ACA, MACRA: What they mean for you, patients

David F. Penson, MD, MPHAlthough the Patient Protection and Affordable Care Act (ACA) remains a complicated and controversial piece of legislation, it’s clear that the way urologists provide care-and how they are paid for that care-will change. In this interview, David F. Penson, MD,MPH, discusses the ACA’s impact on urology, the pros and cons of a single-payer system, and why collecting and reporting outcomes data will be crucial going forward. Dr. Penson is chair of the AUA Public Policy & Practice Support Council (formerly the Health Policy Council) and chair of urology and director of the Center for Surgical Quality and Outcomes Research at Vanderbilt University, Nashville, TN. He was interviewed by Urology Times Editorial Consultant Philip M. Hanno, MD, MPH, professor of urology at the University of Pennsylvania, Philadelphia.

The Patient Protection and Affordable Care Act was enacted to increase the quality and affordability of health insurance, lower the uninsured rate, and reduce health care costs. Despite raising the number of citizens covered by insurance and eliminating many of the negative features of private insurance, a near majority of Americans still oppose the ACA, even though they approve of most of its features. How do you explain this? 

The ACA has been politicized. Health care is the third rail of American politics-how do we pay for it and who gets it. It’s a huge law, and people don’t really go through the details. They get their information from MSNBC or Fox News, depending on what their political leaning is.

It’s such a big law, and there are pros and cons. Parts of it are very good for patients, providers, insurers, and businesses, and there are parts that are not so good.

Remember that when Medicare was passed back in the mid-1960s, a lot of people and groups were initially opposed to it, including the American Medical Association. But ultimately, Medicare has been an incredible boon for physicians. People don’t really understand all the nuances. This is part of what I do for a living and I’ll be frank with you: It’s hard for me to grasp all the nuances. This is partly because those nuances are not spelled out yet, which is how legislation often works. You get a general directive in a law, but it’s the regulations that follow afterwards that really put out the details.

In the end, people hear what they hear on television, read what they read in the newspapers, and they go with their political leanings. The reality is much more complicated.

NEXT: "We’re going to have to show value for our interventions."

How do you see the Affordable Care Act in terms of affecting costs of urologic care?

You can simplify what the Affordable Care Act is designed to do in three broad buckets: improve access for patients, improve quality of care, and reduce costs.

You talked about improving access to health care. It’s done that so far. But in order to improve access, you’ve got to reduce costs. What we are seeing with the ACA, and what we’re going to see more and more in the next phase of implementation, are greater cost-control mechanisms. We’re going to feel this changing the way we practice urology. Some things are going to be harder for us to do. We’re going to have to show value for our interventions.

And now, with the Medicare Access and CHIP Reauthorization Act (MACRA), the recent law that repealed the sustainable growth rate, I think we’re going to see a change in the way we get paid. In January, Health and Human Services Secretary Sylvia Mathews Burwell basically said, “We’re going to get away from fee for service and move toward paying for value.” I think that’s going to happen in some degree. That’s going to affect the way we practice urology. It’s not simply going to be that we’re going to do more, more, more because patients want it and, frankly, it keeps the lights on. It’s going to be that we’re going to try to “do smarter,” because that’s what patients need. If we do smarter, there will be more resources in the system to help us keep the lights on.

NEXT: "I don’t see how the ACA improves urologists’ reimbursement."

How do you see ACA affecting actual incomes to practicing urologists and their share of the health care dollar?

There’s a bit of bad news coming. I don’t see how the ACA improves urologists’ reimbursement; if anything, I think it’s going to negatively impact it. It’s not just urologists, and it’s not just physicians; it’s across the board-hospitals, pharma/device companies, etc. One of the ACA’s key tenets is to control costs. To control costs, you have to either reduce utilization or pay less. There’s not much in the bill to reduce utilization, so the only other option is to pay less. I think in the long run, we’re going to see major incentives to physicians to move away from the traditional fee-for-service model to more capitated payment models.

