Former Senator Bill Frist, MD, opened the 2017 Cancer Center Business Summit in Las Vegas, NV, in early February, with a smile and a warning that we are in unfamiliar territory as the new Congress and the new administration move into 2017, territory that may occur only 2 or 3 times in a century. He said that, “For the first time since 1929, the GOP [the Republican Party] controls Congress, the White House, most governorships and state houses, as well as the Supreme Court.”
This change was not as sudden as some may think, Dr Frist said. He suggested that for the moment, we should forget the implications of President Trump’s campaign and election. Rather, during that period, America and the will of the American people was already “moving toward a world of less intrusive government, of fewer regulations, of more markets, and more focus on the state governments than on the federal [government].” He pointed out that even during President Obama’s tenure between 2008 and 2015, Senate Democrats lost more than 10% of their seats, and House Democrats lost more than 19% of their seats. He also noted that on the state level, the number of Democratic governors decreased by more than 35%.
Dr Frist expressed hope that oncology practices and patients with cancer can expect a world with fewer mandates, fewer regulations, less rigidity, more consumer choice, and more branding, where we as a society can speak to Washington, DC, and the states to effect change where we feel it is necessary. Yet, even at the state level, he says, we can expect to continue to see change. The midterm elections of 2018 will see Democrats defending seats in 25 states, 10 of which President Trump won during his campaign. By comparison, the Republicans will be defending only 8 states, and Mrs Clinton only won 1 of those states.
Currently, only 5 states remain what can be titled as “true blue states” that have a Democratic governor and a Democratic majority state legislature, namely, California, Oregon, Hawaii, Rhode Island, and Connecticut. It is very likely that the GOP will retain control of Congress through the next major election cycle, he says. During his presentation, Dr Frist mentioned more than once that we should stop worrying about outspoken legislators, because, given the makeup of the Senate and the House, they have effectively been negated.
Shaping a New Healthcare Reform
These political changes will result in a new reality for the United States, which will shape our healthcare reform. The 115th Congressional agenda has several ambitious priorities, of which several of its top goals relate to healthcare, including:
- Repealing or replacing the Affordable Care Act (ACA)
- Addressing FDA user fees
- Children’s Health Insurance Program (CHIP) reauthorization and Medicare extenders
- Rollback regulations
- Raising the debt ceiling, and passing the 2017 and 2018 budgets.
The 2015 GOP Reconciliation Bill offers the best perspective on the possible direction that healthcare reform may take as early as mid-March or early April 2017; this could include repealing the individual and employer mandates, by eliminating the related tax penalties, ending all premium subsidies, and ending Medicaid expansion.
As with any president, the power of the pen in creating executive orders is strong. President Trump has noted that the repeal of the ACA is a top priority, as well as reducing the burden of regulations on business in the United States. The administration is able to effect regulatory changes through the Department of Health & Human Services (HHS) with Tom Price, MD, at the helm.
Possible changes could include rewriting many of the ACA rules that were created by the HHS under the Obama administration, using Medicaid waivers to give individual states more flexibility, and adjusting the funding and direction of the Center for Medicare and Medicaid Improvement (CMMI). Dr Frist further stated that we should expect the CMMI to continue, because it is the only true innovation going on in Medicare today.
In addition, he expects that “the Trump/Pence era will drive significant new growth in bundled (value) payments in both the commercial and governmental payer markets.”
Leaders to Watch
With the shift of political power across America, besides the president, the key players to watch are the leaders in Congress, including the Senate Majority Leader Senator Mitch McConnell (R, KY), party leader Senator Charles Schumer (D, NY), and the Speaker of the House of Representatives Paul Ryan (R, WI). In addition, governors from across the country will be more influential than in recent years in shaping the new America.
To help put future healthcare reform in perspective, Dr Frist asked the audience to look back at the 3 previous legislative events of President Bush’s 2003 proposal about block granting Medicaid, the Medicare Part D enhancement, and the failed effort to privatize Social Security. He noted that there are 3 lessons to be drawn from those initiatives:
- Don’t discount the influence of governors in federal politics
- Build bipartisan alliances, because unilateral accomplishments rarely endure: Medicare Part D enhancement of 2003 was bipartisan and was passed by 42 Republicans and 12 Democrats; Obamacare was passed by 60 Democrats and no Republicans
- Do not forget the third rail of politics—Social Security and Medicare. President Trump has pledged not to cut Medicare, which is the most important driver of the increasing national debt, so unfunded mandates must be addressed in the future.
The Future of Oncology
What does the future hold for oncology? Dr Frist pointed to the Oncology Care Model (OCM) as the most significant growth in bundled payment participation in 2016, and expects it to continue. The OCM is one of the first models that qualifies as a specialist-driven alternative payment model within the Medicare Access and CHIP Reauthorization Act of 2015. He predicts that the fate of the OCM will depend on the successful integration of palliative care and population health management to reduce inpatient hospitalizations and share responsibilities for achieving quality metrics, and a reduction in the percentage of spending on chemotherapy.
Dr Frist also believes that palliative care is a core competency of oncology, but says it is difficult to support the volume in the fee-for-service system that is needed to pay for a palliative care provider and team. One solution he thinks may be very likely is the development of an alternative payment model for palliative care that includes outcomes-based payments with achieved quality metrics and cost reduction for prognostically appropriate care or avoidable or preventable costs.
On review, there are at least 4 OCM metrics that can be met by a palliative care provider:
- The proportion of patients who died after being admitted to hospice for 3 days or more
- Pain assessment and management
- Preventive care and screening for clinical depression and a follow-up plan
- Patient-reported experience of care.
He cited a partnership between Aspire Health and Tennessee Oncology as an example to consider.
Dr Frist closed his session by answering follow-up questions, including on the role of the oncologist in value-based care, and the fate of the 2% sequestration. He responded that success in value-based care cannot happen without a team approach, and the oncologist is essential as the team leader, which has to be built into the value model. This is clearly the direction that the OCM is going in, although there is still a good deal of refinement needed, he emphasizes.
As for the 2% sequestration, he said, the purpose of the sequestration was to be a crude fix to the sustainable growth rate, but Dr Frist thinks there is recognition that the flat 2% is too blunt an instrument, and it will need to be addressed.