Abstract: Since its passage in 2010, the Patient Protection and Affordable Care Act (ACA) has caused widespread disruption in the US health care ecosystem. This has put a huge spotlight on the system’s shortcomings, from inefficiencies of care delivery to extreme variability in quality and patient experience—from region to region, and sometimes within the same facility. The uncertainty has been heightened by recent attempts to repeal the ACA, such as the successful passage of the American Health Care Act of 2017 in the House of Representatives. This paper captures the ongoing reactionary moves from key stakeholder groups as they jockey for control and dominance over care design and delivery activities and entities. Using principles of pathways, the paper explores a framework for a restructuring health care that aligns design, delivery, governance, and administration to reconnect providers, caregivers, and patients; improve quality and safety; and continue to lower cost of care. This framework has the potential to increase individual and provider accountability; reduce waste and abuse of taxpayer dollars; and ultimately build a healthier population.
Received January 17, 2017
Accepted May 7, 2017.
Prior to the Affordable Care Act (ACA), health insurers and other third-party administrators (TPAs) facilitated and even controlled the delivery of care, as well as the coordination among providers1 in the health care ecosystem. In addition to its more familiar health insurance coverage reforms, the ACA contains numerous provisions that directly target how health care is organized, delivered, and paid for in the United States. These provisions take aim at the well-known shortcomings of the US health system, from the inefficiency and high cost of the predominantly fee-for-service system to the extreme variability in the quality of care patients receive from region to region. The ACA has pushed dynamic change into the health care ecosystem that has disrupted the traditional roles of insurers and providers, while also introducing new players who are retooling portions of the care continuum and payment models. The need for coordinated and integrated care across the provider spectrum, along with greater efficiencies and improved patient safety and outcomes, has never been greater. The ACA highlighted the importance of care design and care pathways2, based thinking in the form of pathways and bundled payment models. The first failed attempt by Congress to replace the ACA proves that a mere budget reconciliation strategy is not only insufficient, but also unacceptable to address the root causes of the breakdown in the system.
With the repeal of the ACA still on the horizon following the successful passage of the American Health Care Act (AHCA), stakeholders need to examine the lessons learned and use them to inform the next chapter in health care reform. This paper presents key moves of the incumbents, disruptions from new players, underlying disincentives, and a framework based on the principles of pathways that take in to consideration these activities to align the design, delivery, governance, and administration, of health care in pursuit of making high quality affordable faster.
Providers, plans, and other stakeholder groups have responded to the changes brought on by the ACA with strategic responses that are motivated by traditional financial incentives and a need to rapidly retain or gain market power (Table 1). These responses are geared toward how care may be paid for in the future (payment reform). They do not include robust provisions for integrating and coordinating care across care settings that would consistently deliver desired clinical outcomes for the individual or the overall population. The failure to operationally integrate and coordinate care could impact outcomes and continued increase in total health care spending.