public may not have been paying attention to the potential that the reforms hold for shared savings.

Providers could join an accountable care organization (ACO) and see their pay increase for keeping patients well. This system differs from the old model of reimbursement, which was based on the number of patients treated and the services provided. The accountale care idea has gained momentum among private payers as well as government. People are embracing some variation of the ACO model, Kendig says, because they want better quality and lower health care bills.

"I think that because sometimes people only hear sound bites that can be skewed one way or another, we may not recognize some of the power that is in the health care law if we can actually get all these parts working together," she says.

She believes certain portions of the Affordable Care Act will survive regardless of the Supreme Court ruling.

"Provisions for shared savings and quality have taken on a life of their own and will probably stand because nobody is fighting about them," Kendig says.

Even before the government decided to make Medicare data available, it had begun to require hospitals to be graded on the basis of consumer benchmarks that include patient satisfaction and quality outcomes. Hospitals with unacceptably high hospital-acquired infections, for example, will now lose 1 percent of their Medicare reimbursement. The amount of denied reimbursements grows over time unless the hospital improves its performance.

"This is spurring hospitals and physicians to work more closely together to achieve those (quality) outcomes," says Dixie Platt, senior vice president at SSM Health Care.

She says the trend toward tying payments to outcomes will continue even if the Supreme Court declares that the controversial individual mandate is ruled unconstitutional. She predicts that value-based purchasing of health care services will become the norm. This means reimbursements will be based on high-quality clinical, safety and patient satisfaction indicators. Some of these are simple, such as whether the patient got an aspirin within a certain time period after being seen for a potential heart attack. Others are more complicated, such as reducing hospital-borne infections.

"Continuum of Care"

Dr. Kevin Johnson is regional vice president at SSM Health Care-St. Louis. Johnson, says the health system is breaking down what he calls silos of care in which various providers -- hospitals, doctors, nursing homes and home health workers -- have focused only on their part of the patient's recovery. The new rules, focusing on quality outcomes, will force providers to open their silos and communicate with each other. This shift will require additional workers, says Johnson. For example, a case manager or transitional care coordinator could be hired to track and follow high risk patients as they move through the health care system.

"As health care becomes more integrated across the continuum of care, there is an opportunity to reduce cost," he says. "We can reduce the readmission rate and do a better job keeping people well so they don't end up in hospitals."

Louise Probst, executive director of the St. Louis Area Business Health Coalition, says reforms outside of the Affordable Care Act are moving forward because "there is a widespread understanding that the way we pay for health care needs to be changed. On the delivery system side, Health and Human Services has really moved forward with things they have thought about doing for a long time. CMS has been making rapid changes."

She says that, in addition to helping people stay well, the reforms will help to "free up some of the resources going into health care and allow investments in other areas of our economy that are desperately needed for job growth. We have to make that happen. Whenever it comes, however it comes, it needs to come."

Dave Dillon, spokesperson for the Missouri Hospital Association, says "fundamental change" in the system already is occurring and will continue regardless of what happens to the law.

"If the ACA is ruled unconstitutional in whole, it certainly would cause a shift in policy in various areas," he says. "However, many programs -- including quality improvement and reporting, payment system designs based on collaboration and improved performance and focus on community health -- would probably continue. Many of these issues were field tested in demonstration projects or had already taken hold before the law. They would likely continue or be the focus of new, separate legislation."

Electronic Records Are Coming

Although the shift to electronic medical records is running on a track separate from the Affordable Care Act, the new records system helps fulfill the law's promise of eliminating some of the waste, such as needless medical tests. Some health systems, such as SSM, had begun to shift to electronic records long before the health law took effect.

Platt says SSM is investing at least $350 million in installing electronic health records across all system hospitals and for employed physicians. She adds that stimulus funds are covering about 25 percent of the system's total cost of this investment.

The key groups helping hospitals and doctors make the transition to electronic records are Missouri Health Connection and the Missouri Health Information Technology Assistance Center. Both groups are funded through a stimulus law provision known as the Health Information Technology for Economic and Clinical Health Act or HITECH.

Missouri Health Connection is working with a vendor to set up a statewide electronic medical records system. Mindy Mazur, spokesperson for Missouri Health Connection, says electronic medical records are important for improving the quality and efficiency of health care. "Not surprisingly, the goals of HITECH are very compatible with many of the goals" of the health reform law, she says, adding that Health Connection would still be working to set up the network even if the health reform law didn't exist.

The Missouri Health Information Technology Assistance Center helps physician offices make the transition to electronic medical record systems. Nancie McAnaugh, project director of the center for Health Policy at the University of Missouri in Columbia, says training doctors for the new technology is not dependent on the health reform law.

"I don't think it really matters what happens with the Supreme Court decision," she says. "The horse is sort of out the barn when it comes to physicians transitioning to electronic health records. I think that is going to continue and, in fact, accelerate."

Funding for the Beacon's health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization that aims to improve the health of the people in the communities it serves.

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