The Patient Protection and Affordable Care Act turned two years old last week. Its birthday party continued this week with nine U.S. Supreme Court justices who will decide the constitutionality of the mandate requiring individuals to purchase health insurance or pay a penalty. Whatever the outcome, many believe it’s unlikely that we’ll see a complete reversal of the entire law (not impossible, but unlikely).
While the individual mandate, and the ACA in general, sharply divide the country, we should remember that the legislation also includes many relatively uncontroversial measures. These make a good start to reforming our broken, fragmented health care system that all too often endangers patients – particularly frail, vulnerable older adults. A New York Times op-ed last week by Ezekiel Emanuel gives a nice reminder of some of the ACA provisions that are likely to endure. These are pilot programs and demonstrations that we at the Hartford Foundation deeply care about because of their potential to improve the safety and quality of care delivered to older people.
Data and measurement lie at the heart of almost all of these reform efforts. New models of “shared savings,” like Accountable Care Organizations (ACOs) that partner hospitals with physician practices and community-based organizations to provide efficient, coordinated care, absolutely require robust quality measurements. We need these quality measurements to make sure that ACOs and other models don’t simply try to skimp on care to reach savings goals.
On the other hand, while there is widespread agreement on the importance of data and measurement, we also need a nuanced and careful approach when it comes to measuring the quality of care for older patients. We need to be mindful of unintended consequences—which is why policymakers need to incorporate geriatric expertise as the ACA “grows up” and changes over time.
To better understand this, everyone should read Drs. David Reuben and Mary Tinetti’s piece in the New England Journal of Medicine. Drs. Reuben and Tinetti, who are long-time Hartford grantees, propose that quality of care measures incorporate patient-defined goals. Currently, quality of care is measured by the accounting of certain processes (did you get a certain medication for a certain disease?) and outcomes (did your blood pressure go down?). This often works well for patients with a single disease or condition. But for many older adults with multiple chronic illnesses, short life expectancy, or severe disability, these kinds of measures may just not make sense. An older woman whose goal is to get to church on Sunday may choose to decline a recommended medication that makes her dizzy and afraid to walk. Without a way of incorporating the patient’s individualized goals, the patient’s providers may be penalized on their quality measures for not following current guidelines and giving her this medication. Providers may push unwanted or unneeded care onto older adults in the name of providing better quality.
The issue of quality measurement is complex and difficult in general. For example, some interesting research on patient satisfaction measures raises questions about their use in calculating hospital incentive payments, which begins under the ACA this year. It is even more complicated for older adults with multiple chronic conditions, for whom no clear care guidelines exist. This represents one of many areas where geriatrics experts like Drs. Reuben and Tinetti can help improve and refine health reform.
Whether you believe the health reform legislation is good or bad, I think we can all agree that our health care system should be patient-centered and help people live healthier lives, without bankrupting the U.S. economy. At the same time, we should ensure that older adults aren’t unintentionally harmed by well-meaning guidelines and recommendations. Assuming the ACA continues on in some form or another, involving geriatrics experts will be key to its successful transition to a “grown-up” piece of legislation that works for us all, including the most frail, complex older adults.