How can we improve the Affordable Care Act?

[Raider5678]

On March 23rd, 2010 the Affordable Care Act passed into law and mostly took effect on January 1st, 2014(the delay mostly due to infrastructure requirements).

Since then it insured on average 11.4 million people in 2017. But it did more than just establish a government insurance program, it also established several independent hospital guidelines, health insurance regulations, and more. However, there are several problems with the ACA that I feel we could improve on.

 

First off, the HACRP, which stands for Hospital-Acquired Condition Reduction Program. It's designed to penalize hospitals scoring in the worst quartile for rates of hospital-acquired conditions outlined by the CMS(Center for Medicare and Medicaid Services). At the moment, we don't have enough information to judge the impact of HACRP on hospital readmission rates, because prior to HACRP taking effect, there was already a 17% decrease. So we don't know if the decrease we're currently seeing, which is following the trend we saw previous, can be accredited to HACRP. What we do know, however, is that the majority of hospitals penalized by HACRP are from lower-income areas, safety net hospitals, and hospitals with the sickest patients based off of case-mix indices. Essentially, hospitals that already have the sickest and poorest patients, received the brunt of all the penalties which include reduced funding. Since having the sicker patients is directly linked with higher readmission rates and patients living in lower income areas also have higher readmission rates, hospitals with either or both of these characteristics received penalties. HACRP didn't account for these direct links to readmission rates, it's currently taking funding away from some of our poorest and neediest hospitals.

While I'm nowhere near well versed on all of HACRP, I do feel this problem should be addressed in the program by either eliminating it all together or changing it so this isn't a problem anymore. The thing is, however, is that I don't know how I'd go about changing it without it resulting in rich hospitals getting more funding. If you remove penalties and simply put in incentives, this is what will happen. If you give incentives to hospitals who do worse, I'm not sure we'd get the desired effect. Thoughts?

 

Secondly, the HRRP has created a similar problem to HACRP. HRRP required CMS to reduce payments to short-term, acute-care hospitals for readmissions within 30 days for specific conditions. However, it didn't account for a hospital's patient characteristics(income, education level, Medicaid status,etc). As a result, the hospitals in the poorest communities with the sickest patients are again taking even more penalties. How can we change HRRP to better reflect the realities that hospitals face without incentivizing hospitals which do worse?

Again, I'm not extremely well versed in HRRP either, so I don't know if there is a specific clause/section we could modify, or if simply eliminating it all together would be better, or replacing. Thoughts?

 

Third, and finally, because I'm running out of time before my next meeting, HVBP , which stands for the Hospital Value-Based Purchasing Program(it should be HVBPP to follow the other programs, but whatever), is different from the other two programs I listed. Unlike the other two, this program incentives hospitals which improve, which is better than simply rewarding hospitals which are already the best(typically the ones in richer areas, etc). However, it hasn't shown any promising change relative to pre-HVBP times for many different conditions. Additionally, it also suffers from the same problem as the other two programs, where poorer communities(or in this case communities which become poorer/have a few hardships) are penalized over communities which are doing well and improving. Additionally, HVBP doesn't properly account for the complexities of many illnesses, and as a result, penalizes physicians which are already treating extremely sick patients. 

For the third and final time as well, I'm not extremely well versed in HVBP, so I don't know what's the best way to improve this program either. Any thoughts on the smartest and most effecient approch to this program as well? Thoughts?

 

 

 

TLDR; How can we improve the Affordable Care Act?

Edited October 29, 2018 by Raider5678

[John Cuthber]

1 hour ago, Raider5678 said:

How can we improve the Affordable Care Act?

Stop pretending that hospitals are like businesses.

Hospitals are not hotels. You choose your hotel, but fate usually chooses your hospital.

So a set of  "league tables" for various measures of "care" (however you measure it) can't influence your decision.
So all they do is- as you say, penalise those who already have the hardest jobs.

Also, make very sure that your "key point indicators" are not driving the wrong behaviour.
For example, if someone is measuring "waiting time" then hospitals will learn to "game" the system.

If "waiting time" stops when they are seen by a nurse, the hospital will hire a nurse to look at patients and then walk away.

 

Obviously, that's not what the medical profession wants,  but it's what the "business" wants.

[Strange]

9 minutes ago, John Cuthber said:

For example, if someone is measuring "waiting time" then hospitals will learn to "game" the system.

If "waiting time" stops when they are seen by a nurse, the hospital will hire a nurse to look at patients and then walk away.