Also see: States address payer interference with physicians' orders

And that’s the key point. If you’re in the traditional fee-for-service model, you’re going to be working harder and getting paid the same or less. On the other hand, if you’re willing to explore these alternative payment models and new strategies around reimbursement and improving quality, you could end up doing quite well. But you have to be thoughtful; you have to be out of the box and ahead of the curve.

So will urology have a choice?

Yes, we will have a choice. Under MACRA, in 2019 there are going to be two separate payment tracks for providers. One is called the merit-based incentive payment system (MIPS). That’s fee for service wrapped in with pay for performance. If you choose to go down that road, you’ll still be able to do fee for service and get paid, but Medicare is going to set the quality bar very high and I think private payers will follow suit. I think some providers will find that they can’t meet that bar, and they’re going to make less money.

The other option is the alternative payment model, where you participate in something like an accountable care organization and are part of a bundled payment plan. That’s where I think there’s potential for providers to maintain their reimbursement or perhaps even improve it by practicing more efficiently.

NEXT: Measuring quality

While it may be too early to tell, what are some of the issues as they pertain to ACA and health care outcomes that we should be wary of?

I think we all have to recognize that we’ve spent the last decade in the quality improvement domain measuring our processes of care, but no one really bothered to see whether that made a difference to the patient. There’s a growing realization that this is the wrong way to measure the quality of our care, and that the right way to measure quality is to look at our outcomes. If you do a procedure for female stress incontinence, they’re not going to look at whether you did a cystoscopy; they’re going to look at whether the woman was dry a year later. They’re going to start using patient-reported outcomes.

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In some regards, this is a very good thing, because you do want to know how patients are doing, and because that stimulates quality improvement and innovation. The danger, of course, is that some docs see sicker patients than others; some docs see women and men who have greater problems than others. How do you control for that? How do you do the risk adjustment? That’s not in the legislation, and it’s not clear to me. That makes me nervous. We’re going to have to start thinking about and measuring our own outcomes.

The AUA has the AUA Quality Registry (AQUA), which is a very important initiative. The AQUA Registry is starting in prostate cancer and will expand to other diseases. This is going to be something providers can use to measure their outcomes and also report outcomes to Medicare. The AUA plans to have it credentialed by the Centers for Medicare & Medicaid Services as a certified quality-reporting tool. It will also allow urologists to meet the requirements of MIPS.

We’re going to have to collect and report data; there are no two ways about it. There’s going to be a cost to us for collecting the data, but hopefully there will be benefits in recognizing what works and what doesn’t, and having better outcomes.

NEXT: "If you expanded Medicare to everyone, it would hurt a very powerful industry-the health insurance industry."

Why do we need such a complicated system? Would simple expansion of Medicare to people under 65 have been a less expensive way to accomplish these goals?

The short answer is “maybe.” Again, it gets into politics. Medicare costs were expanding exponentially. To some degree, you could say, “To improve access, just make Medicare available to everyone.” That would have been a simpler and easier way to do it. But you still would have had to deal with the question, “How do we control the cost?”

Frankly, there are politics and business interests involved. If you expanded Medicare to everyone, it would hurt a very powerful industry-the health insurance industry. That creates a lot of jobs in this country, so there’s always a balance to things.

With the advent of the ACA, what is the place of the VA system of health care? Would it be more cost effective to shut it down and serve veterans in the private system?

The VA is a unique health care system that serves an important role now and will continue to serve a role going forward. How does that change over time? I don’t know. I think there are a lot of veterans who like getting their care in the VA system. When they’re given the opportunity to go into the private sector, many of them choose to stay in the VA. For some vets, the VA is easier to navigate than the private health care system.

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But I don’t know how it plays out, because if you have expanded access for everyone, and veterans now have Medicaid, private insurance, or Medicare, then maybe we’re better served taking those resources and putting them somewhere else. Time will tell; I just don’t know.

