Edit Topic Article SNMMI: Healthcare reform-cloudy with a chance of cuts

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MIAMI—The current U.S. political arena is characterized by dichotomy. Most pundits, Beltway insiders and ordinary citizens agree there will be both political stagnation and little change in the next six to 18 months. Despite the uncertainty about what lies ahead, some broad predictions about healthcare are likely to withstand the shuffle, Brian P. Carey, Esq, partner at Foley Hoag in Washington D.C., said during the annual meeting of the Society of Nuclear Medicine and Molecular Imaging (SNMMI).

“There will be a fundamental shift in the financing of healthcare. This is the largest driver of the federal deficit,” Carey said. Three broad trends are converging. The push to cut prices will continue as coverage (and utilization) expands. The definition of healthcare value is in evolution, particularly in terms of outcomes and costs. The concept of comparative effectiveness will inform the development of evidence for new treatments and technologies, said Carey. Finally, integration of care delivery will be incentivized.

The most prominent example of incentivization may be the accountable care organization (ACO). Although the fee-for-service payment model will never disappear completely, Carey said that the shift away from fee-for service has bipartisan support.

ACOs are available in three flavors: the Medicare Shared Savings Program, which encourages providers to create or join ACOs focused on Medicare beneficiaries; Pioneer ACOs, which consist of approximately 35 integrated health systems employing coordinated care or bundled payments; and commercial payor ACOs.

One of the primary criticisms of ACOs is that the model basically reproduces the managed care concept, he said. ACO proponents claim that the model improves the shortfalls of managed care, which was viewed as a gatekeeper to limit utilization. In contrast, ACOs aim to encourage coordinated care, using health IT and quality metrics, said Carey.

Although ACOs have grabbed the lion’s share of the healthcare delivery and financing spotlight, other payment reforms also will emerge. Bundled payments and risk-based reimbursement models are in the works.

Finally, although uncertainties about change and the prospect of cuts are unsettling, Carey ended on a positive note. Early ACO findings are limited, but promising. Private payors engaged in ACO projects have reported decreases in hospital readmissions and reduced costs.