by Gregg A. Masters, MPH
In the run up to the passage of the Affordable Care Act (select milestones here), the Senate Finance Committee under the leadership of Chairman Max Baucus presided over a comical volume of amendments proffered by his colleagues on the other side of the isle, see: ‘Senate Democrats Lead Historic Passage of the Patient Protection and Affordable Care Act‘.
Having witnessed gavel-to-gavel coverage of this painful historical consideration (some may say exquisite political theater) I soon began to refer to this bunch as the ‘dis-ingenuous five‘ (Hatch, Grassley, Cronyn, et al) as all of their amendments had one thing in common – to dilute if not distract from the intent of the Act or any of its targeted provisions.
Fast forward some 5+ years and the ideological drama of a very complex piece of legislation still engenders varying degrees confusion, implementation complexity, litigiousness and its share of opposition often nested inside simplistic and dumber by the dozens sound-byte alternatives, witness this recent exchange between former Senator and Governor Judd Gregg and the journalist Chris Hayes.
Yet, forged from private market competitive ‘lessons learned’ experience, supported by tomes of sound bi-partisan health policy reasoning and enabling regulatory consideration two seemingly opposing remedies co-exist with relative degrees of market uptake success: ACOs and ‘DPCs‘ (direct practice‘) including it’s retainer and membership model medicine derivatives.
Some say direct primary care (DPC), still a trickle in terms of share of medical practice participation, is the way to ‘give the finger’ to the prevailing mangled care amended bill and chase model of American medicine (and by proxy the ACA) and exit the system in favor of a more simplified and patient centric model. Yet there is more to this story as few get the provisions in the ACA enabling the inclusion of DPC’s as potentially ‘qualified health plans‘ and thus eligible for listing on State or Federally Facilitated Health Insurance Exchanges, see: ‘DPC and Insurance, HDHP, HSAs‘; not to mention there are a range including ‘hybrid’ DPC models (from Qliance to OneMedical and many in between) that stay tethered to a claims filing and collections model of operations.
ACOs are a statutory construction of the ACA via introduction of Section 3022: The Medicare Shared Savings Program and center core to the impact and efficacy of the law’s intent. To many this rules ACOs out as de-facto agents of change driving transformation of an excessively complex, silo-ed and provider centric healthcare financing and delivery system quagmire.
Another Way To Look At It
So for those willing to dive a little deeper into the chassis of both business models and services line extensions there may be more similarity between these two seemingly oppositional vehicles.
Both are variably tethered to the ACA and thus part of the implementation vision of the President and his then allies in the Congress. At its core the DPC model is a return to HMO roots of ‘pre-paid’ comprehensive primary care services though the DPC model is not in the business of health insurance while HMOs clearly are. While DPCs typically only include the range of primary care services they control, and exclude specialist referrals, lab and imaging services and hospital inpatient or outpatient services, they do leverage principles of ‘re-insurance’ via optional wrap around high deductible or catastrophic plans.
ACOs in the Medicare Shared Savings Program (MSSP) are seen by many especially those risk savvy medical group or integrated delivery system operators of Medicare Advantage health plans (aka ‘HMOs’) as too little too late (or ‘HMO-lite’) versions of the real deal and unlikely to steward the meaningful transformation from a volume-to-value based healthcare economy.
Yet, the truth is they’re both part of the broad brush of initiatives included under the tenets and principles that gave birth to the ACA, see: ‘Obama-care 101: The president’s 8 principles‘.
Clearly this transformation of 1/5 of the U.S.economy will take time and there are many moving parts. The question is do we have enough time for pluralistic remedies to take hold before the ‘system’ collapses on itself? The nightmare scenario being non-risk bearing ACOs can’t deliver the shift to value and DPC led ‘exits’ create a perfect storm of declining supply at the precise time of peak demand for primary care services.
So one more time as I often say here: ‘…we shall see?’