Many questions remain on how specific details of the Affordable Care Act will be resolved, but one significant trend is clear: the shift toward risk sharing among patients, providers and insurers is well underway.
That is the view of Andrew Croshaw, president of the healthcare intelligence firm of Leavitt Partners, who presented "Healthcare Reform: Where Are We Now?" at the Healthcare Financial Management Association's ANI 2014 conference in June. He predicted that one-third of Americans would have a shared risk plan by 2020.
Leavitt Partners is monitoring over 600 accountable care organizations and found a wide range of experimental programs underway with varying degrees of success. But the prevailing trend is to continue those experiments in order to identify models that work.
"The ACA debate about coverage is over," Croshaw told the audience of about 500 financial executives. "The debate now is about how much control does the government have and how much we are willing to spend."
Croshaw noted that the current rate of healthcare spending as a percent of GDP is not sustainable. "You have a tectonic shift of human compassion that wants to extend healthcare coverage and an equally powerful economic shift that says this can't happen."
The question is how quickly the ACA's momentum will push change. He noted that there is plenty of uncertainty, both in administration decision making and in Congress. A key question for the administration is how it will define re-enrollment rules for the next plan year. Will current enrollees be required to re-enroll or will they be automatically re-enrolled if they take no action? Another question is whether the employer mandate delays will be extended again.
At the Congressional level, Croshaw thinks it is likely that the Independent Payment Advisory Board, or IPAB, will be eliminated. He also expects Congress to take steps to pressure providers to bear more risk. And he expects a permanent resolution to the sustainable growth rate formula next year.
Leavitt Partners has a strong background in healthcare administration. Its founder, Michael Leavitt, was Secretary of Health and Human Services under George Bush and a three-time governor of Utah. And the firms' analysis takes into account political forecasts.
No matter which party controls the Senate next year, Croshaw maintains the shift toward sharing risk will continue. His firm estimates about 18 million lives are covered by an ACO with most participating through Medicare.
He believes that CMS will soon release rules that provide more flexibility in creating guidelines that keep Medicare beneficiaries in network. The trend toward government giving the private sector more flexibility will continue, he said.
He also shared research that shows physician groups have become the most active experimenters in risk-bearing arrangements. And among private payers, seven are most active: Cigna, Aetna, United Healthcare, BCBS of Massachusetts, California and Michigan, and Anthem.
Overall, Croshaw said the success of insurance exchanges is well established, with over 8 million participants and evidence that most people are paying their premiums. For the most part, the right balance of young to older enrollees has been achieved. One concern is that most people chose a "silver plan" with $2,500 deductible: "What will happen when people can't pay the deductible?," he asked.
Croshaw told the audience that he expects the government to continue seeking to partner with private industry and the selection of a new chief for HealthCare.gov from private industry is an encouraging sign.
"As exchanges evolve, we will get through the technical problems. They're going to be functional and working," he said. As for ACOs, he said it's hard to read much into first year results.
"Why are some ACO's successful? People are still figuring out what defines success. There are successes with home visits and medication reconciliation, but it is not clear yet which programs worked."