Future Challenges in Health Care: Health Policy, Health Care Financing, Access, and Clinical Care Delivery

A number of recent events, including the COVID pandemic and Black Lives Matter movement have raised awareness of health inequities for marginalized populations in this country and, as a result, have altered the course of health care delivery and health care policy. There is now clear direction from the federal government that ensuring high-quality health care for all is a priority. While the focus has increased considerably, the passage of the Patient Protection and Affordable Care Act (ACA), commonly referred to as Obamacare, was in part designed to reduce the number of uninsured in this country. Additionally, the passage of the ACA, and even before that time, the change in payment for clinical services has moved from predominantly a fee-for-service model, in which payment is linked to volume, to an alternative model in which payment is linked to value. This change in philosophy has broad support, including bipartisan support of the legislature as well as support from the private insurance sector as demonstrated by the Health Care Payment Learning & Action Network (HCP-LAN). The HCP-LAN is a group of public and private health care leaders dedicated to accelerating our care system’s adoption of alternative payment models (APMs). These forces will likely have a profound change on health care for the foreseeable future.

A number of changes in access and delivery of care that occurred during the pandemic have identified both challenges and opportunities related to access, care delivery models, financing of care, and medical necessity. An early impact of the pandemic was the abrupt restriction of in-person care delivery and substantial reduction in elective and routine preventive care. Telehealth services escalated and, in response to this change in practice, CMS and most private insurers quickly pivoted and expanded payment for the provision of telehealth visits outside of a very small group of conditions and locations. Despite the increase in telehealth, the lower volume of direct care services seriously compromised the financial underpinnings of most providers for much of 2020. Those providers and patients who were involved in APMs, particularly population health, have appeared to fare better than those in traditional fee-for-service. At the same time, to ensure that these new payment models do not compromise care but actually provide a benefit to patients, it will be important to continue to evaluate the health outcomes observed for patients in each of these models. Reduction and delays in elective surgery also have had important impacts on providers, health systems, and patients. While many providers, especially surgeons, were preparing for an increase in cases to address the backlog created by the pandemic, the magnitude of the increase has not been as dramatic as anticipated as of the time of this writing. This begs the question of whether there is a general overuse of care (including surgery) or whether we will see a progression of disease and worse health outcomes once the true effects of the public health emergency are studied. If health care utilization is reset to a lower level, depending on the clinical implications of these changes, both the financial model and estimated provider needs will be impacted.

In addition to the implications of the pandemic on need for clinical services and the finances of health systems and providers, the transition to value and APMs remains a priority of the Biden Administration. Liz Fowler, the new Director of the Center for Medicare and Medicaid Innovation (CMMI), has already signaled a move toward more mandatory models as opposed to the previous administration’s approach of voluntary models. The impact for anesthesia practices is significant. Surgery has been the area of care in which payment for hospital, provider, and post-acute care can easily be bundled. One key question is when in the course of care the bundled payment models will begin and whether these bundles will start with the surgical procedure or with evaluation of the condition with a percentage conversion to surgery. Even before joining CMS, I had been in conversation with CMMI about development of a bundle related to spine procedures and suggested that they begin with the initiation of back pain. One of the other key issues for any bundled payment model is the need for care coordination. Virtually all insurers are looking to care coordination as a hallmark of value-based care; it is one of the tenets of the CMS Quality Action Plan. To best coordinate care, all patients need to be linked to a primary care provider. Another critical component is communication and interoperability of electronic health systems to facilitate exchange of information between all the providers of a given individual and reduce redundancy. Shared accountability is also an important component of the CMS Quality Action Plan, with the move from MIPS to MIPS value pathways (MVPs). The recent work of ASA and other organizations related to surprise billing could be viewed within this context of coordinated care, since it has impact on the total cost of care. If an individual is cared for by a provider who accepts their insurance, then none of the providers associated with that care should be sending the patient a surprise bill.

Anesthesia practices will also have to assess the impact of a number of issues affecting clinical care, departmental finances, work force needs, equity, and quality. As one example, the financial impact of APMs must be evaluated to clarify the potential upside and downside risk of participating, as do the implications related to surprise billing and, perhaps most important, the impact expansion of Medicaid may have on these financial models. Anesthesia practices must also be aware of and assess the impact of new models of payment and different delivery systems on whether hospitals and ambulatory surgery facilities are able to support the department to ensure call coverage, perioperative management, and other services not compensated by payment for clinical services. The expansion of care outside of the traditional operating suite also leads to significant inefficiencies and financial hardship. As a result, how anesthesiologists change their negotiation strategy with facilities will become paramount. It is my personal belief that we must be willing to fully participate in all aspects of care, including preoperative evaluation and post operative management, as well as accepting downside risk for poor outcomes if we are to share in the upside benefit related to reducing costs of care. While health care is very local and some locations may be able to survive in the traditional model for several years, I believe that there will be increasing pressure to move to value.

A key lesson from the pandemic is the need to be better prepared for the next emergency. Emergency preparedness is a central component of the Conditions of Participation (COP) of all Medicare-certified facilities. Anesthesiologists were a key component in the strategy to provide large-scale critical care services during the public health emergency. One example was the Society of Critical Care Medicine’s model in which intensivists could oversee multiple anesthesiologists who would be on the front lines of respiratory critical care. There were multiple newspaper stories about the risks anesthesiologists were taking at the beginning of the pandemic, including headlines such as “You’re basically right next to the nuclear reactor.” As the country continues to develop plans to address future public crises, we should be at the table and be fully engaged in defining how we can help.

As more and more attention is paid to quality of care, every practice will be required to address historical inequities in access and quality. The pandemic has clearly demonstrated the unequal effect of disease on different populations, especially people of color. We should evaluate the data by race and ethnicity (self-defined) to ensure that we are avoiding structural racism and inequities leading to unequal treatment. As one of many examples, maternal morbidity and mortality have been increasing in recent years with markedly high rates in African Americans. Anesthesiologists should be engaged with their obstetrical colleagues and hospitals in ensuring that proper protocols are in place to prevent complications and ensuring that complications are addressed quickly to avoid severe morbidity and failure to rescue from mortality. Equity and maternal morbidity and mortality are priorities of the Biden-Harris Administration so it is critical that anesthesiologists participate in these discussions and implementation of policies to address inequities and disparities.

Anesthesia had taken a lead in developing qualified registries related to submission of quality measures to the MIPS program. When the MIPS statute (MACRA) was enacted, it was always believed that the program would evolve. While many anesthesiology departments are independent and submit their quality metrics to CMS, others are part of large groups with single tax identification numbers. The future of MIPS is in MVPs, in which individual specialties will create a program of quality measures, quality improvement programs, and total costs of care. ASA is engaged in developing an MVP, which is both exciting and demonstrates leadership.

A major pillar of the CMS Quality Action Plan is behavioral health and substance abuse. The pandemic has further exacerbated the opioid crisis and deaths from overdose. The SUPPORT (Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities) Act (2018) has included a number of provisions regarding evidence-based pain management that are relevant for the anesthesiology community. Anesthesiologists have led in evidence-based pain management, and it will continue to be important to engage with policymakers to continue to develop evidence in this area.

Twenty-four years ago, I was a young health services researcher working with a Professor of Health Policy and Management at Hopkins and we took a trip to CMS to visit with Sean Tunis, a previous CMS Chief Medical Officer. We discussed my concerns about ensuring safety in ambulatory surgery and how we could design a program to monitor safety. Twenty-one years later, a quality metric for ambulatory surgery was included in a CMS program. Engagement with policymakers using evidence, patience, and persistence is critical in the pursuit of patient safety, quality, and value. CMS has recognized the heroic work of the providers during the pandemic and the need to ensure a resilient system post-pandemic. The organization regularly publishes new regulations to oversee quality, safety, and payment for the health care system, and the experience from the pandemic has been helpful in clarifying the goals for the program. My advice to the specialty and each anesthesiologist is to stay engaged not just through advocacy, but by reading and understanding the regulations and providing comment and evidence to help drive policy.