Getting All Americans Covered Falls By The Wayside

The Disease Management Care Blog gained one major insight during its recent Washington DC health care conference.

In all the talk about "health reform," there was very little discussion about one of the past leading justifications of the Affordable Care Act (ACA): that by giving tens of millions of Americans insurance, there'd be more preventive and screening services, earlier care for chronic illnesses and better access to hospitals after unexpected illness. It was argued that disease detection would be increased, and disease progression would be decreased and avoidable high-cost complications would be... well... avoided. The expensive and shameful "hidden tax" of unnecessary and inefficient cost-shifting would be replaced by enlightened and cost-effective public financing.

There may be merit of the argument, but it's conspicuous absence at a D.C. conference and, by the way, in many of the health journals, policy media and blogs makes the DMCB think that many of the cognoscenti silently doubt it. Ask policymakers and academics about bending the cost curve today and what you'll get is a refrain consisting of bundled payments (that intelligently capitate physician services), primary care medical homes (that shift health services to a cheaper level of care) and accountable care organizations (that align all the economic incentives).

The DMCB sees the merits of each of those concepts. Congress obviously did also when it mandated them in a variety of demos and pilot programs. What's more, the ACA is remarkable for the power it gives to the HHS Secretary to rapidly expand them, and to do so without Congressional approval.

Which is the rub. While the Secretary's flexibility is a good thing, the one thing that is standing in her (or his) way is that the pilots/demos really have to show cost savings. While many of my colleagues believe that is a mere formality, the DMCB recalls many in the disease management industry felt the same way about Medicare Health Support Demo. It didn't quite work out as planned.

Which brings the DMCB to the ultimate question: if the pilots and demos don't work, just what is "Plan B?" The answer at the Conference, for Medicare at least, was across the board delays in any scheduled fee schedule increases and/or reductions. Yikes.

Which is the insight. The discussions about the possibility of across-the-board cuts may have greater visibility today than merits of extending insurance to the uninsured. It's not out there in the media. so you read it here first.

The DMCB will continue to monitor this.