Chapter 21: MD Anderson’s Response to the Affordable Care Act; ACA Requirements; Value-Based Purchasing
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Description
In this segment, Dr. Foxhall continues discussion of the Affordable Care Act.
He sketches MD Anderson’s programs to help with financial assistance.
He then talks about the requirement that institutions report on the quality of care. He gives examples to explain what is involved in this process, noting that historically, medical practices have not had enough transparency in care and outcomes. Reporting enables consumers to have a better idea of how well providers are doing. In addition, this information will be used as a basis for determining payment. Next Dr. Foxhall explains that the ACA requires that institutions participate in an Accountable Care Organization. He explains the reasoning for this, and notes that it is not clear how a specialized hospital will engage with them.
Next Dr. Foxhall talks about the ACA’s requirement for Value-Based Purchasing, giving examples of how examining processes has revealed unnecessary costs in deliver of care.
Identifier
FoxhallLE_05_201405013_C21
Publication Date
5-13-2014
City
Houston, Texas
Interview Session
Topics Covered
The University of Texas MD Anderson Cancer Center - The Finances and Business of MD Anderson; MD Anderson and Government; The Healthcare Industry; Politics and Cancer/Science/Care; The Institution and Finances; Growth and/or Change; MD Anderson History; On Texas and Texans
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey Ann Rosolowski, PhD:
Now, what was the reaction—or I shouldn’t say “reaction.” I mean response. Did MD Anderson have to take certain steps or put certain plans in place to counteract the decision in 2010?
Lewis Foxhall, MD:
Well, there wasn’t anything really that could be done about that situation, so we continued our Financial Assistance Program. We have asked—or we have enrollment brokers who work with us to help get people signed up for anything that they might be eligible for, so we work with them to counsel individuals, particularly those that were in the State Highways [unclear] and preexisting-condition insurance plan that the federal government had to then switch over to some sort of coverage. So I think that was helpful. Anybody who is being considered for care here through the Financial Assistance Program already gets counseled, so during the time that the enrollment was open, they were given assistance as was allowable, to help them get registered if they were potentially eligible. So it’s really been our effort to try to get everybody who is eligible, eligible, and to be sure we’ve maintained our support program for those that were not able to sign up. Then we maintain our program at LBJ, which is our oncology program there at the county hospital, to help take care of patients [unclear].
Tacey Ann Rosolowski, PhD:
I’m sorry, I missed—which program was that?
Lewis Foxhall, MD:
LBJ Hospital through the Harris County Hospital District [unclear] Healthcare System, as it’s now called. So we have our own [unclear] program out there, so patients who live in Harris County can be seen by our faculty at that location.
Tacey Ann Rosolowski, PhD:
Have there been any other—because I’m thinking about that decision, the decision in 2010, which is a reaction to but set in the larger context of big changes in the economics of healthcare. How do you see some of those? How do you see that situation and MD Anderson kind of at the point of connection with them?
Lewis Foxhall, MD:
Well, there are a number of other parts of the Affordable Care Act which are those related to reporting, required reporting, quality measures. So we’ve been working with the Alliance of Dedicated Cancer Centers and other groups to be sure we can obtain the appropriate measures that are being asked for and provide input into what measures are reported so that we can participate in that, which we had not been required to do before.
Tacey Ann Rosolowski, PhD:
And what does participation in that organization mean?
Lewis Foxhall, MD:
Well, we work with them in trying to identify measures. The Act required that the exempt Cancer Centers, of which we are one, report. All other hospitals have been reporting for some time, but we have a different patient population, so it was not felt appropriate for us to use the regular approach to things. So we’ve been working with them to try to develop measures and the other national bodies that have been looking at reporting measures. So we’ve started reporting some. We’ll report more over the next couple of years.
Tacey Ann Rosolowski, PhD:
Now, is this the same or different than the value-based care issue?
Lewis Foxhall, MD:
Well, it’s a part of it. So, we report. So, value is often described as cost over quality. So this is sort of how you report your outcomes, sort of measures that can be used to really look at how people do when they’re treated at different facilities. A lot of them are more process-related measures, but they’re [unclear].
Tacey Ann Rosolowski, PhD:
Can you give me an example?
Lewis Foxhall, MD:
Well, whether patients are treated using recommended therapies or what sort of outcomes are related to surgical interventions and things like that. So there are a series of those that are out there that we’re starting to use, and we use more over time.
Tacey Ann Rosolowski, PhD:
And this may be a dumb question, but why is that important?
Lewis Foxhall, MD:
Well, there’s been a concern historically about medical care in general, that there has not been the level of transparency in the outcomes of medical treatment in general, so this is across the board. This is not just related to oncology care but for all sorts of care. People go in and get treated for this or that. There previously had not been much way to know what happened or how they did. So this has really been a national movement over the last decade or so to gradually begin to provide reporting. One of the state agencies I was involved in a number of years ago was the Healthcare Information Council, where we used information from claims data to report on hospital activities, approach those [unclear]. So that is, is if consumers can get a little better idea what sort of job different healthcare providers are doing, then they can make more informed choices about the healthcare that they’re planning to obtain. So that’s sort of the general idea. Rather than asking Aunt Sally, that’s what it is. (Rosolowski laughs.) So at any rate, the—
Tacey Ann Rosolowski, PhD:
Can I ask one other question about that? Because you talked about the benefit for consumers. What is the benefit for institutions in doing that kind of self-review?
