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With less than 8 months to go until the election, we’re down to two or three realistic presidential candidates: Joe Biden, Bernie Sanders, or – for another term – President Trump.
A poll by the Kaiser Family Foundation suggests that healthcare is the top issue for voters going into this year’s election.
With healthcare reform a key priority for 2021 and beyond – and with value-based healthcare (VBHC) a central component of the ongoing reform today – what could the next phase of VBHC implementation look like under each president?
VBHC implementation began in earnest under President Obama’s administration as part of the Patient Protection and Affordable Care Act (ACA) in 2010 and MACRA in 2015. Prior to that, there had been calls for major health system reform that focussed on quality and cost.
So far, the primary tool to help us get there has been the value-based payment model. Whilst it has all felt like an ongoing experiment with as much failure as success, the end goal has remained the same.
The ultimate aim is a health system that delivers top quality at the lowest cost by design. But, given the fragmented and transactional nature of the U.S. health system with its multiple stakeholders, incremental movement in this direction is being encouraged through value-based payment of services, or value-based incentives.
Even though the current administration has sought to strip significant parts of the ACA away, VBHC has continued to run its course. Indeed, CMS Administrator Seema Verma and HHS Secretary Alex Azar have continued to champion VBHC.
So, with the elections looming – what could VBHC look like next?
Trump – Hard to predict
We haven’t heard much from the current administration on what healthcare would look like after the election, let alone any specific information on VBHC. The recently published 2021 budget includes some mention of value in healthcare, “The president’s great health care vision will ensure better care at lower costs,” including a target of $844 billion in savings over the next decade.
How exactly those savings will be achieved, however, isn’t clear. Neither is the future of the ACA. From what we have seen so far, there will be continued attempts to repeal or strip down the ACA. The case for this – already struck down twice – will be heard in the Supreme Court in the fall, potentially before the election.
Whilst the implementation of mandatory value-based payment models has largely been made voluntary, they are still in play. One of the contextual narratives being pushed by the current administration is that of value-based competition, which is in line with the broader policy play we are seeing.
Only a few days ago, HHS published their final interoperability and data blocking rules, which will facilitate better exchange of data between different healthcare stakeholders – something that would make VBHC implementation a little easier.
So, under Trump, VBHC would likely continue. However, the initiative would continue to lie with the healthcare sector itself, rather than the administration.
Biden – Obamacare 2.0
Joe Biden’s plan is all about protecting and furthering the ACA. Remember, Biden was Obama’s VP and a fellow champion of the ACA when it was put together a decade ago.
Biden and his team have been very forthcoming about their healthcare plan in the Democratic primaries. The first step would be to stop the reversal of the ACA that we’re seeing under the Trump administration. There are other elements that are also taking center stage, such as the public option. We would expect VBHC implementation and value-based payment model experimentation to pick up where it left off under Obama – hopefully with some tweaks based on lessons learned thus far. For example, we’ve learned that provider penalties for missed value targets can lead to unintended consequences – physician avoidance of high-risk patients, non-participation in programs, and so on.
We’ll likely see more of an intentional push under Biden’s government, just as we saw under Obama. More experimentation, more guidance, and more involvement from the administration overall.
Sanders – a different approach to value
As we know, Sanders is going for the jugular when it comes to a lot of things – healthcare among them. He is keen to scrap VBHC in its current form by ending the value-based payment models currently in play. His aim is to transition the U.S. health system into a single-payer system through Medicare-for-All, which aims to deliver value by design – rather than through transaction.
U.S. healthcare is expensive for many reasons. Labor, goods, and administrative costs are higher than in other countries. Price transparency is lacking. And so on. A single player system would indeed allow for better negotiation on price.
However, other countries with single payer systems have similar cost and quality issues, albeit to a lesser degree. These health systems are also implementing VBHC, but their starting point isn’t as bad. Some already have robust data architectures with unique patient identifiers and national data registries that are decades old. Indeed, much of the inspiration for VBHC in the U.S. has come from single-payer European health systems, where care is far more integrated and the need for transactions far less ubiquitous.
Even in a single-payer system, outcomes and costs would need to be measured and optimised, especially because the funding requirements for this plan are so significant – around $30 trillion over 10 years (and many deem this to be an underestimate). Value simply can’t be left out of the picture, and a single-payer health system will simply open the door to implementing VBHC in a different way.
Whichever administration is at the helm come the end of the year, it is likely that VBHC as we know it will continue to run its course – slowly under Trump, quickly under Biden, or, in the less likely scenario (as things stand) where Sanders wins – under a different paradigm altogether.