This happened in the UK where some emergency (A&E) departments checked people in at reception as soon as they arrived and then dumped them on trolleys in the corridors. They had to wait just as long, possibly in worse conditions, but it didn't count in the waiting time stats.

Almost any target is liable to be gamed like this. 

[Raider5678]

@John CuthberWhat behaviors would you look for?

[CharonY]

It is important to note that while these are provisions of the ACA, they are not its cornerstone. Rather these are (fairly unique) measures to try to quantify and improve critical aspects of health care (such as infection with antibiotics resistant bacteria, which is an increasing problem even in otherwise excellent hospitals). For the most part the most obvious solution is a fine-grained analysis of why hospitals fail, which includes the mentioned socioeconomic aspects. As such e.g. adjusting ratings against hospital population demographics would be a step in that direction. 

However, in the broadest sense this also shows the incredible disparity in health care we find in the US system. Depending on where you are, the health care can range from world-leading to rather dismal and while the measures may provide information which hospitals provide low quality care and why, it is still under the assumption that free market forces will somehow make them improve. As others have noted this is not really an ideal way to view or manage crucial services.  

How these things can be improved is literally a billion dollar question. In some areas, enforcing best practices to limit infections and fund measures in underfunded hospitals to implement them would be ideal. However, there are also conditions and situations that require more flexibility. From what I have seen there is little agreement among health care professionals what the best measures are (though almost all agree that measures are needed) and how to reach them.

[John Cuthber]

10 minutes ago, Raider5678 said:

@John CuthberWhat behaviors would you look for?

I'd look out for people trying to pretend that a hospital is a business.
It's unfair to judge a book by its cover but- sometimes that's the only option you have.

So, I'd be wary of people talking about "customers" or "clients" rather than patients.

I'd also be wary of anyone who says "it's simple...".

As CharonY has pointed out, this problem is hard. 
 

[Raider5678]

21 minutes ago, John Cuthber said:

I'd look out for people trying to pretend that a hospital is a business.
It's unfair to judge a book by its cover but- sometimes that's the only option you have.

So, I'd be wary of people talking about "customers" or "clients" rather than patients.

I'd also be wary of anyone who says "it's simple...".

As CharonY has pointed out, this problem is hard. 

Wary?

What would you do if you were wary of a particular hospital? I.E. cut funding, change administrators, etc.

[John Cuthber]

Just now, Raider5678 said:

Wary?

What would you do if you were wary of a particular hospital? I.E. cut funding, change administrators, etc.

What!?

No, if I was wary of something, I'd seek to find out more about what is happening.

[Raider5678]

31 minutes ago, CharonY said:

It is important to note that while these are provisions of the ACA, they are not its cornerstone. Rather these are (fairly unique) measures to try to quantify and improve critical aspects of health care (such as infection with antibiotics resistant bacteria, which is an increasing problem even in otherwise excellent hospitals). For the most part the most obvious solution is a fine-grained analysis of why hospitals fail, which includes the mentioned socioeconomic aspects. As such e.g. adjusting ratings against hospital population demographics would be a step in that direction.

Would you rather see the ratings adjusted or the three of them(or combination/one of them) simply repealed in the meantime?

Which would benefit people the most? Having them repealed as soon as possible or adjusting the ratings system(I'm not sure how long that would take. Anyone have an idea?)

Just now, John Cuthber said:

What!?

No, if I was wary of something, I'd seek to find out more about what is happening.

Person** not hospital.

My apologies.

You mentioned being wary of people referring to patients as customers. How could we apply that to healthcare today?

[Phi for All]

2 hours ago, Raider5678 said:

TLDR; How can we improve the Affordable Care Act?

Transfer its funding to Medicare, drop the age limit, and you'll have bypassed the #1 obstacle to decent healthcare in the US, the medical insurance providers.

[Raider5678]

5 minutes ago, Phi for All said:

Transfer its funding to Medicare, drop the age limit, and you'll have bypassed the #1 obstacle to decent healthcare in the US, the medical insurance providers.

So completely undercut the private health insurance system?

[CharonY]

38 minutes ago, John Cuthber said:

I'd look out for people trying to pretend that a hospital is a business.
It's unfair to judge a book by its cover but- sometimes that's the only option you have.

So, I'd be wary of people talking about "customers" or "clients" rather than patients.

I'd also be wary of anyone who says "it's simple...".