In 2006, by a margin of more than 2 to 1 at 69 to 28, those surveyed by Gallup said the federal government should guarantee health care coverage for all U.S. citizens. By late 2014, Gallup found that this percentage had fallen 24 points to 45%, while the percentage of respondents who said health care is not a federal responsibility doubled to 52%. How do you interpret this massive change in the perception of health care?

I think it’s just a reflection of American politics and the experience with the ACA as fed to the American public by the media. It comes back to politics. People see the ACA as federalization of health care, and they’re told, “It’s no good, it’s not working.” Depending on their political leaning, they either accept that or they don’t. I think that poll just reflects the political mood of the country.

NEXT: "Urology is not specifically addressed in the ACA, but there are pieces of it that have a tremendous impact on urology."

What are some unique aspects of the ACA with regard to urology?

Urology is not specifically addressed in the ACA, but there are pieces of it that have a tremendous impact on urology-unintended consequences, for lack of a better phrase. The example that comes to mind is the United States Preventive Services Task Force.

Prior to the ACA, the USPSTF was just a primary care committee that made recommendations that were not generally impactful. I won’t say no one paid any attention to it, because that’s not true, but it didn’t really have any power or clout. The ACA ties copayment for preventive services to USPSTF recommendations, so if you get an A or a B, there is no co-pay required for that service. If the USPSTF were to recommend prostate cancer screening and give it a grade of  “A,” then men wouldn’t have to pay anything to get their PSA checked. There would be no co-pay. The flip side is if a service has a grade of C or a D, Medicare is not required even to cover it.

Have you read: MACRA’s impact will be felt beyond repealing SGR

So you’ve taken this committee, which before was just sort of a thought panel for primary care, and given it control over reimbursement, and it’s had a tremendous effect. If you look at prostate cancer screening rates and prostate cancer incidence rates, they’re clearly dropping since the recommendation. That’s an unintended consequence of a single line or two in the ACA. There are other examples throughout, so while urology is not specifically mentioned, there are a lot of pieces in there that have turned out to have an impact for us specifically.

So you think it is going to change the practice of urology as we move ahead?

Absolutely. It’s going change the practice of medicine overall, but urology specifically. It’s going to affect us in a lot of different ways. Many of the conditions we treat are “quality of life” issues. They’re important to patients, but they may not come out ahead in the value equation. We are continuing to fight for men’s health initiatives and things like post-cancer-treatment care for erectile dysfunction/sexual dysfunction. But in the ACA, that may not be prioritized, or other things may get prioritized ahead of it. It really is going to change the way we do business.

NEXT: "I don’t think the ACA is going to have a great effect on hospital administrative costs."

In the United States, hospital administrative costs account for 25% of total hospital expenditures, the highest administrative costs in the world by far. What drives these costs, and does the ACA help to push them down?

I’ll answer the second question first. I don’t think the ACA is going to have a great effect on hospital administrative costs. Furthermore, the ACA is unlikely to have a great effect on insurance administrative costs. In fact, it may even increase hospital administrative costs because they’re changing the way hospitals operate, pushing them toward consolidation and networks, and that may require greater administration.

What drives high administrative costs? I don’t know, frankly. It’s easy to say it’s hospital administrator salaries. Certainly, a lot of docs would say that, but I’m not sure that’s fair. I do feel that many hospitals don’t include the perspective of the practicing physician in their administrative structure. If they were to do that, they might realize some savings and not just lower their administrative costs, but also their practice costs. There’s been a movement away from including physicians in hospital leadership. I think that’s a mistake, because if you’re interested in trying to figure out how to practice health care, shouldn’t you be asking people who practice health care, as opposed to an MBA? Yet that’s still how it’s structured.

It seem like physicians gave that up a long time ago.

Yes, we did. I’m not pointing fingers though. We have no one to blame but ourselves for not inserting ourselves into the picture. But it’s very hard to be a practicing physician and run a hospital business. There’s no easy model to make that work. On the other hand, if we want to have control over it, we have to find a way to assert ourselves.