Lewis Foxhall, MD:
Well, it can be used for self-evaluation or comparison with other institutions, you know, how our outcomes related to other similar sorts of facilities, all things being equal, which is sort of the hard part. But potentially you can kind of gauge how you’re doing compared to other facilities, and either be proud of it or figure out how you can do a better job. So there’s that sort of aspect, a process improvements aspect.
Tacey Ann Rosolowski, PhD:
What has MD Anderson been doing with the information collected here?
Lewis Foxhall, MD:
Well, it’s tracked on a regular basis, and it involves a number of measures, both clinical as well as patient satisfaction. So we try to understand what the reports mean and try to help feedback into our patient-care processes, our patient-support processes, about what we can do to help improve situations. So in time, that will be used for [unclear] payment for Medicare payments, so there will be a feedback link there that will say that if your measures are not up to snuff or you’re not improving, then you wouldn’t get paid as much in the Medicare system. So there’s all that. Then there’s the whole value-based purchasing sort of arrangement. Affordable Care Act also calls for implementation of accountable-care organizations, which are really demonstration projects to determine if groups of physicians or hospitals can work together to help provide better care at a lower cost. So it’s all sort of pursuing this triple-aim idea that we talked about before.
Tacey Ann Rosolowski, PhD:
Can I ask one other question? I was curious, since this tracking of processes, I hadn’t—I mean, I’d heard a little bit about that, but I’m wondering is there a new department that’s been established or office to take care of processing that information [unclear]?
Lewis Foxhall, MD:
Well, we have a number of groups. We have a Process Improvement Office. They’re involved in it. Dr. Ron Walters [phonetic] in Medical Affairs is involved in some of that, Dr. Feeley and his team with the Institute for Cancer Care Excellence. So all those groups are really kind of looking at what the measures are, what the measures should be, which ones we think are appropriate for us, and trying to argue for that. You know, it’s really not our decision, but we can provide input into it to try to get measures that seem to be reasonable things that we feel represent what we do and how we do it.
Tacey Ann Rosolowski, PhD:
Interesting. I’m sorry I interrupted you. You were talking about the participation in accountable-care organizations. Have there been—is there more on that?
Lewis Foxhall, MD:
Well, this is a new aspect or new delivery model that’s part of the Act that’s been encouraged by—it was part of the Medicare program. It can be done outside the Medicare program, but there are hundreds of these across the country that are starting to form. It’s not exactly clear how MD Anderson or any other subspecialty hospital could really engage with those sorts of organizations. So here in Houston, for example, the more general-care organizations have begun to look at that. So like Memorial Hermann system and groups like that, that have a broad primary-care base, that have multispecialty clinical operations, are trying to [unclear] those. So the idea is that they would eventually work with insurance companies to take risk and provide some sort of payment mechanism that’s based on quality and outcomes, and that they’re accountable for the care that they deliver as well as just the fee-for-service sort of arrangement. So those are still kind of early in the process.
Tacey Ann Rosolowski, PhD:
Why isn’t it clear how an institution like MD Anderson would dovetail with that [unclear]?
Lewis Foxhall, MD:
[unclear] it’s just not part of the thing. It’s really set up for general-care organizations, not subspecialty. So it requires a broad population base and a primary-care infrastructure and things that we just don’t have. So we may be able to contract with them, provide some pieces of care for them related to cancer sort of things. It’s just not worked out yet.
Tacey Ann Rosolowski, PhD:
Okay. So that’s kind of in the process of figuring out how that linkage will take place.
Lewis Foxhall, MD:
Yeah, how or if it’ll take place. It’s just not clear.
Tacey Ann Rosolowski, PhD:
Right. Interesting.
Lewis Foxhall, MD:
But, anyway, it’s just a new approach. And then there’s value-based purchasing, which [unclear] and pay-for-performance initiatives, which are actually specifically targeting specialty centers like ours. So that’s kind of what Dr. Feeley and his team have been trying to sort out, how we can get ourselves organized to participate in those sort of ventures.
Tacey Ann Rosolowski, PhD:
What sort of issues are coming up with that? What are some of the challenges?
Lewis Foxhall, MD:
Well, Dr. Feeley’s whole team has kind of focused on all that effort. He’s trying to understand what we spend on care, how that care is managed, and what we can do to address cost of care. So there have been a number of initiatives across the institution for the last several years to try to identify costs that are not necessary, drive those down, and try to provide better efficiencies in [unclear] care.
Tacey Ann Rosolowski, PhD:
What’s an example of a situation in which there would be costs that were unnecessary?
Lewis Foxhall, MD:
Well, if we have procedures in the operating room and they pull out every instrument known to exist for a given surgery that only a few are ever used, but at some point somebody asks for something, so they have it ready to go just in case. It’s better done if you determine exactly what’s necessary or at least have some group-thought about what really needs to be provided and reduce the number of things that are sterilized and opened and not used and put back. So just any way we can identify ways to [unclear] or try to improve quality if there are ways we can provide better services or prepare patients for surgeries, such as head and neck surgery, giving them some exercises or instructions before they get operated on so they’re better able to deal with the surgeries that may impact their quality of life afterwards. So there are all different ways to approach it.
Recommended Citation
Foxhall, Lewis E. MD and Rosolowski, Tacey A. PhD, "Chapter 21: MD Anderson’s Response to the Affordable Care Act; ACA Requirements; Value-Based Purchasing" (2014). Interview Chapters. 870.
https://openworks.mdanderson.org/mchv_interviewchapters/870
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