Lost on the American public, and even many physicians and lawmakers, is the fact that the Patient Protection and Affordable Care Act is about much more than helping people get medical insurance.
That’s only part of the law. More than half its 900 pages created more than 100 regulations designed to improve outcomes, so patients get the right care, get it more efficiently and are less likely to be infected or otherwise hurt in the process.
Policies stemming from the act mandate transparency, so consumers and providers can compare hospitals, nursing homes, ambulatory surgery centers and many other care settings. And the law finances efforts to refine ways of measuring quality of care, based on evidence, such as how quickly you’re seen in an emergency department.
Now, Congress and President Donald Trump have resolved to repeal the law. And that makes Dr. Don Berwick angry. Berwick advised congressional staff as the law was being framed and was appointed by President Barack Obama to run the agency that implemented the law after it passed in 2010.
In a two-hour interview, Berwick spoke about the impact of repeal, which he said is “wrong,” “damaging,” and “distressing” and will push the nation’s health care system “backwards.”
“What’s stunning to me is the willingness for these proponents of repeal to advance intellectually unsound, illogical proposals that cannot possibly work,” said Berwick, former administrator for the Centers for Medicare & Medicaid Services.
“I think we’re going to be leaving people out in the cold, and that makes me feel angry, and deeply, deeply concerned.”
This interview was edited for clarity and brevity.
Q: Can you be specific about how the law improves quality of care?
Berwick: It’s not well known to the public, but the ACA has many provisions that make care better, much more reliable, much safer. For example, its provisions allow people to get care in their homes rather than in institutions. Its mechanisms give hospitals and doctors and clinics incentives to make sure patients are getting exactly the right kind of care, and reduce errors in care. Provisions include finding ways to support teamwork between various types of providers for people with chronic illnesses, and using telemedicine and telehealth so patients don’t have to travel to see a doctor.
The results now, after five years of implementation, are really dramatic. We’ve made progress on patient safety like we’ve never seen before.
Q: Can you describe specific provisions that proved they improved quality?
Berwick: There are probably 20, but I’ll name a few.
Before the ACA, if someone was in a (skilled) nursing home but really could be home, there wasn’t a lot of support for getting that person home. The ACA allowed for paying doctors to provide care in the home instead of requiring (patients) to be in an institution. Who wouldn’t rather be at home than in a nursing home? We have evidence that has helped hundreds of thousands of people.
The Center for Medicare & Medicaid Innovation is a second example. Over 10 years, $10 billion is set aside to support new ways to give care. Let’s say you’re having hip surgery. You pay for surgery, then pay (separately) for your rehab, and pay for complications later on. Why not bundle all these payments into a single (upfront) payment? The hospital is paid for your preparation, your surgery, your post surgery care and care of any complications that might occur. And what that does is it starts to let the hospital think differently. Now they’re really, really interested in preventing complications. They can keep some of the money if they prevent complications.
It says that instead of paying (providers) for every single thing you do, we’ll try to pay you for the results of what you do. We want to get providers organized around meeting (patients’) needs, not just the volume of services they provide just doing stuff. Get off the gerbil cage.
Another quality provision is Partnership for Patients, a $500 million program that achieved reductions in hospital-acquired conditions, (such as accidental lacerations, blood clots, pressure ulcers from lying too long in bed,) and infections. It saved tens of thousands of lives and billions of dollars.
Q: Some of the new appointees of federal health agencies are not gung ho on bundled payments, where a group of providers gets paid one flat fee for all services in an episode of care, like a hip replacement. The new secretary for Health and Human Services, Tom Price, a former congressman and orthopedic surgeon, introduced the HIP Act that would block and delay bundled payments for joint replacement. What’s the future of bundled payments?
Berwick: Bundled payment projects were successful experiments. Under the ACA, there is authority to make those mandatory. But this administration doesn’t like government activity. It is saying “What are you doing telling hospitals what to do?” What we’re doing is protecting patients. We’re defending (55) million Medicare and (73) million Medicaid beneficiaries.
Q: Along with the idea that the government should do less, what can or what might the new administration do to eliminate transparency, data now available on CMS.gov for health care provider settings, from physician practices to hospice providers?
Berwick: They haven’t shown us their cards. They seem to want to decrease funding for Medicare and Medicaid one way or the other, and that would affect the ability of (CMS) to provide transparency data. (CMS) pays a lot of bills. It gets information. It’s a national goldmine of knowledge about what’s happening in the American health care system. The ACA made data available, so (a person seeking care) can ask the question, which hospital is doing the best job at hip replacement? Where would I be safest if I had to get my heart valve fixed? We can know that now.
What the Republicans did while I was (CMS administrator) was (constrain) administrative resources, so we really couldn’t go as far and as fast as we should have, and had the authority to do, to make care transparent.
I would say, “Gee, Republicans, if you want markets to work, support this part of the ACA, transparency.”
Q: Is data transparency in jeopardy?