As you’ve noted, the ACA is focused on increasing access, improving quality, and decreasing costs. However, achieving one goal at the expense of the other two goals may actually exacerbate the health care crisis in the country. How should we approach this dilemma?

It’s a real problem, because if you think about it, you can probably have two of those three goals, but you can’t really have all three. If you improve access, you may or may not improve quality. The cheapest health care, however, is no health care. If you don’t pay for an operation, it doesn’t cost you anything. It’s not going to work out well for the patient, but you just saved a lot of money. That’s obviously not high-quality care.

Read: Practice ‘efficiency’ is not a dirty word but a noble goal

There is this feeling out there that perhaps higher quality care is going to be cheaper, but I think that’s a little “Pollyanna”-ish. There’s also a belief that improving access is going to save us money because we’ll have primary prevention on the front end as opposed to spending a lot of money on the back end. I’m not sure I buy that either.  I think we’re going to have to accept the fact that we can achieve two out of three goals, but getting all three just doesn’t seem realistic.

I want to make it clear that I’m agnostic, not just in my role in the AUA, but in general. The ACA is a large piece of legislation. There are pieces that are positive and pieces that are negative, in my opinion. I am neither a strong supporter nor a strong opponent; I just play the hand I’m dealt. The reality is that the ACA is in place now, and it’s highly unlikely that it’s going to be repealed in toto. People who feel that it will be repealed are unrealistic. But there are opportunities to modify it.

If you look at the experience in Massachusetts-and despite what Republicans say, the Massachusetts health care bill that Gov. Romney put in place is really not all that different than the ACA-they’ve made numerous major modifications to that legislation over the years. We’re going to continue seeing major modifications to the ACA. For example, there are calls to get rid of the Independent Payment Advisory Board component. That’s an interest of the AUA and a lot of organized medicine, and I think we’re going to see that go away. That panel is a mistake, because all it does is replace the SGR with a 15-person panel doing the exact same thing. It’s not the right way to control costs.

We’re going to see a lot of changes. But back to your original question, I just don’t see how we’re easily going to get to all three goals.

NEXT: "There are some real pros to the idea of a single-payer system...there are some real cons as well, though."

As we’ve discussed, the U.S. has the highest hospital administrative costs in the world. Administrators’ salaries dwarf physicians’ salaries, and the added value sometimes seems questionable. Is this an argument for a single-payer system?

There are some real pros to the idea of a single-payer system, and there are some strong supporters of it; there are some real cons as well, though. Personally, I can see some advantages, because it would greatly reduce administrative costs-I think-but the devil is in the details. There are flip sides to it that might not be as positive. I think people are very concerned about a single-payer system because of the centralized control and the fact that it might actually reduce access to patients for certain interventions.

The United Kingdom has a single-payer system, the National Health Service, but there is also private insurance on top of it for people who want it. To me, that is a very appealing system, because it guarantees everyone a basic coverage set that is taken care of through the social safety net. But if they want more, they have to get it out of their own pocket. Other countries don’t allow that.

Also see: Why organized medicine needs to operate more like Google

Again, there are Americans who are convinced the ACA was designed to create a single-payer health care system. I don’t believe that. I think the ACA was designed to do away with employer-based health insurance. I truly believe that.

I’m going to mention a few components of the ACA. If you think any of them are important in terms of affecting urology, please expound on them: value-based purchasing, pay for performance, accountable care organizations, bundled payments, and patient-centered medical homes.

The short answer is that they’re all going to be very important for urology, particularly ACOs and value-based purchasing. They’re really going to push providers-not just urologists, but all providers-toward alternative payment models. We’re going to go there, maybe not willingly, but they’re going to make it so much more difficult to stay on the fee-for-service side that it’s going to be easier to switch. For urologists, that’s going to be a very challenging move.

