Welcome to the final installment of the Commonwealth Fund/Modern Healthcare Opinion Leaders Survey, conducted by Harris Interactive.

This is the 27th survey in the series, which began in 2005. The Commonwealth Fund is discontinuing the series to focus on other projects. Modern Healthcare partnered with the Commonwealth Fund on the survey series in 2007, with our first co-produced piece being published Jan. 8, 2007. Since then, the surveys have taken the temperature of key healthcare leaders on the hottest topics of the day as well as brought you expert and often controversial opinions from such notables as HHS Secretary Kathleen Sebelius, who penned one of this edition's two exclusive commentaries. We thank the Commonwealth Fund and its president, Karen Davis, for the opportunity to work together to educate our readers on the latest thinking by those who move the needle in the industry. And we thank our many senior executive readers who volunteered to be surveyed over the past four years as part of the series.

—David Burda

Editor

The Patient Protection and Affordable Care Act continues to have broad support from those on the frontlines of America's healthcare system—and many of them think national per capita healthcare spending can be slowed by an overhaul to the delivery and payment systems.

Insurance reform at the heart of the ACA is the most important element of the law, but the CMS is a strong second, in the view of a majority of respondents to the most recent Commonwealth Fund/Modern Healthcare Opinion Leaders survey.

A full 89% of respondents said it is “very important” or “important” that federal and state policymakers continue to move forward implementing the ACA.

Henley: "Probably a lot of waste" in Medicare and Medicaid.

“Sometimes when you're caught up in all of the news about challenges and polls about public discontent, it obscures the fact that those who are most knowledgeable about the law and about the health system and why change is needed are overwhelmingly supportive,” said Karen Davis, president of the Commonwealth Fund.

Harris Interactive polled 185 leaders in health policy, healthcare delivery and finance in the 27th—and final—iteration of the survey. The survey was conducted between

Sept. 28 and Oct. 25, and the response rate was 14.2%.

Survey respondents liked several cost-cutting proposals for Medicare and Medicaid put forth by President Barack Obama in his framework for reducing the federal budget deficit. Among them:

• Adjusting payments to encourage efficient post-acute care.
• Aligning Medicare and Medicaid drug payment policies.
• Introducing financial incentives to encourage Medicare beneficiaries to use high-value services.

Davis interpreted the results as showing broad support for modifying Medicare and Medicaid programs as they currently exist, rather than implementing radical changes such as block grants or voucher programs.

The most popular item from the president's bag of ideas was to reduce the deficit by reducing waste, fraud and abuse in Medicaid and Medicare.

“I think that's very accurate from an employer perspective,” said Sharron DiMario, director of community initiatives at Employers Health Coalition of Ohio in Cincinnati. “Between fraud and abuse and the whole concept of waste in the system … that is a way to show some quick wins and potentially easy savings.”

Dr. Douglas Henley, executive vice president and CEO of the American Academy of Family Physicians, saw it a bit differently.

“I would put fraud and abuse in a different category than waste,” he said. “I think there probably is a lot of waste in both programs. I'm not sure that there is a lot of intentional fraud or abuse.”

That waste comes in the form of unnecessary and ineffective care, and high-cost care when less expensive options that yield the same outcomes are available, he said. An emphasis on patient-centered medical homes that give a primary-care physician responsibility for directing and overseeing care could eliminate some of that waste, in his view.

Nearly three-quarters of survey respondents say national healthcare spending can be slowed from its current trajectory without harming access to or the quality of care. Per capita spending is projected to increase 5.1% annually through the remainder of the decade, rising from $8,327 a person in 2010 to $13,709 in 2020, according to the Commonwealth Fund. That compares to a 3.9% annual growth in the nation's gross domestic product.

Only 4% of respondents said spending growth must be at 5.1% or greater without hurting access or quality. On the other hand, 23% of respondents said annual growth could fall below 3.9% without ill effect.

Meanwhile, new payment and delivery systems got a big thumbs up from survey respondents, and Davis said she sees that same enthusiasm when she speaks to healthcare audiences around the country.

“Those who are delivering care really think the kind of re-forming of the healthcare system that has been set up by the Affordable Care Act is definitely the way to go,” she said.

The vast majority of respondents—95%—identified more efficient models of healthcare delivery as very important or important in slowing the growth of national health spending. Meanwhile, 84% said major payment system reforms, such as shifting from fee-for-service payment to bundled forms of payment, are very important or important.

That rankled Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, who has been working to change the healthcare payment system for more than a decade.

“It just frustrates me to no end because the percentages on those answers should be flipped,” he said. “It actually means that there's about 10% of the people who think that you are going to change the form of the delivery system without having to change the incentive. Come on, are you serious?”

DiMario, of Employers Health, took encouragement from broad support for reforms of the delivery and payment systems.

“We have to do something. Business as usual is not going to cut it anymore, for either the purchaser community, which we represent, or the hospitals and the physicians themselves,” she said. “They also realize that changes need to be made.”

DiMario: Sees "easy savings" under Obama's deficit plan.

In her market, a consensus that fee-for-service payment must go became evident at a recent summit on payment reform initiatives. The Health Collaborative of Greater Cincinnati partnered with Employers Health and other stakeholders to convene physicians and leaders from hospitals, health plans, federally qualified health centers, the state Medicaid program and employers for the first communitywide discussion on the topic. DiMario reported that participants agreed that they want to move to a payment system that is “a little more creative” in rewarding value in healthcare.

The AAFP does not advocate throwing fee-for-service out entirely. Henley said the organization wants a blended payment model that combines fee-for-service payments with two other pay strategies: a per-patient-per-month management fee to support care coordination and pay-for-performance programs.

He was pleased to see those concepts embedded in the Comprehensive Primary Care Initiative demonstration project recently announced by the CMS.

The survey also found that only 68% of respondents said it is very important or important for states to develop and operate their own insurance exchanges.

More than a dozen states have passed legislation authorizing insurance exchanges to be established, while governors in some other states are planning to issue executive orders to create the exchanges. But efforts to authorize insurance exchanges have been thwarted in several states.

The ACA's requirement that every individual must obtain health insurance coverage drew broad support from the survey respondents, with 84% ranking it as either very important or important.

Constitutional challenges questioning the legality of the individual mandate have put the issue in the hands of the U.S. Supreme Court. De Brantes, who is optimistic that the mandate will win the justices' approval, said the issue actually has bipartisan support.

“I have talked at length with Republican policymakers about this and there is very little, if any, dispute about the importance of the individual mandate as the only way to make the market function,” he said. “I think there is public rhetoric versus private conversations, and generally speaking, there just simply isn't much disagreement on either side of the aisle.”

Lola Butcher is a freelance healthcare writer in Springfield, Mo. Contact Butcher at lola@lolabutcher.com