Health Policy

All Three Legs of the Obamacare Stool Are Working Well – Part 2


2022 Medicare Advantage data gathering process change made last year just made upcoding for plans irrelevant and impossible, but the critics do not accept that it happened. 

CMS just ended that upcoding debate for 2022 by completely killing the coding system for the plans, effective immediately. The plans can’t code risk levels up because the coding system was eliminated entirely for 2022.

RAPS is dead.

The payment approach for Medicare Advantage now has no upcoding components and the government just used their new and more accurate numbers to create the 2023 payment level for the plans.

The numbers went up a bit with the real risk levels because the plans actually seemed to have been undercoding in spite of their best efforts to have higher numbers in their RAPS data flow.

We should now be able to put that issue to bed and look at what has been accomplished overall by the Affordable Care Act.

The Medicare Payment component of the Affordable Care Act just evolved to a new level — and the entire Obamacare package should now be recognized for what it is now and what it has become. 

When the Affordable Care Act was designed, there were people helping with that process who understood that the only way of getting care in America to continuously improve is to buy care as a package, and not by the piece, and to reward the organizations who re-engineered care for achieving those goals in ways that encouraged using the best tools for care delivery in our markets.

The Medicare Advantage plans all know that clean socks and dry feet reduce foot ulcers that create 90 percent of amputations by 40 percent. The plans also know that congestive heart failure is extremely expensive and painful, and they identify the high-risk patients and help them reduce their risk by doing helpful things in people’s homes to make that happen. Some plans even have scales that send an alert to the care plan nurses when people have unexpected weight gains from fluid retention that indicated a CHF crisis is impending.

Interventions at that moment in time work — and the JAMA study cited above shows that the plans have 40 percent fewer hospital admissions for both congestive heart failure and asthma.

Managing blood sugar for diabetic patients cuts blindness by 60 percent for the patients who achieve that goal — and one of the most important goals in the Medicare Advantage five-star plan has always had blood sugar as a major priority. The plans even improved performance in that area under Covid.

The tools used by the plans are very flexible and are aimed at continuous improvement in many settings. The overlap with other patients in those settings is significant because it’s too hard for caregivers to deliver multiple patterns of care for their patients.  

The Affordable Care Act also aspired to improve care for everyone — and it’s good for the country that most major employers are self-insured for their care, and it’s good that the vast majority of those employers hire administrators to manage their self-insurance.

The organizations who do that administrative work for the employers tend to be the same major carriers who also own the vast majority of Medicare Advantage plans and the vast majority of Medicaid administrators and they have an overlap with the care goals set by the significant majority of union trust fund administrators as well. Over 5 million union members are in their own Medicare Advantage plans, and those union plans tend to have some of the highest Medicare Advantage five-star quality scores in the country.

So when the people designing the Affordable Care Act were doing that design work for care improvement, they aspired to have the care improvement spill over to the rest of American health care.

This is the right time for that spillover of best processes to happen.

We should be on the cusp of a golden age for care delivery in America.

We should be able to use artificial intelligence and FIHR like data connection systems to do things like the cancer moon shot now being set up for the best cancer sites in America to make care both cheaper and better for everyone. The very best care team will be able to predict multiple types of cancer a year or more in advance with simple blood tests and other monitoring devices, and that could significantly reduce the cost of care for us as a country, because a stage 1 cancer costs a lot less to treat than a stage 4 cancer.

Fee-for-service Medicare will not support any of those enhancements or improvements in care because they have never supported that level of care improvement and flexibility. The Medicare Advantage plans will now have some plans that support everything that happens to enhance care, and that enhanced care from those programs will create a competitive advantage for those plans that other plans will need to follow by also improving care.

That’s obviously good for everyone. It’s how markets should work and it’s very different from how market forces have been working in fee-for-service American health care.

So, as we look at the Affordable Care Act, the key pieces are clearly supporting some things we need to happen to make care affordable for the country — and we should understand that process and build on those successes in every area that they’re happening, and we should have it anchor continuously improving care for us all.

When the Affordable Care Act was passed, the health care economists fairly consistently projected that America was on a slippery slope to spend more than 20 percent of our GDP on care — and the new markets that use better tools for many patients, and that create better purchasing mechanisms in both Medicaid and private insurance, seem to have had a major positive impact on that agenda.

We are now at 18 percent of our GDP being spent on care — and that is high, but significantly better than the path to 20 percent that we were on before the law was enacted. The timing of those trajectories tells us that is isn’t coincidental.

The problem we face today is that there are some serious enemies to the process of using Medicare Capitation and Medicare Advantage to improve care.

We need to keep the people who clearly and openly still want to kill all of the plans, because they think some version of election fraud happened in some settings, from doing the damage that those opponents seem committed to be doing in order to make Medicare Advantage disappear and die.

That warning about those critics at this point in time should not be necessary, but those people who want to kill those programs and processes do exist and that death is their open goal — and we just need to recognize what they’re doing and keep them from sneaking in back doors and using distorted data flows of various kinds to somehow make those changes happen in damaging ways for our care as a country.

Let’s celebrate Obamacare on each level that it exists.

The Medicaid program is a huge win.

The employment direct access and open enrollment insurance programs and the functional insurance exchanges in every state are major wins.

The Capitated Medicare program is creating better care and doing it for about 10 percent less money than fee-for-service Medicare spends on those same patients in all of those counties.

The people who lost their political careers because they got that Affordable Care Act law passed should be heroes to us now because the wins are so clear today for what they put in motion, and Americans have better lives because those programs exist.

Thank you.

George Halvorson is Chair and CEO of the Institute for InterGroup Understanding and was CEO of Kaiser Permanente from 2002-14.