The concept behind a patient-centered medical home is that the “father” of that home is the primary care provider, who acts as a “care coordinator.” So where does the urologist fit in? If the urologist is dependent on the primary care provider to coordinate the care and make sure the patient gets to the urologist, we’re going to have to be very proactive in how we structure those agreements so that it’s good for our patients and good for us.

I truly believe-and I may be naïve in this regard-specialty care is going to come out all right in all this, because we’re effectively going to be able to say “we’re not going to provide that specialty service at that reduced price” and the primary care provider is not going to provide the care in our place. I am not talking about forming a monopoly or collusion. I’m just saying that there is a natural market value for specialty care (set by the economic principles of supply and demand) and when the people who run the ACOs try to negotiate prices below the true market value, specialty providers are simply going to balk, as it won’t be worth it to them. Now, in patients where specialty care is “discretionary,” these patients may end up not getting those services, resulting in lost revenue to the provider, but I think that we’re going to find we’re in a fairly good negotiating position over time, as I truly believe that much specialty care is necessary (as opposed to discretionary). There just may not be as much volume as we’d like.

NEXT: An increase in discretionary surgery?

Insurance expansion in Massachusetts was associated with increased rates of discretionary surgery and a concurrent decrease in rates of non-discretionary surgery (JAMA Surg 2014; 149:829-36). If similar changes were seen nationally under the Affordable Care Act, what impact would you expect in urology?

I know the study you’re referring to. It’ll be interesting to see if that trend continues, because when people get new access to insurance, they tend to take advantage and have operations they had put off before. We never published this, but we looked at all-payer data from Texas and compared radical prostatectomy rates in patients age 63-64 to those age 65-66. We chose these two groups because Americans become eligible for Medicare when they turn 65. While we would have expected similar prostatectomy rates between the two groups, given they are so close in age, the older group (65-66) actually had a considerably higher prostatectomy rate. We never published this because we were concerned about risk-adjustment, as we didn’t have any information regarding grade, stage, PSA, etc., but the results are thought provoking and are similar to the findings in Massachusetts. The question is “why?” I think it was because patients would put off discretionary operations until they obtained Medicare insurance. In Massachusetts, I think, there was a sort of rush; “Oh, I didn’t have insurance, but now, thanks to this new law, I have it-so I’m going to get that knee replacement I have been putting off because I didn’t want to pay for it.”

I can’t explain why there is a decline in non-discretionary surgeries. One possibility is that they didn’t have the capacity given the increase in discretionary surgeries. The study you mention was limited to Massachusetts, and I don’t know if we will see that on a national level. Only time will tell.

Can you comment on the Urological Surgery Quality Collaborative?

The Urological Surgery Quality Collaborative (USQC) and MUSIC (Michigan Urological Surgery Improvement Collaborative) are incredible programs. We always have room to improve the care we deliver. I’m a firm believer that we do a pretty good job, but I’m also a firm believer that we can always do better.

Unfortunately, the quality improvement has become all about cost. When the government used the top-down, pay-for-performance approach, we started studying to the test. In other words, how can we be compliant with the measures so we get paid?

What’s different about USQC and MUSIC-credit for these goes to Drs. Jim Montie and Dave Miller at the University of Michigan-are that they’re bottom-up approaches. They’re truly about doing a better job with the care they deliver. These are collaboratives of urologists who are friendly and non-competitive; in fact, there is an agreement in most of these collaboratives that participants will not advertise on this and will not stick it to one another. The goal is to make everyone better, because it’s good for the patients. A rising tide lifts all boats-that’s how you get quality improvement.

USQC, which Vanderbilt is part of, is a good project. But what they’re doing in Michigan, where all of the urologists in the state and the primary insurance payer are on board, is absolutely incredible. If you want to improve quality, that’s how you do it. Engage the providers, and don’t use finances as the great motivator. Give people credit; most urologists want to do the right thing. The insurer said, do this and we will leave you alone and we will support it. Suddenly, they’re having better outcomes and are doing better things for the patient, because it comes from the bottom up, not the top down.

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