As CharonY has pointed out, this problem is hard. 
 

Also, it is really somewhat beyond OP, as the question is then not how to improve ACA but really how to improve hospital care as a whole. For the most part though, hospitals like to implement things themselves, if at all possible. And there are good reasons for that. However, whether that works depends a lot on the leadership. The idea behind the various provisions is to provide incentives to implement required changes. Keeping those in place might be a good idea, but requires adjustments following active research (there are several groups looking into the effects of these and other measures of health care). 

But if the goal is to improve overall health care and health care funding, that would require a much longer discussion.

[John Cuthber]

9 minutes ago, Raider5678 said:

So completely undercut the private health insurance system?

You say that like it's a bad thing.
Do you know that healthcare in the US costs roughly twice what it does in most of the Western world?

(and the outcomes are arguably worse)

[Raider5678]

1 minute ago, John Cuthber said:

You say that like it's a bad thing.
Do you know that healthcare in the US costs roughly twice what it does in most of the Western world?

(and the outcomes are arguably worse)

I say that to ensure that's what he is saying. He didn't specifically say he wanted to undercut private health insurance and I figured I'd confirm that's what he said.

Either way a discussion into that will go off topic of the ACA.

[Phi for All]

58 minutes ago, Raider5678 said:

So completely undercut the private health insurance system?

You say it like I'm suggesting to nationalize health insurance. What I mean is that, if Medicare was available to everyone, and people could opt to have their employer make payouts to Medicare instead of private health insurers, they would because it would be much less expensive since Medicare doesn't charge for profits. IOW, we'd be giving people a choice between private and public health insurance, and the public choice would be cheaper so it would gain in popularity until it forced the private insurers out of the market. 

The only thing needed would be to remove the chains conservatives have been hobbling Medicare with to make it look bad. Let them negotiate their drug prices with pharma like everyone else. Private health insurance is like private prisons. It's a stupid use of business models that kills people.

[StringJunky]

3 minutes ago, Phi for All said:

You say it like I'm suggesting to nationalize health insurance. What I mean is that, if Medicare was available to everyone, and people could opt to have their employer make payouts to Medicare instead of private health insurers, they would because it would be much less expensive since Medicare doesn't charge for profits. IOW, we'd be giving people a choice between private and public health insurance, and the public choice would be cheaper so it would gain in popularity until it forced the private insurers out of the market. 

The only thing needed would be to remove the chains conservatives have been hobbling Medicare with to make it look bad. Let them negotiate their drug prices with pharma like everyone else. Private health insurance is like private prisons. It's a stupid use of business models that kills people.

Why can't Medicare negotiate prices?

Edited October 29, 2018 by StringJunky

[Phi for All]

Bush II removed Medicare's ability to negotiate drug prices like private carriers can.

https://en.m.wikipedia.org/wiki/Medicare_Prescription_Drug,_Improvement,_and_Modernization_Act

[StringJunky]

10 minutes ago, Phi for All said:

Bush II removed Medicare's ability to negotiate drug prices like private carriers can.

https://en.m.wikipedia.org/wiki/Medicare_Prescription_Drug,_Improvement,_and_Modernization_Act

Cheers. What a mess. it seems so much simpler to just pay a national Insurance and get on with your life, like we do. i don't think I've read of any significant gripes from the UK populace about the cost of national insurance.

Edited October 29, 2018 by StringJunky

[Phi for All]

39 minutes ago, StringJunky said:

Cheers. What a mess. it seems so much simpler to just pay a national Insurance and get on with your life, like we do. i don't think I've read of any significant gripes from the UK populace about the cost of national insurance.

It's like this with many of our government programs and agencies. Our postal service could deliver more efficiently, securely, and cheaply if they were allowed to buy their own planes instead of being forced to use private carriers. The USPS could do a better job wiring funds than Western Union (they have offices in every zip code), but they aren't allowed. Capitalism is choking our country, no more so than in our healthcare. 

[Raider5678]

13 minutes ago, Phi for All said:

It's like this with many of our government programs and agencies. Our postal service could deliver more efficiently, securely, and cheaply if they were allowed to buy their own planes instead of being forced to use private carriers. The USPS could do a better job wiring funds than Western Union (they have offices in every zip code), but they aren't allowed. Capitalism is choking our country, no more so than in our healthcare. 

Short of completely transferring funds from the ACA to Medicare and expanding coverage to everyone(which wouldn't be enough to fund it), how would you chance the ACA?