The repeal of Obamacare could affect more than just a series of controversial taxes and mandates, as the healthcare law was responsible for jumpstarting changes to the way doctors care for patients.
If the law is repealed, it could gut some of the far-reaching reforms that were meant to tie payments to doctors and hospitals to the quality of care they provide, some experts say.
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Chief among those reforms is accountable care organizations, which is a group of doctors and hospitals that band together to better coordinate care. When such an organization succeeds in improving care and lowering costs, doctors and hospitals receive a share of those savings. But if quality doesn’t reach a threshold, the organization receives no bonuses and in some cases could receive less money from the government.
An expert noted that while accountable care organizations that receive payments from Medicare may be in trouble, as those payments stem from Obamacare, ACOs that are in the private sector and use insurers as the payer will remain.
About 28 million people were covered by an accountable care organization at the end of January. About 8.3 million are in Medicare ACOs, 2.9 million are in Medicaid ACOs and the rest are in private-sector ACOs, according to data published in the journal Health Affairs.
Through Obamacare’s Medicare Shared Savings Program, which handles Medicare payments for ACOs, an organization can receive higher payments from Medicare if it meets certain quality measures but gets less if it doesn’t.
One healthcare analyst said she believes the accountable care organizations will disappear if Obamacare is repealed and replaced with a Republican alternative.
“ACOs have not been the panacea the president projected,” said Sally Pipes, president and CEO of the right-leaning think tank Pacific Research Institute. “The ACOs have not brought about the kinds of savings that were projected.”
In 2015, more than 400 ACOs were operating, but only 125 qualified for shared savings payments by meeting quality performance measures and saving enough money, the Centers for Medicare and Medicaid Services said earlier this year.
Other experts said that ACOs likely would survive any repeal, as the idea of healthcare payments based on the quality of care garnered bipartisan support.
“There are far more Americans enrolled in private-sector ACOs than in Medicare ACOs,” said Josh Seidman, senior vice president of the healthcare consulting firm Avalere. “There is so much activity going on even if Medicare were to stop.”
Private-sector ACOs reach an agreement with insurers to be the payer instead of Medicare or Medicaid.
“If they keep costs at a certain level, they would share in some savings and if they don’t they won’t share in savings,” Seidman said. “In some cases they would be at risk for losses.”
Seidman added that the biggest change for physicians is likely safe as it has nothing to do with Obamacare.
The Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 included a slew of reforms to how physicians are paid under Medicare. That law was passed by a wide bipartisan margin and isn’t related to Obamacare, Seidman said.
However, he said some payment models could go by the wayside under a Trump administration.
Chief among them is a bundled payment program that links payments for multiple services that a Medicare beneficiary gets. For instance, comprehensive joint replacement bundles link payment and quality measurements for hip and knee replacements.
“There is potentially less support for that among Republicans,” Seidman said.
A letter from nearly 180 lawmakers in September took umbrage with the Obama administration’s plans to make the joint replacement bundled payment model and two other bundled models mandatory for physicians instead of voluntary.
While Republicans opposed such bundled payment models before, it remains to be seen what will be left intact from Obamacare.
Republicans have signaled that the plan to use a method called reconciliation to get an Obamacare repeal through the Senate and bypass a filibuster, but they haven’t coalesced around a full replacement plan.
Republicans could keep Obamacare intact for a few years while they decide on an alternative.
