At the iHT2 Health IT Summit in Boston, Paul H. Keckley, Ph.D., former managing director, Navigant Healthcare, and managing editor, The Keckley Report, delivered a keynote presentation on if the goals of healthcare reform, as outlined in the beginning of the Obama Administration, have been met, and what the future holds.
The event, from the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group, LLC corporate umbrella), taking place at the Aloft Seaport Hotel in Boston on June 23-24, kicked off with Dr. Keckly's keynote on healthcare reform on Thursday, titled "Health Reform 2.0: What to Expect and How to Prepare."
Keckley, who has previously facilitated sessions between White House Office of Health Reform sessions and major health industry trade groups as private sector input was sought in legislation, opened his keynote by reflecting on how, in 2009, the stimulus package leading up to the passage of the Affordable Care Act (ACA) included $27 billion to connect the healthcare system. The assumption at the time, Keckley said, was that through meaningful use and major electronic health record (EHR) vendors playing nice, that a connected healthcare system would be somewhat of a smooth sailing. "We have had 400 new entrants in the health IT space annually since 2009. The assumption was that all of this would seamlessly come together, we would develop standardized language, and that privacy and security issues would be worked through," Keckley said.
Paul H. Keckley, Ph.D.
Keckley touched on various components of healthcare policy in his keynote, including some of the core IT elements that will be a major part of reform moving forward. Regarding accountable care organizations (ACOs), Keckley noted that there are 434 of these operating, but "97 of them after have saved a nickel after three years." He added that ACOs "sounded good at the time." He said, "Medicare has tried [this model] before with demonstration projects, but what happens when ACOs start falling apart? The law says doctors have to write a check. Hospitals can't bail out the doctors."
Moving forward, Medicare has said it will push everyone into alternative payment programs, Keckley continued. "Medicare is doubling down on ACOs despite their poor performance. They see the ACO as an organizing principle for primary care. Primary care in the future model is inclusive of all providers along the [continuum], and it's a much bigger platform than what we have today. So the ACO becomes the framework for building primary care. They won't see savings, and in fact it will cost a lot of communities and organizations more to become ACOs than they get back in shared savings," Keckley predicted.
Keckley then brought up bundled payments, specifically how in 67 markets spanning across the U.S., a federal mandate from Medicare now requires that hospitals cannot do complete hip and knee replacement surgeries unless the care is done in the form of a bundled payment (known as the Comprehensive Care for Joint Replacement model). "There is no room for negotiation here," he added.
"All of this is intended to reconfigure the delivery system, from silos that are independent to integrated systems of care," Keckley said. Now, 102 of these systems are operating their own health insurance plans, he noted. "When I was in White House meetings, the President would say that [the future is] about the Kaisers, the Mayos, the Cleveland Clinics, and the Geisingers—all integrated health systems. But at one point, I pulled all of those systems together, and none of them thought that any of the others had the answers," he said.
Keckley touched on other intentions of the ACA, including: that the fee-for-service (FFS) system for how physicians would be paid would be replaced with a model centered around paying for value; standardizing care around evidence so the standard of care is defined without wide variation; and putting a lid on spending, by paying no more than 1 percent above the GDP, despite the fact that for the past 35 years, healthcare spending has exceeded the overall growth of economy by 2.4 percent year after year.
Speaking more about digital health, Keckley noted the multiple court cases in Texas which ruled that states can't restrict telemedicine, leading telehealth company Teladoc to go public. "So how will we regulate digital health in the broad sense?" Keckley asked. "That's a can of worms that has opened. If we're providing actionable data to providers, what world are we in? Does the FDA need to be more aggressive? You have smart watches that capture the number of steps you take. Does the federal government need to look at that if you're going to use that data?
When asked about the potential of a universal patient identifier happening anytime soon, something that has been strongly pushed by CHIME and other healthcare industry groups, Keckley said what typically happens in privacy/security discussions is that incremental improvements are made since that's what is politically expedient. "Congress will default to inaction if one of these industry groups proposes something that disagrees with others," he said, adding that he doesn't anything major happening in this area in the foreseeable future.
In sum, Keckley said that health reform 1.0 is "incomplete." He said, "There is not a lot of evidence that we have reduced costs, but you can also argue that [reform] hasn't accelerated costs. But, the forecast is that costs will go up about 6 percent per year in the next decade. We will have to do something dramatic if what we have now is not working in 2020." Keckley concluded, "The U.S. health system is not on life support, but we're about to be admitted to critical care unit. The data we got yesterday said that Medicare is going to [run out of money] by 2028. That's a pretty good wake up call."