Invited Commentary by Dr. Barry Straube
The Supreme Court recently determined the ACA as constitutional, with the exception of mandatory Medicaid expansion, and allowed continuation of significant U.S. healthcare reform. This is particularly beneficial for patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) and their providers. The preservation of the individual mandate, which requires health insurance coverage, expands coverage to 32 million Americans and permits those currently uninsured to have preventive, ameliorative, curative, and replacement therapy for kidney and other diseases. Coverage cannot be denied based on pre-existing conditions. Health insurance exchanges are being created that will provide insurance options for those without commercial or public insurance plans. Without these legislative assurances, many would have continued to delay or avoid care for their kidney disease. Furthermore, nephrologists would be unable to treat some of their most vulnerable patients.
Mandatory Medicaid expansion was deemed unconstitutional, but only if required without an opportunity to retain existing Medicaid funding. Better coordination between Medicare & Medicaid, with novel approaches to managing “dual-eligible” beneficiaries (up to 40% of dialysis patients are dual-eligible), is enthusiastically promoted. Innovative ways of leveraging community and non-traditional healthcare delivery models abound. Patient safety, prevention, wellness, and health promotion are significantly promoted.
ACA provides valuable tools to improve healthcare quality. Equally important, ACA demands accountability of healthcare providers in improving quality as well as lowering burgeoning healthcare costs. The CMS Innovation Center is implementing various models of Accountable Care Organizations (ACOs) and other payment demonstrations. Although specialty ACOs have been excluded from the first generation ACOs, CMS is committed to a major demonstration of coordinated care for ESRD patients in the near future.
To be successful, the ACA requires providers (nephrologists, dialysis organizations, etc.) to radically change their existing cultures, to provide coordinated care, and to accept responsibility for poor quality and high-costs. Shifting blame isn’t acceptable. Organizational profit and professional autonomy become lesser, albeit simultaneously attainable, goals. Vastly improved patient-centered care and outcomes, plus lower overall costs, become paramount. Can we do it? We must!
Barry M. Straube, MD
Director, The Marwood Group
Former Chief Medical Officer, CMS
New York, NY