Shining light on health care policy and reform: Needs and updates

Health care policy and reform pervade our daily medical practices. Although residency training can temporarily shield trainees, the effects of national health care reforms have profound and career-long implications. The recent Patient Protection and Affordable Care Act (ACA) was signed into federal law in March 2010 and represents watershed legislation fundamentally altering healthcare in the United States.¹ The reform policies created some of the “most aggressive efforts in the history of the nation to address the problems of the [health] delivery system.”² Furthermore, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) introduced new reimbursement paradigms for nearly all healthcare providers.³

Health care policies encompass the body of local, state and national regulations, including delivery, documentation, event reporting, public health, malpractice and payment. Historically, health care resembled a “fee for service” model, linking patient or treatment volume to payment; the recent reform is creating a shift toward provider performance, quality and value. Implementation can vary state by state, so individual residencies, hospitals, and even rotations may have widely differing daily practices. For example, consider the effects of Maryland’s unique all-payer rate setting in which all insurance parties pay the same for hospital-based services.⁴ The implications of health policies, regardless of their temporal or provincial origins, may have significant effects on the scope in which radiation oncologists practice.

During training, policy concepts often are discussed tangentially. Familiar, but mysterious, terms include accountable care organizations (ACOs are intended to integrate inpatient, outpatient and ancillary services for Medicare patients), merit-based incentive payment systems, and alternative payment models (development ongoing, MIPS and APM change Medicare reimbursement structures to incentivize quality measurement reporting). Currently, one of these APMs, the Oncology Care Model, frames a payable episode of cancer treatment as 6 months from initiation of drug therapy; during this period, the oncologist providing the chemotherapy receives a fixed monthly payment to cover all costs for the patient, including potential radiation treatment.⁵ The American Society for Radiation Oncology (ASTRO) has worked on developing an alternative payment model.⁶

These health care reforms will transform, and their downstream programs will undoubtedly change, hopefully with clinician-guided involvement, careful study and rigorous research. Importantly, these changes occur with or without input from those in practice. As our field challenges itself to grow, and we cultivate our technical skills, we must also learn to participate proactively in the national dialogue in health policy. Our future, as thoughtful clinical leaders and advocates for our patients, will rely on our engagement now.

References

1. Chaikind H, Copeland CW, Redhead CS, Staman J. Congressional Research Service. R41664. PPACA: a brief overview of the law, implementation, and legal challenges. Published 2011. https://fas.org/sgp/crs/misc/R41664.pdf. Accessed May 7, 2018.
2. Blumenthal D, Abrams M, Nuzum R. The Affordable Care Act at 5 years. N Engl J Med, 2015;372(25):2451-2458.
3. Centers for Medicare & Medicaid Services (CMS). The Medicare Access and CHIP Reauthorization Act of 2015: path to value. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-LAN-PPT.pdf. Accessed May 7, 2018.
4. Cohen HA. Maryland’s all-payor hospital payment system. The Maryland Health Services Cost Review Commission. http://www.hscrc.state.md.us/Documents/pdr/GeneralInformation/MarylandAll-PayorHospitalSystem.pdf. Accessed May 7, 2018.
5. Centers for Medicare & Medicaid Services. Oncology care model overview. May 2018. https://innovation.cms.gov/Files/slides/ocm-overview-slides.pdf. Accessed May 7, 2018.
6. American Society for Radiation Oncology. Alternative payment models (APMs). https://www.astro.org/Daily-Practice/Medicare-Quality-Payment-Program/APM/APMs/ Accessed May 7, 2018.