Berwick: Oh, I think it is in jeopardy. A lot of the transparency stuff is subregulatory, that means the regulation says make it known, but then there has to be guidance about it. How do you make it known, by when, what mechanism? And that can be changed pretty much by administrative decision-making.
Of course, transparency is uncomfortable. Now you know how you’re doing and the public can know it. And there are some actors on the scene who would prefer there not be so much transparency. We are in adolescence of what we measure, and we have probably overshot a bit. So that (transparency) work is underway, and it’s supported by the ACA.
Q: The ACA financially penalizes some hospitals for avoidable complications such as higher rates of readmissions, and not performing well on other markers, such as being inefficient, up to 6 percent of their entire Medicare payment for one year.
Berwick: That’s a carrot and stick approach. It’s controversial, and it should be controversial. Because you could argue hospitals with higher readmissions may be the ones that need more money, more help. But that’s not cause for repealing the ACA. That’s maybe amending, repairing or improving it. And yes, you get penalized, but you also get a lot of support to learn how not to have high readmissions or infections. That’s a learning process the ACA supports.
Q: You said earlier the public isn’t aware of all these other ways the ACA improves care. Why didn’t your administration and others really tout these parts of the law when you had the chance?
Berwick: It’s as if the coverage story, getting 22 (million) or 30 million people covered in America — which is important — and the controversy around it just sucked oxygen out of the room. And the deeper story about making American health care better wasn’t told. It should be told. And these Republicans now in power would be doing the public a great service if they build on improvement as the agenda instead of (removing provisions that have made care better, safer and more reliable) … taking away stuff.
We haven’t told the story of improvement as boldly as we should have (and that) might have a lot to do with the fact that a lot of people in Washington, then and now, are finance people, economists, policy people. They’re not clinicians. They don’t understand the care being given.
Q: President Trump has called for eliminating two regulations for every new one. Number one on the American Hospital Association’s wish list is to abolish the star rating system.
Berwick: That’s wrong. They should say, improve the star rating system. Eliminating a system that at least gives us a little bit of signal about which hospitals are leading and should be studied and which are lagging and should work harder? No. We need more transparency, not less. If the AHA doesn’t like the way it’s going, help us make it better. Eliminating it is going backwards to an era of secrecy or opacity.
Of course, some regulations should go away.
I would much rather see a continuation of the Obama policy, which said let’s keep getting rid of regulations that don’t make sense, and let’s make them more efficient. One in, two out? That makes for a good headline. Every regulation should prove its worth.
Q: Some people, including many doctors signing an online petition, opposed Price to lead HHS. And stories question some of his private dealings and implied he has profited from his position.
Berwick: I can’t and won’t comment on his motivation. But on his public record he has a number of positions on which I very, very strongly disagree, and which would threaten (care). He’s one of the people who wants to move Medicaid into a more limited amount of federal contribution through block grants (or set amounts of money regardless of demand) and move responsibility to the states.
That ignores the really important parts of Medicaid. When the economy gets worse, the feds help more. If there’s a flu outbreak in a poor state, states, counties, municipalities and healthcare providers end up holding the bag. I disagree with that.
We’re a nation. In Massachusetts, before the ACA, anyone up to 138 percent of the federal poverty level got Medicaid. But in Alabama, it was 13 percent. Above 13 percent and you weren’t eligible. We should be a nation in which health care is available to everybody. If we mean it, we have to have federal policies that say:
“Dear State, we trust you on a lot of issues, but there’s a standard here. We’re one country.” I’m concerned about the kind of variation that could occur when the federal government walks away from the job of protecting Americans.
Q: You mentioned that you’re concerned about Dr. Price’s positions on avoiding federal involvement in care. Explain what you mean.
Berwick: I’m a physician who has long defended the prerogatives of doctors. Price carries that to a level that I think we ought to ask some questions about. I’m very proud of American doctors. I think most of them try to do a very good job. But we are a nation that has a responsibility to make sure the quality of care given doesn’t depend on your ZIP code. Wherever you are, we’re going to help make sure the care is good and therefore things like transparency and public reporting matter, and I’m not sure what he’s going to do with that. He keeps saying, ‘leave the doctors alone.’ I say, ‘yes, leave them alone to see the patients, but do it with responsible public policy.’ I’m concerned.
Q: What do you hope will happen?
Berwick: I have a fantasy. Maybe there are going to be some Republicans now with real courage, courage to admit they made a mistake. They’d say “yes, there were some things we didn’t like, and we got the public riled up but we were wrong. The ACA for all its limitations was a massive step forward, and now that we’re in power our job is to make that step even better.”
I’m looking for people to say that.
Berwick is president emeritus and senior fellow of the Institute for Healthcare Improvement in Cambridge, Massachusetts. He was the administrator of the Centers for Medicare & Medicaid Services for 17 months until December 2011.
He resigned after failing to receive a Senate confirmation hearing after Republicans urged Obama to withdraw his name.
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