The Patient Protection and Affordable Care Act: What s working, what s needed, what next?

Transcription

1 The Patient Protection and Affordable Care Act: What s working, what s needed, what next? Carol J Peden MB ChB, MD, FRCA, FFICM, FFMLM, MPH Professor of Anesthesiology Executive Director of Center for Health System Innovation Keck Medicine of USC carol.peden@med.usc.edu

2 The image part with relationship ID rid2 was not found in the file. Declaration Carol Peden is an IHI Fellow and works with IHI as Faculty on their US and International Programs

3 Boston 2008/9...

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5 The image part with relationship ID rid2 was not found in the file. The ACA at 5 years. NEJM 2015;372:25 Blumenthal et al Adequacy of access The image part with relationship ID rid3 was not found in the file. Increased access from 2010 between M people Young adults, Hispanics and Blacks have made greatest gains Expansion of Medicaid- additional 10.8M enrolled 8-12 M benefiting from prevention of discrimination Some constraint on provider networks NEJM 2015;372:25 Blumenthal et al

6 The image part with relationship ID rid3 was not found in the file. Both the private option and traditional medical expansions improved access to care for low income adults adapted from Sommers, Blendon and Orav. Health Affairs Jan /19/2016

7 The image part with relationship ID rid2 was not found in the file. ACA and Healthcare delivery? Too many initial initiatives lacking a clear strategy Changes in the way the government pays for health care Move from volume to quality e.g. readmission penalties Incentives to make care safer and improve performance Bundled payments Changes in the organization of health care delivery Changes in workforce policy Changes intended to make government more nimble and innovative in pursuing future health care reforms. NEJM 2015;372:25 Blumenthal et al

8 The image part with relationship ID rid2 was not found in the file. Workforce Policy Increase the attractiveness of primary care as a career National Health Service Corps but no workforce commission Make Government more nimble Government now pays for 43% of healthcare Created Center for Medicare and Medicaid Innovation (CMMI) Funded to improve quality and reduce cost at 1B per year for 10 years E.g. Partnership for patients Can spread success rapidly

9 The image part with relationship ID rid2 was not found in the file. The image part with relationship ID rid3 was not found in the file. 5 years on has it worked? Considerable improvement in access Reduced trajectory of spending Reduced harm Impact of greater legislation? 11

10 From The Affordable Care Act and the US Economy: a 5 year perspective wealthfund.org

11 The image part with relationship ID rid2 was not found in the file. Reductions in harm first ever! NEJM 2015;372:25 Blumenthal et al

12 The image part with relationship ID rid2 was not found in the file. Affordability Slightly fewer Americans reporting financial barriers to seeking healthcare and problems with bills But there is a lot still to do..

13 /fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf

14 The image part with relationship ID rid2 was not found in the file. RANK THESE HEALTH CARE SYSTEMS ON OVERALL PERFORMANCE

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19 Mortality Trends Among Working-Age Whites: The Untold Story. Squires D, Blumenthal D. The Commonwealth Fund Jan 29th 2016 The image part with relationship ID rid2 was not found in the file. 21

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21 The image part with relationship ID rid2 was not found in the file. Current and developing opportunities Triple Aim

22 The image part with relationship ID rid2 was not found in the file. The Triple Aim and the ACA Expansion of health care insurance Reforms of healthcare delivery The ACA is judged on 3 critical dimensions Adequacy of access Cost of care- for the individual and the nation Quality of care

23 What has been different about the US? Lack of Universal health care coverage- until recently Administrative challenges for physicians Administrative challenges for patients Slow implementation of Health IT Low investment in population health What could the US adopt from other countries Public reporting of quality Payment systems that reward quality of care Team approach to chronic condition management

24 What are the top 3 challenges affecting all health care systems? 1. Shifts in population demographics and social characteristics 2. Balance between containing costs while maintaining access and quality 3. Fragmented healthcare delivery models

25 KPMG report (Britnell) Davos of resources Looked at 60 systems for worst and best value healthcare Features of high performing value systems Strong primary care system Use of technology High specialization in some areas and an intolerance of waste High spenders misallocation of resources

26 What is high value healthcare? (1) Don Berwick (2008) describes the Triple Aim for the US health care system Health Improve the health status of a whole community Improve the experience of care for an individual Care Cost Reduce the cost of healthcare expenditure

27 What is high value healthcare? (2) Michael Porter (2010) : Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent. BUT: patients only what about people not yet or not able to access care? he emphasises the full cost of the medical condition and not individual services he emphasises outcomes rather than volume and describes them as multidimensional and condition specific Porter. What is value in healthcare? NEJM 2010;363:

28 In Summary - the ACA Improvement in access, cost and reduction in harm Potential challenges: Care of the whole person Designing care around the patient Knitting together a fragmented system Challenging the paradigms Using resources differently and innovatively

29 "This is not the end, it is not even the beginning of the end, but it is perhaps the end of the